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Prescribing for Adolescents. Significant Psychosis**** Hyperactivity OCD Depression**** Tourettes/Tics Rare or not at all MR Autism Conduct Disorder Eating Disorders Sleep Disorder Anxiety Disorder Enuresis.

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scope when is psychotropic drug treatment significant for children and adolescents
Significant

Psychosis****

Hyperactivity

OCD

Depression****

Tourettes/Tics

Rare or not at all

MR

Autism

Conduct Disorder

Eating Disorders

Sleep Disorder

Anxiety Disorder

Enuresis

Scope – when is psychotropic drug treatment significant for children and adolescents?
key issues in adolescence for mental health services
Key issues in Adolescence for Mental Health Services
  • Developmental issues
    • Physical development : puberty
    • Thinking and reasoning
    • Self and identity
    • Relations with family : transition & autonomy
    • Sexuality
    • Friendship and peer groups
    • Education, training and work
    • Anti-social and offending behaviour
    • Stress, coping and adjustment
    • Culture and ethnicity
limits on child adolescent psychopharmacolgy
Limits on Child & Adolescent Psychopharmacolgy
  • Limited evidence base
    • Few RCTs
    • Reliance on downward extrapolation from adult studies
    • Developmental and pharmacodynamic differences child/adult
    • Off-label prescribing [USA 80%, Jensen 1999]
strategy for optimal psychopharmacological treatment of adolescents the big 8
Strategy for optimal psychopharmacological treatment of adolescents [The Big 8]
  • Clear psychiatric diagnosis
  • Identification and measurement of those features that are the target of treatment
  • Treatment “contract” with the patient (and when appropriate, the family]
  • Good knowledge about various treatment options and their relative risks and benefits
  • Factors that can influence treatment:
    • psychological, family, social, and economic
  • Useful methodology for determining efficacy and optimization of treatment
  • A constructively critical attitude about models of patho-etiology and how they relate to treatment.
  • Knowledge of and proficiency in a model of therapeutics that can allow for the implementation and integration of various useful treatments
the school or work and social environment
The school or work and social environment
  • Academic/work history
  • Peer relationships
  • Self-management/independent living skills
  • Contact school/college [with consent]
      • Reports etc
specific child adolescent issues
Specific child & adolescent issues
  • Consent and capacity
    • MHA 1983 & Children Act 1989
    • Gillick competence
    • Refusal of treatment by competent child
  • Child protection
    • Duty to protect
    • Violence and sexual aggression :in-patient units
baseline assessment general issues
Baseline Assessment: General Issues
  • Patient and his or her symptoms
    • Psychiatric history
    • Mental State Examination
    • Measure specific symptoms that are focus of treatment
    • Medical Assessment including baseline assessment of symptoms which may later feature as adverse side effects
the patient s family or living unit
The patient’s family or living unit
  • Family roles
  • Family psychiatric history
    • Response to previous treatments
  • Value systems and attitude to mental health issues and medication
practice points on family interviewing
Practice points on family interviewing
  • Younger adolescents best seen with parents, then alone
  • Older adolescents need the choice
  • Depressed/anxious parents over-report child behaviour
  • Parents are less aware of mood states in their children
  • Crisis management/emergencies may require serial interviews and/or telephone contacts
adolescent onset schizophrenia 13 19 years of age
Adolescent onset schizophrenia (13-19 years of age)
  • 50 times less often before age 15 years than after it (Beitchrnan, 1985).
  • Average of first onset [EPPIC] 19 years
  • Insidious onsets more common
  • Long term Social outcomes are still very poor [Hollis 2000]
atypical antipsychotics
Atypical Antipsychotics
  • Risperidone, Olanzepine, Quetiapine, Clozapine, Amisulpiride,
    • Standard antipsychotic choice for children & adolescents (70-80%o)
    • very limited evidence-base in younger patients (1 RCT:Kumra et al 1996)
    • possible increased efficacy against negative symptoms, cognitive impairment
    • Variable profile of side effects, reduced EPSE
side effects of antipsychotics
Side-Effects of Antipsychotics

Can be more severe in children/ adolescents than adults and include:

  • Dystonias/ EPSE/TD
  • Increased appetite and weight gain
  • Type II diabetes & lipid changes
  • Blood dyscrasias (neutropenia/ agranulocytosis)
  • Cardiac arrhythmias, inc. QTc interval
  • elevated prolactin -> reduced estrogen,osteoporosis
  • Seizures
weight gain in adolescents olanzepine vs risperidone vs haloperidol
Weight Gain in Adolescents Olanzepine vs. Risperidone vs. Haloperidol

Mean age 17 years

mean dosage:

Olanzepine 12.7mg. Risperidone 3.2mg. Haloperidol 7.6mg

drug initiation
Drug Initiation
  • Start Low, Go Slow
    • Risperidone 0.5mgs
    • Olanzapine 2.5mgs nocte
    • Clozapine 12.5mgs [50mgs/2days]
  • Increase every 3 to 5 days
  • Most side-effects occur early (first 4-6 weeks)
  • Add benzodiazepine (e.g lorazepam 1-2 mg, diazepam 2-5mgs, Clonazepam 0.5-2mgs) for arousal/ agitation
  • Severe violence/agitation may need RT protocol
atypicals target dose ranges
Atypicals: Target Dose Ranges

mgs

  • Risperidone 2-6
  • Olanzepine 2.5-20
  • Quetiapine 150-600/750 b.d.
  • Amisulpiride 400-1200
  • Clozapine 300-600

Clozapine plasma level >350ng/ml (0.35mg/L))

switch to clozapine
Switch to Clozapine
  • Review diagnosis and treatment compliance
  • Consider lithium if marked affective component
  • Consider Shot antipsychotic if compliance poor
  • Switch to clozapine: titrate to optimal dose.
  • Control for plasma levels and side effects, Continue for 3 – 6 months

not effective or not tolerated

if clozapine does not work
If Clozapine does not work
  • Review diagnosis and treatment compliance; withdraw all ineffective medication; give previous most effective drug lowest effective dose;

or

  • Consider another atypical or depot antipsychotic;
  • re-consider cognitive behavioural intervention
summary
summary
  • Schizophrenia in children and adolescents requires early detection and intervention.
  • atypicals are first line Tx
  • side Effect profiles mainly determine choice
  • share information and decisions with patient and family
  • interpretation of [NICE] time scales is not clear for >18
  • is early use of Clozapine justified?
depression 1975 marion patrick 1940 1993
Depression (1975), Marion Patrick (1940-1993)

‘A child endures or enjoys overwhelming misery or overwhelming happiness because he isolates the moment and does not connect it with the future or the past. In my work I try to convey this isolation’.

antidepressants for l8 s position up to june 2003
Antidepressants for <l8’sPosition up to June 2003
  • TCA’s: in RCT’s, lack efficacy; risky side-effects, e.g. cardiac
  • MAOI’s: no RCTs; high toxicity
  • SSRIs: Until 2003, considered relatively safe;
    • Fluoxetine and Paroxetine efficacious in RCT’s; many open label trials; ‘TREATMENT OF CHOICE’
    • Nefazodone (NASSA), Venlafaxine (SNRI), some studies (inconclusive)
antidepressants in 18 s current position jan 2004
Antidepressants in ~18’s – current position :Jan. 2004

Licensed use

  • US: Fluoxetine for OCD [>7yrs+ ] and depression [>8yrs]
  • Sertraline for OCD [>6yrs)
  • Paroxetine and Venlafaxine contraindicated: new data show unfavourable balance of risks [esp. re suicidality] vs benefits.
  • Fluvoxamine may be used for OCD
  • Expert Working Group Looking urgently at wider safety issues re SSRl’s in paediatric population
cbt for depressed children and adolescents does it work
CBT for depressed children and adolescents – does it work?
  • NOT for severely depressed adolescents [Harrington 1998]
  • Treatment of choice for mild/moderate depression, high rates of recurrence.
  • IPT - promising, only one RCT
prognosis the transition to adulthood
Prognosis – the transition to adulthood
  • Most will recover from their depressive Episode
  • However, high rate of recurrence Predicted by severe presentation and Absence of conduct disorder
  • Rapid cycling mood overlaps with Emotionally Unstabel PD
  • Dysthymia often confused with depressive Episodes
  • Small number develop Bipolar Disorder Small number go on to kill themselves