Family Medicine Child & Adolescent Psychiatryhsc.ghs.org/.../03/Family-Medicine-Child-Adolescent-Psychiatry.pdf · Child & Adolescent Psychiatry (a brief overview) Lance Feldman,

Child & Adolescent Psychiatry(a brief overview)

Lance Feldman, MD, FAPA, MBA, BSN

Vice Chair Clinical Affairs, Department of PsychiatryAffiliate Clinical Assistant Professor, University of South Carolina School of Medicine Greenville

Diplomate, American Board of Psychiatry & Neurology, PsychiatryDiplomate, American Board of Psychiatry & Neurology, Child & Adolescent Psychiatry

Diplomate, American Board of Addiction Medicine

Disclosures

• None

(We may, however, be discussing some possible off label medication uses, especially in the pediatric population.)

Outline

• Depression

• Anxiety

• Attention Deficit Hyperactivity Disorder (ADHD)

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Prescribing Pearls

• Chlorpromazine (Thorazine) – FDA approved ages >6 months for schizophrenia / psychosis

• CDC – “the long term effects of ADHD medicine on young children are not known”

• FDA – Pregnancy Category C– “Methylphenidate has been shown to have

teratogenic effects in rabbits when given in doses of 200mg/kg/day”

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Before Psychopharm…Modifiable Risk Factors• Sleep• Exercise• Nutrition• Family*• Friends*• Employer / Place of Employment*

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Depression

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Making the Diagnosis…

• Screening Tools – PHQ• Clinical Interview• Collateral Information (the “Fs”)• Criteria• Treatment

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Depression Criteria• Five (or more) of the following symptoms have been present during the same 2-week

period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

– Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

– Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

– Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

– Insomnia or hypersomnia nearly every day.– Psychomotor agitation or retardation nearly every day (observable by others, not merely

subjective feelings of restlessness or being slowed down).– Fatigue or loss of energy nearly every day.– Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly

every day (not merely self-reproach or guilt about being sick).– Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).– Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific

plan, or a suicide attempt or a specific plan for committing suicide.

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Neurotransmitters

• Serotonin• Norepinephrine• Dopamine

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http://www.emed.com.au/conditionsemed/sleep-stress-and-anxiety/depression/the-connection-between-diet-and-mental-health-part-2/

10http://web.stanford.edu/group/hopes/cgi-bin/hopes_test/ssris/

FDA Approved Mood / OCD Medications…

http://mhc.cpnp.org/doi/full/10.9740/mhc.n145473

Other Medications…

• Paroxetine (Paxil)• Citalopram (Celexa)• Venlafaxine (Effexor)• Duloxetine (Cymbalta)• Mirtazapine (Remeron)• Bupropion (Wellbutrin)• Trazodone (Desyrel)

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TADS Trial

• Treatment for Adolescents with Depression Study (TADS)

• 439 patients, 12-17 y/o, MDD, 13 clinics• 12 weeks of: fluoxetine alone, CBT alone,

fluoxetine + CBT, placebo

TADS

Anxiety

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https://quotesgram.com/funny-quotes-about-anxiety/

Making the Diagnosis…

• Screening Tools – SCARED• Clinical Interview• Family History• Criteria• Treatment

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Generalized Anxiety Disorder

• Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

• The individual finds it difficult to control the worry. • The anxiety and worry are associated with three (or more) of the

following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):Note: Only one item is required in children.– Restlessness or feeling keyed up or on edge.– Being easily fatigued.– Difficulty concentrating or mind going blank.– Irritability.– Muscle tension.– Sleep disturbance (difficulty falling or staying asleep, or restless,

unsatisfying sleep).

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Anxiolytics

• SSRIs• Benzodiazepines (Lorazepam, Clonazepam,

Alprazolam)• Buspirone (Buspar)• Hydroxyzine (Vistaril)• Cognitive Behavioral Therapy (CBT)

CAMS Trial

• Child/Adolescent Anxiety Multimodal Study (CAMS)• 488 participants with DSM-IV separation, generalized, or

social anxiety disorder• randomized to 12 weeks of cognitive-behavioral therapy

(CBT), sertraline (SRT), CBT+SRT (COMB), or medication management/pill placebo (PBO).

• Responders attended 6 monthly booster sessions in their assigned treatment arm; youth in COMB and SRT continued on their medication throughout this period.

• Efficacy of COMB, SRT, and CBT (n = 412) was assessed at 24 and 36 weeks postrandomization.

• Youth randomized to PBO (n = 76) were offered active CAMS treatment if nonresponsive at week 12 or over

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CAMS Results

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ADHD

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Making the Diagnosis…

• Screening Tools – Vanderbilts, Connors, CBCL, ADHD Rating Scale IV

• Clinical Interview• Family History• Criteria• Treatment

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ADHD Medications

• Stimulants (Methylphenidate, Amphetamine)• Non-Stimulants

– Alpha-2 agonists– Atomoxetine

• Other

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Stimulants in “Normals”

• Improved Cognition• Improved Memory – working & episodic• Improved Task saliency

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Methylphenidate Mechanism

• Dopamine and Norepinephrine reuptake inhibitor (transporter)

• Increase concentrations of DA and NE in the synaptic cleft

• Activation of Prefrontal Cortex

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Stimulants

• Methylphenidate Products:– IR: Ritalin, Focalin, Methylin– ER:

• Ritalin LA, Ritalin SR, Concerta, Focalin XR, MethylinER, Metadate CD, Metadate ER, Aptensio XR

• QuilliChew ER – chewable• Quillivant XR – liquid suspension• Daytrana - patch

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Long Acting Products…• Concerta – 22% / 78%• Metadate CD – 30% / 70%• Ritalin LA – 50% / 50%• Focalin –

27http://www.rxlist.com/htmlchunks/rxlist_tablepopup.html

Amphetamine Mechanism

• Reuptake Inhibitor of DA & NE• Release of DA & NE• Reduce firing rate • Reverse flow of monoamines

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Stimulants

• Amphetamines:– Short Acting: Adderall, Dexedrine, Procentra– Long Acting: Adderall XR, Vyvanse, Dyanavel XR

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Adderall (Dextroamphetamine)• 25% dextroamphetamine sulfate• 25% amphetamine sulfate• 25% dextroamphetamine saccharate• 25% amphetamine aspartate monohydrate

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Non-Stimulants: SNRI

• Atomoxetine (Strattera)– Selective norepinephrine reuptake inhibitor– 10, 18, 25, 40, 60, 80, 100mg doses– 4-8 weeks at least– Up to 60% efficacy– No abuse potential– No withdrawal effects– Black Box: suicidal ideation– 2012 - $621.4 million (Eli Lilly, 2.7%)

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Non-Stimulants: Alpha 2s

• Guanfacine– Guanfacine ER (Intuniv)– Guanfacine (Tenex)

• Clonidine– Clonidine ER (Kapvay)– Clonidine (Catapres)

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Alpha 2 Agonist Mechanism

• “Modulate noradrenergic tone” in PFC• Extend / Enhance stimulant therapy• Monotherapy XR prodcuts

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Other Treatments for ADHD

• Bupropion• Omega 3 FAs• Diet / Nutrition• Therapy

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Clinical Considerations

• Goal of treatment (Is it realistic?)• Dosing guidelines• Taking medications as prescribed• OTC supplements• Therapy (CBT, DBT, etc)

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Cognitive Behavioral Therapy

36https://en.wikipedia.org/wiki/Cognitive_behavioral_therapy

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Questions?

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Disruptive Mood Dysregulation Disorder• Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or

behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

• The temper outbursts are inconsistent with developmental level.• The temper outbursts occur, on average, three or more times per week.• The mood between temper outbursts is persistently irritable or angry most of the day,

nearly every day, and is observable by others (e.g., parents, teachers, peers).• Criteria A–D have been present for 12 or more months. Throughout that time, the

individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.

• Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.

• The diagnosis should not be made for the first time before age 6 years or after age 18 years.

• By history or observation, the age at onset of Criteria A–E is before 10 years.• There has never been a distinct period lasting more than 1 day during which the full

symptom criteria, except duration, for a manic or hypomanic episode have been met.

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