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A comparison of American and english hospital discharge rates for pediatric bipolar disorder, 2000 to 2010
Objective Controversy exists over the diagnosis and prevalence of pediatric bipolar disorder (PBD). Although several small surveys suggest that the rate of the PBD diagnosis in clinical settings is higher in the United States than in other countries, no comprehensive cross-national comparisons of clinical practice have been performed. Here, we used longitudinal national datasets from 2000 to 2010 to compare US and English hospital discharge rates for PBD in patients aged 1 to 19 years. Method We used the English National Health Service (NHS) Hospital Episode Statistics (HES) dataset and the United States National Hospital Discharge Survey (NHDS) to compare US and English discharge rates for PBD (bipolar I disorder [BP-I], bipolar II disorder [BP-II], bipolar disorder not otherwise specified [BP-NOS], and cyclothymia). We also conducted cross-national comparisons for all other psychiatric diagnoses in youth and for adults with bipolar disorder (BD). Results There was a 72.1-fold difference in discharge rates for PBD in youth between the United States and England (United States, 100.9 per 100,000 population, 95% confidence interval = 98.1-103.8, versus England, 1.4 per 100,000 population, 95% CI = 1.4-1.5). After controlling for cross-national differences in length of stay, discharge rates for PBD remained 12.5 times higher in the United States than in England. For all other child psychiatric diagnoses, the discharge rate was 3.9-fold higher, and for adults with BD 7.2-fold higher, in the United States than in England. Conclusion The disparity between US and English discharge rates for PBD is markedly greater than the disparity for child psychiatric discharge rates overall and for adult rates of BD. This suggests that the difference in discharge rates for PBD may be due to differing diagnostic practices for PBD in the United States versus in England.
Classifying patients and controls using multi-dimensional scaling and exploring the metric of semantic space
Multi-dimensional scaling (MDS) has been used to visualize the organization of semantic memory in normal control subjects and in psychiatric conditions such as schizophrenia and Alzheimer’s disease. However, the potential for such techniques to classify subjects into diagnostic groups has not been realized. This study attempted to tackle this by developing classification statistics and by exploring the dimensional organization of semantic space using models with different underlying metrics. The test data were from controls and patients with early onset schizophrenia. The results indicated subtly altered semantic organization in schizophrenia, sufficient for novel classification statistics to correctly classify subjects as either patient or control with >80% accuracy.
Prescribing antipsychotics for children and adolescents
The prescription of antipsychotic medication in children and adolescents (<18 years of age) has increased immensely for a wide range of disorders including psychoses, bipolar disorder, conduct disorder, pervasive developmental disorder and obsessive-compulsive disorder. This has led to some concerns particularly as the evidence base in some areas is not strong, and antipsychotic medication - both first generation (FGA) and second generation (SGA) - is associated with considerable side-effects. Evidence from an increasing number of randomised controlled trials (RCTs) points to therapeutic efficacy with moderate to large effect sizes. However, some RCTs have a small number of participants, are of short duration, and many are industry funded. The use of antipsychotics alongside psychosocial interventions can be recommended in certain disorders, provided there is continued, careful monitoring. It is important to note, however, that for many conditions the use of antipsychotics is not licensed in the UK.
Longitudinal changes in grey and white matter during adolescence.
Brain development continues actively during adolescence. Previous MRI studies have shown complex patterns of apparent loss of grey matter (GM) volume and increases in white matter (WM) volume and fractional anisotropy (FA), an index of WM microstructure. In this longitudinal study (mean follow-up=2.5+/-0.5 years) of 24 adolescents, we used a voxel-based morphometry (VBM)-style analysis with conventional T1-weighted images to test for age-related changes in GM and WM volumes. We also performed tract-based spatial statistics (TBSS) analysis of diffusion tensor imaging (DTI) data to test for age-related WM changes across the whole brain. Probabilistic tractography was used to carry out quantitative comparisons across subjects in measures of WM microstructure in two fiber tracts important for supporting speech and motor functions (arcuate fasciculus [AF] and corticospinal tract [CST]). The whole-brain analyses identified age-related increases in WM volume and FA bilaterally in many fiber tracts, including AF and many parts of the CST. FA changes were mainly driven by increases in parallel diffusivity, probably reflecting increases in the diameter of the axons forming the fiber tracts. FA values of both left and right AF (but not of the CST) were significantly higher at the end of the follow-up than at baseline. Over the same period, widespread reductions in the cortical GM volume were found. These findings provide imaging-based anatomical data suggesting that brain maturation in adolescence is associated with structural changes enhancing long-distance connectivities in different WM tracts, specifically in the AF and CST, at the same time that cortical GM exhibits synaptic "pruning".
Changes in white matter microstructure during adolescence.
Postmortem histological studies have demonstrated that myelination in human brain white matter (WM) continues throughout adolescence and well into adulthood. We used in vivo diffusion-weighted magnetic resonance imaging to test for age-related WM changes in 42 adolescents and 20 young adults. Tract-Based Spatial Statistics (TBSS) analysis of the adolescent data identified widespread age-related increases in fractional anisotropy (FA) that were most significant in clusters including the body of the corpus callosum and right superior corona radiata. These changes were driven by changes in perpendicular, rather than parallel, diffusivity. These WM clusters were used as seeds for probabilistic tractography, allowing us to identify the regions as belonging to callosal, corticospinal, and prefrontal tracts. We also performed voxel-based morphometry-style analysis of conventional T1-weighted images to test for age-related changes in grey matter (GM). We identified a cluster including right middle frontal and precentral gyri that showed an age-related decrease in GM density through adolescence and connected with the tracts showing age-related WM FA increases. The GM density decrease was highly significantly correlated with the WM FA increase in the connected cluster. Age-related changes in FA were much less prominent in the young adult group, but we did find a significant age-related increase in FA in the right superior longitudinal fascicle, suggesting that structural development of this pathway continues into adulthood. Our results suggest that significant microstructural changes in WM continue throughout adolescence and are associated with corresponding age-related changes in cortical GM regions.
Monitoring Airway Hyperresponsiveness: Pharmacological Stimuli
The role of airway challenge tests using pharmacologic stimuli in asthma has fluctuated in importance over the last 40 years. Initially proposed as diagnostic tests for asthma, they have not found widespread use in this regard. These tests remain useful in the detection of asthma in epidemiological surveys and have been included in the definition of asthma. As our knowledge of the pathology and ‘‘natural’’ history of asthma has increased and the focus of asthma treatment has gradually extended beyond days, weeks, and months to years, the use of direct challenge with pharmacologic stimuli is likely to increase. There are two reasons for this. Firstly, direct airway challenges may be useful to ensure the adequacy of current therapy and secondly, to determine the long-term efficacy of treatment, analogous to the use of the glycosylated hemoglobin in managing diabetes.
The prevalence of psychiatric disorder in children attending a school for pupils with emotional and behavioural difficulties
The research presented in this article suggests that young people attending schools for pupils with emotional and behavioural difficulties are more likely to experience concurrent psychiatric disorders (comorbidity) than their peers in mainstream schools. Dr Cassidy (Consultant in Child and Adolescent Psychiatry), Dr James (Consultant and Honorary Senior Lecturer in Child and Adolescent Psychiatry) and Dr Wiggs (Research Psychologist) used questionnaires and interviews with parents and teachers, together with pupil self-reporting, to gather their data. The two-stage investigation suggested that 89% of the adolescents in one school for pupils with EBD met established criteria for the diagnosis of a psychiatric disorder. Conduct disorder and attention deficit hyperactivity disorder (ADHD) emerged as the most common psychiatric difficulties, but emotional disorders were also prominent in the data. These untreated problems are likely to have significant long-term implications for the psychological and educational development of the pupils concerned, and the authors speculate on some of the ways in which psychiatric and education services might work together in order to improve the outlook. © The National Association for Special Educational Needs 2001.
Bullying a review: Presentations to an adolescent psychiatric service and within a school for emotionally and behaviourally disturbed children
This article reviews the literature on bullying with particular reference to associated psychiatric symptoms and presents data and case examples from an inpatient and outpatient adolescent service and a school for emotionally and behaviourally disturbed children (EBD school). Bullying or its effects do not seem to be a distinguishing factor among those admitted to an adolescent unit. In the outpatient group, however, being bullied is frequently a factor in the presentation of adolescents to psychiatric services, with depression being the diagnosis in over 70% of cases. In contrast, bullies and bully/victims were most likely to present with conduct disorders, which were frequently co-morbid with hyperkinetic disorder/attention deficit hyperactivity disorder (ADHD). Unsurprisingly, regardless of whether bully, victim, bully/victim or neither, the most common psychiatric diagnosis of the EBD school pupils who were interviewed was that of conduct disorder. This was sometimes co-morbid with AD(H)D but also seen alongside generalized anxiety disorder and major depressive disorder. In an adolescent unit and in an EBD school, being bullied or a bully is an important factor associated with psychiatric symptomatology and should be regarded as a substantial mental and public health issue.
Insect transgenesis: Methods and applications
Imagine scientists controlling the transmission of certain diseases through the genetic modification of mosquitoes. Eradicating harmful insects without the use of pesticides. Or increasing the fertility of some insects who in turn eat harmful arthropods or even a plant pathogen. Those are just a few of the real-world applications of insect transgenesis, which offers substantial benefits to humankind-whether it be in improving agricultural productivity or reducing the spread of insect-vectored diseases. Insect Transgenesis: Methods and Applications is the first publication to describe in a comprehensive manner the various methodologies available, possible applications, and the risk assessment and regulatory issues involved in this fascinating area of research. Divided into several areas of interest, the book starts with an overview of the history and methodology of insect gene transfer. The book then examines gene targeting by homologous recombination and recombination systems, and systems for transgenic selection, including visible eye color markers, chemical resistance, and fluorescent proteins. Other sections consider the use of various vector systems to integrate DNA into a host genome or to express foreign genes in a host organism. The work concludes with strategies for the use of transgenic insects, including examples for agricultural pests and vectors of disease. Of particular interest are the final chapters that discuss risk assessment considerations and governmental regulatory procedures for the transport and release of transgenic insects.
Family therapy for adolescents diagnosed as having borderline personality disorder
The family therapy of twenty-four cases of adolescents diagnosed as having borderline personality disorder is described. In comparison to matched psychiatric controls, the families of these adolescents were more angry and irritable and had higher rates of sexual abuse and sibling psychopathology. Relationship difficulties, in particular oscillating attachments, were frequently seen in therapy, which was more tumultuous with frequent impulsive acts of self-harm.
The use of ECT in adolescents: A reply to Jones and Baldwin
In reply to Jones and Baldwin's paper, the current practice of electroconvulsive therapy (ECT) is described with a retrospective case study. Particular reference is made to: indications, consent, immediate and longer term outcome. It is argued that the treatment is beneficial, but systematic audit is necessary.
Case report: Mixed mania - Apparent induction in an adolescent by a Selective Serotonin Reuptake Inhibitor antidepressant (SSRI)
A case is described of mixed mania in a 15-year-old boy, possibly induced by the use of a selective serotonin reuptake inhibitor (SSRI). A potentially dangerous, suicidal mental state was treated with ECT. The implications of the recognition and treatment of adolescent onset bipolar disorder is discussed. Copyright © 1996 Sage Publications.
Protein synthesis induced by heat in an Ixodes tick
We determined whether ambient temperature influences the proteins produced by Ixodes dammini ticks. Nonfed adult females were subjected to temperature pulses, and 35S-labeled methionine was injected into the hemocoel or used as an incubation medium for excised salivary glands. Heat-induced protein synthesis was observed in both whole-body and excised salivary gland preparations from nonattached ticks solely when ambient temperature was raised to 42°C. The approximate Mr of each protein was 88 kilodaltons (kDa), 75 and 74 kDa, and between 21 and 27 kDa for a group of lower molecular weight proteins. In another experimental series, ticks were allowed to attach to rabbits and then were subjected to temperature pulses. The 88 and 74 kDa proteins were present in preparations from nonheated ticks that had attached for 1 h. Only small amounts of these proteins were evident in tissues prepared from ticks attached for 2 days or more. Heat-induced proteins became apparent in ticks that were incubated at 42°C, regardless of time of attachment. © 1989.
Cognitive reappraisal of peer rejection in depressed versus non-depressed adolescents: Functional connectivity differences
Background: Depression is the most common psychiatric disorder in adolescence, and is characterised by an inability to down-regulate negative emotional responses to stress. Adult studies suggest this may be associated with reduced functional connectivity between prefrontal and subcortical regions, yet the neurological mechanisms in adolescence remain unclear. Methods: We developed a novel, age-appropriate, reappraisal paradigm to investigate functional connectivity during reappraisal of a real-life source of stress in 15 depressed and 15 non-depressed adolescents. During fMRI, participants i) attended to, and ii) implemented reappraisal techniques (learnt prior to fMRI) in response to, rejection. Results: Reappraisal reduced negative mood and belief in negative thoughts in both groups alike, however during reappraisal (versus attend) trials, depressed adolescents showed greater connectivity between the right frontal pole and numerous subcortical and cortical regions than non-depressed adolescents. Conclusions: These findings tentatively suggest that, when instructed, depressed adolescents do have the ability to engage neural networks involved in emotion regulation, possibly because adolescence reflects a period of heightened plasticity. These data support the value of cognitive reappraisal as a treatment tool, identify neural markers that could be used to optimise current therapies, and lay the foundations for developing novel neuroscientific techniques for the treatment of adolescent depression.
Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents: A Network Meta-analysis.
IMPORTANCE: Anxiety disorders are common in children and adolescents, and uncertainty remains regarding the optimal strategy of psychotherapies in this population. OBJECTIVE: To compare and rank the different types of psychotherapies and the different ways of delivering psychological treatments for anxiety disorders in children and adolescents. DATA SOURCES: PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ProQuest Dissertations, LILACS (Literatura Latino Americana em Ciências da Saúde), international trial registers, and US Food and Drug Administration reports were searched from inception to November 30, 2017. STUDY SELECTION: Randomized clinical trials that compared any structured psychotherapy with another psychotherapy or a control condition for anxiety disorders in children and adolescents were selected. DATA EXTRACTION AND SYNTHESIS: Four researchers independently performed data extraction and quality assessment. Pairwise meta-analyses and Bayesian network meta-analysis within the random-effects model were used to synthesize data. MAIN OUTCOMES AND MEASURES: Efficacy (change in anxiety symptoms) posttreatment and at follow-up, acceptability (all-cause discontinuation), and quality of life and functional improvement were measured. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS: A total of 101 unique trials including 6625 unique participants compared 11 different psychotherapies with 4 specific control conditions. The certainty of evidence was rated as low or very low for most comparisons. For efficacy, most psychotherapies were significantly more effective than the wait list condition posttreatment (standardized mean difference [SMD], -1.43 to -0.61) and at the longest follow-up (SMD, -1.84 to -1.64). However, only group cognitive behavioral therapy (CBT) was significantly more effective than the other psychotherapies and all control conditions posttreatment. For acceptability, bibliotherapy CBT had significantly more all-cause discontinuations than some psychotherapies and control conditions (range of odds ratios, 2.48-9.32). In terms of quality of life and functional improvement, CBT (delivered in different ways) was significantly beneficial compared with psychological placebo and the wait list condition (SMDs, 0.73 to 1.99). CONCLUSIONS AND RELEVANCE: Group CBT would be the more appropriate choice of psychotherapy for anxiety disorders in children and adolescents, based on these findings. Other types of psychotherapies and different ways of delivering psychological treatment can be alternative options. Further research is needed to explore specific anxiety disorders, disorder-specific psychotherapy, and moderators of treatment effect. TRIAL REGISTRATION: PROSPERO Identifier: CRD42015016283.
Study into COVID-19 Crisis Using Primary Care Mental Health Consultations and Prescriptions Data.
The effect of the 2020 pandemic, and of the national measures introduced to control it, is not yet fully understood. The aim of this study was to investigate how different types of primary care data can help quantify the effect of the coronavirus disease (COVID-19) crisis on mental health. A retrospective cohort study investigated changes in weekly counts of mental health consultations and prescriptions. The data were extracted from one the UK's largest primary care databases between January 1st 2015 and October 31st 2020 (end of follow-up). The 2020 trends were compared to the 2015-19 average with 95% confidence intervals using longitudinal plots and analysis of covariance (ANCOVA). A total number of 504 practices (7,057,447 patients) contributed data. During the period of national restrictions, on average, there were 31% (3957 ± 269, p < 0.001) fewer events and 6% (4878 ± 1108, p < 0.001) more prescriptions per week as compared to the 2015-19 average. The number of events was recovering, increasing by 75 (± 29, p = 0.012) per week. Prescriptions returned to the 2015-19 levels by the end of the study (p = 0.854). The significant reduction in the number of consultations represents part of the crisis. Future service planning and quality improvements are needed to reduce the negative effect on health and healthcare.
A single dose of fluoxetine reduces neural limbic responses to anger in depressed adolescents.
Depression in adolescence is frequently characterised by symptoms of irritability. Fluoxetine is the antidepressant with the most favourable benefit:risk ratio profile to treat adolescent depression, but the neural mechanisms underlying antidepressant drugs in the young brain are still poorly understood. Previous studies have characterised the neural effects of long-term fluoxetine treatment in depressed adolescents, but these are limited by concurrent mood changes and a lack of placebo control. There is also recent evidence suggesting that fluoxetine reduces the processing of anger in young healthy volunteers, which is consistent with its effect for the treatment of irritability in this age group, but this remains to be investigated in depressed adolescents. Here we assessed the effects of a single, first dose of 10 mg fluoxetine vs. placebo on neural response to anger cues using fMRI in a sample of adolescents with Major Depressive Disorder (MDD) who had been recently prescribed fluoxetine. As predicted, adolescents receiving fluoxetine showed reduced activity in response to angry facial expressions in the amygdala-hippocampal region relative to placebo. Activity in the dorsal anterior cingulate cortex (dACC) was also increased. No changes in symptoms were observed. These results demonstrate, for the first time in depressed adolescents, that fluoxetine has immediate neural effects on core components of the cortico-limbic circuitry prior to clinical changes in mood. The effect on anger is consistent with our previous work and could represent a key mechanism through which fluoxetine may act to alleviate irritability symptoms in adolescent depression.