Sharon E. Cain

Treating Childhood Depression over Videoconferencing

Effective cognitive-behavioral treatments for childhood depression have developed over the last decade, but many families face barriers to such care. Telemedicine increases access to psychological interventions by linking the child and the clinician using videoconferencing (VC). The current study evaluated an 8-week, cognitive-behavioral therapy (CBT) intervention for childhood depression either face-to-face (F2F) or over VC. The telemedicine setup included two PC-based PictureTel systems at 128 kilibits per second (kbps). Success was defined by (1) decreasing depressive symptoms at similar rates in both the VC group and the F2F group and (2) demonstrating the feasibility of a randomized controlled trial in telemental health. Children were assessed for childhood depression using the mood section of the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present Episode (K-SADS-P). Twenty-eight children were randomized to either F2F or VC treatment. The participants completed the K-SADS-P and the Childrens Depression Inventory (CDI) at pre- and post-treatment. The CBT treatment across the two conditions was effective. The overall response rate based on post-evaluation with the K-SADS-P was 82%. For the CDI total score, both the Time and the Group by Time effects were significant (p < 0.05). The interaction effect reflected a faster rate of decline in the CDI total score for the VC group. The study serves as a model for building on past research to implement a randomized controlled trial. This information provides persuasive research data concerning treatment effectiveness for clinicians, families, and funders.

Feasibility of telemedicine intervention for childhood depression

Abstract Context: Childhood depression is associated with high short-term and long-term morbidity. Cognitive-behavioural therapy (CBT) for depression has been supported as an effective treatment in the traditional clinic setting. But many families face barriers to depression treatment, including distance to providers, provider shortages, stigma, and other challenges. Telemedicine or interactive televideo offers an innovative way to provide therapy at a distance. The family and therapist see and hear each other in real-time using videoconference. Objective: This pilot project evaluated the same cognitive-behavioural therapy treatment for childhood depression in two different settings — face-to-face (F2F) or over interactive televideo (ITV). Participants: Twenty-eight children with depression and their caregivers completed an eight-session, empirically supported CBT course for parent and child. Results: All parent and child CBT skills were implemented successfully over telemedicine. An 82% remission from de...

An fMRI Study Examining Effects of Acute D-Cycloserine During Symptom Provocation in Spider Phobia

BACKGROUND Exposure-based therapy for anxiety disorders is believed to operate on the basis of fear extinction. Studies have shown acute administration of D-cycloserine (DCS) enhances fear extinction in animals and facilitates exposure therapy in humans, but the neural mechanisms are not completely understood. To date, no study has examined neural effects of acute DCS in anxiety-disordered populations. METHODS Two hours prior to functional magnetic resonance imaging scanning, 23 spider-phobic and 23 non-phobic participants were randomized to receive DCS 100 mg or placebo. During scanning, participants viewed spider, butterfly, and Gaussian-blurred baseline images in a block-design paradigm. Diagnostic and treatment groups were compared regarding differential activations to spider versus butterfly stimuli. RESULTS In the phobic group, DCS enhanced prefrontal (PFC), dorsal anterior cingulate (ACC), and insula activations. For controls, DCS enhanced ventral ACC and caudate activations. There was a positive correlation between lateral PFC and amygdala activation for the placebo-phobic group. Reported distress during symptom provocation was correlated with amygdala activation in the placebo-phobic group and orbitofrontal cortex activation in the DCS-phobic group. CONCLUSIONS Results suggest that during initial phobic symptom provocation DCS enhances activation in regions involved in cognitive control and interoceptive integration, including the PFC, ACC, and insular cortices for phobic participants.

Urban Telepsychiatry: Uncommon Service for a Common Need

Psychiatry is a particularly good specialty to provide by telemedicine. The psychiatric interaction translates very well to the interactive video medium and typically does not require any peripheral medical devices for the consultation compared with other specialties. Although telemedicine is most often thought of as strictly a rural health tool for solving health care shortages, it has sometimes been used to improve access to many health specialists in urban areas of the United States. An urban infrastructure can be more supportive of telehealth from technical and clinical support perspectives, particularly in special or emergent situations. This article highlights the Kansas practice and reviews other urban applications of telepsychiatry.

Loxapine add-on for adolescents and adults with autism spectrum disorders and irritability.

OBJECTIVES Our clinical experience with low dose loxapine (5-15 mg/day) suggests promising efficacy and safety for irritability in autism spectrum disorders (ASD). We studied low dose loxapine prospectively in adolescents and adults with ASD and irritability. Additionally, we measured loxapine and metabolite concentrations, and brain-derived neurotrophic factor (BDNF) as a biomarker of neuromodulation. METHODS We performed a 12 week open trial of add-on loxapine in subjects, ages 13-65 years, diagnosed with ASD, and Aberrant Behavior Checklist-Irritability (ABC-I) subscale scores >14. Loxapine was dosed flexibly up to 15 mg daily, starting with 5 mg on alternate days. From weeks 1 to 6, other psychoactive medications were tapered if possible; from weeks 6 to 12, all medication doses were held stable. The primary outcome was the Clinical Global Impressions-Improvement subscale (CGI-I), ratings of Much Improved or Very Much Improved. Secondary outcomes were the ABC-I, Repetitive Behavior Scale-Revised, and Schalock Quality of Life scale. Serum BDNF and loxapine and metabolite concentrations were assayed. BDNF rs6265 was genotyped. RESULTS Sixteen subjects were enrolled; 12 completed all visits. Median age was 18 years (range 13-39). Median final loxapine dose was 7.5 mg/day (2.5-15). All 14 subjects (100%) with data at week 12 were rated as Much Improved on CGI-I at 12 weeks. Mean change on ABC-I at 12 weeks was -31%, p=0.01. Mean body mass index (BMI)-Z decreased between weeks 6 and 12, p=0.03. Side effects were minimal, and prolactin elevation occurred in only one subject. BDNF concentrations measured in 11 subjects increased significantly (p=0.04). Subjects with AG genotype for BDNF rs6265 required a lower dose of loxapine at study end, but had similar behavioral and BDNF concentration changes as the GG genotype. CONCLUSIONS Low dose loxapine shows promise as a repurposed drug for irritability in ASD. Loxapine effects on BDNF warrant further study.

Considerations for Conducting Telemental Health with Children and Adolescents

Innovative technologies are increasingly used in order to address gaps in access to child behavioral health care. Telemental health is one technological modality in which child behavioral services can be practiced successfully across psychiatry, psychology, and developmental medicine. The authors discuss relevant issues related to delivering telemental health, including why this modality is necessary for delivery, what models and evidence for telemental health exist, when it should be considered across legal/regulatory and ethical considerations, where telemental health services are delivered, who is involved in delivery, and how best telemental health practices may be implemented with diverse youth.