psychiatric illnesses in children and adolescents: types and treatment lee w. bradshaw aprn-bc...
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Psychiatric illnesses in Children and Adolescents:
types and treatment
Lee W. Bradshaw APRN-BCMcKay-Dee Behavioral Health Institute.
Types of illnesses:
Depression Bipolar disorder Anxiety disorders ADHD
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
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
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
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
Types of Anti-depressants
SSRIs: – Prozac/fluoxetine – Paxil/paroxetine– Zoloft/sertraline – Celexa/citalopram or Lexapro/escitalopram– Luvox/fluvoxamine
SNRIs: – Effexor/venlafaxine – Cymbalta/duloxetine
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)
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.
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
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
How are kids different?
No cadillacs and presidents Hypersexuality Grandiosity More unstable with an anti-depressant? Exacerbated by stimulants
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
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)
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
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
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
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
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
Warnings about anti-psychotics
Metabolic syndrome: DM, lipids Parkinsonian symptoms: EPS Tardive Dyskinisia Neuroleptic Malignant Syndrome
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 don’t have it
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 Can’t sustain attention in tasks or play activities
Hyperactivity
Fidgets with hands or feet or squirms in seat Can’t stay in seat Runs about or climbs excessively Can’t be quiet "on the go" or often acts as if "driven by a
motor" talks excessively
Impulsivity
blurts out answers before questions have been completed
difficulty awaiting turn interrupts or intrudes on others (eg, butts into
conversations or games)
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
Treating ADHD
Stimulants:– Methyphenidates
Single vs dual isomers
– Dextroamphetamines single isomer Pro-drugs Multi-isomers, mixed salts
Stattera/atomoxatine Wellbutrin/buproprion
Methyphenidate
Ritalin, Ritalin SR, Ritalin LA Metadate Concerta Focalin Daytrana (patch)
Dextroamphetamines
Dexedrine, spansules, dextrostat Adderall (4 isomers) Vyvanse
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
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.
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
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
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
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
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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