Psychotropic Medications: Their Role in Trauma Treatment

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1 Psychotropic Medications: Their Role in Trauma Treatment Robert Foltz, Psy.D. Associate Professor Child & Adolescent Track Chicago School of Professional Psychology

2 Overview Scope of the Problem Trauma Physiology HPA Amygdala Cortisol Medication standards Examining the evidence base ASET Sample Discussion Q & A

3 Diagnostic Horizon The DSM 5, due in May, 2013 will introduce a new PTSD diagnosis for young children. This diagnosis will be similar to the current PTSD criteria, with developmental considerations. In other words, these criteria will continue to inadequately capture the experience of trauma for many youth. Developmental Trauma Disorder will not be included in the DSM5.

4 The Developmental Trauma Debate

5 NCTSN Trauma Study Sample from Residential Care

6 NCTSN

7 NCTSN

8 NCTSN Boyer et al. (2009) examined additional predictors of clinical outcomes that could improve the prediction of which youth would benefit most from placement in residential treatment settings, and found that the number and types of trauma that youth were exposed to prior to residential placement were negatively associated with positive treatment outcome. They also found that treatment deteriorators (i.e., youth who reliably worsened over the course of intervention) were more likely to have complex trauma histories. Agency for Healthcare Research & Quality, Feb Approximately two-thirds of children and adolescents will experience at least one traumatic event, creating a critical need to identify effective child trauma interventions.

9 AHRQ, Feb Traumatic events are common in childhood. In one longitudinal study of more than 1,400 children 9 to 16 years of age, 68 percent of children reported at least one traumatic event (with 37 percent experiencing more than one event); 13.4 percent of those experiencing trauma developed some post-traumatic symptoms. However, only 0.5 percent of these trauma-exposed children met the full criteria for PTSD. In a survey of adolescents 12 to 17 years of age, the 6-month prevalence for PTSD was 6.3 percent in girls and 3.7 percent in boys.

10 Adverse Childhood Experiences Total ASET Sample Exposures (n=74) Household Substance Abuse 45% Parental Separation 52% Mental Illness 33% Domestic Violence 40% Criminal behavior 52% Abuse Psychological Physical 51% 47% Sexual 37% Neglect Emotional 45% Physical 20%

11 ASET / NCTSN data Total ASET Sample Exposures (n=74) Household Substance Abuse Parental Separation 45% 52% Mental Illness Domestic Violence 33% 40% Criminal behavior 52% Abuse Psychological Physical 51% 47% Sexual 37% Neglect Emotional 45% Physical 20% NCTSN (n = 525) Impaired Caregiver 60.0 Dom Viol 58.3 Emotional 67.6 Physical 54.5 Sexual 40.4

12 ASET Sample: PTSD Despite the extraordinary exposure to traumatic experiences 20 youth have a diagnosis of PTSD Many carry multiple diagnoses Many include Mood Disorders (usually Bipolar)

13 The HPA Axis Hypothalamic-Pituitary-Adrenal Axis Fundamentally involved in the response to stress Activates the release of chemicals throughout the body for the survival of stressful experiences How do psychotropic interventions affect this process?

14 HPA Axis Function The Hypothalamic-Pituitary-Adrenal Axis: The Actions of the Central Nervous System Olson, Marc, Grude, McManus, Hellermann, 2011 The adrenal glands release cortisol, epinephrine, and norepinephrine to preserve a healthy, but dynamic equilibrium. These neurotransmitters are described as initiators of the fight or flight response, as they increase respiration and heart rate, and trigger the release of glucose from energy stores. The glucocorticoid cortisol contributes to carbohydrate, protein, and fat metabolism, regulates blood glucose, and suppresses the immune system. The system is meant to respond to an acute stressor and then terminate that response via a negative feedback mechanism. Chronic HPA stimulation due to ongoing physical or emotional stress can lead to unresponsiveness of hypothalamic nuclei or if adrenals maintain a high level of activity to mobilize cortisol, epinephrine, and norepinephrine, the stores of these chemicals may become depleted. ALLOSTATIC LOAD

15 Intervention Safety is the priority Predictability decreases Anxiety Assessing the trauma Acute / Chronic Establishing a caregiving network Despite the vast range of interventions, a recent study reveals very little evidence base across interventions Managing Symptoms Creating Lasting Change

16 Agency for Healthcare Research and Quality U.S. Department of Health and Human Services, Feb 2013 Medication Treatments No pharmacotherapy intervention demonstrated effectiveness. Authors typically evaluated short-term outcomes. An identified problem in the research is repeated efforts to study the same intervention (establishing reliability). Too many studies examine one intervention repeated analyses are infrequent.

17 Medications in Trauma SSRIs are frequently used in children with PTSD in the absence of demonstrating efficacy. Most of the SSRI efficacy data have been obtained form open trials with adults that suggested that they are beneficial. In adults, clonidine (Catapres) and propranolol (Inderal) have been used to treat symptoms of PTSD with a suggestion of improvement. In 2009, Kaplan & Sadock textbook of C & A Psychiatry stated: No randomized, placebo controlled trials of medication for youth in the treatment of PTSD are being conducted; in general, extrapolation from adult studies point to the likelihood that SSRI medications may provide relief for some symptoms of PTSD among youth.

18 JAACAP Guidelines - PTSD Two recent randomized trials have evaluate the efficacy of SSRI medication for treating PTSD in children and adolescents. The first failed to find any superiority of sertraline over placebo in 67 children with initial PTSD diagnoses, although both groups experienced significant improvement, suggesting a strong placebo effect. The second compared TF-CBT plus sertraline to TF-CBT plus placebo in to 17 year olds with sexual abuse related PTSD symptoms. All children significantly improved with no groupby-time differences found except on Children s Global Assessment Scale scores. This study concluded that, although starting treatment with combined sertraline and TF-CBT might be beneficial for some children, it is generally preferable to begin with TF- CBT alone and add an SSRI only if the child s symptom severity or lack of response suggests a need for additional interventions.

19 JAACAP Guidelines - PTSD On the basis of the above information, there are insufficient data to support the use of SSRI medication alone (i.e., in the absence of psychotherapy) for the treatment of childhood PTSD.

20 SSRI Antidepressants Examples Zoloft - sertraline Function through increasing the availability of serotonin by blocking the re-uptake process Prozac - fluoxetine Paxil - paroxetine Lexapro - escitalopram Zoloft was used in the CAMS study Prozac was used in the TADS study

21 Sertraline vs. Placebo Outcome is rating of PTSD symptoms

22 ASET Sample Polypharmacy Number of Medications Number of PTSD Diagnosed Youth

23 ASET Sample - Psychotropics Antipsychotic Stimulant Antidepressant non-ssri Mood Stabilizer Antihypertensive

24 ASET Sample Subjective Response 38% Medication Negative 62% Medication Positive 69% 31% Therapy Negative Therapy Positive

25 Seeking Effective Care Youth placed in residential care are extraordinarily exposed to traumatic experiences These youth surpass those typically involved in research Established, evidence-based care for these youth is desperately needed Subjective response is as important if not more as objectively based symptom control. Beyond symptom control: Cultivating resiliency

26 References Ernestine C. Briggs, Johanna K. P. Greeson, Christopher M. Layne, John A. Fairbank, Angel M. Knoverek & Robert S. Pynoos (2012): Trauma Exposure, Psychosocial Functioning, and Treatment Needs of Youth in Residential Care: Preliminary Findings from the NCTSN Core Data Set, Journal of Child & Adolescent Trauma, 5:1, 1-15 Schmid et al Developmental Trauma Disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems. BMC Psychiatry 13:3 The Hypothalamic-Pituitary-Adrenal Axis: The Actions of the Central Nervous System Olson, Marc, Grude, McManus, Hellermann, 2011

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