Download yes - adolescon 2013

Pediatricians as Primary Mental
Health Professionals
5 Essential Drugs
Dr. M.K.C.Nair
Director,
Child Development Centre
Medical College, Tvpm
Dr. Paul Russell
Professor &Head
Child & Adol. Psychiatry Division
Christian Medical College, Vellore
Treatment modality as recommended
by WHO or based on evidence
Medication
LDa
CBT
Family therapy
-
-
-
ADHDa
yes
yes
-
Ticsa
yes
yes
yes
Depressiona
yes
yes
yes
Psychosesa
yes
-
yes
Schizophreniaa
yes
-
yes
Autismb
yes
-
-
Anxietyb
yes
yes
yes
Conduct disorderb
yes
yes
yes
Substance abuseb
yes
-
yes
Eating Disordersb
yes
yes
yes
-
-
yes
Attachment
disordersb
Hierarchy of Diagnosis & Treatment
Organic brain syndromes
Psychoses/ Pervasive Dev.l Disroders
Mood disorders / ADHD
Anxiety disorders
Tic / Enuresis / Conduct Disorder
4
Organic Brain Syndromes
H/O: Temporal correlation with a
demonstrable general medical condition,
CNS pathology, drugs and medication
MSE: attention, orientation, memory impaired.
Org.Brain
Syndromes
1st-line drug
Dose
Risperidone (Atypical antipsychotic)
0.25-1mg/day
2nd-line drug
Haloperidol (Typical antipsychotic)
0.25-1mg/day
Medication: Antipsychotic
Psychosis
1. Hallucinations
2. Delusions
3. Catatonic symptoms
4. First Rank Symptoms
Psychoses
Dose
1st-line drug
Risperidone (Atypical antipsychotic)
2-4mg/day
2nd-line drug
Haloperidol (Typical antipsychotic)
0.03 – 0.08mg/kg/day
Medication: Antipsychotic
Autism
1. Deviant/ delayed social interaction
2. Deviant/ delayed communication
3. Restricted-repetitive behaviour
Symptoms
Hyperactivity, impulsiveness, inattention
Rigidity, rituals
Aggression, self injury
Anxiety, Affective symptoms
– Atypical antipsychotic
– Atypical antipsychotic
– Atypical antipsychotic
– Atypical antipsychotic
Review of 19 articles (Barnard et al, J Psychopharmacol 2002)
Medication:
Atypical antipsychotic - Risperidone: Dose: 0.25 – 2mg/day
Mood disorders - Medication of choice
Depressive episode
1.Mood
2. Behaviour
3. Cognition
4. Biological symptoms
o Worthlessness
o Hopelessness
o Helplessness
o Suicidal ideation
(Antidepressant - Fluoxetine (10-20mg/day)
Bipolar & Hypermania (Mood stabilizer & Antipsychotic)
Pediatrician: Valproate Na (20-30mg/Kg) / Carbamazepine (8-12 mg/L)
Psychiatrist: Lithium ± AP (0.6-1mmol/L)
Attention Deficit Hyperactivity Disorder
6 symptoms of attention deficit
6 symptoms of hyperactivity/impulsivity
2 settings
6 months
<7 years
Medication
Line of choice Dose
Dosing schedule
CNS stimulants
Methylphenidate
1St line
1mg/kg/day
Twice /thrice daily
2nd line/ 1st?
1.2 -1.8mg/kg/day
Once/twice daily
SNARI (Serotonin NorAdrenergic
Reuptake Inhibitor )
Atomoxetine
9
Medication: CNS stimulants / SNARI
Symptom to Disorder Transition
1. Symptoms out of proportion to cause
2. Definite body symptom (eg. Depression: Eating,
sleeping, libido affected)
3. Impairment of functions
Anxiety Disorders
1.Phobic anxiety disorder
2.Overanxiety disorder of childhood
3.Seperation anxiety disorder
4.Obssesive compulsive disorder
5.Post-traumatic stress disorder
Medication: Antianxiety
1.Irrational fear
2.Avoidance
1. Obsessive compulsive disorder
1.Obsessions
Disorder
2. Compulsions
1st-line
drug
Dose
OCD
2. Post-traumatic stress disorder
PTSD
(PTSD)
1.Catastrophic trauma
2.Intrusive recollection
3.Autonomic arousal
4.Avoidance
Generalized anxiety
disorder (GAD)
Fluoxetine 10-40mg/day
Phobia
Medication: Antianxiety drugs
Conduct Disorder
Dissocial
Defiant
Aggressive
Conduct Disorder
Dose
1st-line drug
Carbamazepine
8-12 mg/L
2nd-line drug
Risperidone
1-2mg/day
Medication: Mood stabiliser
Tic Disorder
Motor
Vocal
Combined
Tic Disorder
1st-line drug
Dose
Risperidone (Atypical antipsychotic)
0.25.-2mg/day
Haloperidol (Typical antipsychotic)
0.2-2mg/day
2nd-line drug Fluoxetine
10-20mg/day
14
Medication: Atypical antipsychotic
Enuresis
Involuntary voiding
> 4 yrs CA
Enuresis
Dose
1st-line drug
Imipramine
0.3mg/kg/day
2nd-line drug
Desmopressin
20-40g/I.nasal
Medication: TCA
Conclusion
Medication
Disorder
Dose/Day
Dosing/Day
Evidence
Risperidone
Org.Brain Syndromes
0.25-1mg
OD-TID
Level IIa
Risperidone
Psychoses
2 - 4mg
OD-TID
Level Ib
Risperidone
Autism
0.25 – 1 mg
OD-BD
Level Ia
Risperidone
Tic
0.25 - 2mg
OD (dinner)
Level Ib
Risperidone ±
Valproate Na
Mania
2-4mg
20mg/kg
OD-TID
OD (dinner)
Level IIa
2
Valproate Na
Conduct disorder
20mg/kg
OD (dinner)
Level Ib
3
Fluoxetine
Depression
10-20 mg
OD (breakfast)
Level Ia
Fluoxetine
Anxiety disorder (OCD,
PTSD, GAD, Phobia)
10-40 mg
OD (breakfast)
Level Ib
4
Atomoxetine
ADHD
1.2 - 1.8mg/kg OD-BD (break
fast, lunch)
Level Ia
5
Imipramine
Enuresis
0.3mg/kg/BW
Level Ia
1
OD (dinner)