Catatonia in Preadolescent Children

OBJECTIVE

The aim of the study is to describe prepubescent catatonia in very young children, which is poorly documented in the current literature and, as a result, overlooked in medical settings.

METHODS

We examined a convenience sample of 10 patients at an academic center who were younger than 12 years and met criteria for catatonia. After institutional review board approval, we extracted from the electronic medical records demographic and diagnostic information, comorbidity, developmental history, and laboratory testing. Bush Francis Catatonia Rating Scales at initial presentation and other symptomatology were gathered in addition to treatment received. Fifty percent of patients in this group were seen and diagnosed with catatonia at their presentation in an outpatient clinic, whereas the remaining 50% were diagnosed upon hospitalization, by the psychiatry consultation liaison team.

RESULTS

All patients but one was diagnosed with a comorbid condition before the diagnosis of catatonia, including 70% with a previous diagnosis of autism spectrum disorder. Three patients had concurrent anti-N-methyl-D-aspartate receptor encephalitis, and one initially presented with seizures. All patients were treated for catatonia with lorazepam, and two patients additionally received electroconvulsive therapy. Regardless of the presence of early regression invariably associated with an autism spectrum diagnosis, secondary symptoms of regression were noted in each case at the time of diagnosing catatonia.

CONCLUSIONS

Similar to previous observations in adolescents, prepubescent catatonia seems strongly associated with neurodevelopmental disorders, secondary regression, variability in presentation, and comorbidity with other neurological conditions. Delayed recognition of catatonia can hinder rapid and effective treatment in young children.

Family environment and polygenic risk in the bipolar high-risk context

Background

The interaction of polygenic risk (PRS) and environmental effects on development of bipolar disorder (BD) is understudied, as are high-risk offspring perceptions of their family environment (FE). We tested the association of offspring-perceived FE in interaction with BD-PRS on liability for BD in offspring at high or low familial risk for BD.

Methods

Offspring of a parent with BD (oBD; n = 266) or no psychiatric disorders (n = 174), aged 12-21 at recruitment, participated in the US and Australia. Empirically-derived profiles of FE classified offspring by their perceived levels of familial cohesion, flexibility, and conflict. Offspring BD-PRS were derived from Psychiatric Genomics Consortium BD-GWAS. Lifetime DSM-IV bipolar disorders were derived from the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. We used a novel stepwise approach for latent class modeling with predictors and distal outcomes.

Results

Fifty-two offspring were diagnosed with BD. For those with well-functioning FE (two-thirds of the sample), higher BD-PRS tracked positively with liability for BD. However, for those with high-conflict FEs, the relationship between BD-PRS and liability to BD was negative, with highest risk for BD observed with lower BD-PRS. In exploratory analyses, European-ancestry offspring with BD had elevated history of suicidal ideation in high-conflict FE compared to well-functioning-FE, and of suicide attempt with low-BD-PRS and high-conflict FE.

Conclusions

The data suggest that the relationship of BD-PRS and offspring liability for BD differed between well-functioning versus high-conflict FE, potentially in line with a multifactorial liability threshold model and supporting future study of and interventions improving family dynamics.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Bipolar Disorder and Psychosis in Autism

Autism seldom occurs in its pure form. Often labeled as behavioral disorders or psychological reactions, comorbid psychiatric disorders are common. Bipolar disorder is one of the most common psychiatric disorders that occur in persons with autism across their life spans. It can be comorbid with and mistaken for several other conditions. Similarly, psychosis occurs in several psychiatric disorders. Schizophrenia is the prototype psychotic disorder that has a close but controversial relationship with autism. Assessment and treatment of bipolar disorder and psychosis should be based on their individual characteristics, family dynamics, and community resources.

Maintenance Electroconvulsive Therapy Is an Essential Medical Treatment for Patients With Catatonia: A COVID-19 Related Experience

Aim: Describe naturalistic clinical course over 14 weeks in a mixed adolescent and a young-adult patient group diagnosed with developmental delays and catatonia, when the frequency of maintenance electroconvulsive therapy (M-ECT) was reduced secondary to 2020 COVID-19 pandemic restrictions. Methods: Participants were diagnosed with catatonia, and were receiving care in a specialized clinic. They (n = 9), F = 5, and M = 4, ranged in age from 16 to 21 years; ECT frequency was reduced at end of March 2020 due to institutional restrictions. Two parents/caregivers elected to discontinue ECT due to concern for COVID-19 transmission. Majority (n = 8) were developmentally delayed with some degree of intellectual disability (ID). Observable symptoms were rated on a three point scale during virtual visits. Results: All cases experienced clinically significant decline. Worsening of motor symptoms (agitation, aggression, slowness, repetitive self-injury, stereotypies, speech deficits) emerged within the first 3 weeks, persisted over the 14 week observation period and were more frequent than neurovegetative symptoms (appetite, incontinence, sleep). Four participants deteriorated requiring rehospitalization, and 2 among these 4 needed a gastrostomy feeding tube. Conclusion: Moderate and severe symptoms became apparent in all 9 cases during the observation period; medication adjustments were ineffective; resuming M-ECT at each participant's baseline schedule, usually by week 7, resulted in progressive improvement in some cases but the improvement was insufficient to prevent re-hospitalization in 4 cases. In summary, rapid deterioration was noted when M-ECT was acutely reduced in the setting of COVID-19 related restrictions.

Bipolar Disorder and Psychosis in Autism

Autism seldom occurs in its pure form. Often labeled as behavioral disorders or psychological reactions, comorbid psychiatric disorders are common. Bipolar disorder is one of the most common psychiatric disorders that occur in persons with autism across their life spans. It can be comorbid with and mistaken for several other conditions. Similarly, psychosis occurs in several psychiatric disorders. Schizophrenia is the prototype psychotic disorder that has a close but controversial relationship with autism. Assessment and treatment of bipolar disorder and psychosis should be based on their individual characteristics, family dynamics, and community resources.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Electroconvulsive Therapy for the Treatment of Severe Mood Disorders During Adolescence: A Retrospective Chart Review

Objective: Electroconvulsive therapy (ECT) is a well-recognized treatment of refractory mood disorders in adults. However, relatively little is known about its use for similar conditions in adolescents. Based on a chart review, we describe its use and outcome in a sample of adolescents with severe, refractory mood disorders (unipolar or bipolar disorder) hospitalized in an academic medical center. Methods: The sample was drawn from referrals to an adolescent psychiatry service. After obtaining approval from the ethics board, medical records of 54 adolescents with refractory mood disorder were examined. Participants (males 24, females 30; mean age 15.8 ± 1.5 years) had received their first course of ECT before the age of 18 years during the period 1996-2010. Response to treatment was examined after the initial treatment and during a 1-year follow-up. Results: Following the index course of ECT (mean number of treatments = 13.7 ± 6.3), a 52.8% response rate (defined as a Clinical Global Impressions [CGI] score ≤2) was noted, while 15.1% achieved remission (CGI = 1). The response rate was 82.4% after a 1-year follow-up with a remission rate of 23.5%. The Children's Depression Rating scores declined significantly from pre-ECT to the end of the index course (70.7 ± 16.4 to 52.5 ± 18; p ≤ 0.00). A reduction in suicidal ideation and self-injurious behaviors along with increased school attendance was noted. Cognition, monitored by the Mini-Mental State Examination, did not decline significantly. Minor side effects were limited to the day of the treatment. Prolonged seizures (>2 minutes) were common during ECT (74% of subjects experienced one or more). The only side effect noted at the 1-year follow-up was self-reported memory loss involving events during and around the index treatment course. Conclusions: In this severely impaired sample of adolescents, ECT was found to decrease suicidal behavior, reduce depressive symptoms, and improve overall functioning, as indexed by school attendance at follow-up after 1 year. Prospective studies using large samples are needed to determine its effectiveness and safety in refractory mood disorders in adolescents.

Patterns and predictors of family environment among adolescents at high and low risk for familial bipolar disorder

Children's perceptions are important to understanding family environment in the bipolar disorder (BD) high-risk context. Our objectives were to empirically derive patterns of offspring-perceived family environment, and to test the association of family environment with maternal or paternal BD accounting for offspring BD and demographic characteristics. Participants aged 12-21 years (266 offspring of a parent with BD, 175 offspring of a parent with no psychiatric history) were recruited in the US and Australia. We modeled family environment using latent profile analysis based on offspring reports on the Conflict Behavior Questionnaire, Family Adaptability and Cohesion Evaluation Scales, and Home Environment Interview for Children. Parent diagnoses were based on the Diagnostic Interview for Genetic Studies and offspring diagnoses were based on the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Latent class regression was used to test associations of diagnosis and family environment. Two-thirds of all offspring perceived well-functioning family environment, characterized by nurturance, flexibility, and low conflict. Two 'conflict classes' perceived family environments low in flexibility and cohesion, with substantial separation based on high conflict with the father (High Paternal Conflict), or very high conflict and rigidity and low warmth with the mother (High Maternal Conflict). Maternal BD was associated with offspring perceiving High Maternal Conflict (OR 2.8, p = 0.025). Clinical care and psychosocial supports for mothers with BD should address family functioning, with attention to offspring perceptions of their wellbeing. More research is needed on the effect of paternal BD on offspring and family dynamics.

Salivary melatonin onset in youth at familial risk for bipolar disorder

Melatonin secretion and polysomnography (PSG) were compared among a group of healthy adolescents who were at high familial risk for bipolar disorder (HR) and a second group at low familial risk (LR). Adolescent participants (n = 12) were a mean age 14 ± 2.3 years and included 8 females and 4 males. Saliva samples were collected under standardized condition light (red light) and following a 200 lux light exposure over two consecutive nights in a sleep laboratory. Red Light Melatonin onset (RLMO) was defined as saliva melatonin level exceeding the mean of the first 3 readings plus 2 standard deviations. Polysomnography was also completed during each night. HR youth, relative to LR, experienced a significantly earlier melatonin onset following 200 lux light exposure. Polysomnography revealed that LR youth, relative to HR, spent significantly more time in combined stages 3 and 4 (deep sleep) following red light exposure. Additionally, regardless of the group status (HR or LR), there was no significant difference in Red Light Melatonin Onset recorded at home or in the laboratory, implying its feasibility and reliability.

LET's CONNECT community mentorship program for youths with peer social problems: Preliminary findings from a randomized effectiveness trial

This study examined the effectiveness of LET's CONNECT (LC), a community mentorship program for youths who report peer social problems, which is based on a positive youth development framework. Participants were 218 youths (66.5% girls), aged 12 to 15 years, who were recruited from an urban medical emergency department and screened positive for bullying victimization, bullying perpetration, and/or low social connectedness. Youths were randomized to LC (n = 106) or the control condition (n = 112). Six-month outcomes were assessed with self-report measures of youth social connectedness, community connectedness, thwarted belongingness, depression, self-esteem, and suicidal ideation. LC was associated with a significant increase in only one of these outcomes, social connectedness (effect size = 0.4). It was associated consistently with trend-level positive changes for thwarted belongingness (decreased), depression (decreased), community connectedness, and self-esteem (effect sizes = 0.2). There was no effect on suicidal ideation (effect size = 0.0), and although not a primary outcome, eight youths in the LC condition and seven youths in the control condition engaged in suicidal behavior between baseline and follow-up. Although LC effect sizes are consistent with those from previous studies of community mentorship, there were multiple challenges to LC implementation that affected dosage and intervention fidelity, and that may account for the lack of stronger positive effects.

Traumatic Stress Interacts With Bipolar Disorder Genetic Risk to Increase Risk for Suicide Attempts

OBJECTIVE

Bipolar disorder (BD) is one of the most heritable psychiatric conditions and is associated with high suicide risk. To explore the reasons for this link, this study examined the interaction between traumatic stress and BD polygenic risk score in relation to suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) in adolescent and young adult offspring and relatives of persons with BD (BD-relatives) compared with adolescent and young adult offspring of individuals without psychiatric disorders (controls).

METHOD

Data were collected from 4 sites in the United States and 1 site in Australia from 2006 through 2012. Generalized estimating equation models were used to compare rates of ideation, attempts, and NSSI between BD-relatives (n = 307) and controls (n = 166) and to determine the contribution of demographic factors, traumatic stress exposure, lifetime mood or substance (alcohol/drug) use disorders, and BD polygenic risk score.

RESULTS

After adjusting for demographic characteristics and mood and substance use disorders, BD-relatives were at increased risk for suicidal ideation and attempts but not for NSSI. Independent of BD-relative versus control status, demographic factors, or mood and substance use disorders, exposure to trauma within the past year (including bullying, sexual abuse, and domestic violence) was associated with suicide attempts (p = .014), and BD polygenic risk score was marginally associated with attempts (p = .061). Importantly, the interaction between BD polygenic risk score and traumatic event exposures was significantly associated with attempts, independent of demographics, relative versus control status, and mood and substance use disorders (p = .041).

CONCLUSION

BD-relatives are at increased risk for suicide attempts and ideation, especially if they are exposed to trauma and have evidence of increased genetic vulnerability.

Neuroleptic Malignant Syndrome/Malignant Catatonia in Child Psychiatry: Literature Review and a Case Series

OBJECTIVE

To describe the presentation of neuroleptic malignant syndrome (NMS) and malignant catatonia (MC) in children and adolescents.

BACKGROUND

NMS and MC are life-threatening, neuropsychiatric syndromes, associated with considerable morbidity and mortality. NMS is diagnosed when there is a recent history of treatment with an antipsychotic (AP) medication, while MC is diagnosed when the symptoms resemble NMS but without a history of exposure to an AP agent. Some authorities believe that apart from the history of exposure to an AP medication, the two conditions are identical. The symptoms of NMS/MC include severe agitation, behavior disregulation, motor and speech changes, self-injury and aggression, autonomic instability, and a range of psychiatric symptoms (affective, anxiety, or psychotic symptoms). Patients may be misdiagnosed with another disorder leading to extensive tests and a delay in treatment. Untreated, the condition may be fatal in 10%-20% of patients, with death sometimes occurring within days of disease onset.

METHOD

We describe the presentation and management of five children and adolescents with NMS/MC.

CONCLUSION

MC and NMS are life-threatening medical emergencies, which if diagnosed promptly, can be successfully treated with known effective treatments (benzodiazepines and/or electroconvulsive therapy).

Psychosis and catatonia in fragile X: Case report and literature review

Fragile X mental retardation 1 (FMR1) premutation associated phenotypes have been explored extensively since the molecular mechanism emerged involving elevated FMR1 messenger ribonucleic acid (mRNA) levels. Lowered fragile X mental retardation protein (FMRP) can also occur which may have an additive effect to the high levels of mRNA leading to neurodevelopmental problems and psychopathology. This paper was aimed to review psychosis and catatonia in premutation carriers, express the role of elevated FMR1 mRNA and lowered FMRP in the phenotype of carriers and present a case of psychosis and catatonia in a carrier. This case also demonstrates additional genetic and environmental factors which may also affect the phenotype. We review the literature and report an exemplary case of a 25 year old male premutation carrier with elevated FMR1 mRNA, low FMRP, a cytochrome P450 family 2 subfamily D polypeptide 6 (CYP2D6)*2xN mutation and a perinatal insult. This patient developed an autism spectrum disorder, psychosis, catatonia with subsequent cognitive decline after electro-convulsive therapy (ECT) for his catatonia. He had a premutation of 72 CGG repeat in FMR1, FMR1 mRNA level that was over 2.4 times normal and FMRP level at 18% of normal, and additionally, a CYP2D6 allelic variant which leads to ultrarapid metabolism (UM) of medication. There is an overlapping pathophysiological mechanism of catatonia and fragile X-associated premutation phenotypes including autism and psychosis. This case demonstrates the shared phenotype and the overlap of the pathophysiological mechanisms that can influence the intervention. Multiple genetic and environmental hits can lead to more significant involvement in premutation carriers.

Catatonia in Down syndrome; a treatable cause of regression

OBJECTIVE

The main aim of this case series report is to alert physicians to the occurrence of catatonia in Down syndrome (DS). A second aim is to stimulate the study of regression in DS and of catatonia. A subset of individuals with DS is noted to experience unexplained regression in behavior, mood, activities of daily living, motor activities, and intellectual functioning during adolescence or young adulthood. Depression, early onset Alzheimer's, or just "the Down syndrome" are often blamed after general medical causes have been ruled out. Clinicians are generally unaware that catatonia, which can cause these symptoms, may occur in DS.

STUDY DESIGN

Four DS adolescents who experienced regression are reported. Laboratory tests intended to rule out causes of motor and cognitive regression were within normal limits. Based on the presence of multiple motor disturbances (slowing and/or increased motor activity, grimacing, posturing), the individuals were diagnosed with unspecified catatonia and treated with anti-catatonic treatments (benzodiazepines and electroconvulsive therapy [ECT]).

RESULTS

All four cases were treated with a benzodiazepine combined with ECT and recovered their baseline functioning.

CONCLUSION

We suspect catatonia is a common cause of unexplained deterioration in adolescents and young adults with DS. Moreover, pediatricians and others who care for individuals with DS are generally unfamiliar with the catatonia diagnosis outside schizophrenia, resulting in misdiagnosis and years of morbidity. Alerting physicians to catatonia in DS is essential to prompt diagnosis, appropriate treatment, and identification of the frequency and course of this disorder.

Maintenance electroconvulsive therapy for aggression and self-injurious behavior in two adolescents with autism and catatonia

Frequent aggression toward others and repetitive self-injurious behaviors (SIB) can be features of catatonia in patients with autism. Similar to catatonia secondary to other etiologies, catatonia associated with autism responds well to treatment with benzodiazepines and/or electroconvulsive therapy (ECT). The authors report here on two adolescent patients with autism who presented with severe aggression, one of whom also engaged in repetitive SIB. With ongoing treatment with maintenance ECT, dramatic reduction in aggression and SIB were noted, allowing both patients a reasonable quality of life in their own homes. Attempts to taper off ECT coincided with return of aggression symptoms, although not SIB.

A naturalistic study of suicidal adolescents treated with an SSRI: suicidal ideation and behavior during 3-month post-hospitalization period

OBJECTIVE

Describe suicidal ideation and suicide related/other emergencies (SRE), among depressed and acutely suicidal adolescents during a 3-month period following psychiatric hospitalization.

METHODS

One hundred twenty adolescents, who were both depressed and suicidal, were receiving an SSRI either alone or in combination with other medications, remained on a consistent medication regimen between baseline and at 3-months and their 3-month outcome data were available. The participants were divided into four medication groups: SSRI antidepressant only (n=71); SSRI plus mood stabilizer (n=17); SSRI plus antipsychotic (n=20); and SSRI plus antipsychotic and mood stabilizer (n=12). Standardized instruments were used.

RESULTS

Mean age=15.5±1.3, Caucasian=80.8%, female=74.2%, mean CDRS-R=61.7±12.1, suicide attempt during month prior to hospitalization=58.6%. During the 3-month post-hospitalization period: (1) there were no suicides, six participants (5%) attempted suicide and 21 (17.5%) experienced an SRE; (2) decline in suicidal ideation and depression severity was noted; (3) SSRI plus an antipsychotic group reported the highest number of SREs; (4) higher baseline hopelessness and aggression scores were associated with greater reduction in suicidal ideation at 3-months.

CONCLUSION

Declines in suicidal ideation, depression severity, and suicide attempts were noted, irrespective of psychotropic-combination received. A higher rate of SREs was associated with receiving an antipsychotic agent in combination with an SSRI. Given naturalistic design of study, cause-effect conclusions cannot be drawn. The lack of an objective measure to identify medication adherence is a study limitation.

Use of electroconvulsive therapy in the treatment of catatonia

ABSTRACT: 

While the mechanisms of catatonia remain poorly understood, there are known and effective treatments for it, namely high-dose benzodiazepines and electroconvulsive therapy (ECT). For more than 75 years, ECT has been successfully used for the treatment of severe psychiatric disorders, including catatonia. This special report describes ECT in patients with catatonia, its indications, treatment logistics, decision-making about when to use ECT instead of conservative treatment, special circumstances and adverse effects.

Depressed suicidal adolescent males have an altered cortisol response to a pharmacological challenge

Dysregulation of the HPA axis and the dysfunction of the central serotonin (5HT) system are the most replicated biomarkers of depression and suicidal ideation and behavior. However, few studies have examined the two systems simultaneously. In this study, cortisol response was measured in depressed adolescents, following the administration of a central serotonin receptor agonist, meta-chlorphenylpiprazine (mCPP). Adolescents with major depression (MDD; n = 44; males = 15, females = 29; mean age ± SD = 15.5 ± 1.5) were divided into two groups: non-suicidal or those who reported passive suicidal ideation (n = 21), and those who had either threatened suicide or engaged in suicidal acts (n = 23). Sequential infusions of normal saline and mCPP were administered, and serial blood samples were collected for cortisol response. A differential time by group pattern of cortisol response following mCPP was found in the entire group (F(6,242) = 2.6, p=0.018). However, this was mostly attributed to males (F(6,73) = 2.3, p = 0.043) who had threatened or engaged in suicidal acts and displayed a higher cortisol response at 10 and 25 min after the infusion of mCPP, which was not affected by the severity of depression. This differential pattern of cortisol secretion in response to a serotonergic agonist may be a biomarker for more severe forms of suicidal ideation and behavior in adolescent males.

Retrospective chart review of catatonia in child and adolescent psychiatric patients

OBJECTIVE

Identify the frequency of catatonia among at-risk children and adolescents receiving psychiatric treatment.

METHOD

Subjects were children and adolescents (<18 years), who had received psychiatric treatment at a University Hospital during 2004-2009, and were diagnosed with disorders with known risk for catatonia or displayed symptoms suggestive of catatonia. Approval was obtained from the Investigational Review Board (IRB). The first 101 (n = 101) subjects were selected among 570 subjects identified by psychiatric diagnoses: any pervasive developmental disorder, psychosis-NOS (Not Otherwise Specified), intermittent explosive disorder, mental retardation, catatonia and neuroleptic malignant syndrome. Subjects met study-defined criteria for catatonia, if they had three or more of the following symptoms: unexplained agitation/excitement, disturbed or unusual movements, reduced movements, repetitive or stereotyped movements, or reduced or loss of speech.

RESULTS

Eighteen (17.8%) subjects, among a group suspected to be at a higher risk for catatonia, met the study-defined criteria for this syndrome. However, only two subjects had been diagnosed by their treatment providers. Higher rates of intellectual disability and aggression were found among the group that met study-criteria.

CONCLUSION

We concluded that catatonia is under recognized and undertreated among children and adolescents receiving psychiatric treatment.

Suicide rates among Turkish and American youth: a cross-cultural comparison

This study compares youth (<24 years) suicide rates in Turkey and the United States; a demographic and cross-cultural comparison and exploration of possible causative factors. Publicly available data were compared for children, adolescents, and young adults for years 1992-2004. The mean general population suicide rate in Turkey (per 100,000) was, male = 3.53 and female = 2.31 (for the US, males = 18.37, females = 4.31); for ages below 15 years the rate was, males = 0.28 and females = 0.39 (for the US, males = 1.09 and females = 0.38); while for aged 15-24 years the rate was, males = 4.58 and females = 5.22 (for the US, males = 18.84 and females = 3.36). The patterns for Turkey are: (a) Female youth had a higher suicide rate than male youth; this was the reverse of the U.S. pattern, (b) Youth suicide increased during the time period in Turkey, whereas it was relatively stable in the US, (c) However, suicide rates in Turkey were generally lower than the US, (d) Fifty percent of all female suicide victims in Turkey were under the age of 24 years (versus 11% in the US). Possible psychosocial causative factors may include (a) negative social status of females (forced marriage, young marriage age, low literacy, honor killings); (b) substantial rural to urban migration which disrupts ties and exposes migrants to a less traditional cultural system; (c) shortage of mental health services; (d) and possibly, reduced religious education enrollment may be an additional factor.

Major depressive disorder in adolescents: family psychiatric history predicts severe behavioral disinhibition

BACKGROUND

Major Depressive Disorder (MDD) becomes increasingly prevalent during adolescence and is associated with substantial psychiatric comorbidity and psychosocial impairment. The marked behavioral heterogeneity evident among adolescents with MDD suggests the possibility of distinct subtypes. This study was designed to determine whether family psychiatric histories differ between groups of MDD adolescents defined by the presence or absence of severe behavioral disinhibition.

METHODS

Adolescents with MDD (n = 71) completed the Buss-Durkee Hostility Inventory--Adapted, Adolescent Aggressive Incidents Interview (AAII), Measure of Aggression, Violence, and Rage in Children, Diagnostic Interview Schedule for Children, Suicidal Ideation Questionnaire-JR., Suicidal Behavior Inventory, and Reynolds Adolescent Depression Scale. Parents completed the Family Informant Schedule and Criteria, Children's Affective Liability Scale, AAII, and a partial DISC. Behavioral disinhibition (BD) measures were used to assign adolescents to MDD+BD (n = 41) and MDD-BD (n = 30) groups.

RESULTS

The MDD+BD group had a higher prevalence of drug use disorders in biological fathers than the MDD-BD group. The MDD+BD group also had higher proportions of paternal second degree relatives with alcohol use disorders, drug use disorders, and psychiatric hospitalizations, and a higher proportion of maternal second degree relatives with antisocial personality disorder.

LIMITATIONS

Limitations include reliance on single informants for family psychiatric histories and the failure to distinguish between child- and adolescent-onset depression.

CONCLUSIONS

Family psychiatric histories differentiated MDD adolescents grouped by the presence or absence of behavioral disinhibition, suggesting possible etiologic mechanisms. Further research on subtypes or comorbid presentations may assist in the development of targeted treatment strategies.

Catatonia in Autistic Spectrum Disorders: A Medical Treatment Algorithm

Autism is a developmental syndrome with an unknown biology and inadequate therapeutics. Assessing the elements of the syndrome for the presence of depression, psychosis, mania, or catatonia, offers opportunities for systematic intervention. Since almost all descriptions of autism highlight the presence of motor symptoms that characterize catatonia, an assessment for this eminently treatable syndrome is recommended for all patients considered to be autistic. A minimum examination includes a catatonia rating scale and for those patients with defined catatonia, a lorazepam test. For those whose catatonia responds to lorazepam, high dose lorazepam therapy is recommended. If this fails, electroconvulsive therapy is recommended. The assessment and treatment of catatonia offers positive medical therapy for the victims of autism and their families.

Catatonia in autism: a distinct subtype?

Catatonia is a life-threatening disorder characterized by motor abnormalities, mutism, and disturbances of behaviour, which is increasingly being diagnosed in persons with autism. In this report, we describe the presentation and course of catatonia in an adolescent with autism who responded to electroconvulsive therapy (ECT). The illness started with depressive symptoms, but the predominant feature was one of extreme obsessive slowing and immobility. We propose that catatonia should be ruled out as a cause of regression sometimes seen in adolescents with autism, and that catatonia of autism may index a distinct subtype with a particularly poor outcome.

Practice parameter for use of electroconvulsive therapy with adolescents

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75%-100%), whereas psychotic disorders have a lower response rate (50%-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Summary of the practice parameter for the use of electroconvulsive therapy with adolescents

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75-100%), whereas psychotic disorders have a lower response rate (50-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Central serotonergic effects of m-chlorophenylpiperazine (mCPP) among normal control adolescents

Central serotonin function was studied among 21 adolescents (12 males, 9 females), mean age 14.4+/-1.5 years. A placebo-controlled design was used to measure three neuroendocrine hormones (prolactin, cortisol and growth hormone) following a challenge with the central serotonergic agonist m-chlorophenylpiperazine (mCPP). Infusion of mCPP resulted in augmented prolactin, cortisol and growth hormone release. Gender effects were significant for prolactin, cortisol and growth hormone. Females had higher baseline prolactin without significant interactions with infusion or time, cortisol levels were higher in males than in females at all time points without significant interactions with infusion or time, and the augmented growth hormone response to mCPP was limited to males. Systolic and diastolic blood pressure, heart rate and temperature were all mildly elevated following mCPP infusion. Side effects to mCPP infusion were mild and lasted approximately 20 min. We conclude that mCPP is useful in the study of serotonergic neuroendocrine hormones in adolescents, is well tolerated, and the levels of prolactin, cortisol and growth hormone are influenced by gender.

Depression in persons with autism: implications for research and clinical care

Although several studies have investigated the occurrence of medical and neurological conditions in persons with autism, relatively few reports have focused on the phenomenology and treatment of psychiatric disorders in this population. There is emerging evidence that depression is probably the most common psychiatric disorder that occurs in autistic persons. In this review, we examine the factors that influence the presence of depression in this population, such as the level of intelligence, age, gender, associated medical conditions, and the role of genetic factors and life events. We discuss the various forms of treatment available and highlight the need for early detection.

ECT treatment of malignant catatonia/NMS in an adolescent: a useful lesson in delayed diagnosis and treatment

A 17-year-old adolescent female presented to a psychiatric emergency room with excitement, confusion, and psychotic symptoms. After brief exposure to haloperidol and olanzapine, she developed fever, rigidity, waxy flexibility, autonomic instability, and elevated creatinine phosphokinase enzyme. Approximately 6 weeks after the onset of the illness, multiple laboratory tests, and evaluation at three different hospitals, the condition was effectively treated with electroconvulsive therapy (ECT). This case is a lesson in delayed recognition and the delayed use of ECT for the malignant catatonia/neuroleptic malignant syndrome.

Autistic symptoms following herpes encephalitis

Autism is a childhood onset neurodevelopmental disorder characterized by reciprocal social deficits, communication impairment, and rigid ritualistic interests, with the onset almost always before three years of age. Although the etiology of the disorder is strongly influenced by genes, environmental factors are also important. In this context, several reports have described its association with known medical conditions, including infections affecting the central nervous system. In this report, we describe an 11-year-old Asian youngster who developed the symptoms of autism following an episode of herpes encephalitis. In contrast to previous similar reports, imaging studies suggested a predominant involvement of the frontal lobes. At follow-up after three years, he continued to show the core deficits of autism. This case further supports the role of environmental factors, such as infections, in the etiology of autism, and suggests that in a minority of cases, autistic symptoms can develop in later childhood.

Myoclonus during prolonged treatment with sertraline in an adolescent patient

A 15-year-old female adolescent with depression developed myoclonus after uninterrupted treatment with sertraline over 6 years. She was also receiving methylphenidate. Withdrawal of sertraline and continuation of methylphenidate did not result in any improvement. Treatment with valproic acid resulted in improvement of the movement disorder. This report suggests that myoclonus may be a side effect of sertraline in some adolescents. Further, we hypothesized that extended treatment over several years, young age, and a compromised central nervous system due to underlying disorders may be risk factors for the development of this side effect.

Electroconvulsive therapy for minors: experiences and attitudes of child psychiatrists and psychologists

OBJECTIVE

To estimate knowledge, experience, and attitudes towards the use of electroconvulsive treatment in minors (patients < 18 years of age), among child and adolescent psychiatrists and psychologists.

METHOD

1,600 questionnaires were mailed to a group of child and adolescent psychiatrists and psychologists.

RESULT

There were 625 (39%) respondents. 329 (53.8%) of the respondents stated that they possessed minimal knowledge about the use of ECT in children and adolescents. Lack of confidence in providing a second opinion was common and reported by 75%. Compared with those with minimal knowledge, respondents with advanced knowledge reported a higher perception of safety and efficacy. The majority (70%) of the respondents regarded ECT as a treatment of last resort.

CONCLUSION

Many child and adolescent psychiatrists and psychologists have very little knowledge, training, or experience in this treatment. They seem to be ill equipped to appropriately consider or advise patients and families about ECT. Clinical and research implications of these findings are discussed.

Cognitive side effects of electroconvulsive therapy in adolescents

OBJECTIVE

The primary aim of this study was to determine the presence of cognitive impairments among adolescents treated with electroconvulsive therapy (ECT) and whether these deficits would persist several months following the treatment.

METHODS

Retrospective data resulting from standard clinical care of a convenience sample with naturalistic follow-up were used. Subjects were 16 adolescents (13 females, 3 males; mean age = 15.9 +/- 1.6 years) hospitalized with a mood disorder (unipolar depression = 14, bipolar depression = 2). Cognitive tests administered prior to ECT were compared with results at 7.0 +/- 10.3 days following the last treatment and with a second testing at 8.5 +/- 4.9 months after the last treatment.

RESULTS

Comparison of pre-ECT and the first post-ECT testing administered during the first 10 days of the treatment yielded significant impairments of concentration and attention, verbal- and visual-delayed recall, and verbal fluency. A complete recovery of these functions was noted at the second post-ECT testing. There was no deficit in the ability to problem solve during the initial or the subsequent testing.

CONCLUSION

Cognitive parameters found to be impaired during the first few days of ECT recovered over several months following the treatment. Therefore, there was no evidence of long-term damage to concentration, attention, verbal and visual memory, or verbal fluency. There were no impairments of motor strength and executive processing, even during the early (within 7-10 days) post-ECT period. These results should be regarded as preliminary, awaiting confirmation with larger samples.

Anxiety contributes to suicidality in depressed adolescents

Several studies have suggested a positive association between anxiety symptoms and suicidality in adults. However, relatively little is known about this topic in adolescents. To investigate this issue, we examined a group of adolescents admitted to our psychiatric inpatient unit. Fifty-six adolescents (mean age = 14.8 +/- 1.4; females = 34, males = 22; race = 95% Caucasians) participated in the study. Diagnoses were made using the DSM-III-R criteria and a diagnostic interview. Anxiety was found to significantly correlate with depression (r = .60; P = < .05) and suicidality (r = .72; P < .05). A multiple regression analysis revealed that anxiety and depression together accounted for more than half (55%) of the variance in suicidal ideation [F(2,46) = 28.4; P < .0001]. In addition, anxiety had an independent ability to predict suicidality (t = 5.01; P < .0001). Self-rated but not clinician-rated suicidality was positively correlated with both anxiety and depression. Clinical and research implications of these findings are discussed.

Serotonin dysregulation in adolescents with major depression: hormone response to meta-chlorophenylpiperazine (mCPP) infusion

This study examined central serotonin disturbance, as reflected by neuroendocrine hormones, among adolescents with major depression. Prolactin, cortisol, and growth hormone were measured following the infusion of a serotonin agonist, meta-chlorophenylpiperazine (mCPP). Twelve (M=6, F=6) medication-free adolescents with major depression (MDD) were compared with 12 (M=6, F=6) matched normal control subjects, ranging in age from 13 to 17 years. Baseline evaluations and a battery of laboratory tests were completed. mCPP, 0.1 mg/kg i. v., was administered in a placebo-controlled design. Analyses of the neuroendocrine hormones revealed that the depressed group had a higher baseline prolactin level and an augmented prolactin response to mCPP challenge than did the control group. The depressed group experienced a sharper baseline-cortisol decline between 08.00 and 11.00 h, and compared to control subjects they displayed an augmented response to the challenge. The depressed group reported more side effects than the control group during saline infusion, but not during mCPP infusion. Findings suggest that depressed adolescents have an elevated baseline prolactin level, and also experience enhanced prolactin and cortisol responses to the serotonergic challenge. These preliminary findings will be confirmed during our ongoing study.

Psychotic versus nonpsychotic depression in hospitalized adolescents

One hundred fifty adolescent inpatients with major depression were systematically assessed for demographic and clinical differences between psychotic and nonpsychotic depression. Delusions and/or hallucinations were present in 10% of the subjects. The psychotic group had significantly more frequent and severe suicidal ideation. Posttraumatic stress disorder was also more frequent in the psychotic group.

Aggressive behavior in clinically depressed adolescents

OBJECTIVE

To investigate the prevalence and characteristics of aggressive behavior in adolescent inpatients and outpatients with major depressive disorder (MDD). Differences between males and females in prevalence and type of aggression, and level of parent-child agreement in report of aggression, were analyzed.

METHOD

Participants were 74 adolescents with MDD, aged 13 to 17 years. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to identify MDD. Adolescents' aggressive behavior was assessed using an adapted version of the Brown-Goodwin Assessment for Lifetime History of Aggression; the Measure of Aggression, Violence, and Rage in Children; and the Buss-Durkee Hostility Inventory-Adapted Version.

RESULTS

Results indicate high levels of aggressive behavior in adolescents with MDD. Amount and type of aggression did not differ by gender. Results indicate poor correspondence between parent and adolescent reports of aggression, which was most marked for females.

CONCLUSIONS

Aggressive behaviors are highly prevalent in depressed youths, with similar types and levels evident in males and females. Parents tend to under-report and may not be cognizant of aggressive behavior that occurs outside the home, particularly for females.

Medication noncompliance in adolescents with psychiatric disorders

The purpose of the study was to estimate prevalence of medication noncompliance among adolescents, following discharge from hospital. A second purpose was to identify predictors of such noncompliance. Seventy-one adolescents, who had been prescribed a medication during psychiatric hospitalization, were interviewed by telephone, 6-8 months post-hospitalization. Medication noncompliance was defined as discontinuing medication without the recommendation of the treating physician. Twenty-four subjects (33.8%) were noncompliant with medication. Age, race, gender, SES, diagnosis, type and number of medications, severity of depression, and family living arrangement did not predict noncompliance. We concluded that noncompliance with psychotropic medications was relatively common and difficult to predict in adolescents who had been hospitalized to a psychiatric inpatient unit; the majority of them suffered from depression. Clinicians should be aware that medication noncompliance may be common and a relatively unpredictable phenomenon.

Electroconvulsive treatment of a bipolar adolescent postcraniotomy for brain stem astrocytoma

This is the first reported use of electroconvulsive treatment (ECT) in an adolescent with bipolar mania who had been treated with craniectomy for an intracranial neoplasm. The reported case is of a 16-year-old girl with a history of brain stem glioma (pontomesencephalic astrocytoma) diagnosed at 13 years of age. She presented in a psychiatric emergency room with suicidal ideation, depressed mood, irritability, olfactory hallucinations, early insomnia, grandiosity, and guilt. Her symptoms failed to respond to a trial of an antidepressant, mood stabilizer alone, and mood stabilizer in conjunction with a neuroleptic. The decision to use ECT was based on suicidal ideation, extreme disinhibition, and danger to self and others. Significant improvement in mood and remission in psychosis were noted after the eighth treatment. Comparison of 2-week pre-ECT and 3-month post-ECT cognitive testing revealed no change in IQ. This report highlights rapid response and the ability to tolerate ECT in an adolescent diagnosed with bipolar disorder, who had also been treated with radiation and craniotomy.

Comorbidity of Asperger syndrome: a preliminary report

Asperger syndrome (AS) is a pervasive developmental disorder characterized by autistic social dysfunction and idiosyncratic interests in the presence of normal intelligence. There is no history of language delay. Although people with AS are known to suffer from comorbid psychiatric conditions, few studies have systematically addressed this topic. This preliminary report describes the occurrence of psychiatric disorders in a series of patients with AS diagnosed according to the ICD-10/DSM-IV criteria. Out of 35 patients (29 males and six females; mean age 15.1 years; mean verbal IQ 105.9; mean performance IQ 97.5; mean full-scale IQ 102.7), 23 patients (65%) presented with symptoms of an additional psychiatric disorder at the time of evaluation or during the 2-year follow-up. Children were most likely to suffer from attention deficit hyperactivity disorder, while depression was the most common diagnosis in adolescents and adults. The implications of these findings are discussed.

Prediction of positive outcomes for adolescent psychiatric inpatients

OBJECTIVE

To identify individual, parent/family, and treatment follow-through predictors of outcome for adolescent psychiatric inpatients 6 months after hospital discharge.

METHOD

Eighty-nine adolescents participated in a comprehensive baseline evaluation during psychiatric hospitalization. Baseline measures included the Diagnostic Interview Schedule for Children, Social Adjustment Inventory for Children and Adolescents, Reynolds Adolescent Depression Scale (RADS), and Suicidal Ideation Questionnaire-Junior (SIQ-Jr). Structured telephone follow-up interviews assessed treatment follow-through, suicidal behaviors, rehospitalizations, living changes, and social adaptive functioning. The RADS and SIQ-Jr were also readministered.

RESULTS

Baseline indices of adolescent functioning emerged as the strongest predictors of outcomes. Hierarchical multiple regression analyses indicated that baseline depression severity, a cluster of parent/family indices, and medication follow-through were significant predictors of outcome depression severity. Baseline social adaptive functioning, presence/absence of conduct disorder, and medication follow-through were significant predictors of outcome social adaptive functioning.

CONCLUSIONS

The nature and course of adolescent psychopathology was difficult to disrupt, with baseline characteristics as the strongest predictors of outcome. Nevertheless, the significance of medication follow-through as a predictor suggests that treatment-related gains are possible.