PHM 456HPHM 456HIntroduction to Pediatric Pharmacy Practice 2004Introduction to Pediatric Pharmacy Practice 2004
Drug Related Issues in Drug Related Issues in Pediatric PsychiatryPediatric Psychiatry
Claire De Souza BSc MD FRCP(C)Claire De Souza BSc MD FRCP(C)
November 4November 4thth 2004 2004
Audience Survey: Audience Survey:
Experience with pediatric psychiatry: Experience with pediatric psychiatry: medications?medications?patients?patients?
Learning ObjectivesLearning Objectives
At the end of this presentation, the student will:At the end of this presentation, the student will:
be familiar with the spectrum of psychiatric illness in be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involvedthe pediatric population and the assessment involved
have a greater understanding of have a greater understanding of pediatric depression pediatric depression ADHDADHD
any others?any others?
OutlineOutline
Starting PrinciplesStarting Principles Spectrum of Psychiatric Disorders in the Spectrum of Psychiatric Disorders in the
Pediatric PopulationPediatric Population Review of Pediatric DepressionReview of Pediatric Depression Review of ADHDReview of ADHD
PrinciplesPrinciples
accurate diagnosisaccurate diagnosis biological, psychological, social contributorsbiological, psychological, social contributors
informs a comprehensive management planinforms a comprehensive management plan biological, psychological, social interventionsbiological, psychological, social interventions
medications used depending on diagnosis, symptoms, medications used depending on diagnosis, symptoms, and severityand severity antidepressants - SSRIsantidepressants - SSRIs anti-anxiety - benzodiazepinesanti-anxiety - benzodiazepines anti-psychotics – atypicalanti-psychotics – atypical start start lowlow, go slow, go slow
Spectrum of Psychiatric DisordersSpectrum of Psychiatric Disorders Mood Disorders Mood Disorders Anxiety Disorders Anxiety Disorders Psychotic Disorders Psychotic Disorders Substance Use DisordersSubstance Use Disorders Personality DisordersPersonality Disorders Disruptive Behavioural DisordersDisruptive Behavioural Disorders Elimination DisordersElimination Disorders Eating DisordersEating Disorders Tic DisordersTic Disorders Somatoform DisordersSomatoform Disorders etc. etc.
Reference: DSM-Reference: DSM-IVIV
DepressionDepression
DepressionDepression 2% children, 4-8% teens (2% children, 4-8% teens (: : ♂ ♂ = 2:1)= 2:1)
suicide attempt - 9% of teenssuicide attempt - 9% of teens symptoms for 2 weeks:symptoms for 2 weeks:
mood – “bored”, irritablemood – “bored”, irritable cognitive – SI, guilt, worthlessness, concentrationcognitive – SI, guilt, worthlessness, concentration physical - change in sleepphysical - change in sleep↑↑, appetite, appetite↑↑, energy, psychomotor , energy, psychomotor interpersonal – change in interest levelinterpersonal – change in interest level change in functioning (social, academic) / xs distresschange in functioning (social, academic) / xs distress
other features: other features: anxiety - phobias, separation anxietyanxiety - phobias, separation anxiety behaviour - tantrums, oppositional, aggressionbehaviour - tantrums, oppositional, aggression somatic complaintssomatic complaints psychosis – auditory hallucinationspsychosis – auditory hallucinations
range in severityrange in severity
Depression continued …Depression continued … contributing factors (B/P/S)contributing factors (B/P/S)
biological – ie genetics, history of depressionbiological – ie genetics, history of depression psychological – ie loss, trauma, separationpsychological – ie loss, trauma, separation social – ie interpersonal, SES, academicsocial – ie interpersonal, SES, academic
comorbidity: anxiety, substance use, behaviour, etccomorbidity: anxiety, substance use, behaviour, etc
prognosis: recurrenceprognosis: recurrence 20-60 % recurrence in 2 yrs; 70% within 5 yrs20-60 % recurrence in 2 yrs; 70% within 5 yrs episodes become more frequent, more severe, last longerepisodes become more frequent, more severe, last longer 20-40% 20-40% bipolar disorder within 5 years bipolar disorder within 5 years
Depression continued …Depression continued …
Assessment Assessment interview with family interview with family interview with child/teen interview with child/teen interview with parents interview with parents collaterol information from school etc as requiredcollaterol information from school etc as required
Depression continued Depression continued ……
Differential DiagnosisDifferential Diagnosis – extensive – extensive Adjustment Disorder, Dysthymic Disorder, Adjustment Disorder, Dysthymic Disorder,
Bipolar Disorder, Anxiety Disorder, Eating Bipolar Disorder, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Disruptive Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Behavioural Disorder, Personality Disorder, Substance use Disorder, General Medical Substance use Disorder, General Medical Condition (thyroid, anemia, mono etc), Condition (thyroid, anemia, mono etc), Bereavement etc.Bereavement etc.
Depression continued Depression continued ……
Management (B / P / S):Management (B / P / S): PsychoeducationPsychoeducation MedicationsMedications Therapy – individual (CBT, IPT), familyTherapy – individual (CBT, IPT), family School InterventionSchool Intervention Resources / ReferencesResources / References
websites: websites: http://www.mooddisorders.on.ca/mdao.asphttp://www.mooddisorders.on.ca/mdao.asp
http://www.aacap.org/http://www.aacap.org/ (Facts for Families) (Facts for Families)
Depression continued Depression continued ……
MedicationsMedications duration: 9 months or moreduration: 9 months or more 11stst line: SSRIs line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label(ie Prozac, Zoloft, Celexa) – off-label
start low, go slow; increase as tolerated & as requiredstart low, go slow; increase as tolerated & as required ControversyControversy
Efficacy – limited evidence - ProzacEfficacy – limited evidence - Prozac Safety – Health Canada warningSafety – Health Canada warning
MD to monitor: SI, disinhibition, agitation, akathisia MD to monitor: SI, disinhibition, agitation, akathisia off-label use based on limited studies, experience, adult studiesoff-label use based on limited studies, experience, adult studies
drug interactions – cytP450drug interactions – cytP450 Medications added as required (Sx, Rx resistance): Medications added as required (Sx, Rx resistance):
ie BZDs, atypical antipsychoticsie BZDs, atypical antipsychotics
Depression continued Depression continued ……
Red FlagsRed Flags requesting script renewalsrequesting script renewals appearing dysphoric, suicidal, appearing dysphoric, suicidal,
hypomanic, psychotichypomanic, psychotic non-compliance: withdrawal, non-compliance: withdrawal,
worsening symptomsworsening symptoms stockpiling medications, buying stockpiling medications, buying
++OTCs++OTCs medical problems – cytP450 medical problems – cytP450
drug interactionsdrug interactions
Depression continued Depression continued ……ApproachApproach
review Health Canada warning review Health Canada warning discuss need for monitoring by MDdiscuss need for monitoring by MD advise them not to stop medication suddenly advise them not to stop medication suddenly questions / concerns questions / concerns MD MD advise them about what to look for:advise them about what to look for:
ie. restlessness, disinhibition, aggression, ie. restlessness, disinhibition, aggression,
anxiety, worsened depressionanxiety, worsened depression
direct them to resourcesdirect them to resources if concerned about patient’s safety – refer to ERif concerned about patient’s safety – refer to ER
Reference: FDA website, Health Canada, NIMH websitesReference: FDA website, Health Canada, NIMH websites
Attention Deficit Attention Deficit Hyperactivity DisorderHyperactivity Disorder
ADHDADHD 5-9 % of children; 5-9 % of children; ♂: ♂: = 4:1 (= 4:1 (NB:NB: under-Dxunder-Dx))
symptoms – 2+ settings, onset < age 7symptoms – 2+ settings, onset < age 7 inattention – careless mistakes, can’t sustain attn, distractible, forgetful, inattention – careless mistakes, can’t sustain attn, distractible, forgetful,
disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids time/effort-consuming taskstime/effort-consuming tasks
hyperactivity – fidgets, leaves seat, hyperactivity – fidgets, leaves seat, ↑ ↑ runs/climbs, on the “go”, xs runs/climbs, on the “go”, xs talking, can’t play quietlytalking, can’t play quietly
impulsivity- blurts out, interrupts, problems waiting turnimpulsivity- blurts out, interrupts, problems waiting turn interferes with functioning: academic, family, socialinterferes with functioning: academic, family, social
diagnosis diagnosis subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined
reference: DSM-IVreference: DSM-IV
ADHD continuedADHD continued etiology - DA mediated; problems with inhibitory & etiology - DA mediated; problems with inhibitory &
executive controlexecutive control factors:factors:
biological – FHx, difficult temperamentbiological – FHx, difficult temperament psychological - self-esteempsychological - self-esteem social - interpersonal, academic, poor social skillssocial - interpersonal, academic, poor social skills
comorbidity comorbidity learning disorders (in 40% with ADHD), behavioural learning disorders (in 40% with ADHD), behavioural
problems (ODD, CD), substance abuse, depression, anxietyproblems (ODD, CD), substance abuse, depression, anxiety prognosisprognosis
65% 65% adulthood adulthood
ADHD continuedADHD continued
Assessment: Assessment: Interview with Interview with
familyfamily child / teen child / teen parents parents
QuestionnairesQuestionnaires ie Connors Rating Scale – parent / teacher formie Connors Rating Scale – parent / teacher form
Information from schoolInformation from school Psychoeducational testingPsychoeducational testing
ADHD continuedADHD continued
Differential DiagnosisDifferential Diagnosis – extensive – extensive Learning disorderLearning disorder General Medical Condition (hearing, vision, General Medical Condition (hearing, vision,
thyroid, congenital, genetic, lead poisoning, head thyroid, congenital, genetic, lead poisoning, head injury etc)injury etc)
Adjustment Disorder, Dysthymic Disorder, Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Psychotic Bipolar Disorder, Anxiety Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, etc.Personality Disorder, Substance use Disorder, etc.
ADHD continuedADHD continued
Management (B / P / S):Management (B / P / S): PsychoeducationPsychoeducation MedicationsMedications Social skills trainingSocial skills training Parent management Parent management
(+) reinforcement, structure(+) reinforcement, structure School Intervention School Intervention
classroom modifications, individual education plan (IEP)classroom modifications, individual education plan (IEP) Resources / ReferencesResources / References
websites: websites: www.adrn.orgwww.adrn.org http://http://www.aacap.orgwww.aacap.org// (Facts for Families) (Facts for Families)
ADHD continuedADHD continued
MedicationsMedications stimulants - 1stimulants - 1stst line line
short acting – Ritalin, Dexedrineshort acting – Ritalin, Dexedrine long acting – ie Concerta, Dexedrine SRlong acting – ie Concerta, Dexedrine SR Blinded placebo / stimulant trials Blinded placebo / stimulant trials
to determine dose, acceptabilityto determine dose, acceptability coordinated with objective scale – ie Connors Rating Scalecoordinated with objective scale – ie Connors Rating Scale
restricted use – limited scriptsrestricted use – limited scripts abuse potentialabuse potential
other medications for co-morbidity – ie depression, anxiety, other medications for co-morbidity – ie depression, anxiety, ticstics
Use – for school day primarily; also, during weekend & Use – for school day primarily; also, during weekend & summer if problems (social, academic) off meds summer if problems (social, academic) off meds
ADHD continuedADHD continued
Red FlagsRed Flags requesting script renewalsrequesting script renewals non-compliancenon-compliance substance abusesubstance abuse stockpiling medicationsstockpiling medications medical problems - epilepsymedical problems - epilepsy
ADHD continuedADHD continued
ApproachApproach controversy controversy
““over-diagnosed” over-diagnosed” concerns about long-term side effectsconcerns about long-term side effects problems if no treatment problems if no treatment
academic, social, family academic, social, family comorbidity comorbidity
advise them to direct their questions / concerns advise them to direct their questions / concerns MDMD
Questions / CasesQuestions / Cases