Daniel J. Pilowsky

Foster care: an update.

OBJECTIVE To inform child and adolescent psychiatrists about the almost 500,000 children now residing in the American foster care system. This overview surveys the pediatric, developmental, and psychiatric needs of these children. METHOD Child and adolescent psychiatrists, pediatricians, a child welfare researcher, a social worker, and a psychologist developed a consensus paper from their experience with child welfare and a review of the literature in their respective fields. RESULTS Being in foster care is a defining experience in these childrens lives. They are at risk in myriad ways: for instance, being poor, having chronic health deficits, experiencing the trauma of abuse and neglect, and suffering from a gamut of emotional challenges. Evolutionary developments in foster care such as therapeutic foster homes, kinship care, and changes in Medicaid funding will continue to alter the system. CONCLUSIONS Foster children are a huge reservoir of unmet pediatric and psychiatric needs; research on them is spotty at best. It is hoped that child and adolescent psychiatrists will meet the challenges these youngsters present and will advocate for them.

Children of Depressed Mothers 1 Year After the Initiation of Maternal Treatment: Findings From the STAR*D-Child Study

OBJECTIVE Maternal depression is a consistent and well-replicated risk factor for child psychopathology. The authors examined the changes in psychiatric symptoms and global functioning in children of depressed women 1 year following the initiation of treatment for maternal major depressive disorder. METHOD Participants were 1) 151 women with maternal major depression who were enrolled in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study and 2) their eligible offspring who, along with the mother, participated in the child STAR*D (STAR*D-Child) study (mother-child pairs: N=151). The STAR*D study was a multisite study designed to determine the comparative effectiveness and acceptability of various treatment options for adult outpatients with nonpsychotic major depressive disorder. The STAR*D-Child study examined children of depressed women at baseline and involved periodic follow-ups for 1 year after the initiation of treatment for maternal major depressive disorder to ascertain the following data: 1) whether changes in childrens psychiatric symptoms were associated with changes in the severity of maternal depression and 2) whether outcomes differed among the offspring of women who did and did not remit (mother-child pairs with follow-up data: N=123). Childrens psychiatric symptoms in the STAR*D-Child study were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), and maternal depression severity in the STAR*D study was assessed by an independent clinician, using the 17-item Hamilton Depression Rating Scale (HAM-D). RESULTS During the year following the initiation of treatment, maternal depression severity and childrens psychiatric symptoms continued to decrease over time. Decreases in the number of childrens psychiatric symptoms were significantly associated with decreases in maternal depression severity. When childrens outcomes were examined separately, a statistically significant decrease in symptoms was evident in the offspring of women who remitted early (i.e., within the first 3 months after the initiation of treatment for maternal depression) or late (i.e., over the 1-year follow-up interval) but not in the offspring of nonremitting women. CONCLUSIONS Continued efforts to treat maternal depression until remission is achieved are associated with decreased psychiatric symptoms and improved functioning in the offspring.

Adverse Childhood Events and Lifetime Alcohol Dependence

OBJECTIVES We sought to study the association between adverse events occurring in childhood and adolescence and lifetime alcohol dependence in a representative sample of American adults. METHODS With data from the National Epidemiologic Survey on Alcohol and Related Conditions, we conducted logistic regression multivariate analyses to examine the impact of adverse events occurring in childhood (aged < 18 years) on the lifetime prevalence of alcohol dependence. We controlled for age at drinking onset, binge drinking, alcoholism in parents and grandparents of respondents, and demographic characteristics. RESULTS Adverse childhood events were associated with familial alcoholism and with early and binge drinking, and therefore, we controlled for these potential confounders. Experiencing 2 or more adverse childhood events, compared with none, significantly increased the risk for alcohol dependence, even after we controlled for sociodemographic variables and disorder-specific potential confounders not considered in the extant literature (adjusted odds ratio = 1.37; 95% confidence interval = 1.06, 1.77). CONCLUSIONS Individuals who experienced 2 or more adverse childhood events are at increased risk for lifetime alcohol dependence. A better understanding of the factors underlying the risk for alcohol dependence is important for developing better prevention and early intervention measures.

Depressed mothers coming to primary care: maternal reports of problems with their children

BACKGROUND Studies of depressed mothers have generally been conducted in psychiatric settings with non-minority, middle-class women. Primary care has an increasing role in early detection and treatment, especially for the poor who have less access to specialized mental health services. Data on the relationship between maternal depression and problems in the offspring in a primary care context could help physicians to more effectively identify children in need of psychiatric help. METHODS All mothers aged 25 to 55 from a systematic sample of consecutive adults (response rate, 80%) in an urban general medicine practice were screened using the PRIME-MD Patient Health Questionnaire (PHQ). Mothers who screened positive for major depression (n=85); other psychiatric disorders, but not major depression (n=67); or no psychiatric disorders (n=191) were compared on their childrens history of emotional problems, unmet need for mental health treatment, parent-child discord, maternal functional status and mental health treatment. RESULTS Compared to non-psychiatric controls, depressed mothers reported a three-times greater risk of serious emotional problems in their children (95% confidence interval [CI], 1.7-6.1); a four-times greater risk of having their childrens problems left untreated (95% CI, 2.3-8.2), and a 10-times greater risk of having poor mother-child relations within the past month (95% CI, 3.9-29.4). Depressed mothers reported more functional disability, more psychiatric treatment and more problems in their offspring than mothers with non-depressive psychiatric disorders. Although a majority of mothers (regardless of psychiatric status) believed that counseling (96%) or medication (84%) should be offered to those with serious emotional problems, only about half (49%) of the depressed mothers had received mental health treatment in the past month. LIMITATIONS Children were not assessed directly. CONCLUSIONS The children of low-income depressed women at a general medicine practice were reported to have a greatly increased risk for emotional problems. Many mothers had not received treatment for their own emotional problems. By enquiring about the emotional health of children of adult primary care patients, primary care providers have an opportunity to promote early detection and to facilitate appropriate treatment for both the mothers and their children.

Gender differences in posttraumatic stress disorder among primary care patients after the World Trade Center attack of September 11, 2001.

BACKGROUND Debate surrounds the nature of gender differences in rates of posttraumatic stress disorder (PTSD). OBJECTIVE The goal of this study was to quantify and explore the reasons for gender differences in rates of PTSD in low income, primary care patients after the World Trade Center (WTC) attack of September 11, 2001. METHODS A survey was conducted at a large primary care practice in New York City 7 to 16 months after the WTC attack. The study involved a systematic sample of primary care patients aged 18 to 70 years. The main outcome measures were the Life Events Checklist, the Posttraumatic Stress Disorder Checklist-Civilian Version, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, all administered by a bilingual research staff. RESULTS A total of 3807 patients were approached at the primary care clinic. Of the 1347 who met eligibility criteria, 1157 (85.9%) consented to participate. After the addition of the WTC/PTSD supplement to the study, the total number of patients was 992, of whom 982 (99.0%) completed the survey. Both sexes had high rates of direct exposure to the WTC attack and high rates of lifetime exposure to stressful life events. Overall, females had lower rates of exposure to the attack compared with males (P < 0.05). Hispanic females had the highest rate of PTSD in the full sample. Gender differences in rates of PTSD were largely accounted for by differences in marital status and education. The rate of current major depressive disorder (MDD) was higher in females than in males (P < 0.001), and the reverse was true for substance abuse (P < 0.001). Gender differences for MDD and substance abuse persisted even after adjustments for demographic differences between the sexes. CONCLUSIONS The increased rate of PTSD in women attending a primary care clinic was mediated by their social and economic circumstances, such as living alone without a permanent relationship and with little education or income. The increased rate of MDD in women appeared to be less dependent on these circumstances. These findings have implications for the treatment of women with PTSD in primary care and for research on gender differences in rates of psychiatric disorders.

Screening for alcohol and drug use disorders among adults in primary care: a review.

Background The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority. Objective This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions. Methods MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings. Conclusion Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.

Long‐term course of probable PTSD after the 9/11 attacks: A study in urban primary care

Although the short- and midterm psychological effects of the attacks on September 11, 2001 (9/11) have been well described, less is known about the long-term effects. This study examines the course of probable posttraumatic stress disorder (PTSD), its predictors and clinical consequences in a cohort of 455 primary care patients in New York City, interviewed approximately 1 and 4 years after 9/11. The rate of PTSD decreased from 9.6% to 4.1%. Pre-9/11 major depressive disorder emerged as the strongest predictor of PTSD, particularly late-PTSD. At follow-up, late-PTSD was associated with major depressive and anxiety disorders, and PTSD regardless of timing was associated with impaired functioning. Findings highlight the importance of ongoing evaluation of mental health needs in primary care settings in the aftermath of disasters.

The Mental Health Consequences of Disaster-Related Loss: Findings from Primary Care One Year After the 9/11 Terrorist Attacks

This study examines the long-term psychiatric consequences, pain interference in daily activities, work loss, and functional impairment associated with 9/11-related loss among low-income, minority primary care patients in New York City. A systematic sample of 929 adult patients completed a survey that included a sociodemographic questionnaire, the PTSD Checklist, the PRIME-MD Patient Health Questionnaire, and the Medical Outcomes Study Short Form-12 (SF-12). Approximately one-quarter of the sample reported knowing someone who was killed in the attacks of 9/11, and these patients were sociodemographically similar to the rest of the sample. Compared to patients who had not experienced 9/11-related loss, patients who experienced loss were roughly twice as likely (OR = 1.97, 95%; CI = 1.40, 2.77) to screen positive for at least one mental disorder, including major depressive disorder (MDD; 29.2%), generalized anxiety disorder (GAD; 19.4%), and posttraumatic stress disorder (PTSD; 17.1%). After controlling for pre-9/11 trauma, 9/11-related loss was significantly related to extreme pain interference, work loss, and functional impairment. The results suggest that disaster-related mental health care in this clinical population should emphasize evidence-based treatments for mood and anxiety disorders.

Substance use disorders among inhalant users: results from the National Epidemiologic Survey on alcohol and related conditions.

OBJECTIVE To assess the prevalence, correlates, and age of onset of DSM-IV substance use disorders (SUDs) among adult inhalant users. METHODS Analyses were based on structured psychiatric interviews of a nationally representative sample of 43,093 US adults. RESULTS The lifetime prevalence of SUDs among adult inhalant users was 96%. Alcohol (87%), marijuana (68%), nicotine (58%), cocaine (35%), hallucinogen (31%), and stimulant (28%) use disorders were more prevalent than inhalant use disorders (19%). An estimated 62% of inhalant users met criteria for a past-year SUD. Less education, residence in non-metropolitan areas, early onset of inhalant use, and a history of substance abuse treatment were associated with increased odds of having an inhalant use disorder. Inhalant users who were under age 30 or who were members of families with low incomes had increased odds of having nicotine dependence and an alcohol or drug use disorder in the past year. Compared with substance users without a history of inhalant use, inhalant users, on average, initiated use of cigarettes, alcohol, and almost all other drugs at younger ages, and had a higher lifetime prevalence of nicotine, alcohol, and any drug use disorder. CONCLUSIONS Lifetime and past-year SUDs are prevalent among adults with a history of inhalant use.

Trauma exposure and posttraumatic stress disorder among primary care patients with bipolar spectrum disorder

OBJECTIVE To examine relationships between exposure to trauma, bipolar spectrum disorder (BD) and posttraumatic stress disorder (PTSD) in a sample of primary care patients. METHODS A systematic sample (n = 977) of adult primary care patients from an urban general medicine practice were interviewed with measures including the Mood Disorders Questionnaire, the PTSD Checklist-Civilian Version, and the Medical Outcomes Study 12-Item Short Form Health Survey. RESULTS Compared with patients who screened negative for BD (n = 881), those who screened positive (n = 96) were 2.6 times [95% confidence interval (CI): 1.6-4.2] as likely to report physical or sexual assault, and 2.9 times (95% CI: 1.6-5.1) as likely to screen positive for current PTSD. Among those screening positive for BD, comorbid PTSD was associated with significantly worse social functioning. These results controlled for selected background characteristics, current major depressive episode, and current alcohol/drug use disorder. CONCLUSION In an urban general medicine setting, trauma exposure was related to BD, and the frequency of PTSD among patients with BD appears to be common and clinically significant. These results suggest an unmet need for mental health care in this specific population and are especially important in view of available treatments for BD and PTSD.