Use of selective serotonin reuptake inhibitor medications for the treatment of child and adolescent mental illness Flashcards Preview

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Flashcards in Use of selective serotonin reuptake inhibitor medications for the treatment of child and adolescent mental illness Deck (27):
1

What medications are included in the SSRI class?

1. Fluoxetine
2. Sertraline
3. Citalopram
4. Escitalopram
5. Fluvoxamine
6. Paroxetine

2

What is the mechanism of action for SSRI?

Inhibit serotonin transporters, blocking reuptake and increasing concentration of the neurotransmitter serotonin within the synapse

3

Is absorption of SSRI affected by ingestion of food?

No

4

How is SSRI absorbed and metabolized?

Through the liver

5

Are laboratory investigations routinely indicated before initiating or maintaining SSRI medication use?

No

6

What are indications for laboratory investigations?

1. To r/o alternative underlying etiologies of the presenting symptoms e.g. hypothyroidism
2. Assess comorbid medical conditions e.g. hepatic impairment
3. Monitor therapeutic drug levels of medications used in combination with SSRI medication e.g. valproic acid

7

Which SSRI has the highest and which has the lowest reports of discontinuation/withdrawal symptoms?

Paroxetine highest

Fluoxetine fewest

8

What are the half lives for SSRI?

1. Fluoxetine 96h
2. Sertraline 26h
3. Fluvoxamine 15h
4. Citalopram 35h
5. Escitalopram 30h
6. Paroxetine 21h

9

What is the response rate for SSRI in the treatment of adolescent depression?

40-70%

10

Among children <12yo which SSRI have demonstrated benefits over placebo in treating pediatric depression?

Only fluoxetine

11

Among adolescents, which SSRI have demonstrated benefits over placebo in treating pediatric depression?

Escitalopram
Fluoxetine
Some efficacy for citalopram and sertraline

12

In the Treatment for Adolescents with Depression Study (TADS) comparing placebo, CBT alone, fluoxetine alone, and combination fluoxetine + CBT which arms weere most effective?

Fluoxetine alone was more effective than CBT alone or placebo

Fluoxetine alone and Fluoxetine and CBT were equally efficacious

13

What are some short term side effects of SSRI?

Side effects are dose dependent and decrease over time:
1. GI symptoms
2. Sleep changes e.g. insomnia or somnolence, sleep disturbances, vivid dreams
3. Restlessness
4. Headaches
5. Appetite change
6. Sexual dysfunction
Rare but important side effects:
1. Increase agitation or impulsivity
2. Hypomania in children risk of bipolar disorder
3. Increased risk of bleeding
4. SIADH
5. Serotonin syndrome/Toxicity
With citalopram >40mg/day:
1. QT interval prolongation
2. Risk of arrhythmia

14

What are the symptoms of serotonin syndrome?

1. Mental status changes
2. Myoclonus
3. Ataxia
4. Diaphoresis
5. Fever
6. Autonomic dysregulation

15

What populations should not be prescribed citalopram?

1. Absolute: Congenital long QT syndrome
2. With caution: Underlying congenital heart disease or hepatic impairment (affecting citalopram metabolism) incld. predisposition to cardiac arrhythmia due to electrolyte disturbances as risk of torsades de pointes

16

What does the research state regarding the association of SSRI with suicidality?

1. The potential benefits of SSRI use outweigh the potential harms for the treatment of depression in children and adolescents.

2. Untreated depression is more likely to result in harm than appropriate SSRI use.


3. Close initial monitoring, along with careful documentation of symptoms and adverse effects, are required.

17

What are the FDA suggestions regarding clinical monitoring of patients occur at least?

1. weekly for the first four weeks following initiation of SSRI medication;

2. every two weeks for the next four weeks;

3. at 12 weeks;

4. then as clinically indicated beyond the 12-week point.[

18

How long should an SSRI be continues once complete response is achieved and why?

Minimum 6-12m
To reduce risk of relapse

19

How should SSRI be discontinued?

Slow taper to prevent relapse or withdrawal symptoms

20

Which children may warrant a psychiatric consultation before medication discontinuation?

1. History of multiple depressive episodes
2. Comorbid psychiatric illnesses
3. Complex depressive e.g. with psychotic features

21

What are the key messages regarding SSRI in the treatment of child and adolescent depressive disorders?

1. Of the SSRI medications, fluoxetine has the most data supporting its use for treating depression in children and adolescents.

2. Citalopram should not be used in dosages >40 mg/day.

3. Citalopram should be prescribed with caution in certain individuals (described above), and should not be prescribed for children and adolescents with congenital long QT syndrome.

4. The risk of suicidality associated with untreated depression is likely greater than that associated with appropriate SSRI use.

22

Which medications have proven effectiveness in the treatment of generalized anxiety disorder in children and adolescents?

1. Fluoxetine (7-17yo)
2. Sertraline (5-17yo)
3. Fluvoxamine (6-17yo)

23

Which medications have proven effectiveness in the treatment of selective mutism in children and adolescents?

Fluoxetine (6-11yo)

24

Which medications have proven effectiveness in the treatment of social phobia in children and adolescents?

1. Fluvoxamine (6-17yo)
2. Paroxetine (8-17yo)

25

Which medications have proven effectiveness in the treatment of separation anxiety disorder in children and adolescents?

Fluvoxamine (6-17yo)

26

What are the key messages regarding the use of SSRI in the treatment of anxiety?

1. SSRIs may be considered early in the course of treatment for anxiety disorders if anxiety is severe or causing significant functional impairment, or if the child is unable to benefit from psychotherapy.

2. Careful elicitation and documentation of physical symptoms of anxiety should be completed before initiating medication.

3. To improve tolerability of medication for anxious patients, clinicians should include the following in their overall approach:
a) Psychoeducation
b) Lower starting dosages
c) Gradual titration to therapeutic dosages.

27

What are the summary and recommendations regarding the use of SSRI in pediatrics?

1. When undertaken following an appropriate clinical assessment, and within the context of a comprehensive management plan, SSRI medications may be effective in the treatment of child and adolescent depression and anxiety disorders.

2. Because depression in particular is associated with high rates of suicidal ideation, behaviour and completed suicide, untreated illness may be more harmful than appropriate use of SSRI medication.

3. Before initiating pharmacotherapy, physicians should carefully elicit and document baseline depressive and anxious symptoms.

4. Following medication initiation, patients should be closely monitored for potential adverse effects, including suicidal ideation and behaviour.

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