David T. Feinberg

Efficacy of Paroxetine in the Treatment of Adolescent Major Depression: A Randomized, Controlled Trial

OBJECTIVE To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS Paroxetine is generally well tolerated and effective for major depression in adolescents.

Parent-Assisted Transfer of Children's Social Skills Training: Effects on Children With and Without Attention-Deficit Hyperactivity Disorder

OBJECTIVE Previous research has demonstrated that peer rejection is a significant part of the clinical presentation of many children with attention-deficit hyperactivity disorder (ADHD). Outcome studies of treatment interventions have typically failed to show generalization of treatment gains to the home and classroom. This has been especially true for children who have comorbid oppositional defiant disorder (ODD). The present study was intended to demonstrate generalization of an outpatient social skills training program when parents were trained in skills relevant to their childs social adjustment. METHOD Thirty-five children with ADHD and 14 children without ADHD were given 12 sessions of treatment (treatment group). Outcome was compared with 12 children with ADHD and 12 children without ADHD who were on a waitlist for treatment (waitlist group). Nineteen children with ODD were in the treatment group and five in the waitlist. Stimulant medication was prescribed for all children with ADHD. RESULTS Subjects with ADHD showed improvement comparable with that of subjects without ADHD on all teacher- and parent-reported measures of peer adjustment and social skills, except teacher-reported withdrawal. Children with ODD had outcome comparable with that of children without ODD. Effect sized ranged from 0.93 to 1.34 indicating that the average treatment group subject was better off than 83.4% of waitlist subjects on outcome measures. CONCLUSIONS The present results suggest that children with ADHD are best heiped by a combination of social skills training for themselves, collateral training for their parents and stimulant medication.

Social Problems Associated with ADHD vs. ODD in Children Referred for Friendship Problems

Four groups were composed of children referred for friendship problems (age range: 6 to 12 years old). One group was diagnosed with both Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional-Defiant Disorder (ODD), one group with ADHD only, one group with ODD only and one group with neither disorder. Parents and teachers were given questionnaires to rate the social behavior of each child. The groups differed significantly on one parent scale (Self-control) and one teacher scale (Aggression). Inspection of the items composing these scales suggested that some items measured social relationships with adults while other items measured peer relationships. Subsequent factor analysis separated peer and adult components. Analysis of subscales derived from factor analysis revealed the diagnosis of ADHD was associated with increases in classroom disruption and decreased resistance to provocation by peers, while the diagnosis of ODD was associated with increased in hostility towards peers, decreased resistance to provocation by peers and decreased respect for adults. Limitations of the study were: domains of social functioning assessed, sample size and diversity, and the absence of a comparison group with adequate peer relationships. Social skills programs should target social deficits associated with ODD and ADHD. The scales refined in the present study offer a convenient means of assessing peer dysfunction from the points of view of parents and teachers.

Academic Health Centers and the Evolution of the Health Care System

Today there are approximately 135 academic health centers (AHCs) in the United States. These institutions exist to ensure sustainable health care through their multifold, integrated missions of patient care, education, and research. Yet AHCs have in some ways contributed to the intractable problems that threaten both their viability and the sustainability of health care. To flourish— indeed to survive—AHCs must reconfigure and transform rapidly and broadly in size, speed, value, and innovation, driven by self-reflection and leadership.

New drugs for the treatment of attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder of childhood. Recent research indicates that ADHD most often persists into adolescence and adulthood, and is associated with impairments in academic, social and occupational functioning. The ADHD diagnosis is based on history and clinical examination. There are no objective laboratory measures for diagnosis. ADHD is largely heritable. Its underlying pathophysiology has been theorised to include dysregulation of inhibitory noradrenergic frontocortical activity on dopaminergic striatal structures. Evidence shows that ADHD is highly responsive to pharmacological treatments resulting in global functional improvements. Although pharmacotherapy is recognised as the most effective treatment, additional components to optimise ADHD management include proper educational placement, parent management training and social skills development. Central nervous system stimulants, specifically methylphenidate and amphetamine, remain first-line pharmacological treatments. Atomoxetine, a selective noradrenergic re-uptake inhibitor, is the first non-stimulant compound to receive FDA approval for paediatric and adult ADHD. Other medication classes, including α-agonist antihypertensives, tricyclic antidepressants, other antidepressants such as buproprion, and the wake-promoting agent modafinil, are prescribed in off-label therapy. Ongoing development of new ADHD medications is expected to emphasise alternative and extended-release delivery systems and non-stimulant compounds.

Use of the Child Behavior Checklist and DSM-III-R diagnosis in predicting outcome of children's social skills training

A standardized 12-week cognitive-behavioral social skills package in which parents assisted children with socialization homework assignments, was presented to 52 nonpsychotic outpatient boys, many of whom were diagnosed with DSM-III-R Attention Deficit-Hyperactivity Disorder and Oppositional Defiant Disorder. Results demonstrated that the Thought Problems factor of the mother-completed Child Behavior Checklist aided in predicting changes in teacher-rated aggression. DSM-III-R diagnosis of Oppositional Defiant Disorder predicted changes in teacher-rated withdrawal subsequent to treatment. The need for research to determine which children benefit from which treatment was discussed.

Are "carve outs" in or out?

HEALTH CARVE OUTS ARE segments of insurance risk—defined by service or disease—that are isolated from overall insurance risk and covered in a separate contract between the payer (insurer or employer) and the carve-out vendor. In today’s world mental health carve outs are delegated to specialized vendors known as managed behavioral health care organizations (MBHOs). Examples of MBHOs are Magellan Health Service, ValueOptions, United Behavioral Health, PacifiCare Behavioral Health, and Cigna Behavioral Health. The main reason that these companies have expanded is that they boost savings of about 20% for purchasers of their services compared to those that keep mental health and substance abuse “carved in” to a general medical insurance package. They accomplish this savings mainly by reducing inpatient hospitalization, limiting total outpatient visits while at the same time improving access, and by paying providers and facilities less. It is hard to come up with an exact figure, but somewhere between 110 and 180 million Americans are insured by MBHOs. The three largest companies control over half of all those insured. As managed care has become more of a commodity, MBHOs have tried to expand by entering new markets. Specifically, they have moved from the private sector to the public sector. There is also evidence that carving out mental health care causes decreased absenteeism, increases in work performance, and decreased use of medical services (Rosenheck et al., 1999)1. The biggest problem with MBHOs is that by their very nature they promote non-integrated care. Imagine a female adolescent with anorexia nervosa. She has had multiple psychiatric inpatient admissions and secondary to low blood sugar and low blood pressure she faints and injures her head. She is admitted to a pediatric ICU for observation and once stabilized the doctor wants her transferred to a specialized eating disorders unit. Her mental health carve out says she is out of days. Another insurance company is telling the doctor in the pediatric ICU that the patient no longer needs that level of medical treatment. The medical insurance company and the mental health insurance company attempt to “coordinate benefits” and provide a “continuum of care”, but in reality nothing of the sort happens. Each company has separate incentives to deny care or in this case state that the problem belongs to the other company. Usually, a patient like this is discharged from the ICU to home where she further deteriorates. She is readmitted to the ICU and after endless phone calls and letters from lawyers the medical insurance company realizes that they should pay for the specialty eating disorder treatment because it will cost less money than repeated ICU admissions. Organized medicine believes that these “carve outs” don’t make sense and decided to act. The American Medical Association adopted the following resolution in the year 2000: