Sequential Pharmacotherapy for Children With Comorbid Attention-Deficit/Hyperactivity and Anxiety Disorders
J Am Acad Child Adolesc Psychiatry 2005;44:418-427
Objective: Clinically significant anxiety is often present with attention-deficit/hyperactivity disorder (ADHD), but empirical data are lacking to guide the treatment of children who meet full DSM-IV criteria for both ADHD and anxiety disorders. This study investigated the use of sequential pharmacotherapy for children with both disorders. Method: Children aged 6 to 17 years with ADHD and anxiety disorders received open methylphenidate titrated to an optimal dose and were evaluated along with children who were taking a stimulant dose that had been optimized prior to entering the study. Children who experienced an improvement in ADHD but not anxiety were randomly assigned to 8 weeks of double-blind stimulant plus fluvoxamine or stimulant plus placebo. The Swanson, Nolan, Atkins, and Pelham IV Parent and Teacher Rating Scale ADHD scores and the Pediatric Anxiety Rating Scale total score were the primary efficacy measures. Other measures included ADHD, anxiety, and overall Clinical Global Impressions-Improvement scores. Results: Improvement in ADHD was seen in 26 (81%) of the 32 children who had not been previously treated with a stimulant, and 25 children entered the randomized trial. No differences were seen in responder rate between the fluvoxamine (N=15) and placebo groups on the Pediatric Anxiety Rating Scale or Clinical Global Impressions-Improvement according to intent-to-treat analysis. Medications were well tolerated in both treatment arms. Conclusions: The response rate to stimulants is similar for children with ADHD and anxiety disorders and those with ADHD only. The benefit of adding fluvoxamine to stimulants for anxiety disorders remains unproven.
Psychotherapy and Medication in the Treatment of Adult and Geriatric Depression: Which Monotherapy or Combined Treatment?
J Clin Psychiatry 2005;66:455-468
Objective: The authors reviewed the literature with respect to the relative efficacy of medications and psychotherapy alone and in combination in the treatment of depression. Data Sources and Study Selection: Findings from empirical studies comparing medications and psychotherapy alone and in combination were synthesized and prognostic and prescriptive indices identified. Both MEDLINE and PsychINFO were searched for items published from January 1980 to October 2004 using the following terms: treatment of depression, psychotherapy and depression, and pharmacotherapy and depression. Studies were selected that randomly assigned depressed patients to combined treatment versus monotherapy. Data Synthesis: Medication typically has a rapid and robust effect and can prevent symptom return so long as it is continued or maintained, but does little to reduce risk once its use is terminated. Both interpersonal psychotherapy (IPT) and cognitive-behavioral therapy (CBT) can be as effective as medications in the acute treatment of depressed outpatients. Interpersonal psychotherapy may improve interpersonal functioning, whereas CBT appears to have an enduring effect that reduces subsequent risk following treatment termination. Ongoing treatment with either IPT or CBT appears to further reduce risk. Treatment with the combination of medication and IPT or CBT retains the specific benefits of each and may enhance the probability of response over either monotherapy, especially in chronic depressions. Conclusion: Both medication and certain targeted psychotherapies appear to be effective in the treatment of depression. Although several prognostic indices have been identified that predict need for longer or more intensive treatment, few prescriptive indices have yet been established to select among the different treatments. Combined treatment can improve response with selected patients and enhance its breadth (IPT) or stability (CBT).
Taking Well-Child Care Into the 21st Century: a Novel, Effective Method for Improving Parent Knowledge Using Computerized Tutorials
Arch Pediatr Adolesc Med 2005;159:482-485
Background: Time constraints often prevent pediatric providers from administering sufficient anticipatory guidance and educational counseling during well-child visits, despite expert panel recommendations. Objectives: To provide access to interactive, self-guided, computerized tutorials in waiting rooms that give anticipatory guidance to parents at the 6-week and 4-month well-child visits and to determine effect on parent knowledge. Setting: A government-funded New Mexico hospital serving Navajo patients. Methods: Knowledge of issues such as fever management, dental care, sleep position, nutrition, and car seat use was assessed after a well-child visit in 2 groups of parents: (1) the control group received standard care and (2) the intervention group used the computerized tutorials and received standard care. The computerized intervention automatically printed a summary for the medical record and required no additional provider time. Results: The knowledge assessment was completed by 52 parents in the control group and 49 parents in the intervention group. The computerized tutorial was completed by 95% of intervention subjects without clinic staff involvement. The intervention group had superior knowledge in all tested areas compared with the control group. Correct responses to all questions were higher for the intervention group in the categories car seat use (49% vs. 31%, p<.01), dental care (80% vs. 27%, p<.001), and nutrition (43% vs. 21%, p<.001). Among parents of 6-week-old infants, more parents in the intervention group identified fever as >=100.4°F (86% vs. 50%, p<.001), and fewer replied that they would give antipyretics to a febrile child younger than 3 months old without consulting a provider (52% vs. 100%, p<.001). A significantly higher percentage of parents in the intervention group had a perfect score or only 1 question wrong on the 21-item test (p<.001). Conclusion: Computerized anticipatory guidance at well-child visits is usable by most parents and increases knowledge over standard care alone.
Negative Self-Schemas and the Onset of Depression in Women: Longitudinal Study
Br J Psychiatry 2005;186:302-307
Background: Little empirical support has been shown for Beck's cognitive theory of depression. Aim: To determine whether women with negative self-schemas were at risk for depression. Method: Questionnaires, mailed to 12,003 women recruited during early pregnancy, included measures of depressive symptoms and negative self-schemas. Questionnaires were mailed regularly during pregnancy and following childbirth. Results: 8540 women were not depressed when recruited, and of these, 8.6% (95% CI=8.0 to 9.2) became depressed 14 weeks later. Women with the highest negative self-schema scores were more likely to become depressed than those with the lowest scores (OR=3.04, 95% CI=2.48 to 3.73), even after adjustment for baseline depressive symptoms and previous depression (OR=1.6, 95% CI=1.27 to 2.02). A similar magnitude for onset 3 years later was also seen. Conclusions: In support of Beck's cognitive theory, negative self-schema was found to be an independent risk factor for the onset of depression in women. An increased understanding of the development of a negative self-schema can inform preventive policies.
Psychopathology Among New York City Public School Children 6 Months After September 11
Arch Gen Psychiatry 2005;62:545-552
Context: The risk for developing mental disorders may be higher in children exposed to a traumatic event. Objective: To investigate prevalence and correlates of probable mental disorders among New York City, N.Y., public school students 6 months after the September 11, 2001, World Trade Center attack. Design: Survey. Setting: New York City public schools. Participants: A citywide, randomized, representative sample of 8236 students in grades 4 through 12, including oversampling in areas of closest proximity to the World Trade Center site (ground zero) and other high-risk areas. Main Outcome Measure: Screening with the Diagnostic Interview Schedule for Children Predictive Scales for probable mental disorders. Results: Of 6 probable anxiety/depressive disorders, >=1 disorders were identified in 28.6% of all children, and probable agoraphobia (14.8%), probable separation anxiety (12.3%), and probable posttraumatic stress disorder (10.6%) were the 3 most prevalent. A higher prevalence of all probable anxiety/depressive disorders was associated with higher levels of exposure. The most affected were girls and children in grades 4 and 5. Logistic regression analyses revealed that child's exposure (adjusted OR=1.62), exposure of a child's family member (adjusted OR=1.80), and child's prior trauma (adjusted OR=2.01) were related to increased likelihood of probable anxiety/depressive disorders. Results were adjusted for different types of exposure, sociodemographic characteristics, and child mental health service use. Conclusions: A probable mental disorder was found in a high proportion of New York City public school children 6 months after September 11, 2001. A relationship between level of exposure to trauma and likelihood of child anxiety/depressive disorders in the community is suggested. Application of area-wide epidemiologic approaches to mental health assessment is supported after any large-scale disaster.
A Review of the Evidence for the Efficacy and Safety of Trazodone in Insomnia
J Clin Psychiatry 2005;66:469-476
Objective: Trazodone, a triazolopyridine antidepressant, is currently the second most commonly prescribed agent for the treatment of insomnia due to its sedating qualities. Given trazodone's widespread use, a careful review of the literature was conducted to assess its efficacy and side effects when given for treatment of insomnia. Data Sources: In April 2003, a MEDLINE search was conducted using the search terms trazodone and insomnia and trazodone and sleep and restricted to 1980-2003, human subjects, and English language. As trazodone has been implicated in cardiac disorders, a further search was conducted using the term cardiac and trazodone. Study Selection: All clinical trials that measured any endpoint for insomnia efficacy were included in the assessment. A total of 18 studies were identified from the literature search. In addition, commonly used texts were consulted for information regarding adverse effects related to trazodone. Data Extraction: Because so few studies were identified by the literature search, all were evaluated and described. Data Synthesis: Evidence for the efficacy of trazodone in treating insomnia is very limited; most studies are small, conducted in populations of depressed patients, raise issues of design, and often lack objective efficacy measures. Side effects associated with trazodone are not inconsequential, with a high incidence of discontinuation due to side effects, such as sedation, dizziness, and psychomotor impairment, which raise particular concern regarding its use in the elderly. There is also some evidence of tolerance related to use of trazodone. Conclusion: Given the relative absence of efficacy data in patients with insomnia and the adverse events associated with trazodone's use in general, it is uncertain whether the risk/benefit ratio warrants trazodone's use in nondepressed patients with insomnia.
Pain Among Children and Adolescents: Restrictions in Daily Living and Triggering Factors
Pediatrics 2005;115:e152-e162
Objectives: To investigate the impact of perceived pain on the daily lives and activities of children and adolescents and to delineate self-perceived triggers of pain among children and adolescents. This study (1) documents the 3-month prevalence of painful conditions among children and adolescents, (2) delineates their features (location, intensity, frequency, and duration), (3) describes their consequences (restrictions and healthcare utilization), and (4) elucidates factors that contribute to the occurrence of pain episodes among young subjects. Methods: Children and adolescents, as well as their parents/guardians, in 1 elementary school and 2 secondary schools in the district of Ostholstein, Germany, were contacted through their school administrators. Parents of children in grades 1 to 4 of elementary school were asked to complete the pain questionnaire for their children at home. Children from grades 5 and up completed the questionnaire themselves during class, under the supervision of their teachers. The response rate was 80.3%. Chronic pain was defined as any prolonged pain that lasted a minimum of 3 months or any pain that recurred throughout a minimal period of 3 months. The Luebeck Pain-Screening Questionnaire, which aims to delineate the self-perceived factors for the development and maintenance of pain and the impact of these conditions on daily life, was used. The questionnaire evaluates the prevalence of pain in the preceding 3 months, including information on the body area, frequency, intensity, and duration of pain. It also inquires about the private and public consequences of pain among young subjects. Results: Of 749 children and adolescents, 83% had experienced pain during the preceding 3 months; 30.8% reported that the pain had been present for >6 months. Headache (60.5%), abdominal pain (43.3%), limb pain (33.6%), and back pain (30.2) were the most prevalent pain types reported. The following were reported as sequelae to pain: sleep problems (53.6%), inability to pursue hobbies (53.3%), eating problems (51.1%), school absence (48.8%), and inability to meet friends (46.7%). Prevalence of restrictions in daily living related to pain increased with age. Professional help was sought by 50.9% of children and adolescents with pain, and the use of pain medications was reported by 51.5%. The prevalence of doctor visits and medication use increased with age. The most frequent self-perceived triggers for pain noted by the respondents were weather conditions (33%), illness (30.7%), and physical exertion (21.9%). Headache was registered by 30.4% of study participants as the most bothersome pain. 12.3% cited abdominal pain, 10.7% pain in the extremities, 8.9% back pain, and 3.9% sore throat as being most bothersome. Pain episodes occurring >=1 time per week were reported by 35.2% of children and adolescents. Healthcare utilization as a result of pain differed among children and adolescents by location of pain. Back pain (56.7%), limb pain (55.0%), and abdominal pain (53.3%) resulted in a doctor's visit more often than did headache (32.5%), although headache (59.2%) more often resulted in medication use than did back pain (16.4%), limb pain (22.5%), and abdominal pain (38.0%). The prevalence of self-reported medication use and doctor visits because of pain increased significantly with age (c2 test). The prevalence of self-reported medication use was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (c2 test). 51.1% of those with abdominal pain and 43.0% for those with headache but only 19.4% for those with back pain reported having been absent from school because of pain. The prevalence of restrictions attributable to pain was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (c2 test). 39% of girls stated that their pain was triggered by weather conditions (vs. 25% of boys), 35.9% versus 23.9% cited illness, 20.9% versus 11.9% cited anger/disputes, 12.1% versus 5.2% cited family conditions, and 11.9% versus 3.4% cited sadness; 28% of boys stated that their pain was triggered by physical exertion (vs. 17.2% of girls). Conclusions: These results underscore the importance of pediatric pain for public health policy. Additional studies are needed to enhance our knowledge about pediatric pain and to assist young people with pain management.
Factors Associated With Former Smokers Among Female Adolescents in Rural Virginia
Addict Behav 2005;30:167-173
Objective: To examine variables related to former smokers among female adolescents. Method: Multiple ecological factors (individual, family, peer, school, and community) associated with female adolescent former smokers, current smokers, and never smokers were examined in a sample of 2029 seventh- to twelfth-grade girls living in a rural area of Virginia. Results: Compared to current smokers, former smokers reported lower levels of delinquency, less coping by taking drugs, less availability of cigarettes, and less alcohol and marijuana use, less depression, fewer suicidal thoughts, and fewer suicide attempts. Former smokers also spent more time in community clubs, had higher self-esteem, obtained higher grades, and had more parental monitoring, more parental attachment, and more school attachment than current smokers. Logistic regression analysis predicting current or former smoking status showed significant effects on coping by taking drugs, alcohol use, depression, grades, parental monitoring, and perceived availability of cigarettes. Conclusion: According to the authors, these findings have implications for smoking intervention programs with adolescent girls in rural areas.
Posttraumatic Stress Disorder Comorbid With Major Depression: Factors Mediating the Association With Suicidal Behavior
Am J Psychiatry 2005;162:560-566
Objective: To evaluate whether patients with a major depressive episode and comorbid posttraumatic stress disorder (PTSD) have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with a major depressive episode but no PTSD. The authors investigated the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity to determine how comorbid PTSD might increase risk for suicidal behavior in a major depressive episode. Method: 230 patients had a lifetime history of major depressive episodes, and 59 also had lifetime comorbid PTSD. Demographic and clinical characteristics of subjects with and without PTSD were compared. The relationship between suicidal behavior and lifetime history of PTSD was examined through multivariate analysis, with adjustment for clinical factors known to be associated with suicidal behavior. Results: Patients with a lifetime history of PTSD were significantly more likely to have made a suicide attempt. Suicidal ideation or intent, number of attempts made, or maximum lethality of attempts did not differ between groups. Higher objective depression, impulsivity, and hostility scores; a higher rate of comorbid cluster B personality disorder; and a greater likelihood of reporting a childhood history of abuse were found in the PTSD group. In a multiple regression model, cluster B personality disorder was the only independent variable related to lifetime suicide attempts. Conclusions: Frequently comorbid with major depressive episode, PTSD enhances the risk for suicidal behavior. A higher rate of comorbid cluster B personality disorder appears to be a notable factor that contributes to greater risk for suicidal acts in patients with a history of major depressive episode and PTSD, compared to those with major depressive episode alone.
Reading Aloud and Arithmetic Calculation Improve Frontal Function of People With Dementia
J Gerontol A Biol Sci Med Sci 2005;60:380-384
Background: Reading aloud and arithmetic calculation activate bilateral dorsolateral prefrontal cortex of humans according to recent neuroimaging studies. This study sought to measure the effect of these activities on the brain functions and activities of daily living in elderly people who were clinically diagnosed with Alzheimer's type dementia. Method: Sixteen experimental subjects participated as well as 16 control subjects matched for age and Mini-Mental State Examination score. Subjects in the experimental group performed a training program using learning tasks in reading and arithmetic for 2 to 6 days a week. Subjects were assessed with the Frontal Assessment Battery (FAB) at bedside to determine function of the frontal cortex. Results: The experimental group showed a statistically significant improvement in FAB score after 6 months of training. Over the 6-month period, the FAB score of the control group decreased slightly, and the difference in scores between the 2 groups was statistically significant. Restoration of communication and independence was also observed in the experimental group. Conclusion: Reading aloud and arithmetic calculation are indicated for cognitive rehabilitation of dementia patients.
Pregnancy, Delivery, and Neonatal Complications in a Population Cohort of Women With Schizophrenia and Major Affective Disorders
Am J Psychiatry 2005;162:79-91
Objective: To determine incidence of complications during pregnancy, labor, and delivery and neonatal characteristics of infants born to women with schizophrenia, bipolar disorder, or major depression in a population-based cohort. Method: Women with schizophrenia or major affective disorders who had given birth to 3174 children during 1980 to 1992 in Western Australia were included from records linkage across a psychiatric case register and prospectively recorded obstetric data. A comparison sample of 3129 births was randomly selected from women without a psychiatric diagnosis giving birth during the same period. Complications were scored with the McNeil-Sjostrom Scale, and odds ratios were calculated for specific reproductive events. Results: Increased risks of complications during pregnancy, birth, and the neonatal period, including placental abnormalities, antepartum hemorrhages, and fetal distress, were seen in patients with schizophrenia and affective disorders. Women with schizophrenia were significantly more likely to have placental abruption, give birth to infants in the lowest weight/growth population decile, and have children with cardiovascular congenital anomalies. Neonatal complications were significantly more likely to occur in winter, and low birth weight peaked in spring. Pregnancies that occurred after psychiatric illness onset were more likely to have complications other than low birth weight and congenital anomalies compared with pregnancies preceding the diagnosis. Conclusions: Maternal risk factors and biological and behavioral concomitants of severe mental illness appeared to greatly determine increases in reproductive pathology in this cohort, although genetic liability and gene-environment interactions may account for some outcomes. Antenatal and postnatal interventions may reduce the risk in these vulnerable groups.