Download Strategy - GPSC BC

Pharmacologic
Treatments
Psychosocial Interventions
Cognitive Behavioural Therapy (CBT)
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Medication Intro
 Medication Intro
› Provide rationale, expectations & education
› Explain how medication works
› Warn of potential side effects
› Health Canada Warnings
 Suicidal thoughts and behaviors
› Provide timeline
 Titration
 Treatment response
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Pharmacological Treatment of
Adolescent Depression/Anxiety
Disorder
Children & Adolescents
Do not rush into
medication subscribing!
Do not use
to treat mild symptoms
or for “usual” stress
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Antidepressants
 Not all anxiety or depressive disorders require medication
 Recommended first line treatment
› Cognitive Behavioral Therapy Approach e.g. CBIS
› Selective serotonin reuptake inhibitors (SSRI)
 Fluoxetine or Sertraline
› If not tolerable refer child to mental health services
 Medication should not be used alone
› Anxiety and mood management strategies
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Antidepressants
Combine with:
CBT
Support
Education
Self Help Strategies
Wellness Activities
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Antidepressants
in Childhood
 Minimal evidence in < 7 yrs
 SSRI’s:
› Fluoxetine
› Sertraline
 Do not use alone
 Suicidal ideation & self harm behavior
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12 Steps to SSRI Treatment
1. Do no harm
2. Ensure diagnostic criteria are met
3. Check for other psychiatric symptoms/stressors
4. Check for other psychiatric symptoms/stressors
5. Check for agitation, panic or impulsivity
6. Check for family history of mania or bipolar
7. Measure patients current somatic symptoms before
beginning treatment
› Restlessness, agitation, stomach upset, irritability
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12 Steps to SSRI Treatment
 Measure the symptoms
› Pay special attention to suicidality
 Provide comprehensive information
› About disorder and treatment options
 Provide family and child with SSRI info
› Side effects & timelines to improvement
 Start with small test dose of medication
 Slowly increase dose
 Take advantage of the placebo response
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Initiating Pharmacological Treatment
 Fluoxetine
› Best level one evidence
› Do not use alone
› May increase…
 Suicidal ideation ???
 Self harm
› Assessment of suicide risk ongoing
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Fluoxetine Treatment
START LOW & GO SLOW
Begin 5-10 mg/day for 1-2 wks (2.5-5 mg if significant anxiety symptoms)
Liquid form: 2.5 – 5 mg/day; smaller increases
Target dose 20 mg/day for min. 8 wks
Expect continued improvement for a few months at same dose if initial
response is positive
Side Effects:
If problematic cut increases back by 5 mg for 1 week and then add the extra 5
mg to dose.
Discontinuation: Taper gradually over several months at low stress
times
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Short Kutcher Chehil Side Effects Scale (sCKS) for
SSRIs
Item
None
Mild
Moderate
Severe
Headache
Irritability/Anger
Restlessness
Diarrhea/Stomach
upset
Tiredness
Sexual Problems
Suicidal Thoughts
Self Harm Attempt
Other problems
Yes:
No:
If yes, describe:
Was this a suicide attempt (attempt to die)? Yes:
No:
1.
2.
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Side Effects of SSRI’s
Three important side effects to look for when initiating treatment
with SSRI’s are…
 Hypomania
 Suicidal ideation
 Suicidal behaviors
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Hypomania
 Rare side effect
› Decreased sleep
› Increase in activity
 Idiosyncratic/inappropriate
› Increase in motor behavior
(including restlessness), verbal
productivity and social
intrusiveness
 Discontinue medication
 Urgently refer to mental health
services
 Family history of bipolar disorder
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 May onset/exacerbate once medication is
started but overall a substantial DECREASE
> Stop medication immediately due to safety risk
> Most common in first several months of medication
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ID 1209407 stockxchng
Monitoring Treatment of Adolescent Major
Depressive Disorder
Tool
Base
-line
Da
y
1
Day
5
Wk
1
Wk
2
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
KADS
x
x
x
x
x
x
TeFA
x
x
x
x
x
x
sCKS
x
x
x
x
x
x
x
x
x
x
x
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Monitoring Treatment
of Anxiety Disorders
Tool
Base Day
-line
1
Day
5
Wk
1
Wk
2
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
SCARE
D
x
x
x
x
x
TeFA
x
x
x
x
x
sCKS
x
x
x
x
x
x
x
x
x
x
x
o Children – SCARED & sCKS
o Teens – SCARED, TeFA, sCKS
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8 Weeks* of Dosage
3 Possible Outcomes
3 Different Strategies
ALWAYS CHECK ADHERENCE
TO MEDICATION TREATMENT!!!
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OUTCOME 1
OUTCOME 2
OUTCOME 3
Patient not better or only
minimally improved
SCARED > 25 and little or
no functional improvement
Patient moderately improved
SCARED < 25. Some
functional improvement.
Patient substantially improved.
SCARED < 25 and major
functional improvement.
Strategy
Strategy
Strategy
Increase medication
gradually
If medication is well tolerated,
increase slightly
Continue
monitoring/interventions for 2 4 wks
Reassess
If no substantial improvement
Refer
Continue current dosage
Gradually decrease visits; every 2
wks for 2 mths and then monthly
Educate patients/caregivers on
need to continue medications
And identifying relapse
Refer to
Specialty Child/Adolescent
Mental Health Services
Continue weekly monitoring
and all other interventions
until consultation occurs
(50-60% as determined from the
TeFA)
If medication or increase not
well tolerated continue at
current dosage with monitoring
and intervention for 2 wks
Reassess
If no substantial improvement
Refer.
If first episode continue
medications for 9- 12 mths.
If discontinuing, choose a low
stress period. Decrease gradually
over 4-6 wks monitoring
every 2 wks.
“Well checks” every 3 mths
If 2nd or further episode obtain
mental health consultation on
treatment duration
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