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Psychiatric illnesses in Children and Adolescents: types and treatment

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Psychiatric illnesses in Children and Adolescents: types and treatment Lee W. Bradshaw APRN-BC McKay-Dee Behavioral Health Institute. Treating anxiety disorders ... – PowerPoint PPT presentation

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Title: Psychiatric illnesses in Children and Adolescents: types and treatment


1
Psychiatric illnesses in Children and
Adolescentstypes and treatment
  • Lee W. Bradshaw APRN-BC
  • McKay-Dee Behavioral Health Institute.

2
Types of illnesses
  • Depression
  • Bipolar disorder
  • Anxiety disorders
  • ADHD

3
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

4
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

5
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

6
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

7
Types of Anti-depressants
  • SSRIs
  • Prozac/fluoxetine
  • Paxil/paroxetine
  • Zoloft/sertraline
  • Celexa/citalopram or Lexapro/escitalopram
  • Luvox/fluvoxamine
  • SNRIs
  • Effexor/venlafaxine
  • Cymbalta/duloxetine

8
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)

9
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.

10
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

11
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

12
How are kids different?
  • No cadillacs and presidents
  • Hypersexuality
  • Grandiosity
  • More unstable with an anti-depressant?
  • Exacerbated by stimulants

13
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

14
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)

15
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

16
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

17
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

18
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

19
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

20
Warnings about anti-psychotics
  • Metabolic syndrome DM, lipids
  • Parkinsonian symptoms EPS
  • Tardive Dyskinisia
  • Neuroleptic Malignant Syndrome

21
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 dont have it

22
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
  • Cant sustain attention in tasks or play
    activities

23
Hyperactivity
  • Fidgets with hands or feet or squirms in seat
  • Cant stay in seat
  • Runs about or climbs excessively
  • Cant be quiet
  • "on the go" or often acts as if "driven by a
    motor"
  • talks excessively

24
Impulsivity
  • blurts out answers before questions have been
    completed
  • difficulty awaiting turn
  • interrupts or intrudes on others (eg, butts into
    conversations or games)

25
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

26
Treating ADHD
  • Stimulants
  • Methyphenidates
  • Single vs dual isomers
  • Dextroamphetamines
  • single isomer
  • Pro-drugs
  • Multi-isomers, mixed salts
  • Stattera/atomoxatine
  • Wellbutrin/buproprion

27
Methyphenidate
  • Ritalin, Ritalin SR, Ritalin LA
  • Metadate
  • Concerta
  • Focalin
  • Daytrana (patch)

28
Dextroamphetamines
  • Dexedrine, spansules, dextrostat
  • Adderall (4 isomers)
  • Vyvanse

29
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

30
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.

31
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

32
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

33
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

34
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

35
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
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