Guy Palmes

Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide

This study examined clinical characteristics and laboratory-measured impulsive behavior of adolescents engaging in either non-suicidal self-injury with (NSSI+SA; n=25) or without (NSSI-Only; n=31) suicide attempts. We hypothesized that adolescent with NSSI+SI would exhibit more severe clinical symptoms and higher levels of behavioral impulsivity compared to adolescents with NSSI-Only. Adolescents were recruited from an inpatient psychiatric hospital unit and the two groups were compared on demographic characteristics, psychopathology, self-reported clinical ratings, methods of non-suicidal self-injury, and two laboratory impulsivity measures. Primary evaluations were conducted during psychiatric hospitalization, and a subset of those tested during hospitalization was retested 4-6 weeks after discharge. During hospitalization, NSSI+SA patients reported worse depression, hopelessness, and impulsivity on standard clinical measures, and demonstrated elevated impulsivity on a reward-directed laboratory measure compared to NSSI-Only patients. In the follow-up analyses, depression, hopelessness, suicidal ideation, and laboratory impulsivity were improved for both groups, but the NSSI+SA group still exhibited significantly more depressive symptoms, hopelessness, and impulsivity than the NSSI-Only group. Risk assessments for adolescents with NSSI+SA should include consideration not only of the severity of clinical symptoms but of the current level impulsivity as well.

Referral by Pediatricians of Children with Behavioral Health Disorders

A standard interview guide focused on behavioral health referral practices and communication patterns was developed and administered to 47 pediatricians in private practice. Results suggested that the most frequent reasons for referral to a mental health provider were diagnostic uncertainty, failure to respond to treatment, presence of severe affective symptoms, and need for ongoing psychotherapy. Only a third of the providers indicated that their patients frequently followed through with recommendations to receive mental health care. More than half of the pediatricians wanted more information regarding their patients referred for mental health services, and they expressed a strong interest in colocation with a mental health provider.

Behavioral Health Practices in the Midst of Black Box Warnings and Mental Health Reform

A standard guide was readministered to 42 primary care pediatricians after community interventions to assess changes in their behavioral health practices. Among the outcome findings: increased screening of young children (6 months to 5 years); attention deficit hyperactivity disorder continued to be the most frequent diagnosis, with a high level of diagnostic comfort and use of stimulants; decreased comfort in the diagnosis and treatment of depression, with a significant decline in use of selective serotonin reuptake inhibitors; nearly all continued to offer nonmedication, behavioral health treatment; and a significant increase in use of social workers for community referrals. Structured interventions had limited influence on the process of change. Black box warnings exerted a powerful effect on prescribing practices. Systemic changes involving financial incentives, increased access to mental health providers, practice guidelines, and technology for continuing education may offer possibilities for changing practice patterns.

Cross-cultural psychiatry in the field: collaborating with anthropology.

Psychiatry and anthropology may need each other, as Arthur Kleinman 1 claims, but few guidelines exist for how a psychiatrist and an anthropologist can collaborate successfully to reconcile differences in disciplinary perspectives, methodological approaches, and the place of culture and mind in the interpretation of the outcomes. Fruitful dialogue between psychiatrists and anthropologists, nearly as old as the two professions, was highlighted early on by such prominent figures as Freud, Malinowski, Jung, and Mead. A particularly notable collaboration included that of Sapir and Sullivan. 2 One outcome of this interdisciplinary conversation has been a recognition of the degree to which context alters, shapes, and defines mental processes. The effect of culture, construed broadly and as a process, is so profound that a number of psychiatric disorders are now recognized in the DSM as ‘‘culture-bound syndromes,’’ the classification of which also results from joint efforts. 1 Psychiatric and anthropological collaborations, along with related specialties such as psychological anthropology, have produced robust literatures addressing topics ranging from ethics, the relation of culture to the mind and the body, and methodological discussions of the strengths of qualitative versus quantitative approaches, to adjustments that can be made to psychiatric instrumentation or interventions for specific populations. Nevertheless, recommendations for how to work together in the field are notably lacking. In this article, we identify four challenges in the working relation between professionals in psychiatry and anthropology based on our experience in Jharuwarasi, a semi-urban, mainly agricultural village near Kathmandu, Nepal. Jharuwarasi is ideal for investigating the relation between psychological and cultural factors because it lacks a history of professional psychiatric involvement and features variation in educational attainment, conditions of poverty, and social marginalization that favor the expression of psychiatric disorders.

A+KIDS, a Web-Based Antipsychotic Registry for North Carolina Youths: An Alternative to Prior Authorization

OBJECTIVE The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

Low Depression Screening Rates in U.S. Ambulatory Care

Low Depression Screening Rates in U.S. Ambulatory Care To the Editor: Depression is an important public health problem with significant costs both to individuals and society. In 2003, the U.S. lifetime prevalence of major depressive disorder was 16.2% (1). Depression is the leading cause of disability (2), with an estimated cost of

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/ Hyperactivity Disorder

83.1 billion in the United States in 2000 (3). As of 2009, the U.S. Preventive Services Task Force (USPSTF) recommends “screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up” (4). In light of these recommendations, the primary aim of the study reported here was to estimate the rate of depression screening in the U.S. outpatient office setting. The National Ambulatory Medical Care Survey (NAMCS) is an annual cross-sectional survey of visits to officebased physicians across the United States, stratified by physician specialty (5). Approximately two of three sampled physicians participate in the survey. Depression screening at sampled visits is ascertained and recorded by the responding physician, a member of his or her staff, or a U.S. Census Bureau field representative who reviews medical records for documentation of the screening performed. Because information on depression screening was first collected in 2005, data from 2005 to 2010 were analyzed. The USPSTF does not support screening for children 11 years and younger. Therefore, only visits for patients 12 years and older were included. Visits to psychiatrists were excluded from the analysis. SAS version 9.2 was used to analyze the data; SAS SVY PROCS was used to account for the complex survey design. Sampled visit weights were applied, which produced unbiased national estimates. The percentage of visits, overall and with primary care physicians (general and family practitioners, internists, pediatricians, and obstetricians-gynecologists), linked with depression screenings are reportedwith 95% confidence intervals (CIs). Over the period, the average number of annual visits was estimated to be 947 million, and the average annual frequency of documented depression screening was 1.3% (CI51.1%–1.5%). For visits to primary care physicians, the rate was 1.8% (CI51.5%–2.1%). Screening was most common among internists (2.8%, CI51.8%–3.8%), followedby gynecologists (2.4%,CI51.3%– 3.4%), family physicians (1.9%, CI5 1.6%–2.2%), pediatricians (1.8%, CI5 1.0%–2.6%), and other specialists (.5%, CI5.2%–.7%). Among visits for which no screening was documented, 7.7% (CI57.2%–8.2%) were for patients who already had a diagnosis of depression. The NAMCS has several limitations. It does not record whether sampled offices have adequate staff for screening and follow-up care. To our knowledge, the accuracy of NAMCS methods for identifying depression screening through chart review has not been confirmed. Because visits were the unit of analysis and physicians may screen patients only annually, the period prevalence of screening for patients over a year cannot be estimated. Ultimately, depression screening rates are quite low and further steps are required for improvement. Depression screening itself can be as simple as asking two questions. Thus it is likely that screening may not be performed because the necessary follow-up care resources are not available at some offices. It is therefore important to develop a plan that improves access to depression management resources for outpatient offices. Suzanne T. McGoey, M.D., M.S. Karen E. Huang, M.S. Guy K. Palmes, M.D.