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Psychopharmacology in Primary Care: How to treat ADHD, Anxiety and Depression in your school based practice. Presented by: Kristie Ladegard, MD, Monica Morris, LCSW and Elizabeth Milhaupt, LCSW Denver Health School Based Health Centers.
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Kristie Ladegard, MD,
Monica Morris, LCSW and Elizabeth Milhaupt, LCSW
Denver Health School Based Health Centers
No improvement after 3 months
Symptoms worsen after 1 month
Medication change needed
Self harm thoughts/ behaviors
Stable on medication
Mild to moderate symptoms
Comorbidity is common; 40% to 90% of youth with depressive disorder also have other psychiatric disorders and up to 50% have two or more comorbid diagnoses 5
Most frequent comorbid diagnoses are:
Do not use doses higher than 40mg.
Since the FDA issued a black box warning, there has been a decline in antidepressant use, but an increase in completed suicides in adolescents in both the United States and the Netherlands. Although it is not clear how these trends are related this is the first increase in suicide rate reported in over a decade11
Most children and adolescents with the disorder have the Combined Type.
stimulant it is recommended to get a physical
exam, blood pressure, pulse, weight, and height. Once on a stimulant check height, weight, blood pressure and pulse initially after starting the medication, or when a change of dose is made, and when dose is established then check every 3 months 6
DSM-IV TR and V: DSM-V was released at the annual APA’s meeting May 2013.
Vanderbilt Assessment Scales (VAS) as referenced in the ADHD vignette:
1ParentsMedGuide.Org. Retrieved from http://www.parentsmedguide.org/parentsmedguide.htm
2 Birmaher B, Ryan ND, Williamson DE et al. (1996), Childhood and adolescent depression: a review of the past ten years. Part I. Journal American Academy Child Adolescent Psychiatry 35: 1427-1439.
3 Angold A, Costello EJ, Worthman CM (1998), Puberty and depression: the roles of age, pubertal status and pubertal timing. Psychol Med 28: 51-61.
4Lewinsohn PM, Rohde P, Seeley JR (1998), Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clinical Psychological Review 18: 765-794.
5 American Academy of Child and Adolescent Psychiatry, (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Journal of the American Academy of Child and Adolescent Psychiatry (46)11 (1503-1526)
6SadockJ.Benjamin, Sadock A. Virginia (2009) Concise Textbook of Child and Adolescent Psychiatry. Pataki SC, Ahmad S, eds. Philadelphia: Lippencott Williams and Wilkins
7 Forest Laboratories, Inc. (December 2012). Lexapro Prescribing Information. Retrieved from http://www.frx.com/pi/lexapro_pi.pdf
8 American Academy of Child and Adolescent Psychiatry. (2010) FDA Action on Paxil. http://www.aacap.org/cs/root/resources_for_families/psychiatric_medication/fda_action_on_paxil
9Dulcan K. Mina, Wiener M. Jerry (2006) Essentials of Child and Adolescent Psychiatry. Dulcan KM, Wiener MJ, eds. Washington D.C.: American Psychiatric Publishing Incorporated.
10Bridge JA, Iyengar S, Salary CB., Barbe P, Birmaher B, Pincus HA, Ren L, & Brent DA. (2007). Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. Journal of the American Medical Association 297: 1683-1696
11 Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, ErkensJA, Herings RMC, Mann JJ, Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents American Journal of Psychiatry 164:1356-1363, September 2007
12 Walsh, B. W. (2006) Treating Self Injury: A practical guide, Guilford Press
13 Walsh, B. W & Rosen, P. (1988). Self mutilation: Theory, research, and treatment. New York: Guilford Press.
14 American Academy of Child and Adolescent Psychiatry (2010), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Post Traumatic Stress Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, (49)4 414-430
15 American Academy of Child and Adolescent Psychiatry, (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry (46)3 267-283
16Compton S et.al. (2010), Child Adolescent Anxiety Multimodal Study (CAMS); rationale, design, and methods. Child and Adolescent Psychiatry MentalHealth 4:1
17Strawn J etal (2009), Prazosin Treatment of an Adolescent with Posttraumatic Stress Disorder. Journal of Child and Adolescent Psychopharmacology Volume 19:599-600
18Harvard Medical School (May 2009). Take a deep breath. http://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2009/May/Take-a-deep-breath
19 American Academy of Child and Adolescent Psychiatry (2007), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry (46)7 894-921
Rohde P, Lewinsohn PM, Seeley JR (1991), Comorbidity of unipolar depression: II. Comorbidity with other mental disorders in adolescents and adults. Journal of Abnormal Psychology 100: 214-222.
FombonneE, Wostear G, Cooper V, Harrington R, Rutter M (2001), The Maudsley long term follow-up of child and adolescent depression 1. Psychiatric outcomes in adulthood. Br J Psychiatry 179: 210-217.