Sarosh Khalid-Khan

Patient, Treatment, and Health Care Utilization Variables Associated with Adherence to Metabolic Monitoring Practices in Children and Adolescents Taking Second-Generation Antipsychotics

Objective: Children and adolescents with a range of psychiatric disorders are increasingly being prescribed atypical or second-generation antipsychotics (SGAs). While SGAs are effective at treating conduct and behavioural symptoms, they infer significant cardiometabolic risk. This study aims to explore what patient, treatment, and health care utilization variables are associated with adherence to Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) metabolic monitoring guidelines. Method: A retrospective chart review of 294 children and adolescents accessing a large outpatient psychiatry setting within a 2-year study period (2014-2016) was conducted. Baseline and follow-up metabolic monitoring, demographic, treatment, and health care utilization variables were then assessed over a 1-year period of interest. Results: Metabolic monitoring practices did not adhere to CAMESA guidelines and were very poor over the 1-year observation period. There were significant differences between children (ages 4-12 years, n = 99) and adolescents (ages 13-18 years, n = 195). In adolescents, factors associated with any baseline metabolic monitoring were a higher number of psychiatry visits (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.10 to 1.41), longer duration of contact (OR, 14; 95% CI, 2.31 to 82.4), and use of other non-SGA medications (OR, 3.2; 95% CI, 1.17 to 8.94). Among children, having an emergency room visit (OR, 3.4; 95% CI, 1.01 to 11.71) and taking aripiprazole (OR, 7.4; 95% CI, 2.02 to 27.45) increased the odds of receiving baseline metabolic monitoring. Conclusion: Findings from this study highlight the need for better metabolic monitoring for children and adolescents taking SGAs. Enhanced focus on opportunities for multidisciplinary collaboration is needed to improve the quality of care offered to this population.

Effectiveness of online versus live multi-family psychoeducation group therapy for children and adolescents with mood or anxiety disorders: a pilot study

Abstract Objective: [1] To highlight the effectiveness of multi-family psychoeducation group therapy (MFPGT) in children with mood or anxiety disorders; [2] to measure change in knowledge and awareness of mood and anxiety disorders in families and children; and [3] to compare the relative effectiveness of online compared to live MFPGT. Method: Participants included families of children (12 years or younger) referred with a mood or anxiety disorder to the Division of Child and Adolescent Psychiatry at Queen’s University (n=16) who were on a waitlist to see a psychiatrist. Change was measured through questionnaires for all parents before and after the program. Using SPSS v22, comparisons between the online (n=6) and live (n=10) groups were made using the Mann-Whitney U test and within group comparisons were made using Wilcoxon signed-rank test. Results: The online and live education groups showed similar overall improvements in knowledge acquisition and expressed emotion in participating families. However, statistical significance must be interpreted with caution due to the small sample size. Conclusions: Online MFPGT may be an effective way to increase knowledge, provide resources and support and build on skills thus giving individuals more control and confidence when dealing with a mood or anxiety disorder while on a waitlist. MFPGT showed equal efficacy in live and online groups, indicating that the online program has the potential to be a more convenient and accessible program for families. More research is needed with a greater sample size.

A Retrospective Chart Review: Adolescents with Borderline Personality Disorder, Borderline Personality Traits, and Controls

Abstract With an estimated lifetime prevalence as high as 5.9% in the general population, borderline personality disorder (BPD) is a psychiatric disorder characterized by marked impulsivity as well as difficulties in interpersonal relationships, self-image, and affects. The burden on the health care system is immense with BPD patients accounting for 10%–20% of the patients in mental health outpatient facilities and 15%–40% in mental health inpatient facilities. Further, while 75%–80% of BPD patients attempt to commit suicide, 10% succeed; this mortality rate exceeds even that of anorexia nervosa which, with a weighted mortality rate of 5.1%, has often been considered to have the highest mortality rate of any mental disorder. In order to provide treatment and to implement preventative measures, a risk profile as well as clinical features must be identified within the adolescent population. This is presently crucial, as the current criteria for BPD are not developmentally focused, and as a result, criteria initially developed for the adult population are being applied in diagnoses of adolescents. A population of adolescents (n=80) between 16 and 19 years of age meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria either for BPD traits (n=46) or for BPD (n=36) were included in a retrospective chart review; a control group consisting of n=30 mood and anxiety control subjects were included to allow for further comparisons. Complex significant differences were discovered between the three groups in the following areas: history of sexual abuse, suicidal ideation, internalizing/externalizing symptoms, interpersonal difficulties, impulsivity, pre-perinatal stress, bullying, substance abuse, anxiety disorders, disruptive disorders, and finally, learning disorders.

Effectiveness of a modified dialectical behaviour therapy for adolescents within a stepped-care model.

Abstract Objective: Early intervention with evidence-based treatment is important to halt the progression from early manifestations of personality disorder traits to adult personality disorders. The purpose of this study is to evaluate dialectical behaviour therapy (DBT) modified for an adolescent population with borderline personality disorder (BPD), offered within a stepped-care model. Methods: Seven adolescents (M=1, F=6, Mage=16.86) diagnosed with either BPD or BPD traits participated in a modified 15-week DBT group. The group was offered within a stepped-care model, which required participants to have previously completed an 8-week distress-tolerance module. Pre/post scores on self-report measures of BPD symptomatology, including impulse control, emotional regulation and awareness, anxiety, depression, and substance use, were collected. Results: Participants showed a post-treatment decrease in anxiety symptoms (large effect size) and disruptive behaviours (medium effect size). There was also an increase in emotional symptoms (medium effect size) and hyperactivity/inattention (medium effect size). Conclusion: The modified DBT group shows promise in alleviating symptoms of anxiety and some of the disruptive behaviours associated with BPD. The increase in emotional symptoms may be due to the expressive nature of DBT, and may contribute to their eventual therapeutic processing in the next step of the program.

Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics

The prevalence of children and adolescents using second-generation antipsychotics (SGAs) has increased significantly in recent years. In this population, SGAs are used to treat mood and behavioural disorders although considered off-label or not approved for these indications. Metabolic monitoring is the systematic physical health assessment of antipsychotic users utilized to detect cardiovascular and endocrine side effects and prevent adverse events such as weight gain, hyperglycaemia, hyperlipidemia, and arrhythmias. This practice ensures safe and efficacious SGA use among children and adolescents. Despite widely available, evidence-based metabolic monitoring guidelines, rates of monitoring continue to be suboptimal; this exposes children to the unnecessary risk of developing poor cardiovascular health and long-term disease. In this discursive paper, existing approaches to metabolic monitoring as well as challenges to implementing monitoring guidelines in practice are explored. The strengths and weaknesses of providing metabolic monitoring across outpatient psychiatry, primary care, and collaborative community settings are discussed. We suggest that there is no one-size-fits-all solution to improving metabolic monitoring care for children and adolescents using SGA in all settings. However, we advocate for a pragmatic global approach to enhance safety of children and adolescents taking SGAs through collaboration among healthcare disciplines with a focus on integrating nurses as champions of metabolic monitoring.

Eye movement desensitization and reprocessing as a treatment for PTSD: current neurobiological theories and a new hypothesis

Eye movement desensitization and reprocessing (EMDR), a form of psychotherapy for individuals with post‐traumatic stress disorder (PTSD), has long been a controversial topic, hampered in part by a lack of understanding of the neural mechanisms that contribute to its remedial effect. Here, we review current theories describing EMDRs potential neurobiological mechanisms of action involving working memory, interhemispheric communication, de‐arousal, and memory reconsolidation. We then discuss recent studies describing the temporal and spatial aspects of smooth pursuit and predictive saccades, which resemble those made during EMDR, and their neural correlates within the default mode network (DMN) and cerebellum. We hypothesize that if the production of bilateral predictive eye movements is supportive of DMN and cerebellum activation, then therapies that shift the brain towards this state correspondingly would benefit the processes regulated by these structures (i.e., memory retrieval, relaxation, and associative learning), all of which are essential components for PTSD recovery. We propose that the timing of sensory stimulation may be relevant to treatment effect and could be adapted across different patients depending on their baseline saccade metrics. Empirical data in support of this model are reviewed and experimental predictions are discussed.

Exploring how social networking sites impact youth with anxiety: A qualitative study of Facebook stressors among adolescents with an anxiety disorder diagnosis

Adolescents with anxiety disorders often have low self-esteem, poor problem-solving, and a strong desire to be accepted. Combined, these qualities may predispose them to experience unique stressors when using social network sites (SNSs). Focus groups of adolescent Facebook users who have a primary anxiety diagnosis uncovered narratives describing individuals’ perspectives related to how Facebook can influence their anxiety. Qualitative analysis revealed six themes related to Facebook stressors: seeking approval, fearing judgment, escalating interpersonal issues, wanting privacy, negotiating self and social identity, and connecting & disconnecting. Many participants reported a fear of receiving negative comments online and discussed strategies to avoid them, such as posting less content (i.e., comments, photographs) than their peers. Some participants described feeling positive emotions when they received a “like” from a SNS user, however, they also tended to describe these positive emotions as “false”, “unreal” and “fleeting.” Notably, many participants reported comparing themselves to peers on Facebook, which increased feelings of anxiety, as well as compulsive checking behaviours, such as monitoring posted content and friend lists. These findings were coupled with discussions surrounding rumination, privacy, and elevated personal conflict due in part to the public nature of Facebook. The narratives from our exploratory study suggest there are various mechanisms through which Facebook may exacerbate anxiety in adolescents who have pre-existing anxiety disorders and thereby may make them vulnerable to negative online experiences. Understanding the underlying themes of this phenomenon can aid clinicians, school staff, and parents in identifying potential stressors for anxious adolescents who use SNSs, and provide strategies around social media use for this specific patient population. Future quantitative studies are recommended to further understand the relationships between Facebook stressors and expressed anxiety in clinical populations.

EPA-0917 - Multifamily psychoeducation groups: comparing email psychoeducation to live groups

Introduction Mood and anxiety disorders are common in youth and are associated with reduced quality of life and high costs. Access to effective treatment is limited due to long waitlists, high costs and perceived social stigma. Given the high prevalence and treatment barriers, there is a need for brief, inexpensive and effective interventions. Psychoeducational interventions are inexpensive, easily administered and more accessible than conventional interventions. There is some evidence that these are effective in treating or preventing mental disorders. Aims To compare knowledge acquired by participants via email or live psychoeducation groups, to measure symptom change and to compare effectiveness of each modality. Methodology Psychoeducation (live or via email) in multifamily groups will be offered. Forty participants in each group will be enrolled. There will be six 40-minute sessions. Primary outcome measures are: change in parental knowledge about the childs disorder and level of expressed emotion in the parent-child relationship. Measures are Understanding of Mood Disorders Questionnaire and Expressed Emotion Adjective Checklist. To measure changes in symptoms the Childrens Depression Inventory and Multidimensional Anxiety Scale for Children will be used. Questionnaires will be administered before, after and at 4 months. Results Data entered in Excel format. ANOVA used to compare effectiveness of group versus email psychoeducation. Both methods equally effective in delivering psychoeducation. Conclusion Ontario has long waitlists for youth with mood and anxiety disorders. Psychoeducation is effective in increasing understanding of illness, improving symptoms and problem-solving skills of the family. Multifamily group versus email psychoeducation will facilitate access.