Mood Disorders in Adolescence: An Integrative Approach Session #: A2021 10/12/08

1. Mood Disorders in Adolescence: An Integrative Approach Session #: A2021 10/12/08 Kathi J. Kemper, MD, FAAP Caryl J Guth Chair for Holistic and Integrative Medicine Author, The Holistic Pediatrician Wake Forest University School of Medicine Winston-Salem, NC

2. Faculty Disclosure In the past 12 months, I have had no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.

3. Objectives (by the end of this session, you will be able to…): • Define the role of patient-centered communication for mood disorders • Describe the importance of a healthy lifestyle and the safety and effectiveness of dietary supplements in promoting healthy moods. • Refer patients to evidence-based resources for additional information about lifestyle and complementary therapies to promote mental health

4. Depression Case A 17 year old girl who is sad, has had a drop in grades, recently broke up with her abusive boyfriend; less interested in participating in band, has stopped taking her SSRI after hearing about black box warnings. Her only medications are oral contraceptives. Will St. Johns wort help (the news reports are very confusing)? How do you advise her?

5. 10 Answer Now Which of the following is the best answer about SJW? • SJW has proven useless against depression. • SJW is completely safe. She can use any off the shelf brand to help. • She will need to use back up birth control method if she starts SJW. • Based on RCTs, there’s a greater than 80% chance her symptoms will respond to SJW.

6. Are mood disorders are real problem in adolescents? YES • American children have the most psychiatric illness in the civilized world (WHO data) • Childhood depression: epidemic in USA 2001/02 HBSC International Report: Young People's Health in Context
Currie C. et al (eds.) 2004. Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series Blader, J and Carlson, G Biol Psychiatry: 2007: Feb 15 Moreno, C et al Archives of General Psychiatry, 64:1032-8 2007: September

7. Definitions: Mental Health • Most medical literature on mental health focuses on mental illness, eg. Depression, anxiety, Bipolar, schizophrenia, ADHD, cognition/memory problems, adjustment disorders, personality disorders, etc. • Mental health "First say to yourself what you would be; and then do what you have to do." Epitectus “You got to be careful if you don't know where you're going, because you might not get there.” Yogi Berra

8. Optimal Physical health: Example • Strength • Flexibility • Stamina/Endurance • Focus • Coordination • Resilience, and • Effective teamwork

9. Optimal Spiritual Health • Faith • Forgiveness • Hope • Love • Kindness • Charity/generosity, and • Transcendence – connection with something greater than our individual self

10. Mental Health: elements • Confidence and courage • Adaptability • Cheerfulness • Attention / Concentration • Harmony • Hardiness in face of stress • Social Network/ communication skills/ connection to community

11. Mental Health - strategies • Healthy lifestyle – as for promoting heart health, reproductive health, immune function, etc. • #1 Lifestyle: Exercise/Rest, Nutrition, Environment(+/-), Stress management practices (EMS), Communication and community • #2: Supplements/Meds, Professionals (psychologists, massage, acupuncture, etc)

12. Management Issues • Process (communication skills) • Content (focus on healthy lifestyle; if it’s good for the heart, it’s probably good for mood) • Speed (baby steps) • Resources

13. 10 Answer Now Which of the following is true about patient-centered communication? • PCC can significantly improve mental health outcomes • PCC has mild impact on mental health visits, though it is helpful for general primary care • PCC has no impact on mental health outcomes • What is PCC?

14. Process: Communication Skills • Standard approach • Patient-centered care • Health promotion focus

15. Standard approach • Diagnose • Provide diagnosis-specific treatment yourself • Persuade parent / child to accept referral • Challenges • Making a diagnosis; what if they don’t meet criteria? • Mastering medications • Referral resistance; waiting; unavailability • Promoting mental health during well child care (preventing illness) Wissow and Gadomski, 2008

16. Parental expectations Don’t believe they are effective change agents Have prior beliefs about what will help Not sure pediatric visit the place to discuss this Want help but afraid of what you might say Want empathy but expect child is the agenda Wissow and Gadomski, 2008

17. Adolescent Expectations • Here to be “fixed” or punished • Not used to having a substantive role in visit • Uncertain about confidentiality • Different agenda than parent • Incomplete and stigmatizing views of “mental health” Wissow and Gadomski, 2008

18. Physician Expectations • Will be presented with insoluble problems • “Double drowning” – everyone will leave more hopeless and/or angry than they started • Will lose control of time • Won’t be able to be proactive as with other health problems Wissow and Gadomski, 2008

19. Evidence-based skills Agenda setting • Engaging both child and parent • Prioritizing specific concerns; goals; define success Problem formulation and solving • Finding reasons to hope and first steps to solutions • Framework: health promotion and stress management Time management • Managing rambling and interruptions Promoting hope and confidence Advice giving • Avoiding and managing resistance Pediatrics 2008 Feb;121:266-75.

20. Finding a common agenda • Commitment to eliciting it from both parent and child/youth • Setting up and “enforcing” turn-taking • Respecting confidentiality • Encouraging and modeling the ability to talk in front of each other

21. Crude 6-month change in child clinical measures as a function of change in provider’s patient-centeredness Change in SDQ symptom score Change in SDQ impact score p<.0001 adjusted for baseline symptoms p=.015 adjusted for baseline function

22. 10 Answer Now Which of the following is true about patient-centered communication? • PCC can significantly improve mental health outcomes • PCC has mild impact on mental health visits, though it is helpful for general primary care • PCC has no impact on mental health outcomes • What is PCC?

23. Content: Conventional • Psychotherapy • Medications

24. Cognitive Behavioral Therapy “From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents.” Compton SN. JAm Acad Child Adolesc Psychiatry. 2004

25. Conventional Treatment: Rx • TCAs - no evidence of efficacy in pre-pubertal children • SSRIs - no overall evidence of efficacy in pre-pubertal children • SSRIs marginally better than placebo in teens with MDD • SSRIs are HELPFUL in OCD and anxiety disorders, even in pre-pubertal children Safer DJ. Pediatrics, 2006; 118 (3): 1248

26. FDA approved SSRIs for pediatric MDD • As of 2004, “the FDA has approved only Prozac for use in children/adolescents with MDD” • Prozac, Zoloft and Luvox have been FDA approved for use in children diagnosed with OCD FDA 3/24/04; http://energycommerce.house.gov/108/Letters/03242004_1242print.htm

27. SSRI Side effects 1 • GI upset • Headache; sleep disorders • Sexual side effects Dizziness, Fatigue, Sweating • Neonatal withdrawal syndrome • Drug interactions

28. SSRI Side effects 2 • Serotonergic syndrome (HTN, tachycardia, mania) • Agitation and hostility • Suicidal ideation, esp in those with agitation/hostility • Review of 22 RCT pediatric with 9 antidepressant drugs. • 2298 patients with active drug; 1952 with placebo • Serious suicidal adverse events: 78/2298 versus 54/1952 Incidence rate ratio 1.89 (95% CI, 1.18-3.04) Mosholder AD. J Child Adolesc Psychopharmacol. 2006

29. Psychiatric Meds in kids • Little science of long term safety • 1.6 million kids on 2 or more meds: no science • Neurological and hormonal impact mostly unknown

30. Content: natural therapies • Depression is one of the top 10 diagnoses for which patients seek natural therapies • Commonly used among depressed adolescents • Fewer than 30% of depressed teens tell docs they are using natural therapies • Clinicians need to ask!

31. 10 Answer Now Which of the following is true about Lifestyle approaches to mood problems? • Lifestyle affects cardiac health, but has little impact on mental health • Lifestyle affects cancer risk, but has little impact on mental health • Lifestyle affects BOTH cardiac and cancer risks, but has little impact on MH • Lifestyle, such as light, sleep, exercise and nutrition can have profound and clinically significant effects on mental as well as physical health.

32. Integrative Approach • Lifestyle – Environment, Exercise/Sleep, Nutrition, Mind-Body • Supplements • Massage • Acupuncture

33. Lifestyle - overview • Environment: More Sunshine and good music, Less TV and toxins • Exercise/Sleep • Nutrition (Essential nutrients for optimal brain function, EFA, amino acids, vitamins, minerals) • Mind-Body Therapies – manage stress • Meditation • Biofeedback

34. Sunshine, circadian rhythms and sleep Desynchronization of internal rhythms plays an important role in the pathophysiology of depression. Resetting normal circadian rhythms can have antidepressant effects. “Winter depression was first modeled on regulation of animal behavior by seasonal changes in day length, and led to application of light as the first successful chronobiological treatment in psychiatry.” Fuchs E. Int Clin Psychopharmacol, 2006 Wirz-Justice A. Int Clin Psychopharmacol. 2006

35. You are My Sunshine! • SAD - Known association between inadequate sunshine and depression • Frequent indoor tanners are often depressed and seeking relief; watch for rebound depression if they stop • How much? 10 – 15 minute daily of exposure to hands and face in spring, summer fall; wintertime? Latitude?

36. Light Therapy for Depression Plus 3 studies not included in this review, comparing dim light to bright light. Golden R. Am J Psychiatry. 2005

37. Vitamin D and depression • Vitamin D receptors in brain • Low level of serum 25-hydroxyvitamin D and high PTH are significantly associated with depression (Jorde, 2005) • 25-hydroxyvitamin D3 and 1,25-dihydroxvitamin D3 levels are significantly lower in psychiatric patients than in normal controls (Schneider, 2000) • RCT of 44 Australian patients (none, 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998)

38. Light therapy • Proven effective for SAD (Terman M Evid Based Ment Health, 2006) • Meta-analysis of studies from 1987-2001: (effect size=0.53, 95% CI=0.18 to 0.89, similar to medications) for non-SAD • RCT of 29 women with non-seasonal depression; light therapy for 28 days significantly better than control, (McEnany GW, 2005)

39. Light Therapy 2 • Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter • Side effects: hypomania, autonomic hyperactivation (Terman M, 2005)

40. Lifestyle 2: Exercise • Depressed mood / fatigue are common in those deprived of usual exercise. • Mood changes noted in patients with injuries and mono. • Changes over time in kids’ exercise/gym/playground time • Exercise benefits depression * • Common sense precautions Berlin AA. Psychosomatic Med, 2006

41. Exercise as Therapy – Yes Lawlor DA. BMJ 2001

42. Yoga for depression • Five RCTs --each used different forms of yoga. • All trials reported positive findings • No adverse effects except fatigue and breathlessness Pilkington K. J Affective Disord, 2005

43. Lifestyle 3: Sleep • Poor sleep is barometer of later mental health risks (anxiety and depression) • Reduced sleep equals impaired focus and labile mood (ADHD, Learning problems) • Sleep quality is a good screen for good mental health in pediatric population • We sleep 20% less than we did 100 yrs ago

44. Lifestyle 3: Sleep • Regular time; Routine • Hot bath; cool room; dark room • Massage before bed • Lavender, chamomile, melatonin? • No caffeine within 8 hours of bedtime • Music, calm, orderly, quiet • NO TV IN BEDROOM • NO vigorous exercise right before bed • GET MORE versus intentional sleep reduction/deprivation (in those with excessive sleep)

45. 4: Nutrition – essential nutrients for optimal brain function • Omega-3 fatty acids • Amino acids (SAM-E, Trp, 5-HTP) • Vitamins (B vitamins, Vitamin D) • Minerals (Iron, Calcium, Magnesium, Zinc)

46. Omega-6 Fatty Acids Omega-3 Fatty Acids Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3) ∆-6 Desaturase (GLA)γ -Linolenic Acid (18:3n-6) Stearidonic Acid (18:4n-3) Elongase (DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6) Eicosatetraenoic Acid (20:4n-3) ∆-5 Desaturase Eicosanoids (AA)Arachidonic Acid (20:4n-6) (EPA) Eicosapentaenoic Acid (20:5n-3) Elongase 24:5n-3 Eicosanoids Leukotriene 5-series Prostaglandins E3 Thromboxanes A3 ∆-6 Desaturase Eicosanoids Leukotriene 4-series Prostaglandins E2 Thromboxanes A2 24:6n-3 β-Oxidation (DHA) Docosahexaenoic Acid (22:6n-3)

47. Omega 3 EFA’s: mechanism • Neuronal membrane structure and function • Brain development • Second messenger inside cells

48. Mood and Omega-3’s • Inverse correlation between fish intake and depression (Hibbeln: Lancet 1998; 351:1213) • Effective for bipolar patients (Stoll: Arch. of Gen. Psych. 1999; 56: 407-12) • Effective for major depression (Nemets: Am. J. Psych. 2002: 159 (3) 477-9) • Effective for depression in Children ( Am J Psychiatry 2006;163:1098-0) • Effective for Borderline P.D.O. (Am. J. Psych. 2003, 160 (1): 167-9)

49. Fish Oil –Doses, Safety, Brands • Dose: 1 gram daily of EPA probably enough.(Peet M, 2002); Frangou S. Br J Psychiatry, 2006) • Safety: fish allergies, taste, belching; very high doses, increased risk of bleeding, nosebleeds? Little risk of mercury, dioxin, PCB’s; • Brands: Compare brands at www.consumerlabs.com • My family takes Coromega, Carlson’s or Nordic Natural • Read labels: Omega 3 does NOT necessarily all equal EPA/DHA

50. Amino Acids: SAM-E • Produced from ATP and methionine • Low folate can lead to low levels • Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm) • In an open trial of 30 adults with MDD for whom antidepressant meds ineffective, SAM-E led to significant improvements in 50% and remission in 43% (Alpert, 2004) • All tested products approved by ConsumerLab; buy on sale!