Mood disorders in adolescence an integrative approach session a2021 10 12 08
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Mood Disorders in Adolescence: An Integrative Approach Session #: A2021 10/12/08. Kathi J. Kemper, MD, FAAP Caryl J Guth Chair for Holistic and Integrative Medicine Author, The Holistic Pediatrician Wake Forest University School of Medicine Winston-Salem, NC. Faculty Disclosure.

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Mood disorders in adolescence an integrative approach session a2021 10 12 08
Mood Disorders in Adolescence: An Integrative Approach Session #: A2021 10/12/08

Kathi J. Kemper, MD, FAAP

Caryl J Guth Chair for Holistic and Integrative Medicine

Author, The Holistic Pediatrician

Wake Forest University School of Medicine

Winston-Salem, NC


Faculty disclosure
Faculty Disclosure

In the past 12 months, I have had no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.


Objectives by the end of this session you will be able to
Objectives (by the end of this session, you will be able to…):

  • Define the role of patient-centered communication for mood disorders

  • Describe the importance of a healthy lifestyle and the safety and effectiveness of dietary supplements in promoting healthy moods.

  • Refer patients to evidence-based resources for additional information about lifestyle and complementary therapies to promote mental health


Depression case
Depression Case to…):

A 17 year old girl who is sad, has had a drop in grades, recently broke up with her abusive boyfriend; less interested in participating in band, has stopped taking her SSRI after hearing about black box warnings.

Her only medications are oral contraceptives.

Will St. Johns wort help (the news reports are very confusing)?

How do you advise her?


Which of the following is the best answer about sjw

10 to…):

Answer Now

Which of the following is the best answer about SJW?

  • SJW has proven useless against depression.

  • SJW is completely safe. She can use any off the shelf brand to help.

  • She will need to use back up birth control method if she starts SJW.

  • Based on RCTs, there’s a greater than 80% chance her symptoms will respond to SJW.


Are mood disorders are real problem in adolescents yes
Are mood disorders are real problem in adolescents? YES to…):

  • American children have the most psychiatric illness in the civilized world (WHO data)

  • Childhood depression: epidemic in USA

    2001/02 HBSC International Report: Young People's Health in Context
Currie C. et al (eds.) 2004. Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series

    Blader, J and Carlson, G Biol Psychiatry: 2007: Feb 15

    Moreno, C et al Archives of General Psychiatry, 64:1032-8 2007: September


Definitions mental health
Definitions: Mental Health to…):

  • Most medical literature on mental health focuses on mental illness, eg. Depression, anxiety, Bipolar, schizophrenia, ADHD, cognition/memory problems, adjustment disorders, personality disorders, etc.

  • Mental health

    "First say to yourself what you would be; and then do what you have to do."

    Epitectus

    “You got to be careful if you don't know where you're going, because you might not get there.”

    Yogi Berra


Optimal physical health example
Optimal Physical health: Example to…):

  • Strength

  • Flexibility

  • Stamina/Endurance

  • Focus

  • Coordination

  • Resilience, and

  • Effective teamwork


Optimal spiritual health
Optimal Spiritual Health to…):

  • Faith

  • Forgiveness

  • Hope

  • Love

  • Kindness

  • Charity/generosity, and

  • Transcendence – connection with something greater than our individual self


Mental health elements
Mental Health: elements to…):

  • Confidence and courage

  • Adaptability

  • Cheerfulness

  • Attention / Concentration

  • Harmony

  • Hardiness in face of stress

  • Social Network/ communication skills/ connection to community


Mental health strategies
Mental Health - strategies to…):

  • Healthy lifestyle – as for promoting heart health, reproductive health, immune function, etc.

  • #1 Lifestyle: Exercise/Rest, Nutrition, Environment(+/-), Stress management practices (EMS), Communication and community

  • #2: Supplements/Meds, Professionals (psychologists, massage, acupuncture, etc)


Management issues
Management Issues to…):

  • Process (communication skills)

  • Content (focus on healthy lifestyle; if it’s good for the heart, it’s probably good for mood)

  • Speed (baby steps)

  • Resources


Which of the following is true about patient centered communication

10 to…):

Answer Now

Which of the following is true about patient-centered communication?

  • PCC can significantly improve mental health outcomes

  • PCC has mild impact on mental health visits, though it is helpful for general primary care

  • PCC has no impact on mental health outcomes

  • What is PCC?


Process communication skills
Process: to…):Communication Skills

  • Standard approach

  • Patient-centered care

  • Health promotion focus


Standard approach
Standard approach to…):

  • Diagnose

    • Provide diagnosis-specific treatment yourself

    • Persuade parent / child to accept referral

  • Challenges

    • Making a diagnosis; what if they don’t meet criteria?

    • Mastering medications

    • Referral resistance; waiting; unavailability

    • Promoting mental health during well child care (preventing illness)

Wissow and Gadomski, 2008


Parental expectations
Parental expectations to…):

Don’t believe they are effective change agents

Have prior beliefs about what will help

Not sure pediatric visit the place to discuss this

Want help but afraid of what you might say

Want empathy but expect child is the agenda

Wissow and Gadomski, 2008


Adolescent expectations
Adolescent Expectations to…):

  • Here to be “fixed” or punished

  • Not used to having a substantive role in visit

  • Uncertain about confidentiality

  • Different agenda than parent

  • Incomplete and stigmatizing views of “mental health”

Wissow and Gadomski, 2008


Physician expectations
Physician Expectations to…):

  • Will be presented with insoluble problems

  • “Double drowning” – everyone will leave more hopeless and/or angry than they started

  • Will lose control of time

  • Won’t be able to be proactive as with other health problems

Wissow and Gadomski, 2008


Evidence based skills
Evidence-based skills to…):

Agenda setting

  • Engaging both child and parent

  • Prioritizing specific concerns; goals; define success

    Problem formulation and solving

  • Finding reasons to hope and first steps to solutions

  • Framework: health promotion and stress management

    Time management

  • Managing rambling and interruptions

    Promoting hope and confidence

    Advice giving

  • Avoiding and managing resistance

Pediatrics 2008 Feb;121:266-75.


Finding a common agenda
Finding a common agenda to…):

  • Commitment to eliciting it from both parent and child/youth

  • Setting up and “enforcing” turn-taking

    • Respecting confidentiality

    • Encouraging and modeling the ability to talk in front of each other


Crude 6-month change in child clinical measures as a function of change in provider’s patient-centeredness

Change in SDQ symptom score

Change in SDQ impact score

p<.0001 adjusted for baseline symptoms

p=.015 adjusted for baseline function


Which of the following is true about patient centered communication1

10 function of change in provider’s patient-centeredness

Answer Now

Which of the following is true about patient-centered communication?

  • PCC can significantly improve mental health outcomes

  • PCC has mild impact on mental health visits, though it is helpful for general primary care

  • PCC has no impact on mental health outcomes

  • What is PCC?


Content conventional
Content: Conventional function of change in provider’s patient-centeredness

  • Psychotherapy

  • Medications


Cognitive behavioral therapy
Cognitive Behavioral Therapy function of change in provider’s patient-centeredness

“From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents.”

Compton SN. JAm Acad Child Adolesc Psychiatry. 2004


Conventional treatment rx
Conventional Treatment: Rx function of change in provider’s patient-centeredness

  • TCAs - no evidence of efficacy in pre-pubertal children

  • SSRIs - no overall evidence of efficacy in pre-pubertal children

  • SSRIs marginally better than placebo in teens with MDD

  • SSRIs are HELPFUL in OCD and anxiety disorders, even in pre-pubertal children

    Safer DJ. Pediatrics, 2006; 118 (3): 1248


Fda approved ssris for pediatric mdd
FDA approved SSRIs function of change in provider’s patient-centerednessfor pediatric MDD

  • As of 2004, “the FDA has approved only Prozac for use in children/adolescents with MDD”

  • Prozac, Zoloft and Luvox have been FDA approved for use in children diagnosed with OCD

FDA 3/24/04; http://energycommerce.house.gov/108/Letters/03242004_1242print.htm


Ssri side effects 1
SSRI Side effects 1 function of change in provider’s patient-centeredness

  • GI upset

  • Headache; sleep disorders

  • Sexual side effects Dizziness, Fatigue, Sweating

  • Neonatal withdrawal syndrome

  • Drug interactions


Ssri side effects 2
SSRI Side effects 2 function of change in provider’s patient-centeredness

  • Serotonergic syndrome (HTN, tachycardia, mania)

  • Agitation and hostility

  • Suicidal ideation, esp in those with agitation/hostility

    • Review of 22 RCT pediatric with 9 antidepressant drugs.

    • 2298 patients with active drug; 1952 with placebo

    • Serious suicidal adverse events:

      78/2298 versus 54/1952

      Incidence rate ratio 1.89 (95% CI, 1.18-3.04)

      Mosholder AD. J Child Adolesc Psychopharmacol. 2006


Psychiatric meds in kids
Psychiatric Meds in kids function of change in provider’s patient-centeredness

  • Little science of long term safety

  • 1.6 million kids on 2 or more meds: no science

  • Neurological and hormonal impact mostly unknown


Content natural therapies
Content: natural therapies function of change in provider’s patient-centeredness

  • Depression is one of the top 10 diagnoses for which patients seek natural therapies

  • Commonly used among depressed adolescents

  • Fewer than 30% of depressed teens tell docs they are using natural therapies

  • Clinicians need to ask!


Which of the following is true about lifestyle approaches to mood problems

10 function of change in provider’s patient-centeredness

Answer Now

Which of the following is true about Lifestyle approaches to mood problems?

  • Lifestyle affects cardiac health, but has little impact on mental health

  • Lifestyle affects cancer risk, but has little impact on mental health

  • Lifestyle affects BOTH cardiac and cancer risks, but has little impact on MH

  • Lifestyle, such as light, sleep, exercise and nutrition can have profound and clinically significant effects on mental as well as physical health.


Integrative approach
Integrative Approach function of change in provider’s patient-centeredness

  • Lifestyle – Environment, Exercise/Sleep, Nutrition, Mind-Body

  • Supplements

  • Massage

  • Acupuncture


Lifestyle overview
Lifestyle - overview function of change in provider’s patient-centeredness

  • Environment: More Sunshine and good music, Less TV and toxins

  • Exercise/Sleep

  • Nutrition (Essential nutrients for optimal brain function, EFA, amino acids, vitamins, minerals)

  • Mind-Body Therapies – manage stress

    • Meditation

    • Biofeedback


Sunshine circadian rhythms and sleep
Sunshine, circadian rhythms and sleep function of change in provider’s patient-centeredness

Desynchronization of internal rhythms plays an important role in the pathophysiology of depression.

Resetting normal circadian rhythms can have antidepressant effects.

“Winter depression was first modeled on regulation of animal behavior by seasonal changes in day length, and led to application of light as the first successful chronobiological treatment in psychiatry.”

Fuchs E. Int Clin Psychopharmacol, 2006

Wirz-Justice A. Int Clin Psychopharmacol. 2006


You are my sunshine
You are My Sunshine! function of change in provider’s patient-centeredness

  • SAD - Known association between inadequate sunshine and depression

  • Frequent indoor tanners are often depressed and seeking relief; watch for rebound depression if they stop

  • How much? 10 – 15 minute daily of exposure to hands and face in spring, summer fall; wintertime? Latitude?


Light therapy for depression
Light Therapy for Depression function of change in provider’s patient-centeredness

Plus 3 studies not included in this review, comparing dim light to bright light. Golden R. Am J Psychiatry. 2005


Vitamin d and depression
Vitamin D and depression function of change in provider’s patient-centeredness

  • Vitamin D receptors in brain

  • Low level of serum 25-hydroxyvitamin D and high PTH are significantly associated with depression (Jorde, 2005)

  • 25-hydroxyvitamin D3 and 1,25-dihydroxvitamin D3 levels are significantly lower in psychiatric patients than in normal controls (Schneider, 2000)

  • RCT of 44 Australian patients (none, 400 IU versus 800 IU vitamin D) vitamin D3 significantly enhanced mood (Landsdowne, 1998)


Light therapy
Light therapy function of change in provider’s patient-centeredness

  • Proven effective for SAD (Terman M Evid Based Ment Health, 2006)

  • Meta-analysis of studies from 1987-2001: (effect size=0.53, 95% CI=0.18 to 0.89, similar to medications) for non-SAD

  • RCT of 29 women with non-seasonal depression; light therapy for 28 days significantly better than control, (McEnany GW, 2005)


Light therapy 2
Light Therapy 2 function of change in provider’s patient-centeredness

  • Benefits onset within 2 days; effective in institutionalized elderly and community; effective in summer and winter

  • Side effects: hypomania, autonomic hyperactivation (Terman M, 2005)


Lifestyle 2 exercise
Lifestyle 2: Exercise function of change in provider’s patient-centeredness

  • Depressed mood / fatigue are common in those deprived of usual exercise.

  • Mood changes noted in patients with injuries and mono.

  • Changes over time in kids’ exercise/gym/playground time

  • Exercise benefits depression *

  • Common sense precautions

Berlin AA. Psychosomatic Med, 2006


Exercise as therapy yes
Exercise as Therapy – Yes function of change in provider’s patient-centeredness

Lawlor DA. BMJ 2001


Yoga for depression
Yoga for depression function of change in provider’s patient-centeredness

  • Five RCTs --each used different forms of yoga.

  • All trials reported positive findings

  • No adverse effects except fatigue and breathlessness

    Pilkington K. J Affective Disord, 2005


Lifestyle 3 sleep
Lifestyle 3: Sleep function of change in provider’s patient-centeredness

  • Poor sleep is barometer of later mental health risks (anxiety and depression)

  • Reduced sleep equals impaired focus and labile mood (ADHD, Learning problems)

  • Sleep quality is a good screen for good mental health in pediatric population

  • We sleep 20% less than we did 100 yrs ago


Lifestyle 3 sleep1
Lifestyle 3: Sleep function of change in provider’s patient-centeredness

  • Regular time; Routine

  • Hot bath; cool room; dark room

  • Massage before bed

  • Lavender, chamomile, melatonin?

  • No caffeine within 8 hours of bedtime

  • Music, calm, orderly, quiet

  • NO TV IN BEDROOM

  • NO vigorous exercise right before bed

  • GET MORE versus intentional sleep reduction/deprivation (in those with excessive sleep)


4 nutrition essential nutrients for optimal brain function
4: Nutrition – essential nutrients for optimal brain function

  • Omega-3 fatty acids

  • Amino acids (SAM-E, Trp, 5-HTP)

  • Vitamins (B vitamins, Vitamin D)

  • Minerals (Iron, Calcium, Magnesium, Zinc)


Omega-6 Fatty Acids function

Omega-3 Fatty Acids

Linoleic Acid (18:2n-6)

a-Linolenic Acid (18:3n-3)

∆-6 Desaturase

(GLA)γ -Linolenic Acid (18:3n-6)

Stearidonic Acid (18:4n-3)

Elongase

(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)

Eicosatetraenoic Acid (20:4n-3)

∆-5 Desaturase

Eicosanoids

(AA)Arachidonic Acid (20:4n-6)

(EPA) Eicosapentaenoic Acid (20:5n-3)

Elongase

24:5n-3

Eicosanoids

Leukotriene 5-series

Prostaglandins E3

Thromboxanes A3

∆-6 Desaturase

Eicosanoids

Leukotriene 4-series

Prostaglandins E2

Thromboxanes A2

24:6n-3

β-Oxidation

(DHA) Docosahexaenoic Acid (22:6n-3)


Omega 3 efa s mechanism
Omega 3 EFA’s: mechanism function

  • Neuronal membrane structure and function

  • Brain development

  • Second messenger inside cells


Mood and omega 3 s
Mood and Omega-3’s function

  • Inverse correlation between fish intake and depression

    (Hibbeln: Lancet 1998; 351:1213)

  • Effective for bipolar patients

    (Stoll: Arch. of Gen. Psych. 1999; 56: 407-12)

  • Effective for major depression

    (Nemets: Am. J. Psych. 2002: 159 (3) 477-9)

  • Effective for depression in Children

    ( Am J Psychiatry 2006;163:1098-0)

  • Effective for Borderline P.D.O.

    (Am. J. Psych. 2003, 160 (1): 167-9)


Fish oil doses safety brands
Fish Oil –Doses, Safety, Brands function

  • Dose: 1 gram daily of EPA probably enough.(Peet M, 2002); Frangou S. Br J Psychiatry, 2006)

  • Safety: fish allergies, taste, belching; very high doses, increased risk of bleeding, nosebleeds? Little risk of mercury, dioxin, PCB’s;

  • Brands: Compare brands at www.consumerlabs.com

  • My family takes Coromega, Carlson’s or Nordic Natural

  • Read labels: Omega 3 does NOT necessarily all equal EPA/DHA


Amino acids sam e
Amino Acids: SAM-E function

  • Produced from ATP and methionine

  • Low folate can lead to low levels

  • Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications (http://www.ahrq.gov/clinic/epcsums/samesum.htm)

  • In an open trial of 30 adults with MDD for whom antidepressant meds ineffective, SAM-E led to significant improvements in 50% and remission in 43% (Alpert, 2004)

  • All tested products approved by ConsumerLab; buy on sale!


Sam e doses duration products
SAM-E Doses, duration, products function

  • Dose: 800 – 1600 mg daily (adult)

  • Benefits appear within 2-4 weeks of starting daily use

  • Problems –poorly absorbed (need enteric coating); mania in bipolar patients; interactions with SSRI meds; see: http://www.consumerlabs.com/results/same.asp

  • http://www.umm.edu/altmed/ConsSupplements/SAdenosylmethionineSAMecs.html


Amino acids 5 htp and l tryp
Amino Acids: 5-HTP and L-tryp function

  • Acute tryp depletion leads to depression

  • Dietary L-tryp -> 5-HTP -> serotonin

  • Meta-analysis: 5-HTP and L-trp better than placebo for depression (Shaw K, Cochrane. 2002)

  • Food sources – dairy, eggs, poultry, meat, soy, tofu, nuts; WHEY protein


L tryp doses and side effects
L-tryp doses and side effects function

  • Doses - start at 50 mg TID; max dose 1200 mg daily

  • Side effects – EMS related to contaminated lot from one manufacturer; nausea, drowsiness; May potentiate SSRI medications; decreased carbohydrate intake and weight loss?


Vitamin b6 pyridoxine
Vitamin B6 - pyridoxine function

  • Low levels of pyridoxal phosphate (PLP) are associated with depressive symptoms (Hvas AM 2004)

  • Dose: 100 – 200 mg daily benefits PMS- depression; Odds ratio ~2.(Wyatt KM. BMJ, 1999)

  • Side effects: nausea, vomiting, abd. pain, anorexia, headache, somnolence, lower B12 levels, sensory neuropathy (typically with doses over 1000 mg daily, can occur lower)

  • Food: Beans, nuts, legumes, fish, meat


Folate
Folate function

  • Folate (Essential co-factor for synthesis of S-adenosyl-methionine).

    • Lower levels of folate in depressed persons

    • Low folate associated with poorer response to antidepressant meds

  • Methylfolate in depressed pts (elderly, EtOH dependent, dementia) show significant improvement (Guaraldi et al., 1993; Di Palma et al., 1994; Glória et al., 1997; Passeri et al., 1993)

  • RPCT: folate as adjunctive Rx in folate deficient MDD pts showed signif improvement over placebo (Godfrey et al., 1990)

  • RPCT MDD pts randomized to fluoxetine + folate (0.5mg) improved more than fluox. + placebo; differences esp striking in WOMEN (Coppen & Bailey 2000)

  • Studies on supplements in non-folate deficient MDD pts on SSRIs found significant reduction in sx severity and 19% remission (Alpert et al., 2002)

  • Folate augmentation may enhance response to lithium in folate deficient bipolar and unipolar depression (Coppen and Chaudhry, 1986)


Bottom line on b vitamins
Bottom line on B vitamins function

  • Healthy diet rich in green vegetables and nutritious protein sources

  • Consider B-complex supplement


Mood and minerals iron
Mood and Minerals: Iron function

  • Iron deficiency associated with depression

  • Correcting iron deficiency helps with mood and attention

    Beard JL. J Nutr, 2005

    LE Murray-Kolb. Am J Clin Nutr, 2007


Mood and minerals calcium
Mood and Minerals: Calcium function

  • Lower levels of calcium in depressed persons

  • Higher PTH in depressed persons

  • Estrogen regulates calcium and PTH metabolism; sometimes dysregulates? (Thys-Jacobs S. J Am Coll Nutr, 2000)

  • Supplementation may benefit women with PMS-related depression (Dickerson LM. Am Fam Physician, 2003)

  • 1000 – 1200 mg daily


Non dairy sources of calcium
Non-dairy sources of calcium function

  • Soy beans, tofu

  • Calcium fortified OJ

  • Green leafy vegetables (broccoli)


Nutrition summary
Nutrition Summary function

  • Healthy fat (omega 3); not fried foods, saturated fats

  • Healthy protein (essential amino acids)

  • Foods rich in minerals and vitamins (vegetables, grains)

  • Multivitamin-mineral supplement

  • Fish oil supplement

  • Consider SAM-E, B vitamins


Lifestyle stress management
Lifestyle: Stress management function

  • Stress is common

  • Stress commonly triggers mood problems

  • Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit

    • Meditation

    • Biofeedback


Meditation
Meditation function

  • Meditation training ↑ left-sided anterior activation, a pattern associated with positive affect, in meditators compared with the nonmeditators

  • No RCTs specifically on depression, though positive effects on anxiety

  • Few side effects; can combine mindfulness with CBT

    Davidson RJ Psychosom Med, 2003


Emotional self management
Emotional Self-Management function

  • Intentional focus on emotions

  • Gratitude

  • Practice

  • Warm-up


Appreciation audit
Appreciation audit function

  • Daily journal

  • For what are you grateful today?

  • What do you appreciate about those closest to you?

  • To whom have you extended goodwill or kindness?

    What Happy People Know: How the New Science of Happiness Can Change Your Life for the Better (Paperback) by Dan Baker, Cameron Stauth. St. Martin's Griffin. 2004


Stress, Emotion, and Physiological Activation function

High Arousal/High Energy

SYMPATHETIC

Low Arousal/Low Energy

PARASYMPATHETIC


Stress, Emotion, and Physiological Activation function

High Arousal/High Energy

SYMPATHETIC

“Fight-or-Flight”

LOW PERFORMANCE

HIGH PERFORMANCE

Negative

Emotion

Positive

Emotion

Low Arousal/Low Energy

PARASYMPATHETIC


Stress, Emotion, and Physiological Activation function

High Arousal/High Energy

SYMPATHETIC

“Fight-or-Flight”

Frustration, Anger, Hostility,

Exhilaration, Passion,

Fear, Worry Anxiety

Joy, Happiness

Judgment, Resentment,

Love, Care,

LOW PERFORMANCE

HIGH PERFORMANCE

Feeling Overwhelmed, Anguish

Kindness, Appreciation

Negative

Emotion

Positive

Emotion

Hopelessness, Submission,

Compassion, Tolerance,

Despair, Depression

Acceptance, Forgiveness

Burnout, Withdrawal,

Boredom, Apathy

Serenity, Inner Balance,

Reflection, Contentment

Low Arousal/Low Energy

PARASYMPATHETIC


Stress management biofeedback
Stress management: biofeedback function

  • HRV biofeedback appears to be a useful adjunctive treatment for the treatment of MDD

  • Significant improvements in

    • Hamilton Depression Scale (HAM-D)

    • Beck Depression Inventory (BDI-II) by week 4,

      Karavidas, et al. Appl Psychophysiol Biofeedback. 2007

      Nolan RP. Am Heart J, 2005


Which of the following is true about lifestyle approaches to mood problems1

10 function

Answer Now

Which of the following is true about Lifestyle approaches to mood problems?

  • Lifestyle affects cardiac health, but has little impact on mental health

  • Lifestyle affects cancer risk, but has little impact on mental health

  • Lifestyle affects BOTH cardiac and cancer risks, but has little impact on MH

  • Lifestyle, such as light, sleep, exercise and nutrition can have profound and clinically significant effects on mental as well as physical health.


After lifestyle and stress management what
After lifestyle and stress management, what? function

  • St. Johns’ wort

  • Massage

  • Acupuncture


Which of the following is the best statement about saint johns wort

10 function

Answer Now

Which of the following is the best statement about Saint Johns wort?

  • St. Johns wort has repeatedly proven ineffective in treating adolescent depression.

  • St. Johns wort frequently causes allergic reactions.

  • St. Johns wort may be ineffective, but because it is safe, teens can use it safely, so docs can ignore it.

  • St. Johns wort is about as effective as SSRIs but can interfere with the effectiveness of many common medications including OCPs, so docs need to ask about it.


Saint johns wort
Saint Johns wort function

  • Most commonly used CAM therapy for depression

  • Comparable to sertraline in German RCT of 241 depressed adults (Gastpar. Pharmacopsychiatry, 2005)

  • 2 open label trials in teens showed improvement within 2 weeks in 25/33 and 9/11 patients (Findling, 2003; Simeon, 2005); Improvement in 2 weeks predicts long-term response; if no benefit in 2 weeks, stop

  • “Current evidence regarding hypericum extracts is inconsistent and confusing”; different products used in different trials, different kinds of patients; in some studies St. Johns wort is as effective as standard medications, but no more effective than placebo. (2005 Cochrane review)


Herb drug interactions sjw
Herb- drug interactions: SJW function

Speeds elimination of many drugs: digitalis, theophylline, clarithromycin, erythromycin, protease inhibitors and OCPs


Sjw safety
SJW safety function

  • Other side effects - photosensitivity, serotonergic syndrome

  • Product variability; see www.consumerlabs.com: Gaia, Kira, Sundown, Nature’s Bounty

  • Products used in POSITIVE TRIALS: Laif 900 (German STW3-VI); LI160 (Kira), WS5572; WS5570 (Perika by Nature’s Way)

  • St. Johns wort patient handouts are available from:

    University of Maryland Medical Center

    Wake Forest University Baptist Medical Center’s Best Health internet site (www.besthealth.com)

    Harvard Medical School-Intelihealth


Which of the following is the best statement about saint johns wort1

10 function

Answer Now

Which of the following is the best statement about Saint Johns wort?

  • St. Johns wort has repeatedly proven ineffective in treating adolescent depression.

  • St. Johns wort frequently causes allergic reactions.

  • St. Johns wort may be ineffective, but because it is safe, teens can use it safely, so docs can ignore it.

  • St. Johns wort is about as effective as SSRIs but can interfere with the effectiveness of many common medications including OCPs, so docs need to ask about it.


Massage
Massage function

  • Increased blood flow and lymphatic drainage; Muscle relaxation; Stress reduction

  • Balances R & L prefrontal cortex activity in those with right dominance (Jones N Adolescence. 1999)

  • Decreased levels of cortisol and increased levels of serotonin and dopamine in depressed adults (Field T. Int J Neurosci. 2005)

  • In depressed pregnant women, massage, compared with progressive relaxation, led to higher dopamine and serotonin levels and lower levels of cortisol and norepinephrine (Field T. J Psychosom Obstet Gynaecol. 2004 )

  • Who volunteers?


Acupuncture
Acupuncture function

  • RCT of 30 patients: BDI scores fell from baseline by 16.1 points in the intervention group versus 6.8 points in the sham controls (P<0.001) (Acupunct Med. 2005)

  • Meta-analysis: the effect of electroacupuncture similar to antidepressant medication(Mukaino Y Acupuncture Med, 2005).

  • No pediatric studies. Good safety profile. Rare infections, broken needles, forgotten needles, bleeding, bruising


Depression summary 1
Depression SUMMARY 1 function

  • Listen to patients and families

  • Negotiate clear goals and agreements

  • Support healthy lifestyle, including sunshine, sleep, exercise, nutrition (supplement when necessary), appreciation and stress management


Depression summary 2
Depression SUMMARY 2 function

  • Correct deficiencies of B vitamins and minerals

  • Consider supplements of fish oil, SAM-E, 5-HTP

  • Consider safe therapies, including massage and acupuncture

  • Beware of potential interactions, e.g., Saint Johns wort

  • Be PRACTICAL – How?


How behavioral pediatrics
How: Behavioral Pediatrics function

  • Identify the goal

  • Consider various strategies

  • Pick a strategy

  • Identify a small, achievable step that the patient and family can support

  • Explore pros and cons of change

  • Anticipate barriers; identify resources

  • Plan rewards/celebrations!

  • Re-evaluate; take the next step


Goal setting
Goal-setting function

  • Pick a POSITIVE goal

    • E.g., more DRY nights (not just stop bed wetting); healthier lifestyle

  • Identify values behind the goal

    • Health, relationships, esteem, integrity, etc.


Example healthier lifestyle
Example: Healthier lifestyle function

To promote

Better mood

Better focus or concentration

Greater calm More resilience

More cheerfulness Greater adaptability

More confidence More creative

More clarity

Better memory

More harmonious relationships

Higher self esteem

More consistent with personal values

other?


Pick a specific strategy
Pick a specific strategy function

  • More exercise

  • Better nutrition

  • Judicious use of supplements

  • Better sleep

  • Healthier environment

  • Stress management; biofeedback; journal; meditation

  • Use medication

  • Massage, psychotherapy, acupuncture or other professional help


Identify a small achievable step
Identify a small, achievable step function

  • Rome was not built in a day; habits are not changed overnight: BABY STEPS.

  • For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week.

  • Be specific (with or without an MP3 player; with or without a parent; regardless of weather?; distance vs. time)


How important is this to you
How functionimportant is this to you?

0 1 2 3 4 5 6 7 8 9 10

Not Very

Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5)

Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it!


How confident are you that you can do this for one month
How functionconfident are you that you can do this for one month?

0 1 2 3 4 5 6 7 8 9 10

Not Very

If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and planning rewards and follow-up.

If they pick a number less than 8,

“What would it take for you to go from the number you picked to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent about change!



Identify barriers and resources

In addition to (cons listed above), functionwhat other barriers or challenges might you anticipate as you try to make this change? Need new tennis shoes; need leash; need pooper-scooper

What resources do you have/need to help you make this change? Will Mom commit to getting new shoes, leash, etc. ? Will the child want/need a reminder? Is it helpful for Dad to do that? Do they need a chore chart? A calendar?

Identify Barriers and Resources



Plan celebrations rewards
Plan celebrations/rewards function

  • Pick a tangible reward and timing (will it be offered after week 1, 2, 3, 4?)

  • Samples: extra time with mom or dad; extra phone minutes; new walking shoes; get to pick vegetable for dinner!; get to pick family movie; stickers for younger kids; money for older kids – controversial in some families. Support the family and child choices.

  • Emphasize the importance of the reward/celebration. If the family says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it).


Follow up

Follow- up in 4-6 weeks. function

Ask family/child to bring chart and say you plan to be proud of them (build expectation of success) and will ask them what they’d like to do for next step (involve them in problem solving).

Do it!

Follow Up


Behavioral pediatrics
Behavioral Pediatrics function

  • Identify the goal

  • Consider various strategies

  • Pick a strategy

  • Identify a small, achievable step that the patient and family can support

  • Explore pros and cons of change

  • Anticipate barriers; identify resources

  • Plan rewards/celebrations!

  • Re-evaluate; take the next step


10 function

Answer Now

Which of the following best describes your awareness of additional resources about topics discussed in this session? I know where to turn for additional information about….

  • .. natural therapies for depression.

  • .. Patient-centered communication

  • … motivational interviewing

  • All of the above


Resources
Resources function

  • Kemper KJ, Shannon S. Complementary and alternative medicine therapies to promote healthy moods. Pediatr Clin North Am. 2007 Dec;54(6):901-26

  • Wissow LS, Gadomski A, Roter D, et al.Improving child and parent mental health in primary care: a cluster-randomized trial of communication skills training. Pediatrics. 2008 Feb;121(2):266-75

  • Society for Developmental/Behavioral Pediatrics

  • Developmental and Behavioral Pediatrics: A Handbook for Primary Care (Parker, Developmental and Behavioral Pediatrics) (Paperback) Parker, Zuckerman, Augustyn

  • Motivational Interviewing: Preparing People to Change by Miller and Roznik


10 function

Answer Now

Which of the following best describes your awareness of additional resources about topics discussed in this session? I know where to turn for additional information about….

  • .. natural therapies for depression.

  • .. Patient-centered communication

  • … motivational interviewing

  • All of the above


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