Transcript Assessment and Treatment of the Tough Cases: JBD and Psychosis

ADHD or Bipolar Disorder?
Assessment and Differential
Diagnosis of
Bipolar Disorder in Children and
Adolescents
Wanda Fremont MD 1/27/12
Special thanks:
The REACH Institute
Jointly sponsored by SUNY: Buffalo & NY State Office of Mental Health,
in conjunction with The REACH Institute. This activity is supported solely
by the joint sponsors, and received no commercial support of any kind.
Copyright © 2011 The REACH Institute. All rights reserved.
Prevalence in Community Samples
of Pediatric Bipolar Disorder:
<1%
Author
Measure
Bipolar I
Bipolar II
Bipolar NOS
DICA
0.6%
7.0%
10.0%
K-SADS
0.1%
0.06%
0.3%
Costello et al. (1996)
CAPA
0.0%
0.1%
Shaffer/MECA
DISC
1.2
0.6
Carlson and Kashani
(1988)
Lewinsohn et al.
(1996)
Copyright © 2011 The REACH Institute. All rights reserved.
Criteria for Manic Episode (I)
DSM criteria written with adults in mind
A.
B.
Distinct period of abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if hospitalization
is necessary).
During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have
been present to a significant degree:
1)
2)
3)
4)
5)
6)
7)
Inflated self-esteem or grandiosity
Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation
Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments)
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(Adapted from DSM-IV-TR, 2000)
Bipolar Disorder in Children:
The Broad Phenotype
• There is a large group of children who show
many manic symptoms
– Especially the affective storms & rages
– Don’t clearly cycle between mood states
– May not have bipolar in family pedigree
– Severe Mood Dysregulation (Leibenluft et al 2003)
• Are these bipolar cases?
– Will they grow up to look more classic?
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Developmental Differences in the Expression
of Manic and Depressive Symptoms
SYMPTOM
ADULT
CHILD
Grandiosity
I’m the world’s greatest
lover,
The president will be
calling me for advice
I’m smarter than
my teacher; I am the
best writer in my whole
school
Decreased need
for sleep
Several nights in a row
without needing any
sleep and no sense of
fatigue
Needing only a few
hours of sleep and
engaging in activity in
the middle of the night
Hypersexuality
Unprotected sex with
multiple partners
Child propositions adult,
self stimulates in public
Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.
Copyright © 2011 The REACH Institute. All rights reserved.
Developmental Differences in the Expression
of Manic and Depressive Symptoms
SYMPTOM
ADULT
CHILD
Racing
thoughts
Jumping from one
Describes mind is
thought to another in like a video on fast
an illogical manner
forward
Pressured
speech
Hard to interrupt and Child talks
not phased when you continuously and
do
difficult to redirect
Weckerly J., Developmental Behav. Ped.,Vol 23, No. 1, 42-56.
Copyright © 2011 The REACH Institute. All rights reserved.
ADHD vs. Bipolar
• Irritability is non-specific:
– Irritability does not = Bipolar
– Geller et al 2002 found irritability in 72% of Children
with ADHD and 97.9% of Children with Bipolar
Disorder
• Again elation, grandiosity, flight of ideas/racing
thoughts, decreased need for sleep and
hypersexuality provide the best discrimination
between ADHD and BD in children and
adolescents (Geller et al 2002)
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The Unipolar Depression vs.
Bipolar Distinction
• First mood episode of pediatric bipolar disorder is
often a depressive episode
• MDD in children often associated with high rates
of irritability…i.e., children with depression can
present with irritable mood, not depressed mood
• Children and adolescents with major depressive
disorder can have very labile mood
• What do you mean by mood swings?
– euthymia to depressed vs. depressed to manic or
hypomanic
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Substance Abuse vs.
Pediatric Bipolar Disorder
• The substance abuse may mimic a bipolar
presentation
– Check urine drug screens, educate patients and
families
• There are high rates of co-morbid substance
abuse in adolescents with bipolar disorder
– The substance abuse must be addressed
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Conduct Disorder vs.
Pediatric Bipolar Disorder
• Conduct Disorder
– The negative
behaviors are
often calculating
and predatory
• Pediatric Bipolar
– The negative
behaviors are
secondary to
grandiosity and
risky, poor
judgment
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With Pediatric Bipolar Disorder
There Are High Rates of
Co-occurring Psychiatric Conditions
• ADHD
• ODD
• Conduct Disorder
• Learning Disabilities
• Substance Abuse
• Anxiety Disorders
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Individually
or
in combination
A Family History of
Bipolar Disorder
• Take a careful family psychiatric history
– Bipolar disorder in one parent = 5x odds of bipolar
disorder in child (but still only ~5% prevalence; LaPalme
et al., 1997), still less than likelihood of ADHD
– Bipolar disorder in parents, grandparents, and siblings is
clinically meaningful but doesn’t rule out “bad” ADHD
– The presence of bipolar disorder in more distant
relatives may not confer greater genetic risk
– No clear family history doesn’t rule out pediatric bipolar
disorder
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Pediatric Bipolar Rating Scales
• Young Mania Rating Scale for Parents P-YMRS (Gracious et al.
JAACAP,2002)
– the scale can be found at www.healthyplace.com/bipolar/p-ymrs.asp
• General Behavioral Inventory, GBI (Findling et al. Bipolar
Disorder, 2002)
– Self and parent report ages 5-17
– Very long tool 73 mood items
• Life Mood Charts
– Asking about mood symptoms throughout the patient’s life
– Can be found at www.dballiance.org
• These rating scales do a better job of ruling out pediatric bipolar
disorder then ruling it in
• Still very helpful to follow symptoms to assist with diagnosis and
to follow symptoms
Copyright © 2011 The REACH Institute. All rights reserved.
Summary
• In evaluating pediatric bipolar disorder look for classic
criteria
– elevated mood, grandiosity, decreased need for sleep,
racing thoughts
• High rates of psychiatric co-morbidity
– Especially ADHD, ODD, Conduct Disorder and Learning
disabilities
• Careful family history
– Focus on first and second degree relatives
• Rating scales do a better job of ruling out pediatric
bipolar disorder then ruling it in
• If significantly concerned get a child psychiatry
consultation
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Bipolar Disorder
Treatment Options
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FDA Pediatric Labeling for BD
Brand name
Generic Name Indicated Age
Cibalith-S
Lithium citrate
12 and older
Eskalith
Lithium CO3
12 and older
Lithobid
Lithium CO3
12 and older
Risperdal
Risperidone
10 and older
Abilify
Aripiprazole
10 and older
Zyprexa
Olanzapine
10 and older
Seroquel
Quetiapine
10 and older
Copyright © 2011 The REACH Institute. All rights reserved.
Updated
Treatment
Algorithm
for Mania/
Hypomania
in Children
&
Adolescents
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Depression Switching to
Bipolar Disorder
• Prepubertal depression  BD
– Limited outcome studies
– 24/72 (33%) MDD children  BD-I at age 20, 11/72 (11%)  BD-II or
hypomania (Geller et al., 2001)
• Adolescent depression  BD
– Limited studies
– 58 MDD inpatients followed up in 24 months
 Overall: 5/58 (8.6%)  BD; 0/40 without psychotic symptoms, 5/18 (28%) with psychotic
symptoms (Strober et al., 1992)
– Epidemiological sample; 275 teens with MDD, < 1%  BD by age 24
(Lewinsohn et al., 2000)
– 5/26 (19%) of MDD adolescents had BD after ~7 year follow-up
(compared to 0% of controls) (Rao et al.,1995)
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Switching to Bipolar Disorder with
Antidepressants:
• Antidepressants may induce mania in children with
a bipolar diathesis
– In a survey of child and adolescent psychiatrists: 10/228
(4.4%) of children under 13 y/o treated by psychiatrists
switched to BD (Reichart & Nolen, 2004)
– Treatment for Adolescent Depression Study (TADS), of
439 12-17 year olds: 0 switches to BD after 12-week
follow-up (2004)
– large private insurance database, 5.4% switch rates,
increased risk for youth on antidepressants and risk
greatest for age group of 10-14 y/o (San Martin et al.,
2004)
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Switching to Bipolar Disorder with
Stimulants:
• Concerns that stimulants may precipitate mania or
destabilize children with bipolar who are not stabilized on
other medications
– However…
– In the Multimodal Treatment Study of Children with ADHD (MTA),
children with ADHD and some manic symptoms responded well to
stimulants with decrease in ADHD symptoms and without increased
rates of developing bipolar disorder (Galanter et al 2003, 2005)
– “Follow-back” study of children originally diagnosed and treated for
“minimal brain dysfunction.”
 Those diagnosed with bipolar spectrum disorders as young adults had
responded well to stimulants as children
 Those children with more comorbidities did not develop higher rates of bipolar as
compared to those with uncomplicated ADHD (Carlson et al 2000)
Copyright © 2011 The REACH Institute. All rights reserved.
CAP PC: Child and Adolescent
Psychiatry for Primary Care
Providers:
Consultation, Education and
Linkage/Referral Support:
Wanda Fremont MD
1/27/12
Special thanks to David Kaye MD
Copyright © 2011 The REACH Institute. All rights reserved.
OMH EFFORTS TO ADDRESS THE NEEDS
OF PCPs FOR INCREASED SUPPORT
FROM CAPs
Project TEACH (Training and Education
for the Advancement of Children’s
Health)
Two Project TEACH programs covering NYS:
1. CAPES (Child and Adolescent Psychiatry
Education and Support)
Northeastern NY State – Jeff Daly MD
2. CAP PC: (Child and Adolescent
Psychiatry for Primary Care)
Rest of NY State – David Kaye MD , (5 Medical
Copyright © 2011 The REACH Institute. All rights reserved.
CAP PC:
The program’s intent is to
provide support for PCPs to
manage children and
adolescents with mild-moderate
mental health problems and to
assist with linkage/referral
services for those patients
Copyright © 2011 The REACH Institute. All rights reserved.
CAP PC Collaboration:
$2.6 million 3 yr grant
NY State Office of Mental Health
American Academy of Pediatrics
American Academy of Family
Medicine (AAFP)
NY State Conference of Local
Mental Hygiene Directors
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5 Academic University Centers:
Columbia University
Long Island Jewish /Northshore
SUNY Buffalo
SUNY Upstate
University of Rochester
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CAP PC SERVICES
1. Phone consultation/Linkage
Referral
2. Website
3. Face to Face Consultation
4. REACH training
5. Outcomes Evaluation
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Most Common
Childhood Problems:
1. ADHD
2. Anxiety
3. Depression
4. Behavioral Problems
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What CAPPC Grant Does Not
Cover:
• Childhood Schizophrenia
• Bipolar Disorder
• Moderate or Greater Intellectual
Disability
• Substance Abuse
• Persons who have had their 22nd
birthday
• Persons seriously and persistently
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1. Phone Consultation
and Linkage/referral
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ANY PCP in the State of New
York is eligible to call the
1-855-CAP-PC72 line
1-855-227=7272
(9-5 M-F, excluding holidays)
For child psychiatric
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Coverage is provided :
Monday: Upstate Syracuse
Tuesday: LIJ/NSU
Wednesday: Columbia
Thursday: Buffalo Childrens
Friday: Rochester (Strong)
Copyright © 2011 The REACH Institute. All rights reserved.
Regional Site Teams
Each site team consists of a:
1. Child/adolescent Psychiatrist
2. Liaison Coordinator (MSW/PhD)
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Work Flow for Phone
Consultations
The Liaison Coordinator will take
the initial phone call and will
respond to all calls within their
scope of training and expertise.
If a child psychiatrist is
appropriate or requested then the
covering CAP will return the phone
call within 2 hours.
Copyright © 2011 The REACH Institute. All rights reserved.
HIPPA I
Phone calls are considered educational
consultations to the PCP about patient
management, not a clinical service to
patients. It is critical that PCPs
maintain patient confidentiality and
that communications are HIPPAcompliant in these phone calls.
Identifying health information will
NOT be requested and should not be
provided! De-identified demographic
information about you and the patient
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HIPPA II
While informed consent is not
required for HIPPA -compliant
discussion of patient care issues
by telephone, CAP PC encourages
PCPs to inform families and obtain
verbal consent about these phone
consultations
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PCP Cheat Sheet
•
•
•
•
•
•
•
•
•
Contact information for you
Patient grade in school; support services?
Global assessment of function score
Screens completed: ?Vanderbilt; ?PSC
Insurance
Current mental health treatment
Psychotropic med history
Medical history
Family history of mental illness
Copyright © 2011 The REACH Institute. All rights reserved.
2. WEBSITE
Cappcny.org
Copyright © 2011 The REACH Institute. All rights reserved.
Website Contents:
• Screening Tools: e.g. Vanderbilt,
SCARED, PHQ9,
MOAS, PSC17 and 35
• Links: AAP Bright Futures,
AACAP Practice
• References
Copyright © 2011 The REACH Institute. All rights reserved.
3. FACE TO FACE CONSULTS
OPEN
to ALL PCPs
in NEW YORK STATE
(Direct or Telepsych)
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Face to Face Consultations
Selected cases will be seen for a one
time only face-to-face (or
telepsychiatric if the patient is
geographically distant from one of
the program sites) consultation with a
program child psychiatrist. Face to
face (FTF) evaluations will be
scheduled within a few weeks with
the local child/adolescent
Copyright © 2011 The REACH Institute. All rights reserved.
Selection of Face to Face
Consultations
FTF evaluation will be offered for
cases which are diagnostically
confusing or complex, or it is
unclear whether it is appropriate
for PCP management.
Copyright © 2011 The REACH Institute. All rights reserved.
Face to Face Evaluations are
Consultations Only
Face to face evaluations are
consultations only; patients cannot be
picked up by the child psychiatrist for
ongoing treatment and medication
management. Please be sure to
educate your patients/families
about this.
Copyright © 2011 The REACH Institute. All rights reserved.
Our Promise
Following completion of the FTF
evaluation, verbal feedback and a
written report will be provided by
the evaluating CAP to the
referring PCP.
Copyright © 2011 The REACH Institute. All rights reserved.
Emergency Cases
In urgent situations PCPs may call
the 1-855 line for assistance with
referral to an appropriate
emergency service in the region.
Face to face evaluations will not be
scheduled on an urgent basis and
should NOT be looked to for
emergency cases!
Copyright © 2011 The REACH Institute. All rights reserved.
Jumping the Queue for
Linkage/Referral
Assistance
Please note that CAP PC can not
provide assistance with referral and
linkage services for routine cases.
These cases should be referred to
local mental health agencies or child
mental health professionals in private
practice. The same is true for
patients/families who have been
dismissed from mental health agencies
or clinics because of noncompliance or
Copyright © 2011 The REACH Institute. All rights reserved.
4. Education:
REACH TRAINING
Copyright © 2011 The REACH Institute. All rights reserved.
About REACH
• Yearly three day continuing education
workshop
• Developed by Peter Jensen, Child
Psychiatrist
• Interactive dynamic innovative
• Open to 20-25 PCPs in each of the 5 sites
• Biweekly conference calls for the next 6
months
• Up to 32 hours FREE CME
Copyright © 2011 The REACH Institute. All rights reserved.
5. Outcomes Assessment
Copyright © 2011 The REACH Institute. All rights reserved.
Important requirements for the
use of the CAP-PC service
• Necessity of Evaluation
– Required by New York State as part of this
program
• What is involved- details are still being
worked out
– Clinician practice questionnaire• Before this training
• End of this training
• After phone call meetings
• At some future time
Copyright © 2011 The REACH Institute. All rights reserved.
Important requirements for the
use of the CAP-PC service
• Evaluation of phone consultations and
face-to-face consultations
– Brief questionnaire follow-up about
ease of access and usefulness of
consultations
– Brief questionnaire follow-up about
further contacts with the child, the
implementation of recommendations,
and the functioning of the child.
Copyright © 2011 The REACH Institute. All rights reserved.
Direction for the Future
• With regard to moderately to severely
intellectually disabled patients, we
recommend that this group be the subject
of discussion between OMH and OMRDD
with the goal of coming up with a pilot
project similar to CAP-PC to serve this
chronically underserved population.
Copyright © 2011 The REACH Institute. All rights reserved.
Summary
1-855-CAP-PC72
www.cappcny.org
• Phone consultation/Linkage
Referral
• Website
• One time Face-to-Face Consults
• REACH training
Copyright © 2011 The REACH Institute. All rights reserved.
Copyright © 2011 The REACH Institute. All rights reserved.
Thank you!
QUESTIONS?
Copyright © 2011 The REACH Institute. All rights reserved.