Pharmacologic Treatments

2

Cognitive Behavioural Therapy (CBT)

Psychosocial Interventions

3

Medication Intro

› Provide rationale, expectations & education

› Explain how medication works

› Warn of potential side effects

› Health Canada Warnings Suicidal thoughts and behaviors

› Provide timeline Titration Treatment response

Medication Intro

Pharmacological Treatment of Adolescent Depression/Anxiety

DisorderChildren & Adolescents

5

Do not use to treat mild symptoms

or for “usual” stress

Do not rush into

medication subscribing!

6

Not all anxiety or depressive disorders require medication

Recommended first line treatment

› Cognitive Behavioral Therapy Approach e.g. CBIS

› Selective serotonin reuptake inhibitors (SSRI) Fluoxetine or Sertraline

› If not tolerable refer child to mental health services

Medication should not be used alone

› Anxiety and mood management strategies

Antidepressants

7

AntidepressantsCombine with:

CBT

Wellness Activities

Support

Education

Self Help Strategies

8

Minimal evidence in < 7 yrs SSRI’s:

› Fluoxetine

› Sertraline Do not use alone Suicidal ideation & self harm behavior

Antidepressants in Childhood

9

1. Do no harm

2. Ensure diagnostic criteria are met

3. Check for other psychiatric symptoms/stressors

4. Check for other psychiatric symptoms/stressors

5. Check for agitation, panic or impulsivity

6. Check for family history of mania or bipolar

7. Measure patients current somatic symptoms

before beginning treatment

› Restlessness, agitation, stomach upset, irritability

12 Steps to SSRI Treatment

10

Measure the symptoms

› Pay special attention to suicidality Provide comprehensive information

› About disorder and treatment options Provide family and child with SSRI info

› Side effects & timelines to improvement Start with small test dose of medication Slowly increase dose Take advantage of the placebo response

12 Steps to SSRI Treatment

11

Fluoxetine

› Best level one evidence

› Do not use alone

› May increase… Suicidal ideation ??? Self harm

› Assessment of suicide risk ongoing

Initiating Pharmacological Treatment

12

START LOW & GO SLOW

Begin 5-10 mg/day for 1-2 wks (2.5-5 mg if significant anxiety symptoms)

Liquid form: 2.5 – 5 mg/day; smaller increases

Target dose 20 mg/day for min. 8 wks

Expect continued improvement for a few months at same dose if initial response is positive

Side Effects: If problematic cut increases back by 5 mg for 1 week and then add the extra 5 mg to dose.

Discontinuation: Taper gradually over several months at low stress times

Fluoxetine Treatment

13

Item None Mild Moderate Severe

Headache

Irritability/Anger

Restlessness

Diarrhea/Stomach upset

Tiredness

Sexual Problems

Suicidal Thoughts

Self Harm Attempt

Yes: No: If yes, describe:Was this a suicide attempt (attempt to die)? Yes: No:

Other problems 1. 2.

Short Kutcher Chehil Side Effects Scale (sCKS) for SSRIs

14

Three important side effects to look for when initiating treatment with SSRI’s are…

Hypomania Suicidal ideation Suicidal behaviors

Side Effects of SSRI’s

15

Rare side effect

› Decreased sleep

› Increase in activity Idiosyncratic/

inappropriate

› Increase in motor behavior (including restlessness), verbal productivity and social intrusiveness

Discontinue medication Urgently refer to mental health

services Family history of bipolar

disorder

Hypomania

16

Suicide Ideation or Behaviors

Health Canada Warning May onset/exacerbate once medication

is started but overall a substantial DECREASE> Stop medication immediately due to safety risk> Most common in first several months of medication

ID 1209407 stockxchng

17

Tool Base-line

Day 1

Day 5

Wk 1

Wk 2

Wk 3

Wk 4

Wk 5

Wk 6

Wk 7

Wk 8

KADS x x x x x x

TeFA x x x x x x

sCKS x x x x x x x x x x x

Monitoring Treatment of Adolescent Major Depressive Disorder

18

ToolBase-

line

Day 1

Day 5

Wk 1

Wk 2

Wk 3

Wk 4

Wk 5

Wk 6

Wk 7

Wk 8

SCARED x x x x x

TeFA x x x x x

sCKS x x x x x x x x x x x

Monitoring Treatment of Anxiety Disorders

o Children – SCARED & sCKS

o Teens – SCARED, TeFA, sCKS

19

3 Possible Outcomes

3 Different Strategies

ALWAYS CHECK ADHERENCE

TO MEDICATION TREATMENT!!!

8 Weeks* of Dosage

20

OUTCOME 1 OUTCOME 2 OUTCOME 3Patient not better or only

minimally improved SCARED > 25 and little

or no functional improvement

Patient moderately improved

SCARED < 25. Some functional improvement.(50-60% as determined from

the TeFA)

Patient substantially improved.

SCARED < 25 and major functional improvement.

StrategyIncrease medication

gradually

Refer to Specialty

Child/Adolescent Mental Health Services

Continue weekly monitoring and all other

interventions until consultation occurs

StrategyIf medication is well

tolerated, increase slightly Continue

monitoring/interventions for 2 - 4 wks

ReassessIf no substantial

improvementRefer

If medication or increase not well tolerated continue

at current dosage with monitoring and

intervention for 2 wksReassess

If no substantial improvement

Refer.

StrategyContinue current dosageGradually decrease visits;

every 2 wks for 2 mths and then monthly

Educate patients/caregivers on need to continue medications

And identifying relapse

If first episode continue medications for 9- 12 mths.

If discontinuing, choose a low stress period. Decrease

gradually over 4-6 wks monitoring

every 2 wks. “Well checks” every 3 mths

If 2nd or further episode obtain mental health

consultation on treatment duration