D. Catherine Fuchs

Antipsychotics and the risk of type 2 diabetes mellitus in children and youth.

IMPORTANCE The increased prescribing of antipsychotics for children and youth has heightened concerns that this practice increases the risk of type 2 diabetes mellitus. OBJECTIVE To compare the risk of type 2 diabetes in children and youth 6 to 24 years of age for recent initiators of antipsychotic drugs vs propensity score-matched controls who had recently initiated another psychotropic medication. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of the Tennessee Medicaid program with 28 858 recent initiators of antipsychotic drugs and 14 429 matched controls. The cohort excluded patients who previously received a diagnosis of diabetes, schizophrenia, or some other condition for which antipsychotics are the only generally recognized therapy. MAIN OUTCOMES AND MEASURES Newly diagnosed diabetes during follow-up, as identified from diagnoses and diabetes medication prescriptions. RESULTS Users of antipsychotics had a 3-fold increased risk for type 2 diabetes (HR = 3.03 [95% CI = 1.73-5.32]), which was apparent within the first year of follow-up (HR = 2.49 [95% CI = 1.27-4.88]). The risk increased with cumulative dose during follow-up, with HRs of 2.13 (95% CI = 1.06-4.27), 3.42 (95% CI = 1.88-6.24), and 5.43 (95% CI = 2.34-12.61) for respective cumulative doses (gram equivalents of chlorpromazine) of more than 5 g, 5 to 99 g, and 100 g or more (P < .04). The risk remained elevated for up to 1 year following discontinuation of antipsychotic use (HR = 2.57 [95% CI = 1.34-4.91]). When the cohort was restricted to children 6 to 17 years of age, antipsychotic users had more than a 3-fold increased risk of type 2 diabetes (HR = 3.14 [95% CI = 1.50-6.56]), and the risk increased significantly with increasing cumulative dose (P < .03). The risk was increased for use restricted to atypical antipsychotics (HR = 2.89 [95% CI = 1.64-5.10]) or to risperidone (HR = 2.20 [95% CI = 1.14-4.26]). CONCLUSIONS AND RELEVANCE Children and youth prescribed antipsychotics had an increased risk of type 2 diabetes that increased with cumulative dose.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit*

Objective:To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. Design and Setting:A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. Patients:A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. Interventions:None. Measurements:Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. Results:A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66–93%), a specificity of 99% (95% confidence interval, 95–100%), and a high interrater reliability (&kgr; = 0.96; 95% confidence interval, 0.74–1.0). Conclusions:The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children.

Objectives:Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence. Design and Setting:Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU. Patients:Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled. Measurements and Main Results:An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11–37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90–93), sensitivity of 75% (95% CI, 72–78), negative predictive value of 86% (95% CI, 84–88), positive predictive value of 84% (95% CI, 81–87), and a reliability &kgr;–statistic of 0.79 (0.76–0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2–5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis. Conclusions:The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.

Clozapine treatment of bipolar disorder in a young adolescent.

A 13-year-old boy with a 4-year history of bipolar disorder and concomitant obsessive-compulsive disorder required four hospitalizations and two partial hospitalizations due to inadequate responses to combinations of neuroleptics and traditional treatments for bipolar disorder. The use of clozapine in combination with lithium and clomipramine facilitated successful discharge from the hospital and return to a structured school setting. Significant adverse affects from interactions between valproic acid and clozapine necessitated discontinuation of valproic acid.

Antidepressants and Suicide Attempts in Children

OBJECTIVES: Recent data showing possible increased risk for suicidal behavior among children and adolescents treated with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) antidepressants have created significant concern among patients, families, and providers, including concerns about the risk of individual antidepressants. This study was designed to compare the risk for medically treated suicide attempts among new users of sertraline, paroxetine, citalopram, escitalopram, and venlafaxine to risk for new users of fluoxetine. METHODS: A retrospective cohort study included 36 842 children aged 6 to 18 years enrolled in Tennessee Medicaid between 1995 and 2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 days). Medically treated suicide attempts were identified from Medicaid files and vital records and confirmed with medical record review. RESULTS: Four hundred nineteen cohort members had a medically treated suicide attempt with explicit or inferred attempt to die confirmed through medical record review, including 4 who completed suicide. The rate of confirmed suicide attempts for the study drugs ranged from 24.0 per 1000 person-years to 29.1 per 1000 person-years. The adjusted rate of suicide attempts did not differ significantly among current users of SSRI and SNRI antidepressants compared with current users of fluoxetine. Users of multiple antidepressants concomitantly had increased risk for suicide attempt. CONCLUSIONS: In this population-based study of children recently initiating an antidepressant, there was no evidence that risk of suicide attempts differed for commonly prescribed SSRI and SNRI antidepressants.

Identifying suicidal behavior among adolescents using administrative claims data

To assess the safety of psychotropic medication use in children and adolescents, it is critical to be able to identify suicidal behaviors from medical claims data and distinguish them from other injuries. The purpose of this study was to develop an algorithm using administrative claims data to identify medically treated suicidal behavior in a cohort of children and adolescents.

Delirium: An Emerging Frontier in the Management of Critically Ill Children

Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

Suicidal Behavior Differs Among Early and Late Adolescents Treated With Antidepressant Agents

OBJECTIVE: To identify circumstances and characteristics of suicidal behavior among early (aged 10–14 years) and late (aged 15–18 years) adolescents from a cohort of youth who were prescribed antidepressant medication. METHODS: In-depth reviews of all available medical records were performed for 250 randomly chosen confirmed episodes of suicidal behavior identified as part of a large retrospective cohort study of antidepressant users and suicidal behavior. Study data were obtained from Tennessee Medicaid records and death certificates from January 1, 1995, to December 31, 2006. Medical records and autopsy reports for cases identified from electronic data were adjudicated by 2 investigators blinded to exposure status and classified by using a validated scale. RESULTS: Of the 250 cases reviewed, 65.6% were female and 26.4% were aged 10 to 14 years. Medication ingestion was the most frequent method of suicidal behavior for both early and late adolescents; however, early adolescents were significantly more likely to use hanging as a method of suicide. Nearly one-half of the adolescents had previously attempted suicide. Early adolescents were significantly more likely to have a history of sexual abuse and significantly less likely to have a history of substance abuse. Early adolescents were also significantly more likely than older adolescents to have a history of a psychotic disorder and to report hallucinations before the suicide attempt. CONCLUSION: Suicidal behavior among early and late adolescents prescribed antidepressant medication differed in terms of methods used, previous psychiatric history, and proximal symptoms.

Multidisciplinary Treatment Planning: An Educational and Administrative Tool for Resource Management in a University Counseling Center

The evolving complexity of comorbidity of medical illness and mental illness in the context of a changing economy and public policy was noted in the American Psychological Association Presidential Address in 2010 [1]. The address emphasized that professionals in the field of psychology needed to shift their training and focus to a multidisciplinary and integrative approach. In line with this emphasis, our university counseling center identified the need to redesign the system of mental health care on campus. Our counseling center was independent of psychiatric assessment and treatment of students until 2011, at which time individuals trained in psychiatry joined the staff of individuals trained in psychology, social work, and professional counseling. In summer 2012, a child and adolescent psychiatrist was hired as the director of the center to restructure the services. The director identified gaps in communication between medical and therapy providers. A reliance on individual therapy as the treatment modality for all students resulted in the need for services exceeding the available appointment times. The director organized a leadership team tasked with redesigning the system. The team included a psychologist trained in university counseling and an outreach, education, and prevention coordinator with advanced knowledge in education and counseling. This report highlights the use of a clinical case conference to facilitate the development of multidisciplinary treatment plans designed to diversify services, thereby increasing access for students and improving communication among disciplines in a university mental health clinic. University mental health system studies in the past two decades have documented an increase in severity of presenting complaints at university counseling centers [2, 3]. They emphasized a need to shift care toward a “mental health clinic” model [2]. Kettmann et al. [3] reviewed the perception that student acuity has increased in university counseling centers and identified an increase in the complexity of the students seen in university counseling centers, leading to greater service utilization by a subset of students served by the centers. He concluded that counseling centers need a system in which the complexity of students with multiple diagnoses is acknowledged through the development of a range of therapeutic modalities beyond the traditional individual therapy model. Our university counseling center has experienced similar challenges in our efforts to support students who present with multiple diagnoses and complex treatment needs. We anchored our system design to an educational case conference to guide the multidisciplinary staff toward an integrative model that incorporates evidence-based practice for a broad range of clinical presentations. The structure supports a team consultation model that facilitates care of complex students and supports review of resources leading to clinical program development and design of programs for education and prevention on campus. The case conference has enabled the center to successfully implement individual treatment plans and resource review, shifting the care model to prevention and application of evidence-based treatment modalities.

Successful Transition to Young Adulthood with Mental Illness: Common Themes and Future Directions

The transitional age youth (TAY) demographic (as defined in the Preface), representing a unique developmental period in life, has recently garnered the interest of clinicians, researchers, educators, governmental agencies, and policymakers. Historically this age group has been considered late adolescents and early adults rather than a subgroup of its own. The implications of categorization are significant in terms of understanding of these individuals and the ability to support them. Attention to this group has been prompted by increasing the knowledge base in neurodevelopment, epigenetics, epidemiology, prevention, overall young adult health, and functional outcomes, particularly in regard to mental health. Addressing the mental health needs of TAY has become a national priority and there is increasing recognition of the potential for productive interventions in this complex and important developmental period. Mental illness may present in childhood, adolescence, or young adulthood, with influences on psychosocial, emotional, and brain development that vary with the age and context of illness presentation. Temperament and genetics are baseline factors contributing to individual responses to life experiences. Developmental experiences can be protective and build resilience or convey risk to expression of illness or to negative outcomes. In combination, these factors influence developmental trajectories and developmental branch points, contributing to variable expression of health and illness. The authors in this issue have identified many common themes. One overarching theme is the importanceof culturally competent care. There continue to be health disparities related to race, ethnicity, and other diversity. Culture influences howmental health is defined and viewed by individuals. TAY are often in transition, which can introduce a variety of cultural attitudes, challenging familiar normsand introducing, at times, anunanticipated levelof stress. It is imperative todevelopmore sophisticatedawarenessof ourown ethnocentric views and possible ethnocentric graduate medical education training. It is equally imperative to orient training of child and adolescent psychiatry and general psychiatry residents toward cultural understanding within the TAY population. Rivas-Drake andStein (this issue) state it well: “Researchers and practitionersmust strive to build their capacity to keep pace with the demographic shifts of the US youth population.”