23 - Psychiatric disorders in people with 22q11.2D

Psychiatric disorders in people with 22q11.2DS

Drug treatment of psychiatric symptoms in the context of other conditions CHAPTER 10 Psychiatric disorders in people with 22q11.2DS Around 60% of people with 22q11.2DS meet diagnostic criteria for some type of ­psychiatric disorder during their lives.4 Children with 22q11.2DS have an elevated prevalence of anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders.2 Anxiety disorders are profoundly increased in adults, with about 2–3 times the expected population prevalence.1 Schizophrenia is diagnosed in ­approximately one in every four to five adults with 22q11.2DS.1 Box 10.2 summarises the general principles of prescribing in 22q11.2DS. Few studies have evaluated the safety and efficacy of psychotropics in people with 22q11.2DS. However, standard pharmacological (and non-­pharmacological) treatments for ADHD, anxiety, mood disorders and schizophrenia appear to be effective and treatment protocols used in the general population should be followed.1,5 Current evidence and opinion on the treatment of psychiatric disorders in people with 22q11.2DS are summarised in Table 10.7. Box 10.2  General principles of prescribing in 22q11.2 deletion syndrome6,7 ■ ■22q11.2DS confers an increased risk of treatable psychiatric disorders ■ ■Standard pharmacological treatment protocols should be followed ■ ■Consider the individual patient comorbidities and clinical features (Table 10.6) that may increase the propensity to adverse effects from psychotropics (e.g. arrhythmias, seizures, weight gain, EPSEs) ■ ■Endocrine abnormalities (e.g. hypoparathyroidism and hypothyroidism) should be corrected before starting psychotropics because they can mimic psychiatric symptoms and complicate ­treatment with psychotropics4,5 DS, deletion syndrome; EPSEs, extrapyramidal side effects. Table 10.7  Management of psychiatric disorders in people with 22q11.2 deletion syndrome.8 Psychiatric disorder Treatments ADHD There is a theoretical risk of psychosis with psychostimulants in people with 22q11.2DS but standard treatment protocols are advised.4 In those with congenital heart disease, cardiology advice should be sought before initiating stimulant medications.9 Three studies support the efficacy of methylphenidate in children with 22q11.2DS.4,10 Treatment was generally well tolerated. A comprehensive cardiovascular assessment before and during treatment is recommended. Depression and anxiety Both depression and anxiety appear to respond favourably to SSRIs.4 Further management after treatment failure follows standard protocols. Caution should be exercised with drugs that lower the seizure threshold (e.g. bupropion).7 Obsessive compulsive disorder One study of four people with OCD and 22q11.2DS found a mean rate of improvement of 35% in symptom score after treatment with fluoxetine (30–60mg/day). Treatment was well tolerated.11 (Continued )