Depression, Anxiety, & Suicide in Children with …€¦ · • Campo (2012): review of ... -Depressed patients were 3 times more likely to be noncompliant with medical treatment

1

Depression, Anxiety, & Suicide in Children with Chronic Medical Issues

Depression, Anxiety, & Suicide in Children with Chronic Medical Issues

Veena T. Ahuja, MDChild and Adolescent

PsychiatryOctober 2016

Child and Adolescent Psychiatry


• Requires medical school and adult psychiatry residency.

• After residency, you can do more training (a child and adolescent psychiatry 2 year fellowship) to specialize in children and teenagers.

2



• Main focus: evaluation and treatment with medications

- Depression and bipolar disorder

- Anxiety

- ADHD

- Autism

• We receive training in talk therapy.

• 9 child psychiatrists and 2 NPs

What do I do?What do I do?

• Case Presentation

• Etiology

• Assessment

• Comorbid Disorders

• Treatment

• Questions

3

What do I do?What do I do?

• I work at Shaker campus with multiple groups, including Pediatric Pain Rehabilitation Program.

• Patients are evaluated in their second week along with parents if possible.

• We use feedback from team members.

• Medication changes are coordinated through our NP and medical team.

Today’s DiscussionToday’s Discussion

• Why is mental health important to us?

• Brief overview of depression

• Brief overview of anxiety

• Adding in Chronic Medical Issues

• Specific Diseases

• What can we do to help?

• Questions?

There are no disclosures for this presentation.

4

Why is mental health important to us?

Why is mental health important to us?

Why is this important to us?Why is this important to us?

• Suicide is the third leading cause of death among 10-14 year olds and 15-19 year olds (2000).

5



6


• One in five teenagers in the US seriously considers suicide each year.

- 15% make specific plans

- 8% make an attempt

- 2.6% make a medically serious attempt

• In 2000, 1,600 teenagers would die by suicide each year...Now, 4,800 will die each year.


• According to Surgeon General's estimate, only 20% of the children with a mental illness obtain any care at all.

• PCPs are now considered to be the front line “gate keepers” to mental health care.

U.S. Public Health Service, 2000; Horwitz et al. 2007; Trude and Stoddard 2003

7

Let’s talk about depression…Let’s talk about depression…

DepressionDepression

8

9

Depression in ChildrenDepression in Children

• at least two weeks of - Depressed mood

- Changes in appetite or weight

- Changes in sleep

- Fatigue or loss of energy

- Poor concentration

- Irritability

- Poor performance in school

- Physical symptoms: headaches and stomachaches

Depression in AdolescentsDepression in Adolescents

10

Depression in AdolescentsDepression in Adolescents

• at least two weeks of - Depressed mood - Changes in appetite or weight- Fatigue or loss of energy- Poor concentration- Irritability- Poor performance in school- Sleeping too much- Less interest in activities/friends- Hopelessness- Unexplained pain- Sensitivity to rejection/criticism

Functional Somatic SymptomsFunctional Somatic Symptoms

• Campo (2012): review of medically unexplained symptoms

• More common in • Girls• Increasing age• Poor school performance• Interpersonal difficulties• Self-perceived health limitations

• One somatic complaint predicts another• Most common: headache and abdominal

pain

11


• Campo (2012): review of medically unexplained symptoms

• FSS is common and present at all ages

• Symptoms are often stable

• ½ cases are persistent over 3-4 years


• Bohman et al, 2010: Compared 177 depressed vs. 177 non depressed 16-17 year olds

• 86% of depressed youth had at least 1 FSS, most commonly headaches

• Number of FSS was correlated with severity/duration of depressive episode

12

Let’s discuss anxiety…Let’s discuss anxiety…

13

What is anxiety?What is anxiety?

• Social anxiety disorder- Fear of being judged or embarrassed in

public (not just shy)

• Generalized anxiety disorder- excessive worry about everyday

problems for at least 6 months• Specific Phobias

- unexplained fears

• Panic disorder - repeated panic attacks

• Obsessive Compulsive Disorder- Intrusive thoughts and repetitive behaviors

14

Generalized Anxiety Disorder in Children/Teens

Generalized Anxiety Disorder in Children/Teens

• excessive worry for at least 6 months- Future events, pleasing others, friendships, being

accepted, doing well enough in school, etc.

• Described as “worry warts”

• Compared to other children, they worry about more topics and more frequently and have a harder time letting go of worry.

• Often makes it hard to fall asleep (“worry time”) or frequently tired

• Can have physical symptoms and/or frequent muscle tension

Panic DisorderPanic Disorder

15

ScreeningScreening

• Screening for psychiatric disorders

• Documentation

• Communication

- May require a release

• Triage

• Consultation

• Consider financial viability

Diagnosing Psychiatric DisordersDiagnosing Psychiatric Disorders

• Recurrent physical symptoms without a clear cause can suggest psychiatric disorders BUT some psychiatric disorders may be signs of physical syndromes.

• We always recommend starting with a medical work up: - CBC, Comp, TSH, vitamin D level, etc.

- For panic attacks, consider EKG

- Focus on the “good news” talk

16

Criteria for ReferralsCriteria for Referrals

• Risk of harm to self (suicidal behavior, excessive cutting, etc.)

• Risk of harm to others (aggressive behavior, threatening behavior)

• Emotional or behavioral problems that lead to poor functioning (severe tantrums, new onset psychosis)

• History of psychiatric admission• Treatment for > 8 weeks has not helped• Complicated diagnostic issues or family history• Treatment with more than 2 psychotropic

medications• Behavior seriously interferes with treatment of

a medical condition

How to ReferHow to Refer

• If non-urgent, have the patient’s family call the Solon Call Center for psychiatric triage:

- 216-636-5860• If urgent, send to the nearest ER

17

Adding in Chronic Medical Issues

Adding in Chronic Medical Issues

Chronic Medical IllnessChronic Medical Illness

• Children and adolescents with chronic medical illness are at increased risk for emotional adjustment issues.

- More likely to have internalizing symptoms – depression and anxiety.

• This is especially true with:- Diseases affecting CNS function

- Multiple comorbid physical conditions

- Long term physical disability

Wallander et al. 2003; Breslau and Marshall 1985; Stuber 1996; Thompson et al. 1990

18

Chronic Medical IllnessChronic Medical Illness• Children are more likely to struggle with

depression with:- Diabetes- Asthma- Epilepsy- Pain

• Diabetic children with depression have more noncompliance, admissions, and treatment-related complications.

• Dysfunctional families have been found to exacerbate depression and increase asthma severity.

Kovacs et al. 1995; Kovacs et al. 1997; Garrison et al. 2005; Waxmonsky et al. 2006; Wood et al. 2006

Noncompliance in AdultsNoncompliance in Adults

• DiMatteo et al (2000): meta-analysis of the effects of anxiety and depression on adult patient adherence- Depressed patients were 3 times more

likely to be noncompliant with medical treatment

• Hopelessness?

• Poor social support?

• Poor cognitive functioning?

- Anxiety has minimal effect on adherence

19

Noncompliance in ChildrenNoncompliance in Children

• Decreased likelihood of adherence with:- History of depression, oppositional

behavior, and/or poor impulse control

- Family with high level of conflict and low level of cohesion

- Low SES

- Long periods of follow-up

- Complex, invasive treatments without strong evidence

Shaw et al (2003)

Adapting to Medical IllnessAdapting to Medical Illness

• Disease Factors

- Amount of disability to the child AND family

- Predictability of disease course and prognosis

- Stigma associated with the disorder

- Monitoring that is required by family

Shaw and DeMaso, 2006;

20


• History of Illness and Medical Experience- Children and adolescents can be

traumatized by difficult and painful medical procedures.

- Anticipatory anxiety

- PSTD:

• Re-experiencing the event

• Avoidance and emotional numbing

• Increased arousal and hypervigilance


• Developmental Factors- Dealing with a chronic illness requires:

• Understanding medical information• Sense of illness causality and personal

responsibility• Need for compliance

- Preschool: poor understanding fear the unknown and unanticipated

- School – age: worry about loss of control- Adolescents: need independence, body

integrity, identity – “I don’t fit in. How will I look to others?”

21


• Temperament

- Difficult – irritable, emotional, poor regulation

- Slow to warm up – withdraw from new situations

• Coping style- Avoidance-oriented?

- Approach oriented?

- Problem-focused coping style may work best


• Parent Factors

- Anxiety – more likely to be distressed by procedures

- Depression – may be more withdrawn and distracted during treatment

• Must consider parent’s previous experience of illness and death

• Marital conflicts

• Parental feelings of helplessness and loss of control

Kazak et al. 2003

22


• Sibling Factors

- More likely to have lower psychosocial functioning, peer activities, and cognitive development

- Illnesses that affect daily functioning (bowel disease, cancer) were associated with negative effects

- Increased risk of school-related problems and possible increase in physical symptoms

- Jealousy and anger towards sick childBarlow and Ellard, 2006


• Family beliefs about medical treatment• Inappropriate family response:

- Threats, punishments- Over responding to the child, no limits

• 3 phase of Family Adaptation- Crisis – understanding symptoms and

grieving healthy child- Chronic – maintaining family stability,

minimize impact of illness- Terminal – processing responses that

result from death of child or end of illness

Frank et al. 1995; Logan and Scharff 2005; Rolland and Walsh, 2006

23

Specific Diseases:Diabetes

Specific Diseases:Diabetes

DiabetesDiabetes

• 26% depression, 20% anxiety

• Bernstein, et al (2013): 150 patients ages 11-25 with type 1 diabetes were given screening instruments- 1/3 positive screen twice as likely to

have poor glycemic control (HgbA1c)

- 11.3% depression

- 21.3% anxiety

- 20.7% disordered eating

Jacobson et al 2002

24

DiabetesDiabetes

• Dantzer et al, 2003: Review of literature on insulin-dependent diabetes

• Of the 8 empirical studies reviewed, 6 found a significant association between psychiatric disorders and diabetes

• Presence of anxiety/depression did not have a clear relationship to metabolic control

DiabetesDiabetes• Review of literature on insulin-dependent

diabetes• Increased internalizing symptoms

• Somatic symptoms• Sleeping issues• Compulsions• Depressed mood

• Monitoring of patients with IDDM over 10 years 40% had at least 1 psychiatric disorder• 26% depression• 20% anxiety• 16% behavior disorders

Dantzer et al, 2003

25

DiabetesDiabetes

• Review of literature on insulin-dependent diabetes

• Risk factors for adjustment disorder

• Preexisting psychiatric disorder

• Parental marital distress

• Maternal concern regarding diabetes

• Diabetic females had 8.46x the risk of a second episode of depression compared to boys

Dantzer et al, 2003

Specific Diseases:Asthma

Specific Diseases:Asthma

26

AsthmaAsthma

• 20-30% depression, 24.7% anxiety• Strong association with asthma and panic

disorder, GAD, and phobias• Anxiety associated with poor asthma

control, increased functional impairment, decreased quality of life, and increased healthcare costs

• Patients with asthma and comorbid psychiatric disorder are - 4.9x more likely to use an ER - 3.8x more likely to be admitted- 2x increased likelihood of smoking

Goodwin et al, 2005; Roy-Byrne et al 2008

Pulmonary DiseasePulmonary Disease

• Use caution with benzodiazepines

• SSRIs are a better option to treat anxiety

27

Specific Diseases:Chronic Pain

Specific Diseases:Chronic Pain

Chronic PainChronic Pain

• Depression is strongly associated with chronic pain

• High rates of anxiety disorders in patients with chronic spinal pain, rheumatoid arthritis, fibromyalgia, and migraines

• Anticipatory anxiety can worsen functioning• Chronic pain is associated with anxiety >

depression• Tx:

- Cognitive behavioral therapy- Relaxation and distraction techniques- SNRIs for neuropathic pain

Roy-Byrne et al, 2008

28


• King et al (2011): Review of 41 studies of chronic pain in children and adolescents

- Increased prevalence in

• Females

• Older age

• Low SES (especially headaches)

- Abdominal pain was associated with

• Anxiety/depression in children

• Maternal anxiety

• School stress


• King et al (2011): Review of 41 studies of chronic pain in children and adolescents

- Back pain

• Anxiety and depression were predictive of start and end points of back pain trajectories

- Combined pain

• Frequent moves

• Poor school performance

• Frequent tv watching

• Fewer interactions with other children

29

Functional Abdominal PainFunctional Abdominal Pain

• Shelby et al (2013): 332 patients with functional abdominal pain vs. 147 controls were followed into early adulthood- FAP patients had

• Higher lifetime risk of anxiety disorders (51% vs. 20%)

• Higher lifetime risk of depressive disorders (40% vs. 16%)

- Initial onset of anxiety disorders was before FAP evaluation

- Initial onset of depressive disorders was after FAP evaluation

Specific Diseases:Other Diseases

Specific Diseases:Other Diseases

30

Hepatic DiseaseHepatic Disease

• Affects metabolism of antidepressants, diazepam, and antipsychotics

• Citalopram and fluvoxamine are less protein bound better choice

• Avoid carbamazepine and valproate

GI DiseaseGI Disease

• Drug absorption is affected by mucosal integrity and delayed emptying

• Extended release formulations may decrease GI upset

• 54 – 94% in patients with IBS have psychiatric diagnoses

• IBS was associated with high rates of generalized anxiety disorder

Roy-Byrne et al, 2008

31

Renal DiseaseRenal Disease

• Affects metabolism of lithium, gabapentin, methylphenidate, venlafaxine, divalproex sodium, and topiramate

• General rule: decrease dose by 1/3 with renal disease

• Hemodialysis initially lowers plasma blood concentrations followed by rebound

• 20-30% of adult patients on dialysis struggle with depression

Tossani et al, 2005; Wuerth et al, 2005


• Kalender et al (2007): 141 adults with chronic renal failure (73 on dialysis)- 24.1% depression treated with

citalopram 20mg x 8 weeks

- No control group, no adverse effects

- Treatment significantly increased quality of life and decreased depression scores

32


• Atalay et al (2009): 124 adults on peritoneal dialysis- 25.8% depression treated with

sertraline 50mg x 12 weeks

- No control group, no adverse effects

- Treatment significantly increased quality of life and decreased depression scores

Cardiac DiseaseCardiac Disease

• Depression/anxiety and hostility is a risk factor for adult cardiovascular disease

• Panic attacks can mimic a heart attack or arrhythmia

33


• Affects volume of distribution of medication

• TCAs- increases blood pressure and heart

rate- Can cause arrhythmias in overdose

• SSRIs: moderate slowing of heart rate• Bupropion: no documented BP changes in

children• Lithium: sinus node dysfunction and

arrhythmias, T wave inversion


• Clonidine: decreases systolic BP and HR

• Risperidone: may cause hypotension, can cause QT prolongation

• Haloperidol: lengthens QT in high doses

• Stimulants: request cardiac clearance if preexisting cardiac condition

- Ask about a history of syncope, chest pain, or palpitations

34

EpilepsyEpilepsy

• 20-30% depression, 33% anxiety

• Atypical antipsychotics and bupropion can lower seizure threshold

• Lithium can be used carefully if seizures are well controlled

Caplan et al, 2005

What can we do to help?What can we do to help?

35

What is the best response to a medical diagnosis?

What is the best response to a medical diagnosis?

• Physician response:

- Education about disease and prognosis

- Clear expectations

- Be open to problem-solving

• Family response:- Calm, supportive response

- Familiar “family rules”

- Appropriate limit setting

Peterson and Harbaugh, 1995

Transactional Model of Stress and Coping

Transactional Model of Stress and Coping

• Stress response is mediated by one’s resources and ability to cope- Amenable to change- Stress can be controlled!

• Stressors do not have to be negative if a person can use good coping skills.- Evaluate stressor- Assess coping resources and options- Use coping efforts

• Problem management• Emotional regulation

Wallander et al. 2003

36

Improving Noncompliance in Children

Improving Noncompliance in Children

• Interventions- Increasing parental participation- Education on need for supervision

• Recommend use of family therapy techniques:- Normalize adolescent rebellion- Improve family communication- Implement family problem-solving

strategies

Spirito and Kazak, 2006

Improving Noncompliance in AsthmaImproving Noncompliance in Asthma

• Psychosocial interventions can - Reduce symptoms

- Reduce school absences

- Improve adjustment

• Relaxation training

• Family therapy

• Emphasis on behavioral and educational strategies

McQuaid and Nassau, 1999; Lemanek et al, 2001; Drotar, 2006

37

Improving Noncompliance in AsthmaImproving Noncompliance in Asthma

• Evans et al (1999): 5-11yo inner city children with moderate to severe asthma randomized to intervention vs. TAU over 1 year

• Social workers worked with caretakers to follow physician’s plan (met in person every month)- Also supported behavioral training

• Parents attended asthma education classes and received pillow/mattress covers- Intervention group had fewer admissions- 3x greater reduction in children with severe

asthma• At 2 year follow-up, improvements were maintained

even without access to the asthma counselor

Improving Noncompliance in Diabetes

Improving Noncompliance in Diabetes

• Behavioral interventions- Reduced psychological adjustment (.39)

- Improved blood glucose control (.33)

- Improved diabetic self-management (.15)

Hampson et al, 2000; Delamater et al, 2001; Lemanek et al, 2001

38

Improving Noncompliance in CancerImproving Noncompliance in Cancer

• Focus on reducing procedural pain and distress

- Cognitive behavioral therapy

• Psychological interventions may

- Improve social skills in children with brain tumors

- Smooth reentry to school

Katz et al, 1988; Kuppenheimer and Brown, 2002; Barakat et al, 2003

Dealing with Painful ProceduresDealing with Painful Procedures

• Prepare children for procedures

• Use distraction (planned beforehand)

• Coping strategies- Deep breathing

- Deep muscle relaxation

- Rehearsal

- Positive reinforcement

- Visual imagery

Spirito and Kazak, 2006

39

SummarySummary

• Suicide is the third leading cause of death in children and adolescents.

• Children and adolescents with chronic medical illness are at increased risk for depression and anxiety that persist over time.

• There are many factors that affect a child’s ability to cope.

• Family members are often affected and the illness can change family dynamics.

• Psychosocial interventions can help to improve overall adherence to treatment.

Questions?Questions?

40

Documents

Depression, Anxiety, & Suicide in Children with …€¦ · • Campo (2012): review of ... -Depressed patients were 3 times more likely to be noncompliant with medical treatment