The clinical presentation of major depressive disorder in youth with co-occurring obsessive-compulsive disorder

BACKGROUND

Major depressive disorder (MDD) is common in youth and among the most frequent comorbid disorders in pediatric obsessive-compulsive disorder (OCD), but it is unclear whether the presence of OCD affects the symptom presentation of MDD in youth.

METHODS

A sample of youth with OCD and MDD (n = 124) and a sample of youth with MDD but no OCD (n = 673) completed the Patient Health Questionnaire for Adolescents (PHQ-A). The overall and symptom-level presentation of MDD were examined using group comparisons and network analysis.

RESULTS

Youth with MDD and OCD, compared to those with MDD and no OCD, had more severe MDD (Cohen's d = 0.39) and more reported moderate to severe depression (75 % vs 61 %). When accounting for demographic variables and the overall severity of MDD, those with comorbid OCD reported lower levels of anhedonia and more severe difficulties with psychomotor retardation/agitation. No significant differences in the interconnections among symptoms emerged.

LIMITATIONS

Data were cross-sectional and self-reported, gold standard diagnostic tools were not used to assess OCD, and the sample size for the group with MDD and OCD was relatively small yielding low statistical power for network analysis.

CONCLUSIONS

Youth with MDD and OCD have more severe MDD than those with MDD and no OCD and they experience more psychomotor issues and less anhedonia, which may relate to the behavioral activation characteristic of OCD.

Development of a Short Version of the ADHD Rating Scale-IV.es (sADHD-RS-IV.es)

OBJECTIVE

To develop a short version of the Spanish 18-item ADHD-Rating Scale IV.es (sADHD-RS-IV.es) to be used as a potential screening tool in pediatric population.

METHODS

We recruited 652 subjects, ages 6 to 18 (mean ± SD = 11.14 ± 3.27): 518 patients with ADHD (per DSM-IV criteria); and 134 healthy controls. We performed a stepwise logistic regression to select the best subset of ADHD-RS-IV.es items to create a short-form. We calculated internal consistency reliability (Cronbach's and ordinal alphas) and diagnostic accuracy using receiver operating characteristic (ROC) curve.

RESULTS

Six items were found to enter the stepwise analysis significantly. Internal consistency was high (Cronbach's alpha = 0.86; ordinal alpha = 0.90) and offered a good concordance with clinician diagnosis and a high discriminatory power (AUC = 0.98) with an optimal cut-off at a score of six points.

CONCLUSIONS

This shorter questionnaire (six items) was able to discriminate ADHD cases from healthy controls.

The many faces of microbiota-gut-brain axis in autism spectrum disorder

The gut-brain axis is gaining more attention in neurodevelopmental disorders, especially autism spectrum disorder (ASD). Many factors can influence microbiota in early life, including host genetics and perinatal events (infections, mode of birth/delivery, medications, nutritional supply, and environmental stressors). The gut microbiome can influence blood-brain barrier (BBB) permeability, drug bioavailability, and social behaviors. Developing microbiota-based interventions such as probiotics, gastrointestinal (GI) microbiota transplantation, or metabolite supplementation may offer an exciting approach to treating ASD. This review highlights that RNA sequencing, metabolomics, and transcriptomics data are needed to understand how microbial modulators can influence ASD pathophysiology. Due to the substantial clinical heterogeneity of ASD, medical caretakers may be unlikely to develop a broad and effective general gut microbiota modulator. However, dietary modulation followed by administration of microbiota modulators is a promising option for treating ASD-related behavioral and gastrointestinal symptoms. Future work should focus on the accuracy of biomarker tests and developing specific psychobiotic agents tailored towards the gut microbiota seen in ASD patients, which may include developing individualized treatment options.

Texas Youth Depression and Suicide Research Network (TX-YDSRN) research registry and learning healthcare network: Rationale, design, and baseline characteristics

BACKGROUND

American youth are seriously impacted by depression and suicide. The Texas Youth Depression and Suicide Research Network (TX-YDSRN) Participant Registry Study was initiated in 2020 to develop predictive models for treatment outcomes in youth with depression and/or suicidality. This report presents the study rationale, design and baseline characteristics of the first 1000 participants.

METHODS

TX-YDSRN consists of the Network Hub (coordinating center), 12 medical school "Nodes" (manage/implement study), each with 1-5 primary care, inpatient, and/or outpatient Sub-Sites (recruitment, data collection). Participants are 8-20-year-olds who receive treatment or screen positive for depression and/or suicidality. Baseline data include mood and suicidality symptoms, associated comorbidities, treatment history, services used, and social determinants of health. Subsequent assessments occur every two months for 24 months.

RESULTS

Among 1000 participants, 68.7 % were 12-17 years, 24.6 % were ≥ 18 years, and 6.7 % were < 12. Overall, 36.8 % were non-Hispanic Caucasian, 73.4 % were female, and 79.9 % had a primary depressive disorder. Nearly half of the sample reported ≥1 suicide attempt, with rates similar in youth 12-17 years old (49.9 %) and those 18 years and older (45.5 %); 29.9 % of children <12 reported at least one suicide attempt. Depression and anxiety scores were in the moderate-severe range for all age groups (Patient Health Questionnaire for Adolescents [PHQ-A]: 12.9 ± 6.4; Generalized Anxiety Disorder [GAD-7]: 11.3 ± 5.9).

LIMITATIONS

The sample includes youth who are receiving depression care at enrollment and may not be representative of non-diagnosed, non-treatment seeking youth.

CONCLUSIONS

The TX-YDSRN is one of the largest prospective longitudinal cohort registries designed to develop predictive models for outcome trajectories based on disorder heterogeneity, social determinants of health, and treatment availability.

Psychometric properties of Concise Associated Symptom Tracking (CAST) scale in youths and young adults: Findings from the Texas youth depression and suicide research network (TX-YDSRN)

Symptoms of irritability, anxiety, panic, and insomnia are common in patients with depression, and their worsening after antidepressant treatment initiation is associated with poorer long-term outcomes. The Concise Associated Symptom Tracking (CAST) scale was developed to measure these symptoms in adults with major depressive disorder (MDD). Here, we evaluate the psychometric properties of CAST in an ongoing community-based observational study involving children, adolescents, and young adults. Individuals from the ongoing Texas Youth Depression and Suicide Research Network (TX-YDSRN; N = 952) with CAST data available were included. Fit statistics [Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)] from confirmatory factor analyses were used to evaluate the five- and four-domain structure of CAST. Item response theory (IRT) analyses were also used. Individuals were grouped based on age (in years) as youths (8-17) and young adults (18-20). Correlations with other clinical measures were used to inform construct validity. Four-domain (irritability, anxiety, panic, and insomnia) 12-item structure of CAST (CAST-12) was optimal for youths (N = 709, GFI = 0.906, CFI = 0.919, RMSEA = 0.095) and young adults (N = 243, GFI = 0.921, CFI = 0.938, RMSEA = 0.0797) with Cronbach's alpha of 0.87 and 0.88, respectively. Slope of each item exceeded 1.0 on IRT analyses suggesting adequate discrimination for each item. Scores on irritability, anxiety, panic, and insomnia were significantly correlated with similar items on other scales. Together these findings suggest that CAST-12 is a valid self-report measure of irritability, anxiety, insomnia, and panic in youths and young adults.

[Factors associated with adherence to pharmacological treatment of attention deficit hyperactivity disorder (ADHD): preliminary review]

INTRODUCTION

ADHD treatment is safe and effective, but often, adherence to t reatment is suboptimal. We studied factors associated to adherence to treatment in ADHD described in the literature.

METHODS

We conducted a non-systematic bibliographic search on recent articles on medication adherence in children and adolescents with ADHD.

RESULTS

There are factors associated with the disorder itself, the patient, the health system, socio-economic factors, the medication and the environment that can reduce/improve medication adherence. Some factors that improve adherence include: knowledge about ADHD, medication and its benefits and potential adverse effects. Simple, once-daily, extended-release medication regimens. Age of the patient less than 12 years and female sex. Fewer barriers to access the health system. Positive and proactive attitude of parents regarding ADHD and the use of medication.

DISCUSSION

Adherence could be optimized and therefore the long-term prognosis of ADHD improved by reinforcingfactors that increase adherence, and reducing biases and ignorance about ADHD.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Resting-State fMRI to Identify the Brain Correlates of Treatment Response to Medications in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: Lessons From the CUNMET Study

Neuroimaging research seeks to identify biomarkers to improve the diagnosis, prognosis, and treatment of attention-deficit/hyperactivity disorder (ADHD), although clinical translation of findings remains distant. Resting-state functional magnetic resonance imaging (R-fMRI) is increasingly being used to characterize functional connectivity in the brain. Despite mixed results to date and multiple methodological challenges, dominant hypotheses implicate hyperconnectivity across brain networks in patients with ADHD, which could be the target of pharmacological treatments. We describe the experience and results of the Clínica Universidad de Navarra (Spain) Metilfenidato (CUNMET) pilot study. CUNMET tested the feasibility of identifying R-fMRI markers of clinical response in children with ADHD undergoing naturalistical pharmacological treatments. We analyzed cross-sectional data from 56 patients with ADHD (18 treated with methylphenidate, 18 treated with lisdexamfetamine, and 20 treatment-naive patients). Standard preprocessing and statistical analyses with attention to control for head motion and correction for multiple comparisons were performed. The only results that survived correction were noted in contrasts of children who responded clinically to lisdexamfetamine after long-term treatment vs. treatment-naive patients. In these children, we observed stronger negative correlations (anticorrelations) across nodes in six brain networks, which is consistent with higher across-network functional segregation in patients treated with lisdexamfetamine, i.e., less inter-network interference than in treatment-naive patients. We also note the lessons learned, which could help those pursuing clinically relevant multidisciplinary research in ADHD en route to eventual personalized medicine. To advance reproducible open science, our report is accompanied with links providing access to our data and analytic scripts.

Clinical and Neuropsychological Predictors of Methylphenidate Response in Children and Adolescents with ADHD: A Naturalistic Follow-up Study in a Spanish Sample

BACKGROUND

Methylphenidate (MPH) is the most commonly used medication for Attention-Deficit/Hyperactivity Disorder (ADHD), but to date, there are neither consistent nor sufficient findings on conditions differentiating responsiveness to MPH response in ADHD.

OBJECTIVE

To develop a predictive model of MPH response, using a longitudinal and naturalistic follow-up study, in a Spanish sample of children and adolescents with ADHD.

METHODS

We included all children and adolescents with ADHD treated with MPH in our outpatient Clinic (2005 to 2015), evaluated with the K-SADS interview. We collected ADHD-RS-IV.es and CGI-S scores at baseline and at follow up, and neuropsychological testing (WISC-IV, Continuous Performance Test (CPT-II) & Stroop). Clinical response was defined as >30% reduction from baseline of total ADHD-RS-IV.es score and CGI-S final score of 1 or 2 maintained for the previous 3 months.

RESULTS

We included 518 children and adolescents with ADHD, mean (SD) age of patients was 11.4 (3.3) years old; 79% male; 51.7% had no comorbidities; and 75.31% had clinical response to a mean MPH dose of 1.2 mg/kg/day. Lower ADHD-RS-IV.es scores, absence of comorbidities (oppositional-defiant symptoms, depressive symptoms and alcohol/cannabis use), fewer altered neuropsychological tests, higher total IQ and low commission errors in CPT-II, were significantly associated with a complete clinical response to methylphenidate treatment.

CONCLUSION

Oppositional-defiant symptoms, depressive symptoms, and a higher number of impaired neuropsychological tests are associated with worse clinical response to methylphenidate. Other stimulants or non-stimulants treatment may be considered when these clinical and neuropsychological variables converged in the first clinical interview.

Pediatric bipolar disorder in a Spanish sample: results after 2.6years of follow-up

INTRODUCTION

Bipolar disorder (BD) often starts in childhood or adolescence. There is considerable scepticism outside the United States over the validity, stability and prevalence of BD in children and adolescents. Persistence of course lends support to the validity of a diagnosis.

OBJECTIVES

To describe the longitudinal course of pediatric BD in a Spanish sample over a median follow-up period of 2.6years and to examine risk factors associated with outcome.

METHODS

We retrospectively reviewed the medical records of all children and adolescents (N=38) with DSM-IV-TR BD-I, II and NOS evaluated in the Child and Adolescent Psychiatry Unit, University of Navarra (Pamplona, Spain) from 1999 to 2005. We used the NIMH Lifetime Mood Chart and the Clinical Global Impression-Severity Scale to assess clinical course.

RESULTS

79% (N=30) were boys and 21% (N=8) were girls; 44.7% (N=17) had BD-I, 5.3% (N=2) BD-II, and 50% (N=19) BD-NOS. Median (inter-quartile range: IQR: Q25; Q75) age at diagnosis was 13.9 (10.64; 15.84). Median follow-up period was 2.6years (0.91; 3.66). Mean percentage of time in an episode was 46.17% (23.36; 75.26), and it was longer in younger children (p<0.05). 2.6% had rapid cycling. At the end of follow-up, only 47% achieved remission or recovery. Younger children showed a worse treatment response (p<0.05). We found higher rates of hospitalization in children with ADHD (21%) (p<0.05).

CONCLUSION

Children with BD had a chronic course with little interepisodic recovery. BD can be diagnosed in children using DSM-IV-TR criteria. An early age of onset and ADHD comorbidity are risk factors for worse prognosis.

Pediatric bipolar disorder in a Spanish sample: features before and at the time of diagnosis

INTRODUCTION

Bipolar disorder (BD) often starts in childhood or adolescence. Diagnostic delay is common and may have a negative impact on treatment response and outcome.

OBJECTIVES

To describe the clinical characteristics and symptoms of children with BD prior to their diagnosis and at the time of diagnosis in a sample in Spain.

METHODS

We retrospectively reviewed the medical records of all children and adolescents (N=38) with a DSM-IV diagnosis of BD evaluated in the Child & Adolescent Psychiatry Unit, University of Navarra, over a 6-year period. We collected the DSM-IV symptoms of BD prior and at the time of diagnosis using the K-SADS-PL interview template.

RESULTS

BD was diagnosed in close to 4% of clinic patients. Thirty (79%) were boys and 8 (21%) were girls; 17 (44.7%) had BD-1, 2 (5.3%) BD-2, and 19 (49.9%) BD-NOS. Median age at diagnosis was 13.9 (10.6;15.9). Delay of diagnosis was 1.5 (0.7;3.4) years. Symptoms of BD were similar to those reported in U.S. samples with high rates of severe irritability (94.6%) and psychiatric comorbidity: 92.1% of the BD children had at least one comorbid disorder and 18.4% had three comorbidities, most frequently ADHD (21%) and substance abuse (18.4%).

CONCLUSIONS

Clinical findings in this Spanish sample of children with BD closely resembles those described in U.S. clinics. Diagnostic delay, as in the U.S., and frequent misdiagnosis may explain low prevalence estimates found outside the U.S.

Is there a cortical blood flow redistribution pattern related with perseverative error in schizophrenia?

BACKGROUND

We studied relative cortical blood flow (relCBF) patterns associated to correct performance (CP) and perseverative error (PE) during Wisconsin Card Sorting Test (WCST) execution, in controls and patients with schizophrenia.

SUBJECTS AND METHODS

relCBF (regional cortical blood flow (rCBF) / whole cortex blood flow) of 10 well defined cortical regions was measured in 18 patients with schizophrenia and 13 healthy controls by a Technetium - 99 - HMPAO - SPECT, at rest and while they performed WCST.

RESULTS

Patients made significantly more PE than controls during WCST performance. In patients, we found a significant correlation between PE and relCBF in right occipital cortex. In controls, we found a significant correlation between CP and relCBF of several cortical regions during WCST execution: left orbitofrontal cortex and left global frontal cortex positively and parietal bilateral cortex negatively. PE was inversely correlated with relCBF in left temporal cortex.

CONCLUSIONS

Successful WCST performance is associated to a high left frontal activity in controls but not in patients. The severity of PE during WCST performance is associated to a low left frontal-temporal activity in controls and to a high right parietal-occipital activity in schizophrenia. This may represent a cortical activity redistribution pattern related to perseveration in schizophrenia.

The child and adolescent first-episode psychosis study (CAFEPS): design and baseline results

OBJECTIVE

The child and adolescent first-episode psychosis study (CAFEPS) is a multicenter, two-year, longitudinal project aiming to evaluate different clinical, neuropsychological, neuroimaging, biochemical, immunological, and genetic variables and treatment and prognostic factors in these patients. This paper describes the methods and rationale behind the study and the general characteristics of the sample.

METHOD

At six different centers, from March 2003 through November 2005, we consecutively recruited 110 patients, ages 9-17 years, who presented with a first psychotic episode. Controls were recruited from the same geographic areas and were matched for gender and age.

RESULTS

Patients had lower socioeconomic status (SES) (p=0.018) and parental years of education (p<0.001) than controls. The percentage of patients recruited increased with age (p<0.001) and there was a higher percentage of males (p<0.001). The total mean PANSS score was 89.03+/-20.1, the positive score 23.8+/-6.5 and the negative score 20.02+/-8.8. There were no significant differences between the genders with respect to age, parental years of education, SES, or scores in premorbid adjustment or general functioning. There were statistically significant positive correlations between age and positive symptoms and between all PANSS subscales and the Disability Assessment Schedule, and negative correlations between positive symptoms and global functioning. Diagnoses after the baseline evaluation were: psychotic disorder not otherwise specified (NOS) 35.5%, schizophreniform disorder 24.5%, mood disorder with psychotic symptoms 22.7%, schizophrenia 10%, schizoaffective disorder 2.7%, and other psychotic disorders 4.5%. Patients had worse premorbid adjustment (p<0.001) and global functioning (p<0.001) than controls after controlling for SES.

CONCLUSIONS

Infancy and adolescence adjustment and global functioning are lower in children and adolescents with psychotic disorders than in controls, severity of symptoms are related to general disability, and the most frequent diagnoses are psychotic disorders NOS.

Perseverative error in schizophrenia: correlation with cortical blood flow by SPECT

INTRODUCTION

Perseverative error (PE) is a core symptom of schizophrenia which has been proposed as a phenotypic marker of the illness. Moreover, hypofrontality observed in functional neuroimaging studies while executing a cognitive task has also been suggested as a characteristic sign of schizophrenia. We propose combining symptom and sign to demonstrate the existence of a regional cortical blood flow (RCBF) pattern associated to PE that might constitute a biological marker of schizophrenia.

MATERIAL AND METHOD

We used Single Photon Emission Computerized Tomography (SPECT), to study the RCBF associated to PE and to correct response (CR), during the execution of the Wisconsin Card Sorting Test (WCST), of 18 patients with schizophrenia and 13 controls. We focused on five well-defined bilateral brain regions, using the RCBF of the same regions at rest as a baseline.

RESULTS

Patients made more PE than controls in the WCST. Among patients, we observed a correlation between PEs and right occipital RCBF. Among controls, we found a negative correlation between PEs and left temporal cortex RCBF and a positive correlation between CRs and left frontobasal and overall left frontal cortexes RCBF.

CONCLUSIONS

The severity of PE is associated to higher right parietal-occipital activity in patients with schizophrenia. CR in the WCST are associated to higher left frontal activity in controls but not in patients. Probably, there is a RCBF redistribution pattern related to the typical perseveration of schizophrenia which might constitute a phenotypic marker of the illness observable by functional neuroimaging techniques.

Adjunctive lamotrigine treatment for adolescents with bipolar disorder: retrospective report of five cases

BACKGROUND

Our aim was to evaluate the effectiveness, safety, and tolerability of adjunctive lamotrigine in the treatment of adolescents with bipolar disorder.

METHOD

We evaluated all patients under age 18 with Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) bipolar disorder in our outpatient clinic treated with lamotrigine, using the Clinical Global Impression (CGI) scale. We rated response with the CGI-Improvement (CGI-I) scale.

RESULTS

Five patients (mean age = 15.5 +/- 1.8 years; range = 14-17), 1 male and 4 females, were included. One patient (20%) had bipolar I disorder, 1 (20%) had bipolar II disorder, and 3 (60%) had bipolar disorder not otherwise specified (NOS). The polarity of the episode at baseline was depressive in all patients. The mean lamotrigine dose was 100 +/- 87.5 mg/day (1.67 +/- 1.39 mg/kg/day). The mean duration of treatment was 28 +/- 28 weeks. CGI significantly improved from 5 at baseline to 3 +/- 1 at endpoint (p = 0.011). Improvement was marked or moderate in 4 patients (80%) and minimal in 1 patient (20%). One patient referred to dizziness, and there were no reports of increased cycling, worsening of mania, or skin rash.

CONCLUSIONS

This open, retrospective chart review suggests that lamotrigine may be effective and well tolerated as an adjunctive treatment in adolescents with bipolar disorder. Controlled trials are needed.

Family environment in families with versus families without parental bipolar disorder: a preliminary comparison study

OBJECTIVES

To compare family environmental characteristics of families with at least one bipolar parent and families with parents without any Axis I disorder.

METHODS

Family environment of 24 families with at least one parent with bipolar disorder (BPD) and 27 families with healthy parents (healthy families, HF) were assessed using the Family Environment Scale (FES). We compared FES subscale scores between BPD and HF. We also compared FES normative scores with scores of BPD families.

RESULTS

Seventeen (71%) of the 24 BPD families had at least one child with a mood disorder and one (3.7%) of the 27 HF had a child with a mood disorder. Families with BPD reported lower cohesion (p = 0.009) and expressiveness (p = 0.03) scores compared with HF, after controlling for group socioeconomic status differences. Bilineal BPD families had higher cohesion scores than unilineal BPD families (p = 0.05). We found no significant differences in any subscales between BPD families with (n = 9) versus without (n = 15) children with BPD. Compared with normative FES data BPD families reported lower cohesion (C) (p = 0.02) and independence (IND) (p = 0.004) scores and higher conflict (CON) (p = 0.02), intellectual-cultural orientation (ICO) (p = 0.05), moral-religious emphasis (MRE) (p < 0.001) and control (CTL) (p < 0.001) scores.

CONCLUSION

Our results suggest that members of BPD families may have difficulty communicating effectively with one another, suggesting that interventions aimed at improving this may be beneficial to patients with BPD. Results suggest that the impact of different lifestyles in different communities may influence FES scores, and thus it is important to use demographically matched comparison groups.

Worse quality of life for children with newly diagnosed attention-deficit/hyperactivity disorder, compared with asthmatic and healthy children

OBJECTIVE

To evaluate the quality of life (QOL) of untreated children with newly diagnosed attention-deficit/hyperactivity disorder (ADHD), compared with asthmatic and healthy children.

METHODS

This prospective, case-control study included a group of 120 children, 6 to 12 years of age, with newly diagnosed ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Subjects were matched according to age, gender, and health care area with 2 control groups, ie, 93 asthmatic children and 120 healthy children. Sociodemographic characteristics and Child Health Questionnaire scores were collected.

RESULTS

The QOL of children with ADHD was rated worse than that of asthmatic or healthy children for most Child Health Questionnaire domains. The greatest differences were found in behavior, social limitations attributable to physical problems, emotional impact on parents, and family activities. Almost every psychosocial domain was more affected in comparison with asthmatic children and both psychosocial and physical domains in comparison with healthy children.

CONCLUSIONS

ADHD interferes with the daily lives of children, parents, and families even more than asthma, primarily in areas related to psychosocial functioning, although evidence of impaired physical functioning also emerged. Delays in recognition, assessment, and management of ADHD may affect negatively the QOL of those children.

A prospective, multicenter, open-label assessment of atomoxetine in non-North American children and adolescents with ADHD

OBJECTIVE

The aim of this study was to study treatment response to atomoxetine in a large, multicenter study of non-North American patients with ADHD.

METHODS

A total of 604 children and adolescents with ADHD were enrolled in a 10-week open-label trial with atomoxetine prior to randomization to a double-blind relapse prevention phase at 33 sites in the United Kingdom, continental Europe, Israel, South Africa, and Australia. All patients had ADHD symptom severity at least 1.5 standard deviations above United States age and gender norms for their diagnostic subtype as measured by the investigator-scored ADHD Rating Scale (ADHD RS). Outcomes were assessed by analysis of change in the ADHD RS; functional and psychosocial outcomes were assessed using the Child Health Questionnaire (CHQ).

RESULTS

At endpoint, ADHD RS total scores decreased by an average of 56.7%, and 69% of patients were rated as having no or minimal symptoms. Significant improvement was observed in psychosocial and functional outcomes. Discontinuations attributed to adverse events were < 4%.

CONCLUSION

These open-label data, gathered in an international setting, add to our knowledge of the value of atomoxetine in treating ADHD symptoms, as well as its safety and tolerability.

Psychiatric and legal features of 113 men convicted of sexual offenses

BACKGROUND

To increase understanding of the relationships among sexual violence, paraphilias, and mental illness, the authors assessed the legal and psychiatric features of 113 men convicted of sexual offenses.

METHOD

113 consecutive male sex offenders referred from prison, jail, or probation to a residential treatment facility received structured clinical interviews for DSM-IV Axis I and II disorders, including sexual disorders. Participants' legal, sexual and physical abuse, and family psychiatric histories were also evaluated. We compared offenders with and without paraphilias.

RESULTS

Participants displayed high rates of lifetime Axis I and Axis II disorders: 96 (85%) had a substance use disorder; 84 (74%), a paraphilia; 66 (58%), a mood disorder (40 [35%], a bipolar disorder and 27 [24%], a depressive disorder); 43 (38%), an impulse control disorder; 26 (23%), an anxiety disorder; 10 (9%), an eating disorder; and 63 (56%), antisocial personality disorder. Presence of a paraphilia correlated positively with the presence of any mood disorder (p <.001), major depression (p =.007), bipolar I disorder (p =.034), any anxiety disorder (p=.034), any impulse control disorder (p =.006), and avoidant personality disorder (p =.013). Although offenders without paraphilias spent more time in prison than those with paraphilias (p =.019), paraphilic offenders reported more victims (p =.014), started offending at a younger age (p =.015), and were more likely to perpetrate incest (p =.005). Paraphilic offenders were also more likely to be convicted of (p =.001) or admit to (p <.001) gross sexual imposition of a minor. Nonparaphilic offenders were more likely to have adult victims exclusively (p =.002), a prior conviction for theft (p <.001), and a history of juvenile offenses (p =.058).

CONCLUSIONS

Sex offenders in the study population displayed high rates of mental illness, substance abuse, paraphilias, personality disorders, and comorbidity among these conditions. Sex offenders with paraphilias had significantly higher rates of certain types of mental illness and avoidant personality disorder. Moreover, paraphilic offenders spent less time in prison but started offending at a younger age and reported more victims and more non-rape sexual offenses against minors than offenders without paraphilias. On the basis of our findings, we assert that sex offenders should be carefully evaluated for the presence of mental illness and that sex offender management programs should have a capacity for psychiatric treatment.

Obsessive-compulsive disorder secondary to brain dysgerminoma in an adolescent boy: a positron emission tomography case report

The neuroanatomical model involved in the pathophysiology of obsessive-compulsive disorder (OCD) postulates a hyperactivation of orbitofrontal, limbic, and basal ganglia circuits. We report a case of OCD secondary to brain dysgerminoma affecting this circuit in an adolescent who responded to citalopram. The patient is a 16-year-old-boy with a midline germinal tumor (dysgerminoma) affecting the caudate nuclei; left lenticular, right internal capsule's genu; and bilateral involvement of the interventricular septum close to the interventricular foramina. He had OCD symptoms and elevated tumor markers when he had a tumor relapse, and fluorodeoxyglucose positron emission tomography showed caudate nuclei involvement. He responded to citalopram that had to be titrated gradually to 80 mg/day.

Quality of Life in 833 outpatients with major depression treated with open-label venlafaxine extended release: An observational 24-week study

BACKGROUND Quality of Life (QoL) assessments are common in medicine and, recently, in psychiatry, mostly in patients with chronic mental illness. We evaluated QoL in depressed outpatients treated with venlafaxine-XR over a period of 24 weeks. METHOD We evaluated 833 patients with DSM-IV major depression using the Hamilton Depression Rating Scale (HAM-D), the Hamilton Anxiety Rating Scale (HAM-A), the Montgomery-Åsberg Depression Rating Scale (MÅDRS), and the QoL in Depression Scale (QLDS). The patients received venlafaxine-XR and we evaluated them after 4, 8, and 24 weeks of treatment. RESULTS HAM-D scores decreased from a baseline of 24.6 &#45 6.3 to 6.0 &#45 5.5 (mean &#45 SD; P <0.0001) after 24 weeks. HAM-A scores decreased from a baseline of 32.3 &#45 7.9 to 6.8 &#45 6.8 ( P <0.0001) after 24 weeks. QLDS scores decreased from a baseline of 25.8 &#45 5.8 to 6.6 &#45 7.5 ( P <0.0001) after 24 weeks, indicating improvement in QoL. The response after 4 weeks was also significant and continued improving during the study. Venlafaxine-XR was shown to be safe and well tolerated. DISCUSSION Open-label venlafaxine-XR was safe, effective, well tolerated, and improved not only depression and anxiety symptoms, but also QoL, in outpatients with major depression. This study has the limitations of any non-randomized, non-blinded multiple-site clinical trial.

Severity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment

BACKGROUND

Childhood bipolarity (BP) and ADHD frequently co-occur, these children often receive stimulants.

METHOD

We retrospectively evaluated 80 adolescents hospitalized with BP, manic or mixed, assessed severity of hospital course, and compared groups according to current/past stimulant or antidepressant treatment.

RESULTS

Lifetime ADHD rate was 49%; 35% of patients had exposure to stimulants and 44% to antidepressants. Stimulant-exposed patients were younger than non-exposed (mean+/-S.D.=13.7+/-2 vs. 15.1+/-2 years, Z=-3.1, P=0.002). Only stimulant exposure was associated with worse hospitalization course (MANCOVA, Wilks' Lambda=0.87, F=3.4; df=70; P=0.02).

CONCLUSION

Stimulant-exposed BP-adolescents may have more severe illness course not fully explained by ADHD comorbidity.

LIMITATIONS

Retrospective methodology and lack of structured interviewing make it difficult to quantify exposure to stimulants and antidepressants.

Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review

BACKGROUND

Several studies have reported that patient ethnicity influences psychiatric diagnosis, although this has only been examined in adolescents in two prior studies. One study was based on an outpatient sample and the other was a retrospective study involving a relatively small sample of inpatients. We hypothesized that, as reported in adults, African American adolescents would be diagnosed with schizophrenic spectrum disorders more frequently than Caucasians, and Caucasians correspondingly would receive more affective disorders diagnoses.

METHODS

We retrospectively examined the charts of all adolescents (ages 12-18 years) admitted to the Adolescent Psychiatry Unit at Cincinnati Children's Hospital Medical Center (n = 1,001) between July 1995 and June 1998 for demographic information and discharge diagnoses. We used insurance status as a proxy for socioeconomic status.

RESULTS

African American males were more commonly diagnosed with schizophrenic spectrum disorders than were African American women, Caucasian women, and Caucasian men. There were significantly more African Americans diagnosed with conduct disorder than Caucasians. In contrast, Caucasians were diagnosed with alcohol use disorders and major depression more often.

CONCLUSIONS

Patient race and sex may influence clinical psychiatric diagnoses of hospitalized adolescents. Further investigations using structured interviews are necessary to determine whether the disparity in clinical diagnosis is secondary to actual gender and racial differences in the rates of illnesses in hospitalized adolescents or due to other factors that may contribute to diagnostic practices.

Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset

OBJECTIVES

To compare demographic and clinical characteristics between bipolar adolescents with and without a history of stimulant treatment, we hypothesized that adolescents treated with stimulants would have an earlier age at onset of bipolar disorder, independent of co-occurring attention-deficit-hyperactivity disorder (ADHD).

METHOD

Thirty-four adolescents hospitalized with mania were assessed using the Washington University at St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). We systematically evaluated age at onset of bipolar disorder and pharmacological treatment history.

RESULTS

Bipolar adolescents with a history of stimulant exposure prior to the onset of bipolar disorder had an earlier age at onset of bipolar disorder than those without prior stimulant exposure. Additionally, bipolar adolescents treated with at least two stimulant medications had a younger age at onset compared with those who were treated with one stimulant. There was no difference in age at onset of bipolar disorder between bipolar adolescents with and without ADHD.

CONCLUSIONS

Our results suggest that stimulant treatment, independent of ADHD, is associated with younger age at onset of bipolar disorder. A behavioral sensitization model is proposed to explain our findings. There are several limitations to our study including the small sample size, the retrospective assessment of stimulant exposure and age at onset of bipolar disorder, and the inclusion of only hospitalized patients, who may be more likely to present with a severe illness. Nonetheless, future prospective longitudinal investigations that systematically assess the effects of stimulant medications in children with or at genetic risk for bipolar disorder are warranted.

Gabapentin in the treatment of adolescent mania: a case report

Gabapentin is a new antiepileptic drug with an unknown mechanism of action and very favorable pharmacokinetic and safety profiles. An increasing number of reports have described the successful use of gabapentin in bipolar disorder in adults. A 13-year-old boy with bipolar I disorder, manic episode, and ADHD, was treated with gabapentin 1,500 mg/day as add-on therapy to carbamazepine and showed a marked response within 1 month. He had previously failed a divalproex trial, could not tolerate lithium, and carbamazepine could not control his symptoms and induced a low WBC. He remained euthymic 7 months after gabapentin was added. His Young Mania Rating Scale (YMRS) score was 27 when gabapentin was added, 9 after 1 month, 15 after 4 months, and 6 after 7 months. Controlled studies are needed to evaluate the possible anti-manic, mood stabilizing, and/or anti-depressant properties of gabapentin in youth.

Antipsychotics in the treatment of mood disorders and risk of tardive dyskinesia

Psychosis occurs commonly in patients with mood disorders and has traditionally been treated with typical antipsychotics. Exposure to typical antipsychotics poses a risk for the emergence of tardive dyskinesia. Atypical antipsychotics may have advantages over typical agents in the treatment of patients with mood disorders complicated by psychotic features. The studies of typical and atypical antipsychotics in the treatment of mood disorders were reviewed. Similarly, studies regarding the risk of tardive dyskinesia from typical and atypical agents in patients with mood disorders were surveyed. Typical and atypical antipsychotics appear to be comparably effective in the treatment of acute mania. Limited data regarding these medications in psychotic depression are available. Advantages of atypical antipsychotics include, for most agents, minimal extrapyramidal and prolactin effects, inherent thymoleptic activity, and lower rates of tardive dyskinesia. Atypical antipsychotics appear to have a number of advantages over typical agents in the treatment of patients with psychotic mood disorders.

Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder

OBJECTIVE

Etiopathogenetic and treatment studies require homogeneous phenotypes. Therefore, effects of gender, puberty, and comorbid attention deficit hyperactivity disorder (ADHD) on DSM-IV mania criteria and other characteristics of a prepubertal and early adolescent bipolar disorder (PEA-BP) phenotype were investigated.

METHOD

Consecutively ascertained PEA-BP (with or without comorbid ADHD) outpatients (n = 93) were blindly assessed by research nurses with comprehensive instruments given to mothers and children separately, consensus conferences, and offsite blind best estimates of both diagnoses and mania items. To fit the study phenotype, subjects needed to have current DSM-IV mania or hypomania with elated mood and/or grandiosity as one criterion and to be definite cases by severity ratings.

RESULTS

Subjects were aged 10.9 +/- 2.6 years, had current episode length of 3.6 +/- 2.5 years, and had early age of onset at 7.3 +/- 3.5 years. No significant differences were found by gender, puberty, or comorbid ADHD on rates of mania criteria (e.g., elation, grandiosity, racing thoughts), mixed mania, psychosis, rapid cycling, suicidality, or comorbid oppositional defiant disorder (ODD), with few exceptions. Subjects with comorbid ADHD were more likely to be younger and male. Pubertal subjects had higher rates of hypersexuality.

CONCLUSIONS

These findings support that the PEA-BP phenotype is homogeneous except for differences (hyperactivity, hypersexuality) that mirror normal development.

Six-month stability and outcome of a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE

Six-month follow-up data are provided on a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP). Stabilities were defined as continuous presence of PEA-BP and of individual mania criteria between baseline and 6 months.

METHOD

Baseline and 6-month assessments of consecutively ascertained PEA-BP outpatients (n = 91) included comprehensive instruments given to mothers and children, separately, by research nurses; consensus conferences; and offsite blind best estimates of both diagnoses and mania items. To fit the study phenotype, subjects needed to have current DSM-IV mania or hypomania with elated mood and/or grandiosity as one mania criterion and to be definite cases by severity ratings.

RESULTS

Of the 93 baseline subjects, 91 completed the 6-month assessment, for a retention rate of 97.8%. Baseline age was 10.9 +/- 2.7 years, and age of onset of current episode was 7.3 +/- 3.5 years. At 6 months, 85.7% still had full criteria and severity for mania or hypomania, and only 14.3% had recovered. Six-month stabilities of elated mood and grandiosity were high. Cox modeling and logistic regression did not show any significant effect of multiple covariates (e.g., gender, puberty, psychosis, mixed mania, rapid cycling, or naturalistic treatment).

CONCLUSIONS

These longitudinal stability findings provide validation of a PEA-BP phenotype. Poor outcome was consistent with similarity of PEA-BP baseline characteristics to those of treatment-resistant adult-onset mania.

Placebo-controlled trial of sertraline in the treatment of binge eating disorder

OBJECTIVE

The authors' goal was to assess the efficacy of sertraline in the treatment of binge eating disorder.

METHOD

Thirty-four outpatients with DSM-IV binge eating disorder were randomly assigned to receive either sertraline (N=18) or placebo (N=16) in a 6-week, double-blind, flexible-dose (50-200 mg) study. Except for response level, outcome measures were analyzed by random regression methods, with treatment-by-time interaction as the effect measure.

RESULTS

Compared with placebo, sertraline was associated with a significantly greater rate of reduction in the frequency of binges, clinical global severity, and body mass index as well as a significantly greater rate of increase in clinical global improvement. Patients receiving sertraline who completed the study demonstrated a higher level of response, although the effect was not significant.

CONCLUSIONS

In a 6-week trial, sertraline was effective and well tolerated in the treatment of binge eating disorder.

Traumatic brain injury in individuals convicted of sexual offenses with and without bipolar disorder

The authors examined the occurrence of traumatic brain injury (TBI) in individuals convicted of sexual offenses with and without bipolar disorder and a comparison group of patients with bipolar disorder without a history of sexual offending behaviors. Individuals convicted of sexual offenses and diagnosed with bipolar disorder had greater rates of brain injury resulting from head trauma than individuals convicted of sexual offenses without bipolar disorder and comparison patients with bipolar disorder. TBI predated the first sexual offense and/or the onset of bipolar disorder in most subjects.

Psychiatric features of 36 men convicted of sexual offenses

BACKGROUND

To increase understanding of the relationship between sexual violence and mental illness, the authors assessed the legal histories and psychiatric features of 36 males convicted of sexual offenses.

METHOD

Thirty-six consecutive male sex offenders admitted from prison, jail, or probation to a residential treatment facility received structured clinical interviews for DSM-IV Axis I and II disorders. The participants' legal histories, histories of sexual and physical abuse, and family histories of psychiatric disorders were also assessed.

RESULTS

The participants' mean +/- SD age was 33+/-8 years. They had been convicted a mean of 1.8+/-1.4 times (range, 1-9 times) for sexual offenses and incarcerated a mean of 8+/-6 years (range, 0-22 years). Participants displayed high rates of lifetime DSM-IV Axis I disorders: 30 (83%) had a substance use disorder; 21 (58%), a paraphilia; 22 (61%), a mood disorder (13 [36%] with a bipolar disorder); 14 (39%), an impulse control disorder; 13 (36%), an anxiety disorder; and 6 (17%), an eating disorder. Participants also displayed high rates of Axis II disorders, with 26 (72%) meeting DSM-IV criteria for antisocial personality disorder. In addition, subjects reported experiencing high rates of sexual (but not physical) abuse and high rates of Axis I disorders, especially substance use and mood disorders, in their first-degree relatives. Compared with subjects without paraphilias, subjects with paraphilias displayed statistically significantly higher rates of mood, anxiety, and eating disorders, as well as significantly higher rates of childhood sexual abuse.

CONCLUSION

Recognition and treatment of major psychiatric disorders among sex offenders may increase chances for successful rehabilitation, reduce recidivism and public victimization, and produce significant public health and economic benefits. More studies in this area appear warranted to search for more effective interventions for this severe public health problem.

Olanzapine in the treatment of adolescent acute mania: a report of seven cases

BACKGROUND

Clozapine may be effective in adults and adolescents with treatment-resistant bipolar disorder. Olanzapine has a receptor affinity profile similar to that of clozapine.

METHODS

The responses of seven consecutive adolescents (ages 12-17) with DSM-IV bipolar disorder, manic episode, treated with olanzapine were evaluated. Response to olanzapine was rated as marked, moderate, minimal, none or worse.

RESULTS

Five (71%) adolescents showed a marked or moderate response. The mean+/-SD olanzapine dose was 0.146+/-0.086 mg/kg/day (11+/-6 mg/day).

CONCLUSION

Olanzapine may have antimanic effects in some adolescents with acute mania. Controlled studies of olanzapine in adolescent bipolar disorder appear to be warranted.

The psychiatric diagnoses of twenty-two adolescents who have sexually molested other children

The purpose of this study was to assess the prevalence of specific psychiatric disorders in adolescents who have sexually molested other children. Twenty-two adolescent males (aged 13 to 17 years) who sexually molested a child at least once were evaluated with structured clinical interviews for DSM-III-R axis I disorders. All subjects met lifetime DSM-III-R criteria for pedophilia (with the exception of the age requirement), 21 (95%) for two or more paraphilias, 18 (82%) for a mood disorder (12 [55%] for a bipolar disorder), 12 (55%) for an anxiety disorder, 11 (50%) for a substance use disorder, and 12 (55%) for an impulse-control disorder. Also, 12 (71%) of 17 subjects were diagnosed with attention-deficit/hyperactivity disorder, and 16 (94%) with conduct disorder. We conclude that some adolescent child molesters may have pedophilia or other paraphilias. Other axis I disorders with impulsive features, especially conduct, attention-deficit/hyperactivity, bipolar, and substance use disorders, may also be found in these adolescents.

DSM-IV intermittent explosive disorder: a report of 27 cases

BACKGROUND

The authors' objective was to provide data regarding the demographic, phenomenological, course of illness, associated psychiatric and medical comorbidity, family history, and psychiatric treatment response characteristics of rigorously diagnosed subjects who met DSM-IV criteria for intermittent explosive disorder.

METHOD

Twenty-seven subjects meeting DSM-IV criteria for a current or past history of intermittent explosive disorder were given structured diagnostic interviews. The subjects' medical histories, family histories of psychiatric disorders, and responses to psychiatric treatments were also assessed.

RESULTS

Most subjects described their intermittent explosive disorder symptoms as very distressing and/or highly problematic. All 27 subjects described aggressive impulses prior to their aggressive acts. Of 24 subjects who were systematically queried, 21 (88%) experienced tension with the impulses; 18 (75%), relief with the aggressive acts; and 11 (48%), pleasure with the acts. Most subjects stated that their aggressive impulses and acts were also associated with affective symptoms, particularly changes in mood and energy level. Twenty-five (93%) subjects had lifetime DSM-IV diagnoses of mood disorders; 13 (48%), substance use disorders; 13 (48%), anxiety disorders; 6 (22%), eating disorders; and 12 (44%), an impulse-control disorder other than intermittent explosive disorder. Subjects also displayed high rates of comorbid migraine headaches. First-degree relatives displayed high rates of mood, substance use, and impulse-control disorders. Twelve (60%) of 20 subjects receiving monotherapy with an antidepressant or a mood stabilizer reported moderate or marked reduction of their aggressive impulses and/or episodes.

CONCLUSION

Intermittent explosive disorder appears to be a bona fide impulse-control disorder that may be related to mood disorder and may represent another form of affective spectrum disorder.

A pilot trial of adjunctive gabapentin in the treatment of bipolar disorder

Several antiepileptic drugs (AEDs) have documented efficacy in the manic phase of bipolar disorder. To investigate the efficacy, tolerability, and safety of the new AED, gabapentin, in mania, we treated nine consecutive outpatients with bipolar I or II disorder by DSM-IV criteria who were experiencing hypomanic, manic, or mixed states inadequately responsive to standard mood stabilizers with open-label, adjunctive gabapentin. Response of manic symptoms was assessed monthly as none, minimal, moderate, or marked. Of the nine patients, seven displayed a moderate or marked reduction in manic symptoms by 1 month after addition of gabapentin, and an additional patient displayed moderate improvement after 3 months. Of these eight patients, six displayed continued antimanic responses for follow-up periods ranging from 1 to 7 months. Side effects were most commonly neurological, mild, and transient. Adjunctive gabapentin may have antimanic and mood-stabilizing effects in some patients with bipolar disorder and is generally well tolerated. Controlled studies of gabapentin in bipolar disorder appear to be warranted.