Front Line Management of Behavioral Health Conditions (1.3a

7/27/2019 Front Line Management of Behavioral Health Conditions (1.3a

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Focused?


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Front Line Management ofBehavioral Health Conditions

Joshua D. Feder MD,Director of Research, Interdisciplinary Council on

Developmental and Learning Disorders

Associate Professor, Voluntary, Department of Psychiatry

UCSD School of Medicine


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Disclosures, Fall 2103

Clinical - 50% time, 99% of income

SymPlayipad/ UCI research

ICDL Grad School: math, research

Early Yearspeace building

COC state advocacy for EBP

BRIDGE 1,.15m in grants

Circlestretch community resource

Cherry Crisp media company


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Dont sweat the details - this talk will be posted

on

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The Situation

20% of kids have a behavioral health condition

1/10th of those get treated

Many symptoms, many diagnoses:

Examples:

ADHD + learning disorder + anxiety or mood oroppositional, social difficulties

Autism Spectrum with sensory, motor, mood,learning, perseverative, etc

Teen with mood, substances, & abuse history


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Whats Common

ADHD 5% of kids

Mood disorders 4%, 33% lifetime risk

Autism Spectrum Disorder 2% Anxiety 1% (+) in kids, more with age

Severe substance issues 1% (+), spike in teens

EtcEarlier Onsets = Nastier Problems


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Areas of Function to Check

for Common Psychosocial Problems

HEADS

Home: relationships, culture & values, abuse

Education: grades, activities, peer issues

Activities: peers, sports, clubs, community

Drugs: and medications, herbals, diets Sex: identity, exposure, intimacy


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Your Possible Roles

Assessment: Medical check, lab studies, & referrals

Behavioral symptoms checklists DSM 5

What the child tells you, shows you Time to talk to family, teachers, etc.

Management:

Supporting the child in the office & beyond

Continuing medication for a stable patient

When to ask for help


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Assessment

Bio physical, maybe labs Psycholook at symptoms

Social home, school, activities


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Humiliation is Damaging


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Make other time to talk


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Make time Save Time*

*You get important information for treatment.

Bonus:

Specific plans for follow up calls and appointments

reduce family anxiety


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Getting kids to talk

Front load time - pays off later

Stay calm, then they are more calm

Some tell all, some never talkdont force it

Statements may work better than questions

So I hear youve been upset. We can figure this out

Body language try to read their cues ask parents!

Some have strong feelings but dont show them

Avoid talking about kids with parents

in front of the child or teen - call before or after if necessary


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In Office Therapy?

Help set up try, & try again

Goal: repair connections with others, over and over

to build competence, confidence, & resilience

Take time and listen - take their word for it

Get their ideas:

Tell me what you think might help

Set up check in over and over* to try other things

Resources online ideas, etc.

*with you, parent, teacher, coach, therapist, mentor, etc.

Relationships matter!


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Well win some, and well lose some

Thats ok - lets keep trying


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Management

Bio exercise, maybe meds, maybe labs

Psycho building better problem solving

Social home, school, activities

Adult presence is key:

balanced mix of

support and expectations

is critical to a good outcome


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Complete workup: consider (24 hour) EEG, labs, etc. along withcomplete history, physical, t ime with th e chi ld and fami ly, and collateral informationfrom school, therapists, etc.

Diagnosis: a hypothesis meant to focus treatment, as well as other possible &co-occurring diagnoses. The 5 axis system helps, and new dimensional axes may workbetter

Grid and prioritize target symptoms and possibletreatments and fill in likely +s & -s, in a flexible decision matrix

Availability- provider MUST stay in touchwith family and school

GOLDEN RULE: think carefully before rapid, largechanges in dose or before changing more than

one thing at a time.

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How Do We Decide What to Do?

Evidence Based Practice

From Sackett 1996 to American Academy of

Sciences Institute of Medicine 2001 to

Buysee 2006 (IMH), and through to today

(Brandt, Deil, Feder, Lillas 2013)

The combination ofrelevant research with

clinical judgment and experience to

provide families with the information to maketruly informed consent decisions based on

their own family culture and values.


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Name Your Symptoms

Activity,impulsivity

Anger Attention

Anxiety, specificfears

Cognition Depression Eating Elimination GI Distress Moodinstability,

irritability,

aggression

Motor tone Motor Planning

O/C, rigidityPerseverative

Pain Reciprocal

interaction Seizures Sensory

Sensitivity &

Processing

Sleep Tics Trauma s/s

Others??

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Targ

ets

Activity

Atte

ntion

Anx

iety

Cog

nition

Dep

ression

Mood

Inst

ability

aggression

Motor

Plan

ning

O/C

,rigidity

Perseverative

Reciprocal

inte

raction

Sen

sory

Sen

sitivity

Tics

Slee

p

Etc

Com

ments

Stimulants +/- +/- - +/- - - +/- - +? - - - Wt

Ht

tics

SSRIs - - +/- -/+ +? -/+ +? +? -/+ Wt, Ht

Sz

Neuroleptics +? -? + -/+ +? ++? - +? ++?? +? + + Wt. SzTD

NMS

AEDs +? -/+ + -

/+?

+? ++? -? +? +? +? +? +/- Mult.

SE

Steroids -? -? +? +? -/+ -? +? -? ++? -? +? -? Mult

SE

Central AlphaAgonists

+? +? +? -/+ +/- 1/+? -/+? +? +? +? +? + SleepBP

Etc

LIST OTHER

TREATMENTS!

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Support regulation and co-regulation bytreating, e.g., impulsivity, inattention, anxiety, rigid thinking,perseveration.

Widen tolerance of emotions sothe person is less likely to become overwhelmed.

Treat co-occurring conditions,e.g., depression in ADHD, irritability in ASD.

Mightpromote abstractreasoning and thinking.

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Stimulants

Methylphenidate: Ritalin, Concerta, Metadate,Methylin, Focalin, Daytrana Patch, Quillivant liquid

Dextroamphetamine: Adderall, mixed salts, Vyvanse

Slightly different mechanisms.

Similar possible side effects: appetite, sleep,withdrawal, depressed mood, unstable mood, tics,obsessiveness, etc. Get a cardiac history, maybe anEKG.

Drug diversion vs. drug abuse risk

ADHD and ASD

Often makes a good plan workable.

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SSRIs

One of many classes ofantidepressants Can really help depressed mood, maybe anxiety, less

likely obsessiveness (although works well for that forneurotypicals)

Prozac (fluoxteine), Zoloft (sertraline), Paxil (paroxetine),

Luvox (fluvoxamine), Celexa & Lexapro (citalopram). Similar possible side effects: behavioral activation,weight gain (and loss), mood instability, lower seizurethreshold, etc.

Drug-Drug interactions & Serotonin Syndromesweating is often the first sign

Black box warning misleading: suicide rate had beendropping, then the warning in 2004 led to reducedprescriptions and higher rates of suicide.

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Neuroleptics

Zyprexa (olanzapine), Risperdal (risperidone), Abilify(aripiprizole), Seroquel (quetiapine), Geodan (ziprasidone),Haldol (haloperidol), Mellaril (thioridizine), Thorazine(chlorpromazine) and others.

Discovered while looking for cold pills, developed forsymptoms of psychosis.

Helping aggression, mood stability, and miracles? As well astics, and adjunct for depression, perseveration, etc.?

Monitor weight ,fasting lipids, and fasting glucose, as well asfor seizures, fevers (NMS) and new abnormal movements(TD), stroke (elderly), cardiac

Should we always consider neuroleptics in ASD?

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Abnormal Involuntary Movement Scale (AIMS)

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AEDs

Anti-Epileptic Drugs (aka anti-seizure medications)

So many and all so different in character

For seizures, and for mood stabilization

Many kids on the spectrum have seizures! Might help other medications work better (stimulants,

antidepressants)

Combined pharmacology vs. polypharmacy

Sudden stopping might make seizures more likely

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Specific AEDs

Depakote (valproic acid, valproate) pretty reliable, easy

to load, watch levels, platelets, bruising, liver, pancreas,

carnitine, menstrual irregularities, weight, sedation.

Problems when using with Lamictal

Tegretol (carbemazepine) - ?reliable, watch levels, bloodcounts, EKG, lots of drug interactions, induction of

hepatic enzymes, weight gain, sedation, rash

Trileptal (oxycarbezepine)Tegretol light?; motor

problems, electrolyte issues, rash?

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More AEDs

Keppra (levetiricetum) easy to use, but does it work?

Lamictal (lamotragine) mood stability, ?better mood. Must

go slow, and watch for rashStevens Johnson Syndrome

Topamax (topiramate) adjunct, may cause weight loss, loss

of expressive language, usually need to go slow. May beuseful for addiction, Tourettes, OCD.

Neurontin (gabapentin) Does it work at all? Does it harm at

all? Does help pain syndromes, maybe anxiety too.

Lyrica (pregabalin) for pain in fibromyalgia, partial seizures Zarontin (ethosuccimide) for partial/ absence seizures; liver

issues

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Central Alpha Agonists

Tenex & Intuniv (guanfacine), Catapres(clonidine)

Reducing fight flight sympathetic tone,

which can help in many ways Vigilance theory

Side effects can include sedation, dizziness,early tolerance

Mild medicine

Maybe get an EKG for clonidine?

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Other Commonly Considered

Medications

Straterra (atamoxetine) for ADHD; may be as good asplacebo, may act like an antidepressant (+/-)

Wellbutrin (bupropion, etc.) dopaminergic, weight, loss,sleep loss, irritability, seizure risk, headache risk

Rozerem (ramelteon) melatonin agonist SNRIs Effexor (venlafaxine), Cymbalta (duloxetine),

Remeron (mirtazepine), Serzone (nefazedone), Pristique(desvenlafaxine). Watch for withdrawal.

Deseryl (trazodone) antidepressant often used forsleep; cognitive side effects, priapism

Buspar (an azaspirone) mild, serotonergic crossreactions

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More Others

Lithium great mood stabilizer; anti-suicidal;bipolar-ASD connection; levels, thyroid, kidneyfunction; blood levels, NPH (wet, wild &wobbly)

Namenda (memantine) Alzheimers medantagonistof the N-methylD-aspartic acid(NMDA) glutamate receptor, thisdrug washypothesized to potentially modulate learning,blockexcessive glutamate effects that caninclude neuroinflammatoryactivity, and influenceneuroglial activity in autism

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Meds I avoid

Paxil (paroxetine), Effexor (venlafaxine), Cymbalta (duloxetine)- withdrawal

Tegretol (carbemazepine) hard to make it work

Combo Depakote and Lamictal levels unwieldy

Tricyclics Tofranil (imipramine), Norpramin (desipramine),Pamelor (nortriptyline); and, esp. good for typical OCD,Anafranil (clomipramine). Cardiac, blood pressure issues.

Monoamine Oxidase Inhibitors Nardil (phenelzine) , Parnate(tranylcypromine), Marplan (isocarboxazide), Emsam

(selegiline) can be useful although dietary, blood pressuredrop and hypertensive crisis must be considered; lots of drug-drug interactions

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Special Caution on

Benzodiazepines!

Benzodiazepines Valium (diazapam), Ativan(lorazepam), Xanax (alprazolam), Klonopin(clonazepam), and others

Used so freely by many doctors and families

Problems nearly always outweigh risks

Addicting

Destabilizing mood

Interfere with learning

Interfere with motor function

Interfere with memory

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Your Experiences?

Front Line Management of Behavioral Health Conditions (1.3a

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