In Pediatric Cases, Benefits of Treating Disorders Outweighs Risks

Psychiatric disorders among children and teenagers are common, and yet treating them is far from straightforward, in part because of parents’ fears about use of psychotropic medications, said Craig Donnelly, MD, of Geisel School of Medicine at Dartmouth.

Treating disorders while patients are young is important, Dr Donnelly said, not only to bring near-term relief to patients, but also to prevent disorders from evolving into something more complex and difficult to treat. “Most things that happen in adulthood are set up in childhood,” he said.

His presentation, “Update on Pediatric Psychopharmacology for the Allied Health Professional,” came Monday during the US Psychiatric and Mental Health Congress, taking place in Orlando, Florida. Dr Donnelly’s overview covered common medications used to treat depression, anxiety, attention deficit/hyperactivity disorder (ADHD) and autism-spectrum disorders.

He noted the challenges that psychiatrists and other mental health professionals face in gaining familiarity with DSM-5, the update to the Diagnostic and Statistical Manual, which outlines criteria for who has a diagnosis and how treatment should proceed. Much controversy has arisen over the decision to group several diagnoses under “autism,” although Dr Donnelly said treatment had always been for the symptoms, which were similar to ADHD and aggression.

It’s important, he said, to keep a few things in mind: Medicines are tools, and they are not all good or all bad. And, in pediatric psychiatry, comorbidity is the rule rather than the exception.

Often, Dr Donnelly said, “It’s that second disorder that you missed that might limit treatment in the one that you just diagnosed.”

The numbers of children and teenagers suffering some type of disorder are large: estimated rates range from 14% to 20%, including all forms of ADHD and autism-spectrum disorders, and depression. ADHD, for example, is estimated to affect between 4% and 8% percent of children and teenagers. Depression affects about 7%, and anxiety disorders affect between 8% and 15%.

Many pediatric patients will eventually outgrow their disorders, but not all will. Only 1 in 4 patients receives services, and most of these are not delivered in formal settings. Dr Donnelly said novelty-seeking behavior and aggression show up very early; preschool teachers can predict which children are going to be aggressive later on as teenagers and adults.

While the problem of suicide receives attention — it is the third-leading cause of death among teenagers – Dr Donnelly said addressing disorders among young people also matters because failing to do so can set them up for lives of poverty and chronic disease if they develop more serious mental health problems as adults.

Diagnosing teenagers properly may require techniques beyond an interview. Multimodal techniques are needed. “If you interview just the child or just the parent you miss half the cases,” he said. Using a paper and pencil screening test can pick up cases that would otherwise be missed, because research shows patients will be honest when asked to rate their feelings on a scale, even when they won’t volunteer them in an interview.

One challenge pediatric psychiatrists face, Dr Donnelly said, is parents’ singular focus on how well the child is doing at school, no matter how poorly things are going with friends or at home. Yet children spent 1170 hours a year at school, compared with 7590 hours out of school. “That’s not a reasonable bargain to make,” he said.

When it comes to prescribing medication, the adage that “kids are not shrunken adults” is especially true in psychiatry. Dr Donnelly reviewed the use of selective serotonin reuptake inhibitors (SSRIs), saying that research does not support paroxetine in pediatric patients, and most research supports use of fluoxetine, fluvoxamine, and sertraline.

There’s been much attention on the black box warning on SSRIs, and Dr Donnelly has heard parents erroneously call them “suicide pills.” He walked the audience through the history of the FDA placement of the warning, due to a signal for suicidal ideation that was elevated in studies among children and teenagers for SSRIs compared with placebo (4% to 2%). But research by Gibbons, et al,¹ showed that when controlled for demographic factors and whether patients had mental health care, SSRIs were effective in these groups. The 2007 paper by Gibbons and co-authors, in fact, found the FDA warning contradictory and predicted it would lead to an increase in suicides among teenagers if SSRI prescribing to this group fell.¹

“Far and away, not treating depression kills more people than treating depression,” Dr Donnelly said.

Reference

1. Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Mann JJ. Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. Am J Psychiatry 2007;164:1044-1049.