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Pharmacologic Treatments Psychosocial Interventions Cognitive Behavioural Therapy (CBT) 2 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 3 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 5 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 6 Antidepressants Combine with: CBT Support Education Self Help Strategies Wellness Activities 7 Antidepressants in Childhood Minimal evidence in < 7 yrs SSRI’s: › Fluoxetine › Sertraline Do not use alone Suicidal ideation & self harm behavior 8 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 9 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 10 Initiating Pharmacological Treatment Fluoxetine › Best level one evidence › Do not use alone › May increase… Suicidal ideation ??? Self harm › Assessment of suicide risk ongoing 11 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 12 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. 13 Side Effects of SSRI’s Three important side effects to look for when initiating treatment with SSRI’s are… Hypomania Suicidal ideation Suicidal behaviors 14 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 15 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 16 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 17 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 18 8 Weeks* of Dosage 3 Possible Outcomes 3 Different Strategies ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!! 19 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 20