10/21/2008

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November 7, 20089:30-10:15 AM

Lexington Downtown Hotel and Convention Center

Lexington, Kentucky

Karen M. Lommel, DO, MHADepartments of Pediatrics and Psychiatry

Director, Pediatric Consultation Liaison ServiceKentucky Children’s Hospital

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Research support from Eli Lilly through the American Academy of Child & Adolescent Psychiatry

This presentation will include “off label” use of medications

Review common psychiatric issues in primary care settingprimary care setting

Discuss “clinical pearls” to address these issues

Compare treatment options and available resources

Descrive psychopharmacology & associated medical issues

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Child Psychiatrist: Physician (MD/DO)C l t d di l h l d id• Completed medical school and residency Triple Board (Pediatrics/Adult Psych/Child

Psychiatry) Child Psychiatry Fellowship (2 years after 3 year

Adult Psychiatry Residency) Psychologist: PhD or Master’s level

• Therapy and/or Psychological Testing• Therapy and/or Psychological TestingTherapist: LCSW

• Licensed Clinical Social Worker• Individual and family therapy

“Most of America's populace think it’s improper to spank children.

The other day I was talking to one of my younger buddies about methods used to discipline children.

We talked about ‘time outs’, grounding, holding back ‘rewards’ until the child displayed desired behavior, etc. One of the things we discussed was th t f ki d f i d l i d th t h d t k the act of spanking and my friend explained that no, he does not spank any of his children.

He explained that what he does is to take the misbehaving child out for a ride in the car and talk. He said that usually this works and that the child calms down fairly quickly and really doesn't take too much time.

By removing the child, in this case his son, from the immediate situation and providing a change of scenery, the child is allowed to focus on something different. Once the child has the opportunity to change perspective, things get better quickly and the child has better understanding of his place within the family and begins to understand the family’s concept of acceptable behavior.

He kindly shared a picture of the process which I share with you now.”

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Down & Out Daphne (depression)

Chris the Cutter (SIB & suicide)

Up & Down Danny (bipolar disorder)

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“I feel comfortable ordering SSRI’s for easily diagnosed depression and anxiety. I do not feel g p ycomfortable ordering any medication for any other psych problems. My colleague likes Wellbutrin® but I don’t think it is as effective for depression and I don’t think it works well with anxiety. I don’t like Paxil®

much anyway but I have found it to be the best anxiety reducer. Prozac® is the only antidepressant approved but sometimes I think this antidepressant jacks kids up I have virtually no experience with jacks kids up. I have virtually no experience with Lexapro® or Celexa®. Can you advise me? What do you use as a first line for depression? Anxiety? And, when do you use Wellbutrin®???”

Down & Out Daphne

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Daphne is a 15 yo female who presents to your office with 3-month history of • Withdrawal from family and friends• Irritability• Decreased appetite• Sleep disturbance• Admits to intermittent depressed mood

Social Hx: Lives with mother and stepfather. She has a 19 yo sister.

FMHX: Mother with history of depression for which she takes Wellbutrin®. Father has a history of bipolar disorder for which he states is p“well-controlled with Xanax®”. Uncle and GM committed suicide.

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Substance abuse (Parents LEAVE THE ROOM)

EATING DISORDER behaviors?

What medications has the mother taken – which ones didn’t work?

History of manic symptoms?

Suicidal Ideation/Attempts/Gestures?

Guns in the home?!?!

Mnemonic “SIGECAPS”

Sleep disorder (either increased or decreased sleep) Interest decrease (anhedonia) Guilt (worthlessness or hopelessness) Energy decreaseConcentration deficit Appetite disorder (either decreased or increased) Psychomotor retardation or agitation SuicidalitySuicidality

Major Depression 5 of the symptoms and one must be depressed mood

or anhedonia Present in same 2-week period

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Sad or irritable mood Difficulty concentrating

Persistent loss of interest in favorite activities

Appetite changes

Worthlessness/Guilt

Suicidal preoccupation

School difficulties/Refusal

Sleep disturbance

Psychomotor abnormalities

Aggression

Antisocial behavior

Epidemiology0 3% f h l

Prepubertal KidsS ti l i t *• 0.3% of preschoolers

• 1-2% elementary school children

• 5% adolescents

• Somatic complaints*

• Psychomotor agitation

• Hallucinations (mood-congruent)*

• Co-morbid anxiety

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Antisocial behavior* “Agitated Depression”

Restlessness

Irritability*

Aggression* Aggression

Withdrawal from family and friends

Cerebral neoplasms C b l t

Systemic lupus Sl A Cerebral trauma

CNS infections Migraine H/A Multiple Sclerosis Thyroid Disorder

Sleep Apnea Wilson’s Disease Epilepsy Narcolepsy

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Psychotherapy • Cognitive Behavioral Therapy (CBT)

Medications

Most effective treatment is the combination of these

GENERIC (TRADE) HALF-LIFE (HOURS)17

fluvoxamine (Luvox®)

paroxetine (Paxil®)

sertraline (Zoloft®)

citalopram (Celexa®)

17

21

26 (active metab = 40)

36

escitalopram (Lexapro®)

fluoxetine (Prozac®, Sarafem®)

27-32

84 (w/metabolite = 7 days)

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GENERIC (TRADE) HALF-LIFE

venlafaxine (Effexor XR®)

duloxetine (Cymbalta®)

XXXXXXXXXXXXXXXXXXX buproprion (Wellbutrin®)

5 hours (w/metabolite=11)

10-15 hours

XXXXXXXXXXXXXXXXXXXX buproprion (Wellbutrin®)

Lamotrigine (Lamictal®)• Antiepileptic used for unipolar depression• Few studies – anecdotal improvement• Stevens-Johnson Syndrome increased in kids

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“The patient is required to use at least two of the preferred medications. Please provide the strength, dosage form, trial dates (beginning and end) and outcome of trial if the preferred has been tried”

Buproprion (Wellbutrin®) Mirtaxapine (Remeron®)

Trazodone Nefazodone (limited Mirtaxapine (Remeron )

Fluoxetine (Prozac®) Paroxetine (Paxil®) Venlafaxine (Effexor® –

NOT XR) Citalopram (Celexa®) Sertraline (Zoloft®)

Nefazodone (limited availability/use in US)

Desipramine Imipramine Amitriptyline Nortriptyline

Sertraline (Zoloft )

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GastrointestinalSleep NightmaresLibido Weight SweatinggAgitation/Activation (vs. Bipolar D/O)WithdrawalLiver Enzyme interaction (CY P-450)

Serotonin Syndrome

Bruising and Bleeding Risk*

Suicidal Ideation/Attempts

*Serebruany, VL (2006). Selective serotonin reuptake inhibitors and increased bleeding risk: Are we missing something? The American Journal of Medicine 119; 113-116

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Akathisia• Subjective feeling of muscular tension Restlessness, pacing repeated sitting or standing Mistaken for psychotic agitation

TremorClonus (inducible/sustained)

Alt d M t l St tAltered Mental StatusHyperthermia

Fluoxetine (Prozac®) for the non-compliant teenager • Long half-life decreases the withdrawal or discontinuation symptoms

Citalopram (Celexa®) or escitalopram (Lexapro®) for children on multiple medications

• Lexapro® has fewer interactions with CY P-450 enzymes but Medicaid issues

Buproprion (Wellbutrin®)• NEVER use in kids with bulimia (or seizure disorder)!!! ALWAYS ask

about this WITHOUT parent in the room Decreases seizure threshold

• Best with kids who have ADHD (inattentive type) and depressive symptoms

• If dosing twice a day MAKE SURE THE 2nd DOSE IS BEFORE 5 PM• Least likely of antidepressants to induce mania

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Avoid use of tricyclic antidepressants (TCA) for sleep disturbance with patients taking for sleep disturbance with patients taking SSRI• Serotonin Syndrome• amitriptyline (Elavil®)

Avoid SSRI in patients with hereditary l t l t d f t d th t t d ith platelet defects and those treated with

antiplatelet agents

Don’t forget to check thyroid function

Chris the Cutter

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Chris is a 12 yo male who presents to your office after being discharged from the child psychiatric unit where he was hospitalized for one week. He was admitted for what his step-mother says was “a suicide attempt”p

Chris frequently threatens to cut himself or commit suicide when his parents argue He commit suicide when his parents argue. He often uses a pencil or paper clip to inflict superficial scratches on his arms. He openly admits that he does this to stop the fighting. He also mentions something about the kids at school but doesn’t want to tell you about it.

KEYAsk kids why they cut! Ask about bullying at school!

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General Population• 20% of teens think about suicide in a given year• 12% of girls and 5% of boys make a suicide

attempt• Completed suicide Girls 2/100,000 Boys 12/100 000 Boys 12/100,000

Boris Birmaher, M.D. (2007)

2003 – media frenzy around antidepressant use and increased suicidality

2004 (October) – FDA required addition of Black Box Warningg

2005 (Spring) – warnings began to appear on antidepressant labels

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Number of suicides of youth <20 yoincreased 18 2 % between 2003 2004increased 18.2 % between 2003-2004

10 year decline in youth suicide prior to 2003

*Hamilton , et al 2007

Gotland study - improvement in GP’s ability to treat depression resulted in decreased suicide rate

Suicide rate highest 1 month prior to starting antidepressants! (Simon, et al, 2006)g p ( )

KEY FACTOR: ACCESS TO FIREARMS IN THE HOME!

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“Prior to the incident, nearly ¾ of the attackers either threatened to kill themselves, made suicidal gestures or tried to kill themselves, more than half of the attackers had a history of feeling extremely depressed or desperate”y p p

Vossekuil, B, Redy M, Fein R, Borum R. & Modzeleski, W (2000). U.S.S.S. Safe school iniative: An interim report on the prevention of targeted school violence in schools. Washington, DC: U.S. Secret Service, National Threat Assessment Center.

“In over 2/3 of the targeted incidents, the attackers felt persecuted, bullied, threatened, attacked or injured by others prior to the incident.”

Vossekuil, B, Redy M, Fein R, Borum R. & Modzeleski, W (2000). U.S.S.S. Safe school iniative: An interim report on the prevention of targeted school violence in schools. Washington, DC: U.S. Secret Service, National Threat Assessment Center

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Up & Down Danny

Danny is a 16 yo male who presents to your office with a two week history of increasing aggression at home and at school. He has been suspended many times and the parent asks you to “give him medicine to make him better”

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He was discharged for an inpatient unit 3-4 weeks ago and does not have a f/u appointment at Comp Care for 2 more weeks. He was prescribed Risperdal®

and Depakote® and is almost out of his medication. Mom asks you for a refill yuntil he can be seen by the psychiatrist. What do you do?

Elevated or severely irritable or angry

Atypical Antipsychoticsirritable or angry

mood (+/- psychosis)

Violent

Conduct Disorder

Antipsychotics Mood stabilizers

• Lithium• VPA, Tegretol®,

Trileptal®

Combination for difficult cases

Dysfunctional

Weiner & Dulcan, 2004

difficult cases

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Sad or depressed Withd l

Antidepressants less lik l t i d Withdrawal

Worthlessness/Guilt Suicidal thoughts

likely to induce mania• Wellbutrin®

• Paxil®

• Remeron®

Weiner & Dulcan, 2004

Mixture of manic and d i t

Atypical A ti h tidepressive symptoms

Most common presentation of juvenile bipolar disorder

Antipsychotics +/-Mood Stabilizers +/- Antidepressant

Weiner & Dulcan, 2004

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risperidone (Ri d l®)

ziprasidone (G d ®)(Risperdal®)

paliperidone (Invega®)

quetiapine

(Geodon®)

olanzapine (Zyprexa®)

aripiprazole quetiapine (Seroquel®)

aripiprazole (Abilify®)

Extrapyramidal S/E Neuroleptic M li t S d

Due to dopamine blockade

Think Parkinson’s

Malignant Syndrome

Occur at anytime during treatment

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TremorRigidityRigidityBradykinesiaAkathisia (restlessness)Choreiform movements (“dancing”)Athetoid (writhing)

Treatment: Cogentin® 0.5 mg – 1mg BID (up to 4 mg/day) OR Benadryl® 25 – 50 mg

Treatment with antipsychotic Severe muscle rigidityg y Elevated temperature > 2 of the following

• Diaphoresis• Dysphagia• Tremor• Incontinence• Altered mental status• MutismMutism• Tachycardia• Elevated or labile blood pressure• Leukocytosis• Muscle Injury (elevated CPK)

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Often used to treat aggression• Risperidone (Risperdal®) with FDA approval for • Risperidone (Risperdal®) with FDA approval for

aggression in children with autism spectrum disorders

Ability – more EPS and activation • Especially in males (anecdotal)

Weight gain (metabolic syndrome)• Nutrition/Exercise• Nutrition/Exercise• Monitor weight, cholesterol/triglycerides, glucose Baseline and q3 months for obese patients

• PLEASE call prescribing psychiatrist with your concerns and work as a team!

Lithium • Check level if child has GI illness with dehydration

Early signs of toxicity• Early signs of toxicity Coarse tremor (fine tremor seen w/o other signs) Dysarthria Ataxia

• Late-onset side effect = hypothyroidism

Valproic acid (Depakote®)• Tremor• Irritability in children• Thrombocytopenia

Carbamazepine (Tegretol®)• Decreases level or efficacy of other drugs (OCPs, antipsychotics) • Stevens-Johnson Syndrome

Oxcarbazepine (Trileptal®)

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Ask your patients if they s you pat e ts t eyare being bullied at school!!!!

Ask about guns in the home!!!

www.project reassure.org• Resources for caretakers of traumatized kids

www.wpic.pitt.edu Assessment tool for anxiety disorders

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From a Parade article about My Last Lectureby Randy Pausch

Professor at Carnegie Mellon University who has pancreatic cancer.

When you’re frustrated with people, when you’re angry, it may be because you haven’t given them enough time…. In then end…people will show you their good side. Just keep waiting. It will come out.Just keep waiting. It will come out.

Contact Information:kmlomm2@email.uky.edu