Treatment resistant psychosis in children and adolescents and clozapine: Nuances

With proliferation in research on high-risk psychosis spectrum diseases, it is crucial to distinguish a prodrome or psychosis-like episode in children and adolescents from true psychosis. The limited role of psychopharmacology in such circumstances is well-documented, underlining the difficulties in diagnosing treatment resistance. To add to the confusion is emerging data on the head-to-head comparison trials for treatment-resistant and treatment-refractory schizophrenia. Clozapine, the gold-standard drug for resistant schizophrenia and other psychotic psychopathology, lacks FDA or manufacturer guidelines for use in the pediatric population. Possibly due to developmental pharmacokinetic (PK) considerations, clozapine-related side effects are more commonly seen in children than adults. Despite evidence of an increased risk for seizures and hematological problems in children, clozapine is widely used off-label. Clozapine reduces the severity of resistant childhood schizophrenia, aggression, suicidality, and severe non-psychotic illness. There is inconsistent prescribing, administration, and monitoring of clozapine, and limited database evidence-backed guidelines. Despite the overwhelming efficacy, problems remain regarding unambiguous indications of use and risk-benefits assessments. This article reviews the nuances in the diagnosis of treatment resistance psychosis in childhood and adolescents and its management, in particular highlighting the evidence base for clozapine in this population group.

[Neurodevelopmental Disorders, Psychiatric Comorbidities and Associated Pathologies in Patients with Childhood-Onset Schizophrenia and Premorbid Autistic Symptoms.]

INTRODUCTION

Childhood-Onset Schizophrenia (COS) is a rare (1/40000), severe and neurodevelopmental form of schizophrenia beginning before 13 years of age. Little is known about comorbidities and specific COS-related disorders. Thus, the objective of our study was to evaluate them from a psychiatric, neurodevelopmental and somatic perspective.

METHOD

This is an ancillary study of the GenAuDiss protocol. A standardized psychiatric interview (K-SADS-PL DSM5) and a neuropsychological assessment (WISC-V/WAIS-IV) were carried out in outpatients with COS as well as a medical history collection concerning pregnancy, perinatal period, development, biography and medical and psychiatric, personal, and family history.

RESULTS

20 outpatients were included. The mean age of onset of COS was 8.90 years (+/- 2.30). Psychiatric comorbidities (DSM5) were Attention Deficit Hyperactivity Disorder (15/20 patients), Anxiety Disorders (14/20) and Autism Spectrum Disorder (13/20). The average IQ was 70.26 (+/- 18.09). A language delay and a break in school career were noted in 18/20 patients. Finally, the main associated somatic disorder was asthma (15/20 patients).

DISCUSSION

We highlighted in our patients with COS a high frequency of comorbidities including at least one systematic psychiatric disorder. However, although COS is a severe condition impacting the patient, his family and society, its management remains essentially symptomatic. In clinical practice, it is necessary to look for all these comorbidities and to manage them in order to improve the overall quality of care.

Diagnostic clusters associated with an early onset schizophrenia diagnosis among children and adolescents

OBJECTIVE

Given the greater severity and chronicity of psychiatric disorders that first declare in individuals under the age of 18, early onset schizophrenia (EOS) and its association with co-occurring psychiatric conditions deserve further investigation.

METHODS

Cluster and discriminant analyses were used to examine the heterogeneity of children and adolescents diagnosed with schizophrenia in 1 statewide system of care. A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services between January, 1999 and December, 2013 to identify patients ≤17 years of age.

RESULTS

Among the 613 EOS patients selected, 3 main clusters of ICD-9 psychiatric diagnoses were identified: (1) older children with schizophrenia coaggregated with a spectrum of mood/emotional dysregulation conditions; (2) younger children with coaggregated schizophrenia, mental retardation/intellectual disability or autism spectrum disorders; and (3) older children with schizophrenia and significantly fewer diagnosed co-occurring conditions. Externalizing/disruptive behavior disorders (i.e., attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) were significantly associated with Clusters 1 and 2.

CONCLUSION

Symptom patterns plus age of first diagnosis are important differentiators of EOS subgroups in this cohort. Earlier recognition of psychiatric symptom/syndrome patterns that frequently co-occur may enable clinicians to stratify/tailor treatment interventions.

Striatal shape abnormalities as novel neurodevelopmental endophenotypes in schizophrenia: a longitudinal study

There are varying, often conflicting, reports with respect to altered striatal volume and morphometry in the major psychoses due to the influences of antipsychotic medications on striatal volume. Thus, disassociating disease effects from those of medication become exceedingly difficult. For the first time, using a longitudinally studied sample of structural magnetic resonance images from patients with childhood onset schizophrenia (COS; neurobiologically contiguous with the adult onset form of schizophrenia), their nonpsychotic siblings (COSSIBs), and novel shape mapping algorithms that are volume independent, we report the familial contribution of striatal morphology in schizophrenia. The results of our volumetric analyses demonstrate age-related increases in overall striatal volumes specific only to COS. However, both COS and COSSIBs showed overlapping shape differences in the striatal head, which normalized in COSSIBs by late adolescence. These results mirror previous studies from our group, demonstrating cortical thickness deficits in COS and COSSIBs as these deficits normalize in COSSIBs in the same age range as our striatal findings. Finally, there is a single region of nonoverlapping outward displacement in the dorsal aspect of the caudate body, potentially indicative of a response to medication. Striatal shape may be considered complimentary to volume as an endophenotype, and, in some cases may provide information that is not detectable using standard volumetric techniques. Our striatal shape findings demonstrate the striking localization of abnormalities in striatal the head. The neuroanatomical localization of these findings suggest the presence of abnormalities in the striatal-prefrontal circuits in schizophrenia and resilience mechanisms in COSSIBs with age dependent normalization.

A comparison of neuroimaging findings in childhood onset schizophrenia and autism spectrum disorder: a review of the literature

BACKGROUND

Autism spectrum disorder (ASD) and childhood onset schizophrenia (COS) are pediatric neurodevelopmental disorders associated with significant morbidity. Both conditions are thought to share an underlying genetic architecture. A comparison of neuroimaging findings across ASD and COS with a focus on altered neurodevelopmental trajectories can shed light on potential clinical biomarkers and may highlight an underlying etiopathogenesis.

METHODS

A comprehensive review of the medical literature was conducted to summarize neuroimaging data with respect to both conditions in terms of structural imaging (including volumetric analysis, cortical thickness and morphology, and region of interest studies), white matter analysis (include volumetric analysis and diffusion tensor imaging) and functional connectivity.

RESULTS

In ASD, a pattern of early brain overgrowth in the first few years of life is followed by dysmaturation in adolescence. Functional analyses have suggested impaired long-range connectivity as well as increased local and/or subcortical connectivity in this condition. In COS, deficits in cerebral volume, cortical thickness, and white matter maturation seem most pronounced in childhood and adolescence, and may level off in adulthood. Deficits in local connectivity, with increased long-range connectivity have been proposed, in keeping with exaggerated cortical thinning.

CONCLUSION

The neuroimaging literature supports a neurodevelopmental origin of both ASD and COS and provides evidence for dynamic changes in both conditions that vary across space and time in the developing brain. Looking forward, imaging studies which capture the early post natal period, which are longitudinal and prospective, and which maximize the signal to noise ratio across heterogeneous conditions will be required to translate research findings into a clinical environment.

A systematic review of the long-term outcome of early onset schizophrenia

BACKGROUND

The current review analyzes the long-term outcome and prognosis of early onset schizophrenia based on previously published studies in 1980.

METHODS

A systematic search of articles published in the English-language literature after 1980 identified a total of 21 studies, which included 716 patients who were either suffering from early onset schizophrenia (EOS) or both EOS and other psychotic disorders (MIX). The authors of the current review scored the outcome as either "good," "moderate," or "poor." The mean age of onset in these studies was <18 years.

RESULTS

In general, the outcome in studies with EOS is worse than the outcome in MIX studies. Only 15.4% of the patients in EOS studies versus 19.6% of the patients in MIX studies experienced a "good" outcome. In contrast, 24.5% of the patients in EOS studies versus 33.6% in MIX studies experienced a "moderate" outcome, and 60.1% in EOS studies versus 46.8% in MIX studies experienced a "poor" outcome. The authors identified various significant effects on outcome. In EOS, the findings were significantly affected by sample attrition, indicating that in studies with a high dropout rate, fewer patients experienced a "moderate" outcome, and more patients experienced a "poor" outcome; however, the effect sizes were small. Furthermore, the effects were also small and more favourable for specific functioning measures, as opposed to more global measures, small to moderate in terms of worse outcomes for follow-up periods >10 years, small to moderate for more unfavourable outcomes in males, and small to large for worse outcomes in studies including patients diagnosed before 1970.

CONCLUSIONS

In contrast to the adult manifestation, the early manifestation of schizophrenia in childhood and adolescence still carries a particularly poor prognosis. According to these aggregated data analyses, longer follow-up periods, male sex, and patients having been diagnosed before 1970 contribute predominantly to the rather poor course of EOS.

Personal reflections on observational and experimental research approaches to childhood psychopathology

The past 50 years have seen dramatic changes in childhood psychopathology research. The goal of this overview is to contrast observational and experimental research approaches; both have grown more complex such that the boundary between these approaches may be blurred. Both are essential. Landmark observational studies with long-term follow-up (Robins, 1966; Yarrow, Campbell, & Burton, 1970) have had - and continue to have - unique impact on clinical research and practice. Epidemiological studies showed high rates of psychological disorder and their close tie to neurological impairment (Rutter, Tizard, & Whitemore, 1970). These studies have current impact with respect to brain imaging correlates of clinical outcome. Pharmacological studies, particularly those on stimulants and on treatment of pediatric obsessive compulsive disorder (OCD), have propelled experimental methodology and inspired translational approaches. Predicted future trends are: more informed subgrouping of our heterogeneous phenotypes, reliance on multicenter trials, and documentation of non-conventional methods of care delivery.