Concomitant psychotropic medication for youths

OBJECTIVE: This study reviewed the clinical research and practice literature relating to the prevalence and patterns of concomitant psychotropic medication given to youths with emotional and behavioral disorders. METHOD: A MEDLINE search from 1996 through spring 2002, including a review of references from relevant published articles and reports, was undertaken to identify available information on concomitant psychotropic medication for youths. RESULTS: The data supporting concomitant psychotropic medication for youths are almost exclusively based on case reports and small-scale, nonblind assessments. In the mid-1990s, over 20% of outpatient youths treated in community mental health centers and over 40% of youths treated in inpatient psychiatric facilities were given concomitant psychotropic medication. The rate has since increased. Psychiatrists more than primary care physicians prescribe concomitant psychotropic medication, and they show great variability in their prescribing habits. Youths with aggressive behavior, male gender, severe emotional illness, and disabling social maladjustment are most likely to receive concomitant psychotropic medication. CONCLUSIONS: Substantive systematic evidence is needed to clarify this increasingly common, inadequately researched child psychopharmacologic practice.     

Posttraumatic stress disorder and psychiatric comorbidity among detained youths

OBJECTIVE: This study examined the prevalence of posttraumatic stress disorder (PTSD) and comorbid psychiatric disorders among juvenile detainees. METHODS: The sample consisted of a stratified random sample of 898 youths aged ten to 18 years who were arrested and detained in Chicago. RESULTS: Among participants with PTSD, 93% had at least one comorbid psychiatric disorder; however, among those without PTSD, 64% had at least one comorbid psychiatric disorder. Over half (54%) of the participants with PTSD had two or more types of comorbid disorders--that is, affective, anxiety, behavioral, or substance use disorders--and 11% had all four types of comorbid disorders. Among males, having any psychiatric diagnosis significantly increased the odds of having comorbid PTSD. Among females, alcohol use disorder and both alcohol and drug use disorders significantly increased the odds of having PTSD. No significant difference in prevalence rates of PTSD was found between males and females with specific psychiatric disorders. The prevalence of any comorbid psychiatric disorder was significantly greater for males with PTSD than that for females with PTSD (OR=3.4, CI=1.1-10.6, p<.05). CONCLUSIONS: Detection of comorbid PTSD among detained youths must be improved. PTSD is often missed because traumatic experiences are rarely included in standard screens or volunteered by patients. When planning treatment, clinicians must consider ramifications of comorbid PTSD.     

Substance use disorder comorbidity among inpatient youths with psychiatric disorder

OBJECTIVE: Substance abuse/dependence has been reported to show significant association with psychopathology, and is likely to influence the course and outcome of psychiatric illness. The aim of this study was to determine the rate of substance use disorders (other than alcohol) comorbidity among inpatient adolescents with severe Axis 1 psychiatric disorder. METHOD: A retrospective analysis of systematically collected data was carried out. The subjects were 16-18-year-old youths, admitted to an inpatient unit for severe psychiatric disorder. The data collection process utilized the DSM-IV criteria for diagnostic categorization of psychiatric disorder and substance use disorder. Demographic data, and data on suicide attempts were also collected. RESULTS: Over a period of one year (March 2001-March 2002), 62 patients were admitted to the Christchurch Youth Inpatient Unit; 40 (64.5%) had a comorbid Substance Abuse Disorder (SAD) according to DSM-IV criteria and none had a Substance Dependence Disorder. The vast majority involved cannabis and stimulants. Sixty per cent of those with mood disorder, 63% of those with anxiety disorder and 80% of those with schizophrenia spectrum disorder had a comorbid SAD. Internalizing problems, especially mood disorders, pre-dominated among those with SAD reflecting the Unit's admission criteria. There were no differences in attempted suicide rates between those with SAD and those without SAD, but those with SAD were more likely to have unstable accommodation/living arrangements than those without SAD. CONCLUSIONS: Our findings confirm previous reports suggestive of high rates of SAD comorbidity among youth with severe psychiatric illness. There are clinical and process implications for these findings particularly identification of substance use disorders and their treatment as well as resource availability and staff training.     

Prevalence of depression and other psychiatric disorders among incarcerated youths

OBJECTIVE: To determine the prevalence of selected psychiatric disorders among incarcerated youths, compare prevalence rates by sex and ethnicity, assess comorbidity, and determine previous diagnosis. METHOD: From July-December 2000, a total of 1,024 incarcerated adolescents completed self-administered questionnaires that included the Beck Depression Inventory (BDI) and the Patient Health Questionnaire (PHQ), linked to DSM-IV, that assesses depression, drug and alcohol abuse, and somatoform, panic, and anxiety disorders. RESULTS: From the BDI, 261/1,024 (25%) had moderate and 223/1,024 (22%) severe depression. From the PHQ, 100/1,024 (9.77%) had major depressive disorder, 420 (41%) drug abuse, 275 (27%) alcohol abuse, and 297 (29%) one of the other disorders. In comparisons by sex and ethnic group, noteworthy findings included no differences between the sexes for moderate and severe depression from the BDI or for major depressive disorder from the PHQ; less drug and alcohol abuse in African-American males and females; and more anxiety disorder in white males and in females. Sixty percent had one or more psychiatric disorder: comorbidity was particularly common between both depression and anxiety and drug and alcohol abuse. Of depressed youths, 20% had been previously diagnosed and treated, as had approximately 10% with other disorders. CONCLUSIONS: Incarcerated youths had a high prevalence of psychiatric disorders, usually undiagnosed, and comorbidity was common.     

Prevalence of psychiatric disorders among older youths in the foster care system

OBJECTIVE: To estimate the lifetime and past year prevalence rates of major psychiatric disorders in a sample of older youths in the foster care system, to examine the timing of disorder onset and system entry, and to explore variations in past year prevalence rates. METHOD: Using the Diagnostic Interview Schedule for DSM-IV, interviews were conducted with 373 17-year-old youths (90% of those eligible) in one state's foster care system between December 2001 and June 2003. RESULTS:: Sixty-one percent of the youths qualified as having at least one psychiatric disorder during their lifetime; of these youths, 62% reported onset of their earliest disorder before entering the foster care system. In addition, 37% of youths met criteria for a psychiatric disorder in the past year. The number of types of maltreatment experienced was the most robust predictor of psychiatric disorder among several maltreatment variables. There were no differences in prevalence rates for youths in kinship care and those in nonkin foster families. CONCLUSIONS: Older youths in the foster care system have disproportionately high rates of lifetime and past year psychiatric disorders. Results support recommendations for initial and periodic mental health assessments for these youths and mechanisms to continue mental health services for young adults transitioning out of the foster care system.     

Sexual attitudes and associated psychiatric features among youths in a community sample

OBJECTIVE: Using an epidemiological sample of adolescents, this study examined associations between the acceptability of potential sex partners and psychiatric status. METHOD: Subjects aged 14 to 17 years (N = 161) from the Columbia site of the National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study were grouped according to their responses about the acceptability of youths their age having sex with partners of (1) the opposite sex, (2) neither sex, and (3) either sex. Youths endorsing either sex were compared with youths endorsing the other two types of partners according to psychiatric indicators obtained from the Diagnostic Interview Schedule for Children Version 2.3. RESULTS: Higher-than-expected proportions of male and female youths endorsed sex partners of either sex as potentially acceptable for peers. Youths who did so abused substances and used mental health services more than peers but did not differ in rates of suicidal ideation or attempts. Males endorsing either sex also had higher rates of mood disorders and, compared with males endorsing only the opposite sex, a higher intelligence level. CONCLUSIONS: Attitudes about the potential acceptability of sex partners for peers are associated with psychiatric morbidity and mental health service use in the respondent as well as with intelligence level in males. Youths who endorsed potential sex partners of either sex, especially males, appear to be at higher risk for multiple psychiatric problems.     

Patterns and quality of treatment for patients with schizophrenia in routine psychiatric practice

OBJECTIVES: This study provided generalizable national data on the treatment of adult patients with schizophrenia in the United States and assessed conformance with the practice guideline treatment recommendations of the Schizophrenia Patient Outcomes Research Team and the American Psychiatric Association. METHODS: National data from the American Psychiatric Institute for Research and Education's 1999 Practice Research Network study of psychiatric patients and treatments were used to examine treatment patterns for 151 adult patients with schizophrenia. Analyses were performed and adjusted for the weights and sample design to generate nationally representative estimates. RESULTS: Findings indicated that patients with schizophrenia who were treated by psychiatrists had complex clinical problems and were markedly disabled. Forty-one percent of patients had a comorbid axis I disorder, and 75 percent were currently unemployed. Thirty-five percent were currently experiencing medication side effects, and 37 percent were currently experiencing problems with treatment adherence. Although most patients received guideline-consistent psychopharmacologic treatment, treatment was characterized by significant polypharmacy. Rates of conformance with the guideline recommendations were significantly lower for psychosocial recommendations than for psychopharmacologic recommendations. Although 69 percent of patients received at least some psychosocial treatment, none of the unemployed patients received vocational rehabilitation services in the past 30 days. CONCLUSIONS: These data suggest unmet need for psychosocial treatment services among individuals with schizophrenia. These findings raise questions about whether currently available antipsychotic medications are being used optimally or whether they offer limited effectiveness for patients with complex clinical problems who are treated in routine psychiatric practice.     

Homophobia among psychiatric residents, family practice residents and psychiatric faculty.

As the number of AIDS cases has continued to increase, psychiatric research has focused on the victims of this disease. Little has been written about the caregivers and the impact that their attitudes have on patients. There have been a few studies measuring attitudes of health care providers to homosexuals and AIDS patients, but to the best of our knowledge, none have looked at the attitudes of psychiatrists or residents in psychiatry. Psychiatric residents, family practice residents and psychiatric faculty in a medium-sized Canadian medical school completed a questionnaire measuring attitudes toward homosexuals. We report on the results of this questionnaire and comment on the impact of the attitudes of health care professionals on the quality of patient care.     

Improved pharmacotherapy of major depression in psychiatric outpatient care

We studied the ability of mental health care to treat major depression in accordance with given standards. The treatment procedures for 232 patients with first-episode major depression (DSM-III-R) in 3 study years (1989, 1992, 1995) were circumstantially and retrospectively evaluated from documents in community psychiatric outpatient care in Finland. In total, two-fifths of the patients received probably inadequate pharmacotreatment. However, there was a clear improvement in pharmacotreatment of major depression during the study years. The adequacy of given antidepressant medication was associated with high basic education of the patients, accuracy of diagnosis, and new antidepressants.     

Mortality among male and female alcoholic patients treated in a psychiatric unit

A series of patients consisting of 139 men and 118 women had themselves sought treatment and were admitted to a psychiatric unit under a diagnosis of alcohol abuse. Prior to admission, they had not been registered for drinking offences. The series was studied with regard to mortality during an observation period from 5 to 10 years. Compared to the general population the mortality was high for both sexes, and this was more pronounced for women than for men. However, since alcoholism is much more widespread among men, mortality in the male population is affected by alcoholism to a greater extent than mortality in the female population. Differences in excess mortality between the sexes in this study disappear if death-risks applying to men are also applied to women. The specific causes of death broadly follow the same pattern as in earlier studies. The excess mortality from accidents was, however, remarkably low. An explanation for this may be that accidental deaths, more than deaths from other causes, are correlated to the social effects of abuse. Suicide through drug intoxication was more common among women than among men; this corresponds to the situation in the general population.     

Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care

Characteristics associated with psychiatrist-reported treatment-compliance problems were investigated using the 1999 Study of Psychiatric Patients and Treatments from the Practice Research Network of the American Psychiatric Institute for Research and Education (n=1,843). Logistic regression was used to study characteristics associated with compliance problems as perceived by treating psychiatrists. Among the 22 potential predictors of interest, all but three (age, gender, and problems with primary support group) were found to be significantly associated with treatment-compliance problems in bivariate analyses. A predictive model was developed consisting of eight independently significant predictors from diagnostic, clinical, psychosocial, and treatment-history domains. These predictors included substance use disorder diagnosis, medication side effects, moderate to severe psychotic symptoms, personality disorder diagnosis, economic problems, prior hospitalization, current Global Assessment of Functioning scale score, and duration of treatment with current psychiatrist. This predictive model correctly identified the presence or absence of treatment-compliance problems in 91% of patients in a sample randomly drawn from the dataset before model construction. These findings may be useful to clinicians, researchers, and program planners interested in addressing the important issue of treatment-compliance problems in psychiatric care settings.