Management of Youth Acute Psychiatric

 Conditions in the Pediatric Unit Setting

New Perspectives in PediatricsOctober 21, 2015

GABRIEL KAPLAN, M.D.

DisclosuresClinical Associate Professor of Psychiatry, Rutgers NJ Medical School, Newark, New Jersey

Medical Director, Behavioral Health Services, Bergen Regional Medical Center, Paramus, New Jersey

Distinguished Fellow, American Psychiatric Association

Diplomate in Psychiatry and Child Psychiatry, American Board of Psychiatry and Neurology, Inc

No Conflicts to Disclose

Most Frequent Reasons for Pediatric Inpatient Psychiatric Consult Suicidal behavior (SB)

Disruptive behavior (DB) (child or parents)

Depression/ Anxiety comorbidity

We will focus mostly on the Consultation Process and SB, with some comments on DB and comorbidity

General Principles of Psychiatric Consultation Work

C & A Psychiatric Consultation-Liaison: A Request for HelpWhat is a psychiatric consult?Any question –generally clinical- posed by a non

psychiatrist colleague.

There are no “inappropriate” consultsThe answer to the question can have greater focus on the patient (consultation) or the staff (liaison)

The lines often blur

The Consultation Process: The Requesting MDUnderstands that consultant is under similar time pressures

A consultant has your same ½ hour to 45 min window for new patients

Clearly articulates the question, what do you need help with? Sometimes, a “pre-consult” is helpful, call the psychiatrist and think out loud

together

Informs and obtains consent from the parent and assent from patient Parents can feel intruded, fear stigma, and this can defeat the purpose of the

consultation. All stakeholders need to be on board.

Arranges for translators if necessary

Obtains a psychosocial summary to be available at consult time

Connects with an experienced SW to finalize disposition

The Consultation Process: The Consultant Reviews all charted information

Interviews patient if possible and family for sure

Integrates all available information from multiple sources

Evaluates if family and staff are able to work together

Recommends initiation of treatment

Produces a helpful report with clear recommendations

Does all this in an hour or less!!!

Consult Advantages and Limitations

Helpful Increase accurateness of diagnosis Disposition, does the patient need transfer to a psychiatric unit? OPD enough? Should one-to-one be continued? Liaison issues, feedback to staff regarding how to best manage the family/patient Should certain psychopharmacological agent be initiated without delay?

Not helpful Acute agitation, this should be resolved pharmacologically/milieu by the pediatrician,

consultant can fine tune recommendations at the time of visit Day to day management, consultant unable to resolve each instance of conflict that

may develop

It is unlikely that the overall clinical picture will be resolved during the hospital stay. Main goal is to resolve the current crisis and determine and appropriate disposition for therapeutic action to continue

The Consultant’s ReportSummary of circumstances contributing to psychiatric issue

Full mental status exam

DSM-5 diagnosis

Case formulation

Clearly spelled out disposition recommendation

The report should help the pediatrician understand What happened Why it happened What risks to self or others may exist and how to mitigate How to initiate resolution

A Psychiatrist And A Surgeon Get Together…

Suicidal BehaviorWITH BRIEF COMMENTS REGARDING MANAGEMENT OF DISRUPTIVE BEHAVIOR

Suicidal Behavior (SB) In The Pediatric Unit Most typical presentation of SB to the pediatric unit is transfer from ED following an attempt (Overdose, Fire arm, etc) of sufficient medical severity to merit admission.

Less frequently, suicidal ideation is revealed during an assessment for another condition

Patient may be calm or agitated

US Leading Causes of Death (2010)

http://www.cdc.gov/injury/wisqars/LeadingCauses.html

US Data For youth between the ages of 10 and 24, suicide is the third

leading cause of death. It results in approximately 4600 lives lost each year. The top three methods used in suicides of young people include firearm (45%),

suffocation (40%), and poisoning (8%).

Suicide affects all youth, but some groups are at higher risk than others. Boys are more likely than girls to die from suicide. Of the reported suicides in

the 10 to 24 age group, 81% of the deaths were males and 19% were females. Girls, however, are more likely to report attempting suicide than boys.

Deaths from youth suicide are only part of the problem. More young people survive suicide attempts than actually die. Each year, approximately 157,000 youth between the ages of 10 and 24 receive

medical care for self-inflicted injuries

US 2004 Suicide Rates by Gender/Age

http://www.cdc.gov/mmwr/pdf/wk/mm5635.pdf

US Suicide Rate by Age, 2000-2010

American Foundation for Suicide Prevention www.afsp.org/understanding-suicide/facts-and-figures

Rates Have Increased Since 2004

Influence of internet social networks Contagion effect

High suicide among young U.S. troops Higher rates of untreated depression in the wake of

recent “black box” warnings on antidepressants—a possible unintended consequence of the medication warnings, required by the FDA in 2004

Youth Risk Behavior Surveillance SystemThe YRBSS was developed by the Centers for Disease Control (CDC ) in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth and adults in the United States.

The YRBSS includes national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th through 12th grade students.

These surveys are conducted every two years, usually during the spring semester.

HS Students Considering, Planning, or Attempting Su Past 12 Months 2009

Centers for Disease Control: www.cdc.gov/ViolencePrevention/suicide/statistics/

A Suicidal Youth…. Now What? A potentially suicidal youth constitutes a psychiatric emergency

Severity of risk must be assessed ASAP and is determined by integrating mental and medical current status with history Main immediate goal is to prevent injury/death

Severity of risk will drive level of care: Inpatient, Partial Hospital, Outpatient

Specific treatment approaches will vary according to MD preference, experience, and interpretation of research findings Patient/family preference

Suicidal Behavior Continuum

Passive Death Wish

Suicidal Ideation without method

Suicidal Ideation

with method

Attempt SUICIDE

Non Suicidal Self Injury

Determining Severity of Risk: Art and ScienceInvestigate risk factors

Evaluate current mental status

Obtain careful history Personal Family Medical

Assess psychosocial circumstances

Enumerate risk factors applicable to patient

Suicide Risk Factors

History of depression or other mental illness (present in up to 80-90% of adolescent suicide victims and attempters)

Most common psychiatric conditions are mood, anxiety, conduct, and substance abuse disorders.

History of previous suicide attempts

Family history of suicide

Substance abuse

Stressful life event or loss

Easy access to lethal methods

Exposure to the suicidal behavior of others

Incarceration

Bullying (victims and perpetrators)

Hopelessness/guilt

http://www.cdc.gov/violenceprevention/pub/youth_suicide.html

Rating Scales

Are comprehensive checklists

Provide standardized definitions of behaviors

Are easy to administer

Have high inter rater reliability

May have predictive power

Suicide Scales Facilitate Assessment of Risk Factors

Pfeffer’s Spectrum of Suicidal Behavior Scale

Used in multiple studies has high inter rater reliability

Five-point scale ranging from Nonsuicidal behavior (rated 1) Suicidal ideas (rated 2) Suicidal threats (rated 3) Mild suicide attempts (rated 4) Serious suicide attempts (rated 5)

Pfeffer, Newcorn, Kaplan, et al. J.Am. Acad. Child Adolesc. Psychiatry. 1988. 27. 3:357-361

Columbia–Suicide Severity Rating Scale www.cssrs.columbia.edu

Assesses the severity and intensity of suicidal ideation and documents the full range of behaviors with a lethality measure for suicide attempts. It is one page back and front and takes a few minutes to administerValidated for the adolescent populationWidely adopted by government and private health care providersTranslated to multiple languages

“The questions contained in the Columbia-Suicide Severity Rating Scale are suggested probes. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgment of the individual administering the scale.”Am J Psychiatry. 2011 December ; 168(12): 1266–1277

An Ounce of Prevention …..Teacher Education

N.J.S.A.18A:6-112 (2011) requires that public school teaching staff members complete at least two hours of instruction in suicide prevention as part of the State Board of Education's professional development requirement

Student identification The Columbia University TeenScreen Program uses a two-stage process to

identify at-risk youth. Youth have parental consent, and assent to participation, complete a brief mental health check-up. Those who "screen positive" are interviewed by a mental health professional. http://www.nami.org/Content/ContentGroups/CAAC/TeenscreenBrochure.pdf

Limitation of access to firearms

24/7 hotlines

Revue d’Epidemiologie et de Sante Publique 61 (2013) 363–374

General Suicidal Behavior TreatmentsSuicidal behavior is the result of an underlying psychiatric disorder plus a trigger (diathesis model)

Treating the disorder and improving psychosocial circumstances helps decrease suicidal behavior

In-hospital 24/7 monitoring

Specific Suicidal Behavior TreatmentsPharmacology

Clozapine: approved by the FDA for suicide risk reduction in patients with schizophrenia

Lithium: promising with data showing reduced number of deaths (BMJ 2013;346:f3646)

Psychotherapies Cognitive Behavioral Therapy-CBT Arch Gen Psy 2007 64(10):1132-1145

Dialectical Behavioral Therapy-DBT Clin Child Fam Psychol Rev 2013 Mar;16:59-80

The Treatment of Adolescents with Depression Study (TADS) RCT N=327 12 weeks of: fluoxetine alone, CBT alone, CBT with fluoxetine, or

placebo Compared with fluoxetine alone and CBT alone, treatment of

fluoxetine with CBT was superior. Fluoxetine alone is a superior treatment to CBT alone Clinically significant suicidal thinking, which was present in 29%

of the sample at baseline, improved significantly in all 4 treatment groups. Combined TX showed the greatest reduction.

JAMA. 2004 292(7):807-20 and ARCH GEN PSYCHIATRY 2007 64(10):1132-1145

Do Antidepressants Cause Suicidality? 2003 the maker of Paxil disclosed that clinical trial data had found

an increased risk of suicidality in youth. FDA concluded that for every 100 treated patients, 1 to 3

patients might be expected to have an increase in suicidality.

2004 FDA required all antidepressants carry a black box warning The data did not show suicide deaths; the increase referred to

ideas and behaviors.

2007 FDA expanded the warning to include patients up to age 24. There are only two FDA approved agents indicated for use in

adolescent depression: fluoxetine (Prozac) and escitalopram (Lexapro).

Black Box Controversy Data from the CDC show that between 1992 and 2001, the rate

of suicide among American youth ages 10 – 19 declined by more than 25%

The dramatic decline in youth suicide rates correlates with the increased rates of prescribing antidepressant medication (particularly SSRI’s) to young people

Since the black-box suicide warnings appeared on the labels of antidepressants, their use among teens plummeted. At the same time, the suicide rate among U.S. teens rose – bucking a decades long trend

There are no statistical data yet linking the black box to increased suicidality but suspicion is high amongst academicians that this may have been an unintended consequence of the warning

Reanalyses Dispute FDA Results FDA studied only short term data Data were reanalyzed adding longitudinal information,

extending the observational period beyond the short term study end point timeframes assessed by the FDA.

For adult and geriatric patients Medication actually decreased suicidal thoughts and

behavior. The protective effect was mediated by decreases in depressive symptoms with treatment.

For youths Although depression responded to treatment, no

significant effects of treatment on lowering suicidal thoughts and behavior were found, although reassuringly, there was no evidence of increased suicide risk in those receiving active medication.

Gibbons RD,Arch Gen Psychiatry. 2012 Jun;69(6):580-7.

Study on Impact of Black Box WarningLarge data analysis study by Lu et al BMJ 2014;348:bmj.g3596

Data source: A virtual data warehouse that includes information on demographics, health plan enrollment, utilization of inpatient and outpatient care, and outpatient pharmacy data from commercial plans in 12 US states.

Cohort included 1.1 million adolescents aged 10-17

Main outcome measures Rates of antidepressant dispensing, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides before and after warnings.

Before/After Warnings: 10-17 Yr Olds

Lu et al. BMJ 2014;348

No significant in-crease in fatal outcomes

SB Consult SpecificsIs the adolescent an acute risk?

One-to-one should be maintained/initiated

Diagnostic/Treatment Considerations Adjustment Disorder/Anxiety: reassurance, perhaps a BDZ Major Depression: reassurance, perhaps an antidepressant Bipolar psychotic: initiate antipsychotic to calm combativeness----

anticonvulsant? Intoxication: reassurance, withdrawal/detox? Antipsychotic?

Establish without delay level of care necessary following medical clearance (based on suicidal risk) If inpatient, have SW begin referral process, identify availability of beds, fax

all necessary reports If outpatient, schedule first appointment ASAP, patient to visit right after d/c

Agitation/ViolenceAs a result of intoxicated state/medical delirium

One-to-one. Elopement precautions. Reassurance/BDZ/perhaps IM antipsychotic, assess withdrawal potential, assess reasons for delirium and treat accordingly

Family conflict Reassurance, Elopement precautions. limitation of visits, understand the

conflict

Psychosis: Bipolar, psychotic depression, schizophrenia One-to-one. Elopement precautions. Antipsychotic, perhaps initiate

anticonvulsant/lithium

Continued attempt to hurt self One-to-one. Elopement precautions. BDZ, antipsychotic

Depression and Anxiety ComorbidityBRIEF CONSIDERATIONS

Psychiatric Symptoms Worsen Course of Chronic IllnessesPoor self-management and adherence to prescribed medical regimen of chronic conditions during adolescence is associated with bad outcomes.

DIABETES Numerous factors affect adherence, parent–adolescent and family

functioning variables are important. Specifically, cross-sectional and prospective studies show that family conflict, parent–adolescent communication, and family problem solving relate to adolescents’ diabetes outcomes. J Diabetes Sci Technol. 2013 May; 7(3): 727–735.

ASTHMA Clinical data has also shown that psychiatric symptoms are associated with

increased severity of asthma symptomatology, health service use, functional impairment and poorer asthma control, compared to that among youth without psychiatric symptoms. Psychol Med. 2013 Jun; 43(6)

The Consultant at Work…(Yes, you saw this slide already)Reviews all charted information

Interviews patient if possible and family for sure

Integrates all the information from a system’s perspective Admission to hospital (as severe as attempt may have been) is just a cog in

the wheel

Evaluates if family and staff are able to work together

Produces a helpful report with clear recommendations

Does all this in an hour or less!!!

Additional ConsiderationsEstablish if family conflict is contributory (divorce, abuse, poverty, drugs, etc)

Determine if adolescent psychopathology requires comorbid treatment Psychotherapy, Antidepressants, Antipsychotics

Determine if poor self esteem is contributory

GENERAL APPROACHES Diagnose patient condition and understand family conflict Recommend specific treatment for underlying psychiatric pathology Family treatment Supportive psychotherapy Referral to self help associations

Juvenile Diabetes Research Foundation: http://typeonenation.org/resources/ American Lung Association:

http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/?referrer=https://www.google.com/

Conclusions:Results of a Successful ConsultFamily and patient are in agreement with plan

Referring MD and floor staff are satisifed

A disposition was achieved Transfer to inpatient psychiatry Discharge to outpatient care

Medications were initiated if appropriate

One to one may be continued until transfer to inpatient psych or d/c if patient stable and referred to outpatient care

The floor is calm…..

Questions?

Back up slides

Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App

There Are Various Therapeutic ApproachesPsychotherapy

Group Family Individual

Therapeutic school placement

Pharmacology It is generally believed that for depressed and suicidal adolescents a

combination of medication and therapy appears to be superior than each treatment alone

Conclusions

Suicidal ideation (SI) is common in adolescence

Under certain circumstances not entirely well understood (diathesis), SI progresses to suicidal behavior (SB)

Preventive approaches have shown efficacy

SB is a psychiatric emergency

Effective treatments exist for reducing SB

SSRI controversy continues. A few studies correlate increased suicidality with decreased antidepressant prescriptions