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Marino EN, Jha MK, Minhajuddin A, Ayvaci ER, Levinson S, Pipes R, Emslie GJ, Trivedi MH. Problematic substance use in depressed adolescents: Prevalence and clinical correlates. Addict Behav Rep 2024; 19:100539. [PMID: 38510109 PMCID: PMC10951442 DOI: 10.1016/j.abrep.2024.100539] [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] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/26/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
Background Substance use among adolescents is common and associated with significant consequences, including depression. Adolescents can experience myriad problems related to early onset substance use and depression, making further understanding of this comorbidity necessary. Method Participants were a subset from a large-scale performance improvement project and consisted of adolescents aged 12-18 who screened positive for depression during their routine medical or psychiatric appointment and who then completed the substance use assessment Car, Relax, Alone, Forget, Friends, Trouble Version 2.1 (CRAFFT). Participants with problematic substance use had a CRAFFT score ≥2. Results A total of 621 participants were included in this study, and 105 (16.9%) reported problematic substance use. Compared with participants without problematic substance use, those with problematic use were more likely to have moderate to severe depression and anxiety, as well as significantly higher irritability, impulsivity, suicidal propensity, and suicidal thoughts scores. Controlling for age at screening, sex, race, and ethnicity, problematic substance use remained a significant predictor of depression severity, impulsivity, suicidal propensity, and suicidal thoughts. Limitations Participants were from a large, metropolitan area of the Southwest United States who must have screened positive for depression, so results may not generalize. Because all participants were underage, they may have been wary in responding to the substance use assessment accurately. Conclusions By using a large, diverse sample in a real-world clinical setting, findings strengthen the association between problematic substance use and depression and depression-associated symptoms among adolescents, highlighting the need for early detection and universal depression screening.
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Affiliation(s)
- Elise N. Marino
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Manish K. Jha
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Abu Minhajuddin
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Emine Rabia Ayvaci
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Sara Levinson
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Ronny Pipes
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Madhukar H. Trivedi
- Center for Depression Research and Clinical Care, Peter O’Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
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Emslie GJ. Editorial: Novel Approaches to the Treatment of Suicidality and Depression in Youth. J Am Acad Child Adolesc Psychiatry 2024; 63:500-501. [PMID: 37422104 DOI: 10.1016/j.jaac.2023.06.019] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
Suicide continues to be a major cause of mortality in adolescents with limited treatment options.1,2 Effective treatments, both therapy and medication, are available for treating depression, but even with the best combination, treatment remission rates are low.3 The most common approach to treating suicidality, which includes suicidal ideation and suicidal behavior, is to address concomitant depression. Ketamine and its enantiomers have shown rapid anti-suicidal effects in adults with MDD, and intranasal esketamine is approved for treating treatment-resistant depression (TRD) in adults.4,5 The effectiveness of ketamine for the treatment of depression frequently lags behind the treatment of suicidality. There are also many methodological differences and barriers to assessing the effectiveness of short-term treatments. These include measurement of change over short time frames, measurement of suicidality, and so forth. Finally, the use of novel short-term treatments in treating chronic depression and suicidality in real-world situations is unclear.
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Affiliation(s)
- Graham J Emslie
- University of Texas Southwestern Medical Center, Dallas, Texas, and Children's Health, Children's Medical Center, Dallas, Texas.
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Ayvaci ER, Minhajuddin A, Elmore JS, Yagnik K, Jha MK, Emslie GJ, Mayes TL, Trivedi MH. Treatment of Adolescent Depression: Comparison of Psychiatric and Pediatric Settings at an Academic Medical Center Using the VitalSign 6 Application. J Child Adolesc Psychopharmacol 2024; 34:80-88. [PMID: 38252552 DOI: 10.1089/cap.2023.0041] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background: Similar outcomes and remission rates have been found for the treatment of depression in adults in primary and psychiatric care settings. However, comparatively little is known about how pediatric depression is managed across different settings. This study aims to address this gap by comparing depression treatment in pediatric and psychiatric settings. We hypothesized that pediatric care settings would be more likely to treat individuals with lower depression severity and would select pharmacotherapy less frequently as a treatment option. Methods: Patients (n = 3498) were screened for depression at a children's hospital from May 2017 to May 2022 as part of the VitalSign6 project, a web-based application for depression management. The two-item patient health questionnaire (PHQ) was used for screening, and the data set contains patient-reported measures and provider-reported diagnoses and treatment selections at each clinic visit. Patients with nine-item PHQ (PHQ-9) scores ≥10 at baseline were included in the analysis to compare diagnosis and treatment recommendations between pediatric and psychiatric settings. Results: Among the 1323 patients who screened positive for depression, those in psychiatric settings had higher PHQ-9 scores (15.9 ± 5.0 vs. 12.1 ± 5.5; p < 0.0001). Patients with PHQ-9 ≥ 10 in psychiatric settings were more likely to be diagnosed with major depressive disorder (60.6% vs. 24.7%, p < 0.0001) and receive pharmacotherapy (54.8% vs. 6.6%) than those in pediatric settings. Pediatric setting patients were more likely to receive nonpharmacological treatment alone (36.3% vs. 4.3%) or an outside referral (27.7% vs. 5.7%). Remission rates did not significantly differ between the two settings. Conclusions: Youth in psychiatric settings are more likely to screen positive for depression and to have greater depression severity than those in pediatric settings. Both settings provide treatment recommendations for moderate-to-severe depression, but treatment types vary substantially. Yet, remission rates remain similar. Further research is needed to understand the nuances of treatment differences and their implications.
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Affiliation(s)
- Emine Rabia Ayvaci
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
- Children's Health, Children's Medical Center, Dallas, Texas, USA
| | - Abu Minhajuddin
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
- Peter O'Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joshua S Elmore
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kush Yagnik
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Manish K Jha
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Graham J Emslie
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
- Children's Health, Children's Medical Center, Dallas, Texas, USA
| | - Taryn L Mayes
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, UT Southwestern Medical Center, Dallas, Texas, USA
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Sachs R, Nakonezny PA, Balzen KM, Heerschap J, Kennard BD, Emslie GJ, Stewart SM. The effect of parent-adolescent discrepancies in reports of familial dysfunction and depression on suicidal ideation in adolescents. Suicide Life Threat Behav 2024. [PMID: 38385782 DOI: 10.1111/sltb.13062] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/14/2023] [Accepted: 01/05/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Parents and adolescents are often discrepant in their reports of adolescent psychosocial factors. Few studies have addressed parent-adolescent discrepancies in subjective ratings of familial dysfunction and depression as longitudinal predictor variables, and none have done so in a treatment setting for adolescents with acute suicidality. This study examined how parent-adolescent discrepancies in familial dysfunction and depression impact adolescent treatment response in an intensive outpatient program for suicidality. METHODS Adolescents (N = 315) were assessed at treatment entry and exit for familial dysfunction, depression, and suicidal ideation. Parents received parallel assessments of familial dysfunction and adolescent depression at each time point. A polynomial regression was conducted to determine whether parent-adolescent discrepancies in reports of familial dysfunction and depression at entry related to the treatment outcome of adolescent-reported depression and suicide ideation at exit. RESULTS Significant discrepancies were present with on average adolescents reporting more depression and familial dysfunction than parents. Entry discrepancy in familial dysfunction (but not depression) predicted suicide ideation at exit. CONCLUSIONS Our results suggest that parent-adolescent discrepancies in perception of familial dysfunction is a risk factor for poor outcomes in suicidal youth and might be a fruitful target in treatment programs.
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Affiliation(s)
- Raney Sachs
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paul A Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jessica Heerschap
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Sunita M Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
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Garza C, Chapa D, Hernandez C, Aramburu H, Mayes TL, Emslie GJ. Measurement-Based Care for Depression in Youth: Practical Considerations for Selecting Measures to Assess Depression, Associated Features and Functioning. Child Psychiatry Hum Dev 2024:10.1007/s10578-023-01652-4. [PMID: 38217644 DOI: 10.1007/s10578-023-01652-4] [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] [Accepted: 12/07/2023] [Indexed: 01/15/2024]
Abstract
Identification and management of major depressive disorder (MDD) in children and adolescents remains a significant area of public health need. The process for identifying depression (e.g. screening) and management (e.g. measurement based care [MBC]) is substantially enhanced by utilization of clinical measures and rating scales. Measures can be self- or caregiver reported or clinician rated. They can aid recognition of at-risk individuals for future assessment and assist in clinical diagnosis and management of depression. In addition to assessing symptoms of depression, rating scales can be used to assess important associated features (e.g. anxiety, trauma) and functional outcomes (e.g. quality of life, performance/productivity). In this manuscript, we discuss practical considerations for clinicians and researchers when selecting rating instruments for assessing depression, associated factors, functioning, and treatment outcomes (i.e. adherence and side effects) as part of MBC in youth and provide a summary of rating scales commonly used in research and clinical settings.
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Affiliation(s)
- Cynthia Garza
- Department of Psychiatry, University of Texas Rio Grande Valley, Harlingen, TX, USA.
| | - Diana Chapa
- Department of Psychiatry, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Catherine Hernandez
- Department of Psychiatry, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Hayley Aramburu
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Taryn L Mayes
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Graham J Emslie
- Children's Health, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Nandy K, Rush AJ, Carmody T, Kennard BD, Emslie GJ, Slater H, Mayes TL, DeFilippis M, Garza C, Storch EA, Wakefield SM, Trivedi MH. A Comparison of Depressive Symptom Self-Reported Measures in the Texas Youth Depression and Suicide Research Network (TX-YDSRN). J Clin Psychiatry 2023; 85:23m14861. [PMID: 38127311 DOI: 10.4088/jcp.23m14861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Objective: To evaluate psychometrically and provide crosswalks between 3 self-report measures of depressive symptomatology in youth in psychiatric care settings. Ratings included the Patient Health Questionnaire for Adolescents (PHQ-A), a widely used 9-item self-report; the 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16); and the 5-item Very Quick Inventory of Depressive Symptomatology-Self-Report (VQIDS-SR5), a recent effort to create a bridge from the QIDS-SR16 to clinical practice. Methods: Data from the Texas Youth Depression and Suicide Research Network Registry (August 26, 2020-May 11, 2022) were included in this work. At first visit, 795 depressed or suicidal adolescent (12-20 years of age) psychiatric outpatients completed the PHQ-A, QIDS-SR16, and VQIDS-SR5. Classical test theory and item-response theory (IRT) analyses were conducted. Crosswalks among total scales were created. Sensitivity to change over 1-month follow-up was assessed for all 3 scales (n = 682). Results: Cronbach alphas were 0.86 (PHQ-A), 0.80 (QIDS-SR16), and 0.76 (VQIDS-SR5). Item total correlations were 0.49-0.72, 0.29-0.64, and 0.43-0.61, respectively. All 3 scales were unidimensional and sensitive to change over a 1-month period. IRT analyses revealed satisfactory item performance. Modest but significant associations were found between baseline to 1-month changes in PHQ-A and VQIDS-SR5 total scores (r = 0.50, P < .0001) and between PHQ-A and QIDS-SR16 total scores (r = 0.56; P < .0001). Categorical thresholds of severity (ie, mild, moderate, severe, and very severe) were comparable between PHQ-A and QIDS-SR16. Conclusions: The PHQ-A, QIDS-SR16, and VQIDS-SR5 are unidimensional, psychometrically acceptable self-reports of depressive prevalence or severity in adolescents and young adults in this sample. Total scale scores on any measure can be converted reliably to those on any other.
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Affiliation(s)
- Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
| | - A John Rush
- Curbstone Consultant LLC, Santa Fe, New Mexico
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-National University of Singapore, Singapore
| | - Thomas Carmody
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
| | - Beth D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
- Children's Medical Center, Dallas, Texas
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
- Children's Medical Center, Dallas, Texas
| | - Holli Slater
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
| | - Taryn L Mayes
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
| | | | - Cynthia Garza
- Department of Psychiatry, University of Texas Rio Grande Valley, School of Medicine, Edinburg
| | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine Houston Texas
| | - Sarah M Wakefield
- Department of Psychiatry, Texas Tech University Health Science Center, Lubbock
| | - Madhukar H Trivedi
- Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute and the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas
- Corresponding Author: Madhukar H. Trivedi, MD, Center for Depression Research and Clinical Care, Peter O'Donnell Jr. Brain Institute, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9119
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Mayes TL, Carmody T, Rush AJ, Nandy K, Emslie GJ, Kennard BD, Forbes K, Jha MK, Hughes JL, Heerschap JK, Trivedi MH. Predicting suicidal events: A comparison of the Concise Health Risk Tracking Self-Report (CHRT-SR) and the Columbia Suicide Severity Rating Scale (C-SSRS). Psychiatry Res 2023; 326:115306. [PMID: 37364504 DOI: 10.1016/j.psychres.2023.115306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
This report examines the predictive capabilities of two scales of suicidality in high-risk adolescents. Charts of adolescents with severe suicidality participating in an intensive outpatient program were reviewed. Self-report data from the 9-item Concise Health Risk Tracking Self-Report (CHRT-SR9) and clinician-completed data from the Columbia Suicide Severity Risk Scale (C-SSRS) were obtained at entry. Scales' performances in predicting suicide attempts and suicidal events were evaluated using logistic regression models and ROC analyses. Of 539 adolescents, 53 had events of which 19 were attempts. The CHRT-SR9 total score predicted events (OR=1.05) and attempts (OR=1.09), as did the C-SSRS Suicide Ideation (SI) Intensity Composite for events (OR=1.10) and attempts (OR=1.16). The CHRT-SR9 AUC was 0.70 (84.2% sensitivity; 41.7% specificity; PPV=5.0%; NPV=98.6%) for attempts. The C-SSRS Intensity Composite AUC was 0.62 (89.5% sensitivity; 24.1% specificity; PPV=4.2%; NPV=98.4%) for attempts. Both the CHRT-SR9 and C-SSRS capture important parameters related to suicidal events or attempts that can help assess suicidal risk in adolescents.
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Affiliation(s)
- Taryn L Mayes
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas Carmody
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; Peter O'Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - A John Rush
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Duke-National University of Singapore, Singapore
| | - Karabi Nandy
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; Peter O'Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Graham J Emslie
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; Children's Health, Children's Medical Center, Dallas, Texas, USA
| | - Beth D Kennard
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; Children's Health, Children's Medical Center, Dallas, Texas, USA
| | - Kathryn Forbes
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Manish K Jha
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer L Hughes
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Madhukar H Trivedi
- Center for Depression Research and Clinical Care, Peter O'Donell Jr. School of Public Health and Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Balzen KM, Hensley JK, Nakonezny PA, Jones J, Kennard BD, Emslie GJ. Predicting Remission From Depression in Youth Receiving Outpatient Medication Management. J Clin Psychiatry 2023; 84. [PMID: 37195814 DOI: 10.4088/jcp.22m14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 05/19/2023]
Abstract
Objective: To examine 6-month remission rates of adolescents treated for depression in a university-based clinic and examine predictors of eventual remission. Methods: All patients aged 11-18 years treated in the clinic completed self-report measures assessing depression, suicidal ideation, anxiety, and associated symptoms. Remission was operationalized as a total score of ≤ 4 on the Patient Health Questionnaire-9 (PHQ-9) within 6 months of entering treatment. Results: Of the 430 patients, (76.74% female, 65.34% Caucasian, mean ± SD age 14.65 ± 1.69 years), 26.74% achieved remission within 6 months. Mean ± SD scores on the PHQ-9 at visit 1 (clinic entry) were 11.97 ± 4.76 for remitters (n = 115) and 15.03 ± 5.21 for non-remitters (n = 315). Predicted odds of remitting decreased as depressive symptom severity at visit 1 increased (OR = 0.941; 95% CI, 0.886 to 1.000; P = .051) and as scores on the Concise Associated Symptoms Tracking scale at treatment entry increased (OR = 0.971; 95% CI, 0.948 to 0.995; P = .017). As depression severity increased between visits, odds of remitting decreased (OR = 0.873; 95% CI, 0.827 to 0.921; P < .0001). Finally, adolescent males were more likely to achieve remission than females within 6 months (OR = 2.257; 95% CI, 1.351 to 3.771; P = .002). Conclusions: This study reports remission rates for depressed youth receiving medication management in a naturalistic outpatient setting. Results confirm that depression severity at treatment initiation and over time is a strong predictor of remission status. Additionally, monitoring associated symptoms via measurement-based care can provide important clinical information to inform treatment decisions.
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Affiliation(s)
- Kennedy M Balzen
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jane K Hensley
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul A Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
- Peter O'Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica Jones
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Psychiatry, Children's Health, Children's Medical Center, Dallas, Texas
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Psychiatry, Children's Health, Children's Medical Center, Dallas, Texas
- Corresponding author: Graham J. Emslie, MD, 1341 W Mockingbird Lane Suite 1200 E, Dallas, TX 75247
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Haley CL, Kennard BD, Morris DW, Bernstein IH, Carmody T, Emslie GJ, Mayes TL, Rush AJ. The Quick Inventory of Depressive Symptomatology, Adolescent Version (QIDS-A 17): A Psychometric Evaluation. Neuropsychiatr Dis Treat 2023; 19:1085-1102. [PMID: 37159676 PMCID: PMC10163898 DOI: 10.2147/ndt.s400591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
Objective The current study aimed to evaluate the psychometric features of the Quick Inventory of Depressive Symptomatology, Adolescent version (QIDS-A17) and the clinician-rated Children's Depression Rating Scale-Revised (CDRS-R). Methods Altogether, 103 outpatients (8 to 17 years) completed the self-report QIDS-A17-SR. Clinician interviews of adolescents (QIDS-A17-C (Adolescent)) and of parents (QIDS-A17-C (Parent)) were combined to create the QIDS-A17-C(Composite) and the CDRS-R. Results All QIDS-A17 measures and the CDRS-R evidenced high total score correlations and internal consistency. Factor analysis found all four measures to be unidimensional. Item Response Theory (IRT) analysis found results that complemented the reliability results found in CTT. All four also demonstrated discriminant diagnostic validity based on logistic regression and ANOVA analyses. Conclusion The psychometric properties of the self-report and composite versions of the QIDS-A17 suggest acceptability as a measure of depression in adolescents either as a measure of depressive symptoms or severity of illness in adolescents. The self-report version may be a helpful tool in busy clinical practices.
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Affiliation(s)
- Charlotte L Haley
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Children’s Health, Children’s Medical Center of Dallas, Dallas, TX, USA
- Correspondence: Betsy D Kennard, University of Texas Southwestern Medical Center, Child Psychiatry, 5323 Harry Hines Blvd, Dallas, TX, 75390-8589, USA, Tel +1 214.645.8680, Fax +1 214.648.3914, Email
| | - David W Morris
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ira H Bernstein
- Department of Psychology, The University of Texas at Arlington, Arlington, TX, USA
| | - Thomas Carmody
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Children’s Health, Children’s Medical Center of Dallas, Dallas, TX, USA
| | - Taryn L Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A John Rush
- Department of Psychiatry and Clinical Sciences, Duke-National University of Singapore, Singapore, Singapore
- Department of Psychiatry and Behavioral Sciences, Texas Tech University – Health Sciences Center, Permian Basin, TX, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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10
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Athreya AP, Vande Voort JL, Shekunov J, Rackley SJ, Leffler JM, McKean AJ, Romanowicz M, Kennard BD, Emslie GJ, Mayes T, Trivedi M, Wang L, Weinshilboum RM, Bobo WV, Croarkin PE. Evidence for machine learning guided early prediction of acute outcomes in the treatment of depressed children and adolescents with antidepressants. J Child Psychol Psychiatry 2022; 63:1347-1358. [PMID: 35288932 PMCID: PMC9475486 DOI: 10.1111/jcpp.13580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The treatment of depression in children and adolescents is a substantial public health challenge. This study examined artificial intelligence tools for the prediction of early outcomes in depressed children and adolescents treated with fluoxetine, duloxetine, or placebo. METHODS The study samples included training datasets (N = 271) from patients with major depressive disorder (MDD) treated with fluoxetine and testing datasets from patients with MDD treated with duloxetine (N = 255) or placebo (N = 265). Treatment trajectories were generated using probabilistic graphical models (PGMs). Unsupervised machine learning identified specific depressive symptom profiles and related thresholds of improvement during acute treatment. RESULTS Variation in six depressive symptoms (difficulty having fun, social withdrawal, excessive fatigue, irritability, low self-esteem, and depressed feelings) assessed with the Children's Depression Rating Scale-Revised at 4-6 weeks predicted treatment outcomes with fluoxetine at 10-12 weeks with an average accuracy of 73% in the training dataset. The same six symptoms predicted 10-12 week outcomes at 4-6 weeks in (a) duloxetine testing datasets with an average accuracy of 76% and (b) placebo-treated patients with accuracies of 67%. In placebo-treated patients, the accuracies of predicting response and remission were similar to antidepressants. Accuracies for predicting nonresponse to placebo treatment were significantly lower than antidepressants. CONCLUSIONS PGMs provided clinically meaningful predictions in samples of depressed children and adolescents treated with fluoxetine or duloxetine. Future work should augment PGMs with biological data for refined predictions to guide the selection of pharmacological and psychotherapeutic treatment in children and adolescents with depression.
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Affiliation(s)
- Arjun P. Athreya
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMNUSA
| | | | - Julia Shekunov
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA
| | | | | | | | | | - Betsy D. Kennard
- Peter O’Donnell Jr. Brain Institute and the Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Graham J. Emslie
- Peter O’Donnell Jr. Brain Institute and the Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallasTXUSA,Children’s HealthChildren’s Medical CenterDallasTXUSA
| | - Taryn Mayes
- Peter O’Donnell Jr. Brain Institute and the Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Madhukar Trivedi
- Peter O’Donnell Jr. Brain Institute and the Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMNUSA
| | | | - William V. Bobo
- Department of Psychiatry and PsychologyMayo ClinicJacksonvilleFLUSA
| | - Paul E. Croarkin
- Department of Psychiatry and PsychologyMayo ClinicRochesterMNUSA
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11
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Balzen KM, Goette WF, Sachs R, Krantz SM, Heerschap J, Kennard BD, Emslie GJ, Stewart SM. Borderline personality features influence treatment response to suicide prevention. J Affect Disord 2022; 311:515-522. [PMID: 35623481 DOI: 10.1016/j.jad.2022.05.083] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 04/29/2022] [Accepted: 05/15/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Suicide is a notable risk for individuals with features of borderline personality disorder. Given the centrality of interpersonal difficulties in this disorder, we proposed that the negative interpersonal cognitions (perceived burdensomeness and thwarted belongingness) identified by the Interpersonal Theory of Suicide (IPTS) may explain the associations between suicidal ideation and borderline personality features. METHOD Participants were 322 suicidal youth (74% girls) aged 11-18 years (M, SD = 14.74, 1.6) in an intensive outpatient program in the southwest United States. Youth completed measures assessing borderline personality features at program entry, and suicidal ideation and IPTS variables at entry and exit. RESULTS Borderline personality features did not moderate associations of IPTS variables and suicidal ideation. For the entire sample, changes in suicidal ideation from entry to discharge occurred in tandem with changes in perceived burdensomeness and depressive symptoms, but not thwarted belongingness. Youth with elevated borderline personality features entered with greater suicidal ideation, but improved more from treatment entry to exit. Regardless of level of borderline personality features, changes in negative interpersonal cognitions over treatment were associated with changes in suicidal ideation. LIMITATIONS Self-report measures and lack of sample diversity are study limitations. CONCLUSIONS This research highlights the clinical utility of the IPTS variables and the importance of promoting competence and interpersonal connectedness when treating this population. Findings indicate that the IPTS variables carry the same fundamental information for contributing to suicidal ideation, regardless of level of borderline personality features.
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Affiliation(s)
- Kennedy M Balzen
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - William F Goette
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Raney Sachs
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Savannah M Krantz
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jessica Heerschap
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Division of Psychology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Department of Psychiatry, Children's Health Children's Medical Center, Dallas, TX, United States of America
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Division of Psychology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Department of Psychiatry, Children's Health Children's Medical Center, Dallas, TX, United States of America
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Department of Psychiatry, Children's Health Children's Medical Center, Dallas, TX, United States of America
| | - Sunita M Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Division of Psychology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Department of Psychiatry, Children's Health Children's Medical Center, Dallas, TX, United States of America.
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12
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Brown LK, Baltrusaitis K, Kennard BD, Emslie GJ, Chernoff M, Buisson S, Lypen K, Whiteley LB, Traite S, Krotje C, Knowles K, Townley E, Deville J, Wilkins M, Reirden D, Paul M, Beneri C, Shapiro DE. Forty-eight Week Outcomes of a Site-Randomized Trial of Combined Cognitive Behavioral Therapy and Medication Management Algorithm for Treatment of Depression Among Youth with HIV in the United States. J Acquir Immune Defic Syndr 2022; 91:296-304. [PMID: 35839439 PMCID: PMC9561232 DOI: 10.1097/qai.0000000000003058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is Available in the Text. Studies suggest that manualized, measurement-guided, depression treatment is more efficacious than usual care but impact can wane. Our study among youth with HIV (YWH), aged 12–24 years at US clinical research sites in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network, found a significant reduction in depressive symptoms among YWH who received a manualized, measurement-guided treatment. This paper reports outcomes up to 24 weeks after the intervention.
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Affiliation(s)
- Larry K Brown
- Rhode Island Hospital, Providence, RI, USA.,Alpert Medical School of Brown University, Providence, RI, USA
| | - Kristin Baltrusaitis
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Betsy D Kennard
- University of Texas Southwestern Medical Center at Dallas, USA
| | - Graham J Emslie
- University of Texas Southwestern Medical Center at Dallas, USA
| | - Miriam Chernoff
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Shirley Traite
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Rockville, Maryland, USA
| | - Jaime Deville
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Megan Wilkins
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Dan Reirden
- University of Colorado School of Medicine, Children's Hospital Colorado, CO, USA
| | - Mary Paul
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | - David E Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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13
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Zhang CY, Voort JLV, Yuruk D, Mills JA, Emslie GJ, Kennard BD, Mayes T, Trivedi M, Bobo WV, Strawn JR, Athreya AP, Croarkin PE. A Characterization of the Clinical Global Impression Scale Thresholds in the Treatment of Adolescent Depression Across Multiple Rating Scales. J Child Adolesc Psychopharmacol 2022; 32:278-287. [PMID: 35704877 PMCID: PMC9353998 DOI: 10.1089/cap.2021.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/12/2022]
Abstract
Introduction: The Clinical Global Impressions-Improvement (CGI-I) scale is widely used in clinical research to assess symptoms and functioning in the context of treatment. The correlates of the CGI-I with efficacy scales for adolescent major depressive disorder are poorly understood. This study focused on benchmarking CGI-I scores with changes in the Children's Depression Rating Scale-Revised (CDRS-R) and the Quick Inventory of Depressive Symptomatology-Adolescent (17-item) Self-Report (QIDS-A17-SR). Methods: We examined three datasets with the clinician-rated CDRS-R to ascertain equivalent percent changes in total scores and CGI-I ratings. Exploratory analyses examined corresponding percentage changes in the QIDS-A17-SR and the CGI-I ratings. The CGI-I was the reference scale for nonparametric equipercentile linking with the Equate package in R. Results: CGI-I scores of 1 mapped to ≥78%-95% change in CDRS-R scores at 4-6 weeks across three datasets. CGI-I scores of 2 mapped to 56%-94% change in CDRS-R scores at 4-6 weeks across three studies. CGI-I scores of 3 mapped to 30%-68% changes in CDRS-R scores at 4-6 weeks across three studies. CGI-I scores of 4 mapped to a range of 29%-44% at 4-6 weeks across three studies. There was no significant difference (p ≥ 0.6) between treatment groups in both the Treatment of Adolescents with Depression and Treatment of Resistant Depression in Adolescents studies, for each CGI-I score ( = 1, or = 2 or = 3, or ≥4), associated mapping of total depression severity score, or associated percent change from baseline for corresponding follow-up visits. There was no significant sex difference (p > 0.2) in CGI-I linkages to CDRS-R total or percentage changes. Conclusions: These findings establish clear relationships among CGI-I scores and the CDRS-R and the QIDS-A17-SR. These benchmarks have utility for clinical trial study design, inter-rater reliability training, and clinical implementation.
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Affiliation(s)
- Carl Y. Zhang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Deniz Yuruk
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A. Mills
- Department of Economics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Health, Children's Medical Center, Dallas, Texas, USA
| | - Betsy D. Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Taryn Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Arjun P. Athreya
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.,Address correspondence to: Paul E. Croarkin, DO, MS, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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14
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Krantz SM, Heerschap J, Balzen KM, Sachs R, Kennard BD, Emslie GJ, Stewart SM. Fearlessness about death and suicide planning predict lethality of adolescent suicide attempts during and following treatment. J Clin Psychol 2022; 78:1540-1553. [PMID: 35118642 DOI: 10.1002/jclp.23324] [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] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/14/2021] [Accepted: 01/22/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The rate of adolescent suicide attempt has increased drastically over the past 10 years. However, little is known regarding what predicts a more versus less lethal attempt, which is of critical interest to clinicians managing this at-risk population. We sought to extend the study of lethality in adolescents by exploring its relationship with two recognized risk-factors for suicide attempt: fearlessness about death (FAD) and suicide planning. METHODS Participants (N = 254) were administered measures of FAD and depressive symptoms upon entering intensive outpatient treatment for adolescents exhibiting suicidal thoughts and behaviors. Attempts made between treatment entry and 6 months following discharge (n = 47) were scored on a 4-point ordinal scale of lethality. The resulting continuum ranged from no attempt to attempts of low to moderate levels of lethality. RESULTS FAD and suicide planning distinguished between levels of lethality of future attempt at the bivariate and multivariate level. FAD's predictive relationship with lethality while controlling for age, sex, depression, and prior attempt diminished when suicide planning was covaried. CONCLUSION FAD and suicide planning significantly predicted more versus less lethal future attempts in our sample of adolescents in a clinical setting. Our findings suggest that FAD influences the lethality of a future attempt by promoting planning for suicide. More studies are needed to assess whether the brief FAD scale might be a valuable adjunct in the clinical management of youth with suicidal thoughts and behaviors.
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Affiliation(s)
- Savannah M Krantz
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica Heerschap
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Kennedy M Balzen
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raney Sachs
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Sunita M Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Psychology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
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15
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Brown LK, Chernoff M, Kennard BD, Emslie GJ, Lypen K, Buisson S, Weinberg A, Whiteley LB, Traite S, Krotje C, Harriff L, Townley E, Bunch A, Purswani M, Shaw R, Spector SA, Agwu A, Shapiro DE. Site-Randomized Controlled Trial of a Combined Cognitive Behavioral Therapy and a Medication Management Algorithm for Treatment of Depression Among Youth Living With HIV in the United States. J Acquir Immune Defic Syndr 2021; 88:497-505. [PMID: 34483297 PMCID: PMC8585710 DOI: 10.1097/qai.0000000000002790] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Depression is frequent among youth living with HIV (YLWH). Studies suggest that manualized treatment guided by symptom measurement is more efficacious than usual care. SETTING This study evaluated manualized, measurement-guided depression treatment among YLWH, aged 12-24 years at 13 US sites of the International Maternal Pediatric Adolescent AIDS Clinical Trials Network. METHODS Using restricted randomization, sites were assigned to either a 24-week, combination cognitive behavioral therapy and medication management algorithm (COMB-R) tailored for YLWH or to enhanced standard of care, which provided standard psychotherapy and medication management. Eligibility included diagnosis of nonpsychotic depression and current depressive symptoms. Arm comparisons used t tests on site-level means. RESULTS Thirteen sites enrolled 156 YLWH, with a median of 13 participants per site (range 2-16). At baseline, there were no significant differences between arms on demographic factors, severity of depression, or HIV status. The average site-level participant characteristics were as follows: mean age of 21 years, 45% male, 61% Black, and 53% acquired HIV through perinatal transmission. At week 24, youth at COMB-R sites, compared with enhanced standard of care sites, reported significantly fewer depressive symptoms on the Quick Inventory for Depression Symptomatology Self-Report (QIDS-SR score 6.7 vs. 10.6, P = 0.01) and a greater proportion in remission (QIDS-SR score ≤ 5; 47.9% vs. 17.0%, P = 0.01). The site mean HIV viral load and CD4 T-cell level were not significantly different between arms at week 24. CONCLUSIONS A manualized, measurement-guided psychotherapy and medication management algorithm tailored for YLWH significantly reduced depressive symptoms compared with standard care at HIV clinics.
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Affiliation(s)
- Larry K. Brown
- Rhode Island Hospital; Alpert Medical School of Brown University, USA
| | - Miriam Chernoff
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | | | | | - Adriana Weinberg
- University of Colorado School of Medicine, Children’s Hospital Colorado, CO, USA
| | - Laura B. Whiteley
- Rhode Island Hospital; Alpert Medical School of Brown University, USA
| | - Shirley Traite
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Rockville, Maryland, USA
| | - Amber Bunch
- University of Colorado School of Medicine, Children’s Hospital Colorado, CO, USA
| | - Murli Purswani
- BronxCare Health System, Division of Pediatric Infectious Disease, Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ray Shaw
- Jacobi Medical Center, Bronx, NY, USA
| | - Stephen A. Spector
- University of California, San Diego, La Jolla, CA and Rady Children’s Hospital San Diego, CA, USA
| | | | - David E. Shapiro
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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16
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Abstract
Recent theories of suicide behavior have proposed a risk factor that differentiates suicide ideators from suicide attempters: Suicide capability. Fearlessness about death, one component of capability, has predicted the likelihood of a future attempt in adult samples. Although there is preliminary evidence about its value in youth, the fearlessness about death scale (FAD) has not yet been validated in clinical adolescents. We sought to examine the psychometric properties of this scale in adolescents at high risk for making a future suicide attempt. Youth who were evaluated for an intensive outpatient program (IOP) for suicidal adolescents (N = 496; M, SD for age = 14.78, 1.59) reported lifetime history of suicide attempts and NSSI, suicide ideation, depressive symptoms, and completed the FAD at entry and at discharge (n = 329). Confirmatory factor analysis showed structural validity of the FAD scale and its invariance across age, sex, and time. Independent t-tests indicated that FAD scores distinguished between those with and without NSSI, as well as those with single versus multiple attempts. When depression was covaried in logistic regression analyses, FAD's relationship with suicide attempt history persisted, showing the construct's divergence from depression. Our findings present psychometric validity in adolescents for a widely used scale developed for adults. This validation offers confidence that this promising risk factor can be adequately investigated in adolescents. If future studies can confirm its predictive validity, the brevity of this scale would make it a practical addition to a clinical assessment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Savannah M Krantz
- Department of Psychiatry, University of Texas Southwestern Medical Center
| | - Xue Yang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong
| | - Jessica King
- Department of Psychiatry, University of Texas Southwestern Medical Center
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center
| | - Sunita M Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center
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17
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Ferm MS, Frazee LA, Kennard BD, King JD, Emslie GJ, Stewart SM. Fearlessness about death predicts adolescent suicide attempt: A preliminary analysis. Suicide Life Threat Behav 2020; 50:1288-1295. [PMID: 33103267 DOI: 10.1111/sltb.12715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/13/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Several theories of suicide suggest that people will only attempt suicide if they have both the desire to die and the capability for suicide. Fearlessness about death is a key component of capability for suicide. There is little information in the literature about the prospective relationship between fearlessness about death and suicide attempt in adolescents. METHOD We obtained baseline fearlessness about death from adolescents (N = 122; ages 12-18; 80% girls; 82% Caucasian) who received intensive outpatient treatment for active suicidal ideation and/or a recent attempt. We tested if fearlessness about death at treatment entry predicted an attempt (n = 14) between entry and six-month follow-up after discharge from the program. RESULTS Fearlessness about death significantly predicted the presence of an attempt between treatment entry and six-month follow-up after controlling for common covariates (Quade F = 2.15, p < .02). CONCLUSIONS In a preliminary analysis of a group of suicidal adolescents, fearlessness about death was a significant independent predictor of attempt between treatment entry and six months post-discharge, even when controlling for other commonly cited risk factors.
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Affiliation(s)
- Mikael S Ferm
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Laura A Frazee
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Betsy D Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Jessica D King
- Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
| | - Sunita M Stewart
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Psychiatry, Children's Health Children's Medical Center, Dallas, Texas, USA
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18
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Mayes TL, Killian M, Rush AJ, Emslie GJ, Carmody T, Kennard BD, Jha MK, King J, Hughes JL, Trivedi MH. Predicting future suicidal events in adolescents using the Concise Health Risk Tracking Self-Report (CHRT-SR). J Psychiatr Res 2020; 126:19-25. [PMID: 32413596 DOI: 10.1016/j.jpsychires.2020.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 11/26/2019] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several self-report rating scales have been developed to assess suicidal ideation, yet most have limited utility in predicting future suicide attempts. This is particularly critical in adolescence, where suicide is the second leading cause of death. This study evaluated the Concise Health Risk Tracking Self-Report (CHRT-SR) as a prospective predictor of suicide attempts and events in high-risk adolescents enrolled in a suicide-prevention intensive outpatient program (IOP). METHODS Data were collected by retrospective chart review of adolescents treated in IOP for youth with severe suicidality. At baseline, youth completed the 14-item CHRT-SR (CHRT-SR14), which assesses suicide risk based on 3 subscales: Propensity, Impulsivity, and Suicidal Thoughts. Two outcomes were assessed: actual suicide attempts and suicidal events (suicide attempt, inpatient hospitalization, or emergency department visit) during the IOP. RESULTS Of the 251 adolescents who completed the baseline CHRT-SR14, 26 had a suicidal event during IOP (mean time in IOP: 5.4 ± 2.3 weeks), of whom 14 had an actual suicide attempt. Youth with any suicidal event had higher scores than those without an event on the CHRT-SR14 Total (p = .005), Propensity (p = .008), and Suicidal Thoughts (p = .001) scales at baseline. Youth who made a suicide attempt had significantly higher scores than those without an event for the Total Score, Propensity, and Suicidal Thoughts subscales. CHRT-SR14 Total Score of 28 had a sensitivity of 85.7% and specificity of 56.5% in predicting suicide attempts. A score of 22 predicted suicidal events, with a sensitivity of 80.8% and specificity of 40.9%. CHRT-SR7 Total Score of 12 predicted suicide attempts, with a sensitivity of 85.7% and specificity of 53.4%. CONCLUSIONS The CHRT-SR14 self-report predicts suicide attempts and events with at least 80% sensitivity and acceptable specificity in adolescents at high-risk for suicide.
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Affiliation(s)
- Taryn L Mayes
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Michael Killian
- College of Social Work, Florida State University 296 Champions Way, Tallahassee, FL, 32304, Children's Medical Center of Dallas, USA.
| | - A John Rush
- Department of Psychiatry, Duke Medical School, Texas Tech University-Health Sciences Center, Permian Basin, Professor Emeritus at Duke National University of Singapore, Singapore.
| | - Graham J Emslie
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA; Department of Psychiatry, Children's Health Systems of Texas, Children's Medical Center, USA.
| | - Thomas Carmody
- Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Betsy D Kennard
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA; Department of Psychiatry, Children's Health Systems of Texas, Children's Medical Center, USA.
| | - Manish K Jha
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jessica King
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA; Department of Psychiatry, Children's Health Systems of Texas, Children's Medical Center, USA
| | - Jennifer L Hughes
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Madhukar H Trivedi
- Department of Psychiatry, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
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19
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Stewart SM, Emslie GJ. Editorial: Extending Parent-Child Interaction Therapy to Preschool Children Who Are Depressed. J Am Acad Child Adolesc Psychiatry 2020; 59:803-804. [PMID: 31972261 DOI: 10.1016/j.jaac.2020.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/24/2019] [Accepted: 01/03/2020] [Indexed: 11/27/2022]
Abstract
The World Health Organization lists depression as the single largest contributor to global disability. More than 300 million people worldwide are estimated to suffer from this disorder. Success in managing depression once it begins is limited, with questions about the extent of the effectiveness of antidepressant medications and psychosocial treatments on depression in youths.1,2 Depression is associated with a host of attendant comorbidities, such as substance use and suicidal and nonsuicidal self-injury, which are difficult to treat and wreak further havoc on the lives of youths and their families. There are few available nonpharmacological treatments for preschool depression. Parent-Child Interaction therapy (PCIT) is an evidence-based program3 designed to address externalizing behaviors in preschool children. Luby et al.4 present data on the effectiveness of a module that extends PCIT to address symptoms of preschool depression (PCIT-ED). Strengths of this study are the extension of a well-developed program to a group in high need, a sequential approach to examining effects, and the measurement of neural response as an outcome. The study is an exciting contribution to the care of preschool children. It has implications for early intervention, for altering trajectories of negative parent-child interactions in vulnerable families, and for personalized approaches to care.
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Affiliation(s)
- Sunita M Stewart
- UT Southwestern Medical Center, Dallas, Texas; Children's Health Systems of Texas.
| | - Graham J Emslie
- UT Southwestern Medical Center, Dallas, Texas; Children's Health Systems of Texas
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20
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Eaddy M, Zullo L, Horton SE, Hughes JL, Kennard B, Diederich A, Emslie GJ, Schuster L, Stewart SM. A Theory-Driven Investigation of the Association Between Emotion Dysregulation and Suicide Risk in a Clinical Adolescent Sample. Suicide Life Threat Behav 2019; 49:928-940. [PMID: 29745436 DOI: 10.1111/sltb.12472] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 05/22/2017] [Accepted: 04/16/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Emotion dysregulation has been consistently linked to suicide ideation and attempt, but an explanatory model for this relationship has not been adequately investigated in adolescents. This study examined the concurrent relationship among emotion dysregulation, variables from the Interpersonal-Psychological Theory of Suicide (IPTS), and suicide risk (operationalized as a continuous variable that increases in intensity from nonspecific to active suicide ideation to suicide ideation with a plan) in a clinical adolescent sample. METHOD A total of 151 adolescents (aged 12-17) were recruited from an inpatient psychiatry unit. Cross-sectional analyses were conducted to determine whether the relationship between emotion dysregulation and suicide risk was explained by the variables of perceived burdensomeness (PB), thwarted belongingness, and capability for suicide, as proposed by the IPTS. RESULTS As hypothesized, the relationship between emotion dysregulation and suicide risk was explained by PB and capability for suicide. Depressive symptoms had an independent relationship with suicide risk after controlling for IPTS variables. CONCLUSIONS The results from this study suggest that effective treatment strategies that reduce negative cognition tied to PB and depressive symptoms would address the most proximal variables related to suicide risk in adolescents. Enhancing emotion management would serve to maintain low levels of proximal influences on risk.
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Affiliation(s)
- Michael Eaddy
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Lucas Zullo
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Sarah E Horton
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | | | - Betsy Kennard
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Andrew Diederich
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Graham J Emslie
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Lisa Schuster
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
| | - Sunita M Stewart
- Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Children's Medical Center, Dallas, TX, USA
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21
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Duffy ME, Gai AR, Rogers ML, Joiner TE, Luby JL, Joshi PT, Wagner KD, Emslie GJ, Walkup JT, Axelson D. Psychotic symptoms and suicidal ideation in child and adolescent bipolar I disorder. Bipolar Disord 2019; 21:342-349. [PMID: 31025487 PMCID: PMC6597286 DOI: 10.1111/bdi.12789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder. METHODS Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning. RESULTS Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation. CONCLUSIONS Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder.
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Affiliation(s)
- Mary E Duffy
- Department of Psychology, Florida State University, Tallahassee, Florida
| | - Anna R Gai
- Department of Psychology, Florida State University, Tallahassee, Florida
| | - Megan L Rogers
- Department of Psychology, Florida State University, Tallahassee, Florida
| | - Thomas E Joiner
- Department of Psychology, Florida State University, Tallahassee, Florida
| | - Joan L Luby
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Paramjit T Joshi
- Department of Psychiatry, University of California, Irvine, California
| | - Karen D Wagner
- Department of Psychiatry, University of Texas Medical Branch, Galveston, Texas
| | - Graham J Emslie
- Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas, Texas
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John T Walkup
- Department of Psychiatry, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David Axelson
- Nationwide Children's Hospital Research Institute, The Ohio State University College of Medicine, Columbus, Ohio
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22
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Wolfe KL, Nakonezny PA, Owen VJ, Rial KV, Moorehead AP, Kennard BD, Emslie GJ. Hopelessness as a Predictor of Suicide Ideation in Depressed Male and Female Adolescent Youth. Suicide Life Threat Behav 2019; 49:253-263. [PMID: 29267993 PMCID: PMC6013307 DOI: 10.1111/sltb.12428] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [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: 04/13/2017] [Accepted: 09/07/2017] [Indexed: 11/26/2022]
Abstract
We examined hopelessness as a predictor of suicide ideation in depressed youth after acute medication treatment. A total of 158 depressed adolescents were administered the Children's Depression Rating Scale-Revised (CDRS-R) and Columbia Suicide Severity Rating Scale (C-SSRS) as part of a larger battery at baseline and at weekly visits across 6 weeks of acute fluoxetine treatment. The Beck Hopelessness Scale (BHS) was administered at baseline and week 6. A negative binomial regression model via a generalized estimating equation analysis of repeated measures was used to estimate suicide ideation over the 6 weeks of acute treatment from baseline measure of hopelessness. Depression severity and gender were included as covariates in the model. The negative binomial analysis was also conducted separately for the sample of males and females (in a gender-stratified analysis). Mean CDRS-R total scores were 60.30 ± 8.93 at baseline and 34.65 ± 10.41 at week 6. Mean baseline and week 6 BHS scores were 9.57 ± 5.51 and 5.59 ± 5.38, respectively. Per the C-SSRS, 43.04% and 83.54% reported having no suicide ideation at baseline and at week 6, respectively. The analyses revealed that baseline hopelessness was positively related to suicide ideation over treatment (p = .0027), independent of changes in depression severity. This significant finding persisted only for females (p = .0024). These results indicate the importance of early identification of hopelessness.
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Affiliation(s)
- Kristin L. Wolfe
- Children's Health; University of Texas Southwestern Medical Center; Dallas TX USA
| | | | - Victoria J. Owen
- Children's Health; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Katherine V. Rial
- Children's Health; University of Texas Southwestern Medical Center; Dallas TX USA
| | | | - Beth D. Kennard
- Children's Health; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Graham J. Emslie
- Children's Health; University of Texas Southwestern Medical Center; Dallas TX USA
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23
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Mayes TL, Kennard BD, Killian M, Carmody T, Grannemann BD, Rush AJ, Jha MK, Hughes J, Emslie GJ, Trivedi MH. Psychometric properties of the concise health risk tracking (CHRT) in adolescents with suicidality. J Affect Disord 2018; 235:45-51. [PMID: 29649710 DOI: 10.1016/j.jad.2018.03.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 10/04/2017] [Revised: 03/01/2018] [Accepted: 03/10/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Several self-report rating scales have been developed to assess suicidal ideation, yet few examine other factors related to increased suicidal risk, and even fewer have been validated in both adolescents and adults. We evaluate the 14-item Concise Health Risk Tracking - Self Report (CHRT-SR), a measure previously validated in adults, in a sample of adolescents at risk for suicide. METHOD Data are from a retrospective chart review of adolescents treated in an intensive outpatient program for youth with severe suicidality. Teens completed the CHRT-SR and Quick Inventory of Depressive Symptomatology - Adolescents (QIDS-A) at baseline and discharge. The CHRT-SR was evaluated to determine the factor validity, internal consistency, construct validity, and sensitivity to change. RESULTS Adolescents (n = 271) completed the CHRT-SR prior to treatment, and 231 completed the CHRT-SR at discharge. Three factors were identified with excellent model fit: Propensity, Impulsivity, and Suicidal Thoughts. Internal consistency reliability coefficients were good-to-excellent for the total score and all three factors at baseline (a = 0.774-0.915) and exit (a = 0.849-0.941). The total score and all three factors significantly correlated with overall depression severity and suicidal ideation as rated by teens and parent (p = .704-0.756, all p < .001). The CHRT-SR was sensitive to change, with moderate to large effect sizes (Cohen's d = 0.599-1.062). LIMITATIONS Study limitations include generalizability, lack of a control group, and retrospective data from a sample of opportunity. CONCLUSIONS The CHRT-SR is a reliable and valid measure for examining severity of suicidal thoughts and associated risk factors, and is sensitive to change following an intervention in adolescents.
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Affiliation(s)
- Taryn L Mayes
- Department of Psychiatry at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States. taryn.mayes.@utsouthwestern.edu
| | - Betsy D Kennard
- UT Southwestern Medical Center and the Department of Psychiatry at Children's Health Systems of Texas, Children's Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
| | - Michael Killian
- School of Social Work at UT Arlington, 211 S. Cooper St., #201b, Arlington, TX, 76019, United States.
| | - Thomas Carmody
- Department of Clinical Sciences at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
| | - Bruce D Grannemann
- Department of Psychiatry at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
| | - A John Rush
- Professor emeritus, Duke-NUS, 7 Avenida Vista Grande, #112, Santa Fe, NM, 87508, United States.
| | - Manish K Jha
- Department of Psychiatry at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
| | - Jennifer Hughes
- Department of Psychiatry at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
| | - Graham J Emslie
- Department of Psychiatry at UT Southwestern Medical Center, 6300 Harry Hines Blvd. Suite 1200, Dallas, TX 75235, United States.
| | - Madhukar H Trivedi
- Department of Psychiatry at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9119, United States.
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24
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King JD, Horton SE, Hughes JL, Eaddy M, Kennard BD, Emslie GJ, Stewart SM. The Interpersonal-Psychological Theory of Suicide in Adolescents: A Preliminary Report of Changes Following Treatment. Suicide Life Threat Behav 2018; 48:294-304. [PMID: 28370278 DOI: 10.1111/sltb.12352] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 10/12/2016] [Accepted: 01/17/2017] [Indexed: 11/28/2022]
Abstract
This study investigated change in suicide risk in the framework of the interpersonal theory of suicide. Fifty-four adolescents completed measures of interpersonal needs, acquired capability, depressive symptoms, and suicide risk at entry and exit from treatment. There was a significant drop following treatment in unmet interpersonal needs but not in acquired capability, consistent with the theory. Both change in the interaction between interpersonal needs and in depressive symptoms contributed unique prediction to change in suicide risk. These findings extend the research in understanding changes in suicide risk and inform treatment by suggesting cognitive targets for intervention.
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Affiliation(s)
- Jessica D King
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Sarah E Horton
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Jennifer L Hughes
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Michael Eaddy
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Betsy D Kennard
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Graham J Emslie
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
| | - Sunita M Stewart
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.,Children's Health Children's Medical Center Dallas, Dallas, TX, USA
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25
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Matney J, Westers NJ, Horton SE, King JD, Eaddy M, Emslie GJ, Kennard BD, Stewart SM. Frequency and Methods of Nonsuicidal Self-Injury in Relation to Acquired Capability for Suicide Among Adolescents. Arch Suicide Res 2018; 22:91-105. [PMID: 28121238 DOI: 10.1080/13811118.2017.1283266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The objective of this study was to test the Interpersonal Psychological Theory of Suicide (IPTS) proposal that the association of nonsuicidal self-injury (NSSI) with suicide attempt is mediated by acquired capability. Inpatient adolescents (n = 134) reported on suicide ideation and attempts, NSSI frequency and methods, depressive symptoms, and acquired capability for suicide. Consistent with the IPTS, both measures of NSSI were positively associated with acquired capability after accounting for depressive symptoms and past history of attempts. However, both NSSI measures explained independent variance in number of suicide attempts after controlling for suicide ideation and acquired capability. These findings contradict the IPTS and suggest that the role of NSSI in suicide attempt is mediated by variables external to the IPTS.
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26
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Kennard BD, Mayes TL, Chahal Z, Nakonezny PA, Moorehead A, Emslie GJ. Predictors and Moderators of Relapse in Children and Adolescents With Major Depressive Disorder. J Clin Psychiatry 2018; 79:15m10330. [PMID: 29474007 PMCID: PMC9590113 DOI: 10.4088/jcp.15m10330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 08/16/2015] [Accepted: 07/27/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify predictors and moderators of relapse during continuation treatment among depressed youth randomly assigned to fluoxetine or placebo. METHODS Potential predictors and moderators of relapse that were identified by a literature review were examined in 102 youth (aged 7-18 years), diagnosed with major depressive disorder as defined by DSM-IV criteria, who were considered responders after 12 weeks of fluoxetine treatment (acute phase). This randomized controlled trial was conducted from June 2000 through October 2005. Each candidate predictor and moderator was evaluated with a multiple logistic regression model to examine the main and interaction effects of 12 weeks of continuation treatment on relapse status (at week 24) while controlling for age, sex, and depression severity. Relapse was defined as a Children's Depression Rating Scale-Revised total score ≥ 40 with worsening of depressive symptoms for at least 2 weeks. RESULTS Youth with comorbid dysthymia (adjusted odds ratio [OR] = 2.88, P = .03) and low levels of family leadership (adjusted OR = 1.39, P = .006) at baseline are more likely to relapse than their counterparts. Higher levels of depression (OR = 1.21, P = .003) and higher levels of residual sleep disturbance (insomnia) (OR = 6.74, P = .006) and irritability (OR = 7.40, P = .01) at the end of acute treatment (12 weeks) increased the odds of relapse. Higher levels of depressive symptoms at baseline in youth who remained on fluoxetine for continuation treatment were associated with increased odds of relapse (adjusted OR = 1.14, P = .03). Females who remained on fluoxetine for the duration of continuation treatment were almost 9 times more likely to relapse than males (adjusted OR = 8.86, P = .007). CONCLUSIONS This is the first large continuation study for treatment of depression in youth to examine predictors and moderators of relapse. Youth with greater improvement by the end of 3 months of treatment were less likely to relapse than those with continued depressive symptoms. In addition, youth with comorbid dysthymia had 3 times greater risk of relapse that those without. Targeting residual symptoms, particularly sleep disturbance and irritability, earlier in treatment may reduce relapse rates. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00332787.
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Affiliation(s)
- Beth D. Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Children’s Health, Children’s Medical Center, Dallas, Texas,Corresponding author: Beth D. Kennard, PsyD, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8589 ()
| | - Taryn L. Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Children’s Health, Children’s Medical Center, Dallas, Texas
| | - Zohra Chahal
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Children’s Health, Children’s Medical Center, Dallas, Texas
| | - Paul A. Nakonezny
- Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alexandra Moorehead
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Children’s Health, Children’s Medical Center, Dallas, Texas
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Children’s Health, Children’s Medical Center, Dallas, Texas
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27
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Stanley IH, Hom MA, Luby JL, Joshi PT, Wagner KD, Emslie GJ, Walkup JT, Axelson DA, Joiner TE. Comorbid sleep disorders and suicide risk among children and adolescents with bipolar disorder. J Psychiatr Res 2017; 95:54-59. [PMID: 28777984 PMCID: PMC5653415 DOI: 10.1016/j.jpsychires.2017.07.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 06/02/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 01/27/2023]
Abstract
Children and adolescents with bipolar disorder are at increased risk for suicide. Sleep disturbances are common among youth with bipolar disorder and are also independently implicated in suicide risk; thus, comorbid sleep disorders may amplify suicide risk in this clinical population. This study examined the effects of comorbid sleep disorders on suicide risk among youth with bipolar disorder. We conducted secondary analyses of baseline data from the Treatment of Early Age Mania (TEAM) study, a randomized controlled trial of individuals aged 6-15 years (mean ± SD = 10.2 ± 2.7 years) with DSM-IV bipolar I disorder (N = 379). Sleep disorders (i.e., nightmare, sleep terror, and sleepwalking disorders) and suicide risk were assessed via the WASH-U-KSADS and the CDRS-R, respectively. We constructed uncontrolled logistic regression models as well as models controlling for trauma history, a generalized anxiety disorder (GAD) diagnosis, and depression symptoms. Participants with a current comorbid nightmare disorder versus those without were nearly twice as likely to screen positive for suicide risk in an uncontrolled model and models controlling for trauma history, a GAD diagnosis, and depression symptoms. Neither a current comorbid sleep terror disorder nor a sleepwalking disorder was significantly associated with suicide risk. This pattern of findings remained consistent for both current and lifetime sleep disorder diagnoses. Youth with bipolar I disorder and a comorbid nightmare disorder appear to be at heightened suicide risk. Implications for assessment and treatment are discussed.
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Affiliation(s)
- Ian H. Stanley
- Department of Psychology, Florida State University, Tallahassee, FL USA
| | - Melanie A. Hom
- Department of Psychology, Florida State University, Tallahassee, FL USA
| | - Joan L. Luby
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO USA
| | - Paramjit T. Joshi
- Division of Psychiatry and Behavioral Sciences, Children's National Health System, Washington, DC USA
| | - Karen D. Wagner
- Department of Psychiatry, University of Texas Medical Branch, Galveston, TX USA
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX USA,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas, TX USA
| | - John T. Walkup
- Department of Psychiatry, Weill Cornell Medical College, New York, NY USA
| | - David A. Axelson
- Nationwide Children's Hospital Research Institute and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas E. Joiner
- Department of Psychology, Florida State University, Tallahassee, FL USA
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28
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Stewart SM, Lewinsohn PM, Lee PWH, Ho LM, Kennard B, Hughes CW, Emslie GJ. Symptom Patterns in Depression and “Subthreshold” Depression among Adolescents in Hong Kong and the United States. Journal of Cross-Cultural Psychology 2016. [DOI: 10.1177/022022102238269] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study compared the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) Major Depressive Disorder (MDD) diagnostic interview information from a representative, stratified sample of 85 (selected from 2,212) Hong Kong and 1,706 age- and sex-matched U.S. adolescents. Current prevalence rates (Hong Kong: 2.2%, 95% Confidence Interval [CI] = 1.3% to 3.1%; United States: 2.2%, 95% CI = 1.6% to 3.0%) were similar in the two cultures. More Hong Kong compared to U.S. adolescents reported fatigue/loss of energy and fewer reported irritability. All Hong Kong participants with MDD reported fatigue, sleep, and concentration difficulties. Hong Kong adolescents who did not meet criteria for MDD but reported high levels of depressive symptoms showed social function and cognitions similar to youth with MDD and dissimilar to nondepressed youth. The results suggest that adolescent MDD is as prevalent in Hong Kong as in the West and that “subthreshold” depression is not a benign condition. Comparisons of symptom patterns in the two cultures showed culture’s influences on expressions of distress.
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Affiliation(s)
| | | | | | | | - Betsy Kennard
- University of Texas Southwestern Medical Center at Dallas
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29
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Abstract
We evaluated 22 learning disabled students with documented learning disabilities on standardized academic achievement tests at the beginning and end of one academic school year. In addition, at the beginning of the school year, neuropsychological measures were also administered and readministered at 1.5 year follow-up to a subset of these children (N =16). As a group, subjects demonstrated impairment on neuropsychological measures and these measures were stable over the follow-up period. Subjects improved from the beginning of the school year to the end of the school year in the academic area of written language. Specific patterns of neuropsychological ability correlated with academic improvement in specific areas. Our preliminary results suggest that neuropsychological testing may be useful in predicting academic improvement and ultimately in designing educational strategies for learning disabled children.
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Affiliation(s)
- Betsy D. Kennard
- University of Texas Southwestern Medical Center at Dallas, Children's Medical Center at Dallas
| | | | | | - Graham J. Emslie
- University of Texas Southwestern Medical Center at Dallas, Children's Medical Center at Dallas
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30
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Lewis CP, Nakonezny PA, Ameis SH, Vande Voort JL, Husain MM, Emslie GJ, Daskalakis ZJ, Croarkin PE. Cortical inhibitory and excitatory correlates of depression severity in children and adolescents. J Affect Disord 2016; 190:566-575. [PMID: 26580570 PMCID: PMC4685002 DOI: 10.1016/j.jad.2015.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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] [Received: 08/20/2015] [Revised: 10/01/2015] [Accepted: 10/15/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Neurophysiologic correlates of depression severity potentially have great utility in diagnosis and treatment planning. Transcranial magnetic stimulation (TMS) measures of cortical inhibition and excitability have shown promise as biomarkers in psychiatry, but no prior work has examined correlates of illness severity in pediatric mood disorders. This study sought to examine the relationship between depression severity and TMS measures of cortical inhibition and excitability in children and adolescents. METHODS Twenty-four depressed and 22 healthy control youth underwent TMS testing (cortical silent period [CSP], short-interval intracortical inhibition at 2-ms and 4-ms interstimulus intervals (ISIs) [SICI-2,-4], resting motor threshold [RMT] and intracortical facilitation at 10-, 15-, and 20-ms ISIs [ICF-10,-15,-20]). Symptom severity was assessed with the Quick Inventory of Depressive Symptomatology (QIDS-A17-SR) and the Children's Depression Rating Scale-Revised (CDRS-R). RESULTS In the overall sample, the following significant negative correlations were observed: CDRS-R and CSP (right hemisphere, ρ=-0.35, p=0.021); QIDS-A17-SR and CSP (left, ρ=-0.33, p=0.031; right, ρ=-0.42, p=0.004); and CDRS-R and SICI-4 (right, ρ=-0.30, p=0.042). Among healthy control participants, additional significant negative correlations were observed between QIDS-A17-SR and right ICF-10; QIDS-A17-SR and right ICF-15; and QIDS-A17-SR and left ICF-20. Among depressed participants, significant negative correlations were observed between QIDS-A17-SR and bilateral CSP; CDRS-R and bilateral ICF-10; CDRS-R and bilateral ICF-15; QIDS-A17-SR and left ICF-10; and QIDS-A17-SR and bilateral ICF-15. LIMITATIONS Small sample, potential developmental/age- and sex-related effects. CONCLUSIONS These preliminary results provide evidence for a relationship between depression severity and dysfunction in GABAergic and glutamatergic cortical processes in a pediatric population.
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Affiliation(s)
- Charles P. Lewis
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA,Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephanie H. Ameis
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer L. Vande Voort
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry, Mayo Clinic, Rochester, Minnesota, USA
| | - Mustafa M. Husain
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA,Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA,Children's Medical Center of Dallas, Dallas, Texas, USA
| | - Zafiris J. Daskalakis
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry, Mayo Clinic, Rochester, Minnesota, USA
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Affiliation(s)
- Graham J Emslie
- From the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Tex
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Emslie GJ, Kennard BD, Mayes TL, Nakonezny PA, Moore J, Jones JM, Foxwell AA, King J. Continued Effectiveness of Relapse Prevention Cognitive-Behavioral Therapy Following Fluoxetine Treatment in Youth With Major Depressive Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54:991-8. [PMID: 26598474 PMCID: PMC9597885 DOI: 10.1016/j.jaac.2015.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 05/07/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the continued effect of a sequential treatment strategy (fluoxetine followed by continued medication plus relapse prevention cognitive-behavioral therapy [RP-CBT]) on relapse prevention beyond the treatment phase. METHOD Youth (aged 8-17 years) with major depressive disorder (MDD) were treated with fluoxetine for 6 weeks. Responders (≥50% reduction on the Children's Depression Rating Scale-Revised [CDRS-R]) were randomized to continued medication management alone (MM) or continued medication management plus RP-CBT (MM+CBT) for an additional 6 months. Long-term follow-up assessments were conducted at weeks 52 and 78. RESULTS Of 144 youth randomized to MM (n = 69) or MM+CBT (n = 75), 67% had at least 1 follow-up assessment, with equal rates in the 2 groups. Remission rates were high, although most had remitted during the 30-week treatment period. Only 6 additional participants remitted during long-term follow-up, and there were no differences on time to remission between MM+CBT and MM. The MM+CBT group had a significantly lower risk of relapse than the MM group throughout the 78-week follow-up period (hazard ratio = 0.467, 95% CI = 0.264 to 0.823; χ(2) = 6.852, p = .009). The estimated probability of relapse during the 78-week period was lower with MM+CBT than MM only (36% versus 62%). Mean time to relapse was also significantly longer with MM+CBT compared to MM alone by approximately 3 months (p = .007). CONCLUSION The addition of RP-CBT after acute response to medication management had a continued effect on reducing risk of relapse even after the end of treatment. Clinical trial registration information-Sequential Treatment of Pediatric MDD to Increase Remission and Prevent Relapse; http://clinicaltrials.gov/; NCT00612313.
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Affiliation(s)
- Graham J. Emslie
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Betsy D. Kennard
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Taryn L. Mayes
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Paul A. Nakonezny
- Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas
| | - Jarrette Moore
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Jessica M. Jones
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Aleksandra A. Foxwell
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
| | - Jessica King
- University of Texas Southwestern Medical Center and Children’s Health Children’s Medical Center, Dallas
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Nakonezny PA, Mayes TL, Byerly MJ, Emslie GJ. Predicting placebo response in adolescents with major depressive disorder: The Adolescent Placebo Impact Composite Score (APICS). J Psychiatr Res 2015; 68:346-53. [PMID: 26028546 DOI: 10.1016/j.jpsychires.2015.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 01/27/2015] [Revised: 04/17/2015] [Accepted: 05/07/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to construct a composite scoring system to predict the probability of placebo response in adolescents with Major Depressive Disorder (MDD). METHOD Participants of the current study were 151 adolescents (aged 12-17 years) who were randomized to the placebo arm (placebo transdermal patches) of a randomized controlled trial (RCT) comparing the selegiline transdermal patch with placebo (DelBello et al., 2014). The primary outcome of response was defined as a CGI-I score of 1 or 2 (very much or much improved) at week 12 (study-end) or exit. As a first step, a multiple logistic mixed model was used to estimate the odds of placebo response from each predictor in the model, including age, CDRS-R total at baseline (depressive symptom severity), history of recurrent depression (yes vs. no), sex (female vs. male), and race (non-Caucasian vs. Caucasian). On the basis of the initial logistic mixed model analysis, we then constructed an Adolescent Placebo Impact Composite Score (APICS) that became the sole predictor in a re-specified Bayesian logistic regression model to estimate the probability of placebo response. Finally, the AUC for the APICS was tested against a nominal area of 0.50 to evaluate how well the APICS discriminated placebo response status. RESULTS Among the 151 adolescents, with a mean age of 14.6 years (SD = 1.6) and a mean baseline CDRS-R total of 60.6 (SD = 12.1), 68.2% were females, 50.3% was Caucasian, and 39.7% had a history of recurrent depression. Placebo response rate was 58.3%. Based on the logistic mixed model, the re-specified equation with the highest discriminatory ability to estimate the probability of placebo response was APICS = age + (0.32 × CDRS-R Total at baseline) + (-2.85 × if female) + (-5.50 × if history of recurrent depression) + (-5.85 × if non-Caucasian). The AUC for this model was 0.59 (p = .049). Within a Bayesian decision-theoretic framework, in 95.5% of the time, the 10,000 posterior Monte Carlo samples suggested that as APICS decreased the probability of placebo response increased. The observed APICS and related probability of responding to placebo in this adolescent sample ranged from 14.1 = 74.1% (in placebo responders) to 39.1 = 41.8% (in placebo non-responders). CONCLUSION The APICS model estimates the probability of placebo response in adolescents with MDD with a modest degree of accuracy (AUC = 0.59) and with a reasonable degree of positive predictive value (74.5%), and is based on five previously identified patient characteristics of placebo response from prior meta-analytic studies (Bridge et al., 2009; Cohen et al., 2010) of randomized placebo-controlled trials of antidepressants in youth with MDD. Calculation of the APICS should be restricted to the range of the adolescent ages (12-17 years) and CDRS-R total scores (17-113); thus, the APICS can assume possible calculated values and related probability of responding to placebo ranging from about 3 (84%) to 53 (25%). The APICS Bayesian logistic model, based on a given aggregate patient profile, has a range of predicted probabilities of placebo response that is fairly wide, albeit truncated, but potentially meaningful for predicting the probability of placebo response among adolescent youth with MDD. The ability of the APICS to objectify the probability of placebo response in adolescents with MDD could be accounted for in the clinical research design of the trial itself and perhaps aid clinicians in treatment strategy for youth who are more likely to experience placebo response.
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Affiliation(s)
- Paul A Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, USA; Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, USA.
| | - Taryn L Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, USA; Children's Medical Center of Dallas, USA
| | - Matthew J Byerly
- Department of Psychiatry, University of Texas Southwestern Medical Center, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, USA; Children's Medical Center of Dallas, USA
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Emslie GJ, Wells TG, Prakash A, Zhang Q, Pangallo BA, Bangs ME, March JS. Acute and longer-term safety results from a pooled analysis of duloxetine studies for the treatment of children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2015; 25:293-305. [PMID: 25978741 DOI: 10.1089/cap.2014.0076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess acute and longer-term safety of duloxetine in the treatment of children and adolescents with major depressive disorder (MDD), a pooled analysis of data from two completed randomized, double-blind, multicenter, phase 3, placebo- and active-controlled trials was undertaken. In these studies, neither duloxetine (investigational drug) nor fluoxetine (active control) demonstrated a statistically significant improvement compared with placebo on the primary efficacy measure. METHODS Patients ages 7-17 years with MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) received duloxetine (n=341), fluoxetine (n=234), or placebo (n=225) for 10 week acute and 26 week extended (duloxetine or fluoxetine only) treatments. Safety measures included treatment-emergent adverse events (TEAEs), the Columbia-Suicide Severity Rating Scale, vital signs, electrocardiograms, laboratory samples, and growth (height and weight) assessments. RESULTS Significantly more patients discontinued because of adverse events during duloxetine (8.2%) treatment than during placebo (3.1%) treatment (p≤0.05). TEAEs in >10% of duloxetine-treated patients were headache and nausea. No completed suicides or deaths occurred. During acute treatment, 6.6% of duloxetine-, 8.0% of fluoxetine-, and 8.2% of placebo-treated patients had worsening suicidal ideation from baseline. Among patients initially randomized to duloxetine or fluoxetine who had suicidal ideation at study baseline, 81% of duloxetine- and 77% of fluoxetine-treated patients had improvements in suicidal ideation at end-point in the 36-week studies. Suicidal behavior occurred in two fluoxetine-treated patients and one placebo-treated patient during acute treatment, and in seven duloxetine-treated patients and one fluoxetine-treated patient during extended treatment. Duloxetine-treated patients had a mean pulse increase of ∼3 beats per minute, and mean blood pressure (both systolic and diastolic) increases of <2.0 mm Hg at week 36. Weight decrease (≥3.5%) during acute treatment occurred with statistically (p≤0.05) greater frequency for both the duloxetine (11.4%) and fluoxetine (11.5%) groups versus the placebo (5.5%) group; however, mean weight increase occurred for both duloxetine and fluoxetine groups during extended treatment. CONCLUSION Results from this pooled analysis of two studies were consistent with the known safety and tolerability profile of duloxetine. Clinical Trial Registry Numbers: NCT00849901 and NCT00849693.
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Affiliation(s)
- Graham J Emslie
- 1 Department of Psychiatry, University of Texas Southwestern and Children's Medical Center , Dallas, Texas
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Kennard BD, Emslie GJ, Mayes TL, Nakonezny PA, Jones JM, Foxwell AA, King J. Sequential treatment with fluoxetine and relapse--prevention CBT to improve outcomes in pediatric depression. Am J Psychiatry 2014; 171:1083-90. [PMID: 24935082 PMCID: PMC4182111 DOI: 10.1176/appi.ajp.2014.13111460] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [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] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The authors evaluated a sequential treatment strategy of fluoxetine and relapse-prevention cognitive-behavioral therapy (CBT) to determine effects on remission and relapse in youths with major depressive disorder. METHOD Youths 8-17 years of age with major depression were treated openly with fluoxetine for 6 weeks. Those with an adequate response (defined as a reduction of 50% or more on the Children's Depression Rating Scale-Revised [CDRS-R]) were randomly assigned to receive continued medication management alone or continued medication management plus CBT for an additional 6 months. The CBT was modified to address residual symptoms and was supplemented by well-being therapy. Primary outcome measures were time to remission (with remission defined as a CDRS-R score of 28 or less) and rate of relapse (with relapse defined as either a CDRS-R score of 40 or more with a history of 2 weeks of symptom worsening, or clinical deterioration). RESULTS Of the 200 participants enrolled in acute-phase treatment, 144 were assigned to continuation treatment with medication management alone (N=69) or medication management plus CBT (N=75). During the 30-week continuation treatment period, time to remission did not differ significantly between treatment groups (hazard ratio=1.26, 95% CI=0.87, 1.82). However, the medication management plus CBT group had a significantly lower risk of relapse than the medication management only group (hazard ratio=0.31, 95% CI=0.13, 0.75). The estimated probability of relapse by week 30 was lower with medication management plus CBT than with medication management only (9% compared with 26.5%). CONCLUSIONS Continuation-phase relapse-prevention CBT was effective in reducing the risk of relapse but not in accelerating time to remission in children and adolescents with major depressive disorder.
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Affiliation(s)
- Betsy D. Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
| | - Taryn L. Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center,Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center
| | - Jessica M. Jones
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
| | - Aleksandra A. Foxwell
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
| | - Jessica King
- Department of Psychiatry, University of Texas Southwestern Medical Center,Children’s Medical Center of Dallas
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Croarkin PE, Nakonezny PA, Lewis CP, Zaccariello MJ, Huxsahl JE, Husain MM, Kennard BD, Emslie GJ, Daskalakis ZJ. Developmental aspects of cortical excitability and inhibition in depressed and healthy youth: an exploratory study. Front Hum Neurosci 2014; 8:669. [PMID: 25228870 PMCID: PMC4151107 DOI: 10.3389/fnhum.2014.00669] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/11/2014] [Indexed: 02/05/2023] Open
Abstract
Objectives: The objective of this post-hoc exploratory analysis was to examine the relationship between age and measures of cortical excitability and inhibition. Methods: Forty-six participants (24 with major depressive disorder and 22 healthy controls) completed MT, SICI, ICF, and CSP testing in a cross-sectional protocol. Of these 46 participants, 33 completed LICI testing. Multiple linear robust regression and Spearman partial correlation coefficient were used to examine the relationship between age and the TMS measures. Results: In the overall sample of 46 participants, age had a significant negative relationship with motor threshold (MT) in both the right (rs = −0.49, adjusted p = 0.007; β = −0.08, adjusted p = 0.001) and left (rs = −0.42, adjusted p = 0.029; β = −0.05, adjusted p = 0.004) hemispheres. This significant negative relationship of age with MT was also observed in the sample of depressed youth in both the right (rs = −0.70, adjusted p = 0.002; β = −0.09, adjusted p = 0.001) and left (rs = −0.54, adjusted p = 0.034; β = −0.05, adjusted p = 0.017) hemispheres, but not in healthy controls. In the sample of the 33 participants who completed LICI testing, age had a significant negative relationship with LICI (200 ms interval) in both the right (rs = −0.48, adjusted p = 0.05; β = −0.24, adjusted p = 0.007) and left (rs = −0.64, adjusted p = 0.002; β = −0.23, adjusted p = 0.001) hemispheres. This negative relationship between age and LICI (200 ms interval) was also observed in depressed youth in both the right (rs = −0.76, adjusted p = 0.034; β = −0.35, adjusted p = 0.004) and left (rs = −0.92, adjusted p = 0.002; β = −0.25, adjusted p = 0.001) hemispheres. Conclusion: These findings suggest that younger children have higher MTs. This is more pronounced in depressed youth than healthy controls. LICI inhibition may also increase with age in youth.
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Affiliation(s)
- Paul E Croarkin
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, USA
| | - Paul A Nakonezny
- Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center Dallas, TX, USA ; Department of Psychiatry, UT Southwestern Medical Center Dallas, TX, USA
| | - Charles P Lewis
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, USA
| | - Michael J Zaccariello
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, USA
| | - John E Huxsahl
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic Rochester, MN, USA
| | - Mustafa M Husain
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine Durham, NC, USA
| | - Betsy D Kennard
- Department of Psychiatry, UT Southwestern Medical Center Dallas, TX, USA
| | - Graham J Emslie
- Department of Psychiatry, UT Southwestern Medical Center Dallas, TX, USA
| | - Zafiris J Daskalakis
- Department of Psychiatry, Centre for Addiction and Mental Health, University of Toronto Toronto, ON, Canada
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Emslie GJ, Prakash A, Zhang Q, Pangallo BA, Bangs ME, March JS. A double-blind efficacy and safety study of duloxetine fixed doses in children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2014; 24:170-9. [PMID: 24815533 PMCID: PMC4026396 DOI: 10.1089/cap.2013.0096] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [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] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of duloxetine fixed dose in the treatment of children (7-11 years) and adolescents (12-17 years) with major depressive disorder (MDD). METHODS Patients (n=463) in this 36 week study (10 week acute and 26 week extension treatment) received duloxetine 60 mg QD (n=108), duloxetine 30 mg QD (n=116), fluoxetine 20 mg QD (n=117, active control), or placebo (n=122). Measures included: Children's Depression Rating Scale-Revised (CDRS-R), treatment-emergent adverse events (TEAEs), and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Neither active drug (duloxetine or fluoxetine) separated significantly (p<0.05) from placebo on mean change from baseline to end-point (10 weeks) on the CDRS-R total score. Total TEAEs and discontinuation for AEs were significantly (p<0.05) higher only for the duloxetine 60 mg group versus the placebo group during acute treatment. No clinically significant electrocardiogram (ECG) or laboratory abnormalities were observed, and no completed suicides or deaths occurred during the study. A total of 7 (6.7%) duloxetine 60 mg, 6 (5.2%) duloxetine 30 mg, 9 (8.0%) fluoxetine, and 11 (9.4%) placebo patients had worsening of suicidal ideation from baseline during acute treatment. Of the patients with suicidal ideation at baseline, 13/16 (81%) duloxetine 60 mg, 16/17 (94%) duloxetine 30 mg, 11/16 (69%) fluoxetine, and 13/15 (87%) placebo had improvement in suicidal ideation at end-point during acute treatment. One fluoxetine, one placebo, and six duloxetine patients had treatment-emergent suicidal behavior during the 36 week study. CONCLUSIONS Trial results were inconclusive, as neither the investigational drug (duloxetine) nor the active control (fluoxetine) separated from placebo on the CDRS-R at 10 weeks. No new duloxetine safety signals were identified relative to those seen in adults. Clinical Trial Registry Number ( www.ClinicalTrials.gov ): NCT00849693.
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Affiliation(s)
- Graham J. Emslie
- Child and Adolescent Psychiatry Division, University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - Apurva Prakash
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Qi Zhang
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Beth A. Pangallo
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - Mark E. Bangs
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana
| | - John S. March
- Division of Neurosciences Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Atkinson SD, Prakash A, Zhang Q, Pangallo BA, Bangs ME, Emslie GJ, March JS. A double-blind efficacy and safety study of duloxetine flexible dosing in children and adolescents with major depressive disorder. J Child Adolesc Psychopharmacol 2014; 24:180-9. [PMID: 24813026 DOI: 10.1089/cap.2013.0146] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [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] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of duloxetine flexible dose in children (7-11 years) and adolescents (12-17 years) with major depressive disorder (MDD). METHODS Patients (n=337) in this 36 week study (10 week acute and 26 week extension treatment) received duloxetine (60-120 mg once daily [QD], n=117), fluoxetine (20-40 mg QD, n=117), or placebo (n=103). Measures included: Children's Depression Rating Scale-Revised (CDRS-R), treatment-emergent adverse events (TEAEs), and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Neither active drug (duloxetine or fluoxetine) separated significantly (p<0.05) from placebo on mean change from baseline to end-point (10 weeks) on the CDRS-R total score. There were no significant differences between the duloxetine or fluoxetine groups compared with placebo on serious AEs (SAEs), total TEAEs, or discontinuation for AE during acute treatment. There were no completed suicides or deaths, and no clinically significant electrocardiogram (ECG) abnormalities observed during the study. One fluoxetine and one duloxetine patient experienced alanine aminotransferase (ALT) three or more times the upper limit of normal, which resolved during the study. A total of 8 (7.1%) duloxetine patients, 7 (6.8%) placebo patients, and 9 (8.0%) fluoxetine patients had worsening of suicidal ideation from baseline during acute treatment. Of the patients with suicidal ideation at baseline, 15/19 (79%) duloxetine, 19/19 (100%) placebo, and 16/19 (84%) fluoxetine had improvement in suicidal ideation at end-point during acute treatment. One duloxetine and two fluoxetine patients had treatment-emergent suicidal behavior during the 36 week study. CONCLUSION Trial results were inconclusive, as neither the investigational drug (duloxetine) nor the active control (fluoxetine) separated from placebo on the CDRS-R at 10 weeks. No new duloxetine safety signals were identified relative to those seen in adults. Clinical Trial Registry Number: NCT00849901.
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Mansoor B, Rengasamy M, Hilton R, Porta G, He J, Spirito A, Emslie GJ, Mayes TL, Clarke G, Wagner KD, Shamseddeen W, Birmaher B, Ryan N, Brent D. The bidirectional relationship between body mass index and treatment outcome in adolescents with treatment-resistant depression. J Child Adolesc Psychopharmacol 2013; 23:458-67. [PMID: 24024532 PMCID: PMC3779018 DOI: 10.1089/cap.2012.0095] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Depression and obesity are associated, but the impact of obesity on depression treatment outcome, or, conversely, the impact of treatment on body mass index (BMI) in depressed adolescents has not been reported. In this article, we examine the bidirectional relationships between BMI and treatment response in adolescents with treatment-resistant depression. METHOD Participants in the Treatment of Selective Serotonin Reuptake Inhibitor (SSRI) Resistant Depression in Adolescents (TORDIA) study had height and weight assessed at baseline, weekly for the first 6 weeks, biweekly for the next 6 weeks, and monthly from weeks 12 through 24. The impact of baseline BMI as a predictor and moderator of treatment response was assessed. In addition, participants' changes in BMI were assessed as a function of specific treatment assignment and treatment response. RESULTS Participants assigned to SSRIs had a greater increase in BMI-for-age-sex z-score and weight than did those assigned to venlafaxine. Post-hoc, those treated with paroxetine or citalopram had the biggest increases in BMI, relative to fluoxetine or venlafaxine. Overweight or obesity was neither a predictor nor a moderator of treatment outcome, nor of subsequent BMI change. CONCLUSIONS Overweight status does not appear to affect treatment response in adolescents with resistant depression. The successful treatment of depression does not appear to favorably affect weight or BMI. Fluoxetine and venlafaxine are less likely to cause an increase in BMI than paroxetine or citalopram.
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Affiliation(s)
- Brandon Mansoor
- Wayne State University School of Medicine, Detroit, Michigan
| | | | - Robert Hilton
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Giovanna Porta
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
| | - Jiayan He
- The Cleveland Clinic, Cleveland, Ohio
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taryn L. Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Karen Dineen Wagner
- Department of Psychiatry, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Wael Shamseddeen
- Department of Psychiatry, Rosalind Franklin University, North Chicago, Illinois
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Neal Ryan
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
| | - David Brent
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
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Hughes CW, Barnes S, Barnes C, DeFina LF, Nakonezny P, Emslie GJ. Depressed Adolescents Treated with Exercise (DATE): A pilot randomized controlled trial to test feasibility and establish preliminary effect sizes. Ment Health Phys Act 2013; 6:10.1016/j.mhpa.2013.06.006. [PMID: 24244220 PMCID: PMC3827851 DOI: 10.1016/j.mhpa.2013.06.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Depressed Adolescents Treated with Exercise (DATE) study evaluated a standardized aerobic exercise protocol to treat nonmedicated adolescents that met DSM-IV-TR criteria for major depressive disorder. From an initial screen of 90 individuals, 30 adolescents aged 12-18 years were randomized to either vigorous exercise (EXER) (>12 kg/kcal/week [KKW]) or a control stretching (STRETCH) activity (< 4 KKW) for 12 weeks. The primary outcome measure was the blinded clinician rating of the Children's Depression Rating Scale - Revised (CDRS-R) to assess depression severity and Actical (KKW) accelerometry 24hr/7days a week to assess energy expenditure and adherence. Follow-up evaluations occurred at weeks 26 and 52. The EXER group averaged 77% adherence and the STRETCH group 81% for meeting weekly target goals for the 12 week intervention based on weekly sessions completed and meeting KKW requirements. There was a significant increase in overall weekly KKW expenditures (p < .001) for both groups with the EXER group doubling the STRETCH group in weekly energy expenditure. Depressive symptoms were significantly reduced from baseline for both groups with the EXER group improving more rapidly than STRETCH after six weeks (p < .016) and nine weeks (p < .001). Both groups continued to improve such that there were no group differences after 12 weeks (p = .07). By week 12, the exercise group had a 100% response rate (86% remission), whereas the stretch group response rate was 67% (50% remission) (p = .02). Both groups had improvements in multiple areas of psychosocial functioning related to school and relationships with parents and peers. Anthropometry reflected decreased waist, hip and thigh measurements (p = .02), more so for females than males (p = .05), but there were no weight changes for either gender. The EXER group sustained 100% remission at week 26 and 52. The STRETCH group had 80% response and 70% remission rates at week 26 and by week 52 only one had not fully responded. The study provides support for the use of exercise as a non-medication intervention for adolescents with major depressive disorders when good adherence and energy expenditure (KKW) are achieved.
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Affiliation(s)
- Carroll W. Hughes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shauna Barnes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | - Conrad Barnes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Paul Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
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Rengasamy M, Mansoor BM, Hilton R, Porta G, He J, Emslie GJ, Mayes T, Clarke GN, Wagner KD, Keller MB, Ryan ND, Birmaher B, Shamseddeen W, Asarnow JR, Brent DA. The bi-directional relationship between parent-child conflict and treatment outcome in treatment-resistant adolescent depression. J Am Acad Child Adolesc Psychiatry 2013; 52:370-7. [PMID: 23582868 PMCID: PMC3737571 DOI: 10.1016/j.jaac.2013.01.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 12/27/2012] [Accepted: 01/31/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the bidirectional relationship between parent-child discord and treatment outcome for adolescent treatment-resistant depression. METHOD Depressed youth who had not responded to an adequate course of a selective serotonin reuptake inhibitor (SSRI) were randomized to either a switch to another SSRI or venlafaxine, with or without the addition of cognitive behavior therapy (CBT) in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. The Conflict Behavior Questionnaire was used to assess adolescent (CBQ-A) and parent-reported (CBQ-P) parent-child discord. The impact of remission on parent-child conflict, and the differential impact of medication and CBT on the CBQ-A and CBQ-P, were assessed using generalized linear models. RESULTS Although there were no differential treatment effects on parent or adolescent-report of conflict, remission was associated with improvement in the CBQ-P. In general, intake family conflict did not predict remission, except in the sub-group of participants whose parents reported clinically significant parent-child conflict at intake, for whom high levels of parent-reported conflict predicted a lower likelihood of remission. Conflict also did not moderate treatment response. CONCLUSIONS Remission of depression may be sufficient to reduce parent-reported parent-child conflict. However, higher parent-reported conflict, in the clinically significant range, predicts a lower likelihood of remission from depression. Clinical trial registration information-Treatment of SSRI-Resistant Depression in Adolescents (TORDIA); http://clinicaltrials.gov/; NCT00018902.
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Affiliation(s)
- Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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Croarkin PE, Nakonezny PA, Husain MM, Melton T, Buyukdura JS, Kennard BD, Emslie GJ, Kozel FA, Daskalakis ZJ. Evidence for increased glutamatergic cortical facilitation in children and adolescents with major depressive disorder. JAMA Psychiatry 2013; 70:291-9. [PMID: 23303429 DOI: 10.1001/2013.jamapsychiatry.24] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [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] [Indexed: 11/14/2022]
Abstract
CONTEXT Converging lines of evidence implicate the glutamate and γ-aminobutyric acid neurotransmitter systems in the pathophysiology of major depressive disorder. Transcranial magnetic stimulation cortical excitability and inhibition paradigms have been used to assess cortical glutamatergic and γ-aminobutyric acid-mediated tone in adults with major depressive disorder, but not in children and adolescents. OBJECTIVE To compare measures of cortical excitability and inhibition with 4 different paradigms in a group of children and adolescents with major depressive disorder vs healthy controls. DESIGN Cross-sectional study examining medication-free children and adolescents (aged 9-17 years) with major depressive disorder compared with healthy controls. Cortical excitability was assessed with motor threshold and intracortical facilitation measures. Cortical inhibition was measured with cortical silent period and intracortical inhibition paradigms. SETTING University-based child and adolescent psychiatry clinic and neurostimulation laboratory. PATIENTS Twenty-four participants with major depressive disorder and 22 healthy controls matched for age and sex. Patients with major depressive disorder were medication naive and had moderate to severe symptoms based on an evaluation with a child and adolescent psychiatrist and scores on the Children's Depression Rating Scale-Revised. MAIN OUTCOME MEASURES Motor threshold, intracortical facilitation, cortical silent period, and intracortical inhibition. RESULTS Compared with healthy controls, depressed patients had significantly increased intracortical facilitation at interstimulus intervals of 10 and 15 milliseconds bilaterally. There were no significant group differences in cortical inhibition measures. CONCLUSIONS These findings suggest that major depressive disorder in children and adolescents is associated with increased intracortical facilitation and excessive glutamatergic activity.
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Affiliation(s)
- Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
This article reviews the assessment and treatment for depression in children and adolescents, emphasizing the implementation of evidence-based treatments into clinical care. Past trials of antidepressant medications are reviewed, as well as the clinical use of antidepressants and pharmacologic strategies for refractory illness or in the context of comorbid conditions. Clinicians who treat youth now have a body of empiric research to help guide treatment decisions; however, personalized treatment based on associated symptoms, comorbid conditions, contextual factors, and psychiatric history is essential. Further research is needed in the pharmacologic treatment of depressed youth, including expanding the study of non-SSRI antidepressants, augmentation and adjunctive strategies, and treatment in patients with comorbid conditions.
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Affiliation(s)
- Christine J Choe
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-8589, USA.
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Saxena K, Tamm L, Walley A, Simmons A, Rollins N, Chia J, Soares JC, Emslie GJ, Fan X, Huang H. A preliminary investigation of corpus callosum and anterior commissure aberrations in aggressive youth with bipolar disorders. J Child Adolesc Psychopharmacol 2012; 22:112-9. [PMID: 22375854 PMCID: PMC3362324 DOI: 10.1089/cap.2011.0063] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Although behavioral deficits in bipolar disorder (BPD) are well described, the specific brain white matter (WM) disruptions have not been completely characterized, and neural mechanisms underlying dysfunction in BPD are not well established, particularly for youth with BPD and aggression. This preliminary study utilized diffusion tensor imaging (DTI) to investigate commissural tracts (corpus callosum [CC] and anterior commissure [AC]) in youth with BPD, because disruption of interhemispheric communication may contribute to the emotional deficits that are characteristic of the illness. METHOD DTI was used to investigate WM in 10 youth (7-17 years of age) with BPD and 10 typically developing age-matched controls. Tract-based spatial statistics voxel-wise analysis was used to compare fractional anisotropy (FA) of the two groups. We specifically focused on five subdivisions of the midsagittal CC as well as on the decussation of AC, which connects the temporal lobes. Exploratory correlations between FA values and life history of aggression scores were calculated for the BPD group. RESULTS Youth with BPD had significantly lower FA values in the callosal genu and AC. FA values in the AC were negatively correlated with a life history of aggression in the BPD group. CONCLUSIONS These results contribute to a growing literature implicating a role for the genu of the CC in BPD and are the first to report WM variations in the AC of children with BPD. Taken together with the correlational data for aggression and the role of the AC in emotional processing, our data provide preliminary evidence for a possible association between the structural integrity of the WM of the AC and aggression in pediatric BPD.
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Affiliation(s)
- Kirti Saxena
- Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, Texas 77054, USA.
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Tao R, Calley CS, Hart J, Mayes TL, Nakonezny PA, Lu H, Kennard BD, Tamminga CA, Emslie GJ. Brain activity in adolescent major depressive disorder before and after fluoxetine treatment. Am J Psychiatry 2012; 169:381-8. [PMID: 22267183 PMCID: PMC4225078 DOI: 10.1176/appi.ajp.2011.11040615] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [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] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Major depression in adolescents is a significant public health concern because of its frequency and severity. To examine the neurobiological basis of depression in this population, the authors studied functional activation characteristics of the brain before and after antidepressant treatment in antidepressant-naive depressed adolescents and healthy comparison subjects. METHOD Depressed (N=19) and healthy (N=21) adolescents, ages 11 to 18 years, underwent functional MRI assessment while viewing fearful and neutral facial expressions at baseline and again 8 weeks later. The depressed adolescents received 8 weeks of open-label fluoxetine treatment after their baseline scan. RESULTS Voxel-wise whole brain analyses showed that depressed youths have exaggerated brain activation compared with healthy comparison subjects in multiple regions, including the frontal, temporal, and limbic cortices. The 8 weeks of fluoxetine treatment normalized most of these regions of hyperactivity in the depressed group. Region-of-interest analyses of the areas involved in emotion processing indicated that before treatment, depressed youths had significantly greater activations to fearful relative to neutral facial expressions than did healthy comparison subjects in the amygdala, orbitofrontal cortex, and subgenual anterior cingulate cortex bilaterally. Fluoxetine treatment decreased activations in all three regions, as compared with the repeat scans of healthy comparison subjects. CONCLUSIONS While effective treatments are available, the impact of depression and its treatment on the brain in adolescents is understudied. This study confirms increases in brain activation in untreated depressed adolescents and demonstrates reductions in these aberrant activations with treatment.
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Affiliation(s)
- Rongrong Tao
- Department of Psychiatry, the Department of Neurology, the Division of Biostatistics of the Department of Clinical Sciences, and the Advanced Imaging Center, University of Texas Southwestern Medical Center at Dallas, USA.
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Croarkin PE, Wall CA, Nakonezny PA, Buyukdura JS, Husain MM, Sampson SM, Emslie GJ, Kozel FA. Increased cortical excitability with prefrontal high-frequency repetitive transcranial magnetic stimulation in adolescents with treatment-resistant major depressive disorder. J Child Adolesc Psychopharmacol 2012; 22:56-64. [PMID: 22257125 DOI: 10.1089/cap.2011.0054] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [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] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To examine changes in motor cortical excitability in adolescent subjects receiving 30 sessions of high-frequency prefrontal repetitive transcranial magnetic stimulation (rTMS). METHODS Eight adolescents with treatment-resistant major depressive disorder (MDD) enrolled in an open augmentation trial of 10 Hz rTMS. Resting motor thresholds were obtained by the visualization of movement method with a maximum likelihood threshold hunting computer algorithm at baseline and after every five sessions of rTMS. Motor threshold was recorded as the percentage of total machine output at each measurement. RESULTS Motor threshold data from baseline, weeks 2, 4, and 5 were included in a mixed model repeated measure analysis to examine a change in least square mean effect over time. The omnibus effect did not reach statistical significance (F=1.25, p=0.32). However, multiple comparisons from the overall model demonstrated a decrease in the least square mean motor threshold. The mean contrast from baseline to week 5 approached significance (p=0.07). Moreover, a post-hoc analysis with a Wilcoxon signed ranks test demonstrated a significant decrease at week 5 (p=0.03). CONCLUSIONS This suggests that high-frequency rTMS may increase cortical excitability in adolescents with treatment-resistant MDD.
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Affiliation(s)
- Paul E Croarkin
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, UT Southwestern Medical Center Dallas, Dallas, Texas 75390-8589, USA.
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Prakash A, Lobo E, Kratochvil CJ, Tamura RN, Pangallo BA, Bullok KE, Quinlan T, Emslie GJ, March JS. An open-label safety and pharmacokinetics study of duloxetine in pediatric patients with major depression. J Child Adolesc Psychopharmacol 2012; 22:48-55. [PMID: 22251023 DOI: 10.1089/cap.2011.0072] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [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] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This preliminary, 32-week study assessed the safety, tolerability, and pharmacokinetics of duloxetine in pediatric patients (aged 7-17 years) with major depressive disorder. METHODS Patients received flexible duloxetine doses of 20-120 mg once daily, with dose changes made based on clinical improvement and tolerability. Pharmacokinetic samples were collected across all duloxetine doses, and data were analyzed using population modeling. Primary outcome measures included treatment-emergent adverse events (TEAEs), vital signs, and Columbia-Suicide Severity Rating Scale (C-SSRS). RESULTS Of the 72 enrolled patients, 48 (66.7%) completed acute treatment (18 weeks) and 42 (58.3%) completed extended treatment. Most patients (55/72; 76%) required doses ≥ 60 mg once daily to optimize efficacy based on investigator judgment and Clinical Global Impressions-Severity score. Body weight and age did not significantly affect duloxetine pharmacokinetic parameters. Typical duloxetine clearance in pediatric patients was ≈ 42%-60% higher than that in adults. Four patients (5.6%) discontinued due to TEAEs. Many (36/72, 50%) patients experienced potentially clinically significant (PCS) elevations in blood pressure, with most cases (21/36, 58%) being transient. As assessed via C-SSRS, one nonfatal suicidal attempt occurred, two patients (2.8%) experienced worsening of suicidal ideation, and among the 19 patients reporting suicidal ideation at baseline, 17 (90%) reported improvement in suicidal ideation. CONCLUSION Results suggested that pediatric patients generally tolerated duloxetine doses of 30 to 120 mg once daily, although transient PCS elevations in blood pressure were observed in many patients. Pharmacokinetic results suggested that adjustment of total daily dose based on body weight or age is not warranted for pediatric patients and different total daily doses may not be warranted for pediatric patients relative to adults.
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Affiliation(s)
- Apurva Prakash
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana 46285, USA.
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Shamseddeen W, Clarke G, Keller MB, Wagner KD, Birmaher B, Emslie GJ, Ryan N, Asarnow JR, Porta G, Brent DA. Adjunctive sleep medications and depression outcome in the treatment of serotonin-selective reuptake inhibitor resistant depression in adolescents study. J Child Adolesc Psychopharmacol 2012; 22:29-36. [PMID: 22251024 PMCID: PMC3281285 DOI: 10.1089/cap.2011.0027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [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] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In the Treatment of Resistant Depression in Adolescents, study participants who received medication for sleep had a lower response rate. This report sought to clarify this finding. METHOD Depressed adolescents who had not responded to a previous adequate serotonin-selective reuptake inhibitor (SSRI) trial were randomly assigned to another SSRI, venlafaxine, another SSRI+cognitive behavior therapy (CBT), or venlafaxine+CBT. Augmentation with sleep medication was permitted as clinically indicated. RESULTS Youth who received trazodone were six times less likely to respond than those with no sleep medication (adjusted odds ratio [OR]=0.16, 95% confidence interval [CI]: 0.05-0.50, p=0.001) and were three times more likely to experience self-harm (OR=3.0, 95% CI: 1.1-7.9, p=0.03), even after adjusting for baseline differences associated with trazodone use. None (0/13) of those cotreated with trazodone and either paroxetine or fluoxetine responded. In contrast, those treated with other sleep medications had similar rates of response (60.0% vs. 50.4%, χ(2)=0.85, p=0.36) and of self-harm events (OR=0.5, 95% CI: 0.1-2.6, p=0.53) as those who received no sleep medication. CONCLUSIONS These findings should be interpreted cautiously because these sleep agents were not assigned randomly, but at clinician discretion. Nevertheless, they suggest that the use of trazodone for the management of sleep difficulties in adolescent depression should be re-evaluated and that future research on the management of sleep disturbance in adolescent depression is needed. The very low response rate of participants cotreated with trazodone and either fluoxetine or paroxetine could be due to inhibition of CYP 2D6 by these antidepressants.
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Affiliation(s)
- Wael Shamseddeen
- Rosalind Franklin University of Medicine and Sciences, North Chicago, Illinios
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | | | | | - Graham J. Emslie
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Neal Ryan
- University of Pittsburgh, Pittsburgh, Pennsylvania
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