Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Paradoxical physiological responses to propranolol in a Rett syndrome patient: a case report

BACKGROUND

Rett Syndrome (RTT), caused by a loss-of-function in the epigenetic modulator: X-linked methyl-CpG binding protein 2 (MeCP2), is a pervasive neurological disorder characterized by compromised brain functions, anxiety, severe mental retardation, language and learning disabilities, repetitive stereotyped hand movements and developmental regression. An imbalance in the sympathetic and the parasympathetic nervous system (dysautonomia) and the resulting autonomic storms is a frequent occurrence in patients with RTT. The prototypical beta blocker propranolol has been used to manage sympathetic hyperactivity in patients with RTT.

CASE PRESENTATION

A 13 year old girl with RTT was referred to the Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust. Her clinical picture included disordered breathing with concomitant hyperventilation and apnoea, epilepsy, scoliosis, no QT prolongation (QT/QTc [372/467 ms on automated electrocardiogram [ECG], but manually calculated to be 440 ms]), no cardiac abnormalities (PR interval: 104 ms, QRS duration: 78 ms), and generalised anxiety disorder (ICD-10-CM Diagnosis Code F41.1). She was also constipated and was fed via percutaneous endoscopic gastrostomy (PEG). To manage the dysautonomia, propranolol was given (5 mg and 10 mg) and in parallel her physiological parameters, including heart rate, skin temperature and skin transpiration, were monitored continuously for 24 h as she went about her activities of daily living. Whilst her skin temperature increased and skin transpiration decreased, unexpectedly there was a significant paradoxical increase in the patient's average heart rate following propranolol treatment.

CONCLUSION

Here, we present a unique case of a paradoxical increase in heart rate response following propranolol treatment for managing dysautonomia in a child with RTT. Further studies are warranted to better understand the underlying dysautonomia in patients with RTT and the impact this might have on treatment strategies in rare disorders such as RTT.

Impact of comorbid autism spectrum disorders on stimulant response in children with attention deficit hyperactivity disorder: a retrospective and prospective effectiveness study

BACKGROUND

In the recent past, psychiatrists and paediatricians have avoided prescribing stimulant medication, such as methylphenidate and dexamphetamine to patients with autism spectrum disorders (ASD) because of both doubts about efficacy and concern that these medications make stereotypies worse. Recently, a number of small trials have suggested that methyphenidate does have a role in the management of hyperactivity in children with autistic spectrum disorders.

METHODS

Children with ASD and attention deficit hyperactivity disorder (ADHD), and children with ADHD without ASD received standard treatment with methyphenidate from one specialist centre. A combination of standardized and novel outcome tools was used to allow both an exploratory retrospective study of 174 children and then a prospective study of a further 52 children to be carried out.

RESULTS

After treatment with stimulants, the subjects in both groups showed statistically significant improvements in target symptoms of 'hyperactivity', 'impulsivity', 'inattention', 'oppositionality', 'aggression' and 'intermittent explosive rage'. The Clinical Global Impression-Improvement and efficacy index measures also improved in each group. In both the retrospective and the prospective studies, there was no statistically significant difference in the degree of improvements between each group. Importantly, neither tics nor repetitive behaviours worsened in either group. Children in the 'ADHD-only' group who were prescribed stimulants experienced significant 'nausea', 'giddiness', 'headaches' and 'sleep difficulties', whereas sleep difficulties were the only side effect that emerged in children in the ASD with ADHD group.

CONCLUSIONS

Both studies presented here support previous findings from smaller studies that show children with autism and ADHD can respond as well to stimulants as children with ADHD alone. Although randomized controlled trials remain the gold standard for efficacy studies, systems like this that allow clinicians to continue rigorous and consistent monitoring for many years have a valuable role to play. Furthermore, such monitoring systems which now exist electronically can easily accumulate large data sets and reveal details about long-term effectiveness and long-term side effects of medication that are unlikely to be discovered in short-term trials.

Distributed grey and white matter deficits in hyperkinetic disorder: MRI evidence for anatomical abnormality in an attentional network

BACKGROUND

Previous neuroimaging studies of children with attention deficit hyperactivity disorder (ADHD) have demonstrated anatomic and functional abnormalities predominantly in frontal and striatal grey matter. Here we report the use of novel image analysis methods, which do not require prior selection of regions of interest, to characterize distributed morphological deficits of both grey and white matter associated with ADHD.

METHODS

Eighteen children with a refined phenotype of ADHD, who also met ICD-10 criteria for hyperkinetic disorder (mean age 10.4 years), and 16 normal children (mean age 10.3 years) were compared using magnetic resonance imaging. The groups were matched for handedness, sex, height, weight and head circumference. Morphological differences between groups were estimated by fitting a linear model at each voxel in standard space, applying a threshold to the resulting voxel statistic maps to generate clusters of spatially contiguous suprathreshold voxels, and testing cluster 'mass', or the sum of suprathreshold voxel statistics in each 2D cluster, by repeated random resampling of the data.

RESULTS

The hyperkinetic children had significant grey matter deficits in right superior frontal gyrus (Brodmann area (BA) 8/9), right posterior cingulate gyrus (BA 30) and the basal ganglia bilaterally (especially right globus pallidus and putamen). They also demonstrated significant central white matter deficits in the left hemisphere anterior to the pyramidal tracts and superior to the basal ganglia.

CONCLUSIONS

This pattern of spatially distributed grey matter deficit in the right hemisphere is compatible with the hypothesis that ADHD is associated with disruption of a large scale neurocognitive network for attention. The left hemispheric white matter deficits may be due to dysmyelination.

Clinical considerations in the diagnosis of autism spectrum disorders

The diagnosis of autistic spectrum disorders (ASD) is being made more frequently in children and at younger ages. This paper discusses various factors to be considered in the screening of autism, early features of presentation, relevant to assessment and diagnosis, subtypes or different syndromes within the spectrum of autistic conditions including Asperger syndrome, the differential diagnosis from learning and language disorders and the medical and behavioural commonly associated disorders.

Pharmacotherapy of target symptoms in autistic spectrum disorders

There are no aetiologically-based treatments available to cure autism. Though psychotropics have a role in the management of some symptoms of autism, clinical trial evidence for the use of psychotropics is in its infancy and needs close monitoring. About half of the subjects with high functioning pervasive developmental disorders (PDDs) are currently reported to be on psychotropics (anti-depressants, stimulants and antipsychotics), with many of them being on anti-epileptic medication simultaneously. Despite this high level of psychotropic use, few studies exist investigating the pharmacokinetics, pharmacodynamics or side-effect profiles in this population. Multiprofessional and parent partnership is essential in managing autism and psychopharmacology should be used in conjunction with environmental manipulation, educational modification and/or behavioral management strategies. A symptomatic approach to managing the difficult behaviours associated with autism is recommended. Some symptoms of autism may be medication responsive (hyperactivity, obsessions, rituals, inattention, tics, etc), while other symptoms may be responsive to behavioural interventions, but may require medication (aggression, anxiety, depression, impulsivity, sleep difficulties, etc), and symptoms which need specific skill remediation are usually non-responsive to medication (deficits in academic, social or sport domains). The new atypical antipsychotics (such as risperidone, olanzapine, amisulpiride, quetiapine) and SSRIs are increasingly being used in autism, with encouraging results, but a risk-benefit ratio of pharmacotherapy is essential with due weight being given to the side-effects of medication. Despite symptomatic improvement with medication, one should remain cautious about long-term use of psychotropics. It is also important to recognize that psychotropics can sometimes worsen behaviour, and can produce iatrogenic symptoms. Certain anti-epileptic medication and psychotropic drugs are metabolized by the same cytochrome P450 isoenzymes in the liver. In such circumstances, the addition of a psychotropic agent may drastically alter the levels of the anti-epileptic medication and vice versa. It is suggested that specialist clinics should be involved when one is considering complex medication regimes, experimental drugs, polypharmacy, or if patients show unusual side-effects or is drug resistant.

Stimulant drugs

Stimulants are a key element in the treatment of ADHD. Carefully designed trials of stimulants have found substantial improvement in ADHD core behaviours in 65-75 % of subjects with ADHD. Most standard stimulants are rapidly absorbed, with their behavioural effects appearing within 30 minutes, reaching a peak within one to three hours and disappearing within five hours. Doses at school are often necessary, in spite of the risk of peer ridicule and added adult supervision requirements. The mechanism by which stimulants act to reduce hyperactivity is not completely understood, but they improve impulsivity and activity levels. Several controlled evaluations made over periods of time greater than a year show a clear persistence of medication effects over time. A carefully crafted programme of treatment with methylphenidate is more effective in the reduction of hyperactivity symptoms than an intensive programme of behavioural and cognitive intervention. The combination of stimulants with psychosocial interventions in ADHD offers few advantages over medication alone. Unchallengeable guides to practice that would be appropriate everywhere are difficult to propose. It is imperative that clinicians prescribing stimulants should monitor the use of the drug properly, making sure that it is not being abused by the child's family, peers or those dispensing medication at school. Polypharmacy should only be embarked on by a specialist service and the combination of methylphenidate and clonidine should be used cautiously. Apart from ADHD, stimulants are useful in narcolepsy, resistant depression and partial syndromes of attention and hyperactivity. Major gaps in knowledge remain; pharmacokinetics, pharmacodynamics and pharmacogenetics of stimulant effects need further study. Details of stimulant administration regimes seem to have a major effect on the response achieved. Further research is needed, preferably in realistic practice settings, comparing different forms of combination with psychological interventions, investigating the effects in groups of children outside the core of schoolaged children with typical ADHD: preschool children, adults, those with partial syndromes (such as inattentiveness) and those with co-morbid disorders.

Neuroimaging in child and adolescent psychiatric disorders

Neuroimaging in child psychiatry is a rapidly developing field and the number of different techniques being used is increasing rapidly. This review describes the current status of neuroimaging in childhood psychopathology and discusses limitations of the various studies. As yet, no specific and consistent abnormality has been detected in childhood psychiatric disorders. Obsessive compulsive disorder has shown the most consistent findings so far, with orbitofrontal cortex and the caudate nucleus being implicated. Better understanding of the corticostriatal neural networks will shed more light on the neurodevelopmental disorders of childhood.

Psychopharmacotherapy in children and adults with intellectual disability

The prevalence of psychiatric disorders is increased in children and adults with intellectual disability. Brain damage or dysfunction interact with social and family factors to increase susceptibility to mental illness. Psychiatric disorders in the context of genetic syndromes are commonly overlooked, and there is substantial underdiagnosis of mental disorders because of the atypical and non-specific clinical presentations, and the frequent assumption that psychiatric symptoms are an inherent part of the underlying intellectual disability. There is a strong need for evidence-based practice in the prescribing and monitoring of drugs in this population, especially since many of the drugs are unlicensed for use in children. There is an urgent need to understand and establish the pharmacokinetics, pharmacodynamics, and side-effect profiles of psychotropic medication in this population. Positive trends in pharmacotherapy include the use of atypical antipsychotics instead of the classic antipsychotics, serotonin-specific reuptake inhibitors (SSRIs) rather than tricyclic antidepressants, and newer antiepileptic drugs. Another welcome trend is the use of SSRIs instead of antipsychotics in the long-term management of challenging behaviour in this population.

Onset of acute psychotic states in India: a study of sociodemographic, seasonal and biological factors

This is a comparative study of patients with acute-onset, non-affective, non-organic, remitting psychoses and with non-remitting or schizophrenic psychoses in India. Two groups of patients with acute remitting and non-remitting or schizophrenic psychoses were compared with regard to the following variables: month of onset of psychosis; presence of stress, particularly fever, within 4 weeks preceding the onset of psychosis; childbirth within 12 weeks preceding the onset of psychosis; gender differences. It was found that the acute remitting psychoses showed an overrepresentation of females, a higher frequency of associated stress preceding the onset of psychosis, more often had onset during the summer months, i.e. between May and September, and had fever and childbirth preceding the onset of psychosis in a significantly higher proportion of patients, compared to acute non-remitting psychoses or schizophrenia. The implications of the findings which point towards biological factors in the aetiology of acute remitting psychoses are discussed.

A psychosocial study of 'self-immolation' in India

The phenomenon of self-immolation was studied in 22 young people, mostly students, who had indulged in this act to protest against the decision of the Government of India to enlarge the scope of reservations in jobs and educational institutions. Within a short span of time of arriving at one of the two treatment centres after attempting self-immolation, the subjects were interviewed and assessed on a semi-structured interview schedule to elicit sociodemographic and attitudinal data. The subjects were also rated on the Brief Psychiatric Rating Scale, Pierce's Suicide Intent Scale, the Superego Paranoia Depression Scale, the Hostility and Direction of Hostility Questionnaire, the PGI Locus of Control Scale and the Alienation Scale. All subjects except one were free of manifest psychopathology. The group as a whole had a high score on Pierce's Suicide Intent Scale and displayed internal locus of control orientation. Most were ambitious, aggressive, hostile and felt alienated. The absence of manifest psychopathology sets this group apart from cases of deliberate self-harm arising in the context of psychiatric morbidity. Thwarted ambitions, a sense of alienation and intropunitive hostility can lead to protest which at times becomes altruistic and results in self-immolation.

Familial reverse seasonal affective disorder - a case report

A patient with recurrent summer depression for seven consecutive years is described, whose mood significantly worsened with increased environmental temperature. She had a family history of recurrent summer depression in both her brother and paternal grandmother with symptoms similar to those of typical endogenous depression. The patient's mood switched to hypomania with antidepressant therapy.

Loading dose imipramine--new approach to pharmacotherapy of melancholic depression

This study investigated the therapeutic efficacy of loading doses of imipramine hydrochloride and compared it with that of conventional gradually escalating dose regimen of the same drug in 16 melancholic depressives (DSM III-R), done in a comparative, randomized, double-blind research design. There were four males and four females in each group who were comparable on socio-demographic and clinical variables. The study group received the bolus doses of imipramine on two consecutive days and was free of any antidepressant treatment between day 3 and day 7 of the treatment period, whereas the control group received the conventional regime of gradual escalation of imipramine dose over a period of 7 days. The results indicate that imipramine hydrochloride can relieve depression almost completely within 72 h, if given in high bolus doses, thus challenging the theory of lag period for antidepressant action as an inherent property of this drug. The study shows that the pulse loading dose was superior to a conventional dose regime with regard to both antidepressant efficacy and rapidity of onset of action. The various mechanisms possibly involved in such a dramatic improvement and its implications have been discussed.

Varied psychiatric manifestations of acute intermittent porphyria

Acute Intermittent Porphyria (AIP) is an autosomal dominant metabolic disorder that has various psychiatric manifestations. This is a report of a case who had six brief psychotic episodes of varying nature within a 2-month period. The psychotic manifestations included catatonic stupor, hypomania, and delirium in different episodes. The management aspects of the case have been highlighted.

A study of P300 in melancholic depression--correlation with psychotic features

The relationship between delusions and hallucinations (psychotic features) in melancholic depression and auditory P300 was studied. Forty patients with melancholic depression as per DSM-III-R were studied, 20 of whom had hallucinations and/or delusions. The 20 patients of the two groups were individually matched on age, gender, sociodemographic variables, and psychopathology (except for psychotic features). Auditory P300 obtained by the "oddball paradigm" showed that those with hallucinations and/or delusions had a significantly smaller P3 amplitude. Significant correlations between "psychotic features" and P3 amplitude was found. Implications of these findings on research, classification, and management of depression have been outlined.