Image: Tom Varco
If you struggle with titrating psychiatric medications for your pediatric patients, you are not alone. Even for some alumni of the REACH program Patient-Centered Mental Health in Pediatric Primary Care, lack of comfort with psychiatric medications can hamper effective treatment.
What does it take to dose and cross-titrate effectively? We asked two REACH faculty members: Peter S. Jensen, MD, REACH founder, and Amy Kryder, MD, education lead of the statewide REACH program in Virginia.
Dr. Kryder told a story of a patient she was able to help only when she stepped outside her medication comfort zone. Dr. Kryder had been treating “Ava,” now 20, for depression and anxiety for several years.
“I tried her on multiple SSRIs,” said Dr. Kryder. “They helped, but not enough. She still was plagued by negative thoughts and anxieties. Counseling didn’t really help, either.”
Dr. Kryder decided to try a drug in a different but related class, an SNRI that she had never prescribed before. She talked it over with Ava, who was old enough to make an informed decision and trusted her long-time pediatrician.
“My discomfort when crossing medications is that I know symptoms may get worse,” said Dr. Kryder. “So I told her, ‘I want to try this new drug. You may feel a little worse at first. I want you to call me if you experience anything you don’t like.’ Patients hardly ever call me, but putting the option out there makes me feel more comfortable.”
Dr. Kryder cross-titrated quickly, cutting the old SSRI in half while going to a half dose of the new drug in two weeks and then repeating, so that Ava was up to a therapeutic dose in four weeks.
“When she came in a month later, Ava was a new person. She said, ‘I feel better than I have in years.’ That was a hallelujah moment! We found the right medication for her.”
Dr. Kryder’s experience underscores what Dr. Jensen emphasized about medication titration: “Pay attention to the evidence, not your fear.”
The evidence includes research demonstrating that psychiatric medications approved for pediatric use have good safety profiles and relatively mild side effects for most patients.
Furthermore, nearly all such medications have well-established mean effective doses for children–which are, Dr. Jensen pointed out, often quite a bit higher than primary care providers typically go.
“We have pediatricians giving children 25 milligrams of Zoloft,” said Dr. Jensen, “when the average therapeutic dose is 150 to 200.”
Dr. Kryder said that, before REACH training, she had stopped prescribing Zoloft for depression because she thought it didn’t work. In fact, she simply wasn’t prescribing high enough dosages.
“The mantra is, ‘Start low, go slow,'” she said. “I want to add, ‘But don’t take forever to get there.'”
Moving too slowly has its own risks that may outweigh the risk of side effects. Besides the potentially dire consequences of unmanaged anxiety, depression, or ADHD, there’s also the possibility that patients and caregivers will simply give up after spending months on a treatment that isn’t having the desired effect.
“In our training, we teach the rule of three,” said Dr. Jensen. “Lower the dosage of the old medication by one-third one week, the same amount the next week, and down to zero the third week. At the same time, raise the new medication at about the same rate, starting with one-quarter to one-third of the mean effective dose.”
Only if side effects are severe–a rare occurrence, said Dr. Jensen–should you stop a medication cold turkey.
While agreeing that finding an effective treatment is vital and urgent, Dr. Jensen also counseled patience. Many psychiatric medications take weeks to have their full effect. For most, the only way you can tell if you’ve reached the optimal dose is clinical observation.
That’s where another form of evidence comes in: Rating scales give you quantitative measures of patients’ functioning and well-being. Dr. Jensen pointed out that you need to use rating scales repeatedly for optimal results, that is, to make sure that target symptoms reach a normal range. To get a full picture, you may need to get rating scale information not only from caregivers but also from the patients themselves and possibly teachers.
“When I started using rating scales, I increased dosages for almost all of my patients,” said Dr. Kryder. “Kids with ADHD, for example, were doing better than before medication, and the parents were thrilled. But the rating scales showed that they were still struggling.”
“I’m not satisfied with patients just doing better,” said Dr. Kryder. “I want them to do well.”
Dr. Kryder uses SwitchRx to help her cross-titrate psychiatric medications. After registering, you enter the medication and dosage you’re switching from and the medication you want to switch to. The tool provides an approximate cross-titration schedule you can tailor to your patient.
The rating scales provided to trainees in our course Patient-Centered Mental Health in Pediatric Primary Care are available for download on our website.
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