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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 20-40g/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)