Dwight V. Wolf

A randomized controlled trial of risperidone, lithium, or divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents.

CONTEXT There was a paucity of comparative pharmacological research for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. OBJECTIVE To investigate which medication to administer first to antimanic medication-naive subjects. DESIGN, SETTING, AND PARTICIPANTS The Treatment of Early Age Mania (TEAM) study recruited 6- to 15-year-old children and adolescents with DSM-IV bipolar I disorder (manic or mixed phase) at 5 US sites from 2003 to 2008 into a controlled, randomized, no-patient-choice, 8-week protocol. Blinded, independent evaluators conducted all baseline and end-point assessments. INTERVENTIONS Subjects received a titrated schedule of lithium, divalproex sodium, or risperidone. Medications were increased weekly only if there was inadequate response, and no dose-limiting adverse effects, to maximum doses of lithium carbonate (1.1-1.3 mEq/L), divalproex sodium (111-125 μg/mL), and risperidone (4-6 mg). MAIN OUTCOME MEASURES Primary outcome measures were the Clinical Global Impressions for Bipolar Illness Improvement-Mania and the Modified Side Effects Form for Children and Adolescents. RESULTS There were 279 antimanic medication-naive subjects (mean [SD] age, 10.1 [2.8] years; 50.2% female) who had the following characteristics: 100% elated mood and/or grandiosity, 77.1% psychosis, 97.5% mixed mania, 99.3% daily rapid cycling, and mean (SD) mania duration of 4.9 (2.5) years. The mean (SD) titrated lithium level was 1.09 (0.34) mEq/L, and the mean (SD) divalproex sodium level was 113.6 (23.0) μg/mL. The mean (SD) titrated risperidone dose was 2.57 (1.21) mg. Higher response rates occurred with risperidone vs lithium (68.5% vs 35.6%; χ(2)(1) = 16.9, P < .001) and vs divalproex sodium (68.5% vs 24.0%; χ(2)(1) = 28.3, P < .001). Response to lithium vs divalproex sodium did not differ. The discontinuation rate was higher for lithium than for risperidone (χ(2)(1) = 6.4, P = .011). Increased weight gain, body mass index, and prolactin level occurred with risperidone vs lithium (F(1,212) = 45.5, P < .001; F(1,212) = 39.1, P < .001; and F(1,213) = 191.4, P < .001, respectively) and vs divalproex sodium (F(1,212) = 34.7, P < .001; F(1,212) = 45.3, P < .001; and F(1,213) = 209.4, P < .001, respectively). The thyrotropin level increased in subjects taking lithium (t(62) = 11.3, P < .001). CONCLUSIONS Risperidone was more efficacious than lithium or divalproex sodium for the initial treatment of childhood mania but had potentially serious metabolic effects. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00057681

Bipolar disorder in children and adolescents.

There is increased recognition that bipolar disorder has an early age of onset. The prevalence of bipolar disorder in prepubertal children has not been determined, however the prevalence in adolescence is approximately 1%. Bipolar disorder in children poses a diagnostic challenge since the symptoms may differ from those in late adolescence and adulthood. Comorbid disorders, such as attention-deficit/hyperactivity disorder, further complicate both the diagnosis and course of the disorder. There is increasing evidence of the chronicity and severity of this disorder in youths. Bipolar disorder significantly disrupts a childs psychosocial development including impairments in academic functioning, family functioning, and relationship with peers. Although this disorder has significant morbidity in children and adolescents, there is a paucity of controlled studies to assess the efficacy and safety of mood stabilizers in the treatment of this disorder in youths. The treatment literature consists largely of case studies, retrospective chart reviews, and open-label studies. There is a compelling need for double-blind, placebo-controlled trials to determine whether commonly used medications to treat this disorder are significantly superior to placebo. Since many children in clinical practice require more than one psychotropic medication to adequately manage this disorder, studies of combination treatments are warranted. This review will provide an overview of the literature of bipolar disorder in children and adolescents, including discussion of the prevalence, diagnosis, epidemiology, course of the illness, and treatment issues.

Impact of psychiatric illness on decreased survival in elderly patients with bladder cancer in the United States

Treatments for muscle‐invasive bladder cancer are multimodal, complex, and often carry significant risks of physical and psychological morbidity. The objectives of this study were to define the incidence and types of psychiatric illnesses diagnosed after treatment and to determine their impact on survival outcomes.

Creating a Common Curriculum for the DSM-5: Lessons in Collaboration

In 2013, the introduction of the Fifth Edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM-5) created a challenge and an opportunity for psychiatric educators. The challenge consisted of the necessity of revising a standing curriculum for educating medical students and other learners. The opportunity consisted of the stimulus for innovation and collaboration. We decided to take advantage of the challenge of the introduction of the DSM-5 to collaboratively create a new curriculum that could eventually be shared with others. Since some of us were experienced Team-Based Learning practitioners, and others were not, the innovation also created an opportunity to disseminate knowledge about the pedagogy. There are multiple reasons for organizations to work together around a shared goal [1]. When groups collaborate, they can improve decisionmaking, utilize multiple perspectives to solve complex problems, create synergies to enhance creativity and skill development, and pool resources to quicken responsiveness to evolving conditions. The success of a collaborative effort depends on a variety of factors described in published reports, including the environment, membership, process and structure, communication, purpose, and resources. We believed that the environment for our collaboration was ideal because of our shared need to revise our curricula in response to the introduction of the DSM-5. All members of our collaborative knew each other professionally, and several had previous experience working together. While all of the institutions involved in the collaborative had individual resources sufficient to complete a new curriculum, none were capable of autonomously developing the ambitious and high quality product we envisioned. The membership (e.g., collaborative faculty) included experienced clerkship directors and/or educational researchers and thus was capable of meaningfully contributing to the group effort. All members agreed to the process and structure developed by the primary investigator. We established regular communications to facilitate completion of our project via email, conference calls, and face-to-face visits. A clearly defined and shared purpose was developed based on the ensuing publication of the DSM-5. By pooling resources, the collaboration was able to result in a complete curriculum in a relatively short period of time. Following is a description of how we developed the collaboration and some of the lessons learned though our experiences. * Ruth E. Levine rlevine@utmb.edu