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Edelsohn GA, Sisti D. Past Is Prologue: Ethical Issues in Pediatric Psychedelics Research and Treatment. Perspect Biol Med 2023; 66:129-144. [PMID: 38662012 DOI: 10.1353/pbm.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Recent clinical trials of psychedelic drugs aim to treat a range of psychiatric conditions in adults. MDMA and psilocybin administered with psychotherapy have received FDA designation as "breakthrough therapies" for post-traumatic stress disorder (PTSD) and treatment-resistant depression (TRD) respectively. Given the potential benefit for minors burdened with many of the same disorders, calls to expand experimentation to minors are inevitable. This essay examines psychedelic research conducted on children from 1959 to 1974, highlighting methodological and ethical flaws. It provides ethics and policy recommendations for psychedelics research involving children and adolescents, including recognizing that the psychedelic experience is an ineffable one that makes informed proxy consent for parents, guardians, and others especially challenging. Psychedelic experiences are associated with novel benefits and risks, such as significant personality changes, shifts in fundamental values, and possible re-exposure to traumatic memories. These effects may alter the process of personality development in minors. Recommendations for ethically sound psychedelics research in minors include strict adherence to eligibility criteria, including a comprehensive family and individual psychiatric, substance use, and trauma history. An age-appropriate assent process that includes considerations related to the use of therapeutic touch should be developed. In addition, oversight by data safety monitoring boards and patient and family advocates, coupled with the adoption of pharmacoequity best practices, will help to ensure safety and fairness of psychedelics research in children.
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Edelsohn GA, Abright AR. Editorial: Safer Use of Antipsychotics in Youth (SUAY): Should Treatment Be Guided by Symptoms? J Am Acad Child Adolesc Psychiatry 2022; 61:34-36. [PMID: 34311036 DOI: 10.1016/j.jaac.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Abstract
Child and adolescent psychiatrists have company as they wrestle with clinical decision making regarding when it is appropriate to prescribe an antipsychotic. Pediatricians face a similar challenge in trying to determine under what circumstances to prescribe an antibiotic. Both classes of medications are powerful and can be lifesaving, but they are not without the risk of associated adverse events and cumulative exposure. Concerns regarding the widespread use of antipsychotics in children and adolescents have been supported by national trends indicating predominance of prescriptions for conditions (attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, and impulsive aggression)1,2 other than those approved by the U.S. Food and Drug Administration (psychotic disorders, bipolar disorder with mania, irritability associated with autism spectrum disorder, and tic disorders); the risks of weight gain, diabetes mellitus, and other adverse effects to which youths appear to be more vulnerable than adults3; and potential disparities related to the absence of race and ethnicity in large administrative datasets.4 Previous studies of antipsychotic prescribing patterns predate the widespread use of the diagnosis of disruptive mood dysregulation disorder. A recent study found that 58.9% of youths given a diagnosis of disruptive mood dysregulation disorder were prescribed antipsychotics compared with 51% of youths with a diagnosis of bipolar disorder.5 In this issue of the Journal, Penfold et al.6 report on a novel approach to antipsychotic prescribing focused on symptoms rather than diagnoses developed as the initial phase of a pragmatic clinical trial, Targeted and Safer Use of Antipsychotics in Youth (SUAY), funded by the National Institute of Mental Health and designed to test the effectiveness of targeted interventions on the use of antipsychotics for youth 4 to 17 years old in large health care systems. We offer some perspectives on differences that distinguish this approach; the process used in its development; and its promise, potential pitfalls, and policy and clinical implications.
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Affiliation(s)
- Gail A Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, Pennsylvania.
| | - A Reese Abright
- Icahn School of Medicine at Mount Sinai, New York, and New York City Health + Hospitals/Elmhurst, New York
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Mazur SL, Edelsohn GA, DePergola PA, Sarvet BD. Ethical Imperatives for Participation in Integrated/Collaborative Care Models for Pediatric Mental Health Care. Child Adolesc Psychiatr Clin N Am 2021; 30:697-712. [PMID: 34538442 DOI: 10.1016/j.chc.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The significant and ongoing shortage of child and adolescent psychiatrists has limited access to mental health care in the pediatric population. In response to this problem, integrated/collaborative care models have been established. These models, as all imperfect things in medicine, have their own set of challenges. A careful ethical analysis of integrated/collaborative care models is essential to protect the social and emotional health and safety of children with mental illness. To this end, ethical assessment supports the use of integrated/collaborative care models, and recent studies have demonstrated the benefits of their implementation.
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Affiliation(s)
- Shannon L Mazur
- Department of Psychological Medicine, Yale New Haven Hospital, 20 York Street, Fitkin 607, New Haven, CT 06510, USA.
| | - Gail A Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Services Division, 1 East Uwchlan Avenue, Suite 311, Exton, PA 19341, USA
| | - Peter A DePergola
- Department of Medicine, University of Massachusetts Medical School - Baystate, 759 Chestnut Street, Daly 6100B, Springfield, MA 01199, USA; Department of Bioethics and Medical Humanities, College of Our Lady of the Elms, 291 Springfield Street, Chicopee, MA 01013, USA; St. Augustine Center for Ethics, Religion, and Culture, College of Our Lady of the Elms, 291 Springfield Street, Chicopee, MA 01013, USA
| | - Barry D Sarvet
- Department of Psychiatry, University of Massachusetts Medical School - Baystate, 759 Chestnut Street, WG703, Springfield, MA 01199, USA
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McGee ME, Edelsohn GA, Keener MT, Madaan V, Soda T, Bacewicz A, Dell ML. Ethical and Clinical Considerations During the Coronavirus Era. J Am Acad Child Adolesc Psychiatry 2021; 60:332-335. [PMID: 33338576 PMCID: PMC7836851 DOI: 10.1016/j.jaac.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 11/15/2022]
Abstract
The practice of child and adolescent psychiatry is evolving during an unprecedented global health catastrophe, the coronavirus disease 2019 (COVID-19) pandemic. As child and adolescent psychiatrists grapple with COVID-19's enormous medical, educational, social, and economic toll, a mental health crisis is co-occurring. Pre-existing disparities are recognized as contributors to the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities.1 The magnitude of COVID-19's effects on child and family mental health has yet to be fully revealed. child and adolescent psychiatrists are in a unique position to address this mental health crisis. Child and adolescent psychiatrists must stay up-to-date regarding federal, state, local, and institutional mandates, regulations, and policies informed by the Centers for Disease Control and Prevention2 and other public health institutions, while also navigating the ethical dilemmas unique to child and adolescent psychiatry during the coronavirus era.
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Affiliation(s)
- Maria E. McGee
- Creighton University School of Medicine and Catholic Health Initiatives Health, Omaha, Nebraska,Correspondence to Maria E. McGee, MD, MS, MPH, Creighton University Medical Center, Education Building, 7710 Mercy Road, Suite 601, Omaha, NE 68124
| | - Gail A. Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, Pennsylvania
| | | | - Vishal Madaan
- University of Virginia Health System, Charlottesville
| | - Takahiro Soda
- Duke University School of Medicine, Durham, North Carolina
| | | | - Mary Lynn Dell
- Children’s Hospital New Orleans and Tulane University, Louisiana
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Edelsohn GA, Eren K, Parthasarathy M, Ryan ND, Herschell A. Inter-class Concomitant Pharmacotherapy in Medicaid-Insured Youth Receiving Psychiatric Residential Treatment. Front Psychiatry 2021; 12:658283. [PMID: 34093273 PMCID: PMC8173180 DOI: 10.3389/fpsyt.2021.658283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Concomitant pharmacotherapy has become increasingly common in the treatment of youth, including in psychiatric residential treatment facilities (PRTF) despite limited efficacy and safety data. Research is reported on the prevalence of any class and interclass concomitant pharmacotherapy, specific class combinations of psychotropics, and changes in number of medications from admission to discharge for Medicaid insured youth treated in PRTFs in one mid-Atlantic state. Methods: Medicaid administrative claims data were examined for youth under age 18 years who were discharged from one of 21 PRTFs during calendar year 2019. Descriptive statistics were calculated to examine patterns of service utilization 90 days prior to admission. The rates of concomitant psychotropic use at admission were compared to the rates at discharge. Logistic regression models were used to examine covariates associated with discharging on 4 or more medications. Results: Fifty-four % of youth were admitted on either two or three psychotropics, while 25% were admitted on four or more psychotropics. The proportion of youth admitting and discharging on 2 or 3 medications was stable. There was a 27% increase in number of youth discharging on 4 medications with a 24% decrease in those on a 5- drug regimen. Only the number of medications prescribed at admission was found to be significant (p < 0.001), with more medications at admission contributing to probability of discharging on 4 or more medications. Conclusions: Concomitant pharmacotherapy is common in PRTFs. These findings support the practice of deprescribing and underscore the need for further research.
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Affiliation(s)
- Gail A Edelsohn
- Community Care Behavioral Health Organization, University of Pittsburgh Medical Center (UPMC) Insurance Services Division, Pittsburgh, PA, United States
| | - Kemal Eren
- Community Care Behavioral Health Organization, University of Pittsburgh Medical Center (UPMC) Insurance Services Division, Pittsburgh, PA, United States
| | - Meghna Parthasarathy
- Community Care Behavioral Health Organization, University of Pittsburgh Medical Center (UPMC) Insurance Services Division, Pittsburgh, PA, United States
| | - Neal D Ryan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Amy Herschell
- Community Care Behavioral Health Organization, University of Pittsburgh Medical Center (UPMC) Insurance Services Division, Pittsburgh, PA, United States
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Bieber ED, Edelsohn GA, McGee ME, Shekunov J, Romanowicz M, Vande Voort JL, McKean AJS. The Role of Parental Capacity for Medical Decision-Making in Medical Ethics and the Care of Psychiatrically Ill Youth: Case Report. Front Psychiatry 2020; 11:559263. [PMID: 33192675 PMCID: PMC7644854 DOI: 10.3389/fpsyt.2020.559263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction: Parents/legal guardians are medical decision-makers for their minor children. Lack of parental capacity to appreciate the implications of the diagnosis and consequences of refusing recommended treatment may impede pediatric patients from receiving adequate medical care. Child and adolescent psychiatrists (CAPs) need to appreciate the ethical considerations relevant to overriding parental medical decision-making when faced with concerns for medical neglect. Methods: Two de-identified cases illustrate the challenges inherent in clinical and ethical decision-making reflected in concerns for parental capacity for medical decision-making. Key ethical principles are reviewed. Case 1: Treatment of an adolescent with an eating disorder ethically complex due to the legal guardian's inability to adhere with treatment recommendations leading to the patient's recurrent abrupt weight loss. Case 2: Questions of parental decisional capacity amid treatment of an adolescent with schizoaffective disorder raised due to parental mistrust of diagnosis, disagreement with treatment recommendations, and lack of appreciation of the medical severity of the situation with repeated discharges against medical advice and medication nonadherence. Discussion: Decisions to question parental capacity for medical decision-making when risk of imminent harm is low but concern for medical neglect exists are controversial. Systematic review of cases concerning for medical neglect benefits from the assessment of parental decisional capacity, review of ethical standards and principles. Conclusion: Recognition of the importance of parental decision-making capacity as relates to parental autonomy and medical neglect and understanding key ethical principles will enhance the CAP's capacity in medical decision-making when stakes are high and absolute recommendations are lacking.
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Affiliation(s)
- Ewa D Bieber
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Gail A Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh, PA, United States
| | - Maria E McGee
- Department of Psychiatry, Creighton University School of Medicine, Omaha, NE, United States
| | - Julia Shekunov
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Magdalena Romanowicz
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | | | - Alastair J S McKean
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
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Edelsohn GA. Editorial: Making Use of What We Know: Medical Decision-Making and Antipsychotics. J Am Acad Child Adolesc Psychiatry 2019; 58:1051-1053. [PMID: 30928730 DOI: 10.1016/j.jaac.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
Minimizing the duration of untreated psychosis and providing comprehensive early intervention including the use of antipsychotics reflects best practice in the treatment of first-episode psychosis (FEP).1 The adverse effects of second-generation antipsychotics (SGAs) are well known, namely, weight gain, hyperglycemia, and dyslipidemia that are associated with an increased risk of obesity, type 2 diabetes, and cardiovascular disease. Youth appear to be more vulnerable to deleterious cardiometabolic effects than adults.2 Child and adolescent psychiatrists (CAPs) treating FEP have an ethical duty to carefully select an effective antipsychotic medication, being cognizant of the metabolic profile of the considered SGAs and of the likelihood of prolonged antipsychotic exposure. Which is the "right" antipsychotic medication for the young person in front of me? What is known about the adverse effects of available antipsychotics and how do they compare to each other, not just to placebo? Does information exist to help me anticipate whether my patient is more or less susceptible to adverse cardiometabolic effects?
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Affiliation(s)
- Gail A Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Services Division, Pittsburgh, PA.
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Edelsohn GA, Karpov I, Parthasarathy M, Hutchison SL, Castelnovo K, Ghuman J, Schuster JM. Trends in Antipsychotic Prescribing in Medicaid-Eligible Youth. J Am Acad Child Adolesc Psychiatry 2017; 56:59-66. [PMID: 27993230 DOI: 10.1016/j.jaac.2016.10.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/10/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine trends in the use of antipsychotic medication in Medicaid-eligible youth from 2008 to 2013 and the factors associated with this use. METHOD Youth aged 0 to 17 years with at least one claim indicating antipsychotic medication use were identified from the network of a behavioral health managed care organization (BHMCO). Demographic and clinical variables were derived from state eligibility data and service claims data from the BHMCO. Overall and specific prevalence rates of antipsychotic drug use were calculated over the course of 6 years (2008-2013). The probability of antipsychotic use during 2013 was further explored with logistic regression that included demographic and diagnostic groups. RESULTS The overall trend in prevalence for antipsychotics for youth decreased from 49.52 per 1,000 members in 2008 to 30.54 in 2013 (p < .0001). Although rates decreased for all age groups, the rate per 1,000 members in 2013 for the youngest children was 3.79, versus 39.23 for 6- to 12-year-olds and 64.33 for 13- to 17-year-olds. Controlling for demographic and clinical variables, children 0 to 5 years old were 79% less likely to be prescribed antipsychotic medications compared to the oldest youth, 13 to 17 years of age (p < .0001). Rates were higher for males versus females regardless of age (odds ratio [95% CI] =1.48 [1.36-1.62], p < .0001). Children with a diagnosis of attention-deficit/hyperactivity disorder were less likely to be prescribed antipsychotics compared to those with diagnoses of autism spectrum disorder, bipolar disorder, psychoses, and depression. CONCLUSION Prevalence rates decreased significantly over time for all socio-demographic groups. The largest decrease was observed for the youngest children, ages 0 to 5 years, with a rate in 2013 under half the rate for 2008. Clinical, policy, and managed care implications are discussed.
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Affiliation(s)
- Gail A Edelsohn
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh.
| | - Irina Karpov
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh
| | - Meghna Parthasarathy
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh
| | - Shari L Hutchison
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh
| | - Kim Castelnovo
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh
| | - Jaswinder Ghuman
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh
| | - James M Schuster
- Community Care Behavioral Health Organization, UPMC Insurance Division, Pittsburgh; Behavioral Health and Medicaid Services, Behavioral Health Integration, UPMC Insurance Division and University of Pittsburgh School of Medicine
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Edelsohn GA, Parthasarathy M, Terhorst L, Karpov IO, Schuster J. Measurement of Metabolic Monitoring in Youth and Adult Medicaid Recipients Prescribed Antipsychotics. J Manag Care Spec Pharm 2016; 21:769-77, 777a-777cc. [PMID: 26308224 PMCID: PMC10397640 DOI: 10.18553/jmcp.2015.21.9.769] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Individuals being treated with first- and second-generation antipsychotics (FGAs and SGAs) are at risk for a variety of adverse cardiometabolic effects. Although consensus guidelines that recommend metabolic monitoring for patients receiving SGAs have been in place since 2004, the rate of monitoring remains low, especially in the pediatric population. OBJECTIVES To (a) examine differences in rates of laboratory monitoring for glucose and lipids for adults and youth prescribed FGAs and SGAs; (b) look at factors associated with the likelihood of metabolic testing; and (c) describe cohort effects that may have had an impact on the rates of laboratory testing. METHODS This is a retrospective study examining the rates of glucose and lipid testing for 3 separate cohorts of Medicaid recipients who were prescribed antipsychotics during 3 measurement periods-2008, 2010, and 2012-using paid Medicaid pharmacy and laboratory claims data. The sample included adults aged 18 years and older and children aged 17 years and younger. For each measurement period, we identified the rate of metabolic monitoring and the demographic characteristics for each individual, including race, age, and gender. The proportion of laboratory monitoring was assessed using chi square tests for each of the outcomes. Logistic regression models for each time point were used to determine the characteristics of individuals who were more likely to receive monitoring. RESULTS The proportion of individuals receiving glucose and lipid tests increased for both age groups across all measurement periods. For individuals aged 18 years and over, glucose monitoring increased from 56.6%-72.6%. Testing for lipids remained constant, ranging from 38.3%-41.2% for each of the 3 measurement periods. During the first measurement period, in 2008, females were 41% and 15% more likely to receive glucose and lipid laboratory monitoring, respectively, compared with males. Females continued to be more likely to receive glucose monitoring during the measurement periods in 2010 and 2012, although there was no significant difference between females and males for lipid monitoring during these time periods. Individuals aged 17 years and younger were 59%-68% less likely to receive glucose monitoring than adults (aged ≥ 18 years) for all time points. Across all measurement periods, individuals aged ≤ 17 years were also 44%-58% less likely to receive lipid monitoring compared with adults (aged ≥ 18 years). While there was no significant difference between Caucasians and non-Caucasians in the first measurement period, Caucasians were about 30% less likely to receive glucose monitoring and about 50% less likely to receive lipid monitoring during the measurement periods covering 2010 and 2012. CONCLUSIONS Metabolic monitoring in adults improved substantially over the time periods studied; however, rates remained suboptimal, especially in the pediatric population. This finding suggests that interventions to increase metabolic monitoring in adults and children using FGAs and SGAs are necessary.
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Affiliation(s)
- Gail A Edelsohn
- Community Care Behavioral Health Organization, 1 E. Uwchlan Ave., Ste. 311, Exton, PA 19341.
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McGee ME, Dingle AD, Edelsohn GA. Review of the Revised 2014 American Academy of Child and Adolescent Psychiatry Code of Ethics. J Am Acad Child Adolesc Psychiatry 2016; 55:257-61. [PMID: 27015713 DOI: 10.1016/j.jaac.2015.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/24/2015] [Accepted: 01/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Maria E McGee
- American Academy of Child and Adolescent Psychiatry (AACAP) Ethics Committee, the Division of Child and Adolescent Psychiatry at the University of Nebraska Medical Center, Omaha, and the Creighton Psychiatry Residency Training Program, Omaha.
| | - Arden D Dingle
- AACAP Ethics Committee, the University of Texas Rio Grande Valley, and Emory University, Atlanta (Professor Emeritus)
| | - Gail A Edelsohn
- AACAP Ethics Committee and Community Care Behavioral Health Organization, Exton, PA
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Edelsohn GA, Schuster JM, Castelnovo K, Terhorst L, Parthasarathy M. Psychotropic prescribing for persons with intellectual disabilities and other psychiatric disorders. Psychiatr Serv 2014; 65:201-7. [PMID: 24233105 DOI: 10.1176/appi.ps.201300029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Prescribing patterns of psychotropic medication over a five-year period for Medicaid recipients (adults and children) with codiagnoses of an intellectual disability and a mental disorder were compared with patterns for those with sole mental disorder diagnoses. METHODS Each group was identified through paid behavioral health services claims. Four classes of medications (antidepressants, antipsychotics, benzodiazepines, and mood stabilizers) were examined in paid pharmacy claims. Diagnostic categories, rates of psychotropic prescription, and polypharmacy (three or more medications concurrently for 90 days or more) were compared by age group (child or adult). RESULTS Adults with mental disorders only (N=793 to 883; the range reflects the five study years) were prescribed antidepressants at a significantly higher rate compared with adults in the codiagnosis group (N=184 to 217). For three of the five study years, antipsychotics were prescribed to the sole-diagnosis group of adults at a significantly higher rate than to those with codiagnoses. Children in the group with codiagnoses (N=108 to 141) were prescribed mood stabilizers at a significantly higher rate than the comparison group (N=638 to 728) in all five study years. Rates of antipsychotics prescribed were not statistically different between the two groups of children. Polypharmacy rates for both adults and children were higher for the codiagnosis group compared with the group with a sole mental disorder, but the difference did not reach statistical significance. CONCLUSIONS Psychotropic prescribing patterns in the two groups studied varied by class of medication and age. Although evidence exists for using psychotropics to treat psychopathology and challenging behaviors among individuals with intellectual disabilities, consideration of behavioral intervention alternatives and careful monitoring of psychotropic effectiveness and side effects are recommended.
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Edelsohn GA. Ethics and research with vulnerable children. J Am Acad Child Adolesc Psychiatry 2012; 51:566-8. [PMID: 22632615 DOI: 10.1016/j.jaac.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/02/2012] [Indexed: 11/17/2022]
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Muroff J, Edelsohn GA, Joe S, Ford BC. The role of race in diagnostic and disposition decision making in a pediatric psychiatric emergency service. Gen Hosp Psychiatry 2008; 30:269-76. [PMID: 18433660 PMCID: PMC2388247 DOI: 10.1016/j.genhosppsych.2008.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 01/11/2008] [Accepted: 01/15/2008] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We investigated the influence of race/ethnicity in diagnostic and disposition decision-making for children and adolescents presenting to an urban psychiatric emergency service (PES). METHOD Medical records were reviewed for 2991 child and adolescent African-American, Hispanic/Latino and white patients, treated in an urban PES between October 2001 and September 2002. A series of bivariate and binomial logistic regression analyses were used to delineate the role of race in the patterns and correlates of psychiatric diagnostic and treatment disposition decisions. RESULTS Binomial logistic regression analyses reveal that African-American (OR=2.28, P<.001) and Hispanic/Latino (OR=2.35, P<.05) patients are more likely to receive psychotic disorders and behavioral disorders diagnoses (African American: OR=1.66, P<.001; Hispanic/Latino: OR=1.36, P<.05) than white children/adolescents presenting to PES. African-American youth compared to white youth are also less likely to receive depressive disorder (OR=0.78, P<.05), bipolar disorder (OR=.44, P<.001) and alcohol/substance abuse disorder (OR=.18, P<.01) diagnoses. African-American pediatric PES patients are also more likely to be hospitalized (OR=1.50, P<.05), controlling for other sociodemographic and clinical factors (e.g., Global Assessment of Functioning). CONCLUSIONS The results highlight that nonclinical factors such as race/ethnicity are associated with clinical diagnostic decisions as early as childhood suggesting the pervasiveness of such disparities.
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Affiliation(s)
- Jordana Muroff
- School of Social Work, Boston University, Boston, MA 02215, USA.
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Affiliation(s)
- Gail A Edelsohn
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Human Behavior, Thomas Jefferson University, 833 Chestnut St., Suite 210-D, Philadelphia, PA 19107, USA.
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Abstract
The spectrum of psychiatric emergencies in adolescents may be best appreciated using the broad framework of urgency. ED physicians and staff using such a framework will be in a better position to triage and to tailor the evaluation assessment and target the intervention and disposition. Understanding the range of urgency can minimize frustration, enhance the clinician's ability to accurately assess complex situations, and make a tremendous difference in the patient's receipt of future services. This article reviews the epidemiology, risk factors, and critical elements of emergency evaluation and treatment of a variety of juvenile psychiatric emergencies. Factors influencing presentation, disposition,and consideration of local treatment resources are reviewed.
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Affiliation(s)
- Gail A Edelsohn
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, 833 Chestnut Street, Suite 210-D, Philadelphia, PA 19107, USA.
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Abstract
Clinicians need to consider a wide range of differential diagnoses when children and adolescents present with hallucinations. This includes considering whether it is a developmentally normal phenomenon or if there is a psychiatric, medical, or neurologic diagnosis. Nonpsychotic children with hallucinations can be differentiated from psychotic children. Nonpsychotic children who are at risk (or prodromal) for future psychosis can be differentiated from nonprodromal healthier children. We examine the epidemiology, prognosis, and neurobiological research. Lastly, we discuss treatment approaches, including medication and cognitive behavioral therapy.
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Affiliation(s)
- Morton D Sosland
- Thomas Jefferson University, 833 Chestnut Street, Suite 210-D, Philadelphia, PA 19107, USA
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Affiliation(s)
- Gail A Edelsohn
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, PA 19107, USA.
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Abstract
Sixty-two cases of children with hallucinations but without psychosis were identified in a psychiatric emergency service. Auditory hallucinations were more frequent than visual ones. There were positive trends between the content of auditory hallucinations and diagnosis. Recognition of this clinical phenomenon of hallucinations in children in the absence of psychosis and awareness of underlying psychopathology and precipitating factors is necessary in evaluating hallucinations in nonpsychotic children. Children with such presentations run the risk of being misdiagnosed as having psychosis or schizophrenia and being subjected to the inherent risks of treatment with antipsychotics.
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Affiliation(s)
- Gail A Edelsohn
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, 833 Chestnut Street, Suite 210-D, Philadelphia, PA 19107, USA.
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20
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Abstract
OBJECTIVES To test the hypothesis that youth present to a psychiatric emergency service (PES) at least 25% of the time for nonurgent reasons, to examine the demographic characteristics that distinguish urgent from nonurgent visits, and to develop a model to predict urgency. METHOD Psychiatric emergency visits of all patients under 18 years from July 1, 1997, through June 30, 1998, were ed and coded as to level of urgency using Rosenn's classification system. Age, gender, ethnicity, arrival status, social service involvement, violence, substance abuse, and diagnosis were examined with respect to urgency in bivariate and multivariable analyses. RESULTS Forty percent of visits to the PES were not urgent. Demographic factors distinguished urgent from nonurgent visits. Independent predictors of urgency for the entire sample were age, diagnosis, arrival status, social service involvement, and violence. Only violence remained an independent predictor of urgency for the attention-deficit/hyperactivity disorder subgroup. CONCLUSIONS A large percentage of pediatric visits to the PES were for nonurgent reasons. This suggests that there are considerable unmet mental health needs of children and adolescents. These findings can be applied to improve and design appropriate services.
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Affiliation(s)
- Gail A Edelsohn
- Thomas Jefferson University, Department of Psychiatry and Human Behavior, Philadelphia, PA 19107, USA
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21
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Everson MD, Hunter WM, Runyon DK, Edelsohn GA, Coulter ML. Maternal support following disclosure of incest. Am J Orthopsychiatry 1989. [PMID: 2712154 DOI: 10.111/j.1939-0025.1989.tb01651.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The level of maternal support to incest victims following disclosure was found to be more closely related to perpetrator than to child characteristics. Lack of maternal support was significantly associated with foster placement and higher psychopathology scores in a clinical interview. Evidence is presented challenging the validity of maternal behavioral reports in assessments of incest victims.
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Affiliation(s)
- M D Everson
- Department of Psychiatry, University of North Carolina, Chapel Hill
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22
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Abstract
The level of maternal support to incest victims following disclosure was found to be more closely related to perpetrator than to child characteristics. Lack of maternal support was significantly associated with foster placement and higher psychopathology scores in a clinical interview. Evidence is presented challenging the validity of maternal behavioral reports in assessments of incest victims.
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Affiliation(s)
- M D Everson
- Department of Psychiatry, University of North Carolina, Chapel Hill
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23
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Abstract
OBJECTIVE Examining the psychologic risks of court and related interventions on child sexual abuse victims. DESIGN A prospective cohort study with follow-up at 5 months. SETTING Eleven county social service departments in central North Carolina. SUBJECTS 100 sexually abused children, ages 6 to 17 years, were recruited from consecutive referrals by social service departments; 75 completed the study. MEASUREMENTS AND RESULTS Using a structured psychiatric inventory, the Child Assessment Schedule, we found a high degree of distress at referral. The level of distress fell by 26% over the next 5 months (p less than 0.001). The 33 children not involved in criminal proceedings improved 30%, in comparison with a 17% improvement in the 22 children waiting for the proceedings (p = 0.042). The 12 children who had testified in juvenile court improved 42% on the Anxiety subscale, in comparison with a 17% improvement in all other subjects (p less than 0.01). With mathematical modeling that controlled for the factors of vaginal or anal penetration, the relationship to the perpetrator, an estimate of verbal IQ, duration of abuse, and whether counseling was received, it was estimated that children waiting for court proceedings at the follow-up examination were only one twelfth as likely to have improved by one standard deviation on the Depression subscale (p less than 0.05). A second model revealed that children who testified in juvenile court were 20.11 times more likely to improve by one standard deviation on the CAS Anxiety subscale (p less than 0.05). CONCLUSIONS Testimony in juvenile court may be beneficial for the child, whereas protracted criminal proceedings may have an adverse effect on the mental health of the victim.
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Affiliation(s)
- D K Runyan
- Department of Social and Administrative Medicine, University of North Carolina, Chapel Hill School of Medicine 27599
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Kirkpatrick B, Edelsohn GA. Risk factors for the neuroleptic malignant syndrome. Psychiatr Med 1984; 2:371-81. [PMID: 6152857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- B Kirkpatrick
- Biological Services Research Center, University of North Carolina, Chapel Hill 27514
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25
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Abstract
The authors describe two patients with organic psychosis who had vitamin B12 deficiency and no hematologic or spinal cord abnormalities. They review the literature that supports a causal relationship between B12 deficiency and cerebral dysfunction, as measured by the EEG, and consequent organic mental changes. The authors cite evidence that these EEG and organic mental changes are reversible with B12 replacement. They emphasize that psychiatric manifestations may be the first symptoms of vitamin B12 deficiency and thus antedate anemia and spinal cord disease. They recommend consideration of B12 deficiency and serum B12 determinations in all patients with organic mental symptoms.
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