MOOD DISORDERS and ANXIETY in Adolescents€¦ · * Pharmacotherapy: Know the indications If...

MOOD DISORDERS IN ADOLESCENTS

Dr. Roxanne Swiegers

MBChB, CCFP, FCFP

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.

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)

HOW TO DIAGNOSE MOOD in ADOLESCENT?

ANXIOUS DEPRESSED SUICIDAL

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)

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

www.childmentalhealth.org

www.projectteachny.org

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

TOOLS FOR ASSESSMENT How to choose?

• easy to use

• quick to complete

• different languages

• well validated

• free

SCREENING TOOL

• PSC – 17 – PAEDIATRIC SYMPTOM CHECKLIST

• Can be your ROADMAP to guide from:

SCREENING TOOL

• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST

• Can be your ROADMAP to guide from:

INDEX OF SUSPICION

SCREENING TOOL

• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST

• Can be your ROADMAP to guide from:

INDEX OF SUSPICION DIAGNOSIS

SCREENING TOOL

• PSC-17: PAEDIATRIC SYMPTOM CHECKLIST

• Can be your ROADMAP to guide from:

INDEX OF SUSPICION

DIAGNOSIS MONITORING

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

PSC 17 - Y

PSC-17• 17 QUESTIONS• Never = 0• Sometimes = 1• Often = 2• AGES 4-18• 3 SUBSCALES

IF PSC SCORE IS ≥ 15

LOOK AT THE SUBSCALES

🔷 Inattention ≥ 7

☐ Externalizing ≥ 5

✻ Internalizing ≥ 5

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)

0 9 15

EMILY’S PSC

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)

HOW DO WE THINK ABOUT EMILY NOW?

• Definitely anxious/depressed

• Have to investigate further

• SCARED (SCreen for Anxiety Related Disorders)

• ?? Possible Attention difficulties

• 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…..

IMPAIRMENTNever underestimate the pain & suffering that comes from untreated mood disorders

SCREEN FOR CHILD ANXIETY RELATED DISORDERS (SCARED)

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)

Emily’s SCAREDYouth version (completed by herself)

TOTAL SCORE34

Anxiety and Depression

ANXIETY

MOOD

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

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

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.

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

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

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

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)

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

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

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.

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)

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)

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

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.

ANXIETY/ DEPRESSION and ADHD

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

• 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

TREATMENT OF ADHD – a whole talk by itself

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