Treatment of adolescents with early-onset schizophrenia spectrum disorders: in search of a rational, evidence-informed approach

[Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders]

Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders Abstract: As a vulnerable group, minors require special protection in studies. For this reason, researchers are often reluctant to initiate studies, and ethics committees are reluctant to authorize such studies. This often excludes minors from participating in clinical studies. This exclusion can lead to researchers and clinicians receiving only incomplete data or having to rely on adult-based findings in the treatment of minors. Using the example of the study "Computer-Assisted Risk Evaluation in the Early Detection of Psychotic Disorders" (CARE), which was conducted as an 'other clinical investigation' according to the Medical Device Regulation, we present a line of argumentation for the inclusion of minors which weighs the ethical principles of nonmaleficence (especially regarding possible stigmatization), beneficence, autonomy, and fairness. We show the necessity of including minors based on the development-specific differences in diagnostics and early intervention. Further, we present specific protective measures. This argumentation can also be transferred to other disorders with the onset in childhood and adolescence and thus help to avoid excluding minors from appropriate evidence-based care because of insufficient studies.

Identification and treatment of individuals with childhood-onset and early-onset schizophrenia

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Illness-related outcomes of illicit substance use disorder in adolescents with early onset schizophrenia: a multicenter study

OBJECTIVES

Lifetime co-occurring substance use disorders are common at the time of presentation for the treatment of primary psychosis. Our aim was to investigate the clinical characteristics of adolescents with early-onset schizophrenia/schizoaffective disorder (EOS), categorized as either with (EOS + SUD) or without SUD (non-SUD/EOS), in a multi-center sample.

METHODS

Between 2016 and 2022, 255 patients were evaluated across three tertiary-care inpatient units. Diagnoses were confirmed by the treating physician according to the DSM-5 during the hospital stay. The severity of symptoms was measured using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The EOS + SUD group exhibited a higher illness onset, fewer years of education, longer duration of untreated psychosis (DUP), a higher frequency of male gender, more frequent hospitalizations, increased use of clozapine and zuclopenthixol LAI, along with higher rates of post-traumatic stress disorder and conduct disorder. Notably, differences in DUP, clozapine use, and the number of hospitalizations did not persist in the multivariate logistic regression model.

CONCLUSIONS

Our findings support the notion of SUD playing a role in modifying the course of illness in EOS. Future studies should emphasize exploring treatment responses to medications and interventions among youth with dual diagnoses.

Clozapine's multiple cellular mechanisms: What do we know after more than fifty years? A systematic review and critical assessment of translational mechanisms relevant for innovative strategies in treatment-resistant schizophrenia

Almost fifty years after its first introduction into clinical care, clozapine remains the only evidence-based pharmacological option for treatment-resistant schizophrenia (TRS), which affects approximately 30% of patients with schizophrenia. Despite the long-time experience with clozapine, the specific mechanism of action (MOA) responsible for its superior efficacy among antipsychotics is still elusive, both at the receptor and intracellular signaling level. This systematic review is aimed at critically assessing the role and specific relevance of clozapine's multimodal actions, dissecting those mechanisms that under a translational perspective could shed light on molecular targets worth to be considered for further innovative antipsychotic development. In vivo and in vitro preclinical findings, supported by innovative techniques and methods, together with pharmacogenomic and in vivo functional studies, point to multiple and possibly overlapping MOAs. To better explore this crucial issue, the specific affinity for 5-HT₂R, D1R, α_2c, and muscarinic receptors, the relatively low occupancy at dopamine D2R, the interaction with receptor dimers, as well as the potential confounder effects resulting in biased ligand action, and lastly, the role of the moiety responsible for lipophilic and alkaline features of clozapine are highlighted. Finally, the role of transcription and protein changes at the synaptic level, and the possibility that clozapine can directly impact synaptic architecture are addressed. Although clozapine's exact MOAs that contribute to its unique efficacy and some of its severe adverse effects have not been fully understood, relevant information can be gleaned from recent mechanistic understandings that may help design much needed additional therapeutic strategies for TRS.

Sex offending among adolescents and young men with history of psychiatric inpatient care in adolescence

BACKGROUND

Some mental disorders have been associated with increased likelihood of sexual offending in adolescents (and adults), but relevant studies tend to be of established sex offenders.

AIMS

To examine relationships between adolescent mental disorders and subsequent involvement in sex offending and to explore any predictive value of primary diagnoses for subsequent interpersonal offending, whether sexual or violent.

METHODS

We analyse national register-based longitudinal data on males in Finland admitted for their first psychiatric inpatient treatment between the ages of 13-17 in the period 1980-2010 (N = 6749). Cox regression was used for the analysis of multivariate associations.

RESULTS

A subsequent criminal record for sex crime in the 10-year follow up was rare among former child and adolescent psychiatric (CAP) inpatient males (1.5%). Having a subsequent criminal record for non-sex-related violent crime was more common (25%). Time to either sex crimes or non-sex-related violent crimes after a first CAP inpatient treatment was 3-4 years. Whilst the risk of committing non-sex-related violent crimes was elevated in all diagnostic groups compared to those with schizophrenia spectrum disorders, the risk of committing subsequent sex crimes was elevated only in the group with substance use, conduct or personality disorders. Among those with pre-existing criminal history of sex crime, the risk of a subsequent criminal record for sex crime after CAP treatment was increased 11-fold, but the risk for later non-sex-related violent crimes was not increased compared to the rest of the male adolescent CAP population.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

In this first longitudinal study of criminal convictions for sex offending after a period of inpatient psychiatric treatment as an adolescent such convictions were rare, but the difference in post discharge risk of further convictions for sexual offending and non-sexual violent offending raises questions about whether more attention and specific treatment for aberrant sexual behaviours is needed for male adolescents with severe mental disorders.

Safety and effectiveness of lurasidone in adolescents with schizophrenia: results of a 2-year, open-label extension study

BACKGROUND

Minimal long-term benefit: Risk data are available regarding antipsychotic treatments for schizophrenia in pediatric populations. This study evaluated the long-term safety, tolerability, and effectiveness of lurasidone in adolescents with schizophrenia.

METHODS

Patients aged from 13 to 17 who completed 6 weeks of double-blind (DB), placebo-controlled treatment with lurasidone were enrolled in a 2-year, open-label (OL), flexible dose (20-80 mg/day) lurasidone treatment study. Safety was assessed via spontaneous reporting, rating scales, body weight measurement, metabolic, and prolactin testing. Effectiveness measures included the Positive and Negative Syndrome Scale (PANSS) total score.

RESULTS

About 271 patients completed 6 weeks of DB treatment and entered the 2-year OL extension study. Altogether, 42.4% discontinued prematurely, 10.7% due to adverse events. During OL treatment, the most common adverse events were headache (24.0%); anxiety (12.9%), schizophrenia, and nausea (12.5%); sedation/somnolence (12.2%); and nasopharyngitis (8.9%). Minimal changes were observed on metabolic parameters and prolactin. Mean change from DB baseline in weight at week 52 and week 104 was +3.3 kg and + 4.9 kg, respectively, compared to an expected weight gain of +3.4 kg and + 5.7 kg, respectively, based on the sex- and age-matched US Center for Disease Control normative data. Continued improvement was observed in PANSS total score, with mean change from OL baseline of -15.6 at week 52 and -18.4 at week 104.

CONCLUSION

In adolescents with schizophrenia, long-term lurasidone treatment was associated with minimal effects on body weight, lipids, glycemic indices, and prolactin. Continued improvement in symptoms of schizophrenia was observed over 2 years of lurasidone treatment.

Alterations in functional network centrality in first-episode drug-naïve adolescent-onset schizophrenia

Schizophrenia is a disorder resulting from aberrant brain networks and circuits. In the current study, we aimed to investigate specific network alterations in adolescent-onset schizophrenia (AOS) and to help identify the neurophysiological mechanisms of this adolescent disorder. We recruited forty-one subjects, including 20 AOS patients and 21 matched healthy controls (HCs), and we acquired brain images to examine the specific changes in functional network patterns using degree centrality (DC), which quantifies the strength of the local functional connectivity hubs. Whole-brain correlation analysis was applied to assess the relationships between clinical characteristics and DC measurements. The AOS group exhibited increased DC in the right inferior frontal lobe, right fusiform gyrus and right thalamus (p < 0.05, AlphaSim correction). Whole-brain correlation analysis found that the DC value in the right parahippocampus was positively correlated with PANSS-positive symptom scores (r = 0.80); DC in the right superior parietal lobe (SPL) was positively correlated with PANSS-negative symptom scores (r = 0.79); DC in the left precuneus was positively correlated with self-certainty (SC) scores (r = 0.70); and DC in the left medial frontal gyrus (MFG) was negatively correlated with self-reflectiveness (SR) scores (r = 0.69). We conclude that frontoparietal network and cortico-thalamo-cortical pathway disruptions could play key roles in the neurophysiological mechanisms underlying AOS. In AOS patients, the right parahippocampus and SPL are important structures associated with positive and negative symptoms, respectively, and the left precuneus and MFG contribute to deficits in cognitive insights.

Investigation of glycaemic traits in psychiatric disorders using Mendelian randomisation revealed a causal relationship with anorexia nervosa

Data from observational studies have suggested an involvement of abnormal glycaemic regulation in the pathophysiology of psychiatric illness. This may be an attractive target for clinical intervention as glycaemia can be modulated by both lifestyle factors and pharmacological agents. However, observational studies are inherently confounded, and therefore, causal relationships cannot be reliably established. We employed genetic variants rigorously associated with three glycaemic traits (fasting glucose, fasting insulin, and glycated haemoglobin) as instrumental variables in a two-sample Mendelian randomisation analysis to investigate the causal effect of these measures on the risk for eight psychiatric disorders. A significant protective effect of a natural log transformed pmol/L increase in fasting insulin levels was observed for anorexia nervosa after the application of multiple testing correction (OR = 0.48 [95% CI: 0.33-0.71]-inverse-variance weighted estimate). There was no consistently strong evidence for a causal effect of glycaemic factors on the other seven psychiatric disorders considered. The relationship between fasting insulin and anorexia nervosa was supported by a suite of sensitivity analyses, with no statistical evidence of instrument heterogeneity or horizontal pleiotropy. Further investigation is required to explore the relationship between insulin levels and anorexia.

Pharmacogenetics of antipsychotics in adolescents with acute psychotic episode during first 14 days after admission: effectiveness and safety evaluation

Objectives Prediction of the antipsychotic's effectiveness is a relevant topic in the field of personalized medicine. Methods The research design of this study is a prospective observation with posthoc analysis of associations of genetic polymorphisms with safety parameters and effectiveness of antipsychotic therapy. We observed 53 adolescents with an acute psychotic episode which were prescribed antipsychotics for 14 days. We evaluated the effectiveness of antipsychotics with the Positive and Negative Symptoms Scale and the safety with the UKU Side Effects Rating Scale, Simpson-Angus Scale, and Barnes Akathisia rating scale. We genotyped CYP3A4*22 (rs2740574), CYP3A5*3 (6986A>G, rs7767746), CYP2D6*4, *9, *10 (rs3892097, rs1065852), ABCB1 1236C>T (rs1128503), 2677G>T/A (rs2032582), 3435C>T (rs1045642), DRD2 (rs1800497), DRD4 (rs1800955), HTR2A (rs6313) by the real-time polymerase chain reaction method. Results We found significantly more frequent "increased dream activity" between CYP2D6 intermediate metabolizers and normal metabolizers (54 vs. 22%; p=0.043). The «increased duration of sleep» was more often observed in homozygotes TT of ABCB1 2677G>T/A (50 vs. 15.8%, p=0.006) and TT of 3435C>T (41.7 vs. 8.2%, p=0.007). Conclusions We found that CYP2D6 and ABCB1 polymorphisms were associated with the safety of antipsychotics in adolescents with an acute psychotic episode.

Schizophrenia

BACKGROUND

The lifetime prevalence of schizophrenia is 1%. Schizophrenia is among the most severe mental illnesses and gives rise to the highest treatment costs per patient of any disease. It is characterized by frequent relapses, marked impairment of quality of life, and reduced social and work participation.

METHODS

The group entrusted with the creation of the German clinical practice guideline was chosen to be representative and pluralistic in its composition. It carried out a systematic review of the relevant literature up to March 2018 and identified a total of 13 389 publications, five source guidelines, three other relevant German clinical practice guidelines, and four reference guidelines.

RESULTS

As the available antipsychotic drugs do not differ to any great extent in efficacy, it is recommended that acute antipsychotic drug therapy should be sideeffect- driven, with a number needed to treat (NNT) of 5 to 8. The choice of treatment should take motor, metabolic, sexual, cardiac, and hematopoietic considerations into account. Ongoing antipsychotic treatment is recommended to prevent relapses (NNT: 3) and should be re-evaluated on a regular basis in every case. It is also recommended, with recommendation grades ranging from strong to intermediate, that disorder- and manifestation-driven forms of psychotherapy and psychosocial therapy, such as cognitive behavioral therapy for positive or negative manifestations (effect sizes ranging from d = 0.372 to d = 0.437) or psycho-education to prevent relapses (NNT: 9), should be used in combination with antipsychotic drug treatment. Further aspects include rehabilitation, the management of special treatment situations, care coordination, and quality management. A large body of evidence is available to provide a basis for guideline recommendations, particularly in the areas of pharmacotherapy and cognitive behavioral therapy.

CONCLUSION

The evidence-based diagnosis and treatment of persons with schizophrenia should be carried out in a multiprofessional process, with close involvement of the affected persons and the people closest to them.

Long-term outcome of early-onset compared to adult-onset schizophrenia: A nationwide Danish register study

OBJECTIVE

Early-onset schizophrenia (EOS) may have worse outcomes than adult-onset schizophrenia (AOS), but data are scarce. We compared outcomes of EOS vs. AOS.

METHODS

Longitudinal, register-based study of patients diagnosed with schizophrenia in Denmark between 1996 and 2012, with follow-up until 12/2014. Co-primary outcomes were psychiatric inpatient days during the initial two years after schizophrenia diagnosis and mean number of annual inpatient days for the remaining follow-up.

RESULTS

Altogether, 16,337 patients with schizophrenia were included (EOS = 1223, AOS = 15,114, mean follow-up = 9.5 ± 5.0 years). EOS were hospitalized longer during the first two years than AOS (180.9 ± 171.0 vs 163.4 ± 183.1 days, p < 0.005; IRR = 1.27, 95% CI = 1.19-1.35, p < 0.001), but duration and annual rates thereafter did not differ (EOS = 26.8 ± 57.1 days, AOS = 26.6 ± 56.2 days, p = 0.95; IRR = 1.07, 95% CI = 0.94-1.23, p = 0.30). Fewer EOS patients were never psychiatrically hospitalized (EOS = 17.2%, AOS = 20.1%, p < 0.001), but with no difference in re-admissions in patients diagnosed during hospitalization (EOS = 77.1% vs AOS = 78.1%, p = 0.56). More EOS patients were admitted involuntarily (41% vs. 36%, p < 0.02). AOS patients had more often comorbid substance use disorders during follow-up than EOS (EOS = 21.7%, AOS = 34.2%, p < 0.001). Substance use disorders and out-of-home placement were significantly associated with more inpatient days during both short- and long-term follow-up.

CONCLUSION

Although EOS was associated with more inpatient days in the first two years after diagnosis, results do not seem to support a generally poorer long-term outcome of EOS compared to AOS. Longer initial hospitalization may be driven by different treatment patterns in child and adolescent vs. adult psychiatry. These data suggest that patient characteristics other than age of onset significantly affect outcomes.

The Relative Risk of Developing Type 2 Diabetes Mellitus in Young Adults with Schizophrenia Treated with Different Atypical Antipsychotic

Background and aim: While the link between antipsychotic treatment and metabolic adverse events, including type 2 diabetes mellitus (T2DM) are clear in adults with schizophrenia, in young this association is not so well studied although the use of secondgeneration antipsychotics (SGA) is more and more frequent.

Material and methods: The local diabetes register was compared with the list of all registered young adults (18-35 years) with schizophrenia 2 years retrospective and 2 years prospective. Cumulative incidence, rate of incidence and relative risk was calculated knowing the number of persons in this age group within this region.

Results: Cumulative incidence for exposed group was 0.7% with a rate of incidence of 6.27 (95%CI: 4.1-10.5) per 1,000 patientyears, when in normal population was 0.2%, respectively 2.01 (95%CI: 0.72-3.79). This means a relative risk of 3.4736 (95%CI: 1.79-6.72), p=0.0002 and NNH=202 (95%CI: 134-404). Multivariate analysis showed that gender male (OR=1.83; 95%CI: 0.9-2.7; p=0.002) and olanzapine prescription (OR=4.76; 95%CI: 1.7-7.7; p=0.0001) were independent risk factors for T2DM.

Conclusions: The metabolic risk should be taken in account every time introducing or changing a SGA in young schizophrenic patient, balancing the benefits and negative metabolic effects (especially with olanzapine). Healthy nutrition and physical activities are necessary components of these patients lifestyle to avoid early onset of T2DM.

[Evidence-based treatment of acute psychotic episode and schizophrenia in children and adolescents]

Children and adolescents are a special group in the context of psychopharmacotherapy. Given the limited choice of registered antipsychotics permitted in childhood, caution should be exercised in the choice of medication. This literature review reviews the current evidence base for pharmacotherapy of acute psychotic episode and schizophrenia in children and adolescents. The results of major systematic reviews and meta-analyses are compared. Meta-analyses of pharmacotherapy studies of the first psychotic episode are considered separately. Antipsychotics of the first and second generation are comparable in effectiveness for children and adolescents with acute psychotic episode. Olanzapine demonstrates higher efficacy in reducing negative symptoms. Ziprasidone and asenapine are less effective in treating schizophrenia in children and adolescents than other antipsychotics. Compared to adults, children and adolescents are at higher risk of metabolic impairments when taking antipsychotics.

Cariprazine Safety in Adolescents and the Elderly: Analyses of Clinical Study Data

Schizophrenia is a life-long mental disorder, affecting young adolescents to elderly patients. Antipsychotic treatment is indicated for all patients with schizophrenia, including the very young and old as well. Developmental issues in the young and decline in organ functioning in the elderly could influence reactions to the drug, and require different dosing regimens. The aim of the present article was to examine the safety profile and dosing requirements in adolescent (13 to less than 18) and elderly (65 and above) patients treated with cariprazine. Data from two clinical studies (one pharmacokinetic pediatric study and one phase III clinical trial) on 49 adolescent patients and 17 elderly patients (65 years of age or above) treated with cariprazine was examined. Safety measures included assessment of adverse events (AEs), clinical laboratory values, physical examinations, extrapyramidal symptom (EPS)-, depression-, and suicidality rating scales. Safety parameters were summarized using descriptive statistics. Results indicate that cariprazine was generally safe and well tolerated. Adverse events in the marginal age populations were comparable to the adult population, except for less insomnia in the young and no reports of akathisia in the elderly. Laboratory parameters, vital sign values and EEG parameters were comparable to previously published data in the adult population. In conclusion, cariprazine in the approved adult dose-range of 1.5-6 mg might be a safe treatment option also in adolescent and elderly patients with schizophrenia. Further studies are need to verify these preliminary findings.

Evaluation of the Combined Treatment Approach "Robin" (Standardized Manual and Smartphone App) for Adolescents at Clinical High Risk for Psychosis

Introduction: The prevention of schizophrenia and other psychotic disorders has led researchers to focus on early identification of individuals at clinical high risk (CHR) for psychosis and to treat the at-risk symptoms in the pre-psychotic period. Although at-risk symptoms such as attenuated hallucinations or delusions are common in adolescents and associated with a marked reduction in global functioning, the evidence base of effective interventions for adolescents at CHR state and even first-episode psychosis is limited. Thus, the present protocol describes a study design that combines therapy modules for CHR adolescents with a smartphone application supporting the young individuals between the therapy sessions. The treatment approach "Robin" is based on existing therapy strategies for adolescents with first episode of psychosis and the available recommendations for adults with at-risk symptoms. Methods: The evaluation aims firstly to compare the efficacy of Robin in 30 CHR adolescents aged 14-18 to an active control group (treatment as usual) from a previous study. Primary outcome measures will be at-risk symptomatology, comorbid diagnosis, functioning, self-efficacy, and quality of life. For the prospective intervention condition (16 weekly individual sessions + a minimum 4 family sessions), help-seeking adolescents with CHR for psychosis, aged 14-18, will be recruited over 3 years. At-risk and comorbid symptoms, functioning, self-efficacy, and quality of life are monitored at six time points (baseline, during the treatment period; immediately after intervention; and 6, 12, and 24 months later) and compared with the respective measures of the active control group. Discussion: To the best of our knowledge, this is the first controlled trial to test the efficacy of a specific early psychosis treatment in combination with a smartphone application for adolescents at CHR for developing psychosis. The results of the study are expected to add information that may substantially decrease the burden of CHR adolescents and increase their resilience. It may offer age-adapted and targeted strategies to guide clinicians in the treatment of these vulnerable individuals. Furthermore, research in the field of early intervention will be enriched by our findings. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03829527.

Very early-onset psychosis/schizophrenia: Case studies of spectrum of presentation and management issues

Schizophrenia occurs very uncommonly in children younger than 13 years. The disease is preceded by premorbid difficulties, familial vulnerability, and a prodromal phase. The occurrence of positive psychotic symptoms such as delusions and hallucinations depends on the level of cognitive development of child. Furthermore, at times it is very difficult to differentiate the psychopathology and sustain a diagnosis of schizophrenia in view of similarities with disorders such as autism, mood disorders, and obsessive compulsive disorders. Here, we present three case studies with varying presentation of childhood-onset psychosis/schizophrenia and associated management issues.

Management of common adverse effects of antipsychotic medications

The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.

Dilemmas in the treatment of early-onset first-episode psychosis

Early-onset first-episode psychosis (EOP) is a severe mental disorder that can pose a number of challenges to clinicians, young people and their families. Its assessment and differentiation from other neurodevelopmental and mental health conditions may at times be difficult, its treatment may not always lead to optimal outcomes and can be associated with significant side effects, and its long-term course and prognosis seem to be less favourable compared with the adult-onset disorder. In this paper, we discuss some dilemmas associated with the evaluation and management of EOP and propose approaches that can be used in the clinical decision-making process. A detailed and well-informed assessment of psychotic symptoms and comorbidities, a systematic approach to treatment with minimum possible medication doses and close monitoring of its effectiveness and adverse effects, and multidimensional interventions taking into consideration risks and expectations associated with EOP, are paramount in the achievement of the most favourable outcomes for affected children and young people.

National Patterns of Commonly Prescribed Psychotropic Medications to Young People

OBJECTIVE

To describe national annual prescribing patterns of stimulant, antidepressant, and antipsychotic medications to young people.

METHODS

Prescriptions for three commonly prescribed psychotropic classes (stimulants, antidepressants, and antipsychotics) to young people aged 3-24 years were analyzed from the IMS LifeLink LRx National Longitudinal Prescription database (n = 6,351,482). Denominators were adjusted to generalize estimates to the U.S.

POPULATION

Comparisons are presented of percentages filling ≥1 prescription of each medication class during the study year stratified by patient sex, age, and prescriber specialty.

RESULTS

The total annual percentage of prescriptions filled by youth for any of the three medication classes was by age 3-5 years (0.8%), 6-12 years (5.4%), 13-18 years (7.7%), and 19-24 years (6.0%). Stimulant use was highest for older children (age 11 = 5.7%). Antidepressant use tended to increase with age and was highest for young adults (age 24 = 4.8%). Annual antipsychotic prescription percentages were lower than antidepressant or stimulant percentages for all age groups, with a peak in adolescence (age 16 = 1.3%). Annual stimulant and antipsychotic percentages for males were higher than corresponding percentages for females, but converged for young adults. Psychiatrists and child psychiatrists accounted for most of the prescriptions of antidepressants (22.2%-53.2%) and antipsychotics (51.7%-70%), but fewer of the stimulant prescriptions (30.4%-36.2%).

CONCLUSIONS

The age and sex distribution of stimulants and antidepressants among young people is broadly consistent with known epidemiologic patterns of their established indications for attention-deficit/hyperactivity disorder, anxiety, and depression. The pattern of antipsychotics may reflect the heterogeneity of disorders and conditions treated with this medication class.

The incidence, psychiatric co-morbidity and pharmacological treatment of severe mental disorders in children and adolescents

BACKGROUND

Antipsychotic drug use among children and adolescents is increasing, and there is growing concern about off-label use and adverse effects. The present study aims to investigate the incidence, psychiatric co-morbidity and pharmacological treatment of severe mental disorder in Norwegian children and adolescents.

METHODS

We obtained data on mental disorders from the Norwegian Patient Registry on 0-18 year olds who during 2009-2011 were diagnosed for the first time with schizophrenia-like disorder (International Classification of Diseases, 10th revision codes F20-F29), bipolar disorder (F30-F31), or severe depressive episode with psychotic symptoms (F32.3 or F33.3). Data on filled prescriptions for psychotropic drugs were obtained from the Norwegian Prescription Database.

RESULTS

A total of 884 children and adolescents (25.1 per 100 000 person years) were first time diagnosed with schizophrenia-like disorder (12.6 per 100 000 person years), bipolar disorder (9.2 per 100 000 person years), or severe depressive episode with psychotic symptoms (3.3 per 100 000 person years) during 2009-2011. The most common co-morbid mental disorders were depressive (38.1%) and anxiety disorders (31.2%). Antipsychotic drugs were prescribed to 62.4% of the patients, 72.0% of the schizophrenia-like disorder patients, 51.7% of the bipolar disorder patients, and 55.4% of the patients with psychotic depression. The most commonly prescribed drugs were quetiapine (29.5%), aripiprazole (19.6%), olanzapine (17.3%), and risperidone (16.6%).

CONCLUSIONS

When a severe mental disorder was diagnosed in children and adolescents, the patient was usually also prescribed antipsychotic medication. Clinicians must be aware of the high prevalence of depressive and anxiety disorders among early psychosis patients.

Associations between duration of untreated psychosis and domains of positive and negative symptoms

AIM

The duration of untreated psychosis (DUP) has been established as an independent and significant predictor of negative outcomes in first-episode psychosis samples. Whereas literature has supported the association between DUP and severity of positive and negative symptoms, surprisingly little research to date has explored specifically what types of positive and negative symptoms are most associated with DUP.

METHODS

DUP, Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) data were collected in 247 first-episode psychosis participants (mean age: 23.9 ± 4.8) between August 2008 and June 2013.

RESULTS

DUP was significantly but modestly associated with the severity of hallucinations (ρ = 0.222; P = 0.001), delusions (r = 0.202; P = 0.003) and formal thought disorder (ρ = 0.138; P = 0.043) but was not associated with bizarre behaviour. DUP was significantly but modestly associated with SANS avolition-apathy (ρ = 0.164; P = 0.016) and anhedonia-asociality (r = 0.321; P < 0.001) subscales but was not associated with affective flattening or blunting, alogia or attention.

CONCLUSIONS

DUP is a complex and multifaceted phenomenon that is associated with early-course illness development. In efforts to improve early intervention services, prognoses and outcomes, it is vital to understand both the factors that contribute to lengthy untreated psychosis as well as the illness characteristics that are impacted by untreated psychosis.

Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth

OBJECTIVE

Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders.

METHODS

A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts.

RESULTS

Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain.

CONCLUSIONS

Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended.

Oral Aripiprazole as Maintenance Treatment in Adolescent Schizophrenia: Results From a 52-Week, Randomized, Placebo-Controlled Withdrawal Study

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of aripiprazole, a dopamine D₂ receptor partial agonist, as maintenance treatment in adolescent outpatients with schizophrenia.

METHOD

This was a multicenter, double-blind, placebo-controlled, randomized withdrawal design trial. Participants 13 to 17 years of age with a diagnosis of schizophrenia (DSM-IV-TR) were first cross-titrated from their other oral antipsychotic(s) (4-6 weeks), then stabilized (7-21 weeks) on oral aripiprazole 10 to 30 mg/d, and finally randomized 2:1 to continuation of oral aripiprazole or to placebo in a double-blind maintenance phase (≤52 weeks). The primary endpoint was time from randomization to exacerbation of psychotic symptoms/impending relapse. Safety and tolerability were assessed.

RESULTS

Of 201 enrolled participants, 146 were randomized to aripiprazole (n = 98) or placebo (n = 48) in the double-blind maintenance phase. Treatment with aripiprazole was associated with a significantly longer time to exacerbation of psychotic symptoms/impending relapse compared with placebo (hazard ratio, 0.46 [95% CI = 0.24-0.88]; p = .016). Aripiprazole was associated with lower rates of serious treatment-emergent adverse events (TEAEs) versus placebo (3.1% versus 12.5%; p = .059) and severe TEAEs (2.0% versus 10.4%; p = .039). The rate of discontinuation due to TEAEs was lower with aripiprazole versus placebo (20.4% versus 39.6%, p = .014; number-needed-to-harm = 5.1). The incidences of extrapyramidal symptoms, weight gain, and somnolence were similar or lower with aripiprazole than with placebo, and no TEAEs related to elevated serum prolactin were reported. Based on Tanner staging, 27.6% of participants treated with aripiprazole and 16.7% of those who received placebo progressed one or two stages from baseline.

CONCLUSION

Aripiprazole was observed to be safe and effective for the maintenance treatment of adolescents with schizophrenia.

CLINICAL TRIAL REGISTRATION INFORMATION

Efficacy and Safety Study of Oral Aripiprazole in Adolescents With Schizophrenia; http://clinicaltrials.gov/; NCT01149655.

Quetiapine extended release versus aripiprazole in children and adolescents with first-episode psychosis: the multicentre, double-blind, randomised tolerability and efficacy of antipsychotics (TEA) trial

BACKGROUND

Head-to-head trials to guide antipsychotic treatment choices for paediatric psychosis are urgently needed because extrapolations from adult studies might not be implementable. In this superiority trial with two-sided significance testing, we aimed to compare the efficacy and safety of quetiapine-extended release (quetiapine-ER) versus aripiprazole in children and adolescents with first-episode psychosis, to determine whether differences between the two treatments were sufficient to guide clinicians in their choice of one drug over the other.

METHODS

In this multicentre, double-blind, randomised trial in seven Danish university clinics, we recruited children and adolescents aged 12-17 years with a diagnosis of ICD-10 schizophrenia-spectrum disorder, delusional disorder, or affective-spectrum psychotic disorder, and psychotic symptoms scoring at least 4 on at least one of the following Positive and Negative Syndrome Scale (PANSS) items: P1 (delusions), P2 (conceptual disorganisation), P3 (hallucinations), P5 (grandiosity), P6 (suspiciousness/persecution), and G9 (unusual thought content), and a total PANSS score greater than 60. Patients were randomly assigned (1:1) to 12 weeks of treatment with target doses of 600 mg/day of quetiapine-ER (starting from 50 mg/day) or 20 mg/day of aripiprazole (starting from 2·5 mg/day). The assigned drug was titrated over five levels, with 2 days at each dose, and the final dose achieved on day 9. Randomisation was done using a computer-generated concealed sequence with a block size of 8, and stratified by baseline PANSS positive score (≤20 points or >20 points) and age (12-14 years or 15-17 years). Study drugs were administered in identical capsules, and interventions, assessments, and data analysis were done masked. The primary outcome was PANSS positive score. Key adverse outcomes were bodyweight, homoeostatic model of insulin resistance (HOMA-IR), akathisia, and sedation. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01119014.

FINDINGS

Between June 10, 2010, and Jan 29, 2014, 231 participants were assessed for elegibility, of whom 113 were randomly assigned to quetiapine-ER (n=55) or aripiprazole (n=58). PANSS positive score did not differ between groups after 12 weeks (adjusted mean change -5·05 [5·46] for quetiapine-ER, -6·21 [5·42] for aripiprazole; p=0·98), but decreased over time in both groups (p<0·0001). Weight gain was more rapid with quetiapine-ER (p=0·0008), with an adjusted mean weight group difference at week 12 of 3·33 kg (SD 7·23; effect size 0·64; p<0·0001). The HOMA-IR group difference at week 12 favoured aripiprazole (adjusted mean log-transformed group difference 0·259 [SD 0·906]; effect size 0·35; p=0·0060). Akathisia was more common with aripiprazole at week 2 (observed in 34 [60%] of 57 patients; estimated 63·5%) than with quetiapine-ER (15 [30%] of 50; estimated 31·3%; p=0·0021), but not at other timepoints. Sedation proportions did not change significantly over time with either intervention (observed at weeks 2, 4, and 12, respectively, for quetiapine-ER in 43 [83%] of 52, 40 [83%] of 48, and 34 [72%] of 47 patients and for aripiprazole in 49 [89%] of 55, 52 [96%] of 54, and 44 [92%] of 48 patients), and the overall estimated probability combining all timepoints was significantly higher for aripiprazole (97·1%) than for quetiapine-ER (89·2%; p=0·012). In addition to sedation and akathisia, the most common adverse events were tremor (42 [79%] patients in the quetiapine-ER group vs 52 [91%] patients in the aripiprazole group), increased duration of sleep (47 [92%] vs 39 [71%]), orthostatic dizziness (42 [78%] vs 46 [81%]), depression (43 [80%] vs 44 [77%]), tension/inner unrest (37 [69%] vs 50 [88%]), failing memory (41 [76%] vs 44 [77%]), and weight gain (46 [87%] vs 38 [68%]).

INTERPRETATION

This first head-to-head comparison of quetiapine-ER versus aripiprazole in early-onset psychosis showed no significant group differences in severity of psychopathology after 12 weeks of treatment. Quetiapine-ER was associated with more metabolic adverse events and aripiprazole with more initial akathisia and, unexpectedly, more sedation. The limited antipsychotic efficacy and high level of adverse events were noticeable. This trial provides novel information for the treatment of early-onset psychosis and highlights the importance of adverse event profiles when choosing among antipsychotics for children and adolescents who often require chronic treatment.

FUNDING

The National Research Council for Health and Disease Foundation for Health Promotion, AP Møller Foundation, Rosalie Petersens Foundation, Stevn and Rindom Foundation, Foundation for the Promotion of Medical Science, The Capital Region Psychiatric Research Foundation, Tryg Foundation, Region of Southern Denmark Research Foundation, Danish Psychiatric Research Educational Fund, Psychiatry Foundation, Foundation of 17-12-1981, Psychiatric Research Foundation Region Zealand, Capital Region Strategic Research Foundation, Knud og Dagny Andresens Foundation, Psychiatric Research Foundation of 1967, The Capital Region Research Foundation, Dr Sofus Carl Emil Friis and Hustru Olga Friis Scholarship, Tømrerhandler Johannes Fogs Foundation, Brdr Hartmanns Foundation DKK, Aase and Ejnar Danielsens Foundation, Jacob Madsen and wife Olga Madsens Foundation, CC Klestrup and wife Scholarship, Lundbeck Foundation Scholarship, and Tømrermester Jørgen Holm and wife Elisas Scholarship.

Acute Antipsychotic Treatment of Children and Adolescents With Schizophrenia-Spectrum Disorders: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To determine the comparative efficacy and safety of antipsychotics for youth with early-onset schizophrenia using network meta-analytic methods combining direct and indirect trial data.

METHOD

The authors systematically searched MEDLINE, the Cochrane Library, and clinicaltrials.gov and selected randomized controlled trials allocating youth with schizophrenia spectrum disorders to a (non-clozapine) antipsychotic versus placebo or another antipsychotic. Major efficacy outcomes were Positive and Negative Syndrome Scale (PANSS) total and positive symptoms. Major safety outcomes were weight, plasma triglyceride levels, extrapyramidal symptoms, akathisia, and all-cause discontinuation. Sixteen additional outcomes were analyzed. A random-effects arm-based network meta-analysis was applied, and consistency was assessed by pairwise meta-analysis. Confidence in PANSS total estimates was assessed by applying the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twelve 6- to 12-week trials (N = 2,158; 8-19 years old; 61% boys) involving 8 antipsychotics (aripiprazole, asenapine, paliperidone, risperidone, quetiapine, olanzapine, molindone, and ziprasidone) were analyzed. PANSS total symptom change was comparable among antipsychotics (low- to moderate-quality evidence), except ziprasidone (very low- to low-quality evidence), and all antipsychotics were superior to placebo (low- to high-quality evidence), except ziprasidone and asenapine (low- to moderate-quality evidence). PANSS positive changes and additional efficacy outcomes were comparable among antipsychotics. Weight gain was primarily associated with olanzapine; extrapyramidal symptoms and akathisia were associated with molindone; and prolactin increased with risperidone, paliperidone, and olanzapine. Serious adverse events, discontinuation of treatment, sedation, insomnia, or change in triglycerides did not differ among antipsychotics.

CONCLUSION

This network meta-analysis showed comparable efficacy among antipsychotics for early-onset schizophrenia, except that efficacy appeared inferior for ziprasidone and unclear for asenapine. Adverse reaction profiles varied substantially among the investigated antipsychotics and were largely consistent with prior findings in adults. Protocol registration information-Antipsychotic Treatment for Children With Schizophrenia Spectrum Disorders: Network Meta-Analysis of Randomised Trials; https://www.crd.york.ac.uk/PROSPERO/; CRD42013006676.

Gender differences in first onset Schizophrenia spectrum psychoses

BACKGROUND

Mental health profiles differ between boys and girls from puberty onwards. It is not known whether differences also extend to symptom presentation in schizophrenia spectrum disorders. It may be that girls and boys are not treated entirely equally by the professionals.

AIMS

To study gender differences in symptom profiles, family adversities, pathway to care, and characteristics of inpatient treatment at the first episode of diagnosed schizophrenia spectrum disorder (F20-29) among adolescents aged 13-17.

METHODS

A retrospective chart review of all (n = 106) consecutive adolescents diagnosed for the first time with schizophrenia spectrum disorder (F20-29) in a specified catchment area. Girls and boys were compared with regard to sociodemographics, pathways to care, living arrangements, symptom profiles, and treatment received.

RESULTS

During the study period more adolescent girls (n = 70, 66%) than boys (n = 36, 34%) were diagnosed with schizophrenia spectrum (F20-29) psychoses, most commonly F29. Girls were moreover younger (mean age = 15.46) than boys (mean age = 16.62) at admission. Girls more often displayed mood symptoms and boys aggressive behaviours, alcohol abuse problems, and isolation. Family adversities recorded as current stressors were more numerous among girls. Girls were more likely to be referred to specialized after-care than boys.

CONCLUSIONS

The gender differences observed in symptoms presentation are reminiscent of differences encountered in the general adolescent population. Prior to transition to psychosis, girls and boys are equally in contact with psychiatric services due to other (possibly prodromal) symptoms/disorders. Family adversities may be more stressful for girls vulnerable to psychosis than to boys.

Clinical use of second-generation antipsychotics in children

Background

The use of second-generation antipsychotic (SGA) medication among child and adolescent psychiatric patients has increased worldwide in recent years. The increase appears to have been more extensive in the USA than in European countries, but the tendency is similar. However, after a peak the use seems to have declined in the USA. Simultaneously with the increasing numbers, the duration of SGA use has lengthened, indications have broadened, and off-label use has increased. Despite existing follow-up recommendations and evidence for the metabolic adverse effects of SGAs in children, research evidence has not translated into clinical practice.

Objective

The aim of this study was to assess the clinical use and follow-up practices of SGA medication among child psychiatric patients of one university hospital in Finland.

Method

This retrospective patient report-based study was conducted at the Child Psychiatric Clinic of Tampere University Hospital, Finland. The study sample consisted of 133 patients who were younger than 13 years when initiating SGA treatment and had an ongoing SGA medication during the study period. The study sample was divided into two groups according to diagnosis to examine whether there were differences between patients with an autistic or a developmental disorder (F83-84) and patients with other psychiatric diagnoses.

Results:

This study showed that SGA use in children younger than 13 years was mainly off-label. Irrespective of diagnosis, the most common indication was aggression. Especially children with psychiatric diagnoses other than developmental disorders had multiple socio-demographic risk factors and adverse life experiences in their background. The follow-up practices were diverse and partly irregular.

Conclusions:

A need for systematic SGA monitoring practices and dialogue between the medical specialities treating children and their families is evident.

Impact of online resources and social media on help-seeking behaviour in youth with psychotic symptoms

AIM

The objective of the study was to explore the content of existing online resources available to information-seeking youth as psychotic symptoms first emerge and determine how these resources may influence initiation of care.

METHODS

Using 18 hypothetical search terms, developed by the Early Treatment Programme (ETP) staff, we searched three of the most popular websites used by the youth (Google, Facebook and Twitter) and extracted the first five hits from each. Sites were categorized into those that encouraged help seeking, those that potentially contribute to treatment delay, those with an undetermined impact and those that were unrelated to treatment.

RESULTS

An alarmingly few of the first five hits from the top three online resources encourage potentially psychotic youth to seek professional evaluation. The majority of our search results yielded unmonitored chat forums that lacked a unified message. The remainder promoted stigma, normalized potentially psychotic experiences or were completely unrelated to mental health.

CONCLUSION

We must develop innovative, easy-to-access and youth-focused online and social media experiences that encourage symptomatic youth to seek care.

Neurological, Metabolic, and Psychiatric Adverse Events in Children and Adolescents Treated With Aripiprazole

Aripiprazole is a partial dopamine agonist with only minor neurological and psychiatric adverse effects, making it a potential first-line drug for the treatment of psychiatric disorders. However, the evidence of its use in children and adolescents is rather sparse. The aim of this case study is to discuss adverse drug reaction (ADR) reports concerning aripiprazole-associated neurological and psychiatric events in children and adolescents. The ADR report database at Danish Medicines Agency was searched for all ADRs involving children and adolescents (<18 years) reported by the search term [aripiprazole] AND all spontaneous reports since the introduction of aripiprazole in 2003 until December 31, 2015. Nineteen case reports were included in the study and included both patients with psychotic disorders (PS group) and nonpsychotic disorders (non-PS group). The PS group consisted of 5 patients with schizophrenia and psychoses, not otherwise specified; and the non-PS group consisted of fourteen cases including autism spectrum disorders, attention deficit and hyperactivity disorder, obsessive-compulsive disorder, and Tourette syndrome. The main reported adverse effects in the non-PS group were chronic insomnia, Parkinsonism, behavioral changes psychoses, and weight gain, whereas the adverse effects in the PS group was predominantly anxiety, convulsions, and neuroleptic malignant syndrome. Although aripiprazole is considered safe and well tolerated in children and adolescents, severe adverse events as neuroleptic malignant syndrome, extreme insomnia, and suicidal behavior has been reported to health authorities. Clinicians should pay attention to these possible hazards when prescribing aripiprazole to this vulnerable group of patients.

Is it still correct to differentiate between early and very early onset psychosis?

OBJECTIVE

It remains unclear whether very early onset psychosis (VEOP; ≤12years of age) and early onset psychosis (EOP; onset 13-17years of age) are homogeneous in their clinical presentation. We investigated the predictive value of age of psychosis onset for severity, functioning and demographic variation by: 1) comparing groups based on traditional cut-offs for age of psychosis onset, and 2) using receiver operating characteristic (ROC)-curve calculations, without a priori age of onset cut-offs.

METHOD

Participants were 88 (45 female, 43 male) children and adolescents with a recent onset of psychosis (age range=6.7-17.5years; M=13.74, SD=2.37).

RESULTS

The VEOP group had significantly shorter duration of untreated illness and untreated psychosis, and lower functioning than the EOP group. The VEOP and EOP groups did not differ significantly on gender proportion, urbanicity, psychotic diagnosis, family history of psychotic disorder, psychotic, depressive and anxiety symptoms or IQ. When applying ROC-curves to the lowest three quartiles of positive psychotic symptoms scores, the optimal age-cut-off was 14.0years (sensitivity=0.62; specificity=0.75). For the highest quartile of functioning scores, the optimal differentiating cut-off for age of psychosis onset was 14.7years (sensitivity=0.71; specificity=0.70).

CONCLUSIONS

Larger samples of patients, assessed at presentation and followed-up, are necessary to clearly examine clinical presentation and outcome as a function of social and neural development to better understand if the differentiation between VEOP and EOP is justified. This will aid the development of predictive diagnostic tools, more accurate prognosis prediction, and age-tailored therapeutic interventions.

Twelve-month psychosis-predictive value of the ultra-high risk criteria in children and adolescents

OBJECTIVE

The validity of current ultra-high risk (UHR) criteria is under-examined in help-seeking minors, particularly, in children below the age of 12 years. Thus, the present study investigated predictors of one-year outcome in children and adolescents (CAD) with UHR status.

METHOD

Thirty-five children and adolescents (age 9-17 years) meeting UHR criteria according to the Structured Interview for Psychosis-Risk Syndromes were followed-up for 12 months. Regression analyses were employed to detect baseline predictors of conversion to psychosis and of outcome of non-converters (remission and persistence of UHR versus conversion).

RESULTS

At one-year follow-up, 20% of patients had developed schizophrenia, 25.7% had remitted from their UHR status that, consequently, had persisted in 54.3%. No patient had fully remitted from mental disorders, even if UHR status was not maintained. Conversion was best predicted by any transient psychotic symptom and a disorganized communication score. No prediction model for outcome beyond conversion was identified.

CONCLUSIONS

Our findings provide the first evidence for the predictive utility of UHR criteria in CAD in terms of brief intermittent psychotic symptoms (BIPS) when accompanied by signs of cognitive impairment, i.e. disorganized communication. However, because attenuated psychotic symptoms (APS) related to thought content and perception were indicative of non-conversion at 1-year follow-up, their use in early detection of psychosis in CAD needs further study. Overall, the need for more in-depth studies into developmental peculiarities in the early detection and treatment of psychoses with an onset of illness in childhood and early adolescence was further highlighted.

Schizophrenia

Schizophrenia is a chronic psychiatric disorder with a heterogeneous genetic and neurobiological background that influences early brain development, and is expressed as a combination of psychotic symptoms - such as hallucinations, delusions and disorganization - and motivational and cognitive dysfunctions. The mean lifetime prevalence of the disorder is just below 1%, but large regional differences in prevalence rates are evident owing to disparities in urbanicity and patterns of immigration. Although gross brain pathology is not a characteristic of schizophrenia, the disorder involves subtle pathological changes in specific neural cell populations and in cell-cell communication. Schizophrenia, as a cognitive and behavioural disorder, is ultimately about how the brain processes information. Indeed, neuroimaging studies have shown that information processing is functionally abnormal in patients with first-episode and chronic schizophrenia. Although pharmacological treatments for schizophrenia can relieve psychotic symptoms, such drugs generally do not lead to substantial improvements in social, cognitive and occupational functioning. Psychosocial interventions such as cognitive-behavioural therapy, cognitive remediation and supported education and employment have added treatment value, but are inconsistently applied. Given that schizophrenia starts many years before a diagnosis is typically made, the identification of individuals at risk and those in the early phases of the disorder, and the exploration of preventive approaches are crucial.

[The influence of premorbid functioning on the efficacy of psychosocial therapy in adolescents with schizophrenia spectrum disorders]

AIM

To explore an effect of premorbid functioning level on the efficacy of psychosocial therapy in adolescents with schizophrenia spectrum disorders in order to determine a differential approach to its performance.

MATERIAL AND METHODS

A study included 53 adolescents with schizophrenia spectrum disorders at the early stage of remission achievement (PANSS scores <65). An impact of premorbid functioning was assessed with the DD-CGAS and the efficacy of psychosocial therapy with CGAS and PedsQL at baseline and after 3, 6 and 12 months.

RESULTS AND CONCLUSION

We described the most relevant differences in characteristics of treatment effect (dc) between three groups with different levels of premorbid functioning. To increase the efficacy of psychosocial interventions, we suggest a differential approach of psychosocial therapy in each group.

Outcome of Youth with Early-Phase Schizophrenia-Spectrum Disorders and Psychosis Not Otherwise Specified Treated with Second-Generation Antipsychotics: 12 Week Results from a Prospective, Naturalistic Cohort Study

OBJECTIVES

The purpose of this study was to assess differences in the outcomes of youth with schizophrenia-spectrum disorders (SCZ-S) and psychotic disorder not otherwise specified (PsyNOS) during early antipsychotic treatment.

METHODS

The study was a prospective, naturalistic, inception cohort study of youth ≤19 years old with SCZ-S (schizophrenia, schizoaffective disorder, schizophreniform disorder) or PsyNOS (PsyNOS, brief psychotic disorder) and ≤24 months of lifetime antipsychotic treatment receiving clinician's choice antipsychotic treatment. Baseline demographic, illness and treatment variables, and effectiveness outcomes were compared at 12 weeks last-observation-carried-forward across SCZ-S and PsyNOS patients, adjusting for significantly different baseline variables.

RESULTS

Altogether, 130 youth with SCZ-S (n=42) or PsyNOS (n=88), mostly antipsychotic naïve (76.9%), were prescribed risperidone (47.7%), olanzapine (19.2%), aripiprazole (14.6%), quetiapine (11.5%), or ziprasidone (6.9%). Compared with those with PsyNOS, SCZ-S youth were older (16.4±2.1 vs. 14.8±3.2, p=0.0040), and less likely to be Caucasian (19.1% vs. 42.5%, p=0.009). At baseline, SCZ-S patients had significantly higher Clinical Global Impressions-Severity (CGI-S) scores (6.0±0.9 vs. 5.5±0.8, p=0.0018) and lower Children's Global Assessment Scale (CGAS) scores (29.6±9.2 vs. 36.1±8.9, p=0.0002) and were more likely to be in the severely ill CGAS group (i.e., CGAS≤40). SCZ-S and PsyNOS patients did not differ regarding all-cause discontinuation (40.5 vs. 40.3%. p=0.49), discontinuation because of adverse effects (12.2% vs. 12.4%, p=0.97), or nonadherence (29.3% vs. 30.9%, p=0.88), but somewhat more SCZ-S patients discontinued treatment for inefficacy (19.5% vs. 7.4%, p=0.063). CGI-S and CGAS scores improved significantly in both diagnostic groups (p=0.0001, each). Adjusting for baseline differences, PsyNOS patients experienced significantly better CGI-I improvement (CGI-I) scores (p=0.012) and more frequently reached higher categorical CGAS group status (p=0.021) than SCZ-S patients.

CONCLUSIONS

Both youth with SCZ-S and those with PsyNOS experienced significant improvements with clinician's choice antipsychotic treatment. However, treatment discontinuation was common within 12 weeks, with greater inefficacy-related discontinuation in the SCZ-S group, whereas CGI-I and CGAS score-based improvements were greater in the PsyNOS group.

Psychosocial interventions for very early and early-onset schizophrenia: a review of treatment efficacy

PURPOSE OF REVIEW

Very early (VEOS) and early-onset schizophrenia (EOS) represent more severe forms of the disorder, with clear differences from adult-onset schizophrenia (AOS). However, there is a distinct lack of evidence regarding the efficacy of psychosocial interventions in this group of patients, and to date no systematic review has been conducted on the topic. The aim of this article is to review the current knowledge and evidence on the efficacy of psychosocial interventions in VEOS/EOS.

RECENT FINDINGS

A total of eight articles were eligible for inclusion. Four studies evaluated psychoeducational and family interventions for patients with VEOS/EOS, whereas four studies focused on cognitive behavioral therapy or cognitive remediation. Overall, we found some preliminary evidence for the efficacy of psychosocial interventions in the treatment of VEOS/EOS. This evidence was strongest for cognitive remediation.

SUMMARY

Heretofore, VEOS/EOS have been treated primarily with psychosocial interventions based on evidence from interventions tailored for and tested on adults. Although more conclusive studies are still needed, thanks to recent clinical trials, we now have greater evidence to support the efficacy of psychosocial interventions in EOS/VEOS.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Childhood-onset schizophrenia case with 2.2 Mb deletion at chromosome 3p12.2-p12.1 and two large chromosomal abnormalities at 16q22.3-q24.3 and Xq23-q28

Childhood-onset schizophrenia is rare, comprising 1% of known schizophrenia cases. Here, we report a patient with childhood-onset schizophrenia who has three large chromosomal abnormalities: an inherited 2.2 Mb deletion of chromosome 3p12.2–p12.1, a de novo 16.7 Mb duplication of 16q22.3–24.3, and a de novo 43 Mb deletion of Xq23–q28.

Efficacy and safety of paliperidone extended release in adolescents with schizophrenia: a randomized, double-blind study

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of paliperidone extended release (ER) relative to aripiprazole in adolescent schizophrenia.

METHOD

In this multicenter, double-blind, phase 3 study (screening [≤3 weeks], with an acute treatment period [8 weeks] and a maintenance period [18 weeks]), adolescents (12-17 years old) with schizophrenia (DSM-IV diagnosis; Positive and Negative Symptom Score [PANSS] total score 60-120) were randomized (1:1) to once-daily paliperidone ER (6 mg per day [days 1-7], flexibly dosed 3, 6, or 9 mg per day from week 2 to end of study [EOS]), or to aripiprazole (2 mg per day [days 1 and 2], 5 mg per day [days 3 and 4], 10 mg per day [days 5-7], flexibly dosed 5, 10, or 15 mg per day [week 2 to EOS]).

RESULTS

Overall, 76% of enrolled patients (174/228) completed the study (paliperidone ER, 75% [85/113]; aripiprazole, 77% [89/115]). There was no significant difference in change in PANSS total scores from baseline to day 56 (primary endpoint) (paliperidone ER versus aripiprazole, -19.3 [13.80] versus -19.8 [14.56], p = .935); responders, 67.9% versus 76.3%, p = .119) and day 182 (-25.6 [16.88] versus -26.8 [18.82], p = .877; responders, 76.8% versus 81.6%, p = .444). All secondary endpoints (maintenance of clinical stability, change in PANSS-negative symptoms, Clinical Global Impression-Severity, and Personal and Social Performance scores) were similar in both treatment groups. The most common (>10% patients) treatment-emergent adverse events for paliperidone ER were akathisia, headache, somnolence, tremor, and weight gain, and for aripiprazole were worsening of schizophrenia and somnolence. Extrapyramidal symptoms including dystonia and hyperkinesia occurred in >2% in paliperidone ER-treated versus aripiprazole-treated patients.

CONCLUSION

Paliperidone ER did not demonstrate superior efficacy to aripiprazole in treating adolescent schizophrenia. Both drugs showed clinically meaningful improvements in symptom and functional measurements and were generally tolerable. Clinical Trial Registration Information-An Efficacy and Safety Study of Extended-Release (ER) Paliperidone in Adolescent Participants With Schizophrenia; http://clinicaltrials.gov; NCT01009047.

Parenting in children and adolescents with psychosis

NEED AND PURPOSE OF REVIEW

Psychotic symptoms appear in children and adolescents in the most crucial years, during the individual's career development. The challenges faced by parents of psychotic children are in dealing with their disruptive behaviours, negative symptoms, cognitive deficits, delusions and hallucinations. This paper presents an overview of the childhood psychosis and how parenting can be done effectively for this population.

METHODS

Articles were retrieved from the Medline, Cochrane database, Google Scholar, Medscape; using the search terms 'parenting and childhood psychosis', and 'childhood psychoses; and standard textbooks were consulted.

MAIN CONCLUSIONS

Educating parents how to recognize early symptoms, explaining treatment adherence, side effects of medications along with non-pharmacological measures like dealing with expressed emotions, lowering expectations, enhancing social supports, healthy lifestyle, and making patients independent. Awareness, early identification and effective parenting for psychosis may help bridge the wide gap between scarce skilled mental health professionals, inefficient resources and large paediatric population.

Comparing illness presentation, treatment and functioning between patients with adolescent- and adult-onset psychosis

Studies have shown that early- and adult-onset schizophrenia patients differ in pre-morbid traits, illness presentation, psychopathology, and prognosis. We aimed to compare adult-onset patients (age range 26-55 years) with an adolescent-onset cohort (15-25 years) in demographics, illness presentation and functioning at baseline. Participants were from two territory-wide early intervention services for adolescent-onset (n=671) and adult-onset psychosis patients (n=360) in Hong Kong. The adolescent-onset cohort had their initial psychotic episode from 2001-2003; retrospective data collection was done through systematic case note review. The adult-onset cohort was recruited for a larger interventional study from 2009-2011; information was collected via face-to-face interviews. Adult-onset psychosis was significantly associated with more females, more smokers, more non-local birth, more full-time employment, better functioning, poorer medication adherence, more psychiatric hospitalization and fewer with schizophrenia than adolescent-onset psychosis (mean age: 20.4). The effect sizes were small, except for medication adherence where a robust effect was found. No group difference in DUP was found. The finding that adult-onset patients had better functioning challenges the view that adolescent- and adult-onset psychoses share a similar prognostic trajectory. Implications for adapting intervention processes for adolescent- and adult-onset psychosis are discussed.

Patterns and correlates of expressed emotion, perceived criticism, and rearing style in first admitted early-onset schizophrenia spectrum disorders

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence.