Pediatric Psychiatry - Depression PDF

Zarqa University Pharmacy School Clinical Pharmacy Department Advanced Clinical Pharmacy and Therapeutics, Pediatrics Pediatric psychiatry Dr. Fares Al Bahar Pediatric depression Epidemiology About 11% of adolescents have a depressive dis...

Zarqa University Pharmacy School Clinical Pharmacy Department Advanced Clinical Pharmacy and Therapeutics, Pediatrics Pediatric psychiatry Dr. Fares Al Bahar Pediatric depression Epidemiology About 11% of adolescents have a depressive disorder by age 18. Estimated prevalence is 2% in children and 4%–8% in adolescents. Male-to-female ratio of 1:1 during childhood and 1:2 during adolescence The risk of depression increases as a child gets older; increases 2- to 4-fold after puberty, especially in females According to the World Health Organization, major depression is the leading cause of disability among Americans 15–44 years of age. Epidemiology In 2020, suicide was the third leading cause of death for youth 15–24 years of age. For youth 10–14 years of age, suicide was the second leading cause of death. Suicide attempts and self-harm behavior are more common in girls than in boys. Non-Hispanic American Indian/Alaska Native youth are most at risk, with suicide rates of 33:100,000 and suicide attempt rates of 25.5%. Suicide thoughts?? 1. Yonis O.B., Khader Y., Jarboua A., Al-Bsoul M.M., Al-Akour N., Alfaqih M.A., Khatatbeh M.M., Amarneh B. Post-Traumatic Stress Disorder among Syrian Adolescent Refugees in Jordan. J. Public Health. 2020;42:319–324. doi: 10.1093/pubmed/fdz026. 2. Yonis O.B., Khader Y., Al-Mistarehi A.H., Khudair S.A., Dawoud M. Behavioural and Emotional Symptoms among Schoolchildren: A Comparison between Jordanians and Syrian Refugees. East. Mediterr. Health J. 2021;27:1162–1172. doi: 10.26719/emhj.21.072 3. Dehnel R., Dalky H., Sudarsan S., Al-Delaimy W.K. Resilience and Mental Health Among Syrian Refugee Children in Jordan. J. Immigr. Minor. Health. 2022;24:420–429. doi: 10.1007/s10903-021-01180-0. 4. Khader Y., Bsoul M., Assoboh L., Al-Bsoul M., Al-Akour N. 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Prevalence of Mental Health and Behavioral Problems among Adolescents in Institutional Care in Jordan. Psychiatr. Serv. 2013;64:196–200. doi: 10.1176/appi.ps.201200093. 26. Itani T., Jacobsen K.H., Kraemer A. Suicidal Ideation and Planning among Palestinian Middle School Students Living in Gaza Strip, West Bank, and United Nations Relief and Works Agency (UNRWA) Camps. Int. J. Pediatr. Adolesc. Med. 2017;4:54–60. doi: 10.1016/j.ijpam.2017.03.003. 27. Nafi O., Shahin A., Tarawneh A., Samhan Z. Differences in Identification of Attention Deficit Hyperactivity Disorder in Children between Teachers and Parents. East. Mediterr. Health J. 2020;26:834–838. doi: 10.26719/emhj.20.032. 28. Gearing R.E., Brewer K.B., Elkins J., Ibrahim R.W., MacKenzie M.J., Schwalbe C.S.J. Prevalence and Correlates of Depression, Posttraumatic Stress Disorder, and Suicidality in Jordanian Youth in Institutional Care. J. Nerv. Ment. Dis. 2015;203:175–181. doi: 10.1097/NMD.0000000000000267. 29. Al-Sheyab N.A., Gharaibeh T., Kheirallah K. Relationship between Peer Pressure and Risk of Eating Disorders among Adolescents in Jordan. J. Obes. 2018;2018:7309878. doi: 10.1155/2018/7309878. 30. Alassaf A., Gharaibeh L., Zurikat R.O., Farkouh A., Ibrahim S., Zayed A.A., Odeh R. Prevalence of Depression in Patients with Type 1 Diabetes between 10 and 17 Years of Age in Jordan. J. Diabetes Res. 2023;2023:3542780. doi: 10.1155/2023/3542780. 31. Khader Y., Bsoul M., Assoboh L., Al-Bsoul M., Al-Akour N. Depression and Anxiety and Their Associated Factors Among Jordanian Adolescents and Syrian Adolescent Refugees. J Psychosoc Nurs Ment Health Serv. 2021;59:23–30. doi: 10.3928/02793695-20210322-03. 32. Al-Kloub M.I., Al-Khawaldeh O.A., ALBashtawy M., Batiha A.M., Al-Haliq M. Disordered Eating in Jordanian Adolescents. Int. J. Nurs. Pract. 2019;25:1–9. doi: 10.1111/ijn.12694. 33. Dardas L.A., Silva S.G., Smoski M.J., Noonan D., Simmons F.L.A. The Prevalence of Depressive Symptoms among Arab Adolescents: Findings from Jordan. Public Health Nurs. 2018;35:100–108. doi: 10.1111/phn.12363. 34. Mousa T.Y., Mashal R.H., Al-Domi H.A., Jibril M.A. Body Image Dissatisfaction among Adolescent Schoolgirls in Jordan. Body Image. 2010;7:46–50. doi: 10.1016/j.bodyim.2009.10.002. 35. Nafi O., Shahin A., Tarawneh A., Samhan Z. Differences in Identification of Attention Deficit Hyperactivity Disorder in Children between Teachers and Parents. East. Mediterr. Health J. 2020;26:834–838. doi: 10.26719/emhj.20.032. Signs and Symptoms The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for major depressive disorder include: five or more of the following symptoms, and the patient must have either depressed mood or loss of interest or pleasure. Symptoms must occur almost every day for at least 2 weeks and result in a change in function. Signs and Symptoms Depressed mood Lack of interest or pleasure in daily activities Significant changes in weight (increase or decrease) Significant changes in sleep (insomnia or hypersomnia) Psychomotor agitation or retardation Fatigue or decreased energy Feelings of worthlessness or inappropriate guilt Decreased concentration or difficulty making decisions Recurrent thoughts of death, suicidal ideation, or suicidal attempt Signs and Symptoms Signs and symptoms differences in children and adolescents compared with adults: Depressed mood may be expressed as more of an irritable mood. Mood lability ‫مزاج متقلب‬ Low frustration tolerance‫يحبط بسهولة‬ Temper tantrums‫نوبات غضب‬ More physical complaints or feeling sick Social withdrawal or refusing to go to school May not verbalize feelings of depression Tend to have fewer melancholic symptoms, delusions, and suicide attempts than adults 14 15 16 General treatment principles Treatment guidelines recommend supportive therapy and psychoeducation for mild depression. If, after 6–8 weeks, symptoms persist, antidepressants and/or psychotherapy is indicated. While psychotherapy primarily focuses on addressing psychological symptoms and promoting emotional healing, psychoeducation aims to enhance patients' understanding of their condition and treatment options. Both approaches can be valuable in clinical settings, but they differ in their specific goals and techniques. psychotherapy General treatment principles If after another 6–8 weeks with no improvement: Combination of antidepressants and psychotherapy should be considered, if not already tried. If improvement occurs, treatment should continue for 6–24 months. Monitoring should be done monthly for at least the first year. Monitor for the emergence of adverse events during pharmacotherapy treatment. General treatment principles Selective serotonin reuptake inhibitors (SSRIs) Onset and duration of action: Some symptoms such as agitation or anxiety may improve within days to weeks. After 2–4 weeks of treatment, other targets of systems such as depressed mood should improve, including the return of pleasurable experiences and the subsiding of suicidal thoughts. Adverse effects: Anxiety, insomnia, sedation, headache, nausea, diarrhea, anorexia, sexual dysfunction General treatment principles  Serotonin syndrome: Occurs with the use of one or more serotonergic agents, particularly combinations of MAOIs and inhibitors of serotonin reuptake Symptoms include mental status changes, autonomic hyperactivity, and neuromuscular abnormalities and can be life threatening.  Serotonin discontinuation syndrome Risk with SSRIs with a shorter half-life (e.g., paroxetine) Occurs when abruptly discontinuing the serotonergic agent Symptoms: Anxiety, irritability, sadness, insomnia, headache, nausea, nightmares or vivid dreams, electric shock sensations; not life threatening Prevent by slowly tapering the serotonergic antidepressant slowly over a few weeks. General treatment principles Fluoxetine: is the only antidepressant that is FDA label approved for the treatment of depression in children younger than 12 years. It is also FDA label approved for the treatment of obsessive compulsive disorder. Fluoxetine and escitalopram: are the only two SSRIs with FDA label approval for use in adolescent depression. Sertraline: is FDA label approved for obsessive-compulsive disorder in those 6–17 years of age. Fluvoxamine: is approved for obsessive-compulsive disorder in those 8 years and older but not for depression. General treatment principles General treatment principles  Selective serotonin and norepinephrine inhibitors (SNRIs) Safety and efficacy have not been established for depression or anxiety disorders in pediatric patients. Studies have shown no difference between treatment and placebo for venlafaxine and duloxetine. Adverse events are similar to those of SSRIs. Monitor for high blood pressure. General treatment principles Bupropion Studied in ADHD but not FDA indicated No RCTs for depression in pediatric patients  Mirtazapine: One study showed no difference between mirtazapine and placebo. General treatment principles  Tricyclic Antidepressants (TCAs) Meta-analysis showed that SSRIs had better efficacy and were better tolerated. RCTs have not shown greater efficacy than placebo. Risk of overdose and death can occur with TCAs. ECG changes can occur with increased doses. General treatment principles A meta-analysis of 34 trials, 5260 participants, and 14 antidepressants showed that: only fluoxetine was more effective than placebo; fluoxetine was more tolerable than duloxetine and imipramine; and imipramine, venlafaxine, and duloxetine were discontinued more often than placebo because of adverse events. General treatment principles  Suicide risk in children and adolescents All antidepressants have a black box warning for increased suicidal thinking and behavior in children, adolescents, and young adults. Meta-analysis of RCTs showed benefits of antidepressants. Risk of increased suicidal thinking is about 2%. Question 1 B.B. is a 10-year-old boy who says that he is sick and does not want to go to school. On further questioning, he is unable to specify his symptoms. He has been irritable, has had temper tantrums, has a low frustration tolerance, and has been drawing pictures of weapons. He has been preoccupied with thoughts of death. He is given a diagnosis of depression. Which antidepressant is best for B.B.? A. Paroxetine. B. Fluoxetine. C. Sertraline. D. Bupropion. Question 2 Which best depicts the potential adverse effect that is listed as a black box warning and that the parents of B.B. must be counseled on and notified about? A. Pancreatitis. B. Liver toxicity. C. Diabetes insipidus. D. Suicidal ideation. Question 3 If, after 4 weeks of treatment, B.B. has not responded to treatment, which most accurately depicts the medication that has evidence in studies of pediatric patients, even though it is not FDA indicated for pediatric depression? A. Venlafaxine. What about psychotherapy? B. Mirtazapine. C. Sertraline. D. Bupropion.