Transcript Wisconsin Alliance of Child Psychiatry and Pediatrics

Wisconsin Alliance of Child
Psychiatry and Pediatrics
Teleconference on Depression in
Children and Adolescents
October 12th 2010
Wisconsin Alliance of Child
Psychiatry and Pediatrics
Psychiatry Course Director:
Joseph O’Grady Jr. M.D. FAAP
Associate Professor of Clinical Psychiatry
Medical College of Wisconsin
Medical Director
Phoenix Care Systems Inc
414-955-8935
WACPP teleconference
Speakers on depression:
Kambiz Pahlavan M.D.
Medical Director
Rogers Memorial Hospital
414-327-3000
Mark Siegel M.D.
Aurora Psychiatric Hospital
414-454-6000
WACPP teleconference
Outline
Didactic presentation on depression
Case studies review – principles of
management
Question and answer session
WACPP teleconference
Teleconference as an educational activity
not as a specific case consultation activity
For a specific case consultation need, I
would refer you to a child and adolescent
psychiatrist for a clinical consultation
WACPP teleconference
Educational goals for this presentation:
Know and apply diagnostic criteria for
depression
Know and apply the indications for
medication treatment of depression
Know and apply indications for referral to a
child and adolescent psychiatrist
Know and apply the indications for
hospitalization for depression
Know and apply medication treatment options and
monitoring for adverse medication effects
Introduction
Depression in children and adolescents
was misunderstood or poorly recognized
and treated until the late 1970s and early
1980s. To some extent we still don’t fully
appreciate this illness.
Depressed children were often labeled poor
little sad thing, spoiled kid, mommy’s boy or
girl, cry baby, kid who can’t be satisfied, bad
parenting, etc.
The misconception was worse with
preschool children.
While we are in better shape today, still we
are far from accuracy.
Current criteria is predominantly adopted
from adult psychiatry research and
consensus.
However, research in children and
adolescents has brought more descriptive
clarity to the adopted symptomatology from
adult psychiatry.
Epidemiology of Major Depression in
Children and Adolescents:
Point prevalence in pre-pubertal children is
1-2%
Point prevalence in adolescents is 3-8%
Lifetime prevalence by the end of
adolescence is about 20%
PM Lewinsohn, et all 1998
EJ Castello, et all 2003
HZ Reinhertz, 1993
Gender distribution of Major Depression with
the onset in puberty shows a 3:1 dominance
by females probably due to:
1)
2)
3)
Increase in estradiol and testosterone
Higher rate of anxiety and tendency for
rumination in females
Increase in interpersonal conflicts in
adolescents
Risk Factors:
1)
2)
3)
4)
Genetic
Cognitive distortions and negative view
of the self, future, and the world
Family/Parental depression, criminality,
substance abuse, lower education, lack
of cohesion, and parent-child discord
Environmental factors like: neglect,
maltreatment, physical and sexual
abuse, association with devious peers…
5)
6)
7)
8)
Bereavement due to the loss of sibling,
parents, friends and other significant
people
Poor connectedness to the family, school,
church, etc
Provocative challenge of noradrenergic
and serotonergic neuro-transmitter
shows differences between depression
prone children and non depressed ones.
Neuroimmaging: reduce volume of left
subgenual prefrontal cortex.
Steingard, et all showed decreased
prefrontal cortex and increased third and
fourth ventricular volume.
McMillan reported increased pituitary and
amygdala hippocompal ratio size
Thomas et all showed decreased amygdala
activation in depressed children
Diagnostic Criteria for Major
Depression:
A.
1)
2)
Five of the following nine symptoms should be
present in the same two weeks, almost all day
and nearly everyday. Symptom one and/or two
has to be present.
Depressed mood by subjective reports or
others observations. In children and
adolescents it can be irritable mood instead of
depressed.
Markedly diminished interest or pleasure in all
or almost all activities.
3)
4)
5)
6)
7)
8)
9)
Significant weight loss/gain without dieting
and/or decreased/increased appetite. In
children consider failure to make expected
weight gains.
Insomnia/hypersomnia
Psychomotor agitation/retardation (observable
by others, not only subjective feeling)
Fatigue or loss of energy
Worthlessness, excessive or inappropriate guilt
Diminished ability to think or concentrate, or
indecisiveness
Recurrent thoughts of death, suicidal ideations
with or without a plan, suicide attempt
B. Symptoms should cause significant
distress or impairment in some important
areas of life.
C. Symptoms are not as a result of a
medical condition (like hypothyroidism) or
alcohol and drug abuse.
D. Symptoms are not better accounted for
by bereavement, unless is longer than 2
months or are characterized by marked
functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic
symptoms or psychomotor retardation.
Indication for Referral to a
Psychiatrist:
1)
2)
Diagnosis is not crystal clear because of co
morbidities, severe parental confusion and
dispute about their symptoms, severe parental
discord, discrepancies between what you see
and what parents and school report, etc
Initial course of 2-4 weeks of conservative
medical treatment doesn’t cause an
appreciable improvement. Placebo effect of
any intervention is 40+%
3)
4)
5)
6)
7)
8)
Patient’s symptoms are getting worse in spite
of adequate treatment.
Initial course of 2-3 months of psychotherapy
hasn’t fostered appreciable stability.
Recurrence of the symptoms in spite of
adequate treatment.
Numbers of people in the family are having
serious psychopathology.
If you are not interested in treating children
with affective instability.
Serious risk of suicide, homicide, and
destruction of property
Indication for Hospitalization
1)
2)
3)
4)
Suicidality
Homicidality
Aggression which is hard to manage at
home, school or on playground, and may
risk the safety of the patient and others,
and the property.
The patient who has been resistive to
adequate treatment and continues to
deteriorate.
Medication Treatment
FDA approved medications for treatment of
children and adolescents with major depression:
Fluoxetine/prozac age 8-18
Escitalopram/lexapro ages 12-17
All others are ‘off-label’ although some have
research evidence to support use
sertraline/zoloft
citalopram/celexa
Medication treatment
High placebo response with antidepressants
med response placebo res
Fluoxetine
56%
35%
Citalopram
47%
45%
Escitalopram
64%
53%
Sertraline
63%
53%
Medication treatment
Treatment of Adolescents with Depression Study (TADS)
Predictive of positive response:
younger age
less chronically depressed
higher functioning
less hopeless
less suicidal ideation
less melancholic symptoms
fewer co-morbid disorders
more expectation for improvement
Medication treatment
Predictors of suicidal events:
higher levels of suicidal ideation at
baseline
minimal improvement of depressive symptoms
at least a moderate degree of depression
acute interpersonal conflict
Medication treatment
Box warning on antidepressants
depression is associated with an increase
in risk of suicide
monitor appropriately and observe
closely for clinical worsening, suicidal
thinking, or unusual changes in
behavior
Medication treatment
Since FDA warnings, antidepressant use has
declined by 10% overall, with decrease
40% by primary care providers
Meta-analysis of 27 med treatment trials of
major depression in pediatric population:
number to treat: 10
number to harm 112
Medication treatment
SSRI dosing:
Fluoxetine
Escitalopram
Citalopram
Sertraline
10-40 mg
10-20 mg
10-60 mg
25-150 mg
Mediation treatment
Common side effects:
nausea
headache
vomiting
dizziness
sedation
decreased appetite
dry mouth
withdrawal effects: nausea, headaches, muscle aches,
parathesias
Medication treatment
Treatment progression:
Start with SSRI
if response continue for 1 year
if no response, switch or augment
Switch
use different SSRI and cross taper doses
use buproprion (Wellbutrin)
use dual acting agent: venlafaxine
(Effexor) or duloxetine (Cymbalta)
Medication treatment
Augment with:
buproprion (Wellbutrin)
buspirone (Buspar)
lithium
thyroid
aripiprazole (Abilify)
Summary slide
Pediatric depression focus
diagnostic criteria reviewed
indications for medication treatment
indications for child and adolescent psychiatrist
referral
indications for hospitalization
medication treatment options
medication adverse effects monitoring
Case reviews
Questions and answer session