Psychiatric and Addiction Pharmacotherapy for Youth

1. Psychiatric and Addiction Pharmacotherapy for Youth June 20th, 2009 Sparks, Nevada Geetha Subramaniam, M.D. Assistant Professor of Psychiatry Johns Hopkins University Baltimore, Maryland

2. Psychiatric Medications

3. Psychiatric Disorders in Adolescents • Mood Disorders • Major Depressive Disorder, Bipolar Disorder • Anxiety Disorders • Generalized Anxiety Disorder , Obsessive-Compulsive Disorder , Social Phobia, Panic Disorder, Post-traumatic Stress Disorder • Disruptive Behavior Disorders • Attention-Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Conduct Disorder • Psychotic Disorders • Schizophrenia, Schizoaffective Disorder

4. DSM-IV Axis-I Current Psychiatric Disorders n=149 Results based on The Diagnostic interview for children and adolescents (DICA) – Subramaniam et al., 2009

5. Proportion Currently Prescribed Any Psychotropic Medications By Psychiatric Disorders Results based on The Diagnostic interview for children and adolescents (DICA)

6. Prevalence of Substance, Internalizing and Externalizing Disorders by Age Source: Chan, Dennis & Funk in press

7. Major Depressive Disorder • Antidepressants • SSRIs: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro), Paroxetine (Paxil), Fluvoxamine (Luvox), Duloxetine (Cymbalta), • SNRIs: Venlafaxine (Effexor), desvenlafaxine (Pristiq) • Other: Bupropion (Wellbutrin), Mirtazapine (Remeron), Tricyclic antidepressants, Aripiprazole (Abilify) • FDA Approved in Adolescents • Fluoxetine • Escitalopram

8. Changes: Clinical Global Impression Improvement (CGI-I) rating (A), Childhood Depression Rating Scale-Revised (CDRS-R) t scores (B), number of days of substance use in the past 30 days (C), and number of conduct disorder symptoms in the past 30 days (D) Riggs, P. D. et al. Arch Pediatr Adolesc Med 2007;161:1026-1034.

9. Bipolar Disorder • Mood Stabilizers (anticonvulsants) • Lithium, Divalproex (Depakote), Carbamazepine (Tegretol), Lamotrigine (Lamictal), Neurontin, Oxcarbazepine (Trileptal), Topiramate (Topomax) • Antipsychotics • Risperidone (Risperdal), Aripiprazole (Abilify), Ziprasidone (Geodon), Quetiapine (Seroquel), Olanzapine (Zyprexa) • FDA Approved in Adolescents • Lithium (“grandfathered in” for Bipolar Disorder) • Risperidone • Aripiprazole

10. Anxiety Disorders (OCD, GAD, PTSD, Panic Disorder, Social Anxiety Disorder) • SSRIs: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), and Fluvoxamine (Luvox) • Benzodiazepines: Clonazepam (Klonopin), Lorazepam (Ativan), and Alprazolam (Xanax) • Other: Venlafaxine (Effexor), Buspirone (Buspar) • FDA Approved in Adolescents for OCD only • Sertraline • Fluvoxamine • Clomipramine

11. ADHD • Stimulants (short and long-acting preparations) • Methylphenidate preparations: Methylphenidate (Concerta, Metadate CD, Ritalin LA, Ritalin SR, Ritalin); Dexmethylphenidate (Focalin XR, Focalin) • Amphetamine preparations: Mixed Amphetamine salts (Adderall XR, Adderall), dextroamphetamine (Dexedrine, Dexedrine Spansules) ; Lisdexamfetamine (Vyvanse) • Non-stimulants • Atomoxetine (Strattera) • Buproprion (Wellbutrin) • All stimulants and atomoxetine - FDA Approved in Adolescents

12. Schizophrenia • Antipsychotics • Newer Antipsychotics: Risperidone (Risperdal), Aripiprazole (Abilify), Ziprasidone (Geodon), Quetiapine (Seroquel), Olanzapine (Zyprexa) • Typical (older) antispychotics: haloperidol, chlorpromazine, pimozide, thioridazine • FDA Approved in Adolescents • Risperidone • Aripiprazole • Haloperidol

13. Management of Co-occurring Psychiatric Disorders: Some General Principles • Very little efficacy dataamong adolescents with SUD • Educate and obtain informed consent • Integrateboth treatments (preferred over sequential or concurrent treatment strategies) • Assess for safety: suicide risk, risk of overdose, or activation • Consider abuse potentialof certain medications • Whenever possible combine psychotropic medication treatment with empirically based psychosocial SUD Tx(e.g. MET, CBT, family therapy)

14. Addiction Medications

15. Nicotine Dependence • Nicotine replacement* (patch/gum/spray) • Bupropion* (Zyban) • Varenicline (Chantix) • Alcohol Dependence • Disulfiram (Antabuse) • Naltrexone* (ReVia, Vivitrol) • Acamprosate (Campral) • None are FDA Approved for use in Adolescents

16. Opioid Dependence • Buprenorphine (Suboxone, Subutex) • Methadone • Naltrexone (ReVia, Vivitrol) • Only Buprenorphine is FDA Approved for use in Adolescents (older than 16 years)

17. Controlled Trials with Buprenorphine – Adolescents/ Young Adults • Marsch et al, Arch Gen Psych, 2005 • N=38, ages 15-17yrs. Dose range: 6-8mg. 28-day Bup SL vs. Clonidine 0.1-0.3mg plus CRA and CM for op negative urines. • Results: Greater retention in Bup group (72% vs. 39%) and higher percent of opioid negative urines (64% vs. 32%) • NIDA-CTN Bup Adolescent Study – Woody et al., JAMA, 2008 • Enrolled N=154, age 15-21 yrs. Dose range: 8mg -24mg SL • 12-week Bup/Nal (BUP) vs. 2 weeks of Bup/Nal (Detox) plus twice a week counseling • Results: BUP condition compared to DETOX had fewer opioid-positive urines (p<. 001), better retention (p<. 001), less self-reported opioid use (p< .001), less injecting (p = .02), and received less non-study addiction treatment (p<. 004)