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Prof Christoph Correll : schizophrenia in children and adolescents

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Treating Schizophrenia in Children and Adolescents





Hello! You’re on MD-FM INSIGHT, the first medical web radio. Today we’ll be devoting our "Question & Answer" program to the treatment of schizophrenia in children and adolescents.

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At the last annual meeting of the American Psychiatric Association, in San Francisco, we met with Christoph Correll, from the Albert Einstein College of Medicine in New York. Pr. Correll is specialized in child and adolescent psychiatry.


Dr. Correll, First of all can you give us a general idea of how children and adolescents with schizophrenia are treated today –do we use therapy AND medication?

Bob-Correll-1: “So the treatment of psychosis and schizophrenia in adolescents should really follow a similar approach as in adults –that means medications are the mainstay. Without antipsychotics, we will not be able to treat psychosis in adolescents, but medication shouldn’t be given in a vacuum, you have to combine that with psychosocial interventions”


And what medications are available for children with schizophrenia?

Bob-Correll -2: “There are 5 medications –5 second-generation antipsychotics that have produced some significant data and relevance of superiority compared to placebo for total psychopathology and for positive symptoms. So: olanzapine, aripiprazole, quetiapine, risperidone and paliperidone. Patients who have early onset, before age 18, are more likely not to respond as well, so we might have to try various medication and choosing the lowest risk medication early on –it’s the most crucial event to happen in this treatment algorithm because switching later can be destabilizing and we want to prevent side-effects from happening rather than having to treat them afterwards. Also adherence and acceptability of treatment might be much higher when you use the best medication that has relatively low side effects. Since patients in the early phase and first episodes are more responsive to whatever medication you give them, I think, particularly in first episodes, you should use the lowest risk agents.”


Ok and, as you just mentioned: I imagine there are important aspects to take into consideration when you are giving such strong medication to children…

Bob-Correll -3: “So basically, children and adolescents are often early in their illness course and you might have more sensitivity to medications. That means the doses might have to be a little lower, overall, at least when they’re first episode patients, but you should not base it on body weight, like you do for stimulants. You also need to titrate somewhat slowly and measure side effects carefully, because patients who are young and adolescents seem to have higher risk for sedation, extrapyramidal side effects, withdrawal dyskinesia as well as weight gain, prolactin elevation and dyslipidemia. So we do have to deal with these side effects, monitor them and manage them.”


And how do you evaluate the benefits and risks of these medications in these patients?

Bob-Correll -4: “The benefit/risk ratio will depend on how much the symptoms are reduced, and how much, with the symptom reduction, patients can go back to school, have social interactions that are meaningful. And the risk/benefit ratio is something we should always discuss with family members and patients and parents, and this is an ongoing discussion. What might be good now might not be good enough anymore in 6 months.”


And how often should they come in to meet with their practitioner?

Bob-Correll-5: “Yes so the guidelines stipulate baseline, 3 months and annually visits for weight and metabolic abnormalities. We have proposed numerous times that for children and adolescents and first episode patients, it should be baseline, 3 months, 6 months, and then 6-monthly assessments for weight, for waist circumference, fasting blood sugar, fasting blood lipid and blood pressure.”


Ok and concerning the psychotherapeutic approach –what would you recommend?

Bob-Correll-6: “So in a systematic review we recently published, I was quite surprised to see how few randomized control trials there were in young people, augmenting medication treatment with psychosocial intervention. Again, I should stress: these were not monotherapy trials, People don’t believe psychosocial interventions alone are good enough for true schizophrenia or severe psychotic disorder. So we found 4 studies that had cognitive remediation techniques, which did not reduce the symptoms but helped with some cognitive symptomatology. There were 2 studies that investigated the effect of cognitive behavior therapy, and there was a suggestion that maybe remission rates were higher in the CBT group but again, we need larger data because it wasn’t significant in this study. And we had a family-based intervention where, again, relapse rates were not different but rehospitalization rates were significantly lower. So I think we need to get more information but common sense would suggest that you need to involve the family and the patient in psychosocial interventions, increase adherence and acceptability of the treatment.”


What would be your conclusion?

Bob-Correll-7: “Treating early onset psychiatric conditions is a challenging task and, particularly schizophrenia and severe psychotic disorders are particularly challenging because these patients are very severely affected, they often have a long-term neurodevelopmental impairment that determines course and outcomes. We should do as good as we can and we need even better treatments that can help subgroups of patients more in a targeted way and that hopefully you can elevate functioning and cognition and help negative symptoms, whereas current treatments often deal with these dimensions less and help more the positive symptoms.”



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