Michael W. Naylor

Predictors of Comorbid Alcohol and Substance Abuse in Depressed Adolescents

OBJECTIVE To identify clinical profiles discriminating depressed adolescents on the basis of comorbid alcohol/substance use disorders and to determine whether or not profiles with high predictive power are gender-specific. METHOD One hundred three adolescent inpatients with major depression (65 girls, 38 boys) participated in a comprehensive diagnostic evaluation. Independent assessments of depression, suicidality, and psychosocial adjustment were conducted using well-validated instruments. RESULTS Gender-specific clinical profiles were identified that predicted alcohol/substance abuse in depressed adolescents with high levels of sensitivity (90%). The significant discriminant function for depressed girls included the following predictors: longer depressive episodes, more conduct problems and psychosocial impairment, and more active involvement in relationships with boys. The significant discriminant function for depressed boys included conduct disorder, older age, and schoolwork problems. These profiles correctly identified most depressed adolescents with comorbid alcohol/substance abuse. CONCLUSIONS Given that alcohol abuse and depression are associated with highly impaired social functioning and increased risk of self-harm, sensitivity in case identification is critical. Clinicians should conduct comprehensive assessments of alcohol/substance abuse in depressed adolescents with the identified clinical profiles.

Alcohol Consumption in Relation to Other Predictors of Suicidality among Adolescent Inpatient Girls

This study of 54 adolescent inpatient girls examined alcohol consumption in relation to depression severity and family dysfunction as predictors of suicidal ideation and behavior. Although alcohol consumption, depression severity, and family dysfunction were intercorrelated, regression analyses revealed their differential importance to the prediction of self-reported suicidal ideation and severity of clinician-documented suicidal ideation or behavior (none, ideation, intent, gesture, attempt). Self-reported ideation was strongly predicted by depression severity and family dysfunction; severity of clinician-documented suicidal ideation or behavior was predicted by alcohol consumption and family dysfunction. Implications for assessment and treatment are discussed.

Depressed Adolescents with a History of Sexual Abuse: Diagnostic Comorbidity and Suicidality

OBJECTIVE To determine the nature of comorbid psychopathology and suicidality associated with a history of sexual abuse in depressed adolescents. METHOD Twenty-four depressed adolescent inpatients with a history of sexual abuse were compared with a matched control group of 24 depressed adolescent inpatients on measures of depression, suicidal ideation and behavior, and posttraumatic stress disorder (PTSD) symptoms. RESULTS Depressed adolescents with a history of sexual abuse had a higher prevalence of comorbid PTSD than did those without such a history. Chronicity and severity of abuse were significant contributors to a PTSD diagnosis. No differences were found in depression severity, specific depressive symptoms, or suicidal behavior. CONCLUSION Comorbidity of depressive disorders and PTSD are common among adolescent inpatients with a history of chronic sexual abuse. The need for thorough assessment of depression and PTSD with appropriate interventions for sexually abused adolescents is clear.

Update on Lithium Carbonate Therapy in Children and Adolescents

The use of lithium to treat child and adolescent psychiatric disorders is becoming more common. Since the publication of the report of The Committee on Biological Aspects of Child Psychiatry of the American Academy of Child Psychiatry in 1978, a considerable body of literature has accumulated on the efficacy of lithium in treating adolescent bipolar disorders, childhood aggression, and behavioral disorders associated with mental retardation and developmental disorders. Efforts to understand lithiums mechanism(s) and refinements in psychiatric diagnosis have contributed to its growing use.

Language Disorders and Learning Disabilities in School-Refusing Adolescents

OBJECTIVE We undertook this study to test the hypothesis that school-refusing adolescents hospitalized on an inpatient psychiatric unit have more language and learning disabilities than diagnosis-, age-, and sex-matched psychiatric controls. METHOD The Woodcock-Johnson Tests of Achievement-Revised (WJTA-R), the WISC-R, the Adolescent Language Screening Test, the Clinical Evaluation of Language Fundamentals-Revised, and the Test of Language Competence (TLC) were given to a group of well-characterized, primarily depressed school refusers and matched psychiatric controls. RESULTS We found that school-refusing adolescents had significantly lower WISC-R verbal intelligence scores, lower Math and Written Language subscale scores on the WJTA-R, and lower scores on the TLC than nonrefusers. School refusers were found to have a significantly higher incidence of both language impairments and learning disabilities than controls. CONCLUSIONS We infer that academic and communicative frustration and the adolescents resulting inability to meet the academic and social demands in the school environment may play a role in the etiology of school refusal.

Mania Associated with Fluoxetine Treatment in Adolescents

Fluoxetine, a selective serotonin reuptake inhibitor, is gaining increased acceptance in the treatment of adolescent depression. Generally safe and well tolerated by adults, fluoxetine has been reported to induce mania. The cases of five depressed adolescents, 14-16 years of age, who developed mania during pharmacotherapy with fluoxetine, are reported here. Apparent risk factors for the development of mania or hypomania during fluoxetine pharmacotherapy in this population were the combination of attention-deficit hyperactivity disorder and affective instability; major depression with psychotic features; a family history of affective disorder, especially bipolar disorder; and a diagnosis of bipolar disorder. Further study is needed to determine the optimal dosage and to identify risk factors that increase individual vulnerability to fluoxetine induced mania in adolescents.

Sleep Deprivation in Depressed Adolescents and Psychiatric Controls

Up to 70% of depressed adults have an antidepressant response to sleep deprivation. To study the effects of sleep deprivation on depression severity and level of arousal in psychiatrically disturbed adolescents, we deprived 17 patients of sleep for 36 hours. Severity of depression and subjective arousal were assessed at baseline, during sleep deprivation, and after 1 nights recovery sleep. We found that severely depressed adolescents showed a significant decrease in depression severity, whereas depressed patients in remission and psychiatric controls worsened after sleep deprivation. Patients with depression in remission showed a significant decrease in subjective arousal after sleep deprivation. In contrast to findings in depressed adults, the effects of sleep deprivation persisted after 1 night of recovery sleep, and diurnal variation of mood did not predict response to sleep deprivation. These findings are consistent with those reported in the adult literature, and suggest a common psychophysiology between adult and adolescent depression.

Chronic depression and hospital course in adolescents

Survival curves were used to analyze the relationship between chronicity of depression and hospital course in 48 adolescents with unipolar major depression. The 25 adolescents with chronic depression (defined as a continuous course of depressive illness for 1 year or more) did not differ from those with acute depression in age, gender, or socioeconomic status. Despite similar admission and discharge Childrens Depression Rating Scale-Revised scores, adolescents with chronic depression had a significantly slower initial rate of improvement. The study suggests that chronicity of depression has predictive validity with regard to acute hospital course in adolescents.

Plasma dexamethasone levels in children given the dexamethasone suppression test

To determine whether children who demonstrate dexamethasone suppression test (DST) nonsuppression have lower plasma dexamethasone levels than DST suppressors, we administered the DST to 73 patients ranging in age from 5-14 years. Plasma dexamethasone levels and postdexamethasone cortisol levels were measured at 4:00 PM on day 2. We found: (1) DST nonsuppressors had significantly lower plasma dexamethasone levels (p less than 0.03) than suppressors; similar trends were observed when the population was divided into depressed and nondepressed patients; (2) mg/m2 dose of dexamethasone was directly correlated with plasma dexamethasone (p less than 0.003) and inversely correlated with postdexamethasone plasma cortisol levels (p less than 0.04); and (3) a statistically significant inverse correlation between plasma dexamethasone levels and postdexamethasone cortisol levels (p less than 0.04). Our findings show that plasma dexamethasone levels are important in evaluating DST results in psychiatrically disturbed children and suggest that dexamethasone dosage for use in the DST in children might be better calculated in terms of body surface area.

Utility of the head computerized tomography scan in child and adolescent psychiatry

Despite the widespread use of computerized tomography (CT) in child and adolescent psychiatry, studies have not looked at its overall usefulness in a clinical setting. In this report, the authors examined 122 inpatients who had CT scans of the head. Only 27 patients had an abnormal CT scan. None of the patients had a change made in the diagnosis or treatment as a result of the scan findings. The authors suggest that routine CT scans of the head in child and adolescent inpatients is of limited value. In view of the rising costs of medical investigations, and the risk of irradiation to the developing brain, they suggest the need for clear indications for this procedure in clinical child and adolescent psychiatry.