After Prescribing: Midcourse Corrections

(refer to Chapter 9 for more detail)

• If a patient is not improving and the treatment plan does not include evidence-based psychotherapy, adding therapy is recommended.
• If the patient is not improving and the treatment plan includes psychotherapy but not medication, it is recommended that reevaluation include the effectiveness of psychotherapy and whether the therapist is a good “fit” for this patient, before consideration of adding medication.
• If the patient is not improving and the treatment plan includes medication and therapy, both need to be reevaluated. Changing only one or the other at a time is recommended.

• When medication is ineffective:
  • For ADHD, when the initial stimulant fails, available evidence supports switching from an amphetamine to a methylphenidate preparation or vice versa.
  • For depression, available evidence in adolescents suggests that if the first selective serotonin reuptake inhibitor (SSRI) is not effective, the optimal choice for a second medication is another SSRI.
  • For anxiety, there are no data from rigorous studies regarding the best choice for a second medication, although extrapolation from the depression data would support trying a second SSRI for anxiety.
• When the first medication is partially effective:
  • Titrate the dose to maximize treatment benefit while minimizing adverse effects.
  • Addition of a second or “augmenting” medication may be indicated.
• When adverse effects lead to discontinuation of a medication:
  • For ADHD, trying the other type or class of stimulant, as described previously, is a viable option. Bypassing a second type or class of stimulant and recommending guanfacine or clonidine may be considered if, for example, the patient or caregiver(s) objects to a second stimulant.
  • For anxiety or depression, switching to another SSRI, as described previously, is generally recommended.

• While gradual discontinuation is recommended for most Group 1 medications, fluoxetine may be discontinued abruptly because of its long half-life.
• Discontinuation of guanfacine ER and clonidine ER is by 1-mg decrements per week for guanfacine ER and 0.1 mg per week for clonidine ER, per FDA package inserts.

• Stimulants can be switched from the current medication to the new medication the next day, as long as methylphenidate-equivalent total daily doses are generally the same.
• The package inserts for guanfacine ER (Intuniv) and clonidine ER (Kapvay) recommend that the current medication be tapered and stopped before the other medication is started.
• Among SSRIs, if fluoxetine is being discontinued and escitalopram, or sertraline started, the initial dose of the new SSRI can be started about a week after the fluoxetine is stopped. Other switches between SSRIs can be overlapping—the current SSRI can be tapered while the dosage of the new SSRI is titrated up to the optimal dose.
• Switches involving atomoxetine or duloxetine should generally follow the recommendations listed earlier for SSRIs, that is, overlapping dose escalation and dose decrease.

• Several antipsychotics have FDA approval for short-term treatment of youth with psychosis, but typically, they are prescribed by experienced specialists (refer to Chapter 7 and pages 169-170 for more detail).
• If a pediatric primary care clinician (PCC) is unable to obtain an appropriate consultation with or referral to a specialist, there may be circumstances in which it is necessary for the PCC to prescribe an antipsychotic (eg, bridging a patient from a psychiatric inpatient unit to a psychiatrist or other specialist) because referrals can take weeks or months in some regions.
• The National Network of Child Psychiatry Access Programs can be consulted (nncpap.org; please refer to Chapter 10 for more detail).
• Lithium is FDA approved for short-term treatment of mania in bipolar disorder in children and adolescents or used to stabilize mood swings in patients who don’t meet the diagnostic criteria for bipolar disorder.
• Lithium should be prescribed by a specialist with experience in bipolar disorder, with the exception being for a treating PCC who is bridging a patient from inpatient to outpatient care.
• Monitoring of Group 2 medications ideally involves close collaboration between the pediatric PCC and a mental health specialist.

• Group 3 medications are not approved by the FDA for use in youth with psychiatric disorders (refer to Chapter 8 and page 171 for more detail).
• If a circumstance arises where a pediatric PCC finds it necessary to prescribe a Group 3 medication, consultation with a child and adolescent psychiatrist is strongly recommended.

• Drug level testing is indicated for lithium and valproate.
• Most other children’s and adolescent’s psychotropic medications can be safely managed without obtaining drug levels (refer to pages 171-172 for more detail).
• Clinical genotyping of cytochrome P450 isoenzymes for medication management is rarely indicated, and families should discuss any interest they have in utilizing a commercial vendor for such testing before proceeding
• If dosage adjustment and monitoring of drug levels do not result in adequate outcome, it may be useful to establish the patient’s metabolizer status (eg, poor, intermediate, extensive, ultrarapid) by genotyping the isoenzyme(s) involved in the metabolism of a medication.
• Genotyping to hopefully improve treatment response is not recommended at this time.

• Seeking consultation is appropriate anytime a pediatric PCC has doubts or questions about an evaluation, treatment plan, or patient’s clinical status (refer to Chapter 10 for more detail).

(refer to Chapter 10 for more detail)

• The diagnostic approaches described in Chapter 3 should result in accurate diagnoses for most patients. However, limited initial information, multiple potential diagnoses and overlapping symptom clusters, and complex psychosocial presentations can complicate the assessment process.
• If treatment does not appear to be working, a step-by-step reformulation is indicated.

• Examples of misinformation can make initial assessments more challenging, and usually fall into 3 categories.
  • Overreporting: parental/patient beliefs and concerns that typical behaviors within normal range are in fact symptoms of a disease.
  • Underreporting: parental/patient fear of possible consequences of revealing symptoms or key features of the history or reluctance to reveal frequency of symptoms.
  • Misreporting: differing reports or interpretations of symptoms among multiple reporters (eg, patient, family members, teachers).
• Rating scales completed by parents and teachers can be helpful in clarifying symptom type and severity.
  • When using rating scales, it is important to remember that responses can vary depending on how the scales are introduced, who introduced them, and the setting in which they are completed.

• The classification system for making diagnoses has multiple potential overlaps, particularly in youngsters whose externalized behavior may be a final common pathway for various internal states.
• Impaired concentration could be indicative of anxiety disorders, depressive disorders, or trauma-related disorders, rather than stimulant-responsive ADHD.
• Feelings that indicate anxiety, such as frustration or defeat, may be accompanied by more active symptoms such as anger or aggression or oppositional behavior, which are more noticeable than the primary anxiety symptoms.
• Demoralization (loss of hope) may be mistaken for major depressive disorder.

• The most important data for a diagnosis of ADHD are caregivers’ and teachers’ observations that can be recorded and organized using structure rating scales, such as the Vanderbilt ADHD scales.
• Obtaining symptom information from informants over at least 1 week and during various times of the day strengthens the validity of the diagnosis, as symptom severity waxes and wanes over short periods.
• It is important to remember that many symptoms noted on ADHD rating scales are nonspecific; ADHD is a diagnosis not better explained by other conditions.

• Children with anxiety can present to the pediatric PCC in various ways.
  • Caregivers may report a child’s worries, fears, or somatic concerns. They may report the child has been avoiding social or other situations.
  • Anxiety and depression frequently co-occur; when 1 of 2 conditions is suspected, it is important to ask about the other as well.
  • Anxiety rating scales such as the Screen for Child Anxiety Related Disorders (SCARED) can be useful (refer to Appendix A for more detail).

• Diagnosing major depressive disorder (MDD) in youth can be challenging. It is much more common in adolescents than in prepubertal children.
• Youth who are demoralized by various family, social, medical, peer, academic, or other problems can exhibit many of the symptoms of MDD but may not have a medication-responsive episode of MDD.
• Demoralized patients often have mood and cognitive symptoms that appear similar to those of MDD, but loss of interest/pleasure is unusual outside the syndromic illness.
• Before making a diagnosis of MDD, it is important to differentiate symptoms from normal emotions such as sadness, irritability, or grief.
• The PHQ-9 modified for adolescents (PHQ-A) may be helpful in clarifying the range and severity of symptoms.

• In addition to reassessing diagnoses, it is important to consider new information regarding a youngster’s symptoms; newly recognized family psychiatric history; any changes in school, social connections, or substance use; financial, housing, and food security; and other proximal and distant psychosocial details that may be impacting the presentation, treatment, adherence, or participation in therapy.
• Questions that may be useful in reassessment include
  • “Has anything happened since the initial evaluation that might help us understand what is happening right now?”
  • “Are there any problems with medication? How many doses during a typical week do you think you are missing for any reason?”
  • “Is there anything else we should be talking or thinking about?” (refer to page 182 for additional suggested questions)

• Despite the best efforts at diagnosis and treatment, some children and families will need consultation with, or referral to, a child and adolescent psychiatrist or developmental-behavioral pediatrician or psychiatric nurse practitioner.
• Pediatric PCCs should consider which of the following suggested resources might work best for their specific clinical care setting and situation.
  • Phone consultations: The National Network of Child Psychiatry Access Programs (NNCPAP) is a collaboration of about 30 US state programs that provide varying levels of child psychiatry collaboration with and consultation to pediatric PCCs regarding mental health. The level of service and geographic coverage varies across states. Contact email addresses and phone numbers are available on the website (nncpap.org).
  • Child and Adolescent Psychiatry Divisions at Nearby Major Medical Centers: The Office of the Division Director or Fellowship Training Director of the Division of Child and Adolescent Psychiatry at a nearby major medical center will have relevant information about clinics that can serve patients needing evaluation and/or treatment.
  • State Chapters of National Professional Organizations: State chapters of national professional organizations (eg, American Academy of Child and Adolescent Psychiatry, American Psychiatric Nurses Association, American Psychological Association) can be sources of information and may have lists of specialists in your state and region.
  • Practice Resources: Once your practice has accumulated information from these resources, it can be incorporated into a living document. Information can be added over time regarding clinics and clinicians who have accepted referrals, positive and negative feedback from patients and their families, and any insurance that is accepted.