Psychiatric medication paec november 2013


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  • -Prescription abuse amongst adolescents is very common. Most commonly abused prescription drugs are Adderall and Oxycontin and Vicodin. 58% of the drugs abused by students in the 12th grade are prescribed drugs or OTC drugs.-About 71% of high school seniors drink alcohol and 23% had binge episode (which is 5 or more drinks at one time) in the past 2 weeks. Also, about 13% of adolescents has driven a car under the influence of alcohol and about 33% has been in a car with a driver who was drinking.About 50% of homicides/suicides/and injuries are associated with alcohol and alcohol accounts for 80% of teen deathInhalants- about 15% of 8th grades have used inhalants, so other then what's listed above what are other inhalants? Glues, nail polish remover, lighter fluid, hairspray, deodorants, and spray paintsInhalants decrease the oxygen binding capacity in the body which then damages vital organs OTC meds commonly abused are: Cough/cold syrups, Sleep medication, Diet pills
  • -decreased motor performance in intoxication of marijuana is due to slowed sense of time
  • - Unfortunately there are not many drugs approved by the FDA for substance abuse in adolescents. There are only drugs for opioid dependence mostly since only a few have been studied in adolescents
  • Psychiatric medication paec november 2013

    1. 1. PSYCHIATRIC MEDICATION UPDATE FOR CHILDREN & ADOLESCENTS Dr. Daniel Martinez Comprehensive Clinical Services, P.C.
    3. 3. Biological Psychological Sociological Cultural Spiritual
    5. 5. Neuron in Action
    7. 7. SPECT SCAN Neuroimaging in Psychiatry Neuroimaging in psychiatry By Tripura Medical College , Slide 23
    8. 8. Images (c) Dr. Amen
    9. 9. Images (c) Dr. Amen Images (c) Dr. Amen
    10. 10. Images (c) Dr. Amen
    11. 11.
    12. 12. MEDICATIONS APPROVED FOR CHILDHOOD PSYCHIATRY • Depression • Psychosis • Anxiety • Mania • Substance Abuse • Autism/Asperger’s • ADHD
    13. 13. Rema El-Ammori, 3 rd Year Medical Student DEPRESSION
    14. 14. ADOLESCENT CLINICAL PRESENTATION • Anger • Academic difficulties • Behavioral changes • Reckless or hostile behavior • Social withdrawal • Giving away valued possessions • Frequent school absences Source: Beat the Boards
    15. 15. OVERVIEW OF DEPRESSION IN ADOLESCENTS • Prevalence of Major Depressive Disorder: • 2% in children • 4%-8% in adolescents • Lifetime prevalence by age of 18 is approximately 20% • -----------------------------------------------------------------• 20% of teens seriously contemplate suicide • 8% attempt suicide More than 70% of children and adolescents with depressive disorders or other serious mood disorders do not get diagnosed or treated Source: Beat the Boards
    16. 16. TREATMENT FOR DEPRESSION • Therapy • Medications • SSRI’s • Escitalopram: FDA approved treatment of adolescent depression (12-17 yrs) • Fluoxetine: FDA approved treatment of child and adolescent depression (8-18 yrs) • Family Therapy • School / Learning Interventions • Community Source: Beat the Boards
    17. 17. CONSEQUENCES OF FDA WARNING • FDA released a black box warning about suicidal thoughts and behaviors. • Positive correlation between SSRI use and decrease in adolescent and young adult suicide rate • SSRI prescription rates have DECLINED by 25% since there was a warning introduced in 2004 • CDC reported a 14% INCREASE in suicide rates in 5-19 year olds between 2003 and 2004 Source: Beat the Boards
    18. 18. Ranvir Kaur, 3rd Year Medical Student PSYCHOSIS
    19. 19. GENERAL • Definition: • is loss of contact with reality that includes: • False beliefs about what’s going on or who one is (delusion) • Seeing/Hearing things that aren’t there (hallucinations) • It is less common than autistic disorder in children before 5 years of age • Between ages 5 – 7, diagnosis of psychosis can be difficult • Children’s delusions are less complex compared to adults, hallucinations are less elaborated • Most children who report early hallucinations are not schizophrenic
    20. 20. DIFFERENTIAL DIAGNOSIS OF PSYCHOTIC DISORDERS • Early Onset Schizophrenia (EOS) • Onset before age 18 • 3% - 4% of schizophrenic pts present < age 15 • More common in males • Very Early Onset Schizophrenia (VEOS) • Onset before age 13 • Predominant in males 2:1 • Predispositions: • ADHD, speech disturbances, anxiety, substance abuse and OCD • Schizophrenia Dx • Deterioration in social, occupational, and self-care functioning
    21. 21. ASSESMENT & TREATMENT • Assessment • Projective testing • Rorschach ink plot test (3-adult) • Perceptual accuracy and reality testing • Integration of affective and intellectual functioning • Thematic Apperception Test (TAT) (6-adult) • Provides data regarding interpersonal funtioning • Machover Draw a Person Test (DAT) (3-adult) • Treatment • Multimodal • Includes; programs, case management services, psychopharmacology, psychotherapy, vocational & rehabilitative mgt • Supportive therapy – long term • Support the child’s good reality testing and good sense of self and social skills training
    22. 22. TREATMENT • AACAP Guidelines of Pharmacotherapy • Vital signs and weight/BMI: baseline & monthly • Lipid profile and fasting blood sugar: baseline & quarterly • Standardized rating scales and measurement such as AIMS and NRS • EKG is not needed for all patients • Pts with family Hx of sudden death, cardiac abnormalities or personal history of syncope, EKG should be considered
    23. 23. ANTIPSYCHOTICS • Children and adolescents are more sensitive to EPS • Are more effective with negative symptoms • Varies • Withdrawal dyskinesia common in children • In children after remission of acute phase, medication free trial is recommended • FDA Approved Antipsychotics • Aripiprazole • Haloperidol and Chlorpromazine • Risperidone • Schizophrenia in teenagers (13-17) • Bipolar disorder for children (10-17) • Autistic Disorder
    24. 24. ADVERSE EFFECTS • Increased lipids • Increased sugar • Photosensitivity • Hypersensitivity and rash • Weight gain • Cataract and Retinopathy • Increased Liver Enzymes • Sedation and Fatigue • Cardiac Rhythm Effects • More common in young • Highest in clozapine, lowest in risperidone, quetiapine and aripiprazole
    25. 25. ATYPICALS AND REPORTED DANGERS • Clozaril -Agranulocytosis, Seizures • Respirdal • Zyprexa -Weight, Diabetes • Geodon -EKG problems • Seroquel -Cataracts • Abilify -Deaths -EPS, Hyperprolactinemia
    26. 26. Saadia Malik, 3 rd Year Medical Student ANXIETY
    27. 27. ANXIETY DISORDER Generalized anxiety disorder is characterized as excessive worrying, that is uncontrollable and interferes with the individuals’ everyday life. There are several anxiety disorders including: panic attacks, OCD, PTSD, generalized anxiety disorder, social anxiety disorders and Specific phobias. Anxiety Disorder Prevalence • most common psychiatric diagnoses in childhood • 6-15% of school aged children • through adolescences the ratio is girls: boys, 2:1 • except for Obsessive Compulsive Disorder and social anxiety disorder Prevalence Among Adolescences • social anxiety disorder • panic disorder
    28. 28. SOCIAL ANXIETY DISORDER Diagnosis: • Boys are equally as effected as girls • Duration of 6 months if <18 years old • Fear of one or more social performance situations due to fear of scrutiny by others and being humiliated or embarrassed • Exposure to feared situation provokes anxiety • Avoiding social or performance situations or endured with intense anxiety Increased Risk of: • Social isolation • Depression in adulthood • Failure to reach potential Panic Disorder Diagnosis: •Attack usually last 20-40 minutes •With four or more of the following symptoms: •Palpitations •Shortness of breath •Sweating •Choking •Cheat pain •Nausea, abdominal distress •Dizziness •Paresthesias •Chills •Shaking, trembling •Fear of dying •Fear of going crazy •Depersonalization or derealization •Usually occurs in adolescents Increased Risk of: •Depression
    29. 29. TREATMENT First line of Treatment: Cognitive Behavioral Therapy This consists of four components 1. Recognizing anxious feelings and physical reactions to anxiety 2. Understanding feelings in anxiety-provoking situations 3. Develop a coping plan 4. Administrating self-reinforcement Medication: Serotonin Reuptake Inhibitors (SSRI) • Paxil- Social phobia • Sertraline - GAD • Fluoxetine - GAD, social phobia, • Fluvoxamine - social phobia, SAD, GAD Social: School interventions • behavioral modification in school • social work at school Community interventions • extracurricular activities
    30. 30. ANXIETY DISORDERS • Serotonin • Benzodiazepines • Prozac • Valium • Paxil • Ativan • Zoloft • Xanax • Luvox • Klonopin • Celexa • Librium • Lexapro
    31. 31. BENZODIAZEPINES’ 5 DANGEROUS DS • Dependence • Disinhibition • Dizziness • Depression • Deficits in Memory
    32. 32. Rema El-Ammori, 3 rd Year Medical Student MANIA
    33. 33. MANIA PRESENTATION • Elated mood – laughing hysterically without any reason • Grandiose behaviors – acting as if the rules do not pertain to them…so smart they can tell the teacher what to teach • Flight of ideas – jump from topic to topic in rapid succession during a normal conversation • Decreased need for sleep – sleep only 4-6 hours and are not tired the next day • Hypersexuality – act flirtatious beyond their years, may try to touch the private areas of adults (including teachers) and use explicit sexual language Source:, National Alliance on Mental Illness
    34. 34. ACUTE MANIA • FDA Approved Psychiatric medications • Lithium, risperidone, aripiprazole, quetiapine, olanzepine • IF no psychosis evident: • Mood stabilizer OR atypical • Lithium, valproate, carbamazepine • Olanzepine, risperidone, quetiapine, aripiprazole • IF psychosis evident • Mood stabilizer and atypical
    35. 35. Amrin Islam, 3 rd Year Medical Student SUBSTANCE ABUSE IN ADOLESCENTS
    36. 36. OVERVIEW • Nearly 50% of students try illegal drugs by the time they graduate high school • Substance abuse is more common when another family member abuses the same substances • Most adolescents experiment with alcohol and cigarettes • Some advance to use of marijuana • Small portion will further proceed to the use of illicit drugs • Monitoring the future survey by the National Institute on Drug Abuse Monitoring the Future Survey 2010 • 27% of high school students have been drunk in the past 30 days • Illicit substance abuse increased due to increases in marijuana use
    37. 37. LEGALLY AVAILABLE SUBSTANCES • Types • Prescription Drugs • Alcohol • Alcohol/Sedative Intoxication • • Alcohol/Sedative Withdrawal • • Slurred speech, lack of coordination, unsteady walking, unable to concentrate, impaired memory, coma, and involuntary movements of the eye Sweating, rapid heart beat, trembling of hands, sleeplessness, nausea or vomiting, hallucinations, and seizures Inhalants • Fumes from glues, aerosols and solvents • Inhalant abuse risks • • Inhalant Intoxication • • Heart conditions including cardiac arrest, and can effect other vital organs including brain, heart, kidney, and liver Dizziness, involuntary movement of the eyes and blurred vision, slurred speech, lack of coordination, and slowed reflexes OTC medications
    38. 38. ILLEGAL DRUGS • Types • Marijuana • • Intoxication- decrease motor performance, social with drawl, anxiety, red eyes, dry mouth, rapid heart beat, and increased appetite. Cocaine, Crack, Speed • • • Intoxication- euphoria, tachycardia, dilated pupils, anxiety, tension, anger, chills, weight loss Withdrawal- fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite and psychomotor retardation Hallucinogens (LSD) • • Intoxication- Dilated pupils, rapid heart rate, sweating, palpitations, blurred vision, tremors, and lack of coordination Opiates (Heroin) • • • Intoxication- Euphoria, constricted pupils, drowsiness, slurred speech, or impaired attention Withdrawal- muscle aches, diarrhea, nausea, vomiting, dilated pupils Designer Drugs(Ecstasy) • Intoxication- raised pulse and temperature, feeling of wellness, and “rush”, nausea, affection for others, teeth grinding and jaw clenching, anxiety, and loss of appetite
    39. 39. TREATMENT STRATEGIES • Detoxification when indicated • Abstinence • Family, individual, and group treatment • Use of Medication • Twelve Step Programs • Mutual help Groups • Relapse prevention/continuing recovery process
    40. 40. MEDICATIONS • Nicotine Dependence • Bupropion SR (Zyban) • Nicotine Patch • Neither approved in adolescents • Opioid Dependence • Buprenorphine/Naloxone (Suboxone) • Now approved by FDA down to age 16
    41. 41. Rema El-Ammori 3rd Year Medical Student AUTISM/ASPERGER’S
    42. 42. AUTISM • Aspergers is an Autism Spectrum Disorder • Autistic disorder • Impaired social interaction • Impaired communication • Restricted repetitive and stereotyped patterns or behaviors, interests, and activities • Asperger’s disorder • Impaired social interaction • Normal communication/language development • Restricted repetitive and stereotyped patterns or behaviors, interests, and activities Source: Autism Spectrum Disorder
    43. 43. ASPERGER’S PRESENTATION • Naïve and gullible • Socially awkward and clumsy • Unaware of others feelings • Easily upset by changes • Unable to carry conversation • Repetitive and irrelevant comments • Literal in speech and understanding • Sensitive to loud sounds, lights, odors • Fixated on one subject or object • Physically awkward in sports • Accurate memory for details • Trouble understanding things they heard or read • Inappropriate body language & expression Source: Aspergers by Alok Shukla
    44. 44. ASPERGER’S PHARMACOTHERAPY Hyperactivity, inattention, impulsivity: • Clonidine • Tricyclic antidepressants (desipramine, nortriptyline) • Strattera (atomoxetine) Irritability and aggression: • Mood stabilizers (Valproate, carbamazepine, Lithium • Beta Blockers • Clonidine • Naltrexone • Neuroleptics Preoccupations, rituals, compulsions • SSRIs (tricyclic antidepressants) • Clomipramine Anxiety: • SSRIs • Tricyclic Antidepressants Source: Aspergers by Alok Shukla
    45. 45. ETIOLOGY OF AUTISM • We know little of the cause(s) of autism. • In 1995, Dr Andrew Wakefield, British academic gastroenterologist & surgeon with special interest in inflammatory diseases (He discovered that Crohn’s disease was caused by decreased blood flow to the intestines), was approached by group of parents claiming that their children had become autistic following the MMR vaccine. • Wakefield was willing to look into this. His theory was: measles vaccineintestinal inflammation “leaky gut syndrome”harmful proteins can affect brain Autism.
    46. 46. Anton Dietzen, 3rd Year Medical Student ADHD
    47. 47. DEFINITION • Attention Deficit Hyperactivity Disorder includes difficulty sustaining attention, hyperactivity and impulsive behavior. • Three types: • Inattentive (trouble focusing, following instructions, and finishing tasks) • Hyperactive-impulsive (constantly on the go, talking excessively, and interrupting others) • Combined (symptoms of both inattention and hyperactivity-impulsivity)
    48. 48. STATISTICS • 5-10% of children in the US ages 4-17 have been diagnosed with ADHD. • Boys are diagnosed at 3 times more often than girls. • More patients have been diagnosed in recent years due to increased awareness rather than increased incidence.
    49. 49. FACTORS • Biochemical • Dopamine deficiency (most medications target this area) • Norepinephrine deficiency • Some medications target both (Adderall) • Psychosocial • Low arousal to stimuli- require more stimuli than average individuals to maintain attention
    50. 50. MEDICATIONS • Stimulants • Various forms of methylphenidate and amphetamine • Non-stimulants • Strattera (atomoxetine), Intuniv (guanfacine), and Kapvay (clonidine) • Antidepressants • Buproprion • Tricyclic Antidepressants • SSRIs
    52. 52.