An Overview of Psychiatric Medications for Children and Adolesscents John Webber, M.D.

Youth Home, Inc.

(501) 821-5500

Objectives • • • • • The importance of child/teen mental health.

Principles of medication treatment Comprehensive but not exhaustive overview of psychiatric medications.

In-depth review of antidepressants Provide time for questions and discussion.

Goals • • • Add to your understanding of why medications are prescribed for children and teenagers.

Adle to distinguish between antidepressants, stimulants, antipsychotics and anticonvulsants.

Recognize brand and generic names in each class of psychiatric medications.

Housekeeping • • • This presentation and your handout will follow the convention of listing the generic name followed by the brand name.

For example, Sertraline (Zoloft) *medications are newest

Normal Behavior • • Children – Imaginary friends – Events controlled by thoughts/feelings Teens – Moody and irritable – Oppositional and antisocial – Unique insights into the nature of reality

Medication Priniciples • The full range of psychiatric medications are prescribed for children and teenagers.

• Several medications are used off-label.

• Medication is itself a therapeutic issue

Psychotropic Medications • • • • • Stimulants Other medications to treat ADHD Antipsychotic medications Mood Stabilizers Antidepressants

Stimulant Medications

Methylphenidate • Ritalin is the best known example • Includes Metadate, Methylin, Focalin • Concerta is a longer-acting form of methylphenidate with a unique design • Daytrana is a transdermal patch

Dextroamphetamine • Dexedrine and Dextrostat • Adderall and Adderall XR

Newest Class of ADHD Medications (Prodrug Stimulant) • Lisdexamfetamine dimesylate (Vyvanse)

Other Medications to Treat Attention Deficit Hyperactivity Disorder

Nonstimulant Medications • • Atomoxetine Guanfacine (Strattera) (Tenex, *Intuniv) • • • Bupropion Clonidine Imipramine (Wellbutrin) (Catapres, *Kapvay) (Tofranil)

Antipsychotic Medications

Antipsychotics • Psychotic disorders • Bipolar disorder • Irritability associated with autism • Severely agitated/violent behaviors

Antipsychotic Medications • Typical or Conventional or 1 st generation • Atypical or Novel or 2 nd generation

Typical/Conventional/1 st Generation • Haloperidol (Haldol) • Pimozide • Chlorpromazine • Thioridazine (Orap) (Thorazine) (Mellaril)

Atypical/Novel/2 nd Generation • • • • • • • • • • Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole *Paliperidone *Iloperidone *Asenapine *Lurasidone (Clozaril) (Risperdal) (Zyprexa) (Seroquel) (Geodon) (Abilify) (Invega) (Fanapt) (Saphris) (Latuda)

Aripiprazole (Abilify) • FDA approved for the treatment of: – Autism (Irritability) – Bipolar Disorder – Schizophrenia 6 to 17 years old 10 to 17 years old 13 to 17 years old

Quetiapine (Seroquel, Seroquel XR) • FDA approved for the treatment of: – Bipolar Disorder – Schizophrenia 10 to 17 years old 13 to 17 years old • Seroquel XR not approved < 18 years old

Risperidone (Risperdal) • FDA approved for the treatment of: – Autism (Irritability) – Bipolar Disorder – Schizophrenia 5 to 16 years old 10 to 17 years old 13 to 17 years old

Olanzapine (Zyprexa) • FDA approved for the treatment of: – Bipolar Disorder – Schizophrenia 13 to 17 years old 13 to 17 years old

*Paliperidone (Invega) • FDA approved for the treatment of: – Schizophrenia 12 to 17 years old

Clozapine (Clozaril) • Gold standard for treating schizophrenia • Two previous therapeutic trials • Clozaril National Registry • Labs each week X 6 months

Mood Stabilizers

Mood Stabilizers • Lithium • Anticonvulsants or AED

Lithium (Eskalith, Lithobid) • Effective in treating manic symptoms • Used in combination with other medications to treat resistant depression • Protects against suicidal behavior • “Lost” medication

Anticonvulsants/AED • • Divalproex Sodium Carbamazepine (Depakote) (Tegretol) • • • Oxcarbazepine Gabapentin Topiramate (Trileptal) (Neurontin) (Topamax)

Antidepressant Medications

The Opposite of Depression is….

Classes of Antidepressant • Tricyclic Antidepressants • Selective Serotonin Reuptake Inhibitors • Novel Antidepressant

Tricyclic Antidepressants • Amitriptyline • Imipramine • Clomipramine (Elavil) (Tofranil) (Anafranil)

• • • • • • Depression OCD ADHD School Phobia Bedwetting Night Terrors Tricyclics Not recommended Clomipramine Imipramine Mixed Results Amitriptyline/Imipramine Imipramine

Selective Serotonin Reuptake Inhibitors (SSRIs) • Preferred medications for treating child and adolescent depression • First line treatment for GAD, OCD, PTSD, and panic disorder

Selective Serotonin Reuptake Inhibitors • • • • • • • Fluoxetine Parosetine Sertraline Fluvoxamine Citalopram Escitalopram *Vilazodone (Prozac) (Paxil) (Zoloft) (Luvox) (Celexa) (Lexapro) (Vibryd)

Fluoxetine (Prozac) • First SSRI in the United States (1987) • FDA approved MDD 8 to 18 years old • FDA approved OCD 7 to 17 years old • Long-acting so useful in noncompliance

Sertraline (Zoloft) • FDA approved OCD 6 to 17 years old • Scored tablets provide flexibility

Fluvoxamine (Luvox) • FDA approved OCD 8 to 17 years old • Generic fluvoxamine is available

Escitalopram (Lexapro) • FDA approved MDD 12 to 17 years old • Don’t need much – 10 mg. is about the same as 40 mg. Celexa

SSRI Summary • SSRIs preferred in child/teen depression • • • • Lexapro Prozac Zoloft Fluvoxamine Depression Depression and OCD OCD OCD

Novel Antidepressants • • • • • • Bupropion Mirtazapine Venlafaxine Desvenlafaxine Duloxetine Trazodone (Wellbutrin, *Aplenzin) (Remeron) (Effexor) (Pristiq) (Cymbalta) (*Oleptro)

Buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, *Aplenzin • Option for Depression + ADHD • Should not be used with a history of eating disorder or seizures • Bupropion is a treatment for smoking

Mirtazapine (Remeron) • Complex mechanism of action involving multiple neurotransmitter systems • Rapid onset of action in adults • Sedating so prescribed at bedtime • Good choice for “anxious” depression

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) • Venlafaxine • Desvenlafaxine • Duloxetine (Effexor) (Pristiq) (Cymbalta)

Venlafaxine (Effexor, Effexor XR) • Not recommended due to side effects (increased diastolic blood pressure, increased pulse, dermatological)

Duloxetine (Cymbalta) • Relief of physical symptoms • Do NOT use with a history of liver disease

Conclusions • • • • Children/teens can and do have serious mental illness including Major Depression, Bipolar Disorder, and Schizophrenia The full range of psychiatric medications are prescribed to those < 18 years of age Medication is only one part of treatment Many new medications are actually “old wine in new bottles”

Resources • ParentsMedGuide.org

• American Academy of Child and Adolescent Psychiatry