Rémy P. Barbe

Placebo Response in Randomized Controlled Trials of Antidepressants for Pediatric Major Depressive Disorder

OBJECTIVE The authors examined characteristics and predictors of response to placebo in all available reports of short-term randomized controlled trials of antidepressants for pediatric major depressive disorder. METHOD Response, defined as a score <or=2 on the improvement item of the Clinical Global Impression scale, and potential predictors were extracted from 12 published and unpublished randomized controlled trials of second-generation antidepressants in participants 6-18 years of age with major depression. RESULTS The single best predictor of the proportion of patients taking placebo who responded to treatment was the number of study sites. Baseline severity of illness also emerged as a significant inverse predictor of placebo response, although the strength of this relationship was diminished when number of sites was controlled for. After one large fluoxetine trial was excluded, younger participants showed a higher placebo response rate than older adolescents. Higher placebo response rates in more recent studies were explained by an increasing trend toward large multisite trials and by publication delays and failures to publish some negative trials. CONCLUSIONS The recent shift toward large multisite trials of antidepressant medications for pediatric major depression may be contributing to an increasing incidence of response to placebo. Pharmacotherapy studies of pediatric depression that carefully recruit patients with at least moderately severe depression may be more informative and efficient than many trials conducted to date. Such studies should have sufficient power to determine whether age moderates medication and placebo response.

Impaired Decision Making in Adolescent Suicide Attempters

OBJECTIVE Decision-making deficits have been linked to suicidal behavior in adults. However, it remains unclear whether impaired decision making plays a role in the etiopathogenesis of youth suicidal behavior. The purpose of this study was to examine decision-making processes in adolescent suicide attempters and never-suicidal comparison subjects. METHOD Using the Iowa Gambling Task, the authors examined decision making in 40 adolescent suicide attempters, 13 to 18 years old, and 40 never-suicidal, demographically matched psychiatric comparison subjects. RESULTS Overall, suicide attempters performed significantly worse on the Iowa Gambling Task than comparison subjects. This difference in overall task performance between the groups persisted in an exact conditional logistic regression analysis that controlled for affective disorder, current psychotropic medication use, impulsivity, and hostility (adjusted odds ratio = 0.96, 95% confidence interval = 0.90-0.99, p < 0.05). A two-way repeated-measures analysis of variance revealed a significant group-by-block interaction, demonstrating that attempters failed to learn during the task, picking approximately the same proportion of disadvantageous cards in the first and final blocks of the task. In contrast, comparison subjects picked proportionately fewer cards from the disadvantageous decks as the task progressed. Within the attempter group, overall task performance did not correlate with any characteristic of the index attempt or with the personality dimensions of impulsivity, hostility, and emotional lability. CONCLUSIONS Similar to findings in adults, impaired decision making is associated with suicidal behavior in adolescents. Longitudinal studies are needed to elucidate the temporal relationship between decision-making processes and suicidal behavior and to help frame potential targets for early identification and preventive interventions to reduce youth suicide and suicidal behavior.

Reducing hospital readmission in depression and schizophrenia : current evidence

Purpose of review It is estimated that the readmission rate for discharged psychiatric patients is approximately 40-50% within 1 year of hospital discharge. This review focuses on recent developments in our understanding of predictors of readmission in depression and schizophrenia, and on quality improvement methods and models aimed at reducing readmission rates for these patients. Recent findings Multiple factors contribute to the risk of hospital readmission; however, demographic and clinical characteristics alone are of limited utility in identifying patients most likely to be readmitted. Recent research has emphasized the role of enhancing treatment and medication adherence, which is of critical importance given the strong association between non-adherence and rehospitalization. Methodological work is currently underway to improve the measurement of medication adherence and continuity of care, which have been difficult to assess in the past. Despite significant progress during the past few years, the development and evaluation of structured disease management programs for depression and bipolar disorder continues to represent an important challenge for future research. Summary Empirical work is needed to evaluate the effectiveness of different approaches to reducing patient readmission following hospital discharge.

Factor structure of borderline personality disorder symptomatology in adolescents

Objective: To examine the factor structure of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, criteria for borderline personality disorder (BPD) in a sample of adolescents with a borderline symptomatology. Method: The latent structure of borderline criteria, assessed with the Structured Interview for DSM-IV Personality, was explored with a principal factor analysis in a sample of 107 adolescents with a borderline symptomatology drawn from a European research project on BPDs. Results: The principal component analysis revealed 2 homogeneous factors accounting for 66.8% of the variance. The first factor included internally oriented criteria, such as avoidance of abandonment, identity disturbance, chronic feeling of emptiness, and stress-related paranoid ideation. The second factor included externally oriented criteria, such as unstable relationships, impulsivity, suicidal or self-mutilating behaviours, and inappropriate anger. Affective instability was the only criterion loading on both factors. Conclusions: The results of our study suggests that an internal or external dichotomy may be an appropriate way to conceptualize the structure of borderline criteria in adolescents with a borderline symptomatology, with affective instability being a core feature of BPD at this age.

Parental functioning improves the developmental quotient of pediatric liver transplant recipients

Psychomotor development in pediatric liver transplant (LT) recipients depends on several factors. Our aim was to evaluate the importance of parental involvement and family dynamics on psychomotor development by assessing (i) children and parents individually, (ii) the parent–child relationship, and (iii) the correlation between parental functioning and patient outcome, all before and after LT. Age‐appropriate scales were used before and after LT. Twenty‐one patients, 19 mothers, and 16 fathers were evaluated. Developmental quotient (DQ): No subjects scored in the “very good” range. The proportion of children with deficits increased from LT to two yr: 17.6% vs. 28.6%. Subjects 0–2 yr were more likely to have normal DQ at transplant (66.7% vs. 50% for older children). Abnormal DQ was more prevalent two yr post‐LT in children older at LT (p = 0.02). The mother–child relationship was normal in 59% of families pre‐LT and in 67% at two yr. The relationship was more favorable when the child received a transplant as an infant (p = 0.014 at 12 months post‐LT). Normal DQ was associated with higher maternal global functioning score pre‐LT (p = 0.03). Paternal performance scores were higher than maternal scores. Children transplanted after two yr of age suffer greater long‐term deficits than those transplanted as infants.

Screening for bipolar disorder in adolescents with the Mood Disorder Questionnaire – Adolescent version (MDQ‐A) and the Child Bipolar Questionnaire (CBQ)

Screening instruments for bipolar disorders (BDs) in children and adolescents have been developed recently. The present study examined performances of the French versions of the Mood Disorder Questionnaire – Adolescent version (MDQ‐A) and Child Bipolar Questionnaire (CBQ) in a sample of in‐ and outpatients.

Screening for bipolar disorders in adolescents with the French version of the Mood Disorders Questionnaire (MDQ-A)

interventional, longitudinal study of patients diagnosed with BD-I or BD-II with 1 mood event in the preceding 12 months, followed-up for 12–27 months (including retrospective and prospective phases). Patients were selected from a cross-sectional sample representative of BD populations in daily clinical practice from Austria, Belgium, Brazil, France, Germany, Portugal, Romania, Turkey, Ukraine and Venezuela. The study includes descriptive analyses of demographics, diagnosis, medical history and clinical management. Medication use during the retrospective phase will be presented.