CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

Barriers and facilitators to continuity and co-ordination of healthcare for under 18 years old: a systematic review

OBJECTIVE

To determine views and experiences of babies, children and young people relating to continuity of their healthcare.

DESIGN

Qualitative systematic review.

SETTING

Primary research from UK settings where NHS-commissioned or local authority-commissioned healthcare is provided. Systematic reviews from UK and non-UK high-income countries.

POPULATION

Babies, children and young people under 18 years old with experience of healthcare. Parental and/or carer perspectives only included if children are under 5 years old or unable to express their own view.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Thematic analysis of the benefits and facilitators to continuity of care for babies, children and young people.

RESULTS

20 047 abstracts were screened; 186 full-text articles were reviewed; 11 papers fulfilled the review criteria. From these, four main themes and 14 subthemes were identified. The theme 'individuals' had four subthemes: 'knowledge of healthcare system', 'support', 'personal lives' and 'results'. The theme 'healthcare professionals' had four subthemes: 'interservice communication', 'collaboration with babies, children and young people', 'communications' and 'relationships with healthcare professionals'. The theme 'practical' had four subthemes: 'colocation', 'appointment times', 'referrals' and 'waiting times'. The theme 'technological' had two subthemes: 'ease of use' and 'complements current healthcare management'.

CONCLUSIONS

Continuity of healthcare for babies, children and young people can enhance clinical outcomes but requires active facilitation by healthcare providers and services, especially in circumstances where individuals or their families are less able to advocate for themselves. A range of barriers and facilitators were identified together with recommendations for enhancing continuity of care.

PROSPERO REGISTRATION NUMBER

CRD42019145566.

Self-Harm in Children and Adolescents Who Presented at Emergency Units During the COVID-19 Pandemic: An International Retrospective Cohort Study

OBJECTIVE

To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations.

METHOD

This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed.

RESULTS

Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58).

CONCLUSION

Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Therapeutic alliance in the treatment of adolescent substance misuse: a systematic review

BACKGROUND

Therapeutic alliance has been found to play an influential role in predicting outcomes for adults and adolescents in psychotherapy. However, thus far, the information concerning the impact of therapeutic alliance on outcomes for adolescents in treatment for substance misuse has not yet been critically synthesised.

METHODS

In accordance with PRISMA guidelines, the current review aimed to systematically collate published research investigating the association between alliance and outcomes for adolescents undergoing substance misuse treatment. Database searching produced 1083 records, with 16 studies meeting eligibility criteria.

RESULTS

Twelve out of the 16 studies (75%) reported significant alliance-outcome relationships, whereby higher alliance ratings predicted better treatment outcomes, as well as improved engagement and retention in treatment. In addition, the review explored the conditions whereby alliances better predict outcomes, with reference to the alliance rater, the timing of the alliance rating and comorbid diagnoses. These results, however, largely remain inconclusive.

CONCLUSIONS

The evidence as it stands demonstrates the importance of the therapeutic alliance in predicting outcomes for adolescents in substance misuse treatments. The implications of the review's findings and recommendations for future research are discussed.

Editorial: Should child and adolescent mental health professionals be diagnosing personality disorder in adolescence?

Diagnosing personality disorders in adolescence remains a contentious issue, particularly in the United Kingdom (UK). In this debate section we hear from clinicians, service users and family members on this topic; strongly held views are expressed and evidenced.

Lockdown stringency and paediatric self-harm presentations during COVID-19 pandemic: retrospective cohort study

BACKGROUND

Lockdown during the pandemic has had significant impacts on public mental health. Previous studies suggest an increase in self-harm and suicide in children and adolescents. There has been little research on the roles of stringent lockdown.

AIMS

To investigate the mediating and predictive roles of lockdown policy stringency measures in self-harm and emergency psychiatric presentations.

METHOD

This was a retrospective cohort study. We analysed data of 2073 psychiatric emergency presentations of children and adolescents from 23 hospital catchment areas in ten countries, in March to April 2019 and 2020.

RESULTS

Lockdown measure stringency mediated the reduction in psychiatric emergency presentations (incidence rate ratio of the natural indirect effect [IRRNIE] = 0.41, 95% CI [0.35, 0.48]) and self-harm presentations (IRRNIE = 0.49, 95% CI [0.39, 0.60]) in 2020 compared with 2019. Self-harm presentations among male and looked after children were likely to increase in parallel with lockdown stringency. Self-harm presentations precipitated by social isolation increased with stringency, whereas school pressure and rows with a friend became less likely precipitants. Children from more deprived neighbourhoods were less likely to present to emergency departments when lockdown became more stringent.

CONCLUSIONS

Lockdown may produce differential effects among children and adolescents who self-harm. Development in community or remote mental health services is crucial to offset potential barriers to access to emergency psychiatric care, especially for the most deprived youths. Governments should aim to reduce unnecessary fear of help-seeking and keep lockdown as short as possible. Underlying mediation mechanisms of stringent measures and potential psychosocial inequalities warrant further research.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Editorial: Do we need inpatient units?

There is probably a consensus that psychiatric hospitalization for children and adolescents should be part of a continuum of care, but that given its expense and unnatural nature (children should be with families in a community), as noted by Kyriakopoulos in this issue, it should be used sparingly. Child psychiatrists in both the United States (McClellan) and the United Kingdom (Cotgrove and Northover) rue the fact that resources spent on inpatient units would be better spent on preventing hospitalization or providing better aftercare. It is certainly easy to see that the significant financial cost of a child's inpatient stay might well pay for his or her psychiatric treatment in the community for a year - assuming there were enough well-trained clinicians and resources to provide it. As we describe below, that is the rate-limiting step to providing alternatives and may account for why treatment is centralized rather than kept in communities. Hamdani et al eloquently describe the situation in low- and middle-income countries where there is a dearth of both inpatient and community resources; requiring urgent attention to the provision of holistic care for young people with mental health problems from preventive services upwards. The approach they describe is what our other authors are calling for, due to an historical over-reliance on inpatient beds in higher income countries.

Pharmacological management of core and comorbid symptoms in autism-spectrum disorder

In this article we review the evidence base and practical experience supporting the use of psychopharmacological treatments for autism-spectrum disorders across the lifespan. Recent advances in knowledge are highlighted, as are the shortcomings of published data in this field. Psychosocial and educational interventions remain the core of treatment, but there is now evidence that medication management is a good option for certain domains of behaviour. We discuss the evidence in terms of symptom clusters, including the underlying social deficit of autism and common psychiatric comorbidities.

Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis

BACKGROUND

The treatment of adolescent depression is controversial and studies of combined treatment (antidepressants and cognitive-behavioural therapy, CBT) have produced conflicting findings.

AIMS

To address the question of whether CBT confers additional benefit to antidepressant treatment in adolescents with unipolar depression for depressive symptoms, suicidality, impairment and global improvement.

METHOD

Meta-analysis of randomised controlled trials (RCTs) of newer-generation antidepressants and CBT in adolescent depression.

RESULTS

There was no evidence of a statistically significant benefit of combined treatment over antidepressants for depressive symptoms, suicidality and global improvement after acute treatment or at follow-up. There was a statistically significant advantage of combined treatment for impairment in the short-term (at 12 weeks) only. There was some evidence of heterogeneity between studies.

CONCLUSIONS

Adding CBT to antidepressants confers limited advantage for the treatment of an episode of depression in adolescents. The variation in sampling and methodology between studies, as well as the small number of trials, limits the generalisability of the findings and any conclusions that can be drawn. Future studies should examine predictors of response to treatment as well as clinical components that may affect outcome.

The conceptualization and measurement of therapeutic alliance: an empirical review

Therapeutic alliance constitutes a major variable in explaining the outcome of treatment. However, meta-analytic, narrative, and theoretical reviews have all begun to comment on significant deficiencies in both conceptualization and measurement of alliance. While the evidence on the overall impact of alliance on treatment outcomes is impressive, we know much less about its components, modelling and discrete measurement. We review the conceptual and methodological underpinning of current alliance concepts and measures with the aim of identifying the current status of the methods and clarifying the conceptual and measurement tasks ahead. The review makes clear the diversity of concepts and measures available to address treatment alliance; however there is no one current measure of alliance that meets all the predefined criteria in either adult or child populations. We discuss the most successful measures to date, and recommend future developments in the field of alliance, including conceptual and experimental approaches, developmental issues, and analytic techniques.

Impact of hospitalisation on the outcome of adolescent anorexia nervosa

BACKGROUND

Owing to the lack of controlled trials of treatment setting in adolescent anorexia nervosa, the benefits and costs of in-patient treatment are not established.

AIMS

To clarify the relationship between a range of presenting features, treatment received and medium- to long-term outcome in adolescent anorexia nervosa.

METHOD

A range of presenting variables were rated for 75 cases of DSM-III-R anorexia nervosa at presentation to an adolescent service, including the Morgan-Russell Global Assessment Score. Cases were followed up at 2-7 years and outcome rated according to reliable methods. Setting of treatment received was also recorded.

RESULTS

Two out of 75 cases had died by the time of follow-up. Adequate data for 72 enabled an outcome category to be assigned. The 21 who had received inpatient treatment had a significantly worse outcome than the 51 never admitted to hospital. Multivariate analysis suggests admission to be the major predictor of poor outcome.

CONCLUSIONS

The benefits and costs of admission to hospital require further investigation, ideally in a randomised-controlled trial. The negative consequences of in-patient treatment are neglected in research.

Attitudes to people with mental handicap

Nurses working with mentally handicapped people may have much to learn from the work and theories of social psychologists. Ron Elvins' wide-ranging article explores some of these theories and looks at how prejudices arise; examples from socio-psychological research serve as illustrations of the problems which integration of population groups present, and perhaps offer models of how integration can be successfully facilitated.