PHM 456H Introduction to Pediatric Pharmacy Practice 2004 Drug Related Issues in Pediatric Psychiatry

1. PHM 456HIntroduction to Pediatric Pharmacy Practice 2004Drug Related Issues in Pediatric Psychiatry Claire De Souza BSc MD FRCP(C) November 4th 2004

2. Audience Survey: Experience with pediatric psychiatry: medications? patients?

3. Learning Objectives At the end of this presentation, the student will: • be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involved • have a greater understanding of • pediatric depression • ADHD • any others?

4. Outline • Starting Principles • Spectrum of Psychiatric Disorders in the Pediatric Population • Review of Pediatric Depression • Review of ADHD

5. Principles • accurate diagnosis • biological, psychological, social contributors • informs a comprehensive management plan • biological, psychological, social interventions • medications used depending on diagnosis, symptoms, and severity • antidepressants - SSRIs • anti-anxiety - benzodiazepines • anti-psychotics – atypical • start low, go slow

6. Spectrum of Psychiatric Disorders • Mood Disorders • Anxiety Disorders • Psychotic Disorders • Substance Use Disorders • Personality Disorders • Disruptive Behavioural Disorders • Elimination Disorders • Eating Disorders • Tic Disorders • Somatoform Disorders • etc. Reference: DSM-IV

7. Depression

8. Depression • 2% children, 4-8% teens (: ♂ = 2:1) • suicide attempt - 9% of teens • symptoms for 2 weeks: • mood – “bored”, irritable • cognitive – SI, guilt, worthlessness, concentration • physical - change in sleep↑, appetite↑, energy, psychomotor • interpersonal – change in interest level • change in functioning (social, academic) / xs distress • other features: • anxiety - phobias, separation anxiety • behaviour - tantrums, oppositional, aggression • somatic complaints • psychosis – auditory hallucinations • range in severity

9. Depression continued … • contributing factors (B/P/S) • biological – ie genetics, history of depression • psychological – ie loss, trauma, separation • social – ie interpersonal, SES, academic • comorbidity: anxiety, substance use, behaviour, etc • prognosis: recurrence • 20-60 % recurrence in 2 yrs; 70% within 5 yrs • episodes become more frequent, more severe, last longer • 20-40%  bipolar disorder within 5 years

10. Depression continued … Assessment • interview with family • interview with child/teen • interview with parents • collaterol information from school etc as required

11. Depression continued … Differential Diagnosis – extensive • Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, General Medical Condition (thyroid, anemia, mono etc), Bereavement etc.

12. Depression continued … Management (B / P / S): • Psychoeducation • Medications • Therapy – individual (CBT, IPT), family • School Intervention • Resources / References • websites: http://www.mooddisorders.on.ca/mdao.asp • http://www.aacap.org/ (Facts for Families)

13. Depression continued … Medications • duration: 9 months or more • 1st line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label • start low, go slow; increase as tolerated & as required • Controversy • Efficacy – limited evidence - Prozac • Safety – Health Canada warning  MD to monitor: SI, disinhibition, agitation, akathisia • off-label use based on limited studies, experience, adult studies • drug interactions – cytP450 • Medications added as required (Sx, Rx resistance): • ie BZDs, atypical antipsychotics

14. Depression continued … Red Flags • requesting script renewals • appearing dysphoric, suicidal, hypomanic, psychotic • non-compliance: withdrawal, worsening symptoms • stockpiling medications, buying ++OTCs • medical problems – cytP450 drug interactions

15. Depression continued … Approach • review Health Canada warning • discuss need for monitoring by MD • advise them not to stop medication suddenly • questions / concerns  MD • advise them about what to look for: • ie. restlessness, disinhibition, aggression, anxiety, worsened depression • direct them to resources • if concerned about patient’s safety – refer to ER Reference: FDA website, Health Canada, NIMH websites

16. Attention Deficit Hyperactivity Disorder

17. ADHD • 5-9 % of children; ♂: = 4:1 (NB:under-Dx) • symptoms – 2+ settings, onset < age 7 • inattention – careless mistakes, can’t sustain attn, distractible, forgetful, disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids time/effort-consuming tasks • hyperactivity – fidgets, leaves seat, ↑ runs/climbs, on the “go”, xs talking, can’t play quietly • impulsivity- blurts out, interrupts, problems waiting turn • interferes with functioning: academic, family, social • diagnosis • subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined reference: DSM-IV

18. ADHD continued • etiology - DA mediated; problems with inhibitory & executive control • factors: • biological – FHx, difficult temperament • psychological - self-esteem • social - interpersonal, academic, poor social skills • comorbidity • learning disorders (in 40% with ADHD), behavioural problems (ODD, CD), substance abuse, depression, anxiety • prognosis • 65%  adulthood

19. ADHD continued Assessment: • Interview with • family • child / teen • parents • Questionnaires • ie Connors Rating Scale – parent / teacher form • Information from school • Psychoeducational testing

20. ADHD continued Differential Diagnosis – extensive • Learning disorder • General Medical Condition (hearing, vision, thyroid, congenital, genetic, lead poisoning, head injury etc) • Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, etc.

21. ADHD continued Management (B / P / S): • Psychoeducation • Medications • Social skills training • Parent management • (+) reinforcement, structure • School Intervention • classroom modifications, individual education plan (IEP) • Resources / References • websites: www.adrn.org • http://www.aacap.org/ (Facts for Families)

22. ADHD continued Medications • stimulants - 1st line • short acting – Ritalin, Dexedrine • long acting – ie Concerta, Dexedrine SR • Blinded placebo / stimulant trials • to determine dose, acceptability • coordinated with objective scale – ie Connors Rating Scale • restricted use – limited scripts • abuse potential • other medications for co-morbidity – ie depression, anxiety, tics • Use – for school day primarily; also, during weekend & summer if problems (social, academic) off meds

23. ADHD continued Red Flags • requesting script renewals • non-compliance • substance abuse • stockpiling medications • medical problems - epilepsy

24. ADHD continued Approach • controversy • “over-diagnosed” • concerns about long-term side effects • problems if no treatment • academic, social, family • comorbidity • advise them to direct their questions / concerns  MD

25. Questions / Cases