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Psychiatric illnesses in Children and Adolescents: types and treatment Lee W. Bradshaw APRN-BC McKay-Dee Behavioral Health Institute. Types of illnesses: Depression Bipolar disorder Anxiety disorders ADHD Nature vs. Nurture (physical vs. psychological) PHYSICAL Genetics: in the family Brain chemistry -autopsy studies -medications work Brain structure -hippocampus -trauma changes you PSYCHOLOGICAL Family problems are passed on Relationships Job School Legal Depression Major Depression has 5 of the 9 sx for at least two weeks Dysthymia has 3 of 5 sx for more days than not, for two years (one year for kids), will not go for more than 2 months without having at least two sx Depressive disorder NOS Neuro-vegetative symptoms of depression Concentration: impaired, decrease in functioning Appetite and sleep: increased or decreased Energy: decreased energy, tired, sluggish Depressed mood: for most of the day every day (teens often display irritability vs. sadness) Interest: loss of ability to enjoy pleasurable things Isolation and withdrawal: Guilt and worthlessness: excessive (5 minute) Psychomotor agitation or retardation Thoughts of death: may or may not include suicide Treating Depression: Characteristics of anti-depressants Improve symptoms of depression and anxiety Not addictive, but not good to stop suddenly May take weeks to fully work Side effects usually mild, early and transitory May cause agitation or suicidality, if bipolar Usually safe in overdose: except MAOIs Wellbutrin/buprorion, or Effexor, Tricyclics Types of Anti-depressants SSRIs: – – – – – Prozac/fluoxetine Paxil/paroxetine Zoloft/sertraline Celexa/citalopram or Lexapro/escitalopram Luvox/fluvoxamine SNRIs: – – Effexor/venlafaxine Cymbalta/duloxetine Other Anti-depressants Remeron/mirtazepine Serzone/nefazodone Wellbutrin/buproprion Tricyclics, Tetracyclics and other old ones: – – – – – Elavil (amitriptyline) Pamelor (nortriptyline) Tofranil (imipramine) Desyrel (trazodone) Anafranil (clomipramine) Bipolar Disorder Bipolar I Bipolar II Cyclothymia Different with children/adolescents, difficult to diagnose. More important to recognize what the diagnosis means in terms of treatment and management. Bipolar I and II Mania or hypomania: Elevated, expansive or irritable mood for one week for mania, 4 days for hypomania – Includes three of the following (four if irritable) Pressured/excessive talking Less need for sleep Flight of ideas or thoughts racing Distractibility Increase in goal-directed activity Grandiosity – Excessive interest in pleasurable activities: shopping, sex, drugs, investments, that have a high risk Bipolar I vs. II Mania with type I, may have depressive episodes, or mixed episodes: more likely to result in psychotic symptoms: paranoia, hallucinations, delusions, disorganized thinking Hypomania alternating with depressive episodes with type II, less likely to be as severe: become psychotic How are kids different? No cadillacs and presidents Hypersexuality Grandiosity More unstable with an anti-depressant? Exacerbated by stimulants Treating Bipolar Disorder Lithium, Anti-epileptics, Atypical Antipsychotics Stabilizing has priority Is primary focus of treatment high or low Anti-depressants may always cause instability By nature more difficult to treat More difficult to diagnose in younger patients Lithium carbonate Oldest: 1949 Lowest suicide rate of all psychiatric meds Anti-manic, mood stabilizer, helps agitation As a salt, competes with sodium and wins: over hydration or dehydration causes toxicity Change in renal function can change plasma levels: NSAIDS, diuretics, steroids Narrow therapeutic window: 0.6-1.0, toxicity above 1.5, moderate 2-3, severe 3.0, multi-organ failure above 4.0 (dangerous in overdose) Steady-state plasma levels in about 5 days, draw lab 10-12 hours after last dose (trough vs. peak) Anti-epileptics Depakote/divalproate sodium (valproic acid) – – – – Indicated for seizures, headache, mania Limited potential for liver toxicity Weight gain, hair loss, GI distress Therapeutic range: 50-125 Tegretol/carbamazine – – – – Seizures, mania Greater potential for liver toxicity, small percentage have necrotic liver GI distress, excess gum growth Therapeutic range 4-12 More anti-epileptics Topamax/topiramate and Neurontin/gabapentin – – – – Adjunct anti-seizure No liver metabolism, toxicity, drug interactions Topamax is good for headaches, weight loss, but start slowly, rare acute angle glaucoma Neurontin can help chronic neuropathic pain, help with anxiety and sleep, completely non-toxic: 8,000 mg/kg Characteristics of anti-epileptics Metabolized vs. excreted Toxicity and liver failure possible, but unlikely Can cause sedation, weight gain, GI upset May cause depression Anti-manic, mood stabilizer, decrease agitation Watch for drug-drug interactions Atypical Anti-psychotics Seroquel/quietapine – Risperdal/risperidone – Sedation, minimal dystonia, moderate wgt gain, fair anti-psychotic More dystonia, moderate wgt gain, prolactin, good anti-psychotic Zyprexa/olanzapine – Little dystonia, sig. wgt gain, good anti-psychotic Atypical Anti-psychotics Abilify/aripipazole – Geodon/ziprazodone – Moderate dystonia, usually less wgt gain, good anti-psychotic Sedation, moderate dystonia, very rare wgt gain, all or nothing: dose and effectiveness and tolerability Invega/paliperidone – Similar to Risperdal, but usually less Warnings about anti-psychotics Metabolic syndrome: DM, lipids Parkinsonian symptoms: EPS Tardive Dyskinisia Neuroleptic Malignant Syndrome Attention Deficit Hyperactive Disorder Lifelong, no “late onset”, noticed in kindergarten Not ADD anymore Predominately inattentive, hyperactive or combined Paradoxical response to stimulants Can have a mood or anxiety disorder also Younger kids dx with ADHD, but don’t have it Inattention Forgetful Loses things Procrastinates (not defiant) Easily distracted Does not listen even when spoken to directly avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) difficulty organizing tasks and activities fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Can’t sustain attention in tasks or play activities Hyperactivity Fidgets with hands or feet or squirms in seat Can’t stay in seat Runs about or climbs excessively Can’t be quiet "on the go" or often acts as if "driven by a motor" talks excessively Impulsivity blurts out answers before questions have been completed difficulty awaiting turn interrupts or intrudes on others (eg, butts into conversations or games) Other necessary conditions symptoms that caused impairment were present before 7 years of age. impairment from the symptoms is present in 2 or more settings clinically significant impairment in social, academic, or occupational functioning Treating ADHD Stimulants: – Methyphenidates – Dextroamphetamines Single vs dual isomers single isomer Pro-drugs Multi-isomers, mixed salts Stattera/atomoxatine Wellbutrin/buproprion Methyphenidate Ritalin, Ritalin SR, Ritalin LA Metadate Concerta Focalin Daytrana (patch) Dextroamphetamines Dexedrine, spansules, dextrostat Adderall (4 isomers) Vyvanse Other: Strattera: – – – – norepinephrine re-uptake inhibitor may treat depressive symptoms also longer acting: half-life, onset and attenuation may be most agitating if Bipolar Wellbutrin: – – – inhibits dopamine and norephinephrine re-uptake no good data re: effectiveness Very good at treating depression Anxiety Disorders PTSD (Post Traumatic Stress Disorder) – – – Has been exposed to a traumatic event where there was an actual or threatened death or serious injury The person experienced a feeling of horror, helplessness or intense fear. The event is re-experienced in one of the following ways Recurrent and intrusive distressing recollections Recurrent distressing dreams of the event Acting or feeling as if the event were re-occurring Intense stress when there are internal or external cues that symbolize or represent the event Physical reaction when these cues occur. Other Anxiety disorders Panic disorder, an anxiety disorder with episodes of panic attacks: periods of intense fear that last 10 minutes, or longer, usually brief and very intense, with four of the following: – – – – – – – – Palpitations and/or tachycardia Sweating, trembling or shaking SOB or a feeling of smothering, or of choking Cx pain or discomfort, nausea or GI distress Feeling of dizziness, faint or lightheadedness Feeling of derealization Fear of losing control or going crazy, or dying Numbness or tingling, hot flashes or chills Another Anxiety disorder Acute Stress disorder: similar to PTSD, where there is a traumatic event with actual or threatened loss of life, with the sense of helplessness, horror or intense fear. Instead of re-experiencing the event there are three of the following dissociative symptoms: – – – – – – Feeling numb, detached, emotionally unresponsive Reduction of awareness of surrounding, being “in a daze” Derealization Depersonalization Dissociative amnesia Lasts less than 30 days, if more than 30 = PTSD Generalized Anxiety Disorder 6 months of "excessive anxiety and worry" about a variety of events and situations. significant difficulty controlling the anxiety and worry clinically significant distress or problems functioning in daily life. most days over the last six months of 3 or more (only 1 for children) of the following symptoms: 1. Feeling wound-up, tense, or restless 2. Easily becoming fatigued or worn-out 3. Concentration problems 4. Irritability 5. Significant tension in muscles 6. Difficulty with sleep Treating anxiety disorders Treatment of choice: Anti-depressants, usually SSRIs Benzodiazepines – Short-acting – Long-acting Xanax/alprazolam Ativan/lorazepam Klonopin/clonazepam Valium/diazepam Non-addictive – – – – Vistaril/hydroxyzine Neurontin/gabapentin Buspar/buspirone Anti-hypertensives: Inderal/propanolol, Catapres/clonidine, Tenex/guanfacine Characteristics of benzodiazepines Benzodiazepines (xanax, ativan, valium, klonopin) are addictive – – cannot stop suddenly if taken long enough highly likely to be abused with persons with a hx of substance abuse Fairly safe in overdose Very effective, very quickly. – – – Provides more immediate relief If not backed up by anti-depressants, will habituate, symptoms will return Rebound anxiety