Derryck H. Smith

Case Study: Panic Disorder on a Child Psychiatric Consultation Service

In a review of all cases seen from 1984 to 1988 by the psychiatric consultation-liaison service of a tertiary referral pediatric hospital, four cases of definite panic disorder meeting DSM-III-R criteria were identified. Three of these children were referred to the consultation service after intensive investigation of physical complaints had failed to yield a diagnosis. These cases of panic disorder differed from those previously reported in child psychiatric populations by their relative absence of psychiatric comorbidity. This suggests that uncomplicated panic disorder may present with primarily somatic symptoms in pediatric subspecialty clinics, while panic disorder, complicated by behavioral or emotional disturbance, is more likely to present directly to child psychiatric services. Children presenting with somatic symptoms are at risk for receiving nonproductive investigations while having delayed diagnosis and treatment of the panic disorder.

Case Study: Simultaneous Prepubertal Onset of Panic Disorder, Night Terrors, and Somnambulism

Concurrent acute onset of night terrors, somnambulism, and spontaneous daytime panic attacks meeting the criteria for panic disorder is reported in a 10-year-old boy with a family history of panic disorder. Both the parasomnias and the panic disorder were fully responsive to therapeutic doses of imipramine. A second case of night terrors and infrequent full symptom panic attacks is noted in another 10-year-old boy whose mother has panic disorder with agoraphobia. The clinical resemblance and reported differences between night terrors and panic attacks are described. The absence of previous reports of this comorbidity is notable. It is hypothesized that night terror disorder and panic disorder involve a similar constitutional vulnerability to dysregulation of brainstem altering systems.

The psychosocial adaptation of adolescents with cystic fibrosis: A review of the literature

This article reviews the literature pertaining to the psychosocial adaptation of adolescents with cystic fibrosis. This chronic debilitating illness is exceptionally stressful to the patient and his or her family. It may result in significant individual and family psychopathology, yet social adaptation is reported to be remarkably good. Mediating variables in adaptation are reviewed, with special emphasis on family function variables. Directions for current interventions and future research are suggested. An expanded role for psychologic intervention with individual patients and their families is recommended.

Metabolic monitoring training program implementation in the community setting was associated with improved monitoring in second-generation antipsychotic-treated children.

Objective: To determine whether implementation of a metabolic monitoring training program (MMTP) in an urban community-based setting improved monitoring in children treated with second-generation antipsychotics (SGAs) and changed prescription rates of SGAs to children. Method: The MMTP was implemented in the Vancouver Coastal Health Child and Youth Mental Health Teams (CYMHTs) on January 1, 2009. A retrospective review of paper charts and electronic records for children seen at the CYMHTs from September 1, 2007, to May 1, 2010, was performed to collect the following data: age, sex, foster care, immigrant status, Axis I diagnosis, and medications. In SGA-treated children, anthropometric measurements and blood work completed at baseline and 3, 6, and 12 months were also collected. Results: Among the 1114 children seen pre-MMTP and 1262 children seen post-MMTP implementation, 174 (15.4%) and 81 (6.4%), respectively, were SGA-treated (P < 0.001). Among the SGA-treated children seen at the CYMHTs after MMTP implementation, 38.3% had a copy of the MMTP in their paper chart. Metabolic monitoring increased by up to 40% at baseline (P < 0.01), 20% at 3 (P < 0.01) and 6 months (P < 0.01), and 18% at 12 months after MMTP implementation. Conclusions: Implementation of an MMTP was associated with significantly improved monitoring rates of anthropometric and blood work parameters at baseline and the 3- and 6-month time points, with a trend for improvement at the 12-month time point, in SGA-treated children cared for in urban community mental health clinics. In addition, a 56% decrease in SGA prescriptions was observed following MMTP implementation in this population.

THE OPTIMAL PSYCHIATRIST-TO-POPULATION RATIO : A CANADIAN PERSPECTIVE

A systematic effort is underway to rationalize the planning of physician supply. This paper summarizes the current methodologies available and focuses on the attempts to determine the optimal psychiatrist-to-population ratio in Canada. The impact of several variables influencing this ratio is discussed. An outline of the correlation between target physician supply and requirements of future trainees is presented. While the relevant methodology is rapidly evolving, an improved process of data collection is urgently required. A number of challenges for our profession lay ahead, such as the need for sensitive and reliable measures of the adequacy of psychiatrist and subspecialist supply and public issues arising from the poor geographic distribution of psychiatric manpower.

Assisted dying for patients with psychiatric disorders

The article by Kim and Lemmens contains several important errors and omissions.[1][1] First, it was Carter, not just the Parliamentary Special Joint Committee on Physician-Assisted Dying, that stated that patients are not required to accept all treatments to be considered “irremediable.”[2][2

Regarding Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis

I read with interest the article from Alexander Simpson on ethical issues with regard to medical assistance in dying (MAiD). I have long learned from reading ethical articles in regard to MAiD that there are certain conflicts of interest that need to be dealt with quite apart from the usual ones. For example, if Dr. Simpson has a religious affiliation, it would be useful to know this. There is a rich history of ethical “experts” in Canada who have strongly held religious views and have presented these views as “ethics.” Dr. Simpson is correct that Bill C-14 restricts MAiD to situations in which death is “reasonably foreseeable.” He fails to identify, however, that there is a very important word, natural, describing death. This would likely preclude MAiD for patients whose death by suicide is “reasonably foreseeable.” At some point a specific legal challenge may be mounted on this point. Currently there are two other cases before the courts alleging that C14 is not compliant with Carter on other matters. He is correct that the cases before the Supreme Court of Canada in Carter did not require a ruling with regard to “psychiatric disorders.” What he fails to acknowledge, however, is that the Carter decision clearly included psychiatric patients as being eligible for MAiD. This issue was tested in the courts in Alberta before Bill C-14 became law. The case involved “E.F.,” who was applying for MAiD based entirely on a psychiatric diagnosis. On April 22, 2016, E.F. brought an application before the Alberta Court of Queen’s Bench based on the medical condition of a “severe conversion disorder.” Madam Justice M.R. Bast granted E.F. access to MAiD, but this was subsequently appealed by the Attorney General of Canada and the Attorney General of British Columbia. The Court of Appeal consisted of a 3-person panel of Mr. Justice Peter Costigan, Madam Justice Mariana Paperny, and Madam Justice Patricia Rowbotham. The court concluded “persons with a psychiatric illness are not explicitly or inferentially excluded [from MAiD] if they fit the criteria.” Subsequently, E.F.’s right to MAiD was upheld unanimously. The appeal was dismissed. This decision was never appealed to the Supreme Court of Canada, and so it stands as a judicial precedent with regard to psychiatric illness and Carter. It is clear that Carter would allow for MAiD for psychiatric illness, but Bill C-14 does not. In my opinion, this is one of the many ways in which Bill C-14 is not compatible with the Carter decision. At some point, a legal action may be mounted to challenge Bill C-14 as not being compliant with Carter. Dr. Simpson argues primarily from the point of view of clinicians working in mental health. What he fails to recognize is that the Carter decision is not about physicians’ rights but about the autonomy and Charter rights of individual Canadians to have control over their death. I personally see no difference between medical and psychiatric illness. Both are conditions affecting the human body. Both can produce intolerable suffering. All psychiatric illness is a disorder of the brain. To discriminate between psychiatric patients and those with other medical conditions adds further to the stigma of psychiatric illness in my opinion.

Thematic Issue on Child and Adolescent Psychiatry.

It is my pleasure and privilege to introduce to you the work of 4 groups of Canadian researchers spanning the country from Montreal to Ontario, Manitoba, and finally British Columbia. Collectively, these papers1–4 demonstrate that research into child and adolescent psychiatry is thriving across Canada. Although these papers all have distinctly Canadian databases, the results are likely applicable to children and youth around the world. In the first paper, from Gobbi et al,1 the research group studied adolescent distress following a period of 4 to 9 months of separation from their fathers. The sample was drawn from an earlier study looking at nicotine dependence in teens, but this study found that separation from fathers had no impact on alcohol or cigarette use. Perhaps not surprisingly teenagers initially suffered increase in depressive symptoms as well as worry about potential financial implications in their family. Worry about relationships shifted initially from concern about their relationship with their father to later being more concerned about their relationship with their mother. The message for clinicians is that we need to be alive to the fact that parental separation can negatively impact teenagers, and that families undergoing separation may benefit from more support from their caregivers, including family physicians, psychiatrists, and pediatricians. The second paper, from Alavi and her group2 at Queen’s University, studied the effects of bullying on adolescent victims using a database from an urgent assessment clinic. Bullying was defined as repeated aggressive behaviour with an imbalance of power between bullies and their victims. The prevalence of bullying was close to 50%, and verbal bullying was more common than physical bullying, which, in turn, was more common than cyberbullying. However, it was cyberbullying that had the biggest negative effect on victims. Suicidal ideation was 3.6 times higher in patients who had experienced cyberbullying. The results of this study strongly suggest that clinicians should inquire carefully about bullying, and in particular cyberbullying, and that symptom questionnaires, which are routinely used in clinical practice, should include questions about bullying. The other obvious implication for society is that bullying is detrimental and dangerous and that efforts should continue to discourage all forms of bullying. The third paper, from Yallop and her group,3 using a large comprehensive database in Manitoba, focused on young adults aged 18 to 29, and the prevalence of attention-deficit hyperactivity disorder (ADHD). The lifetime prevalence in this group was estimated to be 7.11% and the prevalence of stimulant prescription 3.09%. Not surprisingly, 82% of the subjects with ADHD had been diagnosed prior to age 18. The male-to-female sex ratio was 2.7:1, compared with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, ratios of 2:1 in children and 1.6:1 in adults. The authors discussed the lack of a socioeconomic gradient and postulated that ADHD in this age group may be negatively impacting young adults who are in educational settings. This is an important paper in that it showed a considerably elevated prevalence, compared with the National Comorbidity Survey Replication from 2006. It should reassure clinicians that psychostimulants are not being overprescribed for this group. The fourth paper, from Ronsley and her group4 at the University of British Columbia, who had previously published on metabolic syndrome in children and teenagers treated with second-generation antipsychotics, reports on the first prospective study on this important topic. Patients aged 4 to 18 being treated either with risperidone or quetiapine were followed during a year. Although there was a significant attrition rate, the results were compelling in that children and teenagers treated with these 2 atypical antipsychotics were exposed to a risk of obesity, waist circumference increase, and dyslipidemia. This paper provides compelling evidence that children and teens being treated with atypical antipsychotics should routinely have monitoring of metabolic parameters, and, for those patients who show metabolic abnormalities, early treatment should be initiated. The authors identified a weakness that there was no control group for this study. I was disappointed to see that we were not given diagnoses for the children and teenagers treated with antipsychotics. Although I am in full agreement with the need for ongoing monitoring, it remains my opinion that clinicians must be careful to minimize the use of these medications and to restrict their use to serious psychiatric morbidities in which there are no alternate effective pharmacological, psychotherapeutic, or social interventions. In summary, all 4 of these papers1–4 raise very important clinical issues and should be impactful on clinical practice. They all advance the scientific basis for providing psychiatric care for young patients. They all call for additional research to further inform clinical practice in the management of children, adolescents, and young adults with psychiatric illness.

Independent medical evaluations.

I have conducted several thousand independent medical examinations, and from time to time, as pointed out by Ebrahim[1][1] in his CMAJ commentary, the examinee has a serious medical problem. In my view, our obligation to the individual demands that we take some type of definitive action when the

Book Review: Child Psychiatry: Functional Neuroimaging in Child PsychiatryFunctional Neuroimaging in Child Psychiatry. ErnstMonique, RumseyJudith M., editors. Cambridge (UK): Cambridge University Press; 2000. 426 p. US

– Rod Stewart This re view is an ex peri ment. In the days of re search teams and mul ti cen tred tri als, book re views typi cally de pend on sin gle authors. This re view rep re sents a col lective ef fort of col leagues from vari ous dis ci plines at Chil dren’s and Women’s Health Cen tre in Van cou ver, to bring vari ous ex pert opin ions to bear on a sin gle vol ume. We hope that read ers bene fit from this col lec tive re view, and we encour age col leagues from other aca demic cen tres to rep li cate our ex peri ment.