Magazine article Drug Topics

How to Treat Pediatric Patients with Psychiatric Problems

Magazine article Drug Topics

How to Treat Pediatric Patients with Psychiatric Problems

Article excerpt

All major psychiatric disorders can be seen in a child or adolescent, and therapy may involve both behavioral interventions and medication.


Depression is one of the most common psychiatric disorders in pediatric patients; it occurs in 2% of the general public. No official consensus guidelines exist for the treatment of depression in children and adolescents. Choice of antidepressant is based on published studies of the various agents, the current standard of care in the psychiatric community, and a history of family response.

Imipramine has been the best studied antidepressant in children. However, problems in study design and a high rate of placebo response (up to 60%) make the final analysis more difficult. Tricyclics are noted for their potentially harmful cardiac effects. The American Academy of Pediatrics recommends that a baseline ECG be obtained prior to starting a tricyclic antidepressant. Pulse and blood pressure should be monitored routinely, and the ECG should be repeated if the pulse exceeds 130 beats per minute or is irregular, or if a higher dose of the tricylic is being used. Does should be lowered or discontinued if the PR interval is greater than 0.16 second or the QRS interval exceeds 30% from baseline.

Some clinicians suggest obtaining an additional ECG once steady state has been reached. As with adults, TCA serum plasma concentrations above 450 ng/ml have been associated with increased risk of serious adverse effects such as seizures and sudden death. Several case reports of sudden death in children and adolescents receiving normal doses of desipramine have been reported. However, a review of the current literature may raise questions about desipramine's presumed correlation in this regard.

Given their safety and favorable adverse effect profile, selective serotonin reuptake inhibitors (SSRIs) are being used more frequently in the treatment of childhood depression and are generally considered first-line agents. Low doses such as 25 mg of sertraline (Zoloft, Roerig) or 10 mg of fluoxetine (Prozac, Lilly) should be used initially, with increases as clinically needed after four to six weeks of treatment. Due to their safety in overdose, these agents should probably be used before a tricyclic antidepressant. Fatal doses of tricyclic antidepressants have been as low as 8 mg/kg.

As is the case in adults, target symptom response occurs over several weeks, with disturbances in appetite and sleep generally responding before the depressed mood. Full response may be seen as early as four weeks or in up to 10 weeks in children.

Monitoring will vary based upon the agent selected, and adverse effects can differ between each class. Tricyclic antidepressants produce the usual symptoms of dry mouth, constipation, sedation, orthostasis, and ECG abnormalities.

Bipolar disorders

Bipolar disorder is rare in children but appears to be more common during adolescence. Symptoms of bipolar disorder may include hyperactivity, labile affect, irritability, anger, excitability, paranoia, and explosive or silly behavior.

Lithium is the best studied mood stabilizer in children and adolescents. A starting dose of lithium is 30 mg/kg/day given in three divided doses. Increases should be made to achieve a desired therapeutic serum concentration of 0.6-1.2 mEq/L. Lithium should be given with food to minimize the gastrointestinal effects (e.g., diarrhea, nausea) that can be seen.

Carbamazepine can be used in children and adolescents, although limited research is available. Its usual dose is 1030 mg/kg/day in two or three divided doses given with meals. Valproic acid and its derivative divalproex, although approved for mania in adults, should not be used in children younger than 10 years of age secondary to the high risk of fatal valproate-induced hepatotoxicity. There is no adequate research on the role of calcium-channel blockers, lamotrigine (Lamictal, Glaxo Wellcome), or gabapentin (Neurontin, Parke-Davis) in children or adolescents. …

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