Sergio V. Delgado

A double-blind, placebo-controlled pilot study of quetiapine for depressed adolescents with bipolar disorder.

OBJECTIVE To conduct a pilot study comparing the effects of quetiapine and placebo for the treatment of depressive episodes in adolescents with bipolar I disorder. METHOD Thirty-two adolescents (ages 12-18 years) with a depressive episode associated with bipolar I disorder were randomized to eight weeks of double-blind treatment with quetiapine, 300-600 mg/day, or placebo. This two-site study was conducted from March 2006 through August 2007. The primary efficacy measure was change in Childrens Depression Rating Scale-Revised Version (CDRS-R) scores from baseline to endpoint. Secondary efficacy measures included change in CDRS-R scores over the eight-week study period (PROC MIXED), changes from baseline to endpoint in Hamilton Anxiety Rating Scale (HAM-A), Young Mania Rating Scale (YMRS), and Clinical Global Impression-Bipolar Version Severity (CGI-BP-S) scores, as well as response and remission rates. Safety and tolerability were assessed weekly. RESULTS There was no statistically significant treatment group difference in change in CDRS-R scores from baseline to endpoint (p = 0.89, effect size =-0.05, 95% confidence interval: -0.77-0.68), nor in the average rate of change over the eight weeks of the study (p = 0.95). Additionally, there were no statistically significant differences in response (placebo =67% versus quetiapine = 71%) or remission (placebo = 40% versus quetiapine = 35%) rates, or change in HAM-A, YMRS, or CGI-BP-S scores (all p > 0.7) between treatment groups. Dizziness was more commonly reported in the quetiapine (41%) than in the placebo (7%) group (Fishers exact test, p = 0.04). CONCLUSIONS The results suggest that quetiapine monotherapy is no more effective than placebo for the treatment of depression in adolescents with bipolar disorder. However, limitations of the study, including the high placebo response rate, may have contributed to our findings and should be considered in the design of future investigations of pharmacological interventions for this population.

Failure of psychiatric referrals from the pediatric emergency department

BackgroundRecognition of mental illness in the pediatric emergency department (PED) followed by brief, problem oriented interventions may improve health-care seeking behavior and quality of life. The objective of this study was to compare the frequency of mental health follow up after an enhanced referral compared to a simple referral in children presenting to the PED with unrecognized mental health problems.MethodsA prospective randomized control trial comparing an enhanced referral vs. simple referral in 56 families of children who were screened for mental health symptoms was performed in a large tertiary care PED. Children presenting to the PED with stable medical problems were approached every fourth evening for enrollment. After consent/assent was obtained, children were screened for a mental health problem using both child and parent reports of the DISC Predictive Scales. Those meeting cutoffs for a mental health problem by either parent or child report were randomized to 1) simple referral (phone number for mental health evaluation by study psychiatrist) or 2) enhanced referral (short informational interview, appointment made for child, reminder 2 days before and day of interview for an evaluation by study psychiatrist). Data analysis included descriptive statistics and Chi-Square test to calculate the proportion of children with mental health problems who completed mental health follow-up with and without the enhanced referral.ResultsA total of 69 families were enrolled. Overall 56 (81%) children screened positive for a mental health problem as reported by either the child (self report) or mother (maternal report of child mental health problem). Of these, 33 children were randomized into the enhanced referral arm and 23 into the simple referral arm. Overall, only 6 families with children screening positive for a mental health problem completed the psychiatric follow up evaluation, 2 in the enhanced referral arm and 4 in the simple referral arm (p = .13).ConclusionChildren screened in the ED for unrecognized mental health problems are very unlikely to follow-up for a mental health evaluation with or without an enhanced referral. Understanding the role of ED based mental health screening and the timing of an intervention is key in developing ED based mental health interventions.

Disinhibition as a side effect of treatment with fluvoxamine in pediatric patients with obsessive-compulsive disorder.

Selective serotonin reuptake inhibitors (SSRIs) are usually well tolerated in the pediatric population, and widely used in the treatment of obsessive-compulsive disorder (OCD). Of the 51 pediatric patients with obsessive-compulsive disorder seen in our outpatient clinic between January 2009 and July 2009, 3 of them developed behavioral disinhibition after treatment with fluvoxamine. These cases are described and discussed in relation to the use of CYP2D6 and CYP2C19 pharmacogenetic testing in patients treated with serotonin-selective reuptake inhibitors.

Difficult psychiatric consultations

Difficult psychiatric consultations : , Difficult psychiatric consultations : , کتابخانه دیجیتال جندی شاپور اهواز

Placebo-Controlled Trial of Valproic Acid Versus Risperidone in Children 3–7 Years of Age with Bipolar I Disorder

OBJECTIVE The objective of this study was to determine the efficacy and safety of valproic acid versus risperidone in children, 3-7 years of age, with bipolar I disorder (BPD), during a mixed or manic episode. METHODS Forty-six children with Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision (DSM-IV-TR) diagnosis of bipolar disorder, manic, hypomanic, or mixed episode, were recruited over a 6 year period from two academic outpatient programs for a double-blinded, placebo-controlled trial in which subjects were randomized in a 2:2:1 ratio to risperidone solution, valproic acid, or placebo. RESULTS After 6 weeks of treatment, the least-mean Young Mania Rating Scale (YMRS) total scores change, adjusted for baseline YMRS scores, from baseline by treatment group was: Valproic acid 10.0±2.46 (p=0.50); risperidone 18.82±1.55 (p=0.008); and placebo 4.29±3.56 (F=3.93, p=0.02). The mixed models for repeated measure (MMRM) analysis found a significant difference for risperidone-treated subjects versus placebo treated subjects (p=0.008) but not for valproic acid-treated subjects versus placebo-treated subjects (p=0.50). Treatment with risperidone over 6 weeks led to increased prolactin levels, liver functions, metabolic measures, and weight/body mass index (BMI). Treatment with valproic acid led to increases in weight/BMI and decreases in total red blood cells (RBC), hemoglobin, and hematocrit. CONCLUSIONS In this small sample of preschool children with BPD, risperidone demonstrated clear efficacy versus placebo, whereas valproic acid did not. The laboratory and weight findings suggest that younger children with BPD are more sensitive to the effects of both of these psychotropics, and that, therefore, frequent laboratory and weight monitoring are warranted.

Contemporary psychodynamic psychotherapy for children and adolescents

Contemporary psychodynamic psychotherapy for children and adolescents : , Contemporary psychodynamic psychotherapy for children and adolescents : , کتابخانه دیجیتال جندی شاپور اهواز

The Clinical Presentation

Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

Ethical and Medicolegal Issues

Ethical and medicolegal issues are an inherent part of difficult psychiatric consultations and, as we have illustrated, create special challenges for the consulting psychiatrist working with both pediatric [Ascherman and Rubin (Child Adolesc Psychiatr Clin N Am 17:21–35, 2008)] and adult populations [Arras and Steinbock (Ethical issues in modern medicine, Mayfield, 1998); Gutheil et al. (J Am Acad Psychiatry Law 33(4):432–436, 2005)]. Among the key issues which must frequently be addressed include: autonomy , nonmaleficence , beneficence , and justice . Additionally, the consulting psychiatrist should be savvy regarding the state laws related to involuntary hospitalization as well as the process by which this occurs. Finally, it is critical for the consulting psychiatrist working with the difficult psychiatric consultation to have a strong working understanding of confidentiality , privilege , and the limits limitations of these concepts.

Beyond DSM-5 and IQ Scores: Integrating the Four Pillars to Forensic Evaluations.

The current adult and child forensic psychiatrist is well trained, familiar, and comfortable with the use of the semi-structured Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013 (DSM-5) [In APA, 2003] interview style. The author’s assertion is not that this method is invalid or unreliable; rather, that it can be complemented by integrating elements of the defendant’s four pillar assessment. Assessing the four pillars expands on the information provided by a semi-structured DSM-5-style interview in psychiatry. The four pillars are the foundation of a person’s personality; temperament, cognition (learning abilities or weaknesses), cognitive flexibility (theory of mind) and internal working models of attachment, within the backdrop of the family and of the social and cultural environment in which they have lived. The importance of the study of four pillars is based on the understanding that human behavior and psychopathology as a complex and multifaceted process that includes the level of social-emotional maturity and cognitive abilities (In Delgado et al. Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015). The four pillars are not new concepts, rather they had been studied by separate non-clinical disciplines, and had not been integrated to the clinical practice. As far as we know, it wasn’t until Delgado et al. (Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015) incorporated the four pillars in a user-friendly manner to clinical practice.

Two-Person Relational Psychotherapy: Infants and Preschool Age Children

We open this chapter with Freud’s masterful quote that captures the role children have as active participants in their development. For many years, infants were thought of as being dependent and unaware of the world around them (Mahler et al., Symbiosis and individuation: the psychological birth of the human infant. Basic Books, New York, 1975). The work by early developmental researchers—including Bowlby, Spitz, Emde, Stern, etc.—helped elucidate that infants were hardwired to develop complex abilities for social reciprocity, and if raised by parents with “good enough” capacities for affective attunement, the infants were quite busy in meaning-making processes. Tronick and Beeghly (Am Psychol 66(2):107–119, 2011) state, “In developing systems, such as human infants, sufficient resources must be obtained to enable them to increase their coherence and complexity and to self-organize new capacities.” Further, Bretherton and Munholland ’s (Internal working models in attachment relationships: a construct revisited. In: Cassidy J, Shaver PR (eds) Handbook of attachment: theory, research, and clinical applications. Guilford Press, New York, 1999) work reinforced the notion that interactions between infants and their parents gave meaning to their shared experiences, with the development of internal working models of attachment giving coherence to their relationships. When infants have emotionally available and affectively attuned parents, they develop secure working models in relating with others. When parents provide a secure base for the infant, it increases the likelihood of the infant acquiring the emotional resources needed in the short run, and in the long run, these growth-promoting social interactions will contribute to self-regulatory capacities and resiliency. Over time, infants become part of a larger and more complex system, and they become more flexible and better able to reorganize when confronted by day-to-day discontinuities in their care.