SIMON EPSTEIN, M.D.
91 STRAWBERRY HILL AVE. #140
STAMFORD, CT 06902
203-348-8579

THE EPSTEIN QUARTERLY

Updated January, 2004

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INTRODUCTION

Medication is now a frequent part of the psychiatric treatment of children. Rarely, though, does it represent the complete treatment. Usually it is combined with some type of psychotherapy, so that all aspects of the child’s functioning are included in the treatment.

This edition of the "Epstein Quarterly" will focus on the increasingly important role medication plays today in the psychiatric treatment of children. I will discuss the conditions that are often treated with drugs, and explain the most commonly used medication for their treatment.

NEW DIAGNOSTIC CONSIDERATIONS

In the not too distant past we attempted to make a single psychiatric diagnosis that explained all of a child’s symptoms and therefore defined a single course of treatment. Ongoing research has shown, however, that a child can have several conditions at the same time. This may necessitate a separate course of treatment for each diagnosis. For example, a child who was once diagnosed solely as ADHD may now be diagnosed with ADHD, Depression, and/or Obsessive Compulsive Disorder. Don’t be upset if a child has more than one diagnosis. This actually represents a more careful diagnostic evaluation and leads to better treatment.

NEW WAYS OF LOOKING AT THE USE OF MEDICATION

In recent years there has been a change in how psychiatry approaches the use of medication. Gone is the attitude that implies one medication should be enough. Instead, we are now using several drugs at one time in order to achieve the best results. If the illness is complex, for example, we now commonly combine two or three medications. We will also combine medications if the response to the first medication is less than we would like. Common groupings might include a stimulant and an anti-depressant or a mood stabilizer, an anti-depressant and a neuroleptic.

The same medication may also be used for several different conditions. For example, Prozac can be used as an anti-depressant or as an excellent treatment for Obsessive Compulsive Disorder.

Today we are much more flexible in trying to reach our treatment goals, and have learned how to use the more recently available medications in many ways, as the following information will show.

ANXIETY DISORDERS

The term "Anxiety Disorder" includes many conditions with the common theme being the presence of significant anxiety. However, the way the anxiety presents itself is very different in each type of problem, and each could be a Newsletter in its own right. Let me mention a few. Obsessive Compulsive Disorder is one, and Panic Disorder another. Social Phobia and Post Traumatic Stress Disorder are two more. A more generalized type of anxiety that affects many aspects of a child’s life is known as GAD, or Generalized Anxiety Disorder.

Now, with these in mind, how is medication used in their treatment? The common thread in the treatment of these conditions is the use of a serotonin uptake inhibitor (SSRI). This category includes Prozac, Zoloft, Celexa, Lexapro, Paxil and Luvox. Similar to these is Effexor. The FDA has indicated that a specific one of these drugs is approved for treatment for a given type of anxiety, but the truth is that they all can do the same thing. Therefore, any of these medications can be used in an interchangeable manner, with choice depending on potential side effects or physician preference.

Case 1: Rod, 17, represents a social phobia anxiety. He was very shy and unable to socialize in groups of any size because he became so anxious and uncomfortable. He avoided all social activities such as dances, and he felt like an outcast because of his anxiety. Treatment was with Prozac 20 mg. taken daily. Over a period of 6 weeks the anxiety diminished and Rod was able to go to games and dances without the terrible feelings of anxiety.

Panic Disorder, a not uncommon form of anxiety, is very difficult to live with and requires an additional anti anxiety agent as part of its treatment. . There is a class of medications known specifically as anti anxiety agents. These include Ativan, Klonopin, Xanax, BuSpar, and Valium. Usually Ativan or Klonopin are used as treatment for Panic begins.

Case 2: Art was 15 when he presented with severe feelings of panic that occurred frequently and often for no reason. He also had agoraphobia and was unable to stay in closed spaces, including his classrooms. Art was started on Zoloft, which would be the medication that would actually reduce or remove the panics. However, in this situation the Zoloft takes some time to work. Therefore, he was also started on Ativan, which he used several times a day to control any anxiety that developed. Over about two months the condition improved and he was able to discontinue the Ativan. However, at age 18, he continues to require the Zoloft or the panics return.

MOOD DISORDERS

Depression is, of course, the most common disorder of mood. This condition can vary from mild to very severe and can be chronic in nature. Depression removes joy, and the glass is always half empty. Treatment medications are known as anti-depressants, and include all the SSRI’s just mentioned plus some additional drugs. Three important non-SSRI anti-depressants are Wellbutrin, Remarin and Serzone.

Treatment resistant depressions are not uncommon. These are treated by combining various medications, including Zyprexa, which will be discussed below. However, the important point is that if a depression does not respond to full treatment with a starter drug, don’t give up.

Bi-Polar Disorder

This is a serious condition, and often very difficult to diagnose in young children. It can look like or be combined with ADHD, which complicates the diagnosis. The treatment is complex, but always involves a mood stabilizer. Probably the best known in this group is lithium. However, because of it’s potential side effects it is rarely the first choice. More commonly, Depakote is used.

Depakote has long been used to control seizures in children. More recently, it has been an excellent mood stabilizer. The blood level of this drug can be followed to help determine the correct dose, and occasional liver function tests can make sure that no inflammation of the liver occurs. Weight gain can be a problem, and therefore weight is carefully monitored.

There are other mood stabilizers, including Tegretol, Trileptal, Neurontin, Topimax and Lamictal.

A current book on the subject is "The Bipolar Child" by Demitri Papolos, M.D. and Janice Papolos and published by Broadway Press in 1999.

MAJOR MENTAL ILLNESS

Into this category fall the psychotic conditions. The drugs used in treatment are called "neuroleptics" and are divided into the older and the newer. The older include such well-known medications as Thorazine, Haldol and Mellaril. Their use has largely been replaced by a newer group because the side effects are far fewer.

The new group includes Risperdol, Zyprexa, Seroquel, Geodon and Abilify. Dosing with children has to be done carefully because these are potent medications. Though very effective, Risperdol and Zyprexa can cause major weight gain problems. Because we have more experience treating children with these two medications, they may be the first prescribed. However, weight will need to be carefully watched over the first month of treatment. Neither Seroquel nor Geodon cause as much weight gain, and they can also be considered if indicated.

Case 3: Wyeth is an example of the results with these medications. He was hearing voices, making strange and inappropriate remarks to his teachers, and showing a great deal of anxiety. He was very difficult to handle at home.

He was started on Risperdol .5 mg. twice a day. Over the period of a month his voices disappeared and his behavior became much more acceptable. Wyeth gained 20 pounds, but we decided to stay with the medication because it had been so helpful.

These medications are so safe and effective that we are now using them in the treatment of many conditions such as bi-polar disorders and conduct disorders.

EXPLOSIVE DISORDERS

Explosive behavior is a reaction that generally has aggressive features and is always far more severe than called for by the situation. The explosiveness can be part of other conditions such as ADHD or Bi-Polar Disorder, or it can be an entity unto itself.

In those cases we will call it an Intermittent Explosive Disorder, and treat the symptoms. In this condition a mood stabilizer is used. Depakote, which we have mentioned, is one choice. Others are Tenex or Clonidine. These medications are used to control blood pressure in adults, but in children they can control explosive behavior.

Successful treatment can be very helpful, as it can help a child control his behavior, which improves his/her ability to fit in at school and at home.

CONDUCT DISORDER

This is the anti social individual who ignores the rights of others and the rules of society. Many of these people are in trouble with the law at a young age and in jail by their early 20’s. Treatment with therapy is rarely successful.

A recent study showed some positive changes in teenagers treated with Risperdol. While many more studies are needed, I believe we can try this medication as we have little else to offer.

ATTENTION DEFICIT HYPERACTIVE DISORDER

ADHD is subdivided into a "Hyperactive / Inattentive " form and an "Inattentive" form. Very often the former needs more vigorous therapy because the negative behavioral aspects are more pronounced.

The basic treatment continues to be the stimulant medications, with the current trend being toward once a day dosing. One of the two major stimulant groups is methylphenidate and the other is dextroamphetamine.

Methylphenidate is the generic name for Ritalin, which is the short acting form and lasts 3 or 4 hours. A variation on the Ritalin is Focalin, which may have fewer side effects.

There are three good long acting forms. One is Metadate CD which lasts about 8 or 9 hours and can be opened and sprinkled on applesauce if a child cannot swallow the pill. Concerta is another, and lasts about 12 hours. This is a medication that must be swallowed. It is effective, and comes in several convenient strengths. The newest entry is Ritalin LA. This releases two doses of Ritalin and lasts about 9 hours. It can be sprinkled if necessary..

The long acting dose forms make it possible to skip the visit to the nurse at lunchtime as well as offering a steady amount of the medication in the system. This makes the medication "smoother" as there are no ups and downs in blood levels, and it is less likely that a rebound effect will occur at the end of the day.

The Dextroamphetamine group consists of Dexedrine in both a short acting tablet and a longer acting spansule form. Adderall is also part of this group.. Adderall comes in many convenient doses and is generally used twice a day. One tablet lasts most of the school day, and a second is needed for homework and after school activities. It is available in a generic form that is less expensive and works for most but not all patients.

Adderall has an "XR" form. AdderallXR is a 12 hour tablet in which half the dose is released right away and the second half four hours later. If you are on regular Adderall, the once a day dose of the XR would be the total of the dose being used. For example, if you take 15 mgs. twice a day, the once a day morning dose would be 30 mgs. of the XR form. The medication is very effective, but in my experience often lasts less than the 12 hours.

"The newest medication for the treatment of ADD is Strattera. This has been available for about a year. It is taken once a day and generally takes several weeks to become effective. It is a useful addition to the available medications, but in most cases does not appear to be as effective as the stimulants."

Other medications used include Wellbutrin, Clonidine and Tenex.

The importance of medication as a part of the psychiatric treatment of children cannot be overstated. The suffering during childhood with all its potential complications in later life can now be modified. The Newsletter has discussed a number of the conditions which can be treated with medications, and has mentioned the newer medications used. Things change rapidly, but it is clear that medication is a very significant part of the treatment plan.