Older patients referred to a consultation-liaison psychiatry clinic

BACKGROUND: Little is known about the psychiatric disorders which are associated with somatic presentations of psychological distress in older people. METHOD: A study of patients aged 65 years and over referred to an adult consultation-liaison psychiatry clinic in a general hospital. RESULTS: Of 900 patients referred over a 7-year period, 45 (5%) were aged 65 years and over. The most frequent ICD-10 diagnostic category was somatoform disorder (N=30) followed by depressive disorder (N=6). The age of onset of the physical symptoms was significantly earlier in those with somatoform disorders (mean 49 years; SD 3.1 years) compared with patients with depressive disorders (mean 74 years; SD 3.1 years) (p<0.05). All diagnoses were equally associated with moderate functional impairment. CONCLUSION: Medically unexplained physical symptoms may occur as part of a range of psychiatric disorders in older people and diagnostic groups are distinct in a number of ways. The usefulness of the ICD-10 classification of disorders in relation to these patients is considered. Implications for the delivery of old age psychiatry services are discussed.     

Health-related quality of life and functioning of middle-aged and elderly adults with bipolar disorder

OBJECTIVE: Data characterizing bipolar disorder in older people are scarce, particularly on functional status. We evaluated health-related quality of life and functioning (HRQoLF) among older outpatients with bipolar disorder as well as the relationship of HRQoLF to bipolar illness characteristics. METHOD: We compared community-dwelling middle-aged and older adults (age range, 45 to 85 years) with bipolar disorder (N=54; mean age=57.6 years), schizophrenia (N=55; mean age=58.5 years), or no psychiatric illnesses (N=38; mean age=64.7 years) on indicators of objective functioning (e.g., education, occupational attainment, medical comorbidity) and health status (e.g., Quality of Well-Being scale [QWB] and the Medical Outcomes Study-Short Form Health Survey [SF-36]). Within the group with bipolar disorder, we examined the relationship between HRQoLF and clinical variables (e.g., phase and duration of illness, psychotic symptoms, cognitive functioning). RESULTS: Patients with bipolar disorder were similar in educational and occupational attainment to the normal comparison group, but they obtained lower scores on the QWB and SF-36 (with large effect sizes). Compared with schizophrenia, bipolar disorder was associated with better educational and work histories but similar QWB and SF-36 scores and more medical comorbidity. Patients in remission from bipolar disorder had QWB scores that were worse than those of normal comparison subjects. Greater severity of psychotic and depressive symptoms and cognitive impairment were associated with lower HRQoLF. CONCLUSIONS: Bipolar disorder was associated with substantial disability in this sample of older adults, similar in severity to schizophrenia. Remission of bipolar disorder was associated with significant but incomplete improvement in functioning, whereas psychotic and depressive symptoms and cognitive impairment seemed to contribute to lower HRQoLF.     

Medically unexplained symptoms: an epidemiological study in seven specialities.

OBJECTIVES: This study aimed to estimate the prevalence and risk factors for medically unexplained symptoms across a variety of specialities. METHODS: A cross-sectional survey was conducted at two general hospitals in southeast London between 1995 and 1997. Eight hundred and ninety consecutive new patients from seven outpatient clinics were included. Demographic and clinical characteristic variables were assessed. RESULTS: Five hundred eighty-two (65%) of the subjects surveyed returned completed questionnaires. A final diagnosis was available in 550 (62%). Two hundred twenty-eight (52%) fulfilled criteria for medically unexplained symptoms. The highest prevalence was in the gynecology clinic (66%). After adjustment for confounders, medically unexplained symptoms were associated with being female, younger, and currently employed. Psychiatric morbidity per se was not associated with the presence of medically unexplained symptoms, but was more likely in those complaining of multiple symptoms. Those with medically unexplained symptoms were less disabled, but more likely to use alternative treatment in comparison with those whose symptoms were medically explained. Patients with medically unexplained symptoms were more likely to attribute their illness to physical causes as opposed to lifestyle factors. CONCLUSIONS: Medically unexplained symptoms are common across general/internal medicine and represent the most common diagnosis in some specialities. Medical behavior, training, and management need to take this into account.     

Childhood experiences of illness and parenting in adults with chronic fatigue syndrome

OBJECTIVE: There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as "medically unexplained symptoms." There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life. The aim of this investigation was to compare the contributions of childhood experiences of illness and parenting in adults with CFS with a fracture clinic control group. METHOD: A retrospective case control design was used. Thirty patients with a diagnosis of CFS and 30 patients attending a fracture clinic in an inner London teaching hospital completed questionnaires measuring parental care and protection and were interviewed about childhood experiences of illness. RESULTS: There were no differences in childhood experience of illness in the two groups. However, logistic regression revealed that maternal overprotection and depression were associated with the diagnosis of CFS. CONCLUSION: The findings may represent risk factors for the development of CFS in adult life. It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS.     

Further evidence for a developmental subtype of bipolar disorder defined by age at onset: results from the national epidemiologic survey on alcohol and related conditions

OBJECTIVE: This study examines the relationship between age at onset of bipolar I disorder and illness characteristics among adults in a community sample. METHOD: The National Epidemiologic Survey on Alcohol and Related Conditions identified 1,411 adults with bipolar disorder. For analyses, bipolar disorder subjects were divided into three age at onset groups: childhood (less than 13 years old, N=113), adolescence (13-18 years old, N=339), and adulthood (19 years or older, N=959). RESULTS: Nonremitting bipolar disorder was most prevalent among childhood-onset subjects, and childhood-onset subjects were most likely to experience prolonged episodes. Antisocial personality disorder was most prevalent among childhood-onset subjects. Drug use disorders were more prevalent among childhood-onset and adolescent-onset, as compared with adult-onset, subjects. Prevalence of mixed episodes or irritability did not differ significantly between groups. CONCLUSIONS: Findings corroborate clinical studies: illness characteristics among adults with childhood-onset bipolar disorder are similar to those described in children with bipolar disorder.     

Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study

OBJECTIVE: Little is known about whether illness perceptions affect health outcomes in primary care patients. The aim of this study was to examine if patients' illness perceptions were associated with their self-rated health in a 2-year follow-up period. METHODS: One thousand seven hundred eighty-five primary care patients presenting a new or recurrent health problem completed an adapted version of the illness perception questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline and 3, 12, and 24 months' follow-up. Linear regressions were performed for (1) all patients, (2) patients without chronic disorders presenting physical disease, and (3) patients presenting medically unexplained symptoms (MUS). RESULTS: Negative illness perceptions were associated with poor physical and mental health at baseline. They most strongly predicted changes in health status at follow-up for the whole group of patients. Patients presenting with MUS had more negative illness perceptions and lower mental and physical components subscale of the SF-36 scores at all time points. CONCLUSIONS: Patients' perception of a new or recurrent health problem predicts self-reported physical and mental health up to 2 years after consulting the general practitioner and offers an obvious starting point for addressing nonbiomedical aspects of illness.     

Impact of Different Childhood Adversities on 1-Year Outcomes of Psychotic Disorder in the Genetics and Psychosis Study

While the role of childhood adversity in increasing the risk of psychosis has been extensively investigated, it is not clear what the impact of early adverse experiences is on the outcomes of psychotic disorders. Therefore, we investigated associations between childhood adversity and 1-year outcomes in 285 first-presentation psychosis patients. Exposure to childhood adversity prior to 17 years of age was assessed using the Childhood Experience of Care and Abuse Questionnaire. Data on illness course, symptom remission, length of psychiatric hospitalization, compliance with medication, employment, and relationship status were extracted from clinical records for the year following first contact with mental health services for psychosis. Seventy-one percent of patients reported exposure to at least 1 type of childhood adversity (physical abuse, sexual abuse, parental separation, parental death, disrupted family arrangements, or being taken into care). No robust associations were found between childhood adversity and illness course or remission. However, childhood physical abuse was associated with almost 3-fold increased odds of not being in a relationship at 1-year follow-up compared to patients who did not report such adverse experiences. There was also evidence of a significant association between parental separation in childhood and longer admissions to psychiatric wards during 1-year follow-up and 2-fold increased odds of noncompliance with medication compared to those not separated from their parents. Therefore, our findings suggest that there may be some specificity in the impact of childhood adversity on service use and social functioning among psychosis patients over the first year following presentation to mental health services.Key words: first episode, illness course, psychosis, trauma, psychotic symptoms, service use     

Comorbidity of attention deficit hyperactivity disorder with early- and late-onset bipolar disorder

OBJECTIVE: The relationship between attention deficit hyperactivity disorder (ADHD) and earlier age at onset of affective illness was examined in probands with a history of bipolar disorder. METHOD: The authors assessed 56 adult bipolar subjects. Those with a history of childhood ADHD (N=8) were age and sex matched with bipolar subjects without a history of childhood ADHD (N=8). RESULTS: The age at onset of the first affective episode was lower for the subjects with bipolar disorder and a history of childhood ADHD (mean=12.1 years, SD=4.6) than for those without a history of childhood ADHD (mean=20. 0 years, SD=11.3). CONCLUSIONS: ADHD in children of bipolar probands might identify children at highest risk for development of bipolar disorder.     

Impact of physical symptoms on perceived health in the community

OBJECTIVE: Physical symptoms, such as musculoskeletal pain, dizziness, or headache, are common. People with more symptoms are reported to use more healthcare and have higher sickness absenteeism. We studied the impact of the number of symptoms on perceived health in a community sample. METHODS: Between June 2005 and March 2006, a random sample of 4741 adults was selected from the records of five general practices in The Netherlands. They were sent a questionnaire regarding the frequency and impact of physical symptoms, and other factors that may influence health (potential confounders or modifiers), including lifestyle factors, childhood illness experiences, and psychological factors. We studied the association between increasing number of physical symptoms and perceived health using the SF-36 as the outcome measure. RESULTS: Response rate was 53.5% (n=2447). Fatigue was the most commonly reported symptom with a prevalence of 57%, followed by headache (40%) and back pain (39%). More than half of responders reported three symptoms or more. Responders with multiple symptoms were more often female, had lower educational level, less often paid work, higher body mass index, more negative childhood health experiences, and higher scores for anxiety and depression. Multiple symptoms were strongly associated with perceived health, especially among responders with negative illness perceptions, more anxiety, or those reporting family members with a chronic illness during childhood. CONCLUSION: Physical symptoms are common and often seem to be mild. However, increasing number of symptoms is strongly associated with poorer physical, emotional, and social functioning. Different somatization processes may explain our findings.     

Paths to panic disorder/agoraphobia: an exploratory analysis from age 3 to 21 in an unselected birth cohort

OBJECTIVE: To evaluate childhood temperamental traits and early illness experiences in the etiology of adult panic disorder with agoraphobia. METHOD: Evaluated temperamental and illness experience factors, at ages 3 through 18, as predictors of panic and agoraphobia at ages 18 or 21 in an unselected sample (N = 992). Analyses were conducted with classification trees. RESULTS: Experience with respiratory ill health predicted panic/agoraphobia relative to other anxiety disorders and healthy controls. Also, temperamental emotional reactivity at age 3 predicted panic/agoraphobia in males but did not predict other anxiety disorders, compared with healthy controls. Furthermore, temperament and ill health interacted with gender. CONCLUSIONS: Results are discussed in terms of cognitive theories of fear of physical symptoms and biological models of respiratory disturbance for panic/agoraphobia.     

Sex differences in the effect of childhood trauma on the clinical expression of early psychosis

Childhood trauma, a risk factor of psychosis, is associated the clinical expression of the illness (greater severity of psychotic symptoms; poorer cognitive performance). We aimed to explore whether there are sex differences in this relationship. We studied 79 individuals with a psychotic disorder (PD) with < 3 years of illness and 59 healthy subjects (HS). All participants were administered the MATRICS Cognitive Consensus Cognitive Battery (MCCB) to assess cognition. Depressive, positive and negative psychotic symptoms, and global functioning were also assessed. History of childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Patients reported a greater history of childhood trauma on all CTQ domains (emotional, physical and sexual abuse, and physical and emotional neglect). A poorer cognitive performance was also observed in PD when compared to HS. No sex differences were found in the CTQ scores. In the relationship between childhood trauma and psychopathological symptoms, significant correlations were found between CTQ scores and positive and negative psychotic symptoms, depressive symptoms and poorer functionality, but only in women. Childhood trauma was associated with poorer social cognition in both men and women. Of all CTQ dimensions, emotional neglect and physical neglect were more clearly associated with a more severe psychopathological and cognitive profile. Our results suggest that childhood trauma, particularly emotional and physical neglect, is associated with the clinical expression of psychosis and that there are sex differences in this relationship.     

Posttraumatic stress disorder in abused and neglected children grown up.

OBJECTIVE: The purpose of this study was to describe the extent to which childhood abuse and neglect increase a person's risk for subsequent posttraumatic stress disorder (PTSD) and to determine whether the relationship to PTSD persists despite controls for family, individual, and lifestyle characteristics associated with both childhood victimization and PTSD. METHOD: Victims of substantiated child abuse and neglect from 1967 to 1971 in a Midwestern metropolitan county area were matched on the basis of age, race, sex, and approximate family socioeconomic class with a group of nonabused and nonneglected children and followed prospectively into young adulthood. Subjects (N = 1,196) were located and administered a 2-hour interview that included the National Institute of Mental Health Diagnostic Interview Schedule to assess PTSD. RESULTS: Childhood victimization was associated with increased risk for lifetime and current PTSD. Slightly more than a third of the childhood victims of sexual abuse (37.5%), 32.7% of those physically abused, and 30.6% of victims of childhood neglect met DSM-III-R criteria for lifetime PTSD. The relationship between childhood victimization and number of PTSD symptoms persisted despite the introduction of covariates associated with risk for both. CONCLUSIONS: Victims of child abuse (sexual and physical) and neglect are at increased risk for developing PTSD, but childhood victimization is not a sufficient condition. Family, individual, and lifestyle variables also place individuals at risk and contribute to the symptoms of PTSD.     

Childhood adversity and frequent medical consultations

We assessed possible psychological mediators of the relationship between childhood adversity and frequent medical consultations among new outpatients at neurology, cardiology, and gastroenterology clinics. We assessed whether these differed in patients with and without organic disease that explained their symptoms. At first clinic visit we recorded Hospital Anxiety and Depression scale (HADS--anxiety and depression subscale scores), Illness Perception Questionnaire (IPQ--four subscales: consequences, cure, identity, timeline), Health Anxiety Questionnaire (total score), and Symptom Amplification Scale (total score). Subjects were divided into two groups according to whether they had experienced any type of childhood adversity using the Childhood Experience of Care and Abuse Schedule. Outcome was the (log) number of medical consultations for 12 months before and 6 months after the index clinic visits. Multiple regression analysis was used to determine mediators; this was performed separately for patients with symptoms explained and not explained by organic disease. One-hundred and twenty-nine patients (61% response) were interviewed. Fifty-two (40.3%) had experienced childhood adversity; they made a median of 16 doctor visits compared with 10 for those without adversity (adjusted P=.026). IPQ identity score (number of symptoms attributed to the illness) and HAD depression scores were significantly associated with both childhood adversity and number of medical consultations and these variables acted as mediators between childhood adversity and frequency of consultation in the multiple regression analyses. This association was limited to patients with medically unexplained symptoms and was mediated by IPQ Identity Score (number of symptoms attributed to the patient's illness) and HAD depression score. Sexual abuse and overt neglect were the adversities most closely associated with frequent consultations. In patients with medically unexplained symptoms the association between childhood adversity and frequent medical consultations is mediated by the number of bodily symptoms attributed to the illness. Psychological treatments should be targeted at these patients with a view to reducing their frequent doctor visits.     

Psychological characteristics of women presenting with breast pain

Objective: Extensive evidence links unexplained physical symptoms in adults with childhood abuse. This study investigated a possible link between unexplained breast pain, recalled childhood abuse and emotional and somatic distress. Methods: Consecutive female out-patients presenting with breast pain were categorised as treatment-resistant (n=20), newly diagnosed and requesting treatment (n=37), or newly diagnosed but reassured and not seeking treatment (n=32) and compared with pain-free patients with breast lumps (n=31). Results: All breast pain groups were more anxious and depressed, somatised more and recalled a higher incidence of emotional abuse by comparison with breast lump patients. Logistic regression confirmed that emotional abuse and anxiety were independently associated with breast pain. Conclusion: Clinical management of patients who present breast pain should be sensitive to the evidence that pain is a marker of emotional abuse in some women and is associated with widespread somatic and emotional distress.     

Relationship of brain MRI abnormalities and physical functional status in chronic fatigue syndrome

Chronic Fatigue Syndrome (CFS) is an unexplained illness that is characterized by severe fatigue. Some have suggested that CFS is a "functional somatic syndrome" in which symptoms of fatigue are inappropriately attributed to a serious illness. However, brain magnetic resonance imaging (MRI) data suggest that there may be an organic abnormality associated with CFS. To understand further the significance of brain MRI abnormalities, we examined the relationship between MRI identified brain abnormalities and self-reported physical functional status in 48 subjects with CFS who underwent brain MR imaging and completed the Medical Outcomes Study SF-36. Brain MR images were examined for the presence of abnormalities based on 5 general categories previously shown to be sensitive to differentiating CFS patients from healthy controls. There were significant negative relationships between the presence of brain abnormalities and both the physical functioning (PF) (rho=-.31, p=.03), and physical component summary PCS (rho=-.32, p=.03) subscales of the SF-36. CFS patients with MRI identified brain abnormalities scored significantly lower on both PF (t(1,46) =2.3, p=.026) and the PCS (t(1,41) =2.4, p=.02) than CFS subjects without an identified brain abnormality. When adjusted for age differences only the PF analysis remained significant. However, the effect sizes for both analyses were large indicating meaningful differences in perceived functional status between the groups. These results demonstrate that the presence of brain abnormalities in CFS are significantly related to subjective reports of physical function and that CFS subjects with MRI brain abnormalities report being more physically impaired than those patients without brain abnormalities.     

Childhood trauma and dissociative symptoms in panic disorder

OBJECTIVE: Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. The authors hypothesized that among individuals with a primary diagnosis of panic disorder, those experiencing depersonalization/derealization during panic attacks would be more likely to have a history of childhood trauma. METHOD: Rates of traumatic events were compared between panic disorder patients with (N=34) and without (N=40) prominent depersonalization/derealization during panic attacks. Symptom severity in the two groups was also examined. RESULTS: Contrary to the authors' hypothesis, no evidence was found that depersonalization/derealization during panic attacks was associated with childhood trauma. Minimal differences in severity of illness were found between patients with dissociative symptoms and those without such symptoms. CONCLUSIONS: This finding is consistent with a multifactorial model of dissociation. Factors other than childhood trauma and general psychopathology may underlie vulnerability to dissociative symptoms in panic disorder.     

Clinical features associated with medically unexplained stroke-like symptoms presenting to an acute stroke unit

In many areas of secondary care, symptoms unexplained by disease account for around one-third of all patients seen. We sought to investigate patients presenting with medically unexplained stroke-like symptoms to identify distinguishing features which may help to identify a non-organic aetiology. Patients given a discharge diagnosis of medically unexplained stroke-like symptoms over the preceding 11 years were identified retrospectively from a prospectively completed stroke unit database. Age- and sex-matched controls with ischaemic or haemorrhagic stroke or transient ischaemic attack were also identified. Clinical features on presentation, ischaemic risk factors, alcohol history, marital status and history of depression or anxiety were examined. Previous or subsequent admissions with medically unexplained syndromes were also examined via record linkage with hospital discharge records. A medically unexplained syndrome was assumed to be present if an International Classification of Diseases 9 discharge code for one or more of the thirteen conditions forming recognized functional syndromes was given. Logistic regression was applied to determine predictors of non-organicity. One hundred and five patients and controls, 1.6% of all stroke unit admissions were identified, 62% (65 patients) were females. Mean age was 50.3 +/- 14.9. Compared with age- and sex-matched controls patients with medically unexplained stroke-like symptoms were significantly more probable to have a headache at presentation (47% vs. 26%, P = 0.0004), have a diagnosis of one or more additional medically unexplained syndromes (24% vs. 11%, P = 0.007) but significantly less probable to present with symptoms of vertebrobasilar dysfunction (32% vs. 61%, P < 0.0001). A history of anxiety or depression, as recorded in the notes, was not found to be associated with a medically unexplained presentation. Medically unexplained stroke-like presentations are common (1.6% of all stroke presentations), they are most strongly predicted by the presence of other functional somatic syndromes, headache and the absence of symptoms of vertebrobasilar dysfunction.     

Depressive symptoms during childhood and adult obesity: the Zurich Cohort Study

Depression and obesity have become major health problems with increasing prevalence. Given the limited effectiveness of treatment for weight problems, the identification of novel, potentially modifiable risk factors may provide insights on new preventive approaches to obesity. The purpose of this study was to test the hypothesis that depressive symptoms during childhood are associated with weight gain and obesity during young adulthood. Participants were from a prospective community-based cohort study of young adults (N=591) followed between ages 19 and 40 years. The sample was stratified to increase the probability of somatic and psychological syndromes. Information was derived from six subsequent semistructured diagnostic interviews conducted by professionals over 20 years. The outcome measures were body mass index (BMI) and obesity (BMI>30). Among women, depressive symptoms before age 17 years were associated with increased weight gain (4.8 vs 2.6% BMI increase per 10 years) representing greater risk for adult obesity (hazard ratio=11.52, P<0.05). Among men, only after controlling for confounders, depressive symptoms before age 17 years were associated with increased weight gain (6.6 vs 5.2% BMI increase per 10 years) in adulthood but not with occurrence of obesity. These associations between childhood depressive symptoms and adult body weight were adjusted for baseline body weight, a family history of weight problems, levels of physical activity, consumption of alcohol and nicotine, and demographic variables. As the magnitude of the associations was high, and depression during childhood is a prevalent and treatable condition, this finding may have important clinical implications for the prevention and treatment of obesity. Whether the results of this study are limited to populations with elevated levels of psychopathology remains to be tested.     

Causal illness attributions in somatoform disorders: associations with comorbidity and illness behavior

OBJECTIVE: To compare causal illness beliefs between patients with unexplained physical symptoms and different comorbid disorders and to assess the association of causal illness beliefs with illness behavior. METHODS: We examined a sample of 233 patients attending treatment in primary care. Inclusion criteria were "unexplained physical symptoms." All patients were investigated using structured interviews and self-rating scales [Screening for Somatoform Symptoms (SOMS), Beck Depression Inventory (BDI), Beck Anxiety Inventory, and a 12-item instrument to assess causal attributions]. By means of factor analysis, the following illness attributions were considered: vulnerability to infection and environmental factors, psychological factors, organic causes including genetic and aging factors, and distress (including exhaustion and time pressure). RESULTS: Most patients reported multiple illness attributions. The more somatoform symptoms patients had, the more explanations in general they considered. Especially for vulnerability and organic illness beliefs, patients with somatoform symptoms had increased scores. Comorbidity with depression and with anxiety disorders was associated with more psychological attributions. Even when the influence of somatization, depression, and anxiety is controlled for, illness beliefs still showed associations with illness behavior. Organic causal beliefs and vulnerability attributions were associated with a need for medical diagnostic examinations, increased expression of symptoms, increased illness consequences, and bodily scanning. CONCLUSIONS: Multiple causal attributions can coexist demonstrating different associations with comorbid depression and illness behavior.     

Predictors and course of medically intractable epilepsy in young children presenting before 36 months of age: A retrospective, population-based study

Purpose: To determine the prevalence and identify predictors of medical intractability in children presenting with epilepsy before 36 months of age, and to assess the effect of medical intractability on long‐term mortality and intellectual function. Methods: Children with newly diagnosed epilepsy before 36 months between 1980 and 2009 while resident in Olmsted County, MN, were identified. Medical records were reviewed to collect epilepsy‐specific variables and long‐term outcome data. Medically intractable epilepsy was defined as either (1) seizure frequency greater than every 6 months at final follow‐up and failure of two or more antiepileptic drugs for lack of efficacy, or (2) having undergone epilepsy surgery after failure to respond to two or more antiepileptic drugs. Key Findings: One hundred twenty‐seven children with new‐onset epilepsy were identified and followed for a median of 78 months. Medically intractable seizures occurred in 35%, and significant predictors on multivariate analysis were age ≤12 months at diagnosis (odds ratio [OR] 6.76, 95% confidence interval [CI] 2.00, 22.84, p = 0.002), developmental delay at initial diagnosis of epilepsy (OR 20.03, 95% CI 3.49, 114.83, p = 0.0008), neuroimaging abnormality (OR 6.48, 95% CI 1.96, 21.40, p = 0.002), and focal slowing on initial EEG (OR 5.33, 95% CI 1.14, 24.88, p = 0.03). Medical intractability occurred early in the course in most children, being seen in 61% by 1 year, and 93% by 5 years after initial diagnosis. Mortality was higher (20% vs. 0%, p < 0.001) and intellectual outcome poorer (p < 0.001) if epilepsy was medically intractable. Significance: One third of children presenting with epilepsy before 36 months will be medically intractable, and significant predictors are identified. Medically intractable epilepsy is associated with increased mortality risk and significant intellectual disability.