Pediatric emergency medicine trisk 1048

Symptoms of depression during adolescence are more similar to those seen in adult-onset depression The major symptom is a sad, unhappy or irritable mood, and/or a pervasive loss of interest and pleasure Other symptoms may include a change in appetite, change in a sleep behavior, and psychomotor retardation or agitation Also present in many depressed teenagers are loss of energy, feelings of worthlessness or excessive guilt, decreased ability to concentrate, indecisiveness, and recurrent thoughts of death or suicide Depressed teenagers can also present with somatic complaints, academic problems, promiscuity, drug or alcohol use, aggressive behavior, and stealing Many teenagers with behaviors such as these are unaware of their depression, others simply deny it In talking with these patients about their lives at home, at school, and with peers, the underlying depression usually becomes apparent A medical evaluation is needed to rule out potential medical causes, concurrent medical illness, and to assess for self-injurious/suicidal behaviors and side effects of prescribed medications See Table 126.2 The AACAP Depression Resource Center can be accessed at https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Dep ression_Resource_Center/Depression_Resource_Center.aspx Management The major goals in the management of depression in the ED involve (i) determining suicidal risk (ii) uncovering acute precipitants, (iii) making an appropriate disposition, and (iv) creating a safety plan ED physicians should screen for the presence of suicidal ideation as well as any history of prior attempts Direct questions about suicidal thoughts are critical They are unlikely to catalyze suicide attempts and may actually provide a sense of relief for the depressed child The physician should attempt to determine possible acute precipitants to guide subsequent recommendations The duration of the depression should be determined as well as the family’s response Assessing overall adjustment at home, in school, and with peers is important, as well as looking for the strengths of child and family for use in the treatment plan Outpatient management may be considered when adequate social support is present Parental acknowledgment of the severity of and risk associated with their child’s symptoms as well as a strong commitment to participating in the child’s care are important first steps Cognitive behavioral therapy is a well-studied therapeutic intervention for pediatric depression In moderate to severe depression, therapy is most effective when combined with antidepressant medications Psychotropic medications should be prescribed in the outpatient setting The emergency physician should be familiar with commonly used antidepressants Over the past several decades, the selective serotonin reuptake inhibitors (SSRIs) have displaced TCAs as first-line medications Advantages of SSRIs over TCAs include a decreased likelihood of cardiotoxicity, the absence of anticholinergic side effects, and the relative safety of these medications when taken in overdose Another commonly prescribed antidepressant is bupropion, which is chemically distinct from other agents and primarily acts on the dopaminergic system Seizure is a potential side effect Newer mixed-mechanism agents such as duloxetine, venlafaxine, and mirtazapine are also being used in children and adolescents Paroxetine, an SSRI, is generally avoided in pediatric patients due to its short half-life and heightened concern for inducing suicidal ideation In December 2004, the FDA mandated a “Black Box” warning label on all antidepressants The labels warn about possible increased risk of suicidality with these drugs and about the need to monitor patients for the worsening of depression and the emergence of suicidal ideation The agency advises that children and adolescents on antidepressants should be closely monitored, particularly after starting or increasing the dose of medication Subsequent research has supported the conclusion that, when prescribed appropriately and with appropriate monitoring, SSRIs such as fluoxetine can be safe and effective treatments for adolescent depression and their use correlates with decreased suicide rates in the pediatric population MANIA/BIPOLAR DISORDER Goals of Emergency Treatment The goals of emergency treatment of mania include identifying and treating any medical etiologies, providing acute pharmacologic interventions, and a safe and appropriate disposition plan CLINICAL PEARLS AND PITFALLS Unlike adults, mania in childhood may not always include euphoric mood; irritable mood is much more common Emotional lability is common and can be disorienting to parents, who cannot understand why the child changes so much and so dramatically Unlike the older adolescent, the child often does not have a clear recovery from identified episodes but rather may exhibit continued irritability Explosive, disorganized behavior may also be seen True psychotic features are rare and the course of childhood bipolar disorder tends to be chronic and continuous, rather than episodic Symptoms of bipolar disorder in adolescents are more similar to the adult form Psychotic symptoms, suicide attempts, inappropriate sexual behavior, and a “stormy” first year of illness may be typical of adolescent mania However, when compared with adults, adolescents may have a more prolonged early course and be less responsive to treatment The adolescent with mania has a distinct period of predominantly elevated, expansive, and/or irritable mood ( Table 126.22 ) The patient has a significant decrease in need for sleep, high distractibility, hyperactivity, pressured speech, and emotional lability Patients may also exhibit flight of ideas The manic patient may have inflated self-esteem, self-confidence, and grandiosity which may also include delusional ideas The person may be aggressive and combative, go on buying sprees, pursue other reckless behaviors, or be hypersexual Manic patients usually have a history of previous depressive episodes, but may present with an acute manic episode A family history of psychiatric disturbance usually exists in patients with manic–depressive disorder Typically, manic patients report feeling extremely well, and they are often brought to the ED against their will Sometimes, patients present with mixed episodes and have symptoms of both mania and depression Irritability is usually the prominent manic symptom Mixed episodes are particularly dangerous with a significantly increased risk for suicidal behaviors Initial Assessment Children presenting with symptoms suggestive of mania need a thorough medical evaluation to rule out any potential medical causes of their symptoms including possible toxin exposure ( Table 126.1 ) Assess for potential medical sequelae of impaired judgment, such as sexually transmitted infections, need for emergency contraception, or occult head trauma Laboratory and imaging workup should be based on history and clinical findings TABLE 126.22 ACUTE MANIA IN ADOLESCENCE: MOST COMMON FEATURES Pressured speech Grandiosity Apparent “high” (euphoria) Rapid shifts of emotion Euphoria Anxiety/irritability Combativeness/panic Hypersexuality The AACAP Bipolar Resource Center can be accessed at https://www.aacap.org/aacap/families_and_youth/resource_centers/Bipolar_ Disorder_Resource_Center/Home.aspx Management Psychiatric consultation is indicated if a new diagnosis of bipolar disorder is suspected, a manic/mixed episode is present, or if the patient is engaging in any unsafe behaviors In younger children, outpatient management—with the combination of mood-stabilizing medications and intensive behavioral treatment—may be sufficient Inpatient hospitalization is often required to maintain the patient’s safety while effective treatments are being initiated Patients who are manic can have severely impaired insight and judgment This can lead to dangerous behaviors that can have lifelong consequences ... their use correlates with decreased suicide rates in the pediatric population MANIA/BIPOLAR DISORDER Goals of Emergency Treatment The goals of emergency treatment of mania include identifying and... antidepressant medications Psychotropic medications should be prescribed in the outpatient setting The emergency physician should be familiar with commonly used antidepressants Over the past several... mirtazapine are also being used in children and adolescents Paroxetine, an SSRI, is generally avoided in pediatric patients due to its short half-life and heightened concern for inducing suicidal ideation