MOOD DISORDERS and ANXIETY in Adolescents€¦ · * Pharmacotherapy: Know the indications If...
Transcript of MOOD DISORDERS and ANXIETY in Adolescents€¦ · * Pharmacotherapy: Know the indications If...
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MOOD DISORDERS IN ADOLESCENTS
Dr. Roxanne Swiegers
MBChB, CCFP, FCFP
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Presenter: Roxanne Swiegers
• Speakers Bureau/Honoraria: Speaker – Purdue, Lundbeck, Shire, Janssen
• Grants/Research Support: N/A
• Patents: N/A
• Other: N/A
• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
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LEARNING OBJECTIVES
• When to suspect mood / anxiety disorder in adolescents?
• Which tools can be used in the assessment?
• What strategies can be used in management?
(Pharmacological & non-pharmacological)
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HOW TO DIAGNOSE MOOD in ADOLESCENT?
ANXIOUS DEPRESSED SUICIDAL
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WHEN TO SUSPECT?
• SCREEN: at annual check up
• USPTF (US Preventative Task Force): all adolescents should be screened for mental health concerns
• PHYSICAL CONCERNS: headache & stomach aches
• PSYCHO-SOCIAL STRESSORS: trauma, divorce, school changes (Grade 7 / Grade 10 / post secondary)
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4 TOOLS TO GET COMFORTABLE WITH (where to find them)
1. PSC-17: Psychosocial screen
2. SCARED: Anxiety
3. PHQ-A(Teen): Depression
4. VanderBilt: ADHD & comorbidities
• www.childmentalhealth.org• www.projectteachny.org
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www.childmentalhealth.org
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www.projectteachny.org
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CASE PRESENTATION
• 14 year old EMILY – comes to office with mother
• Stomach aches daily – missing a lot of school
• Parents recently separated – cordial with shared custody
• Started Grade 10. No academic concerns
• No weight loss
• Some difficulty initiating sleep
• Enjoys horseback riding
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TOOLS FOR ASSESSMENT How to choose?
• easy to use
• quick to complete
• different languages
• well validated
• free
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SCREENING TOOL
• PSC – 17 – PAEDIATRIC SYMPTOM CHECKLIST
• Can be your ROADMAP to guide from:
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SCREENING TOOL
• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST
• Can be your ROADMAP to guide from:
INDEX OF SUSPICION
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SCREENING TOOL
• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST
• Can be your ROADMAP to guide from:
INDEX OF SUSPICION DIAGNOSIS
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SCREENING TOOL
• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST
• Can be your ROADMAP to guide from:
INDEX OF SUSPICION
DIAGNOSIS MONITORING
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WHAT IS THIS PSC?
• Screen for psycho-social “wellness” (Mental Health Temperature)
• Developed (1986) Massachucett’s General Hospital
• Well validated over numerous studies in a wide range populations
• Available in 33 languages - also in pictures
• Less than 5 minutes to complete
• If a patient “screens in”: Sub-scale scores help to direct further assessments
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PSC 17 - Y
PSC-17• 17 QUESTIONS• Never = 0• Sometimes = 1• Often = 2• AGES 4-18• 3 SUBSCALES
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IF PSC SCORE IS ≥ 15
LOOK AT THE SUBSCALES
🔷 Inattention ≥ 7
☐ Externalizing ≥ 5
✻ Internalizing ≥ 5
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MENTAL HEALTH EVALUATION ROADMAP
PSC ≥ 15
INATTENTION ≥7
CONSIDER ADHD (VDB)
EXTERNALIZING ≥5
CONSIDER ADHD (VDB)
INTERNALIZING ≥ 5
CONSIDER ADHD (VDB)
CONSIDER ANXIETY/DEPRESSION
(SCARED/PHQ)
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0 9 15
EMILY’S PSC
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EMILY’s PSC
• SCREEN’s IN: TOTAL ≥15 EMILY = 15
• ATTENTION: CUT OFF ≥ 7 EMILY = 6 (what does this mean ?)
• EXTERNALIZING: CUTOFF ≥ 7 EMILY = 0
• INTERNALIZING: CUTOFF ≥ 5 EMILY = 9 (Anxiety/depression)
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HOW DO WE THINK ABOUT EMILY NOW?
• Definitely anxious/depressed
• Have to investigate further
• SCARED (SCreen for Anxiety Related Disorders)
• ?? Possible Attention difficulties
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• SCARED: Anxiety
• PHQ-A: Depression
• VanderBilt: ADHD, ODD, CD, Anxiety/Depression and………IMPAIRMENT
HOW TO TEASE THIS OUT?
REMEMBERSymptoms alone does not equal a diagnosis…
THERE HAS TO BE IMPAIRMENT
Assessment & Detective work…..
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IMPAIRMENTNever underestimate the pain & suffering that comes from untreated mood disorders
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SCREEN FOR CHILD ANXIETY RELATED DISORDERS (SCARED)
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SCARED
• Use for assessment, diagnosis and tracking response
• ≥ 25 may indicate presence of anxiety disorder
• Use the subscales to determine: * Panic disorder* Social phobia* School avoidance* Generalized anxiety disorder* Separation anxiety
Subscales easily calculated with electronic rating scales(www.childmentalhealth.org)
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Emily’s SCAREDYouth version (completed by herself)
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TOTAL SCORE34
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Anxiety and Depression
ANXIETY
MOOD
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PHQ-A
• DERIVED FROM THE ADULT VERSION PHQ-9
• 13 ITEMS, SELF-REPORTED
• 2 ITEMS SPECIFICALLY RELATED TO SUICIDAL IDEATION/RISK
• SIMPLE TO SCORE
• FOLLOWS DSM-V
• TRACKING/RESPONSE TO MANAGEMENT
• FREE
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SCORING PHQ-9
REGARDLESS OF TOTAL IF QUESTIONS 12 OR 13 SCORED POSITIVE THIS WARRANTS INVESTIGATION
• PHQ-9 CAN INDICATE SEVERITY
• 0-4 Minimal Depression
• 5-9 Mild Depression
• 10-14 Moderate Depression
• 15-19 Moderately Severe Depression
• 20+ Severe Depression
• www.ncfhp.org/Data/Sites/1/phq-a.pdf
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MANAGEMENT STRATEGIES
Treatment planning always needs a multimodal approach
* Educate the parents and child about anxiety/depression
* Consult with school and other significant adults for collateral information
* FIRST LINE: Cognitive-behavioral interventions and other psychotherapies
* Pharmacotherapy: Know the indications
If psychotherapy and pharmacotherapy does not restore functionality, consider referral for further evaluation.
* Treatment slides adapted from AACAP Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry 2007.
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THOUGHTS
BEHAVIOURSEMOTIONS
CBTCHANGING PERCEPTIONS
What we THINK affects how we feel and act
What we DO affects how we think and feelWhat we FEEL affects how we think and act
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Treatment planning depends on severity and impairment of the anxiety
* Mild severity - begin with psychotherapy
* Reasons for combining medication and psychotherapy:
* Need for acute symptom reduction in a moderately to severely anxious child
* Comorbid disorder that requires concurrent treatment
* Inadequate response to psychotherapy
* Potential for improved outcome with combined treatment
Monitor functional impairment as well as symptom reduction during the treatment process
TREATMENT
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HOW DO YOU KNOW YOUR PATIENT IS GETTING CBT?
All CBT include:
Cognitive restructuring
HOMEWORK
Relapse prevention plans
- booster sessions & coordination with parents & school
Different types for different MH conditions
Exposure-based CBT has the most empirical support for the treatment of anxiety disorders in youth
•
Sources: Association of Cognitive Behavioral Therapists and National Alliance on Mental Illness
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WHAT CAN YOU DO IN THE OFFICE?
Encourage parents to help their children to engage in CBT therapy
Ask therapist questions on the patient’s treatment
- goals & timeline (INTEGRATED CARE)
Teach relaxation skills
Recommend resources:
www.anxietycanada.ca (MyAnxietyPlan)
APP “Mindshift” (CBT)
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WHEN DO YOU CONSIDER MEDICATION?
SSRIs should be considered for the treatment of youth with anxiety disorders when:
Moderate to severe symptoms
Impairment makes participation in psychotherapy difficult
Partial response to psychotherapy
Monitor progress and side effects of SSRIs 2-4 wk follow-up
If effective, consider tapering after 6-12 months
If ineffective, consider a psychiatric consult
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HEALTH CANADA APPROVED MEDICATIONS
• Health Canada has not approved SSRI’s for under age 18
• FDA-approved Medications for OCD• SSRIs
• Fluoxetine (Prozac) (≥7 y/o)
• Fluvoxamine (Luvox) (>7 y/o)
• Sertraline (Zoloft) (≥6 y/o)• TCAs
• Clomipramine (Anafranil) >10 y/o for OCD
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Child–Adolescent Anxiety Multimodal Study (CAMS)
• Federally funded, multi-site RCT in 488 youth (7-17 yrs) with a primary diagnosis of non-OCD anxiety disorder
• Randomized to 12 weeks with 4 arms:• CBT
• Sertraline (SER)
• Combination of CBT + SER (COMB)
• Placebo (PBO)
Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill J, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC. Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety disorders: acute phase efficacy and safety. New England Journal of Medicine. Dec 25, 2008.
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Child-Adol Multimodal Study in treatment of anxiety
0
10
20
30
40
50
60
70
80
90
CBT ALONE SERTRALINE ALONE CBT AND MED PLACEBO
Child Adolesc Psychiatry Mental Health.2010 Jan5;4:1
(Mean dose Sertraline 146 mg)
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Starting Medication for Anxiety Using SSRI / SNRI
• Educate family & patient: side effects, expectations, treatment duration
• Start Low, Go Slow – BUT GO
• Begin with starting dose, if no significant side effects, gradually increase to target dose
• Monitor for side effects and response
• Obtain baseline and follow up rating scales from patient and/or parent
• Expect some evidence of improvement by 4 weeks. (Full effect takes 8-12 weeks)
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ANXIOLYTICS AND OTHER MEDICATIONS
Not first-line treatment - Use with caution!
Benzodiazepines – unproven
Beta blockers – unproven efficacy
Antipsychotic drugs - serious potential side-effects
Antihistamines – unproven efficacy
Buspirone – unproven efficacy
Tyrer P and Baldwin D; Lancet 2006:368:2156-66
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DO NOT FORGET ABOUT ADHD
• ANXIETY is the symptom. Look for the cause.
• ADHD – (especially predominantly inattentive subtype)
= Great Pretender.
• VanderBilt – rating scale: Very useful in diagnosis and tracking of management ADHD, co-morbities and impairment.
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ANXIETY/ DEPRESSION and ADHD
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VANDERBILT Rating Scale
Useful in diagnosis and tracking of management ADHD, co-morbities and impairment.
• PARENT AND TEACHER VERSIONS
• 9 questions – Inattention
• 9 questions – Hyperactivity
• 8 questions – Oppositional Defiance Disorder
• 15 questions – Conduct Disorder
• 7 questions – Anxiety and depression
• 8 questions – Impairment
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• SUITABLE FOR DIAGNOSIS
AND MONITORING
• QUESTIONS RELATE TO
DSM
• INCLUDES QUESTIONS
ON OTHER MENTAL
HEALTH DISORDERS
• SCALES FOR PARENTS
AND TEACHERS
• FUNCTIONALITY
QUESTIONS
VANDERBILT RATING SCALE
IMPAIRMENT
ANX/DEP = 3/7ATTENTION = 6/9
HYPERACTIVITY = 6/9
OPPOSITIONAL = 4/8
CONDUCT = 3/14
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TREATMENT OF ADHD – a whole talk by itself
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CONCLUSION
• Anxiety = Symptom
• Search for the underlying cause
• Manage the most impairing condition first
• Management does not always mean medication
• When medication is indicated - start low, go slow - BUT GO!
• Use the tools (scales) to track response EVERY time you change management
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