The Quarterly Consultis a quarterly publication highlighting pediatric clinical expertise. If you have an item of interest to include in the Quarterly Consult, contact Dr. Steve Dassel at 206-625-7373, mailbox 8588.
April 2010: Behavioral Health in Primary Care Physician Practices
This issue of Consultrevolves around a discussion with Dr. Robert Hilt regarding childhood mental health and the primary care physician. Hilt is the director of psychiatric emergency services at Seattle Children's Hospital and the director of the Partnership Access Line. He is an assistant professor at the University of Washington School of Medicine (UWSOM) and a fellow of the American Academy of Pediatrics. He attended medical school at the University of Rochester in upstate New York and completed his pediatric residency at the University of Iowa. Hilt practiced general pediatrics on Washington's Kitsap Peninsula. That was followed by a stint as a pediatric hospitalist in Ann Arbor, Michigan, and then a psychiatric fellowship at the University of Massachusetts. After that, he came back to Washington state to work at Seattle Children's Hospital.
Q:Is there a good overall child mental-health resource site on the net?
A:Yes, it is Primary Care Principles for Child Mental Health, August 2008, by Robert Hilt, MD, and the link is http://www.palforkids.org/resources/. This is really an excellent website. Listed are community resources, mental health assessment principles, screening tests, evidence-based treatment advice, overviews and specific care guides for ADHD, anxiety, bipolar, depression, eating disorders, oppositional defiant anger problems, sleep, etc.
Q:Bob, there just aren't enough pediatric psychiatric physicians and providers to take care of all the mental-health issues we primary care providers see. Which entities should we tackle and which ones to refer?
A:Actually, one in five patients coming to your office will be there for a behavioral issue or a mental-health problem. It would be preferable to work in collaboration with a licensed behavioral care provider, though not always possible. Which cases a primary care provider manages on his own should depend on his knowledge base, experience and comfort level.
Q: Which ones do you think we should we care for?
A: Probably you should care for cases as the sole care provider for attention deficit/hyperactivity disorder (ADHD), and as the first-step care provider for anxiety, depression and oppositional defiant disorder.
Q: What is first-step care?
A: First-step care is recognizing the problem and setting up a referral to a therapist. Ideally, you will then be communicating with that therapist about progress of the case. First-step care might also involve prescribing a first or second medication trial in the case of anxiety or depression.
Q: OK, let's start with ADHD. How do you make the diagnosis, other than just trying a stimulant medication and seeing how things go?
A: The problem with that approach is that stimulant medications have clinical effects on everyone, not just kids with ADHD, so seeing an impact from a medicine does not mean there was an ADHD diagnosis. Also there are so many medication possibilities now for ADHD; you don't want to spend a year trying medication after medication only to eventually surmise the problem wasn't actually ADHD.
Q: So what would you recommend?
A:The diagnosis should be based upon information both from home and school and based on DSM IV criteria; a handy tool is the Vanderbilt, a rating form filled out by both parents and teachers. It also gives you information regarding oppositional defiant disorder, conduct disorder, anxiety and depression and how much of a problem the ADHD is creating. Key diagnostic criteria are that symptoms must be present in more than one setting (not just at home, for instance) and not better explained by another diagnosis.
Q: What is the differential diagnosis of an inattentive kid?
A: You have to think broadly, because lots of things can create inattention. Examples would be just young age. Three-year-olds naturally have more difficulty concentrating and are naturally more active. Anxiety disorder and depression both can get in the way of focusing. Learning disabilities can make a child appear to have ADHD in a school setting.
Q:What do we know about the sensitivity and specificity of the Vanderbilt?
A:That is answering the question of what is the sensitivity and specificity of DSM IV, since the first 18 items of the Vanderbilt are the actual symptoms of ADHD as listed in the DSM IV. The answer depends on how well a provider considers the possibility of non-ADHD causes of inattention and hyperactivity. I can say that following an ADHD diagnosis one should expect a robust response to medication treatments - any one stimulant has about a 70% chance of yielding a perfectly satisfactory response, and if you are part of the 30% nonresponding, then switching to the other stimulant medication gives a 90% overall chance of a success. Because these are kids who have been diagnosed as having ADHD by the criteria on the Vanderbilt, it would imply that there is a high probability of success using stimulant medication when the Vanderbilt is positive.
Q: What else works with ADHD?
A: Behavioral modification strategies, classroom modifications and the nonstimulant medications such as Strattera, Wellbutrin, and Intuniv (long-acting guanfacine) which, while not as effective as the stimulants, are certainly significantly better than placebo.
Q: Do you have a preference as to which stimulant medication to start with?
A: No; however, I would favor a methylphenidate over an amphetamine in the less-than-five-year-old, based on the limited research available to us.
Q:You start with a low dose of a stimulant medication and increase to get effect. What is the maximum dose for you?
A:High doses that would trigger a mandatory medication review for our state Medicaid system, in terms of milligrams per day, are methylphenidate 120 mg, dextroamphetamine 60 mg (includes Adderall) and 70 mg for Vyvanse. Some experts say one should not go over 2mg/kg/day of methylphenidate and 1mg/kg/day of dextroamphetamine, but personally I rarely see occasions when it makes sense to push doses up that high.
Q: What are the indications for using the nonstimulant medications? Examples are Strattera, Wellbutrin, and a medication currently being given a lot of publicity: Intuniv (the alpha-agonist guanfacine in a long-acting form).
A: I'd start with one stimulant and, if not successful, use a stimulant from the other medication family (methlyphenidate vs. dextroamphetamine), and if not successful, a nonstimulant as my third choice. There are a few exceptions, such as a child who has a current substance abuse problem, who should trial nonstimulant medications first, and a child with a tic disorder may have both their tics and ADHD well treated by either clonidine or guanfacine.
Q: Would that be the nonstimulant in combination with the stimulant, or alone?
A: Initially, I would start the nonstimulant alone, and then only consider a combination if each medication trial did not work well enough on its own. There is some evidence to suggest that low-dose clonidine plus a stimulant may be uniquely beneficial in some situations.
Q: Anxiety is a problem we primary caregivers encounter. What good rating scales are available?
A:The "SCARED," standing for Screen for Child Anxiety Related Disorder, is free off the Internet and is efficient and effective. It doesn't cover OCD, but that's usually pretty obvious. I also like "MASC" (Multimodal Anxiety Screen for Children).
Q: How should we approach treatment?
A: In an ideal world, you would refer for CBT (cognitive behavioral therapy) which is the treatment of choice. For moderate to severe cases, medication may be used in addition.
Q: Please give us three SSRIs (selective serotonin reuptake inhibitors) you find most useful.
A: Again, ideally, a medication would be used after CBT has failed to produce enough benefit, or medication can be started simultaneous with therapy for cases with severe dysfunction. There is best research support for fluoxetine (Prozac) and sertraline (Zoloft). There is less research but still evidence of benefit in children for fluvoxamine (Luvox) and citalopram (Celexa).
Q:If the first SSRI fails, what are the chances trying a second would be helpful?
A: Around 50%, so, certainly worth a try. After the failure of the second SSRI, there are diminishing returns.
Q: What doses do you use?
A: We are usually treating older kids so a mg/kg dosage is not applicable. Rather we think of these in terms of mg/day. For Prozac, start at 10 and go up to around 40 if needed. Zoloft starts at 25 and goes up to around 150. Celexa starts at 10 and goes to around 40. Decrease those maximum doses by at least a third in the prepubertal patient.
Q: And, finally, what are the side effects of the SSRIs?
A: Suicidal ideation is probably the most troublesome. Compared to a placebo control, Prozac and Celexa are 1.5 and 1.4 more likely to have suicidal ideation. Zoloft comes in at 2.2 and venlafaxine (Effexor) is at around 8.8. This is one reason why I believe Effexor is not a good drug for children, plus withdrawal symptoms may be severe, as well.
Q: Moving on to depression. What about rating scales?
A:I suggest using either of two: SMFQ (Student Mood and Feeling Questionnaire) or the PHQ-9 (Patient Health Questionnaire 9 items). For a fee, the CDI (Childhood Depression Inventory) is good as well.
Q: These can be downloaded at the above-mentioned website. Tell us about treatment for depression.
A: If deemed mild (noticeable but basically functioning okay), education is important. Support increased peer interactions, behavioral activation and exercise, encourage good sleep habits, try to reduce stressors and, prophylactically, remove any guns from the home. Do a follow-up to see if the patient is improving or getting worse.
Q: And if the depression is moderate or severe?
A: Ideally, use CBT, education, and consider SSRIs.
Q: What are your favorite three?
A: Research in children favors the use of Prozac over other SSRIs. There is also some good support for Zoloft and Celexa/Lexapro as well. Dosing is the same as in anxiety. A long half-life of Prozac means no side effects from a missed dose but takes longer to clear if a problem side effect happened. Celexa has very few drug interactions. Zoloft may be prone to side effects when stopping the medication abruptly.
Q: Bob, how do you taper off SSRIs?
A:If the child has not been on it very long, such as within the first couple of weeks, one would simply stop the medication. After longer term use, I typically decrease the dosage by half for at least a few weeks before stopping. Prozac with its very long half-life can self-taper with abrupt discontinuation.
Q: Give us an idea of cost for the SSRIs. Let's use DSHS costs.
A:Generic formulations are always significantly cheaper than brand names. Looking at it relatively there are a few differences for DSHS, in that for them Celexa costs less than Prozac, which is less than Remeron (mirtazapine) and less than Wellbutrin.
Q:Let's briefly talk about oppositional defiant disorder (ODD) and aggression in kids. What shouldn't we miss?
A:As with all child mental health problems, make sure you check out neglect and abuse, drug abuse, a medication causality like an irritability side effect, suicidality, and with aggression - if there are any specific plans to hurt someone.
Q:ODD is an automatic referral for me, but what can the primary care physician do?
A:Check out the possibility of weapons in the home, avoid exposing the child to situations that reinforce undesired behaviors, and encourage increasing general parenting skills for managing defiant behaviors. Time-outs and other behavior strategies work better if the parent and child are also having frequent occasions of positive interactions or special time together. The parents need to get involved in the treatment of ODD.
Q:What are community resources for ODD referral?
A:UW has a program called The Incredible Years for preschoolers. Good books for ODD for parents are The Explosive Childby Ross Greene, PhD, and, of course, by Stan Turecki, MD, The Difficult Child, and, finally, 1-2-3 Magicby Thomas Phelan, PhD.
Q:Thanks for this, Bob, and also thank you for all your work as director of the Partnership Access Line, primary care principals for child mental health. Again, http://www.PALforkids.org. Telephone number, 1-866-599-PALS (x7257).