Howard Y. Liu

Pharmacologic Treatments for Pediatric Bipolar Disorder: A Review and Meta-Analysis

OBJECTIVE A growing body of literature has documented pediatric bipolar disorder to be a severely impairing form of psychopathology. However, concerns remain as to the inadequacy of the extant literature on its pharmacotherapy. Furthermore, treatment studies have not been systematically reviewed for treatment effects on core and associated symptoms. Thus, a systematic evaluation and synthesis of the available literature on the efficacy of antimanic pharmacotherapy for pediatric bipolar disorder on symptoms of mania, depression, and attention-deficit/hyperactivity disorder was undertaken. METHOD A systematic search was conducted through PubMed from 1989 through 2010 for open-label and randomized controlled trials published in English on the pharmacotherapy of pediatric mania. RESULTS There have been 46 open-label (n = 29) and randomized (n = 17) clinical trials of antimanic agents in pediatric bipolar disorder encompassing 2,666 subjects that evaluated a range of therapeutic agents, including traditional mood stabilizers, other anticonvulsants, second-generation antipsychotics, and naturopathic compounds. This literature has documented that the available armamentarium has different levels of efficacy in the treatment of pediatric mania. Because all psychotropic classes are associated with important adverse effects, a careful risk-benefit analysis is warranted when initiating pharmacologic treatment with any of these compounds. In the limited data available, the effects of antimanic agents on depression and symptoms of attention-deficit/hyperactivity disorder have been, in general, modest. Few studies have evaluated the effects of antimanic agents in children younger than 10 years. CONCLUSIONS A substantial body of scientific literature has evaluated the safety and efficacy of various medicines and drug classes in the treatment of mania in pediatric bipolar disorder. More work is needed to assess the safety and efficacy of psychotropic drugs in children younger than 10 years, to further evaluate the efficacy of naturopathic compounds, and to further evaluate the effects of antimanic treatments for the management of depression and attention-deficit/hyperactivity disorder.

Association of DSM-IV Posttraumatic Stress Disorder With Traumatic Experience Type and History in the World Health Organization World Mental Health Surveys

Importance Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions. Objective To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set. Design, Setting, and Participants The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016. Main Outcomes and Measures Prevalence of PTSD assessed with the Composite International Diagnostic Interview. Results Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, including participation in organized violence (OR, 1.3; 95% CI, 1.0-1.6), experience of physical violence (OR, 1.4; 95% CI, 1.2-1.7), rape (OR, 2.5; 95% CI, 1.7-3.8), and other sexual assault (OR, 1.6; 95% CI, 1.1-2.3). Conclusion and Relevance The World Mental Health survey findings advance understanding of the extent to which PTSD risk varies with the type of TE and history of TE exposure. Previous findings about the elevated PTSD risk associated with TEs involving assaultive violence was refined by showing agreement only for repeated occurrences. Some types of prior TE exposures are associated with increased resilience rather than increased vulnerability, connecting the literature on TE history with the literature on resilience after adversity. These results are valuable in providing an empirical rationale for more focused investigations of these specifications in future studies.

Prescribing Patterns for Treatment of Pediatric Bipolar Disorder in a Specialty Clinic

OBJECTIVE The aim of this study was to describe prescribing practices in the treatment of pediatric bipolar disorder in a university practice setting. METHOD A retrospective chart review was performed on 53 youths diagnosed using Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV), criteria with bipolar spectrum disorder under the active care of child psychiatrists practicing in a pediatric psychopharmacology specialty clinic. Current medications, doses, and related adverse events were recorded. Clinicians were asked to provide a target disorder (bipolar mania/mixed state, depression, attention deficit hyperactivity disorder [ADHD], or anxiety) for each medication to the best of their ability. The Clinical Global Impressions-Severity (CGI-S) scale was used to measure severity of each disorder before treatment and the Clinical Global Impressions-Improvement (CGI-I) was used to quantify the magnitude of improvement with treatment. Meaningful improvement of the disorder was defined by CGI-I score of 1 or 2. RESULTS The mean number of psychotropic medications per patient was 3.0 +/- 1.6. A total of 68% of patients were treated for co-morbid disorders; 23% of patients were treated with monotherapy, primarily with second-generation antipsychotics. Mania improved in 80% of cases, mixed state improved in 57% of cases, ADHD improved in 56% of cases, anxiety improved in 61% of cases, and depression improved in 90% of cases. CONCLUSION The management of pediatric bipolar disorder often requires multiple medications. For the treatment of mania/mixed states, clinicians prescribed second-generation antipsychotics more frequently than mood stabilizers, especially in the context of monotherapy. Co-morbidity was a frequent problem with moderate success obtained with combined pharmacotherapy approaches. Further psychosocial strategies to augment pharmacotherapy may improve outcome while reducing the medication burden in pediatric bipolar disorder.

Childhood adversities and post-traumatic stress disorder: evidence for stress sensitisation in the World Mental Health Surveys

BackgroundAlthough childhood adversities are known to predict increased risk of post-traumatic stress disorder (PTSD) after traumatic experiences, it is unclear whether this association varies by childhood adversity or traumatic experience types or by age.AimsTo examine variation in associations of childhood adversities with PTSD according to childhood adversity types, traumatic experience types and life-course stage.MethodEpidemiological data were analysed from the World Mental Health Surveys (n = 27 017).ResultsFour childhood adversities (physical and sexual abuse, neglect, parent psychopathology) were associated with similarly increased odds of PTSD following traumatic experiences (odds ratio (OR) = 1.8), whereas the other eight childhood adversities assessed did not predict PTSD. Childhood adversity-PTSD associations did not vary across traumatic experience types, but were stronger in childhood-adolescence and early-middle adulthood than later adulthood.ConclusionsChildhood adversities are differentially associated with PTSD, with the strongest associations in childhood-adolescence and early-middle adulthood. Consistency of associations across traumatic experience types suggests that childhood adversities are associated with generalised vulnerability to PTSD following traumatic experiences.

Improving child and adolescent psychiatry education for medical students: An inter-organizational collaborative action plan

ObjectiveA new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the longstanding dearth of CAP training for medical students.MethodThe CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP’s CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies.ResultsThe authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

The associations of earlier trauma exposures and history of mental disorders with PTSD after subsequent traumas

Although earlier trauma exposure is known to predict posttraumatic stress disorder (PTSD) after subsequent traumas, it is unclear whether this association is limited to cases where the earlier trauma led to PTSD. Resolution of this uncertainty has important implications for research on pretrauma vulnerability to PTSD. We examined this issue in the World Health Organization (WHO) World Mental Health (WMH) Surveys with 34 676 respondents who reported lifetime trauma exposure. One lifetime trauma was selected randomly for each respondent. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) PTSD due to that trauma was assessed. We reported in a previous paper that four earlier traumas involving interpersonal violence significantly predicted PTSD after subsequent random traumas (odds ratio (OR)=1.3–2.5). We also assessed 14 lifetime DSM-IV mood, anxiety, disruptive behavior and substance disorders before random traumas. We show in the current report that only prior anxiety disorders significantly predicted PTSD in a multivariate model (OR=1.5–4.3) and that these disorders interacted significantly with three of the earlier traumas (witnessing atrocities, physical violence victimization and rape). History of witnessing atrocities significantly predicted PTSD after subsequent random traumas only among respondents with prior PTSD (OR=5.6). Histories of physical violence victimization (OR=1.5) and rape after age 17 years (OR=17.6) significantly predicted only among respondents with no history of prior anxiety disorders. Although only preliminary due to reliance on retrospective reports, these results suggest that history of anxiety disorders and history of a limited number of earlier traumas might usefully be targeted in future prospective studies as distinct foci of research on individual differences in vulnerability to PTSD after subsequent traumas.

Student assessment of psychiatry clinical simulation teaching modules

Recognizing a need for computer-based instruction in psychiatry education, a clinical simulation initiative (CSI) by the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) developed a free database of psychiatry teaching modules, intended to enhance the learning that takes place during a clinical interaction, or provide a meaningful learning experience if the ideal of direct exposure to the desired clinical condition is not possible. The modules contain illness-specific information, including etiology, epidemiology, differential diagnosis, clinical manifestations and treatment, and are illustrated with video-clips of evolving patient cases played by actors. Interactive quizzes are included in each module to consolidate knowledge, promote critical thinking, and stimulate further learning. Of fourteen areas of psychopathology delineated by ADMSEP’s clinical learning objectives, to date modules that address the psychiatric interview, dementia, bipolar disorder, personality disorders, post-traumatic stress and anxiety disorders have been published on MedEdPORTAL for free access by educators, and additional modules are under development. We obtained data on student satisfaction and the modules’ impact on students’ confidence in disorder-specific knowledge, using surveys that evaluated the modules’ quality and effectiveness. Survey items include educational value, general feedback, and confidence in disorder-specific knowledge, diagnosis, and treatment. Items are rated on a 5-point Likert-type scale, where 11⁄4 Strongly Disagree and 51⁄4 Strongly Agree. Comparisons between preand post-module student confidence ratings were assessed using non-parametric Wilcoxon signed rank tests. Complete survey data from 215 students at seven universities in USA yielded mean ratings of 3.9–4.6 on items measuring module quality and effectiveness. All but one of the student confidence ratings were significantly higher post-module as compared to pre-module (p50.05). Data from our study demonstrate student satisfaction with the modules and positive impact on students’ confidence in disorder-specific knowledge. CSI modules help fulfill educational requirements in psychiatry clinical clerkships and the open access model fosters educational collaboration between institutions.

Suicidal thoughts and behaviors among college students and same-aged peers: results from the World Health Organization World Mental Health Surveys

PurposeThe primary aims are to (1) obtain representative prevalence estimates of suicidal thoughts and behaviors (STB) among college students worldwide and (2) investigate whether STB is related to matriculation to and attrition from college.MethodsData from the WHO World Mental Health Surveys were analyzed, which include face-to-face interviews with 5750 young adults aged 18–22 spanning 21 countries (weighted mean response rate = 71.4%). Standardized STB prevalence estimates were calculated for four well-defined groups of same-aged peers: college students, college attriters (i.e., dropouts), secondary school graduates who never entered college, and secondary school non-graduates. Logistic regression assessed the association between STB and college entrance as well as attrition from college.ResultsTwelve-month STB in college students was 1.9%, a rate significantly lower than same-aged peers not in college (3.4%; OR 0.5; p < 0.01). Lifetime prevalence of STB with onset prior to age 18 among college entrants (i.e., college students or attriters) was 7.2%, a rate significantly lower than among non-college attenders (i.e., secondary school graduates or non-graduates; 8.2%; OR 0.7; p = 0.03). Pre-matriculation onset STB (but not post-matriculation onset STB) increased the odds of college attrition (OR 1.7; p < 0.01).ConclusionSTB with onset prior to age 18 is associated with reduced likelihood of college entrance as well as greater attrition from college. Future prospective research should investigate the causality of these associations and determine whether targeting onset and persistence of childhood–adolescent onset STB leads to improved educational attainment.

Recovery from DSM-IV post-traumatic stress disorder in the WHO World Mental Health surveys

BACKGROUND Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors. METHODS The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD. RESULTS 20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2-0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66-55% v. 43%) and later-recovery (75-68% v. 39%). CONCLUSIONS We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.

Social Media and Networking Competencies for Psychiatric Education: Skills, Teaching Methods, and Implications

The Internet has revolutionized medicine and health education, including person-centered and interdisciplinary collaborative patient care [1]. Millennial learners (born between 1981 and 1996) are often considered “digital natives,” including medical students, residents, and early career faculty. They utilize technology to search for information for education or pleasure [2, 3].Medical students and residents often start medical school with a robust online and social media presence for personal use [4–6], but have not begun to develop and hone general clinical skills, much less professional skills about the Internet and technologies. Except for telepsychiatric competencies, medical education as a whole has not kept pace with the media explosion [7]. The current hazards to the technology explosion include patients accessing misinformation about diagnoses and treatments [5], breach of confidentiality, privacy, and professional boundaries. Novice and more advanced learners, alike, require competency-based education related to this topic. Mid and advanced career faculty, often referred to as “digital immigrants,” may be technologically ill-informed [4], and most have not yet applied andragogy (adult learning theories) to the topics of Internet use, social media, and professionalism. Therefore, we have a paradox and a crisis: faculty may trail trainees with regard to hands on experience and expertise with technology and they may require faculty development training to keep current with benefits and potential pitfalls of media [8]. The AmericanMedical Association Professional Guideline on Social Media [9] proposes questions and scenarios as a starting place for clinicians to learn, advice, explore, and mentor others on the opportunities and challenges that arise in new and changing online platforms. Compliance officers and other healthcare leaders do not recommend social media engagement as part of care. An alternative perspective about social media guidelines and best practices comes from the Council of Residency Directors Social Media Task Force, which suggests that a residency program develops a social media policy and a training plan in concert with institutional officials, particularly via the offices of the designated institutional officer (DIO), public affairs, legal or privacy officer, and the information technology (IT) department [10]. This paper advances a framework for social and digital media competency development as the link between clinical care and training. It has three levels of competencies and provides suggestions to implement and teach them, while addressing faculty development needs in this area. Example competencies are described with a vignette, skills involved, and instruction on the teaching methods that may be particularly useful.