Transcript Psychiatric illnesses in Children and Adolescents: types and treatment

Psychiatric illnesses in Children and
Adolescents:
types and treatment
Lee W. Bradshaw
APRN-BC
McKay-Dee Behavioral
Health Institute.
Types of illnesses:
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Depression
Bipolar disorder
Anxiety disorders
ADHD
Nature vs. Nurture
(physical vs. psychological)
PHYSICAL
 Genetics: in the family
 Brain chemistry
-autopsy studies
-medications work
 Brain structure
-hippocampus
-trauma changes you
PSYCHOLOGICAL
 Family problems are
passed on
 Relationships
 Job
 School
 Legal
Depression
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Major Depression has 5 of the 9 sx for at
least two weeks
Dysthymia has 3 of 5 sx for more days than
not, for two years (one year for kids), will not
go for more than 2 months without having at
least two sx
Depressive disorder NOS
Neuro-vegetative symptoms of
depression
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Concentration: impaired, decrease in functioning
Appetite and sleep: increased or decreased
Energy: decreased energy, tired, sluggish
Depressed mood: for most of the day every day
(teens often display irritability vs. sadness)
Interest: loss of ability to enjoy pleasurable things
Isolation and withdrawal:
Guilt and worthlessness: excessive (5 minute)
Psychomotor agitation or retardation
Thoughts of death: may or may not include suicide
Treating Depression: Characteristics
of anti-depressants
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Improve symptoms of depression and
anxiety
Not addictive, but not good to stop suddenly
May take weeks to fully work
Side effects usually mild, early and transitory
May cause agitation or suicidality, if bipolar
Usually safe in overdose: except MAOIs
Wellbutrin/buprorion, or Effexor, Tricyclics
Types of Anti-depressants
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SSRIs:
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Prozac/fluoxetine
Paxil/paroxetine
Zoloft/sertraline
Celexa/citalopram or Lexapro/escitalopram
Luvox/fluvoxamine
SNRIs:
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Effexor/venlafaxine
Cymbalta/duloxetine
Other Anti-depressants
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Remeron/mirtazepine
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Serzone/nefazodone
Wellbutrin/buproprion
Tricyclics, Tetracyclics and other old ones:
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Elavil (amitriptyline)
Pamelor (nortriptyline)
Tofranil (imipramine)
Desyrel (trazodone)
Anafranil (clomipramine)
Bipolar Disorder
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Bipolar I
Bipolar II
Cyclothymia
Different with children/adolescents, difficult to
diagnose. More important to recognize what
the diagnosis means in terms of treatment
and management.
Bipolar I and II
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Mania or hypomania:
Elevated, expansive or irritable mood for one week for
mania, 4 days for hypomania
– Includes three of the following (four if irritable)
Pressured/excessive talking
Less need for sleep
Flight of ideas or thoughts racing
Distractibility
Increase in goal-directed activity
Grandiosity
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Excessive interest in pleasurable activities: shopping, sex,
drugs, investments, that have a high risk
Bipolar I vs. II
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Mania with type I, may have depressive
episodes, or mixed episodes: more likely to
result in psychotic symptoms: paranoia,
hallucinations, delusions, disorganized
thinking
Hypomania alternating with depressive
episodes with type II, less likely to be as
severe: become psychotic
How are kids different?
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No cadillacs and presidents
Hypersexuality
Grandiosity
More unstable with an anti-depressant?
Exacerbated by stimulants
Treating Bipolar Disorder
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Lithium, Anti-epileptics, Atypical
Antipsychotics
Stabilizing has priority
Is primary focus of treatment high or low
Anti-depressants may always cause
instability
By nature more difficult to treat
More difficult to diagnose in younger patients
Lithium carbonate
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Oldest: 1949
Lowest suicide rate of all psychiatric meds
Anti-manic, mood stabilizer, helps agitation
As a salt, competes with sodium and wins: over
hydration or dehydration causes toxicity
Change in renal function can change plasma levels:
NSAIDS, diuretics, steroids
Narrow therapeutic window: 0.6-1.0, toxicity above
1.5, moderate 2-3, severe 3.0, multi-organ failure
above 4.0 (dangerous in overdose)
Steady-state plasma levels in about 5 days, draw lab
10-12 hours after last dose (trough vs. peak)
Anti-epileptics
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Depakote/divalproate sodium (valproic acid)
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Indicated for seizures, headache, mania
Limited potential for liver toxicity
Weight gain, hair loss, GI distress
Therapeutic range: 50-125
Tegretol/carbamazine
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Seizures, mania
Greater potential for liver toxicity, small percentage have
necrotic liver
GI distress, excess gum growth
Therapeutic range 4-12
More anti-epileptics
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Topamax/topiramate and
Neurontin/gabapentin
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Adjunct anti-seizure
No liver metabolism, toxicity, drug interactions
Topamax is good for headaches, weight loss, but
start slowly, rare acute angle glaucoma
Neurontin can help chronic neuropathic pain, help
with anxiety and sleep, completely non-toxic:
8,000 mg/kg
Characteristics of anti-epileptics
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Metabolized vs. excreted
Toxicity and liver failure possible, but unlikely
Can cause sedation, weight gain, GI upset
May cause depression
Anti-manic, mood stabilizer, decrease
agitation
Watch for drug-drug interactions
Atypical Anti-psychotics
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Seroquel/quietapine
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Risperdal/risperidone
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Sedation, minimal dystonia, moderate wgt gain,
fair anti-psychotic
More dystonia, moderate wgt gain, prolactin, good
anti-psychotic
Zyprexa/olanzapine
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Little dystonia, sig. wgt gain, good anti-psychotic
Atypical Anti-psychotics
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Abilify/aripipazole
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Geodon/ziprazodone
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Moderate dystonia, usually less wgt gain, good
anti-psychotic
Sedation, moderate dystonia, very rare wgt gain,
all or nothing: dose and effectiveness and
tolerability
Invega/paliperidone
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Similar to Risperdal, but usually less
Warnings about anti-psychotics
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Metabolic syndrome: DM, lipids
Parkinsonian symptoms: EPS
Tardive Dyskinisia
Neuroleptic Malignant Syndrome
Attention Deficit Hyperactive Disorder
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Lifelong, no “late onset”, noticed in
kindergarten
Not ADD anymore
Predominately inattentive, hyperactive or
combined
Paradoxical response to stimulants
Can have a mood or anxiety disorder also
Younger kids dx with ADHD, but don’t have it
Inattention
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Forgetful
Loses things
Procrastinates (not defiant)
Easily distracted
Does not listen even when spoken to directly
avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
difficulty organizing tasks and activities
fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
Can’t sustain attention in tasks or play activities
Hyperactivity
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Fidgets with hands or feet or squirms in seat
Can’t stay in seat
Runs about or climbs excessively
Can’t be quiet
"on the go" or often acts as if "driven by a
motor"
talks excessively
Impulsivity
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blurts out answers before questions have
been completed
difficulty awaiting turn
interrupts or intrudes on others (eg, butts into
conversations or games)
Other necessary conditions
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symptoms that caused impairment were
present before 7 years of age.
impairment from the symptoms is present in
2 or more settings
clinically significant impairment in social,
academic, or occupational functioning
Treating ADHD
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Stimulants:
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Methyphenidates
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Dextroamphetamines
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Single vs dual isomers
single isomer
Pro-drugs
Multi-isomers, mixed salts
Stattera/atomoxatine
Wellbutrin/buproprion
Methyphenidate
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Ritalin, Ritalin SR, Ritalin LA
Metadate
Concerta
Focalin
Daytrana (patch)
Dextroamphetamines
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Dexedrine, spansules, dextrostat
Adderall (4 isomers)
Vyvanse
Other:
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Strattera:
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norepinephrine re-uptake inhibitor
may treat depressive symptoms also
longer acting: half-life, onset and attenuation
may be most agitating if Bipolar
Wellbutrin:
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inhibits dopamine and norephinephrine re-uptake
no good data re: effectiveness
Very good at treating depression
Anxiety Disorders
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PTSD (Post Traumatic Stress Disorder)
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Has been exposed to a traumatic event where there was an actual
or threatened death or serious injury
The person experienced a feeling of horror, helplessness or
intense fear.
The event is re-experienced in one of the following ways
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Recurrent and intrusive distressing recollections
Recurrent distressing dreams of the event
Acting or feeling as if the event were re-occurring
Intense stress when there are internal or external cues that symbolize
or represent the event
Physical reaction when these cues occur.
Other Anxiety disorders
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Panic disorder, an anxiety disorder with episodes of
panic attacks: periods of intense fear that last 10
minutes, or longer, usually brief and very intense,
with four of the following:
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Palpitations and/or tachycardia
Sweating, trembling or shaking
SOB or a feeling of smothering, or of choking
Cx pain or discomfort, nausea or GI distress
Feeling of dizziness, faint or lightheadedness
Feeling of derealization
Fear of losing control or going crazy, or dying
Numbness or tingling, hot flashes or chills
Another Anxiety disorder
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Acute Stress disorder: similar to PTSD, where there
is a traumatic event with actual or threatened loss of
life, with the sense of helplessness, horror or intense
fear.
Instead of re-experiencing the event there are three
of the following dissociative symptoms:
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Feeling numb, detached, emotionally unresponsive
Reduction of awareness of surrounding, being “in a daze”
Derealization
Depersonalization
Dissociative amnesia
Lasts less than 30 days, if more than 30 = PTSD
Generalized Anxiety Disorder
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6 months of "excessive anxiety and worry" about a variety of
events and situations.
significant difficulty controlling the anxiety and worry
clinically significant distress or problems functioning in daily life.
most days over the last six months of 3 or more (only 1 for
children) of the following symptoms:
1. Feeling wound-up, tense, or restless
2. Easily becoming fatigued or worn-out
3. Concentration problems
4. Irritability
5. Significant tension in muscles
6. Difficulty with sleep
Treating anxiety disorders
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Treatment of choice: Anti-depressants, usually SSRIs
Benzodiazepines
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Short-acting
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Long-acting
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Xanax/alprazolam
Ativan/lorazepam
Klonopin/clonazepam
Valium/diazepam
Non-addictive
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Vistaril/hydroxyzine
Neurontin/gabapentin
Buspar/buspirone
Anti-hypertensives: Inderal/propanolol, Catapres/clonidine,
Tenex/guanfacine
Characteristics of benzodiazepines
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Benzodiazepines (xanax, ativan, valium, klonopin)
are addictive
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cannot stop suddenly if taken long enough
highly likely to be abused with persons with a hx of
substance abuse
Fairly safe in overdose
Very effective, very quickly.
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Provides more immediate relief
If not backed up by anti-depressants, will habituate,
symptoms will return
Rebound anxiety