Counseling Points - January 2009 - (Page 7)

Treating Psychiatric Co-morbidities in Children and Adolescents ADHD and Depression Approximately 18% of children and adolescents with ADHD also have a diagnosis of depression.26 According to the Texas Children’s Medication Algorithm Project (TCMAP), individuals with ADHD along with mild depression can initially be treated with a stimulant.27 They may do well on stimulants, thereby negating the need for an antidepressant.28 Anecdotal experience suggests that if a child or adolescent’s depressive symptoms do not improve after 2-4 weeks of stimulant therapy, an antidepressant should be added to the regimen. Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line pharmacologic agents for children with depression (Table 2).27 SSRIs selectively inhibit the reuptake of serotonin (5HT) into the presynaptic neurons. It usually takes approximately 4-6 weeks to see full effects of SSRIs, with fluoxetine having the longest half-life (approximately 5 days).8,31 Common side effects associated with this class of antidepressant include GI upsets, headache, and insomnia. Patients may also complain of anxiety during the first 1-2 weeks of therapy, but these symptoms are transient. An FDA blackbox warning exists for antidepressants such as SSRIs due to the potential for clinical worsening of depression and suicidal ideation during the early phase of therapy, but the association is weak.32 Nevertheless, clinicians should monitor individuals closely during the first few months after such medication is prescribed. Other antidepressants that may be considered include bupropion and TCAs.27 Well-performed, controlled trials are lacking in children/adolescents with co-morbid ADHD and depression. TCAs are not usually prescribed due to their many unwanted side effects (e.g., dry mouth and arrhythmia). Table 2. Medications That Treat Psychiatric Co-morbidities in Children and Adolescents8,29,30 Medications SelectiveSerotonin Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac®) Paroxetine (Paxil®) Sertraline (Zoloft®) Tricyclic Antidepressants (TCAs) Usages Anxiety, depression, obsessive compulsive disorder 10-20 mg PO QD 10-20 mg PO QD 25-50 mg PO QD (max: 200 mg/day) Anxiety, depression Usual Dosages Amitriptyline (Elavil®) 1-3 mg/kg/day PO divided TID Children 6-12 years: 10-20 mg/day PO divided TID-QID Adolescents: 30-50 mg/day PO divided TID-QID Bipolar disorder Nortriptyline (Aventyl®, Pamelor®) Atypical Antipsychotics Olanzapine (Zyprexa®) Risperdone (Risperdal®) Miscellaneous Divalproex (Depakote®, Dapakene®) 2.5 mg PO QD (up to 20 mg/day) ADHD and Anxiety Approximately 26% of children with ADHD have coexisting anxiety disorder.26 Based on the TCMAP guidelines, stimulants are recommended as a first-line pharmacologic option for individuals with co-morbid anxiety and ADHD.33 Besides stimulants, a nonstimulant such as atomoxetine can be used. Atomoxetine monotherapy has been shown to be as efficacious as the combination of atomoxetine plus fluoxetine for the treatment of ADHD and co-morbid anxiety disorder.34 If the symptoms of anxiety still do not improve with these initial pharmacologic interventions and behavioral therapy, an SSRI can be added to the regimen.35 SSRIs have been shown to be efficacious in reducing anxiety in children.36,37 7 1-3 mg PO QD Bipolar disorder 15-25 mg/kg/day PO divided QD-TID Children: 15-60 mg/kg/day PO divided TID-QID Adolescents: 600-1800 mg/day PO divided TID-QID Lithium (Eskalith®, Lithobid®) Bipolar disorder PO=by mouth; QD=every day; QID=four times a day; TID=three times a day. JANUARY 2009

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Counseling Points - January 2009

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