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Overview of Medications Used in Child and Adol. Psychiatry

Debra Stokan, M.D. :: May 31, 2012 ::

  An Overview of Current Medications Used in Child and Adolescent Psychiatry

 

This is an overview of medications that are commonly chosen as tools in the treatment of disorders seen in school such as ADHD, anxiety and depression.


To decide which medication may be effective, I like to pick out specific targets.  I use the targets to help me decide which neurotransmitters and changes will be most likely to create the desired effect.


Targeting ADHD


In the school setting, certainly ADHD is the top reason children and adolescents are prescribed psychotropic medications. As all the medications that target focus could also potentially cause side effects of anxiety and moodiness, it is important to ensure that anxiety and/or moodiness is not the actual cause of the lack of focus.  After confirming the ADHD diagnosis, to improve focus, attention span and task completion while decreasing hyperactivity and impulsivity, the classic neurotransmitters to target are both Dopamine (DA) and Norepinephrine (NE).  The “stimulants” are the oldest class of medication to target those receptors.  The current stimulants include the decades of Adderall and Ritalin and the many variations of time released “new” medications based on these two.  The efficacy of stimulants runs about 80%.


The “Stimulants”


Ritalin   vs.      Adderall


1) Short acting Ritalin       1) Short acting Adderall

- Lasts only 3-4 hours                 - Lasts only 4-5 hours

- Allows for flexible dosing                - Allows for flexible dosing

- Can have ‘ups’ & ‘downs’                - Can have ups & downs of mood & focus

- Needs at least twice daily dosing         - Likely needs twice daily dosing

- Breakable tablet                 - ‘Popular’ drug of abuse

                        - Breakable tablet


2) Metadate CD     2) Adderall XR

- Lasts about 8 hours        - Lasts about 9-12 hours

- Covers school day                - Bead release capsule

- Gone after school & can be good for            - Small dosing increments

   sleep and appetite

- Bead release capsule


3) Ritalin LA                          3) Vyvanse

    Ritalin SR                        - Lasts about 12 hours                               - Lasts 8-10 hours                - Slow release and decline – can be          

- Bead release capsule                                   “smooth” effect

- Adderall & Lysine (amino acid)

- Capsule with powder that can be mixed    into liquid


4) Concerta ER

- Lasts 8-12 hours

- Smooth release; slow “let down” in afternoon

- Slow build-up in morning

- Tablet only, not breakable


5) Focalin – short acting

- The shortest time 2-3 hours.

- Offers flexibility for dosing.

- The left half of the Ritalin molecule only, so may be “cleaner” and have fewer side    effects.

- Since already metabolized versions of Ritalin, may be more potent or “stronger” and  could have more increase in heart rate.

- Tablet.


6) Focalin XR – the extended release version of Focalin.

- Has very small dosing increments and amounts, which can help minimize side effects.

- Bead release capsule. 


Common Stimulant Side Effects

1) Decreased appetite

2) Insomnia

3) Increased anxiety or moodiness

4) Teeth/jaw clenching

5) Dry mouth

6) Urinary frequency (less than common)

7) Increased risk of tics, involuntary motor movements  


Strattera

Strattera also targets the ADHD symptoms.  Rather than both NE and DA, Strattera increases the norepinephrine only by blocking its reuptake at the nerve terminal.  Strattera’s mode of action takes more time to reach efficacy, up to 3-4 weeks or more.  To prevent side effects, such as sedation and upset stomach, a slow titration to target dose is desired.


Benefits of Strattera

- If efficacious, effects last 24 hours a day as the medication reaches a steady state.  Can be great 24-7 coverage for focus, impulsivity and hyperactivity.

- Elevates baseline focus, so even if not totally covering symptoms, then a smaller dose of the stimulant may become helpful for specific times such as school.

- Doesn’t target DA so that “tics”, such as in simple motor tics or Tourrette’s are not exacerbated. 

- May decrease anxiety or at least be less likely to increase anxiety than stimulant.

- Not a stimulant (controlled substance) so can be called in with refills.


Risks of Strattera

- Only one neurotransmitter, so may not be as efficacious.

- Liver enzymes monitored every six months.

- Can make mood worse.

- Functioning/grades could drop as it takes weeks to reach full effect.


The New Kids on the Block for ADHD

- Intuniv & Kapvay are both alpha-2 agonists, which work to decrease the adrenergic system and improve focus.

- Efficacy can be 8-24 hours. 

- Both are made of decades old blood pressure medicines (guanfacine and clonidine) which have been used ‘off label’ for years to target hyperactivity, impulsivity, tics, anxiety, & ADHD in children.


These medications are in a class that targets the Alpha-2 Receptor.  This receptor is important in the adrenergic (“fight or flight”) system.  By regulating or turning down this system, you see improvement in hyperactivity, impulsivity, over-reactivity, and aggression, as well as focus and attention.


The new version of the old medications have a slow time release, so the side effects have been minimized – their top side effects are sedation and/or dizziness upon standing, especially if dehydrated.  A slow titration helps to decrease the possibility of sedation or “flatness”. 


Targeting Anxiety

A benefit of this class of medication is that they could actually decrease anxiety and motor tics as well as insomnia.  The Intuniv and Kapvay can also be used in combination with the stimulants to allow for broader coverage (targeting several different receptors).  Although child psychiatrists prefer not to use “poly-pharmacy” - the use of two different classes of medication targeting from different directions can help to keep the dose of the stimulant medication lower than in mono-therapy. 


Anxiety is another common disorder that occurs in the school setting.  As psychiatrists, we may step in with medication to help when anxiety begins to interfere with learning in the classroom.  Many of my own patients suffer from anxiety that prevents them from attending class, makes it hard for them to focus on class work, or causes them to have test anxiety that erases the memory.  The top receptors to target for anxiety include the serotonin and GABA receptors.  The medications that target serotonin (SSRIs) are first line treatment for anxiety.


SSRIs

Fluoxetine (Prozac)

Sertraline (Zoloft)

Lexapro

Celexa

Luvox


Benefits – Target generalized anxiety disorder, OCD, panic disorder, separation anxiety.


Risks - Stomach ache

    Headache

    Mood worse

            Feeling cloudy/Feeling flat


The medications that target the GABA receptors include the benzodiazepines and Buspar.  Buspar is very mild, but can be helpful to lower anxiety with minimal side effects.  The benzodiazepines are not commonly used in children or adolescents.  They can be either too sedating or even disinhibiting to the youngsters.  Benzos, such as Xanax, are abused by the teenagers so they must be carefully monitored if used.  Nevertheless, a low dose of Xanax can be used to treat the intense panic disorder symptoms that can prevent kids from getting into the school.  


Unfortunately, depression is also seen in the school setting.  Affecting mood, motivation, concentration, memory and processing speed, depression can clearly affect classroom functioning.  


SNRIs

Effexor

Cymbalta

Pristiq


Benefits:

-  Hit two receptors – serotonin and NE, so can help target depression (and anxiety) that are not responding to serotonin alone.

-  By targeting both serotonin and NE, chronic pain can be decreased.


Risks:

-  Needs a slow taper, off or headache, dizziness, worsened mood or anxiety may occur.

-  The NE increase could increase blood pressure.


The Flexible Augmenters


The atypical antipsychotics are a class of medication that has been used for decades in child psychiatry.  This class is flexible because they can be helpful with a variety of diagnoses.  The atypical antipsychotics can uniquely target disorganized thought processes, intense negative thinking, overreactivity (especially due to negative misperceptions), psychosis, mood swings, and obsessive thinking as well as agitation and aggression.  Because of the possible wide range of target symptoms, this class shows up in the treatment of many disorders.


The “Atypicals”


Risperdal

- Primarily targets dopamine, but also a little serotonin.

- Short acting, small doses create flexibility.

- Could also help sleep, tics.


Invega

- Long acting form of the active ingredient of Risperdal.

- The long acting form can decrease side effects such as sedation.


Abilify

- Also targets both dopamine and is called a serotonin “stabilizer”.

- FDA approved for autistic syndrome, depression augmentation.


Seroquel

- Has short acting and long acting form.

- Only atypical FDA approved for mono-therapy in Bipolar Disorder.


Zyprexa

- The first Atypical identified as being protective cognitively in schizophrenia.


Atypical Benefits


- Can uniquely target impulsivity and aggression in both ADHD and autistic spectrum as well as other disorders.

- Can help block the intense negative thinking of both anxiety and depression faster than the antidepressants.


Atypical Risks


- Extra pyramidal symptoms – muscle stiffness, tension

- Weight gain

- Lipid changes


Rare Atypical Risks


- Risk of Tardive Dyskinesioa

- Seen in the old atypical such as Haldol

- Risk of Neuroleptic Malignant Syndrome

- Noted By: 1) Elevated WBC

-                  2) Autonomic Instability

-                  3) High Fever


Targeting Mood Swings


The mood stabilizers are a class of medications that has been shown through research to decrease mood swing or “episodes”, to decrease agitation or anger outburst, or to decrease recurrent depression episodes.


The Newer Stabilizers


Lamictal

- Targets severe mood swings such as in Bipolar Disorder, as well as recurrent depressions.

- May be useful for depressed patients who did not respond to typical antidepressants and report episodes of higher anxiety with racing thoughts.

- Must be started with a slow titration to prevent a rare (2% incidence) allergic reaction – a small rash at low doses, could be a blistering rash if titrated too fast.


Trileptal

- Used similarly to Lamictal, but on risk of the “Steven’s Johnson Rash” that Lamictal has.


Risks:

- Labs should be done every six months to monitor liver enzymes, WBCs.

- Minimal weight gain.

- Minimal sedation at low to moderate doses.

- Fairly minimal cognitive dulling at mild to moderate doses.

- If  too high a dose, cognitive dulling and/or fatigue may occur.


The Old Stabilizers


Depakote vs. Lithium


As the original Bipolar mood disorder stabilizers, both have been proven in repeated studies that they can stabilize mood swings and agitation associated with Bipolar disorder or other mood swing disorders.


Blood levels of both medications and enzymes must be monitored fairly closely to ensure safety to liver (Depakote) and thyroid and kidney (Lithium) function.


Risks:

- Weight gain 

- Cognitive dulling

- Rashes

- Sedation

- Tremor


Despite their side effects, both continue to stabilize patients.  If titrated slowly, side effects can be minimized.