Mood Disorders in Adolescence: An Integrative Approach Session

1
Mood Disorders in Adolescence An Integrative
Approach Session A2021 10/12/08

• Kathi J. Kemper, MD, FAAP
• Caryl J Guth Chair for Holistic and Integrative
  Medicine
• Author, The Holistic Pediatrician
• Wake Forest University School of Medicine
• Winston-Salem, NC

2
Faculty Disclosure

• In the past 12 months, I have had no relevant
  financial relationships with the manufacturers of
  any commercial products and/or providers of
  commercial services discussed in this CME
  activity. I do not intend to discuss an
  unapproved or investigative use of a commercial
  product or device in my presentation.

3
Objectives (by the end of this session, you will
be able to)

• Define the role of patient-centered communication
  for mood disorders
• Describe the importance of a healthy lifestyle
  and the safety and effectiveness of dietary
  supplements in promoting healthy moods.
• Refer patients to evidence-based resources for
  additional information about lifestyle and
  complementary therapies to promote mental health

4
Depression Case

• A 17 year old girl who is sad, has had a drop in
  grades, recently broke up with her abusive
  boyfriend less interested in participating in
  band, has stopped taking her SSRI after hearing
  about black box warnings.
• Her only medications are oral contraceptives.
• Will St. Johns wort help (the news reports are
  very confusing)?
• How do you advise her?

5
Which of the following is the best answer about
SJW?

• SJW has proven useless against depression.
• SJW is completely safe. She can use any off the
  shelf brand to help.
• She will need to use back up birth control method
  if she starts SJW.
• Based on RCTs, theres a greater than 80 chance
  her symptoms will respond to SJW.

6
Are mood disorders are real problem in
adolescents? YES

• American children have the most psychiatric
  illness in the civilized world (WHO data)
• Childhood depression epidemic in USA
• 2001/02 HBSC International Report Young People's
  Health in Context?Currie C. et al (eds.) 2004.
  Young People's Health in Context international
  report from the HBSC 2001/02 survey. WHO Policy
  Series
• Blader, J and Carlson, G Biol Psychiatry 2007
  Feb 15
• Moreno, C et al Archives of General Psychiatry,
  641032-8 2007 September

7
Definitions Mental Health

• Most medical literature on mental health focuses
  on mental illness, eg. Depression, anxiety,
  Bipolar, schizophrenia, ADHD, cognition/memory
  problems, adjustment disorders, personality
  disorders, etc.
• Mental health
• "First say to yourself what you would be and
  then do what you have to do."
• Epitectus
• You got to be careful if you don't know where
  you're going, because you might not get there.
• Yogi Berra

8
Optimal Physical health Example

• Strength
• Flexibility
• Stamina/Endurance
• Focus
• Coordination
• Resilience, and
• Effective teamwork

9
Optimal Spiritual Health

• Faith
• Forgiveness
• Hope
• Love
• Kindness
• Charity/generosity, and
• Transcendence connection with something greater
  than our individual self

10
Mental Health elements

• Confidence and courage
• Adaptability
• Cheerfulness
• Attention / Concentration
• Harmony
• Hardiness in face of stress
• Social Network/ communication skills/ connection
  to community

11
Mental Health - strategies

• Healthy lifestyle as for promoting heart
  health, reproductive health, immune function,
  etc.
• 1 Lifestyle Exercise/Rest, Nutrition,
  Environment(/-), Stress management practices
  (EMS), Communication and community
• 2 Supplements/Meds, Professionals
  (psychologists, massage, acupuncture, etc)

12
Management Issues

• Process (communication skills)
• Content (focus on healthy lifestyle if its good
  for the heart, its probably good for mood)
• Speed (baby steps)
• Resources

13
Which of the following is true about
patient-centered communication?

• PCC can significantly improve mental health
  outcomes
• PCC has mild impact on mental health visits,
  though it is helpful for general primary care
• PCC has no impact on mental health outcomes
• What is PCC?

14
Process Communication Skills

• Standard approach
• Patient-centered care
• Health promotion focus

15
Standard approach

• Diagnose
• Provide diagnosis-specific treatment yourself
• Persuade parent / child to accept referral
• Challenges
• Making a diagnosis what if they dont meet
  criteria?
• Mastering medications
• Referral resistance waiting unavailability
• Promoting mental health during well child care
  (preventing illness)

Wissow and Gadomski, 2008
16
Parental expectations

• Dont believe they are effective change agents
• Have prior beliefs about what will help
• Not sure pediatric visit the place to discuss
  this
• Want help but afraid of what you might say
• Want empathy but expect child is the agenda

Wissow and Gadomski, 2008
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Adolescent Expectations

• Here to be fixed or punished
• Not used to having a substantive role in visit
• Uncertain about confidentiality
• Different agenda than parent
• Incomplete and stigmatizing views of mental
  health

Wissow and Gadomski, 2008
18
Physician Expectations

• Will be presented with insoluble problems
• Double drowning everyone will leave more
  hopeless and/or angry than they started
• Will lose control of time
• Wont be able to be proactive as with other
  health problems

Wissow and Gadomski, 2008
19
Evidence-based skills

• Agenda setting
• Engaging both child and parent
• Prioritizing specific concerns goals define
  success
• Problem formulation and solving
• Finding reasons to hope and first steps to
  solutions
• Framework health promotion and stress management
• Time management
• Managing rambling and interruptions
• Promoting hope and confidence
• Advice giving
• Avoiding and managing resistance

Pediatrics 2008 Feb121266-75.
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Finding a common agenda

• Commitment to eliciting it from both parent and
  child/youth
• Setting up and enforcing turn-taking
• Respecting confidentiality
• Encouraging and modeling the ability to talk in
  front of each other

21
Crude 6-month change in child clinical measures
as a function of change in providers
patient-centeredness
Change in SDQ symptom score
Change in SDQ impact score
plt.0001 adjusted for baseline symptoms
p.015 adjusted for baseline function
22
Which of the following is true about
patient-centered communication?

• PCC can significantly improve mental health
  outcomes
• PCC has mild impact on mental health visits,
  though it is helpful for general primary care
• PCC has no impact on mental health outcomes
• What is PCC?

23
Content Conventional

• Psychotherapy
• Medications

24
Cognitive Behavioral Therapy

• From an evidence-based perspective,
  cognitive-behavioral therapy is currently the
  treatment of choice for anxiety and depressive
  disorders in children and adolescents.
• Compton SN. JAm Acad Child Adolesc Psychiatry.
  2004

25
Conventional Treatment Rx

• TCAs - no evidence of efficacy in pre-pubertal
  children
• SSRIs - no overall evidence of efficacy in
  pre-pubertal children
• SSRIs marginally better than placebo in teens
  with MDD
• SSRIs are HELPFUL in OCD and anxiety disorders,
  even in pre-pubertal children
• Safer DJ. Pediatrics, 2006 118 (3) 1248

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FDA approved SSRIs for pediatric MDD

• As of 2004, the FDA has approved only Prozac for
  use in children/adolescents with MDD
• Prozac, Zoloft and Luvox have been FDA approved
  for use in children diagnosed with OCD

FDA 3/24/04 http//energycommerce.house.gov/108/L
etters/03242004_1242print.htm
27
SSRI Side effects 1

• GI upset
• Headache sleep disorders
• Sexual side effects Dizziness, Fatigue, Sweating
• Neonatal withdrawal syndrome
• Drug interactions

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SSRI Side effects 2

• Serotonergic syndrome (HTN, tachycardia, mania)
• Agitation and hostility
• Suicidal ideation, esp in those with
  agitation/hostility
• Review of 22 RCT pediatric with 9 antidepressant
  drugs.
• 2298 patients with active drug 1952 with
  placebo
• Serious suicidal adverse events
• 78/2298 versus 54/1952
• Incidence rate ratio 1.89 (95 CI,
  1.18-3.04)
• Mosholder AD. J Child Adolesc Psychopharmacol.
  2006

29
Psychiatric Meds in kids

• Little science of long term safety
• 1.6 million kids on 2 or more meds no science
• Neurological and hormonal impact mostly unknown

30
Content natural therapies

• Depression is one of the top 10 diagnoses for
  which patients seek natural therapies
• Commonly used among depressed adolescents
• Fewer than 30 of depressed teens tell docs they
  are using natural therapies
• Clinicians need to ask!

31
Which of the following is true about Lifestyle
approaches to mood problems?

• Lifestyle affects cardiac health, but has little
  impact on mental health
• Lifestyle affects cancer risk, but has little
  impact on mental health
• Lifestyle affects BOTH cardiac and cancer risks,
  but has little impact on MH
• Lifestyle, such as light, sleep, exercise and
  nutrition can have profound and clinically
  significant effects on mental as well as physical
  health.

32
Integrative Approach

• Lifestyle Environment, Exercise/Sleep,
  Nutrition, Mind-Body
• Supplements
• Massage
• Acupuncture

33
Lifestyle - overview

• Environment More Sunshine and good music, Less
  TV and toxins
• Exercise/Sleep
• Nutrition (Essential nutrients for optimal brain
  function, EFA, amino acids, vitamins, minerals)
• Mind-Body Therapies manage stress
• Meditation
• Biofeedback

34
Sunshine, circadian rhythms and sleep

• Desynchronization of internal rhythms plays an
  important role in the pathophysiology of
  depression.
• Resetting normal circadian rhythms can have
  antidepressant effects.
• Winter depression was first modeled on
  regulation of animal behavior by seasonal changes
  in day length, and led to application of light as
  the first successful chronobiological treatment
  in psychiatry.
• Fuchs E. Int Clin Psychopharmacol, 2006
• Wirz-Justice A. Int Clin Psychopharmacol. 2006

35
You are My Sunshine!

• SAD - Known association between inadequate
  sunshine and depression
• Frequent indoor tanners are often depressed and
  seeking relief watch for rebound depression if
  they stop
• How much? 10 15 minute daily of exposure to
  hands and face in spring, summer fall
  wintertime? Latitude?

36
Light Therapy for Depression

• Plus 3 studies not included in this review,
  comparing dim light to bright light. Golden R. Am
  J Psychiatry. 2005

37
Vitamin D and depression

• Vitamin D receptors in brain
• Low level of serum 25-hydroxyvitamin D and high
  PTH are significantly associated with depression
  (Jorde, 2005)
• 25-hydroxyvitamin D3 and 1,25-dihydroxvitamin D3
  levels are significantly lower in psychiatric
  patients than in normal controls (Schneider,
  2000)
• RCT of 44 Australian patients (none, 400 IU
  versus 800 IU vitamin D) vitamin D3 significantly
  enhanced mood (Landsdowne, 1998)

38
Light therapy

• Proven effective for SAD (Terman M Evid Based
  Ment Health, 2006)
• Meta-analysis of studies from 1987-2001 (effect
  size0.53, 95 CI0.18 to 0.89, similar to
  medications) for non-SAD
• RCT of 29 women with non-seasonal depression
  light therapy for 28 days significantly better
  than control, (McEnany GW, 2005)

39
Light Therapy 2

• Benefits onset within 2 days effective in
  institutionalized elderly and community
  effective in summer and winter
• Side effects hypomania, autonomic
  hyperactivation (Terman M, 2005)

40
Lifestyle 2 Exercise

• Depressed mood / fatigue are common in those
  deprived of usual exercise.
• Mood changes noted in patients with injuries and
  mono.
• Changes over time in kids exercise/gym/playground
  time
• Exercise benefits depression
• Common sense precautions

Berlin AA. Psychosomatic Med, 2006
41
Exercise as Therapy Yes
Lawlor DA. BMJ 2001
42
Yoga for depression

• Five RCTs --each used different forms of yoga.
• All trials reported positive findings
• No adverse effects except fatigue and
  breathlessness
• Pilkington K. J Affective Disord, 2005

43
Lifestyle 3 Sleep

• Poor sleep is barometer of later mental health
  risks (anxiety and depression)
• Reduced sleep equals impaired focus and labile
  mood (ADHD, Learning problems)
• Sleep quality is a good screen for good mental
  health in pediatric population
• We sleep 20 less than we did 100 yrs ago

44
Lifestyle 3 Sleep

• Regular time Routine
• Hot bath cool room dark room
• Massage before bed
• Lavender, chamomile, melatonin?
• No caffeine within 8 hours of bedtime
• Music, calm, orderly, quiet
• NO TV IN BEDROOM
• NO vigorous exercise right before bed
• GET MORE versus intentional sleep
  reduction/deprivation (in those with excessive
  sleep)

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4 Nutrition essential nutrients for optimal
brain function

• Omega-3 fatty acids
• Amino acids (SAM-E, Trp, 5-HTP)
• Vitamins (B vitamins, Vitamin D)
• Minerals (Iron, Calcium, Magnesium, Zinc)

46
Omega-6 Fatty Acids
Omega-3 Fatty Acids
Linoleic Acid (182n-6)
a-Linolenic Acid (183n-3)
?-6 Desaturase
(GLA)? -Linolenic Acid (183n-6)
Stearidonic Acid (184n-3)
Elongase
(DHGLA) Dihomo-?-Linolenic Acid (203n-6)
Eicosatetraenoic Acid (204n-3)
?-5 Desaturase
Eicosanoids
(AA)Arachidonic Acid (204n-6)
(EPA) Eicosapentaenoic Acid (205n-3)
Elongase
245n-3
Eicosanoids Leukotriene 5-series Prostaglandins
E3 Thromboxanes A3
?-6 Desaturase
Eicosanoids Leukotriene 4-series Prostaglandins
E2 Thromboxanes A2
246n-3
ß-Oxidation
(DHA) Docosahexaenoic Acid (226n-3)
47
Omega 3 EFAs mechanism

• Neuronal membrane structure and function
• Brain development
• Second messenger inside cells

48
Mood and Omega-3s

• Inverse correlation between fish intake and
  depression
• (Hibbeln Lancet 1998
  3511213)
• Effective for bipolar patients
• (Stoll Arch. of Gen. Psych.
  1999 56 407-12)
• Effective for major depression
• (Nemets Am. J. Psych. 2002 159
  (3) 477-9)
• Effective for depression in Children
• ( Am J Psychiatry 20061631098-0)
• Effective for Borderline P.D.O.
• (Am. J. Psych. 2003, 160 (1)
  167-9)

49
Fish Oil Doses, Safety, Brands

• Dose 1 gram daily of EPA probably enough.(Peet
  M, 2002) Frangou S. Br J Psychiatry, 2006)
• Safety fish allergies, taste, belching very
  high doses, increased risk of bleeding,
  nosebleeds? Little risk of mercury, dioxin,
  PCBs
• Brands Compare brands at www.consumerlabs.com
• My family takes Coromega, Carlsons or Nordic
  Natural
• Read labels Omega 3 does NOT necessarily all
  equal EPA/DHA

50
Amino Acids SAM-E

• Produced from ATP and methionine
• Low folate can lead to low levels
• Meta-analysis SAMe significantly improves
  depression, comparable to antidepressant
  medications (http//www.ahrq.gov/clinic/epcsums/sa
  mesum.htm)
• In an open trial of 30 adults with MDD for whom
  antidepressant meds ineffective, SAM-E led to
  significant improvements in 50 and remission in
  43 (Alpert, 2004)
• All tested products approved by ConsumerLab buy
  on sale!

51
SAM-E Doses, duration, products

• Dose 800 1600 mg daily (adult)
• Benefits appear within 2-4 weeks of starting
  daily use
• Problems poorly absorbed (need enteric coating)
  mania in bipolar patients interactions with SSRI
  meds see http//www.consumerlabs.com/results/sam
  e.asp
• http//www.umm.edu/altmed/ConsSupplements/SAdenosy
  lmethionineSAMecs.html

52
Amino Acids 5-HTP and L-tryp

• Acute tryp depletion leads to depression
• Dietary L-tryp -gt 5-HTP -gt serotonin
• Meta-analysis 5-HTP and L-trp better than
  placebo for depression (Shaw K, Cochrane. 2002)
• Food sources dairy, eggs, poultry, meat, soy,
  tofu, nuts WHEY protein

53
L-tryp doses and side effects

• Doses - start at 50 mg TID max dose 1200 mg
  daily
• Side effects EMS related to contaminated lot
  from one manufacturer nausea, drowsiness May
  potentiate SSRI medications decreased
  carbohydrate intake and weight loss?

54
Vitamin B6 - pyridoxine

• Low levels of pyridoxal phosphate (PLP) are
  associated with depressive symptoms (Hvas AM
  2004)
• Dose 100 200 mg daily benefits PMS-
  depression Odds ratio 2.(Wyatt KM. BMJ, 1999)
• Side effects nausea, vomiting, abd. pain,
  anorexia, headache, somnolence, lower B12 levels,
  sensory neuropathy (typically with doses over
  1000 mg daily, can occur lower)
• Food Beans, nuts, legumes, fish, meat

55
Folate

• Folate (Essential co-factor for synthesis of
  S-adenosyl-methionine).
• Lower levels of folate in depressed persons
• Low folate associated with poorer response to
  antidepressant meds
• Methylfolate in depressed pts (elderly, EtOH
  dependent, dementia) show significant improvement
  (Guaraldi et al., 1993 Di Palma et al., 1994
  Glória et al., 1997 Passeri et al., 1993)
• RPCT folate as adjunctive Rx in folate deficient
  MDD pts showed signif improvement over placebo
  (Godfrey et al., 1990)
• RPCT MDD pts randomized to fluoxetine folate
  (0.5mg) improved more than fluox. placebo
  differences esp striking in WOMEN (Coppen
  Bailey 2000)
• Studies on supplements in non-folate deficient
  MDD pts on SSRIs found significant reduction in
  sx severity and 19 remission (Alpert et al.,
  2002)
• Folate augmentation may enhance response to
  lithium in folate deficient bipolar and unipolar
  depression (Coppen and Chaudhry, 1986)

56
Bottom line on B vitamins

• Healthy diet rich in green vegetables and
  nutritious protein sources
• Consider B-complex supplement

57
Mood and Minerals Iron

• Iron deficiency associated with depression
• Correcting iron deficiency helps with mood and
  attention
• Beard JL. J Nutr, 2005
• LE Murray-Kolb. Am J Clin Nutr, 2007

58
Mood and Minerals Calcium

• Lower levels of calcium in depressed persons
• Higher PTH in depressed persons
• Estrogen regulates calcium and PTH metabolism
  sometimes dysregulates? (Thys-Jacobs S. J Am Coll
  Nutr, 2000)
• Supplementation may benefit women with
  PMS-related depression (Dickerson LM. Am Fam
  Physician, 2003)
• 1000 1200 mg daily

59
Non-dairy sources of calcium

• Soy beans, tofu
• Calcium fortified OJ
• Green leafy vegetables (broccoli)

60
Nutrition Summary

• Healthy fat (omega 3) not fried foods, saturated
  fats
• Healthy protein (essential amino acids)
• Foods rich in minerals and vitamins (vegetables,
  grains)
• Multivitamin-mineral supplement
• Fish oil supplement
• Consider SAM-E, B vitamins

61
Lifestyle Stress management

• Stress is common
• Stress commonly triggers mood problems
• Managing stress exercise, sleep, nutrition,
  mind/emotion/body/spirit
• Meditation
• Biofeedback

62
Meditation

• Meditation training ? left-sided anterior
  activation, a pattern associated with positive
  affect, in meditators compared with the
  nonmeditators
• No RCTs specifically on depression, though
  positive effects on anxiety
• Few side effects can combine mindfulness with
  CBT
• Davidson RJ Psychosom Med, 2003

63
Emotional Self-Management

• Intentional focus on emotions
• Gratitude
• Practice
• Warm-up

64
Appreciation audit

• Daily journal
• For what are you grateful today?
• What do you appreciate about those closest to
  you?
• To whom have you extended goodwill or kindness?
• What Happy People Know How the New Science of
  Happiness Can Change Your Life for the Better
  (Paperback) by Dan Baker, Cameron Stauth. St.
  Martin's Griffin. 2004

65
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Low Arousal/Low Energy
PARASYMPATHETIC
66
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Fight-or-Flight
LOW PERFORMANCE
HIGH PERFORMANCE
Negative Emotion
Positive Emotion
Low Arousal/Low Energy
PARASYMPATHETIC
67
Stress, Emotion, and Physiological Activation
High Arousal/High Energy SYMPATHETIC
Fight-or-Flight
Frustration, Anger, Hostility,
Exhilaration, Passion,
Fear, Worry Anxiety
Joy, Happiness
Judgment, Resentment,
Love, Care,
LOW PERFORMANCE
HIGH PERFORMANCE
Feeling Overwhelmed, Anguish
Kindness, Appreciation
Negative Emotion
Positive Emotion
Hopelessness, Submission,
Compassion, Tolerance,
Despair, Depression
Acceptance, Forgiveness
Burnout, Withdrawal, Boredom, Apathy
Serenity, Inner Balance, Reflection, Contentment
Low Arousal/Low Energy
PARASYMPATHETIC
68
Stress management biofeedback

• HRV biofeedback appears to be a useful adjunctive
  treatment for the treatment of MDD
• Significant improvements in
• Hamilton Depression Scale (HAM-D)
• Beck Depression Inventory (BDI-II) by week 4,
• Karavidas, et al. Appl Psychophysiol Biofeedback.
  2007
• Nolan RP. Am Heart J, 2005

69
Which of the following is true about Lifestyle
approaches to mood problems?

• Lifestyle affects cardiac health, but has little
  impact on mental health
• Lifestyle affects cancer risk, but has little
  impact on mental health
• Lifestyle affects BOTH cardiac and cancer risks,
  but has little impact on MH
• Lifestyle, such as light, sleep, exercise and
  nutrition can have profound and clinically
  significant effects on mental as well as physical
  health.

70
After lifestyle and stress management, what?

• St. Johns wort
• Massage
• Acupuncture

71
Which of the following is the best statement
about Saint Johns wort?

• St. Johns wort has repeatedly proven ineffective
  in treating adolescent depression.
• St. Johns wort frequently causes allergic
  reactions.
• St. Johns wort may be ineffective, but because it
  is safe, teens can use it safely, so docs can
  ignore it.
• St. Johns wort is about as effective as SSRIs but
  can interfere with the effectiveness of many
  common medications including OCPs, so docs need
  to ask about it.

72
Saint Johns wort

• Most commonly used CAM therapy for depression
• Comparable to sertraline in German RCT of 241
  depressed adults (Gastpar. Pharmacopsychiatry,
  2005)
• 2 open label trials in teens showed improvement
  within 2 weeks in 25/33 and 9/11 patients
  (Findling, 2003 Simeon, 2005) Improvement in 2
  weeks predicts long-term response if no benefit
  in 2 weeks, stop
• Current evidence regarding hypericum extracts is
  inconsistent and confusing different products
  used in different trials, different kinds of
  patients in some studies St. Johns wort is as
  effective as standard medications, but no more
  effective than placebo. (2005 Cochrane review)

73
Herb- drug interactions SJW

• Speeds elimination of many drugs digitalis,
  theophylline, clarithromycin, erythromycin,
  protease inhibitors and OCPs

74
SJW safety

• Other side effects - photosensitivity,
  serotonergic syndrome
• Product variability see www.consumerlabs.com
  Gaia, Kira, Sundown, Natures Bounty
• Products used in POSITIVE TRIALS Laif 900
  (German STW3-VI) LI160 (Kira), WS5572 WS5570
  (Perika by Natures Way)
• St. Johns wort patient handouts are available
  from
• University of Maryland Medical Center
• Wake Forest University Baptist Medical Centers
  Best Health internet site (www.besthealth.com)
• Harvard Medical School-Intelihealth

75
Which of the following is the best statement
about Saint Johns wort?

• St. Johns wort has repeatedly proven ineffective
  in treating adolescent depression.
• St. Johns wort frequently causes allergic
  reactions.
• St. Johns wort may be ineffective, but because it
  is safe, teens can use it safely, so docs can
  ignore it.
• St. Johns wort is about as effective as SSRIs but
  can interfere with the effectiveness of many
  common medications including OCPs, so docs need
  to ask about it.

76
Massage

• Increased blood flow and lymphatic drainage
  Muscle relaxation Stress reduction
• Balances R L prefrontal cortex activity in
  those with right dominance (Jones N Adolescence.
  1999)
• Decreased levels of cortisol and increased levels
  of serotonin and dopamine in depressed adults
  (Field T. Int J Neurosci. 2005)
• In depressed pregnant women, massage, compared
  with progressive relaxation, led to higher
  dopamine and serotonin levels and lower levels of
  cortisol and norepinephrine (Field T. J Psychosom
  Obstet Gynaecol. 2004 )
• Who volunteers?

77
Acupuncture

• RCT of 30 patients BDI scores fell from baseline
  by 16.1 points in the intervention group versus
  6.8 points in the sham controls (Plt0.001)
  (Acupunct Med. 2005)
• Meta-analysis the effect of electroacupuncture
  similar to antidepressant medication(Mukaino Y
  Acupuncture Med, 2005).
• No pediatric studies. Good safety profile. Rare
  infections, broken needles, forgotten needles,
  bleeding, bruising

78
Depression SUMMARY 1

• Listen to patients and families
• Negotiate clear goals and agreements
• Support healthy lifestyle, including sunshine,
  sleep, exercise, nutrition (supplement when
  necessary), appreciation and stress management

79
Depression SUMMARY 2

• Correct deficiencies of B vitamins and minerals
• Consider supplements of fish oil, SAM-E, 5-HTP
• Consider safe therapies, including massage and
  acupuncture
• Beware of potential interactions, e.g., Saint
  Johns wort
• Be PRACTICAL How?

80
How Behavioral Pediatrics

• Identify the goal
• Consider various strategies
• Pick a strategy
• Identify a small, achievable step that the
  patient and family can support
• Explore pros and cons of change
• Anticipate barriers identify resources
• Plan rewards/celebrations!
• Re-evaluate take the next step

81
Goal-setting

• Pick a POSITIVE goal
• E.g., more DRY nights (not just stop bed
  wetting) healthier lifestyle
• Identify values behind the goal
• Health, relationships, esteem, integrity, etc.

82
Example Healthier lifestyle

• To promote
• Better mood
• Better focus or concentration
• Greater calm More resilience
• More cheerfulness Greater adaptability
• More confidence More creative
• More clarity
• Better memory
• More harmonious relationships
• Higher self esteem
• More consistent with personal values
• other?

83
Pick a specific strategy

• More exercise
• Better nutrition
• Judicious use of supplements
• Better sleep
• Healthier environment
• Stress management biofeedback journal
  meditation
• Use medication
• Massage, psychotherapy, acupuncture or other
  professional help

84
Identify a small, achievable step

• Rome was not built in a day habits are not
  changed overnight BABY STEPS.
• For exercise, go from sedentary, to 5 minute
  walks with the dog 5 days a week.
• Be specific (with or without an MP3 player with
  or without a parent regardless of weather?
  distance vs. time)

85
How important is this to you?

• 0 1 2 3 4 5 6 7 8 9 10
• Not Very
• Why did you pick that number and not a lower
  number? (e.g. a 7 instead of a 5)
• Asking this question helps the patient/family
  provide their own rationale for why this is
  important. They talk themselves into it!

86
How confident are you that you can do this for
one month?

• 0 1 2 3 4 5 6 7 8 9 10
• Not Very
• If they pick an 8 or higher (pretty confident),
  proceed with next step of making a chart and
  planning rewards and follow-up.
• If they pick a number less than 8,
• What would it take for you to go from the number
  you picked to a higher number? Begin to explore
  their ambivalence. Its OK to be ambivalent
  about change!

87
Identify Pros and Cons
88
Identify Barriers and Resources

• In addition to (cons listed above), what other
  barriers or challenges might you anticipate as
  you try to make this change? Need new tennis
  shoes need leash need pooper-scooper
• What resources do you have/need to help you make
  this change? Will Mom commit to getting new
  shoes, leash, etc. ? Will the child want/need a
  reminder? Is it helpful for Dad to do that? Do
  they need a chore chart? A calendar?

89
Sample behavior diary (OK to copy)
90
Plan celebrations/rewards

• Pick a tangible reward and timing (will it be
  offered after week 1, 2, 3, 4?)
• Samples extra time with mom or dad extra phone
  minutes new walking shoes get to pick vegetable
  for dinner! get to pick family movie stickers
  for younger kids money for older kids
  controversial in some families. Support the
  family and child choices.
• Emphasize the importance of the
  reward/celebration. If the family says they
  expect good behavior, suggest they consider
  celebrating it (instead of rewarding it).

91
Follow Up

• Follow- up in 4-6 weeks.
• Ask family/child to bring chart and say you plan
  to be proud of them (build expectation of
  success) and will ask them what theyd like to do
  for next step (involve them in problem solving).
• Do it!

92
Behavioral Pediatrics

• Identify the goal
• Consider various strategies
• Pick a strategy
• Identify a small, achievable step that the
  patient and family can support
• Explore pros and cons of change
• Anticipate barriers identify resources
• Plan rewards/celebrations!
• Re-evaluate take the next step

93
Which of the following best describes your
awareness of additional resources about topics
discussed in this session? I know where to turn
for additional information about.

• .. natural therapies for depression.
• .. Patient-centered communication
• motivational interviewing
• All of the above

94
Resources

• Kemper KJ, Shannon S. Complementary and
  alternative medicine therapies to promote healthy
  moods. Pediatr Clin North Am. 2007
  Dec54(6)901-26
• Wissow LS, Gadomski A, Roter D, et al. Improving
  child and parent mental health in primary care a
  cluster-randomized trial of communication skills
  training. Pediatrics. 2008 Feb121(2)266-75
• Society for Developmental/Behavioral Pediatrics
• Developmental and Behavioral Pediatrics A
  Handbook for Primary Care (Parker, Developmental
  and Behavioral Pediatrics) (Paperback) Parker,
  Zuckerman, Augustyn
• Motivational Interviewing Preparing People to
  Change by Miller and Roznik

95
Which of the following best describes your
awareness of additional resources about topics
discussed in this session? I know where to turn
for additional information about.

• .. natural therapies for depression.
• .. Patient-centered communication
• motivational interviewing
• All of the above