Biomedical subjects
Gabrielle A Carlson
Publications and source records attributed to Gabrielle A Carlson.
Response to methylphenidate in children with attention deficit hyperactivity disorder and manic symptoms in the multimodal treatment study of children with attention deficit hyperactivity disorder titration trial.
OBJECTIVE: Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children. METHODS: Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two "mania proxies" were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies. RESULTS: Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects. CONCLUSION: Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms.
Stimulant rebound: how common is it and what does it mean?
OBJECTIVE: To examine rates and implications of stimulant-induced rebound - the behavioral deterioration that may occur as stimulant medications wear off. METHODS: This study compares nurse observations on evening shifts compared to day shifts in 149 psychiatrically hospitalized children treated with short-acting stimulants, usually methylphenidate, comparing nonmedication and stimulant-treated states. RESULTS: Behavioral deterioration (rebound), was observed in 30% of children on at least one dose of stimulants but was serious enough to discontinue treatment in only 8.7%. Children experiencing rebound did not differ clinically from those who did not. CONCLUSIONS: Rebound exists, occurs significantly in less than 10% of psychiatrically hospitalized children with attention deficit hyperactivity disorder, and does not appear to have specific diagnostic significance.
Drug-induced disinhibition in psychiatrically hospitalized children.
OBJECTIVE: To examine rates and predictors of drug-induced behavioral disinhibition (DIBD) in psychiatrically hospitalized children. METHODS: DIBD was examined in 267 children psychiatrically hospitalized for at least 4 weeks. Age, gender, diagnosis, and medication were covariates. DIBD was defined as dramatic increase in aggression identified by increased time-outs while on medicaton. RESULTS: Twenty (7.5%) children met our criteria. Attention deficit hyperactivity disorder, pervasive developmental disorder, and selective serotonin reuptake inhibitor use appeared to increase the risk, and older age and stimulant use decreased the risk of DIBD. However, it was often difficult to distinguish true DIBD from the behavioral fluctuations of these disturbed children. Fifteen percent of children subsequently improved on the same regimen, 40% improved when the offending drug was stopped and another treatment was started, and the remainder had adverse response to many medications. CONCLUSIONS: DIBD is a complex phenomenon that does not lend itself to simple conclusions and requires further study.
Rates and predictors of developing a manic or hypomanic episode 1 to 2 years following a first hospitalization for major depression with psychotic features.
INTRODUCTION: Although the presence of psychosis during major depression has been identified as a predictor of later developing mania or hypomania, to our knowledge there have been no studies examining rates and predictors of developing a manic or hypomanic episode in patients who were admitted for their first psychiatric hospitalization for major depressive disorder with psychosis (MDDP). METHODS: Patients admitted for their first psychiatric hospitalization, with a Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of MDDP, were recruited from three sites (N = 157) and evaluated prospectively for up to 2 years to identify new symptoms of mania or hypomania. Family history was assessed using the Family History-Research Diagnostic Criteria Interview. Clinical and demographic factors associated with developing a manic or hypomanic episode were identified using stepwise logistic regression. RESULTS: Thirteen percent (n = 21) of patients with MDDP developed mania or hypomania within the follow-up period. Family history of affective disorders and age at onset of MDDP were not predictive of switch. MDDP patients who were treated with antidepressants were four times less likely to develop mania or hypomania than those who were not treated with antidepressants, after controlling for site differences. CONCLUSIONS: Our findings suggest that within the first 1 to 2 years following first hospitalization for MDDP, a subset of patients will develop mania or hypomania. Additionally, our data suggest that antidepressant exposure does not increase the risk of, and may be protective against, developing a manic or hypomanic episode in patients hospitalized for MDDP.
Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents.
OBJECTIVE: To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources. METHOD: The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained. RESULTS: The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants. CONCLUSIONS: Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.
What is new in bipolar disorder and major depressive disorder in children and adolescents.
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Correspondence between adolescent report, parent report, and teacher report of manic symptoms.
OBJECTIVE: To examine differences between source-specific manic symptoms. METHODS: In total, 104 consecutive adolescent outpatient referrals were evaluated for their psychiatric status using a questionnaire based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders that was completed by parents, teachers, and youths. RESULTS: Approximately one third of the youths met symptom criteria for mania by at least one informant; however, only 38% of these met such criteria by at least two informants. Youths who had manic symptoms according to two informants were significantly more symptomatic both on mental status exam and in other dimensions of psychopathology than youths who did not have corroborated manic symptoms. Cross-informant agreement was generally poor when symptoms were scored dimensionally. CONCLUSIONS: Manic symptoms are relatively nonspecific in outpatient samples. Using more than one informant increases the likelihood of selecting subjects with serious and possibly manic disorders.
A DSM-IV-referenced, adolescent self-report rating scale.
OBJECTIVE: To examine the reliability and validity of the Youth's Inventory-4 (YI-4), a DSM-IV-referenced self-report rating scale. METHOD: Youths (N = 239) aged between 11 and 18 years who were clinically evaluated between 1996 and 1999 completed the YI-4, and 79% completed at least one additional self-report. Parents and teachers completed a companion measure. A second sample (N = 47) was retested 2 weeks after an initial evaluation. RESULTS: The YI-4 demonstrated satisfactory internal consistency (alpha values = .66-.87) and test-retest reliability (r values = 0.54-0.92), convergent and to lesser extent divergent validity with other self-report measures, and discriminant validity by differentiating children with and without diagnosed attention-deficit/hyperactivity disorder, conduct disorder, substance use, generalized anxiety disorder, or major depressive disorder. Youth-parent (r values = 0.05-0.50) and youth-teacher (r values < 0.18) agreement was generally modest. CONCLUSIONS: These findings provide preliminary support for the clinical utility of the YI-4 for symptom assessment in referred youths.
An open-label trial of divalproex in children and adolescents with bipolar disorder.
OBJECTIVE: This study evaluated the safety and effectiveness of divalproex sodium (Depakote ) in the treatment of youths with bipolar disorder. METHOD: Forty bipolar disorder patients aged 7 to 19 years, with a manic, hypomanic, or mixed episode, enrolled in an open-label study of divalproex (2-8 weeks), followed by a double-blind, placebo-controlled period (8 weeks). RESULTS: Twenty-two subjects (61%) showed > or =50% improvement in Mania Rating Scale (MRS) scores during the open-label period. Significant ( <.001) improvements from baseline were seen for mean scores of all efficacy measures, including the MRS, Manic Syndrome Scale, Behavior and Ideation Scale, Brief Psychiatric Rating Scale, Clinical Global Impressions Severity scale, and Hamilton Rating Scale for Depression. Of the 23 subjects who discontinued the study during the open-label period, 6 (15%) discontinued for ineffectiveness, 6 (15%) for intolerance, 6 (15%) for noncompliance, and 6 (15%) for other reasons. Adverse events were generally mild or moderate in severity, with the most common being headache, nausea, vomiting, diarrhea, and somnolence. Laboratory data results were unremarkable. Too few subjects participated in the double-blind period for statistical analysis. CONCLUSION: This study provides preliminary support for the safety and effectiveness of divalproex in the treatment of bipolar disorder in youths.
Age at onset, childhood psychopathology, and 2-year outcome in psychotic bipolar disorder.
OBJECTIVE: The relationships of age at onset and childhood psychopathology to 2-year clinical and functional outcomes in first-admission patients with bipolar I disorder were examined. METHOD: Patients with bipolar I disorder (N=123) presenting with psychotic symptoms were followed over a 2-year period. Age at onset was stratified into <19 and >or=19 years. Childhood psychopathology was categorized as behavior problems, other psychopathology, and none. Functional and clinical outcomes were rated with standard measures. RESULTS: Childhood psychopathology and age at onset were independently related to poorer functional and clinical outcome. In the multivariate models that included psychopathology, age at onset, sex, and education, early age at onset was related to incomplete remission, and childhood psychopathology was related to functional outcome. CONCLUSIONS: Childhood psychopathology and age at onset contribute independently to outcomes of bipolar disorder. Childhood psychopathology is a much stronger predictor of functioning than age at onset.
Gaps in use of antipsychotics after discharge by first-admission patients with schizophrenia, 1989 to 1996.
The authors examined gaps in the use of antipsychotic medications during the one-year period after discharge in an epidemiological sample of 189 first-admission patients with schizophrenia between July 1989 and January 1996. Sixty-three percent of the patients had one or more such gaps, and 51 percent had gaps of 30 days or longer, with an average total time off medication of about seven months. Most gaps occurred soon after discharge, and 73 percent were initiated by the patient. These data, which were obtained before the widespread use of atypical antipsychotic agents, provide a benchmark against which to examine the impact of the newer medications on adherence and continuity of treatment in the critical early stages of schizophrenia.