Transcript Prescribing for Adolescents

Prescribing for Adolescents
Scope –
when is psychotropic drug treatment significant for children and adolescents?
• Significant
–
–
–
–
–
Psychosis****
Hyperactivity
OCD
Depression****
Tourettes/Tics
• Rare or not at all
–
–
–
–
MR
Autism
Conduct Disorder
Eating Disorders
Key issues in Adolescence for
Mental Health Services
• Developmental issues
–
–
–
–
–
–
–
–
–
–
Physical development : puberty
Thinking and reasoning
Self and identity
Relations with family : transition & autonomy
Sexuality
Friendship and peer groups
Education, training and work
Anti-social and offending behaviour
Stress, coping and adjustment
Culture and ethnicity
Limits on Child & Adolescent
Psychopharmacolgy
• Limited evidence base
– Few RCTs
– Reliance on downward extrapolation from
adult studies
– Developmental and pharmacodynamic
differences child/adult
– Off-label prescribing [USA 80%, Jensen 1999]
Strategy for optimal psychopharmacological
treatment of adolescents [The Big 8]
1. Clear psychiatric diagnosis
2. Identification and measurement of those features that are the target
of treatment
3. Treatment “contract” with the patient (and when appropriate, the
family]
4. Good knowledge about various treatment options and their relative
risks and benefits
5. Factors that can influence treatment:
–
psychological, family, social, and economic
6. Useful methodology for determining efficacy and optimization of
treatment
7. A constructively critical attitude about models of patho-etiology and
how they relate to treatment.
8. Knowledge of and proficiency in a model of therapeutics that can
allow for the implementation and integration of various useful
treatments
The school or work and social
environment
• Academic/work history
• Peer relationships
• Self-management/independent living skills
• Contact school/college [with consent]
• Reports etc
Specific child & adolescent issues
• Consent and capacity
– MHA 1983 & Children Act 1989
– Gillick competence
– Refusal of treatment by competent child
• Child protection
– Duty to protect
– Violence and sexual aggression :inpatient units
Baseline Assessment: General
Issues
• Patient and his or her symptoms
– Psychiatric history
– Mental State Examination
– Measure specific symptoms that are focus of
treatment
– Medical Assessment including baseline assessment of
symptoms which may later feature as adverse side
effects
The patient’s family or living unit
• Family roles
• Family psychiatric history
– Response to previous treatments
• Value systems and attitude to mental
health issues and medication
Practice points on family
interviewing
• Younger adolescents best seen with parents,
•
•
•
then alone
Older adolescents need the choice
Depressed/anxious parents over-report child
behaviour
Parents are less aware of mood states in their
children
• Crisis management/emergencies may require serial
interviews and/or telephone contacts
Adolescent onset schizophrenia
(13-19 years of age)
• 50 times less often before age 15 years
than after it (Beitchrnan, 1985).
• Average of first onset [EPPIC] 19 years
• Insidious onsets more common
• Long term Social outcomes are still very
poor [Hollis 2000]
Atypical Antipsychotics
• Risperidone, Olanzepine, Quetiapine,
Clozapine, Amisulpiride,
– Standard antipsychotic choice for children &
adolescents (70-80%o)
– very limited evidence-base in younger
patients (1 RCT:Kumra et al 1996)
– possible increased efficacy against negative
symptoms, cognitive impairment
– Variable profile of side effects, reduced EPSE
Side-Effects of Antipsychotics
Can be more severe in children/ adolescents than
adults and include:
• Dystonias/ EPSE/TD
• Increased appetite and weight gain
• Type II diabetes & lipid changes
• Blood dyscrasias (neutropenia/ agranulocytosis)
• Cardiac arrhythmias, inc. QTc interval
• elevated prolactin -> reduced estrogen, osteoporosis
• Seizures
Side Effect Profiles
EPSE
Wt
gain
increased
Prolactin
Sedation Reduced Seizures
WBC
D2
H1/5ht2a
Haloperidol +++
5HT2 /D2
C/H1
+
++
-
-
-
Risperidone ++
++
++ +
+
-
-
Olanzepine +
++ +
+
++
-
-
Quetiapine -
+
-
++
-
-
Clozapine -
++
-
+++
1-3%
++
EPSE BY AGE
Weight Gain in Adolescents
Olanzepine vs. Risperidone vs. Haloperidol
Mean age 17 years
mean dosage:
Olanzepine 12.7mg.
Risperidone 3.2mg.
Haloperidol 7.6mg
Drug Initiation
• Start Low, Go Slow
– Risperidone 0.5mgs
– Olanzapine 2.5mgs nocte
– Clozapine 12.5mgs [50mgs/2days]
• Increase every 3 to 5 days
• Most side-effects occur early (first 4-6 weeks)
• Add benzodiazepine (e.g lorazepam 1-2 mg,
•
diazepam 2-5mgs, Clonazepam 0.5-2mgs) for
arousal/ agitation
Severe violence/agitation may need RT protocol
Atypicals: Target Dose Ranges
• Risperidone
• Olanzepine
• Quetiapine
• Amisulpiride
• Clozapine
mgs
2-6
2.5-20
150-600/750 b.d.
400-1200
300-600
Clozapine plasma level >350ng/ml
(0.35mg/L))
Switch to Clozapine
•
•
•
•
Review diagnosis and treatment compliance
Consider lithium if marked affective component
Consider Shot antipsychotic if compliance poor
Switch to clozapine: titrate to optimal dose.
• Control for plasma levels and side effects, Continue for 3 – 6 months
not effective or not tolerated
If Clozapine does not work
• Review diagnosis and treatment compliance;
withdraw all ineffective medication; give
previous most effective drug lowest effective
dose;
or
• Consider another atypical or depot antipsychotic;
• re-consider cognitive behavioural intervention
summary
• Schizophrenia in children and adolescents
•
•
•
requires early detection and intervention.
atypicals are first line Tx
side Effect profiles mainly determine choice
share information and decisions with patient and
family
• interpretation of [NICE] time scales is not clear for >18
• is early use of Clozapine justified?
Depression (1975),
Marion Patrick
(1940-1993)
‘A child endures or enjoys overwhelming
misery or overwhelming happiness
because he isolates the moment and
does not connect it with the future or the
past. In my work I try to convey this
isolation’.
Antidepressants for <l8’s
Position up to June 2003
• TCA’s: in RCT’s, lack efficacy; risky side-effects,
•
e.g. cardiac
MAOI’s: no RCTs; high toxicity
• SSRIs: Until 2003, considered relatively safe;
– Fluoxetine and Paroxetine efficacious in RCT’s;
many open label trials; ‘TREATMENT OF
CHOICE’
– Nefazodone (NASSA), Venlafaxine (SNRI),
some studies (inconclusive)
Antidepressants in ~18’s – current
position :Jan. 2004
Licensed use
• US: Fluoxetine for OCD [>7yrs+ ] and depression
[>8yrs]
• Sertraline for OCD [>6yrs)
• Paroxetine and Venlafaxine contraindicated: new data
•
•
show unfavourable balance of risks [esp. re suicidality]
vs benefits.
Fluvoxamine may be used for OCD
Expert Working Group Looking urgently at wider safety
issues re SSRl’s in paediatric population
CBT for depressed children and
adolescents – does it work?
• NOT for severely depressed adolescents
[Harrington 1998]
• Treatment of choice for mild/moderate
depression, high rates of recurrence.
•IPT - promising, only one
RCT
Prognosis – the transition to
adulthood
• Most will recover from their depressive Episode
• However, high rate of recurrence Predicted by
•
•
•
severe presentation and Absence of conduct
disorder
Rapid cycling mood overlaps with Emotionally
Unstabel PD
Dysthymia often confused with depressive
Episodes
Small number develop Bipolar Disorder Small
number go on to kill themselves