Psychiatric illnesses in Children and Adolescents:

types and treatment

Lee W. Bradshaw APRN-BCMcKay-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– Sedation, minimal dystonia, moderate wgt gain,

fair anti-psychotic

Risperdal/risperidone– More dystonia, moderate wgt gain, prolactin, good

anti-psychotic

Zyprexa/olanzapine– Little dystonia, sig. wgt gain, good anti-psychotic

Atypical Anti-psychotics

Abilify/aripipazole – Moderate dystonia, usually less wgt gain, good

anti-psychotic Geodon/ziprazodone

– 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

Single vs dual isomers

– Dextroamphetamines 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 restless2. Easily becoming fatigued or worn-out3. Concentration problems4. Irritability5. Significant tension in muscles6. Difficulty with sleep

Treating anxiety disorders

Treatment of choice: Anti-depressants, usually SSRIs Benzodiazepines

– Short-acting Xanax/alprazolam Ativan/lorazepam

– Long-acting 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