Clinicians “in the trenches” are getting squeezed We’re asked to do “evidence-based treatment” using evidence that has little to do with patients we see in the real world Example…Mixed Amphetamine Salts in adolescents Example: aripiprazole in newly diagnosed patients with bipolar disorder More pressure to see more kids in less time…how can we be more sure that we have it right? When to depart from practice guidelines?
I’m realistic Cleveland will be challenged to win the NBA championship because free agents don’t want to come We won’t get what we want
Why do so many kids stop taking medication that’s reportedly very helpful? Tolerability very different in patients with comorbid conditions Docs rely on medication because the results are more consistent…PATS/TADS study…how will anxious kids do with the therapists I have available to me in my community or my agency? TDD…discussion of need for diagnosis…how to treat them? Not much data to validate TMAP…ADHD with comorbidities is what we treat most often
Conundrum…You’re in a mental health center…your patient is 8-in his parents’ bedroom with a knife…command hallucinations to stab and kill his parents African American-125# Father has HTN, 300+# both of his grandfathers spent 15+ years in state psychiatric hospitals You’d like to know risks of TD Acute-term studies with atypicals…what will he weigh in 12 months? 24 months? Two small, short-term studies evaluating stimulants in bipolar disorder, but most kids with bipolar disorder have ADHD
Does long-term medication treatment impact the course of the illness? How does behavioral, psychosocial treatment effect the long-term course?
When do we depart from the algorithms?
A A C A P Research Forum 2010 Grcevich
Child Psychiatry Research: Equipping our Colleagues in the Trenches <ul><li>Stephen Grcevich, MD </li></ul><ul><li>President and Founder, Family Center by the Falls Chagrin Falls, OH </li></ul><ul><li>Assistant Professor of Psychiatry Northeastern Ohio Universities College of Medicine </li></ul><ul><li>Division of Child and Adolescent Psychiatry Case Western Reserve University School of Medicine </li></ul><ul><li>AACAP Research Forum, October 26, 2010 </li></ul>E-mail: firstname.lastname@example.org Phone: (440) 543-3400 Twitter: @drgrcevich
Educational objective: <ul><li>Provide an office-based clinician’s perspective to the discussion of research priorities in child and adolescent mental health </li></ul>
Stephen Grcevich, MD: disclosures: Pharmaceutical Industry Consulting: Shire US (100% of compensation donated to charity since 1/1/08) Grant/Research Support Child and Adolescent Psychiatry Trials (CAPTN) Network-ASK, PARCA, NOTA studies funded through NIMH Speakers’ Bureaus None since 2006 Other Financial/Material Support Web MD/Medscape Leerink-Swann Major Shareholder None
What research would be most helpful to clinicians “in the trenches?” <ul><li>“ Real world” data-from more representative patient populations </li></ul><ul><li>Predicting adverse responses to medication </li></ul><ul><li>Research that helps answer common questions from parents </li></ul><ul><li>Research that would help improve accuracy of diagnosis </li></ul><ul><li>“ Personalized medicine”…offering the most effective or acceptable treatment first, knowing when to depart from algorithms…drug, dose, alternative treatments </li></ul>
The conundrum : What’s desirable may not be possible
The best possible treatments: <ul><li>More “real-world” clinical trials…atypicals in treatment-naïve bipolar patients, intermediate to long-term acceptability of medications (ADHD treatments) </li></ul><ul><li>How effective is community-based psychotherapy performed by clinicians on managed care panels? Working for public agencies? </li></ul><ul><li>Kids with severe irritability, aggression, self-injurious behavior in chaotic living situations (SMD, TDD) </li></ul><ul><li>Validation of existing algorithms, practice parameters (TMAP-ADHD) </li></ul>Pliszka, SR et al. J. Am. Acad. Child Adolesc. Psychiatry, 45:6, JUNE 2006
With the fewest adverse effects: <ul><li>Studies to help predict in advance which patients will experience serious adverse effects… </li></ul><ul><li>Who’ll develop metabolic syndrome, tardive dyskinesia on a SGA? </li></ul><ul><li>What are the intermediate to long term effects of SGAs? </li></ul><ul><li>Suicidal behavior, behavioral activation on a SSRI? </li></ul><ul><li>Precipitation or exacerbation of mania on stimulants, atomoxetine, SSRIs </li></ul>
Answering questions from parents: <ul><li>Long term effects on medications on neurodevelopment…unintended consequences of treatment? </li></ul><ul><li>For how long will their child need medication? </li></ul><ul><li>How does therapy, psychosocial treatment attenuate the need for medical intervention? </li></ul><ul><li>Safety, effectiveness of homeopathic treatments </li></ul>
Improving accuracy of diagnosis: <ul><li>Biological markers (DNA analysis, neuroimaging) to help confirm accuracy of diagnosis </li></ul><ul><li>Essential questions to include in electronic medical record templates-evaluation, follow-up </li></ul>
Personalized medicine: <ul><li>Identification of genetic factors contributing to response (or lack of response) to standard treatments </li></ul><ul><li>Rapid vs. slow metabolizers </li></ul>Rockhill, C, Althof R. J Am Acad Child Adolesc Psychiatry - December 2009 (Vol. 48, Issue 12, Pages 1135-1136) McGough JJ, McCracken JC, Loo SK. J Am Acad Child Adolesc Psychiatry - December 2009 (Vol. 48, Issue 12, Pages 1155-1164), ,