March 31 2022 Linda Jo Volness MS APRN PMHCNS My pronouns are he her hers Quality Life Mental Health and Wellness Center Mood Disorders in Children amp Psychiatric Medications Used to Treat ID: 916810
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Slide1
North Dakota Family Based Services Conference
March 31, 2022
Linda Jo Volness MS, APRN, PMH-CNS,
My pronouns are: he, her, hers
Quality Life Mental Health and Wellness Center
Mood Disorders in Children & Psychiatric Medications Used to Treat
Slide2Linda Jo Volness will be discussing off-label use of
medications
in this presentation
Disclosure
Slide3Objectives
Slide4Mental Health Diagnosis in Childhood
. Estimates for ever having a diagnosis among children aged 3-17 years, in 2016-19, are given below.ADHD 9.8% (approximately 6.0 million)2
Anxiety 9.4% (approximately 5.8 million)2Behavior problems 8.9% (approximately 5.5 million)2Depression 4.4% (approximately 2.7 million)2
This Photo
by Unknown Author is licensed under
CC BY
This Photo
by Unknown Author is licensed under
CC BY-ND
Slide5Slide6Mental Disorders can occur together
Slide7Slide8Adverse childhood events (ACE)
Children with
3+
reported ACEs, compared to children with zero reported ACEs,
had higher prevalence of one or more mental, emotional, or behavioral disorder (
36.3% versus 11.0%).
6
Slide9Statistics
NIMH » Any Mood Disorder (nih.gov)
2
Slide10Statistics
NIMH » Any Mood Disorder (nih.gov)2
Slide11Adolescent Mental Health Concerns
15.1% had a major depressive episode.
2
36.7% had persistent feelings of sadness or hopelessness.
2
4.1% had a substance use disorder.
2
1.6% had an alcohol use disorder.2
3.2% had an illicit drug use disorder.2
18.8% seriously considered attempting suicide.
215.7% made a suicide plan.
28.9% attempted suicide.22.5% made a suicide attempt requiring medical treatment.2AdolescentData and Statistics on Children's Mental Health | CDC
Slide12Slide13Severe Mood Dysregulation (SMD) HX
Criteria developed by Leibenluft et el. In consultation with investigators at other sights.
Designed to address scientific question: to what degree do children meeting these criteria (DMD) resemble youth with BP on variables used to validate psychiatric disorders?
Children with chronic irritability no distant manic episodes should be differentiated from those with BP and BP-NOS.
Towbin K, Axelson D, Leibuenluft E, Birmaher B.
Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation. J Am Acad Child Adoles Psychiatry. 2013:52:466-481
Slide14Statistics
Disruptive Mood Dysregulation Disorder
None available
Slide15DMDD
Slide16PRIMARY FEATURES OF CHILDHOOD
MOOD DISORDER MOOD CYCLING
vs. CHRONICITY
DEPRESSIVE
SYMPTOMS
“ADHD”
SYMPTOMS
MANIC
incl.
DISTRACTIBILITY-
INATTENTION
MANIC
SYMPTOMS
OTHER
incl.
LATE SLEEP ONSET
RAGE/
? DMDD
RAGE/BIPOLAR
Slide17UNIPOLARDEPRESSION
? Bipolar I
BIPOLAR DEPRESSIVE SYMPTOMS
HYPOMANIC SYMPTOMS
Mania Mixed
Bipolar II
Disorder
Mood Disorder Spectrum DSM-5
Bipolar NOS?DMDD
? DMDD
Slide18Slide19Persistent Depressive
D
isorder
New term in DSM-5, originally known as dysthymia and chronic major depression
For children or adolescents, the
mood
can be irritable instead of depressed
, and the time requirement is 1 year. For both groups, symptoms cannot be absent for greater than 2 months. In addition to depressed/irritable mood, at least 2 of the following symptoms have to be present. Poor appetite or overeatingInsomnia or hypersomnia
Low energy/fatigueLow self-esteemPoor concentration/decision makingHopelessness
Slide20RACING THOUGHTS
LESS SLEEP
GRANDIOSITY
ELATION
RAGE
IRRITABILITY
severe angerwith agitation,
aggression;
Slide21Disruptive Mood Dysregulation Disorder (DMDD) (F.34.8)
The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level. 2013 American Psychiatric Association.
Slide22DMD Criteria
B. ExclusionExhibits any of cardinal manic symptomsElevated or expansive moodGrandiosity or inflated self-esteemEpisodically decreased need for sleepSymptoms occur in distinct periods lasting > 1 d Hyperarousal of following: insomnia, agitation, distractibility, racing thoughts, or flight of ideas, pressured speech, intrusiveness. Meets criteria for schizophrenia, PDD or PTSD.Meets criteria for substance abuse in pasts 3 months
5. IQ <706. Symptoms due to direct physiological effects of a drug abuse, medical or neurological condition. Towbin K, Axelson D, Leibuenluft E, Birmaher B. Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation. J Am Acad Child Adoles Psychiatry. 2013:52:466-481
Slide23DMDD
Slide24DMDD
Slide25DMDD
J. Criteria (cont.) The behaviors can coexist with other disorderMajor Depressive DisorderADHDConduct DisorderSubstance Use DisorderCan not coexist with Oppositional Defiant Disorder Intermittent explosive disorder Bipolar2013 American Psychiatric Association
Slide26DMDD
Risk and Prognostic Factors
Many have qualified for Oppositional Defiant Disorder (ODD)
Also often meet criteria for ADHD
Also often meet criteria for anxiety disorders
Some also meet criteria for MDDGeneticsuggested …can be differentiated from children with BP in their family-based riskDMDD do NOT differ from BP familiar rates of anxiety disorders, unipolar depressive disorders or substance abuse.
Slide27DMDD
Functional consequences
Extremely low frustration tolerance
Difficulty succeeding in school
Often unable to participate in the activates typically enjoyed by healthy children
Family life is severely disrupted
Trouble initiating or sustaining friendships
Both DMDD and BP children
Dangerous behavior
Suicidal behaviors or suicide attempts
Severe aggression
Psychiatric hospitalizations are common
Slide28Disruptive Mood Dysregulation Disorder
Slide29Mood Disorders
Slide30Medications Approved for DMDD
Currently, there are
No
medications approved by the U.S. Food and Drug Administration (FDA) specifically for treating children or adolescents with DMDD.
However, health care providers may prescribe certain medications—such as stimulants, antidepressants, and atypical antipsychotics—to help relieve your child’s DMDD symptoms
Disruptive Mood Dysregulation Disorder: The Basics (nih.gov)
Slide31FDA Approved Psychopharmacological Treatment for ADHD in Children/Adolescents
AgentsADHD
amphetamine (Adderall = ages 3-12; Adderall XR=6-17 & adults; Mydayis=13-17, 18-55 )atomoxetine (Strattera=ages 6 through adults)
methylphenidate (Ritalin’s includes Concerta, Metadate’s, Quillivant XR, QuilliChew ER, Jornay
PM, Cotempla XR-ODT, Daytrona) ages vary depending on formulations
lisdexamfetamine (Vyvanse=6 yrs old through adults)guanfacine (Tenex, not approved for ADHD, use is off label) immediate release and er not interchangeable
guanfacine er (Intuniv = ages 6-18 yrs)
clonidine XR (Catapress, Kapvay XR ages 6 and above) immediate release and er not interchangeableModafinil (Provigil) not approved off label
bupropion (Wellbutrin) not approved off labelViloxazine (Qelbree =ages 6-17 yrs)
ADHD Side EffectsStimulantsInsomniaHeadacheExacerbation of ticsNervousnessIrritability
OverstimulationTremorDizzinessAnorexiaNauseaDry MouthConstipationDiarrheaWeight LossStrattera/atomoxetineSedationFatigueDecreased appetiteRare priapismIncreased heart rate/BPInsomniaDizzinessAnxietyAgitationAggressionIrritabilityDry mouth
ConstipationNausea/vomitingUrinary hesitancy
Slide33ADHD Side EffectsClonidine/KapvayDry mouthDizzinessFatigueInsomnia
HeadacheMajor depressionHypotensionTachycardiaNervousnessAgitatedNausea, vomitingIntuniv/guanfacine erSedationDizzinessFatigue/weaknessHypotension
Slide34Slide35Slide36MAJOR DEPRESSIVE DISORDER (MDD)
Slide37Medication approved for Pediatric MDD
Medications FDA Approved to treat pediatric Major Depressive Disorder
Fluoxetine (Prozac)
is the only SSRI approved by the FDA for treatment of depression in children aged 8-18 years
Black Box WarningPediatric Depression. Medscape. Mar 15, 2016
Slide38FDA Approved Psychopharmacological Treatment for Depression in Children/Adolescents
AgentsDepression
AnxietyOCD
Antidepressants
fluoxetine (Prozac)
+
-
+
citalopram (Celexa)--
-
escitalopram (Lexapro)
-
-
-
sertraline (Zoloft)
-
-
+
mirtazapine (Remeron)
–
-
-
paroxetine (Paxil)
-
-
+
duloxetine (Cymbalta)
-
+
-
bupropion (Wellbutrin)
–
-
-
clomipramine (Anafranil)
–
-
+
venlafaxine (Effexor)
-
-
-
Slide39Antidepressants Side EffectsSSRI (Prozac, Zoloft, Celexa, Lexapro, Paxil). SNRI (Effexor)Insomnia/Sedation/Headaches/DizzinessDiarrhea/Nausea/Constipated/Dry mouth/SweatingEmotional flattening/apathy
Cognitive slowingSexual dysfunctionProzac Agitation (akathisia)AnxietySwitch to maniaCymbalta (duloxetine)Above plus increase in blood pressureWellbutrin (bupropion)InsomniaTremorAgitationHeadache/DizzinessDry mouth/Constipation/NauseaAnorexiaSweatingRemeron (mirtazapine)Dry mouth/ConstipationIncreased appetite/Weight gainSedation/Dizziness/Abnormal dreams
Flue-like symptomsHypotension Urinary function
Slide40AMs
PMs
SLOWER low energy
LESS
DEPRESSED
MORE DEPRESSED
Slide41Differential Diagnosis: Unipolar or Bipolar?
Mania Symptoms
Key Elements
Age of first mania/depression
Time between episodesLength of episodes
History of treatmentMultiple treatment failures?Non-response or erratic response to antidepressants?
Higher rates of mood disorder impairment?
Unevenness in intimate relationships? Distractibility, Insomnia, Grandiosity, Flight of ideas,
Activities, Pressured speech, ThoughtlessnessCourseof Illness
Key Elements
Treatment
Response
Key Elements
Family History
Key Elements
Associated Features
Key Elements
Slide42Slide43PRINCIPLE OF BIPOLAR MOOD, SPEED, AND
ENERGY CHANGES DURING DAY
AMsPMs
FASTER high energy
MORE
MANIC
Slide44Longitudinal Assessment of Bipolar Disorder Is Critical
Hypomania
Mania
Depression
Euthymia
Depression
Subsyndromal
Depression
Polarity of Symptoms
Slide45CYCLING WITHIN ONE DAY
(ultradian)
INFREQUENT CYCLING
PMs
AMs
SUMMER
mania
WINTER
depression
typical
diurnal
pattern of
childhood bipolar cycling
Slide46Bipolar DSM-5 Codes
Slide47Mania DSM 5
Manic Episode
A. A distinct period of abnormally and persistently
elevated
, expansive
or irritable mood and Abnormally increased goal-directed activity or energy
Manic Episode lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is required). Hypomanic Episode lasting 4 consecutive days and present most of the day, nearly every day.2013 American Psychiatric Association
Slide48PRINCIPLE OF BIPOLAR MOOD, SPEED, AND
ENERGY CHANGES DURING DAY
AMsPMs
FASTER high energy
MORE
MANIC
Manic Bipolar Cycle
B. During the period of mood disturbance and increased energy or activity
Slide49NEED LESS SLEEP
RACING THTS./
FLIGHT OF IDEAS
GRAND- IOSITY
ELATION
plus three+ of seven others BIPOLAR ILLNESS
IRRITABILITY plus four+
of seven others BIPOLAR ILLNESS
RECKL.
IMPULS.
PRESS.
SPEECH/
MORE TALKATIVE
DISTRACT
-
IBILITY
ii
INCREASE
ACTIVITY
GOAL OR NON
(AGITATION)
MANIC
B. During the period
of mood disturbance and
increased energy
or activity
Slide50Psychomotor
AccelerationHedonia
Psychosis
IrritableAggression
Dysphoric Mood
Factor Structure of Mania
Cassidy et al. 1998
elation
grandiosity
depression during mania
rage violent aggression
pressured speech
racing thoughts
distractibility
hyperactivity
impulsivity
Bipolar Disorder
Slide51DIGFAST:
Symptoms of Hypomania and Mania
D Distractibility: poorly focused, multitaskingI Insomnia: decreased need for sleepG Grandiosity: inflated self-esteemF Flight of ideas: complaints of racing thoughtsA Activities: increased goal-directed activitiesS Speech: pressured or more talkative
T Thoughtlessness: “risk-taking” behaviors — sexual, financial, travel, drivingGhaemi. Prim Psychiatry. 2001;8:28-34.
Slide52RACING THOUGHTS
LESS SLEEP
GRANDIOSITY
ELATION
RAGE
EXPLOSIVEIRRITABILITY
periods of
prolonged excessive silliness
(esp. evenings)
Bipolar Mania Disorder
Slide53RACING THOUGHTS
LESS SLEEP
ELATION
RAGE
EXPLOSIVE
IRRITABILITYGRANDIOSITY
“tall tales” cocky, entitled,
arrogant attitude;
bossy, bullying;
Bipolar Disorder
Slide54RACING THOUGHTS
LESS SLEEP
GRANDIOSITY
ELATION
RAGE
EXPLOSIVEIRRITABILITY
“100 miles
per hour”;flying from
subject to subject
Bipolar Disorder
Slide55(Goodwin and Jamison 1990; Bauer et al. 1991)
*
Rapid speech (racing thoughts) is an almost invariant finding in mania.
LESS SLEEP
RACING THTS.
PRESS.
SPEECH DISTR-ACTIBIL.
HYPER-
ACTIVITY
B2
B4
B3
B5
B6
B7
RECKLESS
IMPULSIVITY
ELATION
GRAND-
IOSITY
A
B1
*
Slide56overlapping
defining features
TALKS EXCESSIVELY
DISTRACTIBILITY
HYPERACTIVITY
ADHD
IMPULSIVITYexcessive elation
/ irritability grandiosity
excessive bedtime energy
racing thoughts
PRESSURED SPEECH
DISTRACTIBILITY
HYPERACTIVITY
Mania
harmful
IMPULSIVITY
Slide57Bipolar Disorder Symptoms
RACING THTS.
LESS
SLEEP
GRAND- IOSITY
ELATION
OR IRRIT- ABILITY
“ADHD” MANIC SYMPTOMS PRESSURED SPEECH
DISTRACTIBILITY HYPERACTIVITYRECKLESS IMPULSIVITY
DEPRESSION
RAGE
EXPLOSIVE
IRRITABILITY
EIGHT DSM-IV MANIC SYMPTOMS
Slide58fidgets, squirms
diff. staying seated
runs inappropr.driven by a motor
blurts out answersdiff. awaiting turninterrupts others
manic
press. speech
careless mistakes
diff. sustaining attn.doesn’t seem to listen
fails to finish tasksdiff. organizing tasks
loses thingsforgets daily activitieseasily distracted avoids difficult tasks
ADHD Inattention Criteria
manic
distract
ibility
ADHD Hyperactivity-
Impulsivity Criteria
loud play
--- is a sx. of mania
talks excessively
manic
hyper
activity
manic
impuls
ivity
Essentially all of the ADHD symptoms are
present when bipolar patients are manic.
Chronically hypomanic children will be
misdiagnosed as having primary ADHD.
Slide59Behavioral ratings from a large number of studies
indicate that racing thoughts, pressured speech, increased motor activity, and decreased sleep are the most common clinical findings in mania.
Goodwin and Jamison 1990; Benazzi 2003.
RACING THOUGHTS
PRESSURED SPEECH
HYPER- ACTIVITY
LESS
SLEEP
Slide60ADHD? No.
Probably an atypicalform of bipolar illness.
ADHD criteria met
LESS
SLEEP
RACING THTS.
B2B4B3
B5
B6
B7
ELATION
GRAND-
IOSITY
A
B1
Slide61mornings
before schoolAT HOME
after school
and evenings AT HOME
SCHOOL DAYS
“ADHD” symptoms
TIRED
SLOW
ANGRY
DEFIANT
“HYPER”
RACING
SILLY
COCKY
Diurnal Bipolar Cycling
(a common childhood bipolar illness presentation)
Slide62Chronic Mania or Hypomania
HYPERACTIVITY
PRESS. SPEECH
DISTRACTIBILITY
ELATION
GRANDIOSITY
RACING THOUGHTS
PMs
AMs
Slide63Chronic Mixed State
ADHD
SYMPTOMS
RAGE
DYSPHORIC MOOD LITTLE INTEREST
LOW SELF-ESTEEM
RACING THTS.
LESS
SLEEP
Suicide
Slide64THE DEVELOPMENTAL PROGNOSIS OF BIPOLAR
CHILDREN IS MADE WORSE BY THE FREQUENT PRESENCE OF MULTIPLE COMORBID PSYCHIATRIC ILLNESSES
Attention-Deficit Hyperactivity Disorder 85% Oppositional Defiant Disorder 75%
Anxiety Disorder(s) 40% Obsessive Compulsive Disorder
Generalized Anxiety Disorder
Substance Abuse (adolescents) 40% Conduct Disorder 2x that of
ADHD Children
ADULT
(ANY) SUBSTANCE ABUSE DISORDER 70% ANXIETY DISORDER(S) 60+%
Slide65DISTRACTIBILITY
HYPERACTIVITY
DEPRESSIVE SXS.
INCREASING AGE
NORMAL
MANIC SXS.
YOUNG
ADULTHOOD
AGE
3 YRS.
RAGE
VERY RAPID CYCLING
CHRONIC MOOD LABILITY
DEVELOPMENTAL COURSES OF
BIPOLAR AND “ADHD” SYMPTOMS
IMPULSIVITY
Slide66FDA Approved Psychopharmacological Treatment for Bipolar Disorder in Child/Adolescents
AgentsManic
MixedMaintenanceDepression
OTHER
Carbamazepine ER (
Equetro
TM)-
-––
Oxycarbamazepine--
-
-
Divalproex DR (Depakote®)
-
–
–
–
Lamotrigine (
Lamictal
®
)
–
–
-
–
Lithium (
Lithobid
®
,
Eskalith
®
)
age 12-17
+
–
–
–
Topiramate (Topamax
®
)
-
-
-
-
Slide67Mood Stabilizer Side EffectsLithiumAtaxia, tremor, memory problems, deliriumPolyuriaDiarrhea, nauseaWeight gainDecrease thyroid function
Acne/rash/hair lossLithium toxicity/life threateningNeed blood workDepakote (valproate), seizure medSedationTremorDizziness/ Ataxia/headacheAlopecia (hair loss)Following controversialPolycystic ovariesHyperandrogenismDecreased bone mineral density
Slide68Mood Stabilizer Side EffectsLamictal (lamotrigine) seizure medSedationBlurred or double visionDizziness/Ataxia/HeadacheTremor
InsomniaNausea/Vomiting/ConstipationRare serious life threating rashSteve Johnsons SyndromeTopamax (topiramate)Kidney stonesParesthesiasNausea/Appetite loss/wt. lossMood problemsMemory problemsLanguage/speech problemsTaste perversion
Slide69FDA Approved Psychopharmacological Treatment for Bipolar Disorder in Children/Adolescents
AgentsManic
MixedMaintenanceBipolar
DepressionATYPICALS
a
ripiprazole (Abilify®) age 10-17+
++
–asenapine (Saphris®) age 10-17
++--olanzapine/fluoxetine (Symbyax
®)Age 10-17-
-
-+
lurasidone (Latuda) age 10-17
-
-
-
+
o
lanzapine (Zyprexa
®
) age 13-17
+
+
-
–
q
uetiapine (SEROQUEL
®
) age 10-17
+
–
-
-
q
uetiapine XR (SEROQUEL XR
®
) age 10-17
+
+
-
-
r
isperidone (Risperdal
®
) age 10-17
+
+
–
–
z
iprasidone (Geodon
®
)
withdrew
from completing study in pediatric mania
-
-
–
–
paliperi
done (Invega
®
) age
12-18, for
schizophernia
-
-
-
-
Slide70Let’s look at the symptom of irritabilityWhat medications FDA approved to treat the symptom irritability?Oct. 10, 2006 The FDA has approved Risperdal (risperidone) to treat irritability in children and adolescents with autism.It's the first approval of a drug for use in treating behavior related problems associated with autism in children. Classified under the
general heading of irritability, these behaviors include aggression, deliberate self injury, and temper tantrums.http://www.webmd.com/brain/autism/news/20061010/fdaoksdrugautismirritability?print=true Abilify (aripiprazole) indicated irritability associated with autistic disorder age 6-17 years of agehttps://www.abilify.com
Slide71Prescribing Information for SEROQUEL
Atypical Boxed WarningSuicidality in children and adolescents – antidepressants increased the risk of suicidal thinking and behavior (4% vs 2% for placebo) in short-term studies of 9 antidepressant drugs in children and adolescents with major depressive disorder and other psychiatric disorders. Patients started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. (see Boxed Warning)
Slide72Metabolic MonitoringThis is suggestion based on American Academy of Child and Adolescent Psychiatry, updated 2013
Slide73Slide74Movement Disorder AKATHISIA
Slide75Movement Disorder Tardive Dyskinesia (TD)
Slide76Movement Disorder Tardive Dyskinesia (TD)
Slide77Questions?
Slide78ReferencesData and Statistics on Children's Mental Health | CDC2. NIMH » Any Mood Disorder (nih.gov)Disruptive Mood Dysregulation Disorder: The Basics (nih.gov)
Suicidality in Children and Adolescents Being Treated With Antidepressant Medications | FDA
Slide79ReferencesAmerican Psychiatric Association, 2010. Diagnostic and statistical manual of mental disorders, fourth edition. DSM-IV. American Psychiatric Association, Washington, DC. American Psychiatric Association , 2010. Diagnostic and statistical manual of mental disorders, fifth edition. DSM-5. American Psychiatric Association, Washington, DC Cassidy, F., Murry, E., Forest, K., Carroll, B.J., 1998b. Signs and symptoms of mania in pure and mixed episodes. J. Affect. Disord.50, 187-201. Towbin, K.,
Axelson, D., Leibenluft, E., Birmaher, B., Differentiating bipolar disorder-not otherwise specified and severe mood dysregulation. Psychiatry. 2013:52:466-481