Childhood internalizing behaviour: analysis and implications

The concept of 'internalizing behaviour' reflects a child's emotional or psychological state and typically includes depressive disorders, anxiety disorders, somatic complaints and teenage suicide. Genetic and environmental causes have been largely implicated, although research continues to explore social etiological factors. Some research suggests females may be especially vulnerable to internalizing disorders, while data across ethnicities are somewhat variable. Regarding treatment, cognitive-behavioural therapies and use of pharmacological approaches (i.e. selective serotonin reuptake inhibitors) have both shown great promise in reducing symptoms of internalizing disorders. However, given the role of the social environment, prevention programmes aimed at reducing exposure to drugs, violence/abuse and environmental toxins are highly important. Internalizing disorders are associated with a host of deleterious outcomes (e.g. school drop-out, substance use and potentially suicide) as well as psychopathological outcomes (e.g. co-morbid anxiety or depression, externalizing disorders - including suicide). Children with mental health problems suffer educationally and are more likely to become entangled in the justice and welfare systems. Clearly, early treatment and prevention programmes for internalizing disorders need to be a priority from a public health perspective as well as from a family and community perspective.

Childhood internalizing behaviour: analysis and implications

The concept of 'internalizing behaviour' reflects a child's emotional or psychological state and typically includes depressive disorders, anxiety disorders, somatic complaints and teenage suicide. Genetic and environmental causes have been largely implicated, although research continues to explore social etiological factors. Some research suggests females may be especially vulnerable to internalizing disorders, while data across ethnicities are somewhat variable. Regarding treatment, cognitive-behavioural therapies and use of pharmacological approaches (i.e. selective serotonin reuptake inhibitors) have both shown great promise in reducing symptoms of internalizing disorders. However, given the role of the social environment, prevention programmes aimed at reducing exposure to drugs, violence/abuse and environmental toxins are highly important. Internalizing disorders are associated with a host of deleterious outcomes (e.g. school drop-out, substance use and potentially suicide) as well as psychopathological outcomes (e.g. co-morbid anxiety or depression, externalizing disorders - including suicide). Children with mental health problems suffer educationally and are more likely to become entangled in the justice and welfare systems. Clearly, early treatment and prevention programmes for internalizing disorders need to be a priority from a public health perspective as well as from a family and community perspective.

Childhood internalizing behaviour: analysis and implications

The concept of 'internalizing behaviour' reflects a child's emotional or psychological state and typically includes depressive disorders, anxiety disorders, somatic complaints and teenage suicide. Genetic and environmental causes have been largely implicated, although research continues to explore social etiological factors. Some research suggests females may be especially vulnerable to internalizing disorders, while data across ethnicities are somewhat variable. Regarding treatment, cognitive-behavioural therapies and use of pharmacological approaches (i.e. selective serotonin reuptake inhibitors) have both shown great promise in reducing symptoms of internalizing disorders. However, given the role of the social environment, prevention programmes aimed at reducing exposure to drugs, violence/abuse and environmental toxins are highly important. Internalizing disorders are associated with a host of deleterious outcomes (e.g. school drop-out, substance use and potentially suicide) as well as psychopathological outcomes (e.g. co-morbid anxiety or depression, externalizing disorders - including suicide). Children with mental health problems suffer educationally and are more likely to become entangled in the justice and welfare systems. Clearly, early treatment and prevention programmes for internalizing disorders need to be a priority from a public health perspective as well as from a family and community perspective.

Childhood diet and behavioural problems: results from the ALSPAC cohort

OBJECTIVE

To investigate whether a 'junk food' diet at 81 months of age is associated with the development of behavioural problems over the following 16 months.

SUBJECTS/METHODS

The study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) and 12,942 children were included. The main outcome measure was behavioural problems, measured using the Strengths and Difficulties Questionnaire (SDQ). SDQ scores were available at 81 and 97 months of age. Child-based dietary data were collected at 81 months by food frequency questionnaire; from this a 'junk food' score was derived, and mean weekly non-milk extrinsic sugar (NMES) intake estimated. Statistical analyses examined the associations between dietary exposures at 81 months and SDQ outcomes at 97 months. Children with SDQ scores suggesting behavioural problems at baseline were excluded in order to identify new cases. Adjustments were made for potential confounders such as socioeconomic status.

RESULTS

Unadjusted analyses suggested associations between the 'junk food' score at 81 months and both total difficulties and pro-social behaviour at 97 months. However, adjustment for baseline SDQ scores attenuated these associations, with confidence intervals including the null for both total difficulties (OR (95% CI): 1.05 (0.92, 1.21); P=0.45) and pro-social behaviour (1.13 (1.00, 1.26); P=0.04). Adjustment for other potential confounders further attenuated the effects. Adjustment for confounders similarly attenuated modest associations between NMES intake and behavioural problems.

CONCLUSIONS

There was no evidence to support an association between a 'junk food' diet at 81 months of age and behavioural problems after 16 months.

A pragmatic randomised controlled trial to compare antidepressants with a community-based psychosocial intervention for the treatment of women with postnatal depression: the RESPOND trial

OBJECTIVES

To evaluate clinical effectiveness at 4 weeks of antidepressant therapy for mothers with postnatal depression (PND) compared with general supportive care; to compare outcome at 18 weeks of those randomised to antidepressant therapy with those randomised to listening visits as the first intervention (both groups were to be allowed to receive the alternative intervention after 4 weeks if the woman or her doctor so decided); and to assess acceptability of antidepressants and listening visits to users and health professionals.

DESIGN

A pragmatic two-arm individually randomised controlled trial.

SETTING

Participants were recruited from 77 general practices: 21 in Bristol, 21 in south London and 35 in Manchester.

PARTICIPANTS

A total of 254 women who fulfilled International Classification of Diseases version 10 criteria for major depression in the first 6 postnatal months were recruited and randomised.

INTERVENTIONS

Women were randomised to receive either an antidepressant, usually a selective serotonin reuptake inhibitor prescribed by their general practitioner (GP), or non-directive counselling (listening visits) from a specially trained research health visitor (HV). The trial was designed to compare antidepressants with general supportive care for the first 4 weeks, after which women allocated to listening visits commenced their sessions. It allowed for women to receive the alternative intervention if they had not responded to their allocated intervention or wished to change to, or add in, the alternative intervention at any time after 4 weeks.

MAIN OUTCOME MEASURES

The duration of the trial was 18 weeks. Primary outcome, measured at 4 weeks and 18 weeks post randomisation, was the proportion of women improved on the Edinburgh Postnatal Depression Scale (EPDS), that is scoring < 13. Secondary outcomes were the EPDS measured as a continuous variable at 4 and 18 weeks, and scores on various other questionnaires.

RESULTS

At 4 weeks, women were more than twice as likely to have improved if they had been randomised to antidepressants compared with listening visits, which started after the 4-week follow-up, i.e. after 4 weeks of general supportive care [primary intention-to-treat (ITT), 45% versus 20%; odds ratio (OR) 3.4, 95% confidence interval (CI) 1.8 to 6.5, p < 0.001]. Explanatory analyses emphasised these findings. At 18 weeks, ITT analysis revealed that the proportion of women improving was 11% greater in the antidepressant group, but logistic regression analysis showed no clear benefit for one group over the other [62% versus 51%, OR 1.5 (95% CI 0.8 to 2.6), p = 0.19]. Overall, there was a difference between the groups in favour of the antidepressant group of about 25 percentage points at 4 weeks, which reduced at 18 weeks. No statistical support existed for a benefit of antidepressants at 18 weeks, but 95% CIs could not rule out a clinically important benefit. It was difficult for GPs not to prescribe antidepressants to women randomised to listening visits after the initial 4 weeks, so many women received both interventions in both groups by 18 weeks and consequently power was reduced. Qualitative interviews with women revealed a preference for listening visits but an acceptance that antidepressants might be necessary. They wished to be reassured that their GP and HV were offering continuity of care focusing on their particular set of circumstances. Interviews with GPs and HVs revealed lack of collaboration in managing care for women with PND; neither professional group was willing to assume responsibility.

CONCLUSIONS

At 4 weeks, antidepressants were significantly superior to general supportive care. Trial design meant that by 18 weeks many of the women initially randomised to listening visits were also receiving antidepressants, and more vice versa. The lack of evidence for differences at 18 weeks is likely to reflect a combination of reduced power and the considerable degree of switching across the two interventions. Qualitative study revealed that women found both antidepressants and listening visits effective depending on their circumstances and preferences. The trial indicates that early treatment with antidepressants leads to clinical benefit for women with PND.

Age- and puberty-dependent association between IQ score in early childhood and depressive symptoms in adolescence

BACKGROUND

Lower cognitive functioning in early childhood has been proposed as a risk factor for depression in later life but its association with depressive symptoms during adolescence has rarely been investigated. Our study examines the relationship between total intelligence quotient (IQ) score at age 8 years, and depressive symptoms at 11, 13, 14 and 17 years.

METHOD

Study participants were 5250 children and adolescents from the Avon Longitudinal Study of Parents and their Children (ALSPAC), UK, for whom longitudinal data on depressive symptoms were available. IQ was assessed with the Wechsler Intelligence Scale for Children III, and self-reported depressive symptoms were measured with the Short Mood and Feelings Questionnaire (SMFQ).

RESULTS

Multi-level analysis on continuous SMFQ scores showed that IQ at age 8 years was inversely associated with depressive symptoms at age 11 years, but the association changed direction by age 13 and 14 years (age-IQ interaction, p<0.0001; age squared-IQ interaction, p<0.0001) when a higher IQ score was associated with a higher risk of depressive symptoms. This change in IQ effect was also found in relation to pubertal stage (pubertal stage-IQ interaction, 0.00049<p=0.038). At age 17 years, however, sex-specific differences emerged (sex-age squared-IQ interaction, p=0.0075). Whilst the risk effect of higher childhood IQ scores for depressive symptoms declined in females, and some analyses even supported an inverse association by age 17 years, it persisted in males.

CONCLUSIONS

Our results suggest that the association between cognitive ability in childhood and depressive symptoms in adolescence varies according to age and/or pubertal stage.

Characterisation of zuclopenthixol metabolism by in vitro and therapeutic drug monitoring studies

OBJECTIVE

Zuclopenthixol pharmacokinetics is incompletely characterised. We investigated potential interactions mediated through cytochrome P450 enzymes.

METHOD

In vitro, we examined the impact of CYP2D6 and CYP3A4 inhibitors on zuclopenthixol metabolism in microsomes from six human livers. Subsequently, we compared dose-corrected serum zuclopenthixol concentrations in 923 samples from a therapeutic drug monitoring database from patients prescribed oral (n = 490) or injected (n = 423) zuclopenthixol alone or with fluoxetine, paroxetine, levomepromazine or carbamazepine.

RESULTS

In vitro fluoxetine, paroxetine, ketoconazole and quinidine all significantly inhibited zuclopenthixol metabolism. Ketoconazole and quinidine together abolished zuclopenthixol disappearance. Clinically, dose-corrected oral zuclopenthixol serum concentrations increased significantly, after adjustment, by 93%, 78% and 46% during co-treatment with fluoxetine, paroxetine and levomepromazine and decreased 67% with carbamazepine. Carbamazepine caused dose-dependent reductions in the oral zuclopenthixol concentration-dose ratio (P < 0.001), fluoxetine (P < 0.001) and paroxetine (P = 0.011) dose-dependent increases and levomepromazine an increase related to its serum concentration (P < 0.001). Results for injected zuclopenthixol were similar but not all reached statistical significance.

CONCLUSION

The In vitro study suggests zuclopenthixol is metabolised primarily by CYP2D6 and CYP3A4. The clinical study supports this, demonstrating the impact of co-prescribed inhibitors or inducers. Guidelines should incorporate these interactions noting the potential for zuclopenthixol-related toxicity or treatment failure.

Common mental disorders in late pregnancy in women who wanted or attempted an abortion

BACKGROUND

In countries where legal abortion is restricted, many unwanted pregnancies are carried to term. Attempting an unsuccessful abortion may influence women's mental health. This study investigated the common mental disorders (CMDs) of depression and anxiety in the third trimester of pregnancy in women who wanted or had attempted an abortion in a poor region of Brazil.

METHOD

CMDs were assessed by using the 20-item Self-Reporting Questionnaire (SRQ-20) in all pregnant women aged 18-49 years who were registered with publicly funded primary health care in Recife, Northeast Brazil.

RESULTS

The study achieved a high response rate and 1121 (98.9%) women completed the interview. The prevalence of CMDs for the sample was 43.1% [95% confidence interval (CI) 40.2-46.1], and 63.6% (95% CI 55.4-71.2) among the 13.7% of women who attempted an abortion. The association between CMDs and attempted an abortion [odds ratio (OR) 2.05, 95% CI 1.3-3.1] remained after adjustment for confounders.

CONCLUSIONS

This study found that attempting an abortion in the current pregnancy was associated with CMDs. Good access to family planning programs, including access to contraceptive methods and safe abortion, should help to improve the mental health of women.

Perinatal folate-related exposures and risk of psychotic symptoms in the ALSPAC birth cohort

BACKGROUND

It is unclear to what extent non-clinical psychotic experiences during childhood and adolescence share underlying aetiological mechanisms with schizophrenia. One candidate mechanism for schizophrenia involves the epigenetic status of the developing fetus, which depends on the internal folate-status of mother and child. Our study examines the relationships between multiple determinants of perinatal folate-status and development of psychotic experiences in adolescence.

METHODS

Study participants were up to 5344 mother-child pairs from the Avon Longitudinal Study of Parents and their Children, UK, with information on maternal and/or child MTHFR C677T genotype, maternal folate intake (supplementation at 18/32- weeks gestation; dietary intake at 32- weeks gestation) and psychosis-like symptoms (PLIKS) for children assessed at age 12.

RESULTS

Nominal evidence was observed that maternal folate supplementation at 18 weeks increased the odds of PLIKS in children (odds ratio(OR)=1.34; 95%-CI:[1.00;1.76]) and, consistent with this, that children of MTHFR C667T TT homozygous mothers had decreased odds of PLIKS (OR=0.72; 95%CI:[0.50;1.02]; recessive model) with strongest effects in boys (OR=0.44, 95%-CI:[0.22;0.79]; sex-specific p=0.029). None of the reported effects remained significant when corrected for multiple testing.

CONCLUSIONS

Overall, this study found no support that maternal/child MTHFR C677T genotype and maternal folate intake during pregnancy contribute to common aetiological pathways that are shared between schizophrenia and non-clinical psychotic symptoms in adolescents, assuming that decreased folate-status increases schizophrenia risk.

Paternal and maternal ages at conception and risk of bipolar affective disorder in their offspring

BACKGROUND

A consistent association between paternal age and their offspring's risk of schizophrenia has been observed, with no independent association with maternal age. The relationship of paternal and maternal ages with risk of bipolar affective disorders (BPAD) in the offspring is less clear. The present study aimed at testing the hypothesis that paternal age is associated with their offspring's risk of BPAD, whereas maternal age is not.

METHOD

This population-based cohort study was conducted with individuals born in Sweden during 1973-1980 and still resident there at age 16 years. Outcome was first hospital admission with a diagnosis of BPAD. Hazard ratios (HRs) were calculated using Cox's proportional hazard regression.

RESULTS

After adjustment for all potential confounding variables except maternal age, the HR for risk of BPAD for each 10-year increase in paternal age was 1.28 [95% confidence interval (CI) 1.11-1.48], but this fell to 1.20 (95% CI 0.97-1.48) after adjusting for maternal age. A similar result was found for maternal age and risk of BPAD [HR 1.30 (95% CI 1.08-1.56) before adjustment for paternal age, HR 1.12 (95% CI 0.86-1.45) after adjustment]. The HR associated with having either parent aged 30 years or over was 1.26 (95% CI 1.01-1.57) and it was 1.45 (95% CI 1.16-1.81) if both parents were >30 years.

CONCLUSIONS

Unlike schizophrenia, the risk of BPAD seems to be associated with both paternal and maternal ages.

Cost-Effectiveness of Erlotinib versus Docetaxel for Second-Line Treatment of Advanced Non-Small-Cell Lung Cancer in the United Kingdom

This study was designed to assess the cost-effectiveness of erlotinib compared with docetaxel in the second-line management of advanced non-small-cell lung cancer (NSCLC) within the UK National Health Service (NHS). A health-state transition model, based on two randomized phase III studies of erlotinib or docetaxel versus best supportive care, was used to estimate total direct costs, quality-adjusted life years (QALYs) and the subsequent net monetary benefit. Erlotinib was associated with a reduction in total costs (£13 730 versus £13 956) and improved outcomes (total QALYs of 0.238 versus 0.206) compared with docetaxel. Sensitivity analyses demonstrated the robustness of this analysis. In summary, erlotinib appeared to generate similar overall survival, an increase in QALYs and a small reduction in total NHS costs compared with docetaxel, due to lower adverse event and drug administration costs. Consequently, from a health economics perspective for the treatment of relapsed stage III - IV NSCLC patients in the UK, erlotinib has advantages over docetaxel.

Fed-batch operation of an industrial cell culture process in shaken microwells

Recently we have demonstrated batch suspension culture of mammalian cells in microwell plates. Here we describe a method for fed-batch culture of an industrially relevant GS-CHO (Glutamine Synthetase-Chinese Hamster Ovary) cell line in shaken 24-standard round well (24-SRW) plates. Use of a commercially available 'sandwich lid' and appropriate dilution of the bolus feeds counteracted liquid evaporation from the wells resulting in similar cell growth and antibody formation kinetics in both 24-SRW plates (800 mul) and shaken flasks (50 ml). Peak viable cell densities obtained were 8 +/- 0.5 x 10(6) and 9 +/- 1.3 x 10(6) ml(-1), respectively, while comparable final titres of a whole IgG of approximately 1.5 g l(-1) were recorded. Use of microwells provides at least a 50-fold reduction in medium requirements compared to shake-flask and other culture devices currently used in early stage cell culture process development. The ability to run multiple wells in parallel and to automate culture operation also offers considerable enhancements in experimental throughput.

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND

Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence.

METHOD

A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy.

RESULTS

The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia.

CONCLUSIONS

Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

Association of measures of fetal and childhood growth with non-clinical psychotic symptoms in 12-year-olds: the ALSPAC cohort

BACKGROUND

Previous studies have suggested that impaired fetal and childhood growth are associated with an increased risk of schizophrenia, but the association of pre-adult growth with non-clinical psychotic symptoms (psychosis-like symptoms) in children is not known.

AIMS

To explore the associations of body size at birth and age 7.5 years with childhood psychosis-like symptoms.

METHOD

Prospective cohort of children followed up from birth to age 12: the ALSPAC cohort.

RESULTS

Data on 6000 singleton infants born after 37 weeks of gestation. A one standard deviation increase in birth weight was associated with an 18% reduction in the risk of definite psychosis-like symptoms after adjusting for age and gestation (Odds ratio (OR) = 0.82, 95% CI = 0.73-0.92, P = 0.001). This association was partly confounded by maternal anthropometry, smoking during pregnancy, socioeconomic status and IQ. A similar association was seen for birth length and psychosis-like symptoms, which disappeared after controlling for birth weight. There was little evidence for an association of 7-year height or adiposity with psychosis-like symptoms.

CONCLUSIONS

Measures of impaired fetal, but not childhood, growth are associated with an increased risk of psychosis-like symptoms in 12-year-olds.