psychopharmacology update - 2018 annual conference · • step back and rethink your plan •...
TRANSCRIPT
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PsychopharmacologyUpdate - 2018Annual Conference
Kimberly Roberts, MSN,ARNP, PMHNP-BC
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Objectives
• Review evidence-based treatment to common pediatric mental health disorders
• Review when & what psychotropic meds to use based on target symptoms & diagnosis
• Review side effects & monitoring of commonly used psychotropic meds
• Discuss common challenges in pediatric psychiatry
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Mental Health Report Card
• Access/receiving mental health care– Iowa ranked 49th Adults, 40th children
• 30% children & teens have a diagnosable psychiatric disorder
• 20% of those children receive mental health care, often PCP
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Prescriptions Written• Off label use
– 75% pediatric psych meds– Cost prohibitive
• How many Rx are not taken correctly or not even filled?– Cost, taste, time of dosing, parent– Misinformation: Internet, other parents, family
members, community– Medicaid: foster care, Prior authorization
www.fda.gov/cder/drugsatfda
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General principles• Children are not small adults (usually)• Establish diagnosis/diagnostic category• Collaboration is key – family/caregiver, teachers,
therapist• Combined treatment regardless of severity yields
better outcomes• Goal in behavioral health is control, not cure
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Evaluation Tools
Clinical interview
History
ScalesMedical Records
Testing
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Differential Diagnosis
• Thyroid, caffeine, seizures, asthma, and allergy medications
• Other psychiatric disorders (anxiety, ADHD, akathisias, bipolar, autism, learning disorders, substance abuse)
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Principles of prescribing
• Target system approach• Start low and go slow• Efficacy vs. side effects• Patience • Establish baseline• PRN prescriptions with caution
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When should you consider medication?
• Negative impact on functioning• Safety issues• Poor response to other interventions• Probability of efficacy for target symptoms
*selection should be based on past history of response, side effect profile, & co-existing medical conditions
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• Lipophilic medications– most psychotropic meds are highly lipophilic– Different volumes of fat for drug storage at
different ages• CYP450
– Drug-metabolizing enzyme levels often exceed adult levels, declining after puberty
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Antidepressants
Indications: bipolar depression, mood disorders, schizoaffective disorder, GAD, OCD, panic, social phobia, PTSD, PMDD, & impulsivity assoc. with personality disorders
SSRI SDNRI SNRI TCA MAOI
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Black Box Warning
• Black Box Warning (2004, 2007revised)– Incr. risk of suicide in children and adolescents
with major depressive disorder or other psychiatric disorders within the 1st month
– No complete suicides in any studies– Liability in NOT treating too
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SSRI
Selective serotonin reuptake inhibitor: affects release and reuptake of pre- and post-synaptic receptors
Differences between SSRIs
Fluoxetine, escitalopram, sertraline, citalopram, fluvoxamine, paroxetine
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SSRI
Common side effects Headache GI issues sedationInsomnia sexual dysfunction
Rare side effects Activation Black Box Warning serotonin syndrome (hyper-reflexia, fever, flu-like sx, seizures, coma)
Cardiac (celexa over 20mg, EKG indicated)
Uses: Depression, Anxiety, OCD, PTSDOther: rigid thinking associated with autism
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NDRI
Norepinephrine dopaminergic reuptake inhibitor
Uses: MDD, seasonal affective d/o, ADHD, nicotine addiction, and chronic pain
Affects the release and reuptake of brain NTs serotonin, norepinepherine, dopamine
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NDRI
Buproprion (good for augmenting, ‘meh’)
Common side effectsDry mouth anorexiaConstipation insomniaNausea tremorWeight loss sweating
Rare side effectsRisk or seizuresActivation
* Avoid in TBI and eating disorders
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SNRI
Serotonin Norepinephrine Reuptake Inhibitor
Affects the release and reuptake of brain NTs serotonin, norepinepherine.
Uses: MDD, anxiety, OCD, ADHD, chronic pain
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SNRI
Duloxetine, Venlafaxine, Desvenlafaxine
Common side effectsHeadache GI Sweating urinary retentionsomnolence
Rare side effects SeizuresDiscontinuation syndrome
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TCA
Tricyclic Antidepressants
Increase serotonin and norepinephrine availability
Uses: depression, ADHD, social phobia, panic, PTSD, eating disorders, enuresis, sleep, chronic pain, OCD (clomipramine only)
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TCA
Clomipramine, Amitriptyline, Imipramine
Common side effects Anti-cholinergic (dry mouth,sedation, constipation, urinary retention)
Rare side effects DeliriumHeart arrythmiaDeath in OD
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BuspironeSerotonin agonist, decreases serotonin levels in specific areas of the brain while increasing DA & NE. also weak antagonist of D2 receptor
Not good by itself, better paired with SSRI
Uses: anxiety, ADHD, irritability, aggression
Side Effects: dizziness, headaches
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Mirtazapine Adrenergic antagonist and serotonin, tetracyclic antidepressant
MDD, Anxiety, PTSD, appetite stimulant, weight gainer
Side effects: hypotension, mania, photosensitivity, discontinuation syndrome
Dose 15-45mg/hs
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Benzodiazepines
Increases GABA
GAD, sleep and panic disordersAlso used for agitation, alcohol withdrawal
Short term use, abuse potential
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Benzodiazepines
Lorazepam, clonazepam, alprazolam, diazepamCommon side effects
SedationCognitive issuesDecreased libidodepression
Rare side effects Addiction SeizuresDeliriumBlurred vision
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Mood Stabilizers
Bipolar, disruptive behaviors disorder, aggression, DMDD
MOA unknown, possibly inhibits neuronal signaling and alters sodium transport
Lithium, valproic acid, lamotrigine, topiramate
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Lithium
Gold standard mania, mood disorder, depression, schizophrenia
Common side effects: nauseam dizziness, weight gain, tremors, acne
Serious side effects: arrhythmia
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Valproic acid
Affects GABA by blocking sodium channels and inhibit histone enzymes
Seizure mgmnt, migraines, mood disorder, impulsivity, pain control, aggression
Occassional labs (LFT, platelets)
Side effects: weight gain, sedation, Polycystic ovary disease, pancreatitis
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Lamotrigine
Controls glutamate release, activates serotonin
Depressive phase of bipolar, epilepsy
Start 25-50mg/day, titrate up to 500mg BID
Fatigue, blurred vision, nightmares, dry mouth, Stevens Johnson Rash
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TopiramateInhibits glutamate and enhances GABA
Seizures, migraines, chronic pain, alcohol cravings, aggression, impulsiveness
Side effects: brain fog, N/V, sedation,delirium, hot flashes (no weight gain)
Labs: LFTs, CBC/diff
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Propanolol
Blocks epinephrine and norepinephrine
Migraine, performance anxiety
Nausea, constipation. Worsen depression
Contraindicated in those with heart issues
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Alpha2-agonistsStrengthens working memory/connectivity in PFCClonidine (0.025-4mg/day)
– ADHD, tics, sleep problems, aggression– Side effects: bradycardia, sedation
Guanfacine (1-4mg/day) – ADHD, tics, sleep problems, aggression– Intuniv (extended release)– Side effects: sedation, somnolence, trigger depression
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PsychostimulantsLong acting are safe to start in most kids Block reuptake of DA and NEADHD, off label MDD
Common side effects: loss of appetite, insomnia, irritability, emotionality, tics Rare side effects: mani, hallucinations, hypertension
Vanderbilt, Connors gauge severity. EKG if family heart hx
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Newest Stimulants
• Methylphenidate: Quillichew, Cotempla-ODT, Aptensio
XR
• Amphetamine: Myadyis, Dynavel XR, Adzenys-ODT
• Amphetamine mixed salts : Evekeo
• Lisdexamfetamine: Vyvanse
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Memantine
Partial antagonist of the NMDA receptor, downregulates activity of glutamate
Controversial use in autism (mixed results)
Studies in anxiety and ADHD
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First Generation Antipsychotics
Haloperidol, thioridazine, pimozide, chlorpromazine
Blocks receptors of dopamine
Treats psychosis, schizophrenia, bipolar, depression, aggression, tourettes, sleep, anxiety
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First Generation Antipsychotics
Common side effects: sedation, dry mouth, constipation, increased hunger, restlessness, metabolic issues (Diabetes, lipids), sexual side effects
Rare side effects: prolonged QT interval, EPS, TD, NMS (rigid, high fever, unstable autonomic system), increase prolactin, pseudoparkinsonism
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Second Generation Antipsychotics
Post-synaptic blockage of dopamine D2 receptors.
Tics, bipolar mania, schizophrenia, severe behavior disturbances, sleep, irritability associated with autism
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Second Generation Antipsychotics
Risperidone (Risperdal) - Side effects are dose dependent- Weight gain and sedation very commonOlanzaoine (Zyprexa, Zydis)- Weight gain very common & Metabolic labsQuetiapine (Seroquel)- Sedation & Weight gain common - Hangover effect
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Second Generation Antipsychotics
Ziprasidone (Geodon)- Prolonged QT- No associated weight gain- Good for aggression and bipolar- Take with foodAsenapine (Saphrys)- sublingual (no food/drink x 10 min)- rapid action, BID dosing, start at therapeutic dose
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Second Generation Antipsychotics
Aripiprazole (Abilify)- D2 partial agonist- Low EPS, low QT, low sedation, With fluoxetine- possible activation
Lurasidone (Latuda)- Daily with food, can start at therapeutic dose, rapid onset- No prolonged QT, no weight gain
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FGA/SGA lab monitoring
• Every visit: height, weight, BMI, AIMS• Baseline, 3 months, then annually
– hgbA1c, fasting glucose, fasting lipids– Prolactin – LFTs
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Anticholinergics
Facilitates dopamine
Treats EPD, TD• Benztropine, trihexyphenidyl, diphenhydramine• Anticholinergic side effects: dry out
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Complimentary and Alternative Medicine
Vayarin (Omega 3s/6s) 2 capsules dailyEPA/DHA (brain health) 250-500mg dailyN-acetylcysteine (trichotillomania)SAM-e 400-1600mg dailyL-methylfolate 3-15mg daily
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CAM
• Investigational studies on the horizon– Electroconvulsive therapy– Transcranial magnetic stimulation– Deep brain stimulation
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Pharmacogenetic Testing
• How well certain medications may be tolerated and effective
• Limitations – cannot determine how you will respond to all medications
• No tests for many over the counter medications• MTHFR assists in converting essential amino acids• Saliva sample• No covered by all insurance
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Take home points• Know what you are treating and any comorbid diagnosis
(often can get 2 birds / 1 stone)• Diagnosis may unfold over time• Step back and rethink your plan • Drug-drug interactions• Decrease stigma through education • Collaborate and connect with others (Medications do not
replace family support, safety, parenting, friends, hobbies, self-esteem, etc)
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Thank You!
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Helpful websites & resources• http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm
143565.htm• REACH Institute: designed to provide pediatric primary care
practitioners with evidence-based instruction and mentoring around treatment of behavioral/mental health disorders http://www.thereachinstitute.org/primarycareprofessionals. html
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Helpful websites– AIMS: http://www.psychiatrictimes.com/clinical-scales-
movementdisorders/clinical-scales-movement-disorders/aims-abnormal-involuntarymovement-scale
– AACAP’s Resources for Primary Care: http://www.aacap.org/AACAP/Resources_for_Primary_Care/Hom e.aspx?hkey=59bfdf7f-149f-43fd-babb-a6a77c5e8caf
– NAPNAP’s Developmental Behavioral & Mental Health Special Interest Group: http://www.dbmhresource.org/
– Massachusetts Child Psychiatry Access Project https://www.mcpap.com/Default.aspx
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Helpful websites– National Network of Child Psychiatry Access Projects
http://www.nncpap.org/ – http://www.aacap.org/AACAP/Families_and_Youth/Fact
s_for_Families/Facts_for_families_Pages/Psychiatric_Medication_For_Children_And_Adolescents_Part_II_Types_Of_Medications_29.aspx
– Healthy Children.org https://www.healthychildren.org/English/Pages/d efault.aspx
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References • AACAP. (2014). AACAP Workforce Fact Sheet. Retrieved from
http://www.aacap.org/AACAP/Resources _for_Primary_ Care/Workforc e_Issues.aspx
• APA. (2013).Retrieved from http://www.dsm5.org/documents/changes %20from%20dsm-iv-r%20to%20dsm-5.pdf
• AAP Policy statement, March 2014 http://pedoatrocs.aapublications.org/content/133/3/563
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References• American Academy of Pediatrics, Subcommittee on Quality
Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management: ADHD Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011;128:1007-1022.
• Bridge, J. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment. JAMA 2007; 297:15: 1683-96.
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References• Center for Mental Health Services in Pediatric Primary Care. (2016). A
Guide to Psychopharmacology for Pediatricians. Retrieved from: http://web.jhu.edu/pedmentalhealth/Psychopharmacolog%20use.html
• Choice, T. (2016). Clinical conversations: Depression in pediatric primary care. MCPAP. Retrieved from: https://www.mcpap.com/Docs/March%20Clinical%20Conversations% 20-%20Depression.pdf
• Chugani DC et al. Efficacy of low-dose buspirone for restricted and repetitive behavior in young children with ASD: a randomized trial. J Pediatr 2016; 170:45–53.e4
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References
• Daughton, J.M. & Kratchovil, C.J. (2009). Review of ADHD Pharmacotherapies. Journal of the American Academy of Child and Adolescent Psychiatry, 48(3), 240-248.
• Fanton J, Gleason MM.Psychopharmacology and preschoolers: a critical review of current conditions. Child Adolesc Psychiatric Clin N Am 2009; 18: 753–771.
• Faraone, Comparing the efficacy of stimulants for ADHD in children and adolescents using a meta-analysis. Eur Child and Adolescent Psychiatry (2010)19; 353-364
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References• FDA (2007). Revised Black Box Warning. http://www.fda.gov/
CDER/Drug/antidepressants/antidepressants_label_change_2007.pdf
• Fibinger, H. C. (2012). Psychiatry, the pharmaceutical industry, and the road to better therapeutics. Schizophrenia Bull., 38, 649-650
• Gurnani T,Ivanov I, Newcorn J. Pharmacotherapy of aggression in child and adolescent psychiatric disorders. J Child AdolescPsychopharm 2016;26: 65-73.
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References• March J. Expert Consensus guidelines: treatment of obsessive
compulsive disorder. J. Clinical Psychiatry. 1997; 58(1-72).• Olfson M, Marcus, S (2009) National Patterns in
Antidepressant Medication Treatment Arch Gen Psychiatry. 2009;66(8):848-856
• Olfson, et al. (2006). Antidepressant Drug Therapy and Suicide in Severely Depressed Children and Adults A Case-Control Study. Arch Gen Psychiatry, 63, 865-872.
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References
• Rockhill C, Kodish I, DiBattisto C, Macias M, Varley C, Ryan S. Anxiety disorders in children and adolescents. Curr Probl Pediatr Adolesc Health Care 2010 Apr;40(4):66-99
• Sharma, T., et al. (2016). Suicidality and aggression during antidepressant treatment…..British Medical Journal, 2016:352:i65/doi:10.1136/bmj.i65
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References
• Sparks JA,Duncan BL. Outside the black box: re-assessing pediatric antidepressant prescription. J Can Acad Child AdolescPsychiatry. 2013 Aug; 22(3): 240–246.
• Stroeh O, Trivedi HK. Appropriate and judicious use of psychotropic medications in youth. Child Adolesc Psychiatric ClinN Am 2012; 32:703-711.
• Survey of Commonwealth of PA Medicaid findings (also published NEJM 1 Sept 2015).
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References
• Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes. Am J Psychiatry. 2010 Jul;167(7):782-91.
• Van Cleave J, Leslie LK. Approaching ADHD as a chronic condition: implications for long-term adherence. Journal of Psychosocial Nursing & Mental Health Services 2008;46(8):28-36.