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A Potpourri of Timely Topics

Karen Dineen Wagner, MD, PhD

Published: September 15, 2011

A Potpourri of Timely Topics

This section of Focus on Childhood and Adolescent Mental Health includes articles addressing the prevalence rate of pediatric bipolar disorder, the proposed temper dysregulation disorder with dysphoria diagnosis, adjunctive use of repetitive transcranial magnetic stimulation for treatment-resistant depression in adolescents, long-term safety and tolerability of aripiprazole for treatment of autistic disorder, and long-term effects for youths who are exposed to terrorism.

There is a perception that the rate of pediatric bipolar disorder has risen in the United States and is higher than that of other countries. Van Meter and colleagues conducted a meta-analysis of 12 epidemiologic studies that included 16,222 youths from the United States and 6 other countries to determine the prevalence rate of pediatric bipolar disorder. The overall rate of pediatric bipolar disorder was 1.8%, and there was no significant difference in the mean rates between the United States and other countries. The prevalence of bipolar disorder did not increase over time. The authors conclude that the differences in reported rates across studies are attributable to the use of different diagnostic criteria, in particular the inclusion of bipolar not otherwise specified and other broader criteria of bipolar disorder in the United States. The authors caution that the rate of bipolar disorder in children under the age of 12 years remains uncertain since most of the epidemiologic studies did not include children younger than age 12 years.

Temper dysregulation disorder with dysphoria has been proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This proposed disorder has caused significant controversy in the field of child and adolescent psychiatry. Axelson and colleagues provide a compelling argument against the inclusion of temper dysregulation disorder with dysphoria in the DSM-5 and suggest other methods to address diagnostic issues related to chronically irritable youth.

Although antidepressant medication and psychotherapy are effective treatments for many youth with major depressive disorder, some depressed youths fail to respond to either or both of these treatment modalities. Wall and colleagues assess the use of adjunctive repetitive transcranial magnetic stimulation (rTMS) in the treatment of adolescents with depression. In a 6- to 8-week open trial, 8 adolescents with major depressive disorder who had failed to respond to 2 antidepressant medication trials received a selective serotonin reuptake inhibitor and adjunctive rTMS. Seven of 8 adolescents completed the full treatment series. Significant improvement in depression as assessed by Children’s Depression Rating Scale-Revised scores from baseline to treatment 10 was found, as well as continued improvement throughout the 30-treatment series and at 6-month follow-up. The most commonly reported adverse event was temporary scalp discomfort, and there were no serious treatment adverse events. On the basis of these findings, a controlled trial of rTMS for treatment-resistant depression in adolescents is warranted.

Aripiprazole has US Food and Drug Administration approval for the treatment of irritability associated with autistic disorder in children aged 6 years and above. This approval was based on 2 short-term 8-week trials. However, since most children with autistic disorder receive longer-term antipsychotic medication, information about the safety of these agents is needed. Marcus and colleagues evaluated the long-term safety and tolerability of aripiprazole in a 52-week open-label study. Of the 330 youths who entered the study, 199 (60.3%) completed 52 weeks of treatment; 10.6% of youths discontinued due to adverse events, particularly aggression and weight increase. Adverse events were experienced by the majority of youths, and the most common adverse events were weight increase, vomiting, nasopharyngitis, increased appetite, pyrexia, upper respiratory tract infection, and insomnia. Extrapyramidal symptoms occurred in 14.5% of treated youth. This article provides important information for clinicians about adverse events of aripiprazole when used for long-term treatment.

Moscardino and colleagues examined the psychological functioning and coping behaviors of 33 adolescents who were either directly or indirectly exposed to the 2004 terrorist attack in Beslan, Russia. Initially, the directly and indirectly exposed adolescents had similar levels of psychological distress. However, over time adolescents who were directly exposed to the terrorist attack had a significant increase in psychological distress and a decrease in active coping, whereas indirectly exposed youth showed less distress and better coping skills. Posttraumatic stress disorder was more likely in adolescents who were directly exposed and who had an avoidant coping strategy compared to other youths. The authors recommend that youths who are exposed to traumatic events be monitored long term to potentially prevent the development of posttraumatic stress disorder.

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