Utility of the head computerized tomography scan in child and adolescent psychiatry

Use of routine computed tomography brain scanning of psychiatry patients

The aim of this study was to evaluate the usefulness of CT of the brain in patients presenting with a psychiatric condition without focal neurological signs. The reports of 397 consecutive CT brain scans of patients presenting to two acute tertiary hospital psychiatric services over a 2-year period were assessed retrospectively. Of the 397 patients, 241 had psychosis, 87 had depression, 44 had bipolar affective disorder, seven had alcohol dependence, five had dementia, and the remaining 13 had a variety of diagnoses including personality disorder and transient ischaemic attack. Findings on 377 (95%) of the CT scans showed no abnormality. Specific abnormalities were described in 20 (5%) of the CT scans. Three scans showed non-specific minor abnormalities, which, when followed up by MRI, showed no relevant abnormality. All the abnormalities shown on CT were considered to be clinically unrelated to the patient's psychiatric condition. In conclusion, the pretest probability of finding a space-occupying lesion or other pertinent abnormality in patients presenting with psychiatric illnesses in this retrospective study appears not to be greater than that of the general population. The outcome of this study could be implemented to develop a clinical pathway for limiting assessment by CT for possible organic pathology in acute psychiatric illness.

Increasing the clinical yield of computerized tomography for psychiatric patients

Computerized tomography (CT) continues to be extensively utilized to exclude intracranial pathology in psychiatric practice, but little is known about clinical risk factors, which might predict those patients most likely to benefit from the procedure. We reviewed 150 cases of psychiatric patients who received CT scans to exclude intracranial pathology. We assessed the relationships of patient age, psychiatric diagnosis, and findings from neurologic and cognitive examinations to CT results that influenced patient care, and overall normal and abnormal CT results. Fifty-three percent of the CT scans were abnormal, 11% influenced patient care, and only 2% identified potentially reversible lesions. Cognitive exam results and, to a lesser extent, neurologic exam results, were sensitive predictors of CT findings that influenced patient care. All patients with clinically influential CT results had cognitive deficits and all but one had neurologic deficits. Patients older than 60 years of age and those with organic mental syndromes were most likely to have clinically influential CT findings. Our results suggest that utilizing specific clinical risk factors such as findings from clinical examinations, patient age, and psychiatric diagnosis, to guide the ordering of CT scans, can greatly increase the yield of the procedure for psychiatric patients, without excess medical morbidity.

Laboratory and diagnostic testing in child and adolescent psychiatry: a review of the past 10 years

OBJECTIVE

To review in a critical fashion the literature of the past decade covering diagnostic and laboratory testing in the field of child and adolescent psychiatry.

METHOD

A computerized search of articles published during the past decade was made, and selected articles are presented. Because of the paucity of articles specifically relating to minors, selected articles from adult psychiatry are cited.

RESULTS

With a few notable exceptions, few controlled studies on the specificity and sensitivity of any laboratory test for any specific disorder of behavior presenting in children have been conducted in children and adolescents. A high index of suspicion will remain the clinician's best ally in utilizing laboratory measures in the assessment of psychopathology. Nonetheless, studies have appeared that will guide the clinician as to what tests are not clinically useful.

CONCLUSION

Indications and the lack of indications for specific laboratory studies are an integral part of the knowledge base that child psychiatrists must have. Much more empirical data will need to be collected prospectively to inform the field and to move the judicious use of the laboratory from an art to a science.

Diagnostic yield of brain CT in a limited-access environment

It is not clear why brain CT continues to be used in psychiatric patients in spite of reports of a low yield of useful information. Hypoihetically, in circumstances (such as in Israel) where access to CT is more limited, clinicians will use brain CT more judiciously, resulting in a higher yield. To test this hypothesis, we retrieved and reviewed brain CT results and discharge summaries for 23 patients with abnormal brain scans, from 91 scans performed at two psychiatric inpatient facilities, in order to determine if the brain CT had a significant effect on the diagnosis or treatment of the patient. We found no indication that the abnormal CT findings had a significant effect on the diagnosis or treatment of any of the patients.

Economic evaluations and interventions for children and adolescents with mental health problems

Economic evaluations of interventions for children and adolescents with mental health problems are comparatively rare, although the growing need for them is now quite widely recognized. This review paper first explains how demands for such evaluations have built up, and for what reasons, and then considers the response from evaluators. The various modes of economic evaluation are introduced and illustrated. Previous and current research is discussed by reference to five generic research questions commonly addressed in the wider health economics field: What treatment should be provided? When? Where? To whom? How? The review concludes with recommendations as to how economic evaluations should be taken forward in this increasingly important area of intervention.

Diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis

OBJECTIVE

To determine the diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis.

METHOD

111 consecutively admitted adolescents (aged 13 through 19 years) who presented with a first-onset psychosis and who had an unremarkable medical history and normal physical examination were given a battery of endocrine and neuroimaging screening tests. Diagnostic utility of a screening test was defined as an abnormal result (a positive test) that either led to a previously unknown or unsuspected medical diagnosis or played an important role in the clinical care of the patient.

RESULTS

15.4% of the endocrine screening tests and 11.0% of the neuroimaging screening tests were identified as positive. However, no endocrine and no neuroimaging tests met criteria for diagnostic utility. The direct cost of this screening battery was $636.95 per patient.

CONCLUSION

Routine endocrine and neuroimaging screening tests in first-onset adolescent psychosis provide no diagnostic utility and are not cost-effective. Selective use of appropriate endocrine and neuroimaging diagnostic tests in populations with symptoms suggestive of organic disorders should replace routine screening procedures.