Medication for Mental Health in Young People

Medication Use for Mental Health in Young People

• Principles include good assessment, clear rationale, information, monitoring, and use alongside other interventions.
• Only about 20% of medications are licensed for young people, leading to off-label use with evidence.
• Challenges include lack of research, stigma, and consent issues.
• Start with low doses and increase slowly due to increased side effects in young people.
• Monitor regularly during the initiation phase and avoid combining medications.

Antidepressants

• Lifetime prevalence of depression by the end of adolescence is 20%.
• Treat depression to prevent recurrence.
• For moderate to severe depression, NICE guidelines recommend referral to CAMHS and psychological intervention like CBT or family therapy.
• Antidepressants should be used after review by a child and adolescent psychiatrist and combined with therapy.
• Fluoxetine is typically the first choice.
• Monitor weekly for the first four weeks and inform about the rationale, delay in effect, duration, adverse effects, and adherence.
• Continue medication for 6 months after remission, defined as no symptoms and full functioning for at least 8 weeks.
• If fluoxetine isn't effective, transition to sertraline or citalopram.
• Antidepressants also treat anxiety, OCD, and chronic pain.
• NICE recommends SSRIs, which include fluoxetine, sertraline, citalopram/escitalopram, and paroxetine.
• Fluoxetine is the only one licensed for those >8.
• Sertraline for OCD and citalopram are used off-label.
• SSRIs have common but transient side effects like GI upset, headaches, anxiety, tiredness, insomnia, and erectile dysfunction.
• Rare side effects include self-harm, switch to mania, seizures, galactorrhea, clotting abnormalities, anaphylaxis, and serotonin syndrome.
• Take SSRIs with food and be aware of risks when mixing with other medications, pregnancy, alcohol, or recreational drugs.
• Do not take more than the prescribed dose.
• Other antidepressants like mirtazapine, venlafaxine, and duloxetine should be prescribed by a specialist due to lack of evidence.
• Tricyclics are older, have more side effects, are toxic in overdose, and have minimal effectiveness in young people except for clomipramine for OCD.
• Start antidepressants slowly, stop slowly, and monitor for discontinuation symptoms.
• Monitor for treatment effect, which can take 2-6 weeks.
• If no effect after 4 weeks, reassess the plan.
• To change medications, wean off the first, wait 7 days, then start the new one gradually.
• If antidepressants aren't working, review the treatment plan, reassess formulation, and consider psychological and social factors.
• Options include increasing the dose, switching SSRIs, or augmentation, though quetiapine isn't effective for adolescent bipolar depression.

Antipsychotics

• For psychosis/schizophrenia and mania/bipolar disorder, but NOT for "at-risk mental states".
• Lower doses are used for aggression in autism, conduct disorder, intellectual disability, Tourette’s, and OCD.
• Atypical antipsychotics (risperidone, olanzapine, aripiprazole) are used more often in young people due to fewer movement side effects.
• Typical antipsychotics (haloperidol, chlorpromazine) are older and have more movement side effects. Functional improvement is key to predicting longer term outcome
• NICE guidelines focus on functional improvement as key to predicting longer-term outcomes
• Other interventions include psychoeducation, CBT for psychosis, occupational and functional improvement, family work, and diet and lifestyle interventions.
• Efficacy of antipsychotics is modest, treatment resistance is common, effects on negative symptoms are limited, and side effects are more severe in young people.
• There's little evidence that atypicals are better than typicals.

Conduct Disorder

• Medication should not be routinely used, but comorbidities like ADHD should be treated.
• In rare cases, risperidone may be used for severe aggressive behavior, explosive anger, and emotional dysregulation.
• Expected benefits need to be clear, and medication should be discontinued if no response occurs at 6 weeks.

Eating Disorders

• No clear evidence about medication for anorexia nervosa, but comorbidities like depression should be treated.
• Olanzapine may increase weight gain and improve psychological symptoms in adults, but evidence is mixed in young people.
• SSRIs are thought to maintain normal weight.
• Fluoxetine is effective for bulimia nervosa alongside psychological treatment at doses higher than those used for depression (up to 60mg).

Pediatric Bipolar Affective Disorder

• For mania/hypomania, atypical antipsychotics (aripiprazole, risperidone, olanzapine, quetiapine) and lithium are used.
• Lithium requires baseline blood work, ECG, pregnancy test (teratogenic), and regular monitoring.
• Combination therapy involves an antipsychotic and lithium, or anti-epileptic medication like valproate, carbamazepine, or lamotrigine.
• For depression, use an atypical antipsychotic and, if severe, an SSRI, with olanzapine and fluoxetine having the best evidence.
• Maintenance lasts at least 1-2 years.
• First-line treatment is antipsychotics, second-line is lithium.
• ECT is used for severe, persistent, and disabling bipolar disorder that doesn't respond to 5-10 medications.

Assessment

• Assess presenting complaint, history, psychiatric, developmental, medical, family and social and premorbid personality
• Carry out mental state examination

Case Study Formulation & Management

• Differential diagnoses include intellectual disability, autism, social anxiety, depression, neurodiversity, eating disorder, and prodromal phase psychosis.
• Gather more information from family and school.
• Conduct a physical health examination, including blood work, ECG, CT/MRI, and neurology referral.
• Consider a trial of antidepressants or antipsychotics
• Treatment should be a multidisciplinary approach
• Mirtazapine can lift mood

SSRI Evidence

• Bridge 2007 RCTs antidepressant treatment vs. placebo found in response rate 61% vs 50% NNT : 10
• Cipriani 2016 study indicated good evidence for fluoxetine but may not offer clear advantage for children and adolescents
• TADS study indicated a 26% difference in response rate for combined antidepressant and psychological therapy.
• Fluoxetine has the most evidence.

Discontinuation Effects

• Warn patients about potential discontinuation effects from stopping medication too suddenly.
• Symptoms can include electric shock sensations, dizziness, GI upset, headache, anxiety, and flu-like symptoms.
• Recommend gradual weaning to minimize symptoms.

SSRI and Suicidality

• Mixed evidence on SSRIs and suicidality.
• Observational evidence suggests suicides decreased as SSRI use increased.
• Problems with RCT include bias, rare outcome, retrospective reporting
• Observational studies suggest suicides decreased as SSRI use increased and lower suicide rates in areas with higher SSRI use.
• SSRIs are activating, so monitor risk closely

Antipsychotics

• First line for psychosis (NICE)
• Atypical over typical, choice based on presentation, most used are risperidone, olanzapine, aripiprazole
• Psychoeducation is important.
• Side effects include movement disorder and akathisia, weight gain and metabolic effects, elevated prolactin levels, sedation, arrhythmias, NMS, and seizures.

Depot Preparations

• Long-acting injectable antipsychotics are not licensed in young people but can be used for compliance concerns.
• Should not be used in those who have never had an antipsychotic.

Treatment Duration

• 1-2 years following full recovery without relapse.
• Withdraw gradually and monitor regularly.
• Monitor for 2 years after cessation.
• Treatment trials for 4-8 weeks at optimum dose; change if no effect.
• Two trial failures indicate treatment resistance; consider clozapine.

Clozapine

• NICE guidelines recommend it for young people whose illness has not responded to pharmacological treatment
• Key side effects include weight gain, metabolic effects, constipation, fever, nocturnal enuresis, and myocarditis/cardiomyopathy.
• Neutropenia/agranulocytosis requires mandatory rigorous monitoring.
• Consultant psychiatrists 40% don’t use clozapine

Obsessive Compulsive Disorder

• CBT with exposure and response prevention is first-line, but medication can be considered if it doesn't work (sertraline, fluoxetine, fluvoxamine).
• Suicide risk in OCD may be less but comorbid depression may not have been detected.
• Augment SSRIs with low-dose risperidone.
• Can use tricyclic antidepressant clomipramine.

Sleep Disorders

• Behavioural treatment (sleep hygiene) is first-line, with advice such as limiting blue light exposure.
• Mediation use is common; none are licensed.
• Melatonin show most effective in neurodevelopmental disorders
• Antihistamines, Benzodiazepines and Alpha agonists used with caution