Transcript Pediatric psychopharmacology

Pediatric Psychopharmacology
What’s your decision?
IACAP
Seminar on child and adolescent
psychopharmacology
Ordibehesht 1393
Strong climate
against medication for children with
mental disorders
Past
• Psychoanalytically oriented psychotherapy was
the generally preferred treatment (until the
late 1970) .
The eventual acceptance of medication use was
based on the growing evidence of efficacy of
drug treatments with large ESs for disorders that
had been resistant to psychological treatments.
Stimulants responsible for the actual “start”
Dramatic expansion of the use of
psychotropic
medications in children in recent years
Different causes:
• medications are easy to prescribe and to apply
• treatments are less time consuming compared
to psychotherapy
• in some disorders (such as ADHD)
there is a large group of quick responders
• A switch from a categorical to a dimensional
model of disease, facilitating the treatment of
less severe cases by using lower cut-off points
and not taking so much into account the
burden of suffering.
• The Internet is full of advertisements of
“brain doping as a quiet revolution”.
This period of success has been followed
by a series of challenges
•
•
•
•
Poly pharmacy
long term adverse effects of medications
the inadequacy of long-term drug surveillance
the growing alienation of the media from
psychiatric illness :
medications unnecessary
diagnoses unscientific / harmful
Strong climate
against medication for children with
mental disorders
Today concerns
• Children are being over treated with
medication, especially in the US.
• Stimulants
• Antipsychotic medications usage in children 5
times higher than in adults.
• Current medications are only partially
successful, with 40–50% of patients having
incomplete response/ intolerance.
• Most of drugs still act on the monoaminergic
& glutaminergic targets.
Under treatment
is perhaps a bigger problem
globally
than
overmedication
WHO’s definition
• hyperkinetic disorder (about 1% of school-age
children)
• those children with ADHD that falls short of
hyperkinetic disorder (about 4%) who fail to
respond to behavioral interventions (perhaps
half of that 4%)
• then there would be approximately
30 per 1,000 children eligible for treatment
Stimulants use rates
73 per 1,000 in the USA
Europe
9.2 / 1,000 (6–12y) in the UK
7.4/ 1,000 (13–17y) in the UK
1.8 per 1,000 in France
a few centers in Italy
(preschool use too rare)
Child Psychopharmacology
in LMIC
Outside the university settings, children are
seen:
• with inadequate diagnosis
• being treated with ineffective doses for short
periods of time
• with medications not supported by empirical
evidence
• frequently with poly pharmacy
• by non-specialists ( the lack of adequate
training)
In fact in LMIC, , ordinarily, only those
from middle-high to high income class
families have access to the few child
psychiatrists in these regions by paying
out of their pockets.
What factors
influence
these startling differences?
1 - Availability of prescribers
Medication clinics in the US
PMT in the UK : available and free
lack of child psychiatric services in general,
and of professionals qualified to prescribe in
particular
2 - Perceived efficacy of
drugs and alternatives
In some low-prescribing countries, non
pharmaceutical interventions are regarded as more
or less equivalent to drugs
( European Guidelines and those in the NICE)
childhood depression: SSRIs after 3 months of
psychological therapy
• Recent studies arguing that the combination of
both is more effective and safer than either
treatment alone
A recent meta-analysis of non-pharmacological
interventions in ADHD casts some doubt on the
value of treatments such as behaviorally oriented
parent training and most dietary interventions.
Need to be some re-evaluation of the power of
medication relative to psychological interventions
3 – Cultural factors
• The perceived overuse of medication in the
USA has generated widespread media criticism
in Europe.
• Opposition to biological psychiatry, e.g., from
sociological and psychoanalytic perspectives
• The resulting polarization can get in the way
of balanced and discriminating use.
4 - Adverse effects
• Differing perceptions of drug dangers influence
regulatory authorities and prescribers.
• The hazards of stimulants are few/manageable .
• Oral administration especially of extended action
preparations is unlikely to lead to misuse.
5 - Uncertainty of indications
• Most of the problems of child mental health are
distributed in the population as continuous
dimensions.
• A real difficulty to decide where to place cut-offs for
the use of medication, or how to decide on the
balance between medication and psychological
therapy.
• A large part of pediatric
psychopharmacological literature comes from
the US and European countries.
• only about 10% of randomized clinical mental
health trials for children and adolescents
come from LMIC, while almost 90% of children
and adolescents live in those countries.
• Different ethnic groups metabolize drugs
differently, and hence safety and efficacy in
one group cannot be easily generalized to the
others.
• While we have a great deal of efficacy data,
true real-world effectiveness data and real
functional outcomes as dependent
variables are sorely missing.
What we really want to know, as in other areas
of medicine, is how our treatments impact on
the natural history of the disorders.
• Do antidepressants decrease suicides in
adolescence?
• Do ADHD medications reduce school
repetitions and accidents at home?
The stigma
• some drugs used in child psychiatry have
larger effect sizes than those used in other
areas of medicine ( asthma , headache or
atopic dermatitis / ADHD) . Still, they are
much less controversial.
• We should not allow the stigma related to
mental disease to preclude us from providing
the right treatment to our patients.
Psychopharmacological treatments
in children should always consider the
developmental perspective
• Child psychopharmacology means prescribing
medication for individuals with a developing
brain and, most of the time, for long periods.
• In order to develop new drug targets, we
need to expand our knowledge on the normal
trajectories of brain development and how
child mental disorders impact on it.
• We need to pursue effective ways to interfere
on these trajectories as early as possible,
addressing the so-called “at risk” conditions.
The future of
pediatric psychopharmacology seems bright
• With the recognition of financial conflicts of
interests and increased governmental funding to
test various psycho tropics for different
conditions in children and adolescents,
• with the development of psychiatric
pharmacogenomics : more targeted drugs and
understand genetic variations which influence
treatment response, thus moving from empirical
selection of medications to personalized
medicine in true sense.
• One opportunity is the increasingly accepted
view that we should move towards early
intervention and prevention and that most
psychiatric conditions develop during
childhood and adolescence.
• That should shift the target, not only of drug
discovery but also of therapeutic approaches
in general ,toward a younger population than
is typically included in clinical trials.
• Parents are usually fearful of administering
psycho tropics to their children and often prefer
psychological treatments over pharmacological
agents
• Clinician should not ignore the need to assess
patients’ and caregivers’ attitudes and concerns.
Clinicians should work with them to clarify
possible erroneous beliefs and misconceptions
associated with use of medications in childhood
and adolescence.
Gold Standard for Clinical Assessment
• In light of not having clear-cut laboratory tests
to validate psychiatric diagnoses or
• clinical assessment instruments, Spitzer (1983)
introduced a provisional gold standard, the
• LEAD standard. LEAD encompasses three core
concepts: “Longitudinal, Expert, and All
• Data”
• “Longitudinal” means that clients’ symptoms
are monitored over time. Past,
• present, and future symptoms are factored
into diagnostic decisions (with diagnoses
being
• revised in light of new information).
• “Expert” refers to clinicians who can make
reliable
• diagnoses based on independent evaluation
of the available data, comprehensive clinical
• interviews, and discussion with other experts
around any diagnostic disagreement. Expert
• clinicians ultimately make consensus
diagnoses that serve as the criterion measure.
• “All
• Data” refers to multiple sources of
information, such as secondary informant
reports from
• parents or teachers and data provided by
other professionals (e.g., psychiatric history,
etc.).
• LEAD standard represents a comprehensive
and thorough approach to
psychiatricevaluation.
• LEAD standard represents a comprehensive
and thorough approach to
psychiatricevaluation.