-written by Joshua Stein, MD
The initial steps in managing a variety of anxiety disorders in teenagers is initiation of an SSRI. Commonly this class of medications can result in symptomatic improvement with initial notable benefits occurring at 6-8 weeks with additional improvement over time. At times, the medications do not appear to work or are not tolerable. The following considerations would be appropriate if SSRI’s do not appear to be the correct option.
Q: Have you experienced very much hypertension with Pristiq?
Q: Do you recommend Wellbutrin as monotherapy ever? I have only used it in combination, but have several parents who are on it in monotherapy and inquire about it.
Q: Is dose of Wellbutrin to restore sexual dysfunction the same as normal augmenting dose?
Q: Are there any long term effects for using hydroxyzine long term?
Q: Which benzo do you use for flight anxiety?
- Dr. Adam Klapperich
What Lies in a Bed but Never Sleeps?: A Quick Review of Sleep Pharmacology - written by Dr. Joshua Stein
While the answer to the riddle “What lies in a bed but never sleeps” is actually “A River,” many parents may assume it is their eight-year-old or teenager. Despite it being a necessary and standard part of existence, getting a good night’s sleep is increasingly evasive. In fact, the 2020 sleep aid global market reached 78.7 billion dollars and is expected to reach 162.5 billion dollars by 2030, according to ResearchandMarkets newswire. There are numerous assumed potential causes, including increased screen time, sleep apnea, and shift work, but overall, sleep concerns are becoming more pertinent and a regular patient concern. Notably, sleep changes are ubiquitous across the DSM-5.
The goal of this post is to review pharmacologic strategies in children, both on and off label, and some common issues each may have.
Sleep hygiene seems to be mentioned often, but rarely enforced by parents. This practice includes the implementation of standard bedtimes, absence of caffeine, a relaxed bedroom and primarily the removal of screens. While this article does not go in depth into these practices, it is important for any primary care provider to familiarize themselves with screening and education on sleep hygiene. Additionally, screening for sleep apnea in any child with attentional issues is important as well.
The ever present melatonin has become so commonplace that it now occupies an entire section in most pharmacies. In children, it is FDA approved and there is clear evidence it improves sleep initiation, duration and quality; however the risks remain unknown. As melatonin is a hormone, long term use appears to disrupt endogenous production, especially when used at high doses. There appears to be evidence that 0.5mg is appropriate, while higher doses are used most often when chasing waning benefit. It is recommended to only be used short term or as needed. Most parents report loss of effectiveness in their children after regular use. At times, subsequent insomnia may occur as well. It can be helpful both to initiate sleep and to promote a healthier circadian rhythm. For patient centered information consider the mayo clinic website: https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/melatonin-side-effects/faq-20057874
Clonidine is also commonly used in children for sleep initiation. Often 0.1-0.2 mg given at bedtime promotes rapid sleep initiation. This can often help benefit sleep when rebound hyperactivity occurs as a stimulant wears off. While it does not carry FDA approval, it does meet community standard for care and is generally quite safe. One drawback is that it wears off after 4-6 hours, potentially not benefiting those with middle insomnia or early waking. However, given the short half-life, a second dose can be used. Please note that overdoses can be lethal due to respiratory depression. This medication must be locked away from small children.
Trazodone is so sedating that it often cannot be prescribed when needed as an anti-depressant. On the other hand, it is inexpensive and benefits middle waking due to long duration of action. Given this, it has found a place as a commonly used sleep aid. Community standard initial dosing is commonly 25 mg, though at times patients may find up to 150 mg beneficial. Notably, in patients under 25yo, a reminder that it is an anti-depressant and carries the black box warning regarding increased suicidal ideation is important. It is certainly a serotonergic agent. A reminder to discuss serotonin syndrome in patients on additional serotonergic meds including but not limited to SSRI’s, SNRI’s and Triptans. Additionally, in males there is a rare but present risk of priapism. It is necessary to discuss with the patient and their parents before prescribing. Finally, trazodone can cause vivid dreams. In patients with nightmares this can be unpleasant if not unbearable. If prescribing trazodone is commonplace in your practice, consider reviewing this short Healthline article to review its side effects: https://www.healthline.com/health/sleep/trazodone-for-sleep#risks
In certain depressed patients, initiation of Remeron, especially at low doses, may complement their primary treatment. Its boost of appetite and benefit to sleep initiation and maintenance is strikingly beneficial. The rapid onset of these side effects are due to histamine 1 antagonism. Often its long term use is not tolerated due to weight gain, but in the short term, can jump start treatment. Common starting dose of 7.5 mg to 15 mg is appropriate. A reminder that, similar to trazodone, this medication carries the black box warning related to increased suicidal ideation in persons younger than 25 years old.
Benadryl, Atarax, Hydroxyzine, Doxylamine Succinate are off label anti-histamines often used in children to promote sleep. Commonly these are used as needed rather than on a regular basis. While sleep latency greatly improves, there is question if the sleep is in fact restorative, with numerous studies noting a decrease in REM time when used. Often there is AM grogginess related to this class that may undermine daytime learning, especially in the morning. Given this concern there is a greater consideration to use only as needed rather than on a regular basis. Doses 25 mg or less often avoid frustrating side effects related to anti-histamine use. Approximately ten percent of the childhood population has a paradoxical energizing. It would be best to test dose prior to any long distance overnight flights.
In adults, the use of benzodiazepines and its sibling medications Zolpidem, lunesta etc have found a place in daily dosing and as needed. Currently, there is not an FDA indication in children under age 18. There are often only rare cases where these medications are considered. Notably, there is street value with these medications and if prescribed, please review DEA considerations with the patient.
Finally, Seroquel and other atypical anti-psychotics clearly can be sedating, and at times are prescribed as standalone sleep aids. This practice should be avoided due to risks of weight gain, odd/abnormal movements, pre-diabetes and lipid derangement. However, if a child requires an atypical antipsychotic due to a primary mental health condition, such as ASD agitation, it may be appropriate to consider Seroquel due to its sedating nature if insomnia is present. As always, the lowest effective dose should be considered.
This list is clearly not exhaustive but hopefully offers some guidance regarding initial steps in the treatment of insomnia in children and teens. A second stanza of the previously mentioned River Riddle is “what runs but never walks?” Perhaps use this as a reminder that if a child is running bedtime and refusing to turn off screens, the most potent, safe and necessary treatment is family therapy rather than any of the meds listed above.
Joshua Stein MD
For further information: https://link.springer.com/article/10.1007/s40675-016-0036-1#Sec3
“You might’ve noticed I’ve got a slight weight problem. I went to this doctor. Well, he told me I swallowed a lot of aggression…along with a lot of pizzas.”
You might recognize this quote from the 1981 movie Stripes. I sometimes think of Dewey Oxberger, played by John Candy, when prescribing psychotropic medications that can cause weight gain. We all know the second generation antipsychotics can lead to our patients swallowing a lot of pizzas. However, things are less clear regarding antidepressant medications. We know that risk of weight gain can be a major factor in a teen’s decision to start an antidepressant medication, and weight gain can lead to noncompliance. The aim of this article is to review the risk of weight gain with antidepressants commonly prescribed in the primary care setting.
Data points to a definite risk of mild weight gain with “long term” treatment with SSRI medication (meaning six months or more). This is less likely in treatment of six months or less. When weight gain does occur with short term SSRI treatment, the rates are comparable with placebo. This does not apply to Paroxetine (Paxil), which is more likely to cause weight gain than the other SSRIs in short or long term treatment.
In a 6-month placebo controlled trial (N=284) paroxetine showed significant weight gain (increase 7% or greater body weight) in 25.5% of patients. Sertraline (Zoloft) showed 4.2% significant weight gain and fluoxetine (Prozac), which showed 6.8%. Fluoxetine may show a transient weight loss in the initial phase of treatment.
There is limited data indicating citalopram (Celexa) and escitalopram (Lexapro) may cause higher rate of weight gain than sertraline and fluoxetine, though this is likely not significant.
Mirtazapine is well known to cause weight gain in the short and long term. Often this is prescribed to stimulate appetite. Weight gain is related to its histamine H1 and serotonin 2C receptor activity. Weight gain is often seen in the first four weeks of treatment.
As far as SNRI medication, Venlafaxine (Effexor) has been shown less likely than SSRI to cause weight gain. In a 52-week open-label study, duloxetine (Cymbalta) treated patients had a mean weight gain of 1.1 kg at endpoint. Duloxetine-treated patients experienced weight loss after short-term treatment, followed by modest weight gain on longer-term treatment.
Overall, antidepressants, aside from paroxetine and mirtazapine, and tricyclics, appear to have minimal large scale effects on body weight. Fluoxetine appears to be the SSRI least likely to cause weight gain.
Should Lamictal Make Us LABILE: “A Review of the Lamotrigine and Personality Disorder” - written by Dr. Joshua Stein
At times, psychotropic decision making can feel more like an art form than science. Decision trees based on various trials inform the prescriber, but often are based on having the correct diagnosis in the first place. Lamotrigine is increasingly prescribed in when the primary diagnosis is “Emerging Borderline Traits” or Borderline Personality disorder (BPD). Compared to alternative mood stabilizers, especially the atypical antipsychotic class, it appears to have a more tolerable side effect profile with potential for benefit. While lamotrigine is just one of many medications used off label in treating symptoms of BPD, it warrants investigation.
In 2018 the UK National Health Service (NHS) attempted to clarify this very point with the “
LABILE resulted in over 270 patients with BPD separated into a lamotrigine arm and placebo arm. Each arm received normal treatment as well. Review of the study demonstrate reliable and valid results. Patients were recruited from NHS treatment centers and demonstrated severity across the spectrum of the condition.
To put it simply, in as real world a study as possible, with the largest number of patients yet, lamotrigine did not hold up the initial suggestion of benefit from earlier research. Results between placebo and lamotrigine treatment were equivocal. Levels of depression, the likelihood of self-harming or suicidal behavior and likelihood of problem drug or alcohol use were all comparable across the groups at follow-up. Social functioning was also equivalent across groups.
Additionally, medication compliance was poor for all patients after 12 weeks, with only thirty three percent demonstrating consistency. In a medication where inconsistent/rapid titration can be life-threatening this can be especially concerning. The indication is that lamotrigine, similar to all other medications, does not treat or alleviate BPD symptoms. It adds cost and risk.
A notable risk of lamotrigine is that of Steven’s Johnson Syndrome, a serious and life threatening blistering rash of mucosa and skin. When the medication is titrated too quickly, the risk increases markedly. After a two days of missed medication the 2 week titration schedule for lamotrigine must be started again. Poor compliance with
this medication certainly places patient at greater risk.
On the other hand, there is some reason to conclude hopefully regarding BPD. The interaction with the physician was stabilizing. The indication of having a legitimate treatable condition was validating. However the lamotrigine did not add to this benefit any better than an inert placebo.
BPD warrants treatment. Patients with the disorder have a completed suicide rate greater than fifty times the general population. They utilize emergency and clinic resources to an extensive degree. Anti-depressants fair worse than placebo. Benefits of atypical anti-psychotics match placebo. Sadly, lamotrigine, much like many medications before it, once scrutinized does not meet the hope of its initial small studies and open label trials.
Therefore do not fall into the trap of avoiding the valid and successful treatment of Dialectical Behavior Therapy and Mentalization Based Therapy.
Crawford MJ, Sanatinia R, Barrett B, et al. Lamotrigine for people with borderline personality disorder: a RCT. Southampton (UK): NIHR Journals Library; 2018 Apr. (Health Technology Assessment, No. 22.17.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK493476/
In the practice of medicine, there are clear moments where a specialist is needed. Seizures require a neurologist. Leukemia requires a hematologist. In mental health, there are similar lines in the sand. Acute mania requires psychiatry, commonly on an inpatient unit. Management with clozapine requires a psychiatrist. Electro-convulsive therapy requires a psychiatrist.
However for less severe/complicated conditions, the potential to refer is often less clear. The following considerations may help extend care in the primary care setting or lead to a need for a referral:
The list above displays some of the considerations when referring to psychiatry. Access delays are not uncommon. If you are questioning a referral it would be appropriate to immediately refer to avoid morbidity while waiting for an appointment. Again, PAL can assist in bridging care in the meantime when needed.
- Dr. Joshua Stein
From the Rocky Mountain Mental Illness Research, Education & Clinical Center, located at the Rocky Mountain Regional VA Medical Center in CO:
The “How to Talk to a Child about a Suicide Attempt in Your Family” booklet/DVD was created to support all families (civilians and military), and is nationally, publicly available free of charge both virtually and real world. The booklet was created by a small team led by child & family Psychiatrist Dr. Doug Gray. Since its release, this resource has been recommended by agencies such as the Department of Education, Suicide Prevention Resource Center, and the American School Counselor Association.
“How to Talk to a Child about a Suicide Attempt In Your Family” aims to support parents and other caregivers who are challenged with comforting and/or explaining a loved one’s suicide attempt. The combination booklet/DVD (available free of charge, either virtually or in print) addresses four main challenges: demonstrating how speaking with a child about a suicide attempt is both necessary and beneficial; providing key strategies for meeting the needs of three developmental groups (Preschool, School Age, and Teen); offering tools to increase skill and comfort level with this delicate task; and, supplying further resources to better care for themselves as well as their family members. The 24-page booklet provides the basis, addressing critical issues such as mental illness, substance use, hopelessness and suicidal thoughts and behaviors, as well as building resiliency and restoring hope. The professionally produced video demonstrates these principles in action, and shows how real-life conversations might unfold. Free print copies of booklet and DVD are also available
Suicide prevention is a commonly used and understood term. However not everyone recognizes suicide postvention. Suicide postvention builds upon prevention efforts by providing immediate and ongoing support to those impacted by a suicide loss.
Postvention is critical for healing after suicide. Uniting for Suicide Postvention (USPV) provides resources and support for everyone touched by suicide loss.
Visit the USPV online resource hub to find support tailored for three audiences: community, providers and workplace.
Other clinician resources also available:
BY TODD ARCHBOLD, LSW, MBA
Finding ways to balance the physical risks and emotional distress caused by COVID-19 is important for both health care personnel and patients. The mental health needs of entire communities are on the rise. The best practices that we are promoting to keep people safe from the virus are completely contrary to the practices we rely on to stay mentally well and emotionally resilient. “Social distancing,” the pillar of these efforts, has led to fear and isolation for many people. The reality is that COVID-19 is not a “social” disease at all, since it is transmitted by respiratory droplets among individuals who may have never had any social interaction. The inadvertent side effect of trying to keep physically safe through social distancing has in fact created emotional distress and removed us from the usual comforts of life and means of support. These necessary measures are our best defense in fighting infectious diseases, but many patients are now reporting an increase in emotional distress as a result.
Health care providers around the world are now tasked with providing exams and treatments to patients who are fearful of clinics and hospitals. In addition, the added stress of dealing with this pandemic is interfering with preventative visits, and the costs of care for patients dealing with comorbid conditions will likely increase even more. The challenge for our health systems and clinicians will be to provide necessary care while addressing the added complexity of the impact to the mental health of patients and providers alike.