Pediatricians as Primary Mental Health Professionals 5 Essential Drugs Dr. M.K.C.Nair Director,...

Pediatricians as Primary Mental Health

Professionals5 Essential Drugs

Dr. M.K.C.NairDirector, Child Development CentreMedical College, Tvpm

Dr. Paul RussellProfessor &Head

Child & Adol. Psychiatry Division

Christian Medical College, Vellore

Treatment modality as Treatment modality as recommended recommended

by WHO or based on evidenceby WHO or based on evidenceMedication CBT Family therapy

LDa - - -

ADHDa yes yes -

Ticsa yes yes yes

Depressiona yes yes yes

Psychosesa yes - yes

Schizophreniaa yes - yes

Autismb yes - -

Anxietyb yes yes yes

Conduct disorderb yes yes yes

Substance abuseb yes - yes

Eating Disordersb yes yes yes

Attachment disordersb

- - yes

4

Hierarchy of Diagnosis & Hierarchy of Diagnosis & TreatmentTreatment

Organic brain syndromes

Psychoses/ Pervasive Dev.l Disroders

Mood disorders / ADHD

Anxiety disorders

Tic / Enuresis / Conduct Disorder

Medication: Antipsychotic

Org.Brain Syndromes

Dose

1st-line drug Risperidone (Atypical antipsychotic) 0.25-1mg/day

2nd-line drug Haloperidol (Typical antipsychotic) 0.25-1mg/day

Organic Brain SyndromesOrganic Brain Syndromes

H/O: Temporal correlation with a

demonstrable general medical condition,

CNS pathology, drugs and medication

MSE: attention, orientation, memory

impaired.

PsychosisPsychosis

Psychoses Dose

1st-line drug Risperidone (Atypical antipsychotic) 2-4mg/day

2nd-line drug Haloperidol (Typical antipsychotic) 0.03 – 0.08mg/kg/day

1.Hallucinations

2.Delusions

3.Catatonic

symptoms

4.First Rank

Symptoms

Medication: Antipsychotic

AutismAutism

Symptoms

Hyperactivity, impulsiveness, inattention – Atypical antipsychotic

Rigidity, rituals – Atypical antipsychotic

Aggression, self injury – Atypical antipsychotic

Anxiety, Affective symptoms – Atypical antipsychotic

Review of 19 articles (Barnard et al, J Psychopharmacol 2002)

1. Deviant/ delayed social interaction

2. Deviant/ delayed communication

3. Restricted-repetitive behaviour

Medication: Atypical antipsychotic - Risperidone: Dose: 0.25 – 2mg/day

Mood disorders - Medication of Mood disorders - Medication of choicechoice

Depressive episode1.Mood2. Behaviour3. Cognition4. Biological symptoms

o Worthlessnesso Hopelessnesso Helplessnesso Suicidal ideation

(Antidepressant - Fluoxetine (10-20mg/day)

Bipolar & Hypermania (Mood stabilizer & Antipsychotic)

Pediatrician: Valproate Na (20-30mg/Kg) / Carbamazepine (8-12 mg/L)

Psychiatrist: Lithium ± AP (0.6-1mmol/L)

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Attention Deficit Hyperactivity Attention Deficit Hyperactivity DisorderDisorder

Medication Line of choice Dose Dosing schedule

CNS stimulants

Methylphenidate 1St line 1mg/kg/day Twice /thrice daily

SNARI (Serotonin NorAdrenergic Reuptake Inhibitor )

Atomoxetine

2nd line/ 1st? 1.2 -1.8mg/kg/day Once/twice daily

6 symptoms of attention deficit

6 symptoms of hyperactivity/impulsivity

2 settings

6 months

<7 years

Medication: CNS stimulants / SNARI

Symptom to Disorder Symptom to Disorder Transition Transition

1. Symptoms out of proportion to cause

2. Definite body symptom (eg. Depression:

Eating, sleeping, libido affected)

3. Impairment of functions

1.Irrational

fear

2.Avoidance

Anxiety DisordersAnxiety Disorders

1.Phobic anxiety disorder

2.Overanxiety disorder of

childhood

3.Seperation anxiety disorder

4.Obssesive compulsive disorder

5.Post-traumatic stress disorder

Medication: Antianxiety

1.Obsessions

2. Compulsions

1.Catastrophic trauma

2.Intrusive recollection

3.Autonomic arousal

4.Avoidance

1. Obsessive compulsive disorder

2. Post-traumatic stress disorder (PTSD)

Disorder 1st-line drug

Dose

OCD

Fluoxetine 10-40mg/day

PTSD

Generalized anxiety disorder (GAD)

Phobia

Medication: Antianxiety drugs

Conduct DisorderConduct Disorder

Dissocial

Defiant

Aggressive

Conduct Disorder Dose

1st-line drug Carbamazepine 8-12 mg/L

2nd-line drug Risperidone 1-2mg/day

Medication: Mood stabiliser

14

Tic DisorderTic Disorder

Tic Disorder

Dose

1st-line drug Risperidone (Atypical antipsychotic)

Haloperidol (Typical antipsychotic)

0.25.-2mg/day

0.2-2mg/day

2nd-line drug Fluoxetine 10-20mg/day

Motor

Vocal

Combined

Medication: Atypical antipsychotic

EnuresisEnuresis

Involuntary voiding

> 4 yrs CA

Enuresis Dose

1st-line drug Imipramine 0.3mg/kg/day

2nd-line drug Desmopressin 20-40g/I.nasal

Medication: TCA

ConclusionConclusionMedicationMedication DisorderDisorder Dose/DayDose/Day Dosing/DayDosing/Day EvidenceEvidence

1 Risperidone Org.Brain Syndromes 0.25-1mg OD-TID Level IIa

Risperidone Psychoses 2 - 4mg OD-TID Level Ib

Risperidone Autism 0.25 – 1 mg OD-BD Level Ia

Risperidone Tic 0.25 - 2mg OD (dinner) Level Ib

Risperidone ± Valproate Na

Mania 2-4mg20mg/kg

OD-TIDOD (dinner)

Level IIa

2 Valproate Na Conduct disorder 20mg/kg OD (dinner) Level Ib

3 Fluoxetine Depression 10-20 mg OD (breakfast) Level Ia

Fluoxetine Anxiety disorder (OCD, PTSD, GAD, Phobia)

10-40 mg OD (breakfast) Level Ib

4 Atomoxetine ADHD 1.2 - 1.8mg/kg OD-BD (break fast, lunch)

Level Ia

5 Imipramine Enuresis 0.3mg/kg/BW OD (dinner) Level Ia