psychotherapeutics in child psychiatry psychotherapeutics in child psychiatry the bppa - bapa annual...
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Psychotherapeutics in Psychotherapeutics in Child PsychiatryChild Psychiatry
THE BPPA - BAPA ANNUAL CONFERENCE 2011Saturday 18th November
Dr Gordon BatesHuntercombe Hospital
University of Birmingham
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OverviewOverviewBasic PrinciplesRange of medicationsAntipsychoticsAntidepressantsADHD treatments:
◦Stimulants◦Atomoxetine◦Alpha agonists
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Principles of Child Principles of Child PharmacokineticsPharmacokinetics
Children are not small adults
Area is less well researched
Rates of absorption in children are faster and peak levels are reached faster (esp. liquids)
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Proportion of Water in Body through Proportion of Water in Body through Life Life
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Volume of distribution results for the full database (22 substrates). *p < 0.1.
Ginsberg G et al. Toxicol. Sci. 2002;66:185-200
© 2002 Society of Toxicology
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Clearance results for the full database (27 substrates). *p < 0.01; **p < 0.0001.
Ginsberg G et al. Toxicol. Sci. 2002;66:185-200
© 2002 Society of Toxicology
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Principles of Child Pharmacokinetics II
Hepatic metabolism is almost double adult rate in middle childhood and approaches adult rates by 15 years
Fat stores in children act to slow elimination of liposoluble drugs (e.g. fluoxetine, pimozide)
Cytochrome P450 2d6 and 2c19 unaffected by age but remember racial effects
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Is it bad enough?Is it pervasive?Have psychological strategies or
environmental modification been tried?Is it part of a wider treatment package?Do parents and adolescent give consent?Is it licensed/unlicenced or off indication?Is it an emergency?Risk/Benefit analysis
When to use Medication
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Monotherapy is better than polypharmacy
Develop a range of familiar drugsStart low and go slowReview frequentlyConsider use of rating scalesMonitor for side effectsMonitor for drug/drug interactionsPharmacogenomics: the future?
How to use MedicationHow to use Medication
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Range of TreatmentsAnxiolyticsSedatives and MelatoninAntipsychoticsAntidepressants: FluoxetineMood stabilisersADHD treatments
Mostly unlicensed for children
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Prescribing to children:Prescribing to children:Licensed or unlicensed in UKLicensed or unlicensed in UK
Antipsychotic Child (<12) Adolescent (12-18)
Chlorpromazine Yes Yes
Haloperidol oral Yes Yes
Haloperidol IM No Yes
Pimozide No Yes
Trifluoperazine Yes (anxiety) Yes
Sulpiride No Yes (>14)
Zuclopenthixol IM No No
Amisulpiride No Yes(>15)
Clozapine No Yes(>16)
Olanzapine oral No No
Olanzapine IM No No
Risperidone oral No Yes(>15)
Risperidone IM No No
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AAntipsychoticsHaloperidol and Chlorpromazine have licenseUnlicensed Olanzepine, Risperidone and
Aripiprazole most commonly used in UK practice
Wide range of usage: ◦ Psychosis◦ Bipolar◦ Tourette’s◦ Rapid tranquillisation◦ Mood swings in Borderline Personality Disorder◦ Irritability in ADHD and Autism
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NICE recommendations
Predominantly aimed at adults and remaining within product licence:◦Atypical antipsychotics (TA 43 June
2002)◦Core Interventions in Schizophrenia
(CG 1 Dec 2002)◦Bipolar Disorder (CG38 July 2006)◦Violence & Acute behavioural
disturbance (CG25 Feb 2005)
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Personal experience
Side effect profileFamily history of
responsePatient or carers
preference“local expert”
How to chooseHow to choose
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Side Effects of Antipsychotics Side Effects of Antipsychotics (Bazire 2007)(Bazire 2007)
Drug AntiCh Cardiac EPSE Low BP Sedation Minor O/D
Wt gain Prolactin Proconvulsant
Aripiprazole - + - - - ? + - -Olanzapine + - - - ++ - +++ + +Quetiapine + + - + + + + + +Risperidone - - + + + ? + ++ -Zotapine ++ ++ + ++ ++ ? +++ +++ +++Clozapine +++ +++ - + +++ ? +++ - +++Amisulpiride - - + - - - + ++ ?+Chlorpromaz +++ ++ ++ +++ +++ ++ +++ +++ +++Haloperidol + ++ +++ + + + + +++ ?+
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AntidepressantsDepression in childhood and adolescence
has similarities and differences to adulthood
Response to medication is differentTricyclics ineffective in Childhood
depressionSSRI controversy: suicidality and mood
lability in early treatmentCSM and NICE guidance:
◦ Psychological therapies first◦ If medication indicated only Fluoxetine first line
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Father of Child Psychopharmacology
14 of 30 children showed a ”spectacular change in behavior… remarkably improved school performance”
SerendipityGiven after pneumo-
encephalographyChildren called them
their “arithmetic pills”(Am J Psych 1937)
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Potential Mechanisms of ActionDopamine-Reuptake inhibition and direct release
MethylphenidateDexamphetamine
Dopamine-reuptake inhibitor
Modafanil
Noradrenaline-Agonists
L-amphetamine
Noradrenaline-reuptake inhibitor
Atomoxetine
Alpha 2 adrenergic - agonists
ClonidineGuanfacine
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Stimulants
LicensedMethylphenidateDexamphetamineUnlicensedAmphetamine –
◦L-amphetamine ◦mixed salts (Adderall)
Modafanil
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Features of Stimulant activity
Greatest effects on Attention and restlessness
Less useful for impulsive behavioursRapid actingShort half lifeClear dose effect relationshipWell established side effect profile
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Dose Response of Methylphenidate on Attention in clinic and classroom(Rappoport et al 1987)
1520253035404550556065
placebo 5mg 10mg 15mg 20mg
% on task
% academicefficiencyADHD CompTeachers RSCPT
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Efficacy of the stimulantsEfficacy of the stimulants
Responder rate (%) 75-90• Methylphenidate 75• Amphetamine 70
Normalisation rate (%) 50-60Symptom improvement (%)
•Behaviour scales 30-50
Effect size (SD)• Behaviour 0.9 high• Attention 0.7 medium• IQ/ Performance tests 0.3 low
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Time of effect Comments
Methylphenidate
Equasym XL 6-8hrs School day coverMedikinet
Concerta® XL 8-12hrs Sleep and appetite
Daytrana ® 6-16hrs Transdermal
US only
Amphetamine compounds Adderall XR 6-8hrs Import only
Vyvanase 12-14hrs Prodrug, ltd abuse (lisdexamfetamine) Awaiting UK approval
Long Acting Stimulants
Stimulant
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Transdermal Methylphenidate(Daytrana))
Doses: 10mg, 15mg, 20mg 30mg
Applied to hip each morning
Stays on after swimming or bathing
Irritation rareSuggested use for 9
hours but effects last 3 hours after removal
Heal and Pierce CNS drugs (2006)
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Lisdexamfetamine(Vyvanase)(Vyvanase)
Metabolised in GI tract to Lysine and Dexamphetamine
Doses: 30mg, 50mg, 70mg
Little euphoric effect reducing abuse potential
Clin Ther 2007;29: 450-463
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Side EffectsAnorexia, weight loss
Give with mealsUse supplementsDietary advice
Insomnia Give earlierUse shorter acting prepConsider melatonin/clonidine
Rebound Change to long acting prepAssess timing and overlap
Dysphoria Consider comorbidity and treatChange to long acting or alternative stimulant
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Cardiovascular Risk
Sudden death rates in General Population:◦ 0.6-6/100,000 children per year◦ 1/1000 adults per year
Estimated sudden death rate on Stimulants:◦ 0.25/100,000 people per year based on Rx data◦ 0.5/100,000 people per year (assuming 50%
under-reporting) FDA reevaluation 24/3/2006:
◦ No additional risk in medically healthy children
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Atomoxetine
Recent analyses suggest:• Children similar to adolescents for
outcome• Monitor height and weight esp in
younger children• Some response by week 2 but
continue to 6-10 weeks• Reduction in irritability precedes core
symptom improvements
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Atomoxetine
NichesTreatment resistance, partial responseIntolerable side effectsImportance of all day coverPossible substance misuse or diversionComorbid anxiety disorderTic disorder
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AtomoxetineSide Effects:- Somnolence, insomnia, nausea,
headache, reduced appetite, abdominal discomfort, raised BP and pulse, sexual dysfunction
Drug Interactions:- Care with some SSRIs (fluoxetine and
paroxetine)- No interaction with stimulants or
alcohol
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Atomoxetine
Rare hepatitis reported- 1 confirmed case in 3.4 million prescriptions- 1 further suspected case in 3.4 million
prescriptionsImplications: Discuss rare event not routine
LFTs
Known increase in mood lability in 3%Possible slight increase in suicidal ideation- 0.037% Atomoxetine v 0% Placebo- One suicide attempt/1357 studied
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Clonidine
Used for ADHD therapy and night sedationBetter for restlessness than attentionUseful but popularity waning due to side fxGood for tics and comorbid ADHD
◦ Doses 0.05 mg-0.2 mg tds◦ Evening rebound◦ Patch available but import only◦ Care with joint prescribing (ECG recommended)
Look out for sedation, hypotension, depression, constipation and dry mouth
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Clonidine controversyClonidine and Methylphenidate
◦ 3 case reports of sudden death◦ FDA review decided no causal link◦ Other relevant factors in all cases
Clonidine4 case reports of cardiac arrythmias, one
with congenital malformation
Use with care if history or family history of collapse. ECG sensible for combination.
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GuanfacinePossible alternative to ClonidineHalf life of 18 hours in adults1 open label study and one RCT show
efficacy:◦ Scahill et al JAACAP 2001◦ Spencer et al JAACAP 2009
Similar to clonidine but less sedating, more headaches and insomnia
? Better for attention than hyperactivity
Recent licence in US
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ConclusionsConclusionsVariations in child pharmacokinetics
can lead to less predictable responsesRequirement of closer monitoring and
shared care with parentsMany adult approved drugs are given
off licence to childrenMedications have a restricted but
important part in holistic care planMedications are often given
symptomatically rather than for diagnosis
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