1. PHM 456H Introduction to Pediatric Pharmacy Practice 2004 Drug Related Issues in Pediatric Psychiatry Claire De Souza BSc MD FRCP(C) November 4 th 2004

2. Audience Survey: Experience with pediatric psychiatry:  medications?  patients?

3. Learning Objectives At the end of this presentation, the student will: be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involved be familiar with the spectrum of psychiatric illness in the pediatric population and the assessment involved have a greater understanding of have a greater understanding of pediatric depression pediatric depression ADHD ADHD any others? any others?

4. Outline Starting Principles Starting Principles Spectrum of Psychiatric Disorders in the Pediatric Population Spectrum of Psychiatric Disorders in the Pediatric Population Review of Pediatric Depression Review of Pediatric Depression Review of ADHD Review of ADHD

5. Principles accurate diagnosis accurate diagnosis biological, psychological, social contributors biological, psychological, social contributors informs a comprehensive management plan informs a comprehensive management plan biological, psychological, social interventions biological, psychological, social interventions medications used depending on diagnosis, symptoms, and severity medications used depending on diagnosis, symptoms, and severity antidepressants - SSRIs antidepressants - SSRIs anti-anxiety - benzodiazepines anti-anxiety - benzodiazepines anti-psychotics – atypical anti-psychotics – atypical start low, go slow start low, go slow

6. Spectrum of Psychiatric Disorders Mood Disorders Mood Disorders Anxiety Disorders Anxiety Disorders Psychotic Disorders Psychotic Disorders Substance Use Disorders Substance Use Disorders Personality Disorders Personality Disorders Disruptive Behavioural Disorders Disruptive Behavioural Disorders Elimination Disorders Elimination Disorders Eating Disorders Eating Disorders Tic Disorders Tic Disorders Somatoform Disorders Somatoform Disorders etc. etc. Reference: DSM-IV

7. Depression

8. Depression 2% children, 4-8% teens (  : ♂ = 2:1) 2% children, 4-8% teens (  : ♂ = 2:1) suicide attempt - 9% of teens suicide attempt - 9% of teens symptoms for 2 weeks: symptoms for 2 weeks: mood – “bored”, irritable mood – “bored”, irritable cognitive – SI, guilt, worthlessness, concentration cognitive – SI, guilt, worthlessness, concentration physical - change in sleep ↑, appetite ↑, energy, psychomotor physical - change in sleep ↑, appetite ↑, energy, psychomotor interpersonal – change in interest level interpersonal – change in interest level change in functioning (social, academic) / xs distress change in functioning (social, academic) / xs distress other features: other features: anxiety - phobias, separation anxiety anxiety - phobias, separation anxiety behaviour - tantrums, oppositional, aggression behaviour - tantrums, oppositional, aggression somatic complaints somatic complaints psychosis – auditory hallucinations psychosis – auditory hallucinations range in severity range in severity

9. Depression continued … contributing factors (B/P/S) contributing factors (B/P/S) biological – ie genetics, history of depression biological – ie genetics, history of depression psychological – ie loss, trauma, separation psychological – ie loss, trauma, separation social – ie interpersonal, SES, academic social – ie interpersonal, SES, academic comorbidity: anxiety, substance use, behaviour, etc comorbidity: anxiety, substance use, behaviour, etc prognosis: recurrence prognosis: recurrence 20-60 % recurrence in 2 yrs; 70% within 5 yrs 20-60 % recurrence in 2 yrs; 70% within 5 yrs episodes become more frequent, more severe, last longer episodes become more frequent, more severe, last longer 20-40%  bipolar disorder within 5 years 20-40%  bipolar disorder within 5 years

10. Depression continued … Assessment interview with family interview with family interview with child/teen interview with child/teen interview with parents interview with parents collaterol information from school etc as required collaterol information from school etc as required

11. Depression continued … Differential Diagnosis – extensive Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, General Medical Condition (thyroid, anemia, mono etc), Bereavement etc. Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, General Medical Condition (thyroid, anemia, mono etc), Bereavement etc.

12. Depression continued … Management (B / P / S): Psychoeducation Psychoeducation Medications Medications Therapy – individual (CBT, IPT), family Therapy – individual (CBT, IPT), family School Intervention School Intervention Resources / References Resources / References websites: http://www.mooddisorders.on.ca/mdao.asp websites: http://www.mooddisorders.on.ca/mdao.asp http://www.mooddisorders.on.ca/mdao.asp http://www.aacap.org/ (Facts for Families) http://www.aacap.org/ (Facts for Families) http://www.aacap.org/

13. Depression continued … Medications duration: 9 months or more duration: 9 months or more 1 st line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label 1 st line: SSRIs (ie Prozac, Zoloft, Celexa) – off-label start low, go slow; increase as tolerated & as required start low, go slow; increase as tolerated & as required Controversy Controversy Efficacy – limited evidence - Prozac Efficacy – limited evidence - Prozac Safety – Health Canada warning Safety – Health Canada warning  MD to monitor: SI, disinhibition, agitation, akathisia  off-label use based on limited studies, experience, adult studies drug interactions – cytP450 drug interactions – cytP450 Medications added as required (Sx, Rx resistance): Medications added as required (Sx, Rx resistance): ie BZDs, atypical antipsychotics ie BZDs, atypical antipsychotics

14. Depression continued … Red Flags requesting script renewals requesting script renewals appearing dysphoric, suicidal, hypomanic, psychotic appearing dysphoric, suicidal, hypomanic, psychotic non-compliance: withdrawal, worsening symptoms non-compliance: withdrawal, worsening symptoms stockpiling medications, buying ++OTCs stockpiling medications, buying ++OTCs medical problems – cytP450 drug interactions medical problems – cytP450 drug interactions

15. Depression continued … Approach review Health Canada warning review Health Canada warning discuss need for monitoring by MD discuss need for monitoring by MD advise them not to stop medication suddenly advise them not to stop medication suddenly questions / concerns  MD questions / concerns  MD advise them about what to look for: advise them about what to look for: ie. restlessness, disinhibition, aggression, ie. restlessness, disinhibition, aggression, anxiety, worsened depression direct them to resources direct them to resources if concerned about patient’s safety – refer to ER if concerned about patient’s safety – refer to ER Reference: FDA website, Health Canada, NIMH websites

16. Attention Deficit Hyperactivity Disorder

17. ADHD 5-9 % of children; ♂:  = 4:1 ( NB:  under-Dx ) 5-9 % of children; ♂:  = 4:1 ( NB:  under-Dx ) symptoms – 2+ settings, onset < age 7 symptoms – 2+ settings, onset < age 7 inattention – careless mistakes, can’t sustain attn, distractible, forgetful, disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids time/effort-consuming tasks inattention – careless mistakes, can’t sustain attn, distractible, forgetful, disorganized, loses things, doesn’t listen, doesn’t complete tasks, avoids time/effort-consuming tasks hyperactivity – fidgets, leaves seat, ↑ runs/climbs, on the “go”, xs talking, can’t play quietly hyperactivity – fidgets, leaves seat, ↑ runs/climbs, on the “go”, xs talking, can’t play quietly impulsivity- blurts out, interrupts, problems waiting turn impulsivity- blurts out, interrupts, problems waiting turn interferes with functioning: academic, family, social interferes with functioning: academic, family, social diagnosis diagnosis subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined subtypes: 1) inattentive, 2) hyperactivity – impulsivity, 3) combined reference: DSM-IV

18. ADHD continued etiology - DA mediated; problems with inhibitory & executive control etiology - DA mediated; problems with inhibitory & executive control factors: factors: biological – FHx, difficult temperament biological – FHx, difficult temperament psychological - self-esteem psychological - self-esteem social - interpersonal, academic, poor social skills social - interpersonal, academic, poor social skills comorbidity comorbidity learning disorders (in 40% with ADHD), behavioural problems (ODD, CD), substance abuse, depression, anxiety learning disorders (in 40% with ADHD), behavioural problems (ODD, CD), substance abuse, depression, anxiety prognosis prognosis 65%  adulthood 65%  adulthood

19. ADHD continued Assessment: Interview with Interview with family family child / teen child / teen parents parents Questionnaires Questionnaires ie Connors Rating Scale – parent / teacher form ie Connors Rating Scale – parent / teacher form Information from school Information from school Psychoeducational testing Psychoeducational testing

20. ADHD continued Differential Diagnosis – extensive Learning disorder Learning disorder General Medical Condition (hearing, vision, thyroid, congenital, genetic, lead poisoning, head injury etc) General Medical Condition (hearing, vision, thyroid, congenital, genetic, lead poisoning, head injury etc) Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, etc. Adjustment Disorder, Dysthymic Disorder, Bipolar Disorder, Anxiety Disorder, Psychotic Disorder, Disruptive Behavioural Disorder, Personality Disorder, Substance use Disorder, etc.

21. ADHD continued Management (B / P / S): Psychoeducation Psychoeducation Medications Medications Social skills training Social skills training Parent management Parent management (+) reinforcement, structure (+) reinforcement, structure School Intervention School Intervention classroom modifications, individual education plan (IEP) classroom modifications, individual education plan (IEP) Resources / References Resources / References websites: www.adrn.org websites: www.adrn.orgwww.adrn.org http://www.aacap.org/ (Facts for Families) http://www.aacap.org/ (Facts for Families) http://www.aacap.org/

22. ADHD continued Medications stimulants - 1 st line stimulants - 1 st line short acting – Ritalin, Dexedrine short acting – Ritalin, Dexedrine long acting – ie Concerta, Dexedrine SR long acting – ie Concerta, Dexedrine SR Blinded placebo / stimulant trials Blinded placebo / stimulant trials to determine dose, acceptability to determine dose, acceptability coordinated with objective scale – ie Connors Rating Scale coordinated with objective scale – ie Connors Rating Scale restricted use – limited scripts restricted use – limited scripts abuse potential abuse potential other medications for co-morbidity – ie depression, anxiety, tics other medications for co-morbidity – ie depression, anxiety, tics Use – for school day primarily; also, during weekend & summer if problems (social, academic) off meds Use – for school day primarily; also, during weekend & summer if problems (social, academic) off meds

23. ADHD continued Red Flags requesting script renewals requesting script renewals non-compliance non-compliance substance abuse substance abuse stockpiling medications stockpiling medications medical problems - epilepsy medical problems - epilepsy

24. ADHD continued Approach controversy controversy “over-diagnosed” “over-diagnosed” concerns about long-term side effects concerns about long-term side effects problems if no treatment problems if no treatment academic, social, family academic, social, family comorbidity comorbidity advise them to direct their questions / concerns  MD advise them to direct their questions / concerns  MD

25. Questions / Cases