Management of Pediatric Depression and Anxiety

in Primary Care

Travis Mickelson, M.D.Assistant Professor of Pediatrics

University of Utah School of MedicinePrimary Children’s Hospital

Disclosure:

The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report.

I will be discussing off-label use of antidepressants in pediatric populations.

The “What” Objectives:

Review pediatric depression and anxiety.

Discuss management of SSRIs:Choosing the med adjusting the dose monitoring progressthe black box warning managing comorbidities and side effects

The “How” Objective:

Change clinical behavior by promoting mastery and fostering collaborative relationships.

Why??

Most mental health needs of children are unmet.Most psychotropic meds are prescribed by PCPs.Most PCPs get minimal if any formal training in

mental health care.

Our purpose:

“The (whole) Child First (and their family) and Always (within their world)”

Prologue: The Big Picture

How the World Sees Me

The 20/20 Rule

1 in 5 children have a diagnosable mental health disorder that interferes with daily function and requires intervention or monitoring.

1 in 5 of those children are receiving adequate management of their illness.

Mental Health: A Report of Surgeon General, 1999.

National Comorbidity Survey Replication – Adolescent (NCS-A)

10,123 adolescents surveyed face-to-face

22.2% with severe impairment40% with 2+ diagnoses

JAACAP (October 2010). Merikangas, et al. Vol 49:Issue10;980-9.

Disorder Lifetime Prevalence (%)

Median Age of Onset (y/o)

Anxiety 31.9 6

Behavior (ADHD) 19.1 (8.7) 11

Mood 14.3 13

Substance Use 11.4 15

National Comorbidity Survey Replication – Adolescent (NCS-A)

Service Utilization = 36.2%

Severity related to likelihood of treatment½ w/ severe illness had never received treatment

JAACAP (Jan 2011). Merikangas, et al. Vol. 50:Issue1;32-45.

Disorder Service Rate (%)

ADHD 59.8

Behavior 45.4

Mood 37.7

Anxiety 17.8

Substance Use 15.4

Eating 12.8

The Pediatrician

An important resource for parents who are worried about their child’s behavioral problems, particularly when there is limited access to mental health specialists.

They are trusted by parents and caregivers, and are familiar with the social and economic stressors that affect family stability.

The Medical Home

Coordinates the medical and non-medical needs of the child in an environment that is accessible, continuous, comprehensive, family-centered, collaborative, compassionate, and culturally effective to all children, including those with special health care needs.

Pediatrics and Mental Health

Mental Health Competencies: “The Big Five”

ADHDAnxietyDepressionSubstance abuseRecognizing psychiatric and social emergencies

Pediatrics, 2009, Vol 124(1):410-21.

Pediatrics and Mental Health

Will require innovations in residency training and CME

Collaborative relationships with Mental Health specialists must precede

Pediatrics, 2009, Vol 124(1):410-21.

Collaborative Relationships

Level of Complexity Role of Pediatrician

Role of CAP

Role of Care Coordinator

Zero Screening, education, health promotion

Liaison, Teaching,Advocacy

Less involved

One Direct care Consultation, More involved

Two-Three Co-management,Consultation

Co-management,Direct Care

Heavily involved

Promote Prevent Treat Maintain

ZeroOne

TwoThree

PCP

PCP & CAPCAP

Stage I: The Nuts and Bolts

First Visit to Clinic

DSM-5 Diagnoses

Anxiety Disorders: Separation Anxiety, Generalized Anxiety, OCD, Social Phobia, Panic, specific phobias, PTSD, Anxiety NOS.

Mood Disorders: Major Depressive, Dysthymia, Depression NOS, Mood NOS, Bipolar.

** Symptoms must cause clinically significant distress or problems functioning in daily life.

** The condition is not due to a substance or medical issue.

Anxiety

All children experience anxiety.

Normal at specific times in development. Separation anxiety = 8 months through the preschool years short-lived fears (such as fear of the dark, storms, animals, or

strangers)

Anxious children are often overly tense or uptight.

Parents should be alert to the signs of severe anxiety so they can intervene early to prevent loss of function.

Anxiety Constant worries or concerns

about family, school, friends, or activities

Many worries about things before they happen

Inability to “shut off” the worry

Fears of embarrassment or making mistakes

Low self esteem and lack of self-confidence

Other Symptoms:

Restlessness Fatigue Poor concentration Irritability Muscle tension Trouble sleeping

Depression

Feelings of depression persist and interfere with a child or adolescent’s ability to function.

5 percent of children and adolescents in the general population suffer from depression at any given point in time.

Higher rates after puberty.

Depression tends to run in families.

The behavior of depressed children and teenagers may differ from the behavior of depressed adults.

Depression DSM-5 Criteria (SIGECAPS for 2+ weeks)

Sleep Disturbance Irritability Guilt Energy Concentration Appetite Psychomotor Agitation or Retardation Suicidality

Symptoms must cause clinically significant distress or problems functioning in daily life. The condition is not due to a substance or medical issue.

AACAP Practice Guideline Highlights:

Each Phase of treatment should include: Psychoeducation, Supportive Management, and Family and School Involvement.

Treatment should include monitoring for: efficacy and side effects and management of comorbidities.

AACAP Practice Parameter Highlights:

Therapy alone is often a good place to start for mild to moderate depression and/or anxiety.

SSRI medications are first line for moderate to severe depression and/or anxiety.

Fluoxetine, Sertraline, Escitalopram, and Fluvoxamine have FDA approval for use in children and adolescents.

Rare risks of SSRIs (including agitation, activation, and suicidality) warrant close monitoring.

Initial Treatment

Titrate SSRI to effective dose

Add Therapy

Partial ImprovementIncrease med to max dose

Add therapyadherence, comorbiditiesConsider augmentation

No ImprovementReassess diagnosis

Add therapyadherence, comorbidities

Switch to another SSRI

Improvement

Discontinue med in 6-12 months to assess

for continued indication

After 8 weeks

SSRIs: Which to choose? 1st - SSRI (fluoxetine, sertraline, citalopram, escitalopram)

Side effect profileDrug-drug interactionsDuration of actionPositive response to a particular SSRI in first-degree

relative 2nd - Another SSRI (as above and paroxetine) 3rd - Alternative antidepressants

mirtazapine, bupropion, venlafaxine, duloxetine

SSRIs and FDA Approvals

Approved for Depression Fluoxetine ≥ 12 years Escitalpram ≥ 12 years

Approval for OCD Clomipramine ≥ 10 years Fluvoxamine ≥ 8 years Sertraline ≥ 6 years Fluoxetine ≥ 7 years

Approval for non-OCD Anxiety None

The black box warning All SSRIs have a black box warning for increased suicidality

(4% vs. 2%).

The black box warning has not reduced suicide rate.

Studies conducted since development of Columbia Suicide Severity Rating Scale have not supported this increased risk.

Provider and family must have this discussion prior to starting medication.

Monitor for suicidality throughout treatment.

Stage II: The Real Deal

Does That Make Me Crazy?

Johnny is a 12yo boy with symptoms of GAD.

6-month history of excessive worries, mood irritability, school

avoidance and frequent complaints of headaches.

Mom adds his grades have dropped.

No past history of psychotherapy or pharmacotherapy.

Mom has GAD and takes paroxetine.

Parents want to try an SSRI.

GAD-7: 16 out of 21, “very difficult”

Here’s Johnny!

Diagnostic Assessment

Pediatric Symptom Checklist (PSC-17, PSC-35)Strength and Difficulties Questionaire (SDQ)

anxiety: GAD-7, SCARED

depression: PHQ-9, PHQ-A

Clinical Global Impression Severity Scale (CGI-S)

GAD-7Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it's hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all __________ Somewhat difficult _________ Very difficult _____________ Extremely difficult __________

Clinical Global Impression (CGI) ScaleCGI - Severity CGI - Improvement

1 Normal- symptoms not present Very much improved- nearly all better

2 Borderline ill- subtle or suspected pathology

Much improved- notably better with significant reduction in symptoms, increased function with some symptoms remaining

3 Mildly ill- clear symptoms with minimal impairment

Minimally improved- slightly better with little or no clinically meaningful reduction of symptoms.

4 Moderately ill- overt symptoms with noticeable but modest impairment

No change- symptoms remain unchanged

5 Markedly ill- intrusive symptoms with distinct impairment

Minimally worse- slightly worse but not clinically significant

6 Severely ill- disruptive pathology, behavior and function frequently impaired

Much worse- clinically significant increase in symptoms and loss of function

7 Extremely ill- pathology drastically interferes with function, may be hospitalized

Very much worse- severe exacerbation of symptoms and loss of function

SSRI Dosing Chart

MedicationStarting

Dose(mg/d)

WeeklyIncrements

(mg)

EffectiveRange(mg)

MaximumDose(mg)

Citalopram 10 10 20-40 40

Fluoxetine 10 10 20-40 80

Paroxetine 10 10 20-40 60

Sertraline 25 25 50-150 200

Escitalopram 5 5 10-20 20

Two weeks later…

Both Johnny and Mother report no improvement and no

observed side effects including no suicidal ideation.

Mother and Johnny agree to increase fluoxetine to 20mg today

and to 30mg in two weeks.

RTC in 4 weeks.

Mother asks, “How will I know if the med is working?”

Johnny adds, “What is the best dose for me?”

Monitoring Improvement

Use a Rating Scale to monitor progress as compared to baseline.

anxiety: GAD-7

depression: PHQ-9, PHQ-A

Clinical Global Impression Improvement Scale (CGI-I)

SSRI Dose Adjustment Titrate to a goal dose using Evidence-based

Medicine.

NIMH Study Med alone(mean dose)

Med + CBT(mean dose)

Placebo(mean dose)

TADSFluoxetine

33.4mg 28.4mg 34.1mg

CAMSSertraline

146mg 134mg 175mg

POTSSertraline

170mg 133mg 176mg

Scenario 1: Four weeks later…

Johnny is on 30mg and reports taking his medications every day.

He is feeling less anxious and is having easier time getting to school

and has even noticed less headaches.

However, he also reports getting angry easily, and feels “hyper”.

Mother agrees that he has been more irritable and has noticed he is

having harder time falling asleep.

SSRI Side Effects

Medication Half-lifeDrug

interaction potential

More common side effects

Citalopram 35 hrs low sexual side effects

Fluoxetine 2-4 days high agitation, nausea

Paroxetine 20 hrs high sexual, weight gain, sedation, anticholinergic

Sertraline 26 hrs moderate diarrhea, nausea

Escitalopram 30 hrs low expensive

Managing side effects of SSRIs

Remember side effect profiles and unique characteristics of individual SSRIs (i.e. activation and longer half-life with fluoxetine).

lower fluoxetine to dose in which side effects were not noted to assess if benefit is maintained.

Address Environmental precipitants / perpetuants

Therapy – Learning skills to identify and regulate emotions and better tolerate distress

RTC in 2-4 weeks

Scenario 2: Four weeks later…

Johnny reports a worsening in symptoms.

GAD-7 score suggests less than 25% improvement.

Mother reports Johnny’s grades have dropped since entering middle

school.

When Johnny is asked if there have been any recent stressors at

school or home and he reports that his mom has a new boyfriend

and they have been spending several nights a week at his house

over the past month.

A failed SSRI trial??

Is the diagnosis correct? Remember differential.

If yes, Try a second SSRI (sertraline)

Psychoeducation and Therapy:

Consider 504 plan to help with school impairment.

Maternal Anxiety / Parental Stressors / Family Chaos

Managing comorbid conditions and environmental stressors

Is there a comorbid condition? Common comorbidities include ADHD, ODD, learning d/o, substance use, ACE. Use Vanderbilt ADHD scale

ADHD, ODD, Conduct d/o, depression, anxiety

Treat comorbid conditions using evidence-based approaches. ADHD: stimulants, alpha-2 agonists, atomoxetine Learning d/o: testing, IEP / 504. ACE: supportive therapy, DCFS referral

Utah Academy of Child and Adolescent Psychiatry

www.UACAP.org

Questions??

Thank You!