Dr. James Schaller, MD
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Title: A Case of Mood Problems & Behavior Troubles
Excerpt from 60 Case Solutions for Out of Control Youth

Aggressive Irritable Depression

Len is 14 years old and he speaks to adults as if dying from boredom. He sits low in his chair with a slouch that is almost a gymnastic feat. His grades have fallen from B's to F's. He is very hostile and yells back at you for trivial reasons. He seems to do little else but computer games and "hanging out" with a few local friends. He is very distant, uncooperative and annoyed at you for trivial reasons. His only new stress is a move three years ago.


Biological Depression in children and adolescents is not easy to see. Often a child is merely hostile, irritable and moody. They may not be sad and can often still enjoy a number of things. Many become more prone to fights, partly because depression thins a child's defenses. It is like they are dressed in rice paper in a hailstorm. They seem frustrated with everything.

A practitioner must not be satisfied with 60% improvement. Since, that means 40% of aggression and irritability remains.

We will talk about natural options in other sections, but for some parents they take too long, and may not work significantly. And Major Depression has a death rate of 15% that should be taken seriously.

Medications

Some oppositional youth will not take medication without a reward. Do not assume they will be "reasonable." Medication may make them feel flawed. Yet once they feel better they will often be willing to take with no reward.

Most anti-depressants are started at doses far too high and make youth anxious, restless, nauseated and cause headaches. This is especially true if a youth is anxious. Many recommended starting doses are profoundly aggressive. So youth that are already oppositional or inclined to reject medication, get a side effect that fuels further rejection. The solution?

Use a pill cutter or open the capsule and make the first dose 1/4th of the smallest starting pill or capsule. If you are eager to speed treatment, you can always take another _ dose in 12 hours if no side effects. You can always increase the medication fairly quickly, perhaps a half tablet a day if no side effects. Signs the dose does not need to be raised include new vivid dreams, worsening insomnia, new headaches and nausea.

The starting dose has nothing to do with the final dose of a medication, which might need to be high.

For simplicity sake let me only mention a sampling of key medications and common errors in using them in an out patient setting:

  • Lexapro - a pure medication with no useless metabolites. However, the first dose should be _ of 10 mg. If tolerated after 7 days, it can be increased to 5 mg for a 7 days, and then 10 mgs if no side effects.


  • Effexor - Useful for youth who do not respond to gentle anti-depressants. The starting dose of 37.5 mg is usually too high for the first few days, and you will have to open the capsule by pulling it apart. Please have the child's blood pressure and pulse checked with each dose increase. Most physicians do not get blood levels, but peak blood levels might be useful if doses over 375 mg are needed. The company markets the drug as a once a day medication, but to prevent mild withdrawal symptoms in some, consider splitting the dose.


  • Wellbutrin SR - starting dose should be _ of a 100 mg slow release tablet. According to new research, it can be cut but not crushed. It is not useful for anxiety, unless it is part of Major Depression. The dose can be raised quickly if no side effects. It helps some youth with ADD or ADHD but this benefit can be overstated.


  • Zoloft - a medication with a long history of use in youth. A careful first day dose is _ of 25 mg tablet, but the dose can be raised quickly. If the benefit is lost over months or seasons, it may need to be raised fairly often. In my research on Zoloft blood levels over 2 years, they seemed to fall commonly.


The Most Effective Natural Treatment

SAMe - we have started to use this natural liver substance in youth. My team has invented a cream form that works very quickly. Its main side effect is anxiety or some belly cramping if the dose is excessive. Like all anti-depressants, it can induce mania in bipolar youth with as little as 300 mg. In youth who have manic relatives or possible mania, start with oral dosing at 200 mg per am, and increase up by 100 mgs till 600 mg per am. If no problem with 600 mg it is doubtful mania is an issue.

A young child might only need 200-600 mg. A larger adolescent may need 1000 to 1600 mg.

If the child has no problems with mania or anxiety, you might consider switching to a special SAMe cream, which allows you to bypass the liver and deliver 400 mg through the skin (which equals about 1200 mg to 1400 mg by mouth). It is cheaper to give it through the skin. While we have a lot of research on its use in adults, there is little research in dosing youth.


Diplomate: American Board of Psychiatry & Neurology
Diplomate: Forensic Medicine & Forensic Examination
Certification: American Soc. Clinical Psychopharmacology

Community Bank Towers • Newgate Center
5150 Tamiami Trail, N • Naples, FL 34103
Phone: (239) 263-0133

Recognized in "America's Top Psychiatrists"

Bank Towers, Tamiami Trail, Naples, FL
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