Pediatric emergency medicine trisk 4190 4190
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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
