7/24/2018

Objectives Depression & Anxiety in Adolescents 1) Review diagnosis of anxiety and depression in adolescents 2) Provide overview of evidence-based treatment options 3) Increase provider comfort level with medication management

»Kristin M. Rager, MD, MPH, FAAP, FSAHM

What is normal? Depression Diagnosis

5 of the following during same 2 week period and a • Normal does not mean always happy, always significant change from baseline easy – Teens have a lot going on, physical, social, and 1. Depressed or irritable mood cognitive changes, which can make their behaviors seem “abnormal” to adults at times 2. Decreased interest or lack of enjoyment 3. Decreased concentration or indecision • Normal does not mean significantly impaired 4. or hypersomnia function – this is out of the realm

Depression Diagnosis SIGECAPS or DIGSPACES

• Depressed mood • Sleep 5. Change of appetite or change of weight • Interest • Interest 6. Excessive fatigue • Guilt • Guilt 7. Feelings of worthlessness or excessive guilt • Sleep • Energy 8. Recurrent thoughts of death or suicidal ideation • Psychomotor • Concentration • Appetite 9. Psychomotor agitation or retardation • Appetite • Psychomotor • Concentration • Suicidality • Energy • Suicidality

1 7/24/2018

Anxiety Diagnosis

• Excessive worry more days than not for at least 6 months about a number of events and they find it difficult to control the worry • 3 or more of the following symptoms: • Restlessness or feeling keyed up or on edge • easily fatigued • difficulty concentrating, • irritability • muscle tension • sleep disturbance Causes significant distress or impairment

PHQ Scoring GAD 7

Total Score Depression Severity

1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

GAD 7 Scoring First and most important step…. » 5-9 mild anxiety » 10-14 moderate anxiety » 15 and up severe anxiety Identifying those teens who need help

2 7/24/2018

Treatment OPTIONS Psychotherapy

• Should be recommended to ALL patients with depression or anxiety • May be through multiple different venues!

Medication Psychotherapy PLUS Medication

• Selective reuptake inhibitors • Child and Adolescent Anxiety Multimodal (SSRI’s) Study (CAMS) • Medication should be recommended to all • SSRI and CBT led to signif clinical patients with moderate to severe depression improvement in 80% – May consider therapy alone first in mildly affected • Treatment for Adolescents with Depression (TADS) study – SSRI and CBT led to significant clinical improvement in 71%

Psychotherapy Medications

• Cognitive behavioral therapy (CBT) - helps • SSRI’s patient recognize and change negative – (Prozac) patterns of thinking that may contribute to – (Paxil) depression – (Zoloft) • Significant evidence for its efficacy – (Celexa) – (Lexapro) – Viibryd (Vilazodone)

3 7/24/2018

Fluoxetine (Prozac) Fluoxetine Dosing

• FDA Indications- MDD 8 yo and above and • Starting dose 10 mg daily  OCD 7 yo and above, BN and PD 18 and above • Longest ½ life (1-3 days after a single dose) • Target dose 20 mg daily  • May help prevent relapse as well – (40% at 2 years without treatment) • Maximum dose 60 mg daily

Sertraline (Zoloft) Paroxetine (Paxil)

• FDA Indications -MDD, PD, PTSD, SAD, • Several studies have found no indication of PMDD 18 and over, OCD 6 yo and above efficacy against depression in adolescents • Dosing • FDA 2003 – Starting dose 25 mg daily  – “strongly advises against its use in patients under 18 years old” – Target dose 50 mg daily  – “There is currently no evidence that Paxil is effective in – Maximum dose 200 mg daily children or adolescents with MDD”

Citalopram (Celexa) Escitalopram (Lexapro)

• FDA Indication - MDD 18 and over • FDA Indication - MDD 12 yo and above and • Adult Starting dose 20 mg daily  GAD 18 and above • Target dose 40 mg daily  • Starting dose 10 mg daily • Maximum dose 40 mg daily • Target dose 10 mg daily • Maximum dose 20 mg daily

4 7/24/2018

Vilazodone (Viibryd) Liquid Formulations

• No FDA Pediatric Indication - MDD 18 and » Fluoxetine 20mg/5 ml above » Sertraline 20mg/1 ml • Starting dose 10 mg daily » Escitalopram 5mg/5ml • Target dose 20 mg daily » Citalopram 10/5ml • Maximum dose 40 mg daily

SSRI tidbits Side effects of SSRI’s

• Start low, go slow (increase from starting • Generally well tolerated with minimal or no dose to target dose after 1-2 weeks) side effects • Improvement is not instantaneous • Generally increase with increase in dose – Symptoms begin to improve 2-4 weeks after target • Usually subside in 1-2 weeks dose is reached • Most commonly – , abdominal pain, • 30 – 40% of teens do not respond to the initial , , sleep changes, jitteriness treatment at all

Side effects of SSRI’s Why the black box?

• Changes in sexual functioning (decreased • 23 trials involving more than 4300 children libido, delayed ejaculation, anorgasmia) and adolescents • Can induce or in those with • NO suicides in any of these studies • Information was looked at 2 ways… • Suicidality…???

5 7/24/2018

Suicidality and the Black Box Black Box Warning Warnings

• Did not prohibit use of the medications in • October 15, 2004 FDA directed youth, but called on physicians and parents to pharmaceutical companies to label all closely monitor children and adolescents who with the warning that they are taking antidepressants for a worsening in "..increase the risk of suicidal thinking and symptoms of depression or unusual changes in behavior. behavior (suicidality) in children and adolescents with major depressive disorder • As of May 2007 includes young adults (MDD) or other psychiatric disorders” 18-24 years

Black Box Warning… Adverse Event Reports

• States that the increased risk of suicidal • Reports made by the investigator if the patient thinking and/or behavior in a small proportion spontaneously reports a side effect (suicidal of children and adolescents is most likely to thoughts) occur during the early phases of treatment – 4% in patients on meds – 2% in those on placebo

When patients were asked about suicidal thoughts and behaviors at SO what happened in response… each visit…

• Existing suicidality was not increased nor was • In the year following the Black Box, in those new suicidality produced by meds less than 17 years old • Suicidal thoughts were decreased – Overall prescribing of antidepressants decreased by 10% – New prescriptions decreased by 20%

6 7/24/2018

What to do instead of not In addition prescribing - Close Monitoring

• The overall rate of suicide in the 10-19 year • Weekly for the first 4 weeks age range has declined by 25% over the past • Every other week for the next 4 weeks decade • This decade has been associated with a • After 12 weeks dramatic increase in the prescription rates of • Then as clinically indicated SSRI’s • SSS – symptoms, sides, suicidality • If meds increased suicidal behaviors, you would expect an increase in the suicide rate as prescriptions went up…

How long to stay on meds? What if first med doesn’t work?

• “I feel better now, so I stopped my Prozac” » 6-12 weeks at therapeutic dose • Should continue for 9-12 months after the patient is “back to normal” » try 2nd ssri and/or ADD THERAPY • Relapse is significantly higher if meds are » after 6-12 weeks at therapeutic dose stopped sooner » try other med and/or ADD THERAPY • Should taper dose down to prevent “discontinuation syndrome” • decrease the dose by 25 to 50% weekly

Other Meds Other other meds

» (Welbutrin) » aminoketone for MDD, SAD 18 and over » (Buspar) » (Effexor) » SNRI for MDD, GAD, SAD, PD 18 and over » Non benzo » (Pristiq) » » SNRI for MDD 18 and over » » (Cymbalta) » SNRI for MDD, GAD, Pain, FM 18 and over » Benzos » in general, just no

7 7/24/2018

Conclusions Conclusions

• Depression and anxiety are national public • When recognized and correctly diagnosed, health problems for children and adolescents depression and anxiety can be treated • Both are serious medical illness and may be successfully potentially lethal because of the risk of • A combination of therapeutic approaches suicide. should be utilized, preferably medication AND psychotherapy individualized to the needs of a teen and his or her family

Thanks! Questions

» [email protected]

8