Transcript Psychiatry Treatment in Individuals with Developmental Delays

Psychiatry Treatment in
Individuals with
Developmental Delays
Philip L. Baese, MD
Assistant Clinical Professor of Psychiatry
University of Utah, Department of Psychiatry
Neurobehavior/HOME Program
Background Issues
 Under-recognized/under-treated psychiatric problems
 Why?
 Doesn’t fit neatly into descriptive categories of DSM IV
 Behaviors themselves become the focus of treatment, without
understanding underlying etiology
 Complicating medical problems
 Complex psychosocial environments with variable
amounts/consistency of collateral information from observers
 Increased risk of psychiatric illness in those with MR
around 2-3X that of general population
 Prevalence estimates of 30-70% of those with MR have
an additional psychiatric diagnosis
Typical Diagnostic Categories
 Mood Disorders
 Depression
 Bipolar Disorder
 Anxiety Disorders
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Generalized Anxiety
Panic Disorder
Post-traumatic Stress Disorder
Obsessive Compulsive Disorder
 Autism Spectrum Disorders (ASD)/Pervasive
Developmental Disorders (PDD)
 Asperger’s
 Autism
Typical Diagnostic Categories
 Disruptive Behavior Disorders
 Oppositional Defiant Disorder
 Conduct Disorder
 Attention Deficit/Hyperactivity Disorder
 Tic/Stereotypic Movement Disorders
 Tourette’s Syndrome
 Psychotic Disorders
 Schizophrenia
General Aspects of Mental
Retardation
 Significantly subaverage intellectual
functioning (intelligence quotient below the
70-75 range measured on standardized
test)
 Significantly impaired adaptive functioning
 Onset prior to age 18
 85% fall in the mild-moderate range
General Aspects of Mental
Retardation
 35% an identifiable genetic cause is found
(such as Fragile X Syndrome, Down’s
Syndrome, etc.)
 <10% a malformation syndrome of
unknown origin is found
 33% external/pre/peri/post natal factors
can be identified (infections, trauma,
toxins, hypoxia, drug exposure,
prematurity)
Challenging Behaviors: The Big
Four
1. Self-injurious Behavior
2. Physical Aggression towards others
3. Destruction of Property
4. Inappropriate Sexual Behaviors
Broad Etiologic Categories
1. Medical Conditions
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Genetic disorders with identifiable “behavior”
phenotypes
 Prader-Willi Syndrome
 Down’s Syndrome
 William’s Syndrome
 FG Syndrome
 Fragile X Syndrome
 Smith-Magenis Syndrome
Broad Etiologic Categories
1.
Medical Conditions
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Epilepsy
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Partial complex
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Generalized
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absence
Endocrinologic/Metabolic Disorders
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Thyroid disease
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Diabetes
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Wilson’s Disease (copper metabolism)
Toxin Effects
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Lead poisoning
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Fetal alcohol (or other drug) effects
Sleep Disorders
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Obstructive sleep apnea (central and peripheral)
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Periodic limb movement disorder
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narcolepsy
Broad Etiologic Categories
1. Medical Conditions
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Gastrointestinal Conditions
 Constipation
 Reflux
Infections/Pain
 Chronic otitis, dental abscess, sinusitis
Toxin Effects
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 Lead poisoning
 Fetal alcohol (or other drug) effects
Sleep Disorders
 Obstructive sleep apnea (central and peripheral)
 Periodic limb movement disorder
 Narcolepsy
Broad Etiologic Categories
2. Psychiatric Disorders
3. Adaptive Dysfunction (mismatch between
individual and environment)
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COMMUNICATION limitations
Parental temperament
Level of supervision/support
Failure to recognize/manage major life changes
(puberty, graduation from school system, move out
of family of origin’s home, loss)
Treatment Approach
 Assess each of the broad categories listed
above and exclude medical causes first
 Functional Analysis of Behavior
 Biopsychosocial formulation
 Family history is important
 Early developmental history is important
 Psychosocial history is important (assess
home life, school life, and peer relationships)
Treatment Approach
 Formulate a working hypothesis
 Consider medication side-effects or adverseeffects as a primary cause
 Consider a worsening or undetected medical
cause (e.g., worsening seizure control or
sleep apnea)
 If underlying psychiatric illness suspected,
consider psychopharmacologic trial
General Rules for
Psychopharmacology in DD
Population
1. All bets are off – dealing with ‘fragile’ brains
that do not always respond as expected
2. Start low/go slow – begin at low dosages
(1/3-1/2 of usual dose in non-DD population
3. Be methodical – make one change at a time
and wait adequate amount of time for a
response; quantify response as much as
possible (e.g., serial rating scales)
4. Follow-up frequently – reassess on a
frequent/ongoing basis for adverse effects
General Rules for
Psychopharmacology in the DD
Population
 Additional Considerations
 Compliance with oral medications
 transdermal patch
 Intramuscular injection
 Liquid/rapidly dissolving preparations
 Need for invasive monitoring for side effects
 Drug levels
 Liver and bone marrow function
 EKG (QTc interval)
 Interactions with other medications, including over-the-counter,
herbals, etc.
 Effects of multiple time/day dosing on providers/school system
 Risk of ingestion or overdose
Commonly Used Medications
 Depression/Anxiety
 SSRI = selective serotonin reuptake
inhibitor
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Fluoxetine = Prozac (20 – 60 mg)
Sertraline = Zoloft (50 – 200 mg)
Paroxetine = Paxil (20 – 60 mg)
Fluvoxamine = Luvox (50 -200 mg)
Citalopram = Celexa (20 – 60 mg)
Escitalopram = Lexapro (5 – 20 mg)
Commonly Used Medications
 Depression/Anxiety
 Benzodiazepines
 Clonazepam = Klonopin (0.25 – 6 mg)
 Diazepam = Valium (5 – 20 mg)
 Lorazepam = Ativan (0.5 – 8 mg)
 Other
 Buspirone = Buspar (5 – 30 mg)
 MMA = mixed mechanism antidepressants
 Venlafaxine = Effexor (50 – 300 mg)
 Bupropion = Wellbutrin (75 – 300 mg)*
 Duloxetine = Cymbalta (20 – 60 mg)
*lowers seizure threshold/contraindicated with epilepsy
Expected Response/Adverse
Effects
 SSRIs: takes 3-6 weeks or more for anxiety for
potential benefit
 MMAs: takes 2-4 weeks for potential benefit
 Adverse Effects/Side Effects that are common
include diarrhea, GI upset, sexual dysfunction,
sleep problems, sedation, paradoxic agitation or
“activation” of manic symptoms
 Benzodiazepines: work within 1-2 hours
 Adverse Effects/Side Effects include
disinhibition, agitation, sedation
Commonly Used Medications
 Mood Dysregulation (Bipolar): so-called “mood
stabilizers”
 Non-AEDs
 Lithium = Eskalith (150 – 1200 mg) [blood level 0.8-1.2)
 AEDs (antiepileptic drugs)
 Divalproate = Depakote (125 – 1500 mg) [blood level 80-100]
 Carbamazepine = Tegretol (200 – 800 mg) [blood level 8-10]
 Oxcarbazepine = Trileptal (300 – 1200 mg)
 Lamotragine = Lamictal (50 – 400 mg)
 Gabapentin = Neurontin (300 – 2000 mg)
Expected Response/Adverse
Effects
 Lithium: can work within 7-10 days or
sooner; therapeutic blood level is key
 Adverse Effects include upset stomach,
diarrhea, excessive urination, cognitive
dulling, weight gain, acne, tremor
 Toxic Effects (overdose) are life
threatening: gait problems, confusion, and
coma
 Therapeutic blood level is key
Expected Response/Adverse
Effects
 AEDs: can work within days for stabilizing mood symptoms
 Often need to be tapered up and down slowly (shouldn’t be stopped
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abruptly due to risk of rebound siezure)
Some require therapeutic blood level for optimal efficacy
Some require monitoring of liver function and bone marrow function
(carbamezepine/divalproate)
Common side effects include weight gain, cognitive dulling,
sedation, tremor
Blood monitoring can be difficult in DDMR population
Some more effective than others (divalproate > carbamezepine >
gabapentin)
Lamotragine is promising (antidepressant effects), but must be
tapered upward slowly due to risk of life threatening rash (Steven
Johnson Syndrome)
Commonly Used Medications
 Agitation/Mood Dysregulation/Overarousal
 “Atypical” Antipsychotics (block dopamine
receptors and serotonin receptors)
 Risperidone = Risperdal (0.5 – 8 mg)
 Olanzapine = Zyprexa (5 – 30 mg)
 Quetiapine = Seroquel (50 – 800 mg)
 Ziprasidone = Geodon (40 – 120 mg)
 Arapiprazole = Abilify (5 – 20 mg)
Expected Response/Adverse
Effects
 Atypical Antipsychotics
 Work within hours (calming/sedating effects) to days (mood stabilizing
effects)
 Common side effects include weight gain (except
ziprasidone/aripiprazole), long-term metabolic changes and insulin
resistance (can lead to diabetes), sedation
 Changes in cardiac rhythm can occur (potentially lethal, such as
prolonged QTc interval)
 Less risk of EPS (extrapyramidal symptoms), but can occur = drug
induced Parkinsonism (cogwheel rigidity, tremor, wide based gait,
drooling); dyskinesias
 Serious long-term effects include tardive dyskinesia = involuntary
movements that are not reversible, even with drug discontinuation
 Life threatening reaction = NMS (neuroleptic malignant syndrome)
characterized by stiffness, vital sign instability, fever, delerium
Commonly Used Medications
 Disruptive Behavior Disorders (like AD/HD)
 Stimulants*
 Methylphenidate = Ritalin (multiple long-acting formulations)
 Dextroamphetamine = Dexedrine
 Mixed amphetamine salts = Adderall
*dosed by weight: methylphenidate least potent with average
dose of 1 mg/kg/day
 Non-stimulants
 Atomoxetine = Strattera (18 – 80 mg)
 Clonidine = Catapress (0.025 – 0.4 mg)
 Guanfacine = Tenex (0.5 – 2 mg)
Expected Response/Adverse
Effects
 Stimulants work in 30 minutes; short acting preparations
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are dosed multiple times per day
Stimulants improve attention/focus and decrease
impulsivity
Common side effects include appetite suppression,
upset stomach, tics (reversible), tachycardia
Need to monitor growth/weight in children and blood
pressure
Non-stimulant (atomoxetine) takes 2 weeks for effects
Non-stimulant (clonidine) causes a non-specific
decrease in hyperactivity and can be sedating; need to
monitor blood pressure
Sleep Medications
 Sleep Medications: these are many and varied
in their effectiveness
 Sleep problems are complex issues and may be
secondary effects of a psychiatric problem or
may be primary sleep disorders
 Remember, tiredness does not equate to the
quality/restfulness/restorative nature of sleep
 Many medications cause sedation, but do not
improve sleep quality (and some actually
interfere)
 Example: Benzodiazepines suppress REM sleep
Commonly Used Medications
 Trazodone = Desyrel (25 – 200 mg)
 Melatonin (over the counter) (1 – 6 mg_
 Diphenhydramine = Benedryl (25 – 100
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mg)
Zolpidem = Ambien (5 – 20 mg)
Zaleplon = Sonata (5 – 20 mg)
Eszopiclone = Lunesta (1 – 3 mg)
Ramelteon = Rozerem (8 mg)
Expected Response/Adverse
Effects
 Most sleep aids produce sedation within 1 hour of taking them
 Some are designed only for initial insomnia and sedating effects
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wear off by 3-4 hours
Some are designed for middle insomnia and continue to cause
sedation up to 8 hours after taking
Continuous use can cause attenuation of sedating effect over time
Can be used for months at a time, but should prompt ongoing
evaluation for underlying causes that are amenable to nonmedication treatment (like sleep hygiene).
Primary sleep disorders (apnea) need treatment with CPAP
(continuous positive airway pressure to prevent long-term
complications (cardiopulmonary)
Treatment Approach to
Developmentally Delayed
Individuals
 Assessment (takes time)
 Current symptoms/behaviors of concern:
severity, duration, setting, triggers
 Psychiatric review of symtoms including
adaptive functioning, self-care,
communication, social/school functioning
 Details of previous psychiatric treatment
including previous medications, response,
side effects
Treatment Approach to
Developmentally Delayed
Individuals
 Assessment (cont.)
 Parent/Caregiver attitudes and long-term
plans
 Review of prior psychological/cognitive testing
 Past/Present educational/work and habilitative
functioning
 Work programs, living situation, habilitative
supports
Multidisciplinary/Team Approach
 Due to complexity of caring for those with
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Developmental Disabilities, multiple care
providers are usually involved
Results in complex, interacting systems where
communication is critical (both within and
outside of clinic setting)
Communication with outside caretakers/teachers
is often indirect (parent reports/letters)
Often, direct communication is neccesary/useful
Constraints placed on patient confidentially or
parental preference can be barriers
Multidisciplinary/Team Approach
 The Players
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Parents/Care Providers
Child/Adolescent/Adult Psychiatrist
Behavior Specialist
Case Manager
Medical Assistants
Primary Care Physician
Geneticist
Specialty Consultants (Pulmonologist/Neurologist/Rehabilitation)
Therapists (family, individual)
Special Education Teachers
Adaptive Therapists (speech/physical/occupational)
Human services (Utah = DSPD and/or DCFS)
UNI H.O.M.E. Program (Healthy
Options Medical Excellence)
UNI HOME Clinic
Behavioral/Psychiatric Services
•Psychiatrist
•Therapist
•Behavior Specialist
•Group Therapists
Case Management
•Liaison with school (teachers)
•Liaison with DSPD
•Liaison with residential providers/families
•Facilitate communication
•Treatment planning meetings
•IEP reviews
•Letters
•Specialist care coordination
•Advocacy
Primary Care
•Family Physician (focus on preventive care)
•Nurse Practitioners (physician extenders)
•Nutritionist
•Access to Habilitative Services
(speech, physical, occupational)
Medical/School System Interface
 Barriers to Communication
 Legal – HIPPA (Health Information Portability
and Protection Act): requires
parental/guardian permission to disclose
protected medical information
 Geographic – school and clinic staff in
different locations
 Time – teachers and caregivers are busy
(difficult to connect)
Medical/School System Interface
 Unhelpful Stances
 The demanding/entitled physician, teacher, or
parent
 The disparaging physician, teacher, or parent
 The undermining physician, teacher, or parent
 The overwhelmed physician, teacher, or
parent
 The indifferent physician, teacher, or parent
Medical/School System Interface
 Constructive Stances
 Open communication (invite parent/care
providers/teachers into dialogue
 Capitalize on natural settings within each culture (IEP
meetings at school or treatment planning meetings at
a clinic)
 Discuss expectations ahead of time to avoid
disappointment
 Review interventions regularly
 Utilize technology/variety of communication forms
(letters, e-mail, video tape (with consent), phone,
rating scales)
 Be flexible
Medical/School System Interface
 Practical Advice for Special Education Teachers
 Be open to observing/documenting behaviors in the
classroom in the context of ongoing treatment
 Allow yourself to be a blinded observer and complete
requested rating scales
 Communicate concerns about effects of medication
(side effects such as sedation or agitation) to parents
 Don’t tolerate the sedated/sleeping child who isn’t
disruptive
 Guide clinicians/parents in their advocacy efforts
 Be over vigilant with sensitive psychiatric or mental
health information
Medical/School System Interface
 Practical Advice for Special Education Teachers
 You know the child’s educational style/behavior in the
classroom better than anyone else
 Communicate observations of social and learning
interactions impartially, but accurately (avoid using
extreme descriptions which can be misleading)
 Utilize existing resources within the school system
(school psychologist)
 Advocate within your school for the resources you
need to do your job