Validation of a youth suicide risk calculator in an adult sample with bipolar disorder

BACKGROUND

Bipolar disorder (BD) conveys the highest risk of suicide of all mental disorders. We sought to externally validate a risk calculator (RC) of suicide attempts developed in youth with BD from the Course and Outcome of Bipolar Youth (COBY) study in an adult sample.

METHODS

A prospective cohort of adults with BD from the National Institute of Mental Health Collaborative Depression Study (CDS; N = 427; mean (+/- SD) age at intake (36 +/- 13 years)) was secondarily analyzed to validate the COBY RC for one-year risk of suicide attempts/deaths. Nine of the ten predictor variables from the COBY RC were available in the CDS and used: age, age of mood disorder onset, first and second (partial) degree family history of suicide, history of psychotic symptoms, substance use disorder, prior suicide attempt, socioeconomic status, and non-suicidal self-injury (prospectively, incompletely at baseline).

RESULTS

Over a mean (SD) follow-up of 19 (10) years, 29 % of the CDS sample attempted suicide. The RC predicted suicide attempts/deaths over one-year follow-up with an area under the receiver operating characteristic curve (AUC) of 0.78 (95 % CI 0.75-0.80). The RC performed slightly better in those with a younger age of mood disorder onset.

LIMITATIONS

Clinical samples may limit generalizability; the RC does not assess more acute suicide risk.

CONCLUSIONS

One-year risk of suicide attempts/deaths can be predicted with acceptable accuracy in youth and adults with BD, comparable to commonly used RCs to predict cardiovascular risk. This RC may help identify higher-risk individuals with BD for personalized treatment and research. https://cobysuicideattemptsrc.shinyapps.io/Shiny.

Systematic Review: White Matter Microstructural Organization in Adolescents With Depression

Objective

A growing body of literature has focused on the neural mechanisms of depression. Our goal was to conduct a systematic review on the white matter microstructural differences in adolescents with depressive disorders vs adolescents without depressive disorders.

Method

We searched PubMed and PsycINFO for publications on August 3, 2022 (original search conducted in July 2021). The review was registered on PROSPERO (registration number: CRD42021268200), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Eligible studies were original research papers comparing diffusion tensor/spectrum imaging findings in adolescents with vs without depression (originally ages 12-19 years, later expanded to 11-21 years). Studies were excluded if they focused on depression exclusively in the context of another condition, used only dimensional depressive symptom assessment(s), or used the same dataset as another included publication.

Results

The search yielded 575 unique records, of which 14 full-text papers were included (824 adolescents with depression and 686 without depression). The following white matter regions showed significant differences in fractional anisotropy in at least 3 studies: uncinate fasciculus, cingulum, anterior corona radiata, inferior fronto-occipital fasciculus, and corpus callosum (genu and body). Most studies reported decreased, rather than increased, fractional anisotropy in adolescents with depression. Limitations include the possibility for selective reporting bias and risk of imprecision, given the small sample sizes in some studies.

Conclusion

Our systematic review suggests aberrant white matter microstructure in limbic-cortical-striatal-thalamic circuits, and the corpus callosum, in adolescents with depression. Future research should focus on developmental trajectories in depression, identifying sources of heterogeneity and integrating findings across imaging modalities.

Recognizing Suicidal Risk in Very Young Children

Suicidal thought and behavior (STB) in preschool and kindergarten-age children is an alarming event. Until recently, these young children's experiences have been under recognized, in part due to an under appreciation for their awareness of the finality of death. Although rare, serious suicide attempts and death by suicide among preschool and kindergarten-age children are well documented. There is limited research on the risk factors that contribute to STB in very young children. We present de-identified case descriptions of very young children seen for psychiatric treatment at a day hospital program who presented with self-injurious behavior and suicidal ideation (SI). The patients described have common risk factors, including exposure to trauma, family conflict and family history of suicidal behavior. It is critical that children presenting with STB be assessed and offered services to mitigate these risks.

Assessing the Quality of Patient Responses to a Psychosocial Intervention Implemented on an Adolescent Psychiatric Inpatient Unit: Devising the Safety Plan Quality Metric

The Safety Planning Intervention (SPI) helps patients use coping strategies when in a suicidal crisis. This project aimed to characterize SPI quality and determine if it is associated with reduced risk of readmission to psychiatric hospitals. The sample included 145 participants hospitalized on an adolescent psychiatric unit from May to December 2018 who met suicidal criteria per items 18 and 91 on the Youth Self Report. The Safety Plan Quality Metric was created to rate SPI quality. A significant association between higher-quality SPI and fewer instances of readmission was identified (X2 (1, N = 94) = 4.32, p = .038). A logistic regression conducted to determine the impact of other patient factors on readmission did not yield a statistically significant model, (X2 (5, N = 94) = 8.43, p = 0.13). The results suggest that patients with higher quality SPIs were less likely to be rehospitalized.

Higher socioeconomic status and less parental psychopathology improve prognosis in youths with bipolar disorder

BACKGROUND

To identify prospectively ascertained individual and family factors that are associated with improvement in Bipolar Disorder (BD) among youths who initially presented with poor course.

METHODS

82 youths with BD with persistent poor mood symptomatology ("predominantly ill course") were compared to 70 youths with BD who at intake had poor course, but showed improvement during the follow-up ("ill with improving course"), (ages 12.3 ± 3.3, vs. 11.7 ± 3.3 years old, at intake). Improvement was measured by the percentage of time euthymic during a mean follow-up of 12.8 years. Youths and parents were interviewed to assess psychopathology, functioning, treatment, and familial functioning and psychopathology.

RESULTS

Compared to the ill group, since intake, the improving group showed significantly lower subthreshold depression and hypo/mania, Attention Deficit Hyperactivity Disorder, and Disruptive Behavior Disorders. Parental Socioeconomic Status (SES) remained unchanged over time in the ill group, but progressively increased in the improving group. Importantly, the change in SES predated the improvement in the mood trajectory. The most influential variables that predicted improvement were higher SES, and absence of parental BD and Substance Use Disorder (SUD). Parental SUD also negatively affected the parental SES, which was directly associated with worse mood course.

LIMITATIONS

Predominantly self-reported White samples may limit generalizability; other factors potentially associated with outcome (e.g., treatment adherence), were not ascertained.

CONCLUSIONS

In addition to treating mood/comorbid psychopathology in symptomatic BD youths, to improve their prognosis, it is crucial to address their parent's BD and SUD and promote parental education/employment.

Validation of the youth mood recurrences risk calculator in an adult sample with bipolar disorder

BACKGROUND

The ability to predict an individual's risk of mood episode recurrence can facilitate personalized medicine in bipolar disorder (BD). We sought to externally validate, in an adult sample, a risk calculator of mood episode recurrence developed in youth/young adults with BD from the Course and Outcome of Bipolar Youth (COBY) study.

METHODS

Adult participants from the National Institute of Mental Health Collaborative Depression Study (CDS; N=258; mean(SD) age=35.5(12.0) years; mean follow-up=24.9 years) were utilized as a sample to validate the youth COBY risk calculator for onset of depressive, manic, or any mood episodes.

RESULTS

In this older validation sample, the risk calculator predicted recurrence of any episode over 1, 2, 3, or 5-year follow-up intervals, with Area Under the Curves (AUCs) approximating 0.77. The AUC for prediction of depressive episodes was about 0.81 for each of the time windows, which was higher than for manic or hypomanic episodes (AUC=0.72). While the risk calculator was well-calibrated across the range of risk scores, it systematically underestimated risk in the CDS sample by about 20%. The length of current remission was a highly significant predictor of recurrence risk in the CDS sample.

LIMITATIONS

Predominantly self-reported White samples may limit generalizability; the risk calculator does not assess more proximal risk (e.g., 1 month).

CONCLUSIONS

Risk of mood episode recurrence can be predicted with good accuracy in youth and adults with BD in remission. The risk calculators may help identify higher risk BD subgroups for treatment and research.

Prospectively ascertained mania and hypomania among young adults with child- and adolescent-onset bipolar disorder

OBJECTIVES

While adults with bipolar disorder (BD) often report symptoms starting in childhood, continuity of mania and/or hypomania (mania/hypomania) from childhood to adulthood has been questioned. Using longitudinal data from the Course and Outcome of Bipolar Youth (COBY) study, we assessed threshold mania/hypomania in young adults who manifested BD as youth.

METHODS

COBY is a naturalistic, longitudinal study of 446 youth with BD (84% recruited from outpatient clinics), 7-17 years old at intake, and over 11 years of follow-up. Focusing on youth with BD-I/II (n = 297), we examined adult mania/hypomania risk (>18 years old; mean 7.9 years of follow-up) according to child (<13 years old) versus adolescent (13-17 years old) onset. We next used penalized regression to test demographic and clinical predictors of young adult mania/hypomania.

RESULTS

Most participants (64%) had child-onset mania/hypomania, 57% of whom also experienced mania/hypomania in adolescence. Among those who experienced an episode in adolescence, over 40% also had mania/hypomania during adulthood; the risk did not differ according to child versus adolescent onset. In contrast, 7% with mania/hypomania in childhood, but not adolescence, experienced mania/hypomania in adulthood. Family history (of mania and suicide attempts) predicted mania/hypomania in young adulthood (p-values <0.05); age of onset was not a significant predictor. Among participants with no mania/hypomania during adulthood, 53% (105/198) still experienced subthreshold manic episodes.

DISCUSSION

We find substantial continuity across developmental stage indicating that, in this carefully characterized sample, children who experience mania/hypomania-particularly those who also experience mania/hypomania in adolescence-are likely to experience mania/hypomania in young adulthood.

Adapting Teaching to the Clinical Setting

Adapting teaching to the clinical setting is most successful when the teacher and trainee are able to work alongside of each other allowing the cognitive apprenticeship model to be embraced. Six tools of experiential learning as components of this framework are described including scaffolding, modeling, coaching/supervision, articulation, reflection, and exploration. These tools provide useful guidance for supervisors to teach in clinical settings. Inherent in this process is the concept of validation of the trainees and includes the importance of supervisors cultivating nonjudgmental acceptance of themselves. Optimal teaching and learning in the clinical environment requires investment of time and resources.

Prevalence and clinical indices of risk for sexual and gender minority youth in an adolescent inpatient sample

OBJECTIVE

Rates of self-injurious thoughts and behaviors have increased in adolescents over the past two decades. Sexual and gender minority (SGM) youth report elevated rates of self-injurious thoughts and behaviors compared to heterosexual and cisgender youth. Studies of factors influencing suicide risk in SGM youth remain limited, however, and have largely been conducted in community or epidemiological samples.

METHOD

The present study aimed to address these limitations by examining the prevalence and clinical characteristics of sexual and gender minority youth in a sample of 515 youth admitted to an adolescent inpatient unit. In addition, the present study aimed to compare rates of self-reported self-injurious thoughts and behaviors, adverse early childhood experiences, and rates of rehospitalization in sexual and gender minority compared to non-sexual and gender minority youth.

RESULTS

Results show that nearly 40% of the sample identified as sexual and/or gender minority. Sexual minority youth reported higher rates of suicidal ideation (t = -6.19, p < .001), higher rates of prior suicidal behavior (Chi2 = 27.44, p < .001) and non-suicidal self-injury (Chi2 = 48.09, p < .001), and greater numbers of adverse childhood experiences (t = -3.99, p < .001); gender minority youth reported higher rates of suicidal ideation (t = -3.91 p = .001). There were no group differences for SGM youth in rates of rehospitalization in the 6-months following initial admission. These results held when controlling for sex assigned at birth and current depression status in multi-variate analyses.

CONCLUSIONS

The study illuminates the importance of assessing SGM status in clinical care and highlights the need to evaluate sexual and gender minority specific risk factors for self-injurious thoughts and behaviors in youth.

Sex Differences in the Longitudinal Course and Outcome of Bipolar Disorder in Youth

OBJECTIVE

Despite substantial literature on sex differences in adults with bipolar disorder (BD), little is known about this topic in youth; this study examines sex differences in mood symptomatology and psychiatric comorbidity in prospectively followed youth with BD.

METHODS

A subsample of the Course and Outcome of Bipolar Youth study (N = 370; female n = 199, male n = 171) enrolled October 2000-July 2006 (age at intake = 7-17.11 years) who met DSM-IV criteria for bipolar I disorder (BD-I; n = 221), bipolar II disorder (BD-II; n = 26), or operationalized BD not otherwise specified (BD-NOS; n = 123) with ≥ 4 years follow-up was included. Analyses examined sex differences at intake and, prospectively, in mood symptomatology and psychiatric comorbidity for a mean ± SD follow-up of 10.5 ± 1.72 years.

RESULTS

Females were older than males at intake (mean ± SD age = 13.33 ± 3.32 vs 12.04 ± 3.16 years; P = .0002) and at age at mood onset (9.33 ± 4.22 vs 7.53 ± 3.74 years; P < .0001). After adjustment for confounders, males spent more time with syndromal ADHD (Padjusted = .001) and females spent more time with syndromal anxiety (Padjusted = .02). There were trends toward males spending more time with substance use disorder and females having more non-suicidal self-injurious behavior (Padjusted = .07 and .09, respectively). There were no sex differences on outcome variables, including rate of or time to recovery and recurrence.

CONCLUSIONS

Contrasting with adult literature, this study identified minimal sex differences in the course of youth with BD. Longer-term studies are needed to clarify if youth-onset BD remains a "sex neutral" subtype of BD or diverges according to sex in adulthood.

Youth Self Report Thought Problems and Sleep Difficulties Are Linked to Suicidal Ideation Among Psychiatrically Hospitalized Adolescents

Objectives: Thought problems, such as hallucinations and delusional or disorganized ideas, have been associated with increased sleep problems and risk for suicidal ideation (SI). Sleep problems have also been linked directly to suicidality in adolescence. The nature of the relationship between these symptoms among adolescents with acute suicidality is not well understood. This study aims to examine the interrelationships between thought problems, sleep difficulties, and SI in adolescents psychiatrically hospitalized for safety concerns, with the goal of informing suicide risk screening and intervention for this population. Methods: Participants included adolescents (n = 690) aged 11-18. A retrospective chart review was used to obtain scores on study measures, including the Suicidal Ideation Questionnaire Junior (SIQ-Jr), the thought problems and sleep disturbance scales on the Youth Self Report (YSR), and mental health diagnoses using the Children's Interview for Psychiatric Syndromes (ChIPS). Results: Findings indicate that SIQ-Jr scores are moderately correlated with both YSR thought problems (r = 0.51, p < 0.001) and YSR sleep disturbance (r = 0.47, p < 0.001). Further, linear regression analyses support the hypotheses that thought problems (β = 0.28) and sleep difficulties (β = 0.11) are uniquely associated with SI, beyond the significant effects of depression (β = 0.36) and female sex (β = -0.07); R² = 0.43, F (8, 673) = 62.49, p < 0.001). Conclusions: These results suggest that sleep interventions and treatment of thought problems may be important for reducing SI, within and outside the context of depression. Furthermore, the adolescent version of the YSR may be a useful tool to evaluate these risk factors alongside other psychiatric concerns.

A Process Evaluation of a Substance Use Brief Intervention for Adolescents in a Psychiatric Inpatient Program

The present study represents a two-phase process evaluation of the implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) on an adolescent psychiatric inpatient unit. The first phase analyzed uptake efforts using chart review data, which revealed that 158 (16.8%) of 942 hospitalized patients (Mean age = 15.81, SD = 1.24) were eligible to receive the brief intervention; however, only 30 (19%) adolescents received the intervention, 15 (9.5%) declined treatment, and 113 (71.5%) were never offered. The second phase involved directed content analyses of clinical staff and providers’ perceived facilitators and barriers to the implementation. Qualitative findings revealed that providers and staff accepted and agreed with the use of the brief substance use intervention, though perceived time constraints, competing demands, and insufficient staffing interfered with implementation across disciplines. Barriers included patients’ length of stay and competing treatment priorities. Several recommendations emerged including, utilization of non-clinical staff, a clear administration protocol, and the use of computer-based interventions. Findings from the present study shed light on the need to consider alternate or more streamlined substance use treatments such as computerized approaches and focus on ways in which protocol can be modified to fit the needs within an acute, short-term setting.

Course of longitudinal psychosocial functioning in bipolar youth transitioning to adults

OBJECTIVES

Few studies have examined domain-specific psychosocial functioning in Bipolar Disorder (BD) youths. This prospective study examines (1) Interpersonal Relationships with Family; (2) Interpersonal Relationships with Friends; (3) School/Work; (4) Recreation; (5) Life Satisfaction, in BD youths.

METHOD

A Course and Outcome of Bipolar Youth subsample (n = 367; mean intake age = 12.6 years, SD = 3.3; 46.6% female) was previously grouped into 4 Classes based on their illness trajectories and percentage of time euthymic using Latent Class Growth Analysis: Class 1 Predominantly Euthymic; Class 2 Moderately Euthymic; Class 3 Ill with Improving Course; Class 4 Predominantly Ill. Psychosocial functioning within the domains were examined for greater than 10 years using the Adolescent Longitudinal Interval Follow-Up Evaluation.

RESULTS

Class 1 demonstrated better functioning across all domains; Class 4 demonstrated worse functioning across all domains. Class 2 showed worsening relationships and recreation, and improvement in work/schoolwork. Class 3 showed variable domain declines and improvements. Despite symptomatic remission, 13%-20% of Class 1 and 20-47% of Classes 1/3 still had impairments across different domains. Early age of BD onset impacted impairment across most domains, and low SES significantly predicted impairment in family relationships.

LIMITATIONS

The study does not have a healthy control group to compare functioning findings.

CONCLUSIONS

Participants with more symptomatic mood trajectories had greater impairment across domains. Moreover, even with symptomatic remission, participants still exhibited impairment. Each Class and domain had different trajectories for impairment. Results suggest the importance of examining specific (vs. global) domains for targeted treatment, even when symptomatically remitted.

Piloting of COPES: An Empirically Informed Psychosocial Intervention on an Adolescent Psychiatric Inpatient Unit

OBJECTIVES

This study evaluated the feasibility and initial efficacy of an empirically informed psychosocial intervention on an adolescent psychiatric inpatient unit.

METHODS

Data were obtained for 463 adolescents 12-16 years of age on a psychiatric inpatient unit. Information collected included demographics, psychiatric diagnoses, length of inpatient stay, completion of four treatment modules, rehospitalizations, and emergency room visits during 12 months after discharge from index admission.

RESULTS

Around 98.70% of patients completed at least one out of the four treatment modules and 93.95% of patients completed two modules. There were no significant barriers to completing treatment modules on the basis of participant characteristics (demographics, psychiatric diagnosis, number of diagnoses, or length of stay). Completion of the four treatment modules, particularly modules on developing a safety plan and enhancing life, predicted lower risk for rehospitalization and emergency room contact in the 12 months postdischarge.

CONCLUSION

Findings suggest that the intervention is feasible to implement regardless of common barriers in an inpatient psychiatric setting, such as complex psychopathology and brief duration of hospitalization. Completion of treatment modules significantly reduces risk for subsequent emergency intensive service utilization, suggesting this intervention may be an effective method for reducing acute clinical events.

Family-focused cognitive behavioral treatment for depressed adolescents in suicidal crisis with co-occurring risk factors: a randomized trial

BACKGROUND

Suicide is the second leading cause of death among adolescents. The purpose of this study was to test a family-focused outpatient cognitive behavioral treatment (F-CBT) protocol for depressed adolescents following psychiatric hospitalization for a suicide attempt or suicidal ideation, and who had a co-occurring risk factor (suicidal behavior prior to the index admission, nonsuicidal self-injury, and/or a substance use disorder), in a randomized Phase 2 efficacy trial.

METHOD

One hundred forty-seven adolescents (mean age = 14.91 years; 76.2% female, 85.5% White) and their families, recruited primarily from an inpatient psychiatric hospitalization program, were randomly assigned to F-CBT or enhanced treatment-as-usual (E-TAU). A suicide attempt was the primary outcome variable. Depression, suicidal ideation, and nonsuicidal self-injury are also reported here. Assessments were completed at pretreatment as well as 6, 12, and 18-months postrandomization (Trial Registration ClinicalTrials.gov Identifier: NCT01732601).

RESULTS

In the sample as a whole, rates of attempts decreased from 20% at 6 months to 9% at 12 months to 7% at 18 months. There was no evidence of a significant difference between treatment arms in rates of suicide attempts, major depressive disorder, suicidal ideation, or nonsuicidal self-injury at any of the postrandomization assessment points.

CONCLUSIONS

Though F-CBT was associated with reductions in suicidality, depression, and nonsuicidal self-injury, E-TAU showed an equally strong effect. Greater frequency of F-CBT treatment sessions, particularly at the start of care, and alternative approaches to transitioning to care at 12 months, may be necessary when using F-CBT with this population.

Predictors of longitudinal psychosocial functioning in bipolar youth transitioning to adults

OBJECTIVES

In a sample of participants diagnosed with Bipolar Disorder (BD) in youth, we aim: (1) to examine longitudinal psychosocial functioning; (2) to determine whether psychosocial impairment remains in those who remitted from mood disorders during later periods of follow-up; (3) to examine predictors of psychosocial impairment despite symptomatic remission.

METHOD

A Course and Outcome of Bipolar Youth subsample of 367 (≥ 4 years follow-up data) were grouped into mood trajectories: Class 1 Predominantly Euthymic; Class 2 Moderately Euthymic; Class 3 Ill with Improving Course; Class 4 Predominantly Ill. Psychosocial functioning was assessed via Children's Global Assessment Scale (C-GAS) for those under age 22; Global Assessment of Functioning (GAF) scale after 22. Current school, employment, and disability status were examined. Established predictors of symptomatic impairment were analyzed.

RESULTS

The Predominantly Euthymic Class had better psychosocial functioning, and were more likely to be in school/employed. The Persistently Ill Class had worse psychosocial functioning, and were more likely to receive disability. However, 44% of Predominantly Euthymic and 93% of Ill with Improving Course participants continued to experience current psychosocial impairment. Early BD onset, low Socioeconomic Status (SES), and current comorbidity, predicted poor psychosocial functioning. Low SES, and current comorbidity, predicted no school enrollment/unemployment.

LIMITATIONS

The study does not have a healthy control group to compare functioning findings.

CONCLUSIONS

In general, youth with persistent mood symptoms had worse psychosocial functioning, moreover, those with remitted symptoms still exhibited current psychosocial functioning deficits. High risk individuals with predictors of impairment should be targeted for functioning interventions.

Longitudinal cognitive trajectories and associated clinical variables in youth with bipolar disorder

OBJECTIVE

There is substantial interest in delineating the course of cognitive functioning in bipolar (BP) youth. However, there are no longitudinal studies aimed at defining subgroups of BP youth based on their distinctive cognitive trajectories and their associated clinical variables.

METHOD

Cognitive functioning was measured in 135 participants from the Course and Outcome of BP Youth (COBY) study using several subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Youth were prospectively evaluated three times on average every 13.75 months over 2.5 years. Clinical and functional outcomes were assessed using the Longitudinal Interval Follow-Up Evaluation (LIFE).

RESULTS

Latent class growth analysis identified three longitudinal patterns of cognitive functioning based on a general cognitive index: class 1, "persistently high" (N=21; 15.6%); class 2, "persistently moderate" (N=82; 60.74%); and class 3, "persistently low" (N=32; 23.7%). All classes showed normal cognitive functioning when compared with the CANTAB normative data. After adjustment for confounders, youth from class 3 had a significantly greater percentage of time with overall, manic, and depressive syndromal symptoms than youth in the other two classes. Also, after adjustment for confounders, youth from class 3 had significantly poorer global, academic, and social functioning than youth from class 1.

CONCLUSIONS

BP youth showed normal overall cognitive functioning that remained stable during the follow-up within each class. However, 24% of BP youth showed poorer cognitive functioning than the other BP youth. This subgroup had poorer mood course and functioning, and may benefit from cognitive remediation and early management with evidence-based pharmacological treatments.

Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder

Greater understanding of cognitive function in children and adolescents with bipolar disorder (BD) is of critical importance to improve our ability to design targeted treatments to help with real-world impairment, including academic performance. We sought to evaluate cognitive performance among children with either BD type I, II, or "not otherwise specified" (NOS) participating in multi-site Course and Outcome of Bipolar Youth study compared to typically developing controls (TDC) without psychopathology. In particular, we sought to test the hypothesis that BD-I and BD-II youths with full threshold episodes of mania or hypomania would have cognitive deficits, including in reversal learning, vs. those BD-NOS participants with sub-threshold episodes and TDCs. N = 175 participants (BD-I = 81, BD-II = 11, BD-NOS = 28, TDC = 55) completed Cambridge Neuropsychological Automated Testing Battery (CANTAB) tasks. A priori analyses of the simple reversal stage of the CANTAB intra-/extra-dimensional shift task showed that aggregated BD-I/II participants required significantly more trials to complete the task than either BD-NOS participants with sub-syndromal manic/hypomanic symptoms or than TDCs. BD participants across sub-types had impairments in sustained attention and information processing for emotionally valenced words. Our results align with prior findings showing that BD-I/II youths with distinct episodes have specific alterations in reversal learning. More broadly, our study suggests that further work is necessary to see the interaction between neurocognitive performance and longitudinal illness course. Additional work is required to identify the neural underpinnings of these differences as targets for potential novel treatments, such as cognitive remediation.

The influence of comorbid disorders on the episodicity of bipolar disorder in youth

OBJECTIVE

Bipolar disorder (BP) frequently co-occurs with other psychiatric disorders. We examine whether course of anxiety disorders (ANX), attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), and substance use disorders (SUD) influence likelihood of recovery and recurrence of depression and mania in BP youth.

METHOD

Weekly ratings of psychiatric disorder intensity were obtained from 413 participants of the Course and Outcome of BP Youth project, followed for an average of 7.75 years. Multiple-event Cox proportional hazards regression analyses examined worsening of comorbid disorders as predictors of mood episode recovery and recurrence.

RESULTS

Increased severity in ANX and SUD predicted longer time to recovery and less time to next depressive episode, and less time to next manic episode. Multivariate models with ANX and SUD found that significant effects of ANX remained, but SUD only predicted longer time to depression recovery. Increased severity of ADHD and DBD predicted shorter time to recurrence for depressive and manic episodes.

CONCLUSION

There are significant time-varying relationships between the course of comorbid disorders and episodicity of depression and mania in BP youth. Worsening of comorbid conditions may present as a precursor to mood episode recurrence or warn of mood episode protraction.

Motivational Interviewing to Reduce Substance Use in Adolescents with Psychiatric Comorbidity

Substance use among adolescents with one or more psychiatric disorders is a significant public health concern. In this study, 151 psychiatrically hospitalized adolescents, ages 13-17 with comorbid psychiatric and substance use disorders, were randomized to a two-session Motivational Interviewing intervention to reduce substance use plus treatment as usual (MI) vs. treatment as usual only (TAU). Results indicated that the MI group had a longer latency to first use of any substance following hospital discharge relative to TAU (36 days versus 11 days). Adolescents who received MI also reported less total use of substances and less use of marijuana during the first 6 months post-discharge, although this effect was not significant across 12 months. Finally, MI was associated with a significant reduction in rule-breaking behaviors at 6-month follow-up. Future directions are discussed, including means of extending effects beyond 6 months and dissemination of the intervention to community-based settings.

Irritability and elation in a large bipolar youth sample: relative symptom severity and clinical outcomes over 4 years

OBJECTIVE

To assess whether relative severity of irritability symptoms versus elation symptoms in mania is stable and predicts subsequent illness course in youth with DSM-IV bipolar I or II disorder or operationally defined bipolar disorder not otherwise specified.

METHOD

Investigators used the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children to assess the most severe lifetime manic episode in bipolar youth aged 7-17 years who were recruited from 2000 to 2006 as part of the Course and Outcomes of Bipolar Youth prospective cohort study (N = 361), conducted at university-affiliated mental health clinics. Subjects with at least 4 years of follow-up (N = 309) were categorized as irritable-only (n = 30), elated-only (n = 42), or both irritable and elated (n = 237) at baseline. Stability of this categorization over follow-up was the primary outcome. The course of mood symptoms and episodes, risk of suicide attempt, and functioning over follow-up were also compared between baseline groups.

RESULTS

Most subjects experienced both irritability and elation during follow-up, and agreement between baseline and follow-up group assignment did not exceed that expected by chance (κ = 0.03; 95% CI, -0.06 to 0.12). Elated-only subjects were most likely to report the absence of both irritability and elation symptoms at every follow-up assessment (35.7%, versus 26.7% of irritable-only subjects and 16.9% of those with both irritability and elation; P = .01). Baseline groups experienced mania or hypomania for a similar proportion of the follow-up period, but irritable-only subjects experienced depression for a greater proportion of the follow-up period than did subjects who were both irritable and elated (53.9% versus 39.7%, respectively; P = .01). The groups did not otherwise differ by course of mood episode duration, polarity, bipolar diagnostic type, suicide attempt risk, or functional impairment.

CONCLUSIONS

Most bipolar youth eventually experienced both irritability and elation irrespective of history. Irritable-only youth were at similar risk for mania but at greater risk for depression compared with elated-only youth and youth who had both irritability and elation symptoms.

Improving child and adolescent psychiatry education for medical students: an inter-organizational collaborative action plan

OBJECTIVE

A new Child and Adolescent Psychiatry in Medical Education (CAPME) Task Force, sponsored by the Association for Directors of Medical Student Education in Psychiatry (ADMSEP), has created an inter-organizational partnership between child and adolescent psychiatry (CAP) educators and medical student educators in psychiatry. This paper outlines the task force design and strategic plan to address the long-standing dearth of CAP training for medical students.

METHOD

The CAPME ADMSEP Task Force, formed in 2010, identified common challenges to teaching CAP among ADMSEP's CAPME Task Force members, utilizing focus-group discussions and a needs-assessment survey. The Task Force was organized into five major sections, with inter-organizational action plans to address identified areas of need, such as portable modules and development of benchmark CAP competencies.

RESULTS/CONCLUSION

The authors predict that all new physicians, regardless of specialty, will be better trained in CAP. Increased exposure may also improve recruitment into this underserved area.

Clinical skills verification in general psychiatry: recommendations of the ABPN Task Force on Rater Training

OBJECTIVE

The American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct clinical skills verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates' eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation.

METHODS

Materials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments.

RESULTS

Recommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase interrater reliability, and improve the quality of feedback.

CONCLUSIONS

The implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder, but, to our knowledge, no studies examined the course of anxiety disorders in youth and adults with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, ages 7 to 17 years who met criteria for Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) bipolar I disorder (n = 244), bipolar II disorder (n = 28), and operationally defined bipolar disorder not otherwise specified (n = 141) were recruited primarily from outpatient clinics. Subjects were followed on average for 5 years using the Longitudinal Interval Follow-Up Evaluation. We examined factors associated with the persistence (> 50% of the follow-up time) and onset of new anxiety disorders in youth with bipolar disorder.

RESULTS

Of the 170 youth who had anxiety at intake, 80.6% had an anxiety disorder at any time during the follow-up. Most of the anxiety disorders during the follow-up were of the same type as those present at intake. About 50% of the youth had persistent anxiety, particularly generalized anxiety disorder (GAD). Persistence was associated with multiple anxiety disorders, less follow-up time in euthymia, less conduct disorder, and less treatment with antimanic and antidepressant medications (all P values ≤ .05). Twenty-five percent of the sample who did not have an anxiety disorder at intake developed new anxiety disorders during follow-up, most commonly GAD. The onset of new anxiety disorders was significantly associated with being female, lower socioeconomic status, presence of attention-deficit/hyperactivity disorder and substance use disorder, and more follow-up time with manic or hypomanic symptoms (all P values ≤ .05)

CONCLUSIONS

Anxiety disorders in youth with bipolar disorder tend to persist, and new-onset anxiety disorders developed in a substantial proportion of the sample. Early identification of factors associated with the persistence and onset of new anxiety disorders may enable the development of strategies for treatment and prevention.

Problematic video game use scale: initial psychometric properties with psychiatrically hospitalized adolescents

OBJECTIVE

Excessive video game use among youth has been a growing concern in the United States and elsewhere. The aims of this study are to establish validity of a video game measure in a large adolescent inpatient sample, identify clinical factors underlying problem video game use, and identify associations with measures of psychopathology.

METHOD

Three hundred eighty participants admitted to an adolescent inpatient psychiatric unit between November 2007 and March 2009 were administered a battery of self-report measures, including a questionnaire developed for this study that assessed reinforcers and consequences of past-year video game use (ie, Problematic Video Game Use Scale). Factor analysis was used to identify the underlying structure of behaviors associated with problem video game use.

RESULTS

A factor analysis of the Problematic Video Game Use Scale indicated 2 primary factors. One was associated with engaging in problem behaviors that impaired the adolescent's functioning as a result of playing video games and one reflected the reinforcing effects of playing video games. Both factors were associated with measures of psychopathology, although associations were generally stronger for impairment in functioning than for reinforcing effects. Both factors were significantly correlated with self-reported daily video game use (P < .001).

CONCLUSIONS

Two underlying factors emerged to account for problem video game playing: impairment in functioning and reinforcing effects. Initial evidence of the content validity of the video game measure was established. Findings highlight the importance of assessing video game use among an adolescent population, the factors associated with video game use, and associations with symptoms of psychopathology. Limitations include a common reporter for multiple measures and cross-sectional data that do not allow for causal links to be made.

Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified

OBJECTIVE

To determine the rate of diagnostic conversion from an operationalized diagnosis of bipolar disorder not otherwise specified (BP-NOS) to bipolar I disorder (BP-I) or bipolar II disorder (BP-II) in youth over prospective follow-up and to identify factors associated with conversion.

METHOD

Subjects were 140 children and adolescents recruited from clinical referrals or advertisement who met operationalized criteria for BP-NOS at intake and participated in at least one follow-up evaluation (91% of initial cohort). Diagnoses were assessed at follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. The mean duration of follow-up was 5 years and the mean interval between assessments was 8.2 months.

RESULTS

Diagnostic conversion to BP-I or BP-II occurred in 63 subjects (45%): 32 (23%) to BP-I (nine of whom had initially converted to BP-II) and 31 to only BP-II (22%). Median time from intake to conversion was 58 weeks. First- or second-degree family history of mania or hypomania was the strongest baseline predictor of diagnostic conversion (p = .006). Over follow-up, conversion was associated with greater intensity of hypomanic symptoms and with greater exposure to specialized, intensive outpatient psychosocial treatments. There was no association between conversion and exposure to treatment with particular medication classes.

CONCLUSIONS

Children and adolescents referred with mood symptoms that meet operationalized criteria for BP-NOS, particularly those with a family history of BP, frequently progress to BP-I or BP-II. Efforts to identify these youth and effectively intervene may have the potential to curtail the progression of mood disorders in this high-risk population.

Affect regulation in pediatric bipolar disorder

Increasingly, clinicians and researchers alike are describing children presenting with emotional and behavioral problems as suffering from deficits of "affect regulation." The present article reviews the current understanding of affect regulation. The authors also discuss recent findings implicating affect dysregulation in children and adolescents with bipolar disorder.

Psychiatric correlates of nonsuicidal cutting behaviors in an adolescent inpatient sample

This archival study of 288 adolescent psychiatric inpatients examined the psychiatric correlates of cutting behavior. Participants were categorized into Threshold cutters (n = 61), Subthreshold cutters (n = 43), and Noncutters (n = 184). Groups were compared on psychiatric diagnoses, suicidality, and self-reported impairment. Results demonstrated that females were more likely to cut relative to males; however, gender did not affect the correlates of cutting behavior. Adolescents in the Threshold group were more likely to be diagnosed with Major Depression and had higher self-reported suicidality, depression, and trauma-related symptoms of depression and dissociation relative to the Noncutting group. The Subthreshold group did not differ from the other groupings except for an elevated risk for Posttraumatic Stress Disorder compared to the Noncutting group.

Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and clinical characteristics

BACKGROUND

This study assessed prevalence and clinical correlates of body dysmorphic disorder (BDD), eating disorders (ED), and other clinically significant body image concerns in 208 consecutively admitted adolescent inpatients. It was hypothesized that adolescents with BDD would have higher levels of depression, anxiety, and suicidality. Adolescents with eating disorders were expected to have higher levels of depression, anxiety, and trauma-related symptoms. Trauma-related symptoms were also examined in relation to BDD, in the absence of specific hypotheses.

METHOD

Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ) and reliable and valid self-report measures of suicidality, depression, anxiety, post-traumatic stress disorder (PTSD), dissociation, and sexual preoccupation/distress. Prevalence of BDD, eating disorders, and other clinically significant body image concerns was determined, and clinical correlates were examined.

RESULTS

6.7% (n = 14) of participants met DSM-IV criteria for definite (n = 10) or probable (n = 4) DSM-IV BDD, 3.8% (n = 8) met criteria for an eating disorder, and 22.1% (n = 46) had clinically significant shape/weight concerns (SWC) that did not clearly meet criteria for BDD or an eating disorder. Both the BDD and SWC groups scored significantly higher than the group with no significant body image concerns (no BDD/ED/SWC group) on measures of anxiety and suicidality. The BDD, SWC, and ED groups all had significantly higher levels of depression than the no BDD/ED/SWC group. Only the SWC group scored significantly higher than the no BDD/ED/SWC group on measures of PTSD, dissociation, and sexual preoccupation/distress.

CONCLUSIONS

A high proportion of participants had clinically significant body image concerns or a body image disorder. These concerns/disorders were associated with higher levels of depression, anxiety, and suicidality. In addition, the group concerned with body shape or weight had significantly greater symptoms of PTSD, dissociation, and sexual preoccupation/distress. These relatively common body image concerns and disorders deserve further study in adolescents.

Frequency of manic symptoms and bipolar disorder in psychiatrically hospitalized adolescents using the K-SADS Mania Rating Scale

OBJECTIVE

The aim of this study was to assess the frequency of manic symptoms and bipolar spectrum disorders in an adolescent inpatient psychiatric sample using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale (MRS), parent and adolescent measures.

METHOD

A total of 391 consecutive admissions to a psychiatric inpatient unit were assessed using the K-SADS MRS, the Childhood Inventory of Psychiatric Syndromes (CHIPS), and other clinically relevant measures.

RESULTS

The frequency of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) manic symptoms in this population was generally high. However, only 19.6% received a consensus diagnosis of juvenile bipolar disorder. The K-SADS MRS discriminated bipolar from non-bipolar patients when parents rated symptoms but not when rated by adolescents.

CONCLUSIONS

This study of non-selected adolescents over a one-year period demonstrates that bipolar spectrum disorders in an inpatient population are common, and that the use of the KSADS MRS is effective in identifying this syndrome.

Neuroleptic withdrawal in patients meeting criteria for supersensitivity psychosis

In an attempt to prospectively validate the existence of supersensitivity psychosis (SSP), five schizophrenic patients meeting Chouinard's criteria for SSP and five non-SSP schizophrenic controls had neuroleptic treatment withdrawn for 2 weeks under double-blind conditions. The sudden worsening of psychotic symptoms and tardive dyskinesia postulated in the SSP group was not observed on the Brief Psychiatric Rating Scale, the Clinical Global Impressions scale, and the Abbreviated Dyskinesia Rating Scale. In conclusion, the authors' pilot data do not seem to support the existence of SSP.

Neuroleptic-induced supersensitivity psychosis: retrospective study of schizophrenic inpatients

Chouinard has suggested that a significant number of schizophrenic outpatients may rapidly relapse after discontinuing or abruptly reducing antipsychotic drugs, and he has hypothesized that this relapse reflects a supersensitivity psychosis related to mesolimbic postsynaptic dopamine supersensitivity caused by drug therapy. Using Chouinard's criteria, the authors found 12 probable but no definitive cases of this syndrome while conducting a chart review of 265 hospitalized schizophrenic patients. Six of the 12 patients were subsequently rediagnosed as schizoaffective. Four patients had tardive dyskinesia, but this condition did not worsen after the drug dosage was decreased. Although supersensitivity psychosis was not common among this population, further study of the syndrome is needed to determine if neuroleptics are causing a subgroup of patients to relapse early or if the early relapses are a manifestation of the natural course of illness in these patients.