4/7/2021
Considering and Starting Treatment for Depression & Anxiety
Abigail Schlesinger MD
1
Goals and Objectives
At the completion of this program, participants should be able to: 1. Recognize the importance of the behavioral health differential diagnosis when prescribing medication for depression/anxiety 2. Describe a method to deploy components of their behavioral health toolbox(therapy strategy, safety plan, and/or medication) 3. Recognize the importance of appropriate follow-up for behavioral health interventions provided in pediatric primary care
2
2
1 4/7/2021
Therapeutic Toolbox
Follow-up
Non-medication Interventions
Safety Planning
Medication
Referral and Coordination
3
3
Nonmedication Interventions
Relationship HELLPP Skills Assessment Health Behavior Interventions BH Interventions
4
4
2 4/7/2021
Organizing the Session
Set Agenda
Recognize frustration/fears/anger/strengths & instill hope
Clarify Needs(assessment, differential, safety planning)
• Listen and Ask targeted questions sleep, appetite, routines, school, friends, mood, hope/helplessness
Create clear plans
• I understand you are here for depression. Today I am going to ask questions and listen to you so that I can better understand your concerns.Then we will come up with initial goals/strategies to improve your mood
5
5
GAD-7
6
6
3 4/7/2021
PHQ-9
7
7
Depression: Assessment with SIG-E-CAPS
Depressed and/or irritable mood PLUS…. Sleep problem(up or down) Interest deficit (anhedonia) Guilt (worthlessness, hopelessness, regret) Energy deficit Concentration deficit Appetite changes(up or down) Psychomotor agitation or retardation
Suicidality 8
8
4 4/7/2021
DSM 5 Criteria: Major Depressive Disorder
1. Sad, down, negative mood, Irritable, easily frustrated, empty feeling, hopelessness, argumentative. Focused irritability in children on negative events, interprets events as 2. Anhedonia, decreased interest or loss of pleasure negative, discounts positives. “I don’t care” 3. Changes in sleep attitude
4. Changes in appetite Not enjoying or quitting activities; Subjective report or observed by others
May sleep/eat more or less.
9
9
DSM 5 Criteria: Major Depressive Disorder
5. Decreased concentration, Easily swayed by others, decisiveness changes mind, may question if developed 6. Psychomotor agitation or ADHD, amotivation retardation, observable by others Complaints of feeling agitated, noted pacing/ increased negative energy, or “couch potato”, amotivation
10
10
5 4/7/2021
DSM 5 Criteria: Major Depressive Disorder
7. Complaints of fatigue or Regardless of increased or decreased sleep decreased energy
Negative about self, low self esteem, may feel 8. Feelings of responsible for events out of worthlessness or their control, discount positives and focus on excessive/inappropriate negatives guilt May think family would be better off without them for 9. Death wish, suicidal fleeting moments or chronically think life isn’t ideation worth it, want to hurt self but no plan, or have a plan, and/or intent 11
11
DSM 5 Anxiety Disorders
• Generalized Anxiety Disorder
• Separation Anxiety Disorder
• Specific Phobia
o Animal, natural environment, blood-injection-injury, situational, other
• Panic Disorder
• VS Panic as a part of depression
• Other Specified Anxiety Disorder
• Also consider: Somatoform Disorder, OCD
12
12
6 4/7/2021
Anxiety: Developmental Issues
Preschool=predominantly separation
School age=worries decrease for separation and focus on performance
Adolescents=worries of peer acceptance
13
13
DSM 5 Criteria: Generalized Anxiety Disorder
Diagnostic Criteria Clinical Pearls
• Essential feature is • These kids can worry excessive worry about the fact that they (apprehensive worry. expectation, fear of the • If they’ve had it their future) more days than whole life they might not not for at least 6 months see it as a problem, • Worries are difficult to even though their entire control family alters their life to help
14
14
7 4/7/2021
DSM 5 Criteria: Generalized Anxiety Disorder
Diagnostic Criteria Clinical Pearls • In children, must have one of • Be alert for this diagnosis the following: when a child and/or o c/o restlessness family is concerned o easily fatigued about ADHD but the teacher reports only o difficulty concentrating minimal inattentive o irritability symptoms. o muscle tension • Teachers often love o sleep disturbance these kids.
15
15
GAD: Assessment
Most common anxiety disorder diagnosis Screening questions Would you describe yourself as a worrier? Ask the kid or parents about bedtime. “What if” questions Give examples of common worries—the weather, robbers, grades, terrorism, health concerns. Ask teens if they worry about their future
16
16
8 4/7/2021
DSM 5 Criteria: Social Anxiety Disorder Diagnostic Criteria Clinical Pearls • Anxiety caused by • May take a bad grade exposure to a feared or skip school in order to social situation o Exposed to scrutiny avoid situation. o Must include peer settings o Fear of embarrassment/rejection by peers • Doesn’t mean that they • Attempt to avoid social are not social…they situations or endure at must have some age great distress appropriate friendships. o Children may cry, tantrum, freeze, or shrink from the exposure • Will overuse • Symptoms present for at texting/internet for least 6 months communication
17
17
SAD: Assessment • Would you describe yourself as shy? • When you are around your peers, do you worry about saying the wrong thing? Getting embarrassed? • Will you raise your hand in class? • Will you order food at a restaurant?
18
18
9 4/7/2021
DSM 5 Criteria: Separation Anxiety Disorder 3+ of the following symptoms are present: Distress with separation or anticipated separation Worry about losing caregiver or harm coming to them Illness, injury, disasters, death Worry of untoward event causing separation lost, kidnapped, illness Physical complaints w/ separation or anticipated separation Headaches, stomachaches. Sunday nights. Persistent reluctance to leave home because of fear of separation Persistent reluctance to sleep away from home or sleep without having caregiver near 19 Repeated nightmares of separation
19
DSM 5 Criteria: Separation Anxiety Disorder Onset from preschool until 18 years of age
Duration at least 4 weeks
Developmentally inappropriate worry related to separation from home or to whom one is attached
20
20
10 4/7/2021
Separation Anxiety Disorder: Assessment • Question parents but sometimes children may have insight.
• Ask about difficulties separating in general. Start with younger years— preschool, school age.
• Ask how they did in preschool/kindergarten separating from parents
• Where do they sleep? Do they sleep alone?
• Will they go on overnights/sleepovers?
• History of separation anxiety increases risk of other anxiety disorders.
21
21
DSM 5 Criteria: Panic Disorder
Recurrent, unexpected panic Dizzy, Derealization attacks Chills or unsteady, depersonalization flushed light- Panic attack: an abrupt surge of headed intense fear that reaches peak within minutes
4+ symptoms Sweating Chest Choking Palpitations, fast pain HR Attacks followed by 1+ months: Fear of losing Persistent concern/worry about Shaking GI distress Fear of control/”going more panic or their dying crazy” consequences
Significant, maladaptive change in behaviors SOB, suffocating Paresthesias
22
22
11 4/7/2021
Panic Disorder: Assessment
• Have you ever had a panic attack? o Describe it. • Have you ever had anxiety so extreme that you noticed symptoms in your body? • How long did it last? • Are there precipitants? • Are you avoiding certain things out of fear of having another panic attack? • Panic disorder vs. panic attack specifier.
23
23
SCAReD Scoring
24
24
12 4/7/2021
25
25
26
26
13 4/7/2021
Initiation Check(s)
1.Validate Diagnosis & Safety 2.Review Family History 3.Complete Consent/Assent 4.Clarify Goals/Expectations/Safety Plan 5.Start Medication 6.Schedule follow-up
27
27
1. Validate Diagnosis & Safety
Review work-up - medical diagnosis & comorbid psychiatric ASSURE SAFETY Confirm Diagnosis Review Behavioral Scales SCARED parent and child(7-18) or GAD-7(13 and over 18) PHQ9(or PHQ9a) Consider Comorbidities that can Complicate Treatment
28
28
14 4/7/2021
Consider Psychiatric Comorbidities that Could Complicate Treatment
Bipolar Disorder Assess personal history Autistic Spectrum Are ASD driving “anxiety behaviors” Disorder Trauma Acute or Chronic Trauma Substance Use Consider Substance Screen Eating Disorder Medication won’t work if you don’t have enough food to feed the brain Suicidality Assess past and Current ADHD & ODD Consider Vanderbilts
29
29
Screening for Bipolar Disorder
“Was there ever a period of time, for more than a few days, that you(or your child) didn’t need sleep, was on top of the world, and significantly different than usual”
Note
This should be a clear change from baseline.
Child should be energetic during the day, ie not need a nap, not go to bed early
There is the most concern for bipolar disorder if the child was euphoric(more happy than normal) or grandiose(felt that they were special, had special powers etc) and there is no reason for it(ie it’s not the day before a holiday)
30
30
15 4/7/2021
Safety
Safety should be assessed in all children and adolescents
31
31
Depression & Suicide
Untreated depression is the number one cause of suicide
Over 90% of children and teens who complete suicide have a mental health diagnosis (Mental Health: A Report of the Surgeon General)
Suicide is the #2 cause of death in the U.S. in those 10-24 years-old (NCHS)
32
32
16 4/7/2021
Risk Assessment
Begin with general questions: “Have you ever thought you would be better off dead….your family would be better off without you”
Death wish: 20% prevalence
Progress to more specific questions: “Have you ever had a plan?” Means to carry out?
Much less common
Gave away possessions?
Normalize:
Many times children who are feeling down or depressed describe having thoughts that they don’t want to be alive. Have you ever felt that way?
33
Self-Injury and Suicidal behavioral
Having self-injury is risk-factor for suicide
There is a continuum from superficial self-injury to a suicide attempt
It is important to be able to differentiate in order to assess current risk
Most-often people can tell you that they were harming themselves to
Kill themselves and/or
Harm themselves(often described as coping mechanism to deal with psychological pain)
Ask what their method of self-injury is(where and with what)
Must ask about plans when kids have thoughts of suicide (even if they say “I would never do it”)
34
34
17 4/7/2021
2. Review Family History
Bipolar Disorder
Response to Antidepressants
35
35
3. Consent/Assent
Parent should consent
Adolescent(and preferably child) should assent
36
36
18 4/7/2021
Consent/Assents Warn about side effects More common that will probably go away if not too bothersome(if they even occur) Rare and concerning Suicidality Mania Serotonin Syndrome Other Activation – some kids get increased energy during the day, but have no trouble with sleep
37
37
SSRI Side Effects
• GI: nausea, abdominal pain, diarrhea, weight loss, weight gain • Headaches • Easier bruising • Sweating • Light-headedness/dizziness • Nervousness/restlessness • Sleep difficulties: sedation/insomnia, vivid dreams • Sexual dysfunction • Irritability/activation • Potential risk for suicidal thinking 38 • Precipitation of mania
38
19 4/7/2021
FDA Black Box Warning
Based on a 2004 FDA review of reported adverse events in 23 clinical trials which involved 4300 children and adolescents, 9 different medications Studies used two different measures for suicidal thoughts and behavior FDA clumped both thoughts and behaviors as “suicidality”
39
39
FDA Black box
First measure “event report” Second measure – 17 of 23 studies “standardized forms” questioned suicidality at each visit Second measure technique considered more accepted
40
40
20 4/7/2021
FDA Black Box warning
Studies that used event reporting noted that 2% who received placebo expressed increased suicidality compared to 4% on medication. Studied that used standardized forms that questioned suicidality at each visit demonstrated a slight reduction in suicidality for the medication group.
41
41
Black Box Warning
“Less than 2% of kids who start an SSRI will see an increase in suicidality – often suicidal thoughts/ & thoughts about self-injury. I am recommending this medication because the benefits of treating this depression/anxiety far outweigh any risk associated with increased suicidality. But, because we take behavioral health seriously I will follow-up with you closer while starting medication to make sure that you are safe.”
42
42
21 4/7/2021
4. Clarify Goals/ Expectations/Safety
GOALS What does the family/child want to get out of treatment? Do you anticipate that this intervention will help? Are goals aligned with treatment
43
43
Clarify Expectations: Roles
Providers in the practice Help design & support the treatment plan that includes evidence-based intervention Maintain confidentiality, with caveats Help child/adolescent get better Parents & Patients Participate in treatment Help design and support the treatment plan Speak up if things aren’t going well
44
44
22 4/7/2021
Expectations of Treatment
Expectation of Treatment Getting better takes time SSRIS take time – 4-12 weeks at therapeutic dose Dose may need to be adjusted over time So response needs to be monitored Treatment works better if you participate in therapy
45
45
Safety Plan
1. Coping strategies 2. Adult(s) who child will contact if distressed 3. Emergency numbers
Write the plan down Share with the family
46
23 4/7/2021
Safety Plan
1. Coping strategies 2. Adult(s) who child will contact if distressed 3. Emergency numbers
Write the plan down Share with the family
47
5. Start Medication
You can increase medication weekly You can start at typical starting dose or low starting dose We often start at low dose for kids with a lot of anxiety, somatic symptoms, young kids, or kids with developmental concerns
48
48
24 4/7/2021
Choose a medication
Factors to consider in choosing Fluoxetine has the most data Sertraline has more data for anxiety If you have any concern about bipolarity don’t use Prozac Celexa has histaminergic properties – helps belly pain
49
49
SSRI Titration Schedule
Medication Low Typical Typical Typical Typical Starting Starting Effective Dose Escalation Dose Dose Dose Range amount
Fluoxetine 5mg 10mg 20mg 60mg 10mg
Sertraline 25mg 50mg 100-150mg 200mg 25mg
Citalopram 5mg 10mg 20mg 40mg 10mg
Escitalopram 2.5mg 5mg 10mg 20mg 5mg
50
50
25 4/7/2021
SSRI General Information Medication Typical Typical Dose Half-life Half-life of Active Effective Dose Range Metabolites
Fluoxetine 20mg 60mg 2-3 days 2 weeks
Sertraline 100-150mg 200mg Males – 22.4 NA hours females 32- 36 Citalopram 20mg 40mg 20-35 hours NA
Escitalopram 10mg 20mg 20-35 hours NA
51
51
FIRST SSRI CHECK
When 1-2 Weeks after starting medication
1.Check Side Effects
2.Check for Response
3.Review Expectations/Goals/Safety
4.Increase medication(if you started low)
52
52
26 4/7/2021
FIRST SSRI CHECK
We don’t expect clinical response yet.
So condition may continue to worsen
This check is predominantly to check
Side effects
Assure safety
Get medication to therapeutic dose
(Have a check in – in case it appears a higher level of care is needed)
53
53
FIRST SSRI Check
Check side effects
“Are you concerned about side effects? Has anything changed that you are worried might be related to medication”
“Have you had any thoughts about hurting yourself or anyone else?”
Check for response
“How are you doing?”
“On a scale of 1-10, 10 being as good as you could feel, how are you doing?”
Review goals
“Are you still hoping to work on ___”
Review safety plan
“Have you had to use your safety plan? Or How close have you come to using your safety plan? Do you still feel like you could use your safety plan”
“Could you repeat your safety plan?”
Review expectations
“It’s early to see an impact of medication but you should see some positive response in 2- 4 weeks.”
“We look forward to your next check-in in 1-2 weeks”
Increase medication (if you started low) 54
54
27 4/7/2021
First SSRI Check
1. Check Side Effects
Are you concerned about side effects? Has anything changed that you are worried might be related to medication”
“Have you had any thoughts about hurting yourself or anyone else?”
2. Check for Response
How are you doing?”
“On a scale of 1-10, 10 being as good as you could feel, how are you doing?”
3. Review Expectations/Goals/Safety
4. Increase medication(if you started low)
55
55
First SSRI Check
1. Check Side Effects
2. Check for Response
3. Review goals
“Are you still hoping to work on ___” → Review safety plan
“Have you had to use your safety plan? Or How close have you come to using your safety plan? Do you still feel like you could use your safety plan”
“Could you repeat your safety plan?” →Review expectations
“It’s early to see an impact of medication but you should see some positive response in 2-4 weeks.”
“We look forward to your next check-in in 1-2 weeks” 4.. Increase medication (if you started low)
56
56
28 4/7/2021
Ongoing Follow-up
What to do other than “how General Comments have things been going” Remember these medications 1. Check Side Effects actually work slowly 2. Check for Response(GAD7, PHQ9)
4 weeks for depression 3. Review Expectations/Goals/Safety
Up to 12 weeks for anxiety • Are expectations too high(or low)?
Assure patient has frequent • Are their roving expectations?
follow-up until getting better 4. Increase medication and/or And then at least monthly follow- psychotherapy if not in full remission up until in full remission and not generally improving weekly
57
57
Thank-you!
“Move Your Feet”/ “DANCE” / “It's A Sunshine Day ... – YouTube
58
58
29