Sm 11.05.06 - evaluacion tratamiento esquizofrenia.pmd
Salud Mental 2011;34:419-423 Schizophrenia in children and adolescents; diagnosis and treatment
Assessment and treatment of schizophrenia
in children and adolescents: a current review
Rosa Elena Ulloa Flores,1 Tizbé del Rosario Sauer Vera,2 Rogelio Apiquian Guitart3
Schizophrenia is a severe and chronic disorder affecting children,
La esquizofrenia es un trastorno prevalente, crónico e incapacitante
adolescents, and adults. The international recommendations for the
en niños, adolescentes y adultos. Las recomendaciones internacio-
treatment of pediatric patients with this disorder point to a
nales para su tratamiento en edad pediátrica incluyen programas
comprehensive management, which includes early detection
de detección temprana y tratamiento farmacológico y psicosocial. El
programs, and pharmacological and psychosocial treatments. This
presente trabajo muestra una revisión actualizada de la eficacia y la
work presents a review of current information regarding the efficacy
seguridad de los antipsicóticos en niños y adolescentes, así como el
and safety of antipsychotics in children and adolescents, as well as
efecto de las intervenciones psicosociales en el funcionamiento aca-
the effect of psychosocial interventions on the academic and social
démico y social en pacientes con esquizofrenia de inicio temprano.
functioning of patients with early onset schizophrenia.
La meta del tratamiento farmacológico es lograr un resultado
The goal of pharmacological treatment is to achieve optimal
óptimo a dosis mínimas efectivas del antipsicótico y tener el menor
outcome with the lowest effective dose and the fewest side effects.
número de efectos secundarios. Deben de considerarse los
Treatment should be started with an antipsychotic that has been
antipsicóticos evaluados en estudios controlados en edad pediátrica.
assessed for its efficacy and safety in this age group. Risperidone,
La risperidona, la olanzapina y el aripiprazol han sido aprobados
olanzapine and aripiprazole have been approved by the FDA for the
por la FDA para el tratamiento de la esquizofrenia en adolescentes;
treatment of schizophrenia in adolescents; clozapine has shown
la clozapina ha mostrado mayor eficacia en el tratamiento de la
greater efficacy with the treatment-resistant psychosis, while its adverse
psicosis resistente, sus efectos adversos deben de ser monitorizados
side effects must be monitored during use.
The objectives of psychosocial treatment are to provide
El tratamiento psicosocial brinda información al paciente y su
information, to promote the patient’s adaptation, to reduce comorbidity
familia, promueve la adaptación y disminuye la comorbilidad para
and to prevent relapses through psychoeducation, psychotherapy, and
prevenir recaídas, por medio de programas de psicoeducación,
rehabilitation programs. Psychoeducation programs include infor-
psicoterapia y rehabilitación. Los programas de psicoeducación
mation about the characteristics and causes of the illness, the available
incluyen la información acerca de la enfermedad y sus causas, los
treatment choices and the factors associated with recovery or relapse.
tratamientos disponibles y los factores asociados a las recaídas. La
Psychotherapy in schizophrenia has been examined in individual, group,
psicoterapia puede darse en el contexto individual, familiar o grupal,
and family modalities; cognitive behavioral therapy has demonstrated
de acuerdo a las necesidades del paciente. La terapia cognitivo
efficacy on cognition, social adjustment, and quality of life. Rehabili-
conductual ha mostrado eficacia en la adaptación social, cognitiva
tation programs include training on social skills, cognitive remediation
y en la calidad de vida. Los programas de rehabilitación incluyen
therapy, and exercise programs, which would increase the wellbeing
entrenamiento en habilidades sociales, rehabilitación cognitiva y un
of patients and reduce metabolic alterations associated with the use of
programa de acondicionamiento físico para promover el bienestar
general del paciente y evitar la aparición de los efectos secundarios
In conclusion, the treatment of patients with early onset schizo-
phrenia must be multimodal with the aim of improving their long-
En conclusión, la esquizofrenia en niños y adolescentes requiere
de tratamiento multidisciplinario a fin de mejorar el pronóstico delos pacientes.
Key words: Schizophrenia, treatment, children, adolescents, anti-psychotics.
Palabras clave: Esquizofrenia, tratamiento, niños, adolescentes,antipsicóticos.
Developmental Psychopharmacology, Dr. Juan N. Navarro Children’s Psychiatric Hospital.
Psychiatric Care Services, Secretariat of Health.
Department of Behavioral Sciences, Universidad de las Américas (University of the Americas).
Correspondence: Dr. Rosa Elena Ulloa. Hospital Psiquiátrico Infantil «Dr. Juan N. Navarro», San Buenaventura 86,
Fax: (52 55) 5573 9161. E-mail: [email protected]
Schizophrenia is among the ten most common disabilitiesin the world1,2 and is defined as a psychotic disorder that
The process of clinically assessing a pediatric patient with
affects the perception, thought, emotions, and behavior of
schizophrenia includes a clinical history supported by
patients, breaking down their family, academic, and social
diagnostic interviews such as the K-SADS-PL12 or the
MINIKid,13 and once the diagnosis is confirmed, through
The lifetime prevalence of this illness has been reported
specific severity scales such as the Brief Psychiatric Rating
at between 0.3% and 1.6%3 and its incidence is between
Scale (BPRS)14, or the Positive and Negative Symptoms of
0.002% and 0.011%. In one third of patients with schizo-
Schizophrenia (PANSS) scale.15 It is important to assess the
phrenia the onset of the condition occurs before the age of
risk of auto- or hetero-aggression and the patient’s capacity
18,4 and in 6% before the age of 16.5 Within this population
a higher proportion of cases have been described among
Laboratory and clinical studies should also be
considered, as they provide information about the patient’sstate of health prior to commencing pharmacologicaltreatment and help to rule out any physical pathology that
Clinical manifestation of schizophrenia includes diverse
symptoms that are classified as positive (deliriums andhallucinations), negative (apathy, anhedonia, a reduction in
In Mexico there are few mental healthcare centers for
the lucidity and content of speech), affective (depression or
children and adolescents. The few there are handle the
anxiety that can accompany both the positive and the negative
majority of cases of schizophrenia. In such centers the
symptoms), cognitive (loss of memory, impaired judgment,
comprehensive management of schizophrenia should
disorganization), and excitability/hostility (agitation,
include programs for early detection, and pharmacological
aggression). In the case of pediatric patients the manifestation
of these symptoms is frequently preceded by developmentaldisorders, and a higher frequency of low IQ, cognitive deficits
and acute negative symptoms has been noted. There is also
In early detection it is important to take into account risk
a high prevalence of undifferentiated and disorganized
factors for the manifestation of psychotic symptoms, such
subtypes of the illness in children and adolescents.7,8
as a family history of psychosis, perinatal and neurode-
In the same way as adults, psychotic symptoms can
velopmental disorders, substance abuse, adolescence, and
often be preceded by prodromal symptoms.5 These include
stress. Different healthcare workers can participate in the
a decrease in attention, concentration and motivation,
early detection programs designed to examine these risk
energy, mood disorders, abnormalities in the sleep-wake
factors. The principal components of such programs are
cycle, isolation, suspicion, and a decrease in functioning.
information about the illness, referral of patients to care
The course of schizophrenia includes remissions and
centers that specialize in their assessment and treatment,
exacerbations, although in some patients a serious psychotic
and the follow-up of cases in a way that can determine the
state will persist. Factors associated with a poor prognosis
effect of the staff’s intervention on the symptoms and
include poor premorbid functioning,9,10 greater duration
functioning of patients over the medium- and long-term.17
of untreated psychosis,11 greater severity of the illness anda greater number of relapses.5
This work presents a current review of all aspects of
treatment for this condition, offering recommendations
Trifluoperazine was the first antipsychotic medication
regarding the handling of schizophrenia in our field. For
assessed in a controlled clinical study.18 One of the first
this review articles were identified that covered the efficacy
efficiency studies compared chlorpromazine and
and safety of antipsychotic medications in children and
haloperidol,19 which was subsequently compared with the
adolescents, as well as the effects of psychoeducation and
other psychosocial interventions on the symptoms as well
Risperidone has been studied in various open clinical21
as the academic and social functioning of patients. The
and placebo-controlled22,23 trials, and with other atypical
search for materials focused on articles published in
antipsychotics like quetiapine.24 Olanzapine25 and aripipra-
medicine and psychology databases (PsychINFO, Medline,
zol26 are the antipsychotics most recently approved for use
1966–2011, Cochrane); also examined were the works
in adolescents with schizophrenia. Clozapine was assessed
referred to in the tracking studies.
in controlled studies with haloperidol27 and olanzapine.28
Schizophrenia in children and adolescents; diagnosis and treatment
Recent reviews recommend it for patients who have not re-
psychosocial function, reduce comorbidity, and prevent
sponded to other antipsychotics;29,30 it has been recommend-
relapses. The strategies for this treatment include psycho-
ed for patients who have not responded to other treatments
education, psychotherapy, and rehabilitation, which are
and has been assessed in a clinical study. Recently the study
applied in comprehensive treatment programs. An example
for Treatment of Early Onset Schizophrenia Spectrum
of this is the «Trialog» Project in Germany, which includes
Disorders (abbreviated to TEOSS) compared the efficacy of
psychoeducation and provides tools for social competence
typical and atypical antipsychotics, showing no significant
and self-care, as well as a process of cognitive rehabilitation
differences between molindone, olanzapine and risperidone
for adolescents with schizophrenia. Results at two years
when monitored at eight weeks and at one year, emphasizing
showed that patients experienced a lower intensity of
that the affects of atypical antipsychotics on metabolism must
symptoms, and an improvement in cognition and social
functioning.39 Here in Mexico, a randomized study of adult
Treatment should be started with an antipsychotic
patients with schizophrenia showed that the combination
medication that has been assessed for efficacy and safety for
of pharmacotherapy with a program of psychosocial
the pediatric group. Such medication should be prescribed
treatment increased adherence to treatment, reduced the
in adequate doses for a minimum of six weeks. At the end
severity of symptoms, and improved the overall functioning
of this period the patient should be assessed regarding
of the patients, while also reducing relapses.40
reduction of symptoms as well as functional improvement.
The process of psychoeducation includes familiar-
If a good response is observed (a 30% score reduction on the
ization with the characteristics and causes of the illness,
scales and a functional improvement), treatment should be
the available treatment options, and the factors that help
maintained for at least two years. If a good response is not
or hinder the patient’s recovery. Furthermore, it provides
observed (after adherence to the treatment has been
tools for managing stress and for the timely detection of
confirmed), a change in antipsychotics should be considered.
symptoms in case of relapse. Although information is scarce
If there is a predominance of positive symptoms a typical
regarding psychoeducation programs for adolescents,
antipsychotic should be considered, and if there is a
studies in adults have proven the efficacy of psychoedu-
predominance of negative symptoms, an atypical. If after
cation,41 even in comparison with cognitive behavioral
six weeks on a second antipsychotic there is no response, an
assessment of the use of clozapine is recommended.33
Psychotherapy for schizophrenic patients can be given
In establishing and monitoring treatment with anti-
in several contexts, according to their personal needs and
psychotics it is advisable to use the minimum effective dose
of the medication, as the use of a high dose won’t accelerate
Cognitive behavioral therapy has proven effective in
the recovery of the patient, but would in fact increase the
decreasing symptoms and the number of rehospitalizations,
risk of side effects and the need for polypharmacy to control
and in improving the quality of life; various studies have
them. Furthermore, it is important to take note of side effects
assessed its efficacy in comparison with psychoeducation
such as tardive dyskinesia, neuroleptic malignant syndrome,
extra-pyramidal symptoms, hyperprolactinemia, metabolic
The rehabilitation of patients with schizophrenia should
syndrome and agranulocytosis; although these side effects
include training in social skills48 and personal care tasks, an
have been associated with specific antipsychotics, they could
exercise program to increase patient’s general wellbeing and
occur with the use of any atypical antipsychotic.4,34-36 It is
prevent metabolic alterations,49,50 and cognitive rehabili-
therefore recommended that laboratory tests be conducted
tation, particularly in processes of attention, memory, and
every six months, as well as the recording of vital signs
information processing, with the aim of facilitating the
and weight of the patient at every appointment.
Patients with schizophrenia could develop comorbidity
with other psychopathologies throughout their lives. Thosemost frequently reported are attention deficit hyperactivity
able 1. Key objectives of psychotherapy in its various contexts
disorder (84%), oppositional defiant disorder (43%), anddepression (30%).37,38 Comorbidity with disorders due to
Reduce vulnerability and stress, optimize adjustment
substance abuse should particularly be examined in ado-
capability and functioning of the patient, and prevent
lescents. The treatment of comorbidity should be multi-
Improve adherence to treatment, promote problemsolving, encourage social interactions and preventrelapses.
Build partnerships with families, foster families’ potentialto anticipate and resolve problems, reduce outbursts
The objectives of psychosocial treatment are to increase
of distress and guilt, along with maintaining realistic
knowledge about the illness, promote adjustment, improve
expectations about the functioning of the patient.
pective study with risperidone long-acting injectable. J Clin Psychophar-macol 2011;31:75-81.
This review presents the current outlook of the clinical
11. Marshall M, Lewis S, Lockwood A, Drake R et al. Association between
duration of untreated psychosis and outcome in cohorts of first-episode
characteristics, assessment, early detection, and treatment
patients: a systematic review. Arch Gen Psychiatry 2005;62:975-983.
of schizophrenia in children and adolescents with evidence-
12. Ulloa R, Ortiz S, Higuera F, Fresán A et al. Estudio de fiabilidad intere-
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valuador de la versión en español de la entrevista Schedule for Affecti-
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ve Disordes and Schizophrenia for School- Age children- Present and
the earlier the age of onset, the more complicated the treat-
Lifetime versión (K-SADS-PL). Actas Esp Psiquiatr 2006;34:36-40.
ment becomes and the poorer the prognosis. The handling
13. Sheehan D, Lecrubier Y, Colón-Soto M. MINI KID. Mini International
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Madrid; 2000. Available at: http://www.medical-outcomes.com. Access
of antipsychotic medications, which have not been assessed
in controlled studies of child and adolescent populations in
14. Bech P, Kastrup M, Rafaelsen O. Mini-compendium of rating scales for
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DSM-III syndromes. Acta Psychiatr Scand 1986;73:1-37.
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The authors wish to thank Gamaliel Victoria and Gabriela López
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for their assistance in drafting this manuscript.
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Dr. Rogelio Apiquian Guitart has served as part of the Advisory Board ofAstra Zeneca and has been paid as a lecturer from Janssen Cilag and AstraZeneca. He has participated in and/or received payment for Janssen Cilag,Astra Zeneca, and Roche randomized, controlled studies. The other authorshave no relationship with the pharmaceutical industry or other institutionsthat could result in a conflict of interest.
MATERIAL SAFETY DATA SHEET 1. IDENTIFICATION OF MATERIAL AND SUPPLIER PRODUCT NAME: Barmac Permethrin D INSECTICIDAL GROUP: Group 3A APVMA REGISTRATION NUMBER : 49084 AUSTRALIAN DISTRIBUTOR: USE : Insecticide EMERGENCY PHONE NUMBERS: Fire Brigade, Ambulance and Police Services: 000 FORM: Dust 2. HAZARD IDENTIFICATION Classified as hazardous according to the
Preventive Veterinary Medicine 63 (2004) 237–256A meta-analysis of the milk-production responseafter anthelmintic treatment in naturallyJavier Sanchez , Ian Dohoo , Jeromy Carrier , Luc DesCˆoteaux a Department of Health Management, Atlantic Veterinary College, University of Prince Edward Island, 550 University Avenue, Charlottetown, PEI, Canada C1A 4P3 b Faculté de Médécine Vet