Psychopharmacology for Children With Advanced Illnesses a Challenge
From Medscape Medical News
An Expert Interview With Jeremy M. Hirst, MD
Vancouver, British Columbia - March 10, 2011 - Editor's note: Psychopharmacologic treatment of children and adolescents with advanced illness presents special challenges to the physician. Many medications available to treat adults have not been tested in children. A discussion of the psychopharmacologic management of depression, anxiety, delirium, and insomnia in children was featured at the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association (AAHPM/HPNA) Annual Assembly, held February 16 to 19 in Vancouver, British Columbia.
To find out more about the treatment of these conditions in children with advanced illness, Medscape Medical News interviewed Jeremy M. Hirst [1], MD, assistant director of the clinical and educational psychiatry programs of The Institute for Palliative Medicine at San Diego Hospice, California.
Dr. Hirst also runs the Child and Adolescent Palliative Care Psychiatry Program at The Institute for Palliative Medicine at San Diego Hospice, which provides comprehensive psychiatric diagnostic assessment and treats children and adolescents with severe medical illnesses, such as cancer, pulmonary, neurologic, gastrointestinal, and muscular diseases.
Medscape: How common are depression, anxiety, insomnia, and delirium in children and adolescents with advanced illnesses?
Dr. Hirst: The rates of these disorders in children with advanced illness are not known specifically, as there are many confounding variables and limited research thus far. In the general adolescent population, rates of depression, for example, are noted to range from 7% to 20%. Advanced illness is a major life stressor and will predispose to more cases of these disorders.
Studies conducted at San Diego Hospice in adults with terminal illness have found that delirium is present in up to 85% of patients. Studies looking at insomnia in medically well children have stated rates as high as 48%. In the patients we see at San Diego Hospice, comorbid symptoms of pain and nausea make insomnia much more likely to be a problem.
Medscape: What are the most important challenges right now in treating these conditions in children? Dr. Hirst: The most important challenge in treating these disorders in children with advanced illness is to accurately
identify the problem and then have quick-acting, well-tolerated treatments.
At San Diego Hospice, we use an interdisciplinary team to address psychiatric disorders. The team includes a palliative care physician, palliative care pharmacist, social worker, nurse, and chaplain. This has allowed for careful screening and assessment of the pediatric patients. This team is also instrumental in implementing nonpharmacologic and pharmacologic treatments for any psychiatric disorders.
One recent example includes a 15-year-old boy with advanced Duchenne muscular dystrophy who was experiencing symptoms of severe anxiety, depression, and insomnia. This was recognized by his social worker and chaplain. After a psychiatric consultation, his primary physician and primary nurse were able to follow-up regularly regarding his treatments to ensure that his symptoms were palliated. He responded quickly to a combination of pharmacologic and nonpharmacologic treatments.
Medscape: Is it difficult to distinguish symptoms of depression, anxiety, insomnia, and delirium from symptoms of the illness itself?
Dr. Hirst: Yes. Not only do advanced medical illnesses often cause a lot of the symptoms of mood and anxiety disorders, it is also frequently considered "normal" to suffer from depression, anxiety, insomnia, and delirium during a severe illness.
While it is normal for all of us to have periods of anxiety, low mood, and even trouble sleeping, it is not normal for these symptoms to become an impairment in our lives. That is, it should not be considered normal for a patient with advanced illness to suffer from a major depressive disorder, an anxiety disorder, severe insomnia, or delirium. These are treatable conditions. When treated, they dramatically improve the quality of life for the patient and their families.
At San Diego Hospice, we use our complete interdisciplinary team to screen and assess for these disorders. Our psychiatric program is specialized in being able to identify patients who are experiencing a true mental illness, as opposed to symptoms attributable only to the medical condition. For example, a medical illness is likely to cause fatigue and loss of appetite, but unlikely to cause hopelessness, loss of meaning to one's life, and suicidal ideation, as one may see in a depressive disorder.
Medscape: How challenging is it to find drugs that can work for children, given that they're almost always tested in adults? Is it a matter of scaling down dose, or are there other concerns with medication?
Dr. Hirst: The field of child and adolescent psychopharmacology is growing. With that growth, there has been an increase in research studies showing the safety and efficacy of a variety of medications. The field of palliative care psychiatry is quite young. Applying what we know from the general population to children, and then to children with advanced disease, is a challenge. At San Diego Hospice, we approach all issues from a whole-person perspective and focus on much more than just medications. We look at medications through time-limited trials, using careful dosing, titration, and frequent assessment for effect and side effect.
Medscape: How does a child's prognosis fit into the picture?
Dr. Hirst: The consideration of prognosis is important when selecting therapies for patients with advanced illness. Many of the standard therapies, such as the class of antidepressants, the selective serotonin reuptake inhibitors, may take too long to see any positive effect. For example, side effects are frequently experienced in the first days of treatment while the onset of any benefit is not experienced for 4 to 8 weeks. If a patient has a prognosis of days to weeks to months, every moment is a critical moment. Choosing a medication that can provide positive results within hours to days can have a dramatic impact on one's life.
Medscape: I understand one of your colleagues is working on a fast-acting treatment for depression. Can you describe the work?
Dr. Hirst: Scott A. Irwin [2], MD, PhD, director of psychiatry programs at The Institute for Palliative Medicine at San Diego Hospice, is conducting studies of 2 medications for the rapid treatment of depression in people with serious medical illnesses. Standard antidepressant therapies are only about 30% effective and often take more than 4 weeks to work, with more time needed for optimal treatment. This constitutes a significant time that our patients would suffer with depression, interfering with their ability to interact with love ones, make final preparations, or even complete their bucket list.
The 2 medications under investigation appear to eradicate depression, often within minutes, with very few side effects. The use of these medications has changed the lives of our patients and their families. More investigation is needed to fully understand the efficacy and safety of these medications in these patients. For more information, contact Dr. Irwin directly at sirwin@sdhospice.org [3].
Dr. Hirst has disclosed no relevant financial relationships.
About San Diego Hospice and The Institute for Palliative Medicine
San Diego Hospice and The Institute for Palliative Medicine (www.sdhospice.org [4]), the leader in the relief of suffering, is one of the 10 largest community-owned, not-for-profit hospices in the country, with one of the largest resources in the world for training palliative medicine physicians and other specialists. The organization brings compassionate, expert medical care to more than 1,000 seriously ill adults and children each day throughout San Diego and North County. More information is available online at www.sdhospice.org [4] or call toll-free at 1-866-688-1600.
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