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Salud mental
versión impresa ISSN 0185-3325
Salud Ment vol.29 no.4 México jul./ago. 2006
Artículos originales
Principios generales sobre la psicofarmacoterapia en niños y adolescentes. Una revisión.
1Unidad de Investigación. Hospital Psiquiátrico de Tampico. Ejército Mexicano 1403, col. Allende, 89130, Tampico, Tamaulipas, México. Teléfonos: 2170679, 2131862.
2Coordinador de la Clínica de Niños y Adolescentes, Hospital Psiquiátrico de Tampico, México.
El trabajo de Charles Bradley realizado en 1937 que documenta los efectos de la benzedrina en 30 pacientes pediátricos con problemas conductuales, marca el inicio de la psicofarmacoterapia infantil; desafortunadamente la persistencia de las dificultades para conducir ensayos clínicos controlados ha sido una constante, la psicofarmacoterapia en adultos ha tenido un desarrollo diferente. En la década de 1950 la clorpromazina y los antidepresivos tricíclicos empiezan a utilizarse y en las décadas de 1980 y 1990 se desarrollan nuevos productos para el tratamiento de la esquizofrenia, la depresión y la manía. Actualmente la actividad clínica en psiquiatría infantil enfrenta algunos retos, como la sobre-prescripción de psicofármacos en los menores de edad por personas sin la suficiente formación académica, o los deficientes resultados terapéuticos causados por prescripciones equivocadas. Pero lo más grave son las falsas promesas dirigidas a familiares y pacientes respecto a productos o sustancias que no se han sometido a un escrutinio científico riguroso, sobre todo en problemas clínicos tan difundidos como el Trastorno por Déficit de la Atención e Hiperactividad (TDAH) o el autismo. El objetivo de este trabajo es efectuar una revisión de los principios generales recomendados para una adecuada psicofarmacoterapia en niños y adolescentes. Se enfatiza en primer término lo que es básico, es decir, que un diagnóstico correcto es fundamental para la selección del medicamento apropiado. Aunque esto debería estar sobreentendido, en la realidad es frecuente que suceda lo contrario. El desarrollo de taxonomías como el Manual Diagnóstico y Estadístico de Enfermedades Mentales o la Clasificación Internacional de Enfermedades ha permitido que exista un orden en la elaboración de los diagnósticos paidopsiquiátricos. Considerando la relevancia y responsabilidad que implica la atención a menores de edad, una instancia tan prestigiada como la Academia Americana de Psiquiatría Infantil propuso desde 1997 lo que se denominó parámetros para la evaluación psiquiátrica de niños y adolescentes, que sin duda son guías útiles para el trabajo clínico. La selección de un medicamento se recomienda que tenga su fundamento en dos premisas, por un lado el diagnóstico del trastorno en sí mismo y por el otro los síntomas blanco.
La psicofarmacoterapia pediátrica deberá basarse en la correlación de las acciones y efectos de los fármacos y los aspectos bioquímicos y evolutivos del trastorno, pero además será necesario que el clínico esté alerta respecto a los cambios que inevitablemente se producen en la dinámica de absorción, distribución y eliminación de los medicamentos según la etapa del desarrollo biológico infantil. Al tratar a niños muy pequeños, la imposibilidad de que proporcionen información directa obliga a considerar las realidades cognitivas y verbales propias de cada etapa del desarrollo infantil. Siempre será recomendable que el plan de tratamiento se organice conjuntamente con los padres del menor para que éstos estén informados de los objetivos de la prescripción; una tarea prioritaria será asegurar una alianza terapéutica. Durante el tratamiento el monitoreo clínico debe ser constante con instrumentos clinimétricos; siempre será recomendable contar con una historia médica completa, y con una evaluación física y neurológica.
El apoyo de los estudios de laboratorio juega un rol importante, la recomendación para efectuar una evaluación electrocardiográfica previa a la administración de algunos psicofármacos cada vez cuenta con más adeptos. La polifarmacia es una práctica muy común, se recomienda que se tome en cuenta la interacción droga/droga incluso con medicamentos de uso frecuente en estas edades por otras condiciones mórbidas no paidopsiquiátricas.
La estrategia para seleccionar un plan de tratamiento farmacológico para el paciente pediátrico deberá realizarse en forma individualizada. El objetivo del psiquiatra infantil deberá ser el de alcanzar el máximo beneficio terapéutico con el mínimo de efectos colaterales, evaluando siempre el riesgo-beneficio. No hay tiempos específicos normados para retirar la administración de un psicofármaco, pero ésto deberá hacerse paulatinamente.
Palabras clave: Psicofarmacoterapia; niños y adolescentes; principios generales; psiquiatría infantil
The work of Charles Bradley done in 1937, which reports the effects of Benzedrine in 30 pediatric patients that had behaviour problems, is a classic document considered by many as the beginning of child psychopharmacotherapy.
In spite of a coordinated effort made by the National Institute of Mental Health in the United States carried out by a panel, called "Conferences on Infantile Research in Psychopharmacology", for many years this practice kept being inarticulate.
Psychopharmacotherapy in adults with psychiatric diseases has had a different development. During the decade of 1950 substances such as chlorpromazine and tricycle antidepressives started to be used in clinical practice and between 1980 and 1990 new products were developed for treating schizophrenia, depression and mania. Even if there is no such as the "ideal drug", the new psychopharmacological developments have allowed patients to have a better quality of life.
In pediatric population the difficulty to conduct controlled clinical tests has been a constant; for this reason the practice of child psychopharmacotherapy keeps facing challenges; also, in the United States several very strict norms have been dictated in order to endorse the security and efficacy of a product for infantile use. Other problems faced today in clinical practice are the excesive use of medications for minors prescribed by people without enough practice and academic information, and also the deficient therapeutic results provoked by wrong prescriptions. But the worst of all are the false promises made to relatives and patients, on the usage of products or substances that have not been tested by a rigorous scientific scrutiny, specially concerning diffused clinical problems such as the Attention Deficit Hyperac-tivity Disorder (ADHD) or Autism. These facts, most of all, determine the rejection and fear for medications and become an adverse variable that we must face continuously.
The main objective of this work is to make a review about the general principles that are suggested for a good psychopharmaco-therapy on children and teen-agers, a practice that must always be part of a planned multimode treatment that follows an adequate paidopsychiatric evaluation.
A right diagnose will always be important for the appropriate selection of the medication. The development of taxonomies such as those described in the Mental Disorders Statistics and Diagnostic Manual of the American Psychiatric Association or by the International Classification of Diseases of the World Health
Organization, have allowed the existence of an order in the ela-boration of paidopsychiatric diagnosis, that even if being mainly descriptive, allow to make a more structured clinical work. The parameters for the psychiatric evaluation of children and teen-agers recommended by the American Academy of Child and Adolescent Psychiatry (AACAP) in 1997 is an example of the importance that proves the attention on minors, its objective is to give a guide without pretending to make it a golden standard. The selection of a medication must be based on two premises: a diagnose of the disorder itself, and on the other hand, the recognition of target symptoms. Considering this interrelation will allow a more acceptable evaluation on the risks and benefits of a phar-macological prescription for children and teenagers.
Thus pediatric psychopharmacotherapy must be based on the correlation between the actions and effects of drugs and the biochemical and evolving aspects of the disorder, but it will also be necessary that the professional be aware of the changes that inevitably will take place in the dynamic of absorption, distribution and elimination of the medications according to the stage of the biological child's development.
When someone deals with very small children, it is almost impossible for the child psychiatrist to get direct information as it is for children to understand the information that the expert would pretend to give them. This constrains to consider the cognitive and verbal realities proper of each stage of the development, so the direct evaluation of the small patient must be complemented with reports of a multi-informers system. It will be fundamental to consider also that small children have little differentiated emotions and that it must not be ignored that for them concepts such as time and space are difficult to understand. Clinical exploration through recreational activities will be a primordial tool in the daily work with children. It will also be recommendable that the plan of the treatment be organized jointly with the parents of the minor in order to inform them completely about the goals and objectives of the prescription of a drug; the participation of the small patient must be included too. It must not be forgotten that the pharmacological treatment is part of a more integral attention program in which other experts must participate, such as pedagogues, clinical psychologists or language therapists, a fact that will be more common than irregular.
The therapeutic adherence is a variable that must be constantly checked. If it is carried out irregularly or the wrong dose of the recommended drug is taken, the presence of symptoms as a result of the abrupt interruption of the medication could be confused with the adverse collateral effects, which would make worse the clinical condition.
Pediatric patients must have a complete medical history complemented by a physical and neurological evaluation, which must be included in the registry of vital constants as well as size and weight of the minor; other registers could be more convenient if they are considered to be needed.
The support on laboratory surveys plays an important roll and at the present time the recommendation for making an electro-cardiography evaluation previous to the administration of some drugs is more accepted; in this sense it is undoubtedly important to consider the recommendations proposed by the American Association of Cardiology for monitoring the cardiovascular function of children and teen-agers who receive medications after prolonged periods of time.
Polypharmacy is a common practice; due to this fact, the interaction between drug/ drug must be carefully valued. The child psychiatric evaluation must be made with the support of structured or semistructured interviews for the clinical diagnosis and with evaluation scales for measuring the severity of the specific symptoms or global clinical conditions. The strategy for choosing a plan of pharmacological treatment for the pediatric patient must be made individually; in this sense, the development of algorithms for the administration of medications on children and teenagers has been the result of many efforts in order to make prescriptions more rational and neat. The revision of controlled clinical tests on the efficacy and security of these agents in the pediatric population is fundamental for the election of a prescription.
The responsibility of the professional that prescribes a medication devolves on structuring a plan of formal treatment and an individualized monitoring according to the stages of the treatment (beginning, maintenance and interruption ). As it is expected, the expert must reach the maximum therapeutic benefit in a child or an adolescent with the minimum of collateral effects, evaluating always the risk and the benefits. Some authors recommend the prescription of drugs on children and teen-agers only for short periods of time as the nondesirable effects in long terms are not quite well known. There are no specific times for stopping the administration of a drug. However, it is recommended that during the stages of the treatment, clinical changes in minors be watched and registered rigorously, in order to be able to reduce or stop the dose in the appropriate moment, even in cases of clinical conditions such as schizophrenia, depression or development generalized disorders. The main objective of this clinical work will be that the quality of life of the minor becomes optimum.
Key words: Psychopharmacotherapy; children and adolescents; general principles; child psychiatry
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Recibido: 20 de Abril de 2006; Aprobado: 03 de Mayo de 2006
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