Majority of United States Adolescents with Severe Mental Disorders Have Never Received Treatment for Their Conditions

A recent study by Merikangas and colleagues published in the January 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) shows that only half of adolescents that are affected with severely impairing mental disorders ever receive treatment for these conditions.

The researchers found that approximately one third of adolescents with any mental disorder received services for their illness (36.2%). Disorder severity was significantly associated with an increased likelihood of receiving treatment, yet only half of adolescents who were identified as having severely impairing mental disorders had ever received mental health treatment for their symptoms.

In the article titled “Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A),” Dr. Merikangas and colleagues examined the rates of treatment for specific mental disorders in the NCS-A. The NCSA is a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States.

The authors examined rates of treatment for DSM-IV disorders, and correlated the severity, number of disorders, and comorbidity in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Sociodemographic correlates were also evaluated.

Treatment rates were highest in those with attention-deficit/hyperactivity disorder (ADHD) (59.8%) and behavior disorders, such as oppositional defiant disorder (ODD) and conduct disorder (CD) (combined 45.4%). The picture is more discouraging for those adolescents with anxiety, eating, or substance use disorders for whom less than 20% received treatment.

Furthermore, the investigators found that Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. In the article, Merikangas and colleagues comment, “marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.”

Read the full press release on JAACAP.

Teens Who Recover from Hard-to-treat Depression Still at Risk for Relapse

Teens with hard-to-treat depression who reach remission after 24 weeks of treatment are still at a significant risk for relapse, according to long-term, follow-up data from an NIMH-funded study published online ahead of print November 16, 2010, in the Journal of Clinical Psychiatry. The long-term data reiterate the need for aggressive treatment decisions for teens with stubborn depression.

Background

In the Treatment of Resistant Depression in Adolescents (TORDIA) study, teens whose depression had not improved after an initial course of selective serotonin reuptake inhibitor (SSRI) antidepressant treatment were randomly assigned to one of four interventions for 12 weeks:

• Switch to another SSRI-paroxetine (Paxil), citalopram (Celexa) or fluoxetine (Prozac)
• Switch to a different SSRI plus cognitive behavioral therapy (CBT), a type of psychotherapy that emphasizes problem-solving and behavior change
• Switch to venlafaxine (Effexor), a different type of antidepressant called a serotonin and norepinephrine reuptake inhibitor (SNRI)
• Switch to venlafaxine plus CBT

As reported in May 2010, nearly 40 percent of those who completed 24 weeks of treatment achieved remission, regardless of the treatment to which they had initially been assigned. However, those who achieved remission were more likely to have responded to treatment early—during the first 12 weeks.

After 24 weeks of treatment, the participants were discharged from the study and urged to continue care within their community. They were then asked to return for an assessment at 72 weeks.

Results of the Study

Of the 334 original TORDIA participants, about 61 percent had reached remission by week 72. Symptoms of depression steadily decreased after the initial 24 weeks of treatment. But at 72 weeks, many participants still reported having residual symptoms of depression, such as irritability, fatigue and low self-esteem.

Those with more severe depression at baseline were less likely to reach remission. Those who responded early to treatment—within the first six weeks of treatment—were more likely to reach remission. Initial treatment assignment during the study did not appear to influence the remission rate or time to remission.

However, of the 130 participants who had remitted by week 24, 25 percent had relapsed by week 72. Ethnic minorities tended to have a higher risk for relapse than whites.

Significance

Because more than one-third of the teens did not recover and the relapse rate was high, the authors conclude that more effective interventions early in the treatment process are needed. In addition, the higher risk of relapse for ethnic minorities suggests that cultural factors may influence the long-term course of depression and recovery, but it is unclear what those factors may be.

What’s Next

The findings indicate that new methods are needed to accurately identify those who may not respond early in treatment so that patients unlikely to reach remission using a particular treatment may be offered alternative treatments earlier in the process. More data is needed, however, to be able to predict who might be more likely to remit and who may not.

Reference

Vitiello B, Emslie G, Clarke G, Wagner K, Asarnow JR, Keller M, Birmaher B, Ryan N, Kennard B, Mayes T, DeBar L, Lynch F, Dickerson J, Strober M, Suddath R, McCraken JT, Spirito A, Onorato M, Zelazny J, Porta G, Iyengar S, Brent D. Long-term outcome of adolescent depression initially resistant to SSRI treatment. Journal of Clinical Psychiatry. online ahead of print November 16, 2010.

Source: NIMH

Event: Parent Training, Missouri

Seen in the Joplin Independent:

National Alliance on Mental Illness (NAMI) Joplin will hold a Family to Family Education Class beginning Thursday, Sept. 16, 2010. It is an 11 week course taught by trained family members for families of individuals with severe brain disorders (mental illness).

The curriculum focuses on schizophrenia, bipolar disorder (manic depression), clinical depression, panic disorder and obsessive-compulsive disorder (OCD). The course discusses the clinical treatment of these illnesses and teaches the knowledge and skills that family members need to cope more effectively. All course materials are furnished at no cost.

Classes will be held at the NAMI Joplin office at 2701 S. Davis Blvd., Joplin on consecutive Thursdays from 6-9 p.m. To register or get more information please call NAMI at (417) 781-6264.

Depression, Lack of Social Support Trigger Suicidal Thoughts in College Students

A press release from Johns Hopkins:

Depression and lack of social support appear to precipitate suicidal thoughts and behavior in some college students, according to research from Johns Hopkins Children’s Center, the University of Maryland and other institutions.

The study, published in the Journal of Affective Disorders, followed more than a thousand students throughout their college years,
identifying factors linked to suicidal thinking and highlighting the importance of spotting high-risk students early on and referring them
for treatment.

Suicide is the second leading cause of death among college-age students in the United States, with some 1,100 deaths by suicide occurring in this age group each year.

The findings emanate from the NIH-funded College Life Study, in which researchers conducted in-depth face-to-face interviews with more than a thousand incoming freshmen at a large public university in the mid-Atlantic and annual follow-up interviews throughout their four years in college.

The researchers conducted in-depth face-to-face interviews with more than a thousand incoming college freshmen at the University of Maryland College Park and follow-up annual interviews throughout their four years in college.

Of the 1,085 students, 151 (12 percent) said they had pondered committing suicide at least once, 37 of whom (24.5 percent) said they did so repeatedly. Ten of the 151 said they made specific plans or carried out full-fledged attempts during college. Two of the 10 said they attempted suicide without ever planning to do so. Of the 151, 17 students reported attempting suicide before college, and 22 reported planning a suicide before college but not attempting it.

Read more

What’s the most disabling co-morbid condition for individuals with Tourette’s Syndrome?

Sometimes research confirms my impressions based on clinical experience, other times it surprises. Here is a press release from the University at Buffalo about a new study where the results might at first blush seem somewhat surprising, but may be accounted for by the age of the research participants:

An assessment of patients with adult Tourette syndrome (TS) to identify clinical factors that contribute to psychosocial and occupational disabilities resulting from the vocal or motor tics that define TS found that anxiety/panic disorder may be the most disabling psychiatric condition associated with the disorder.

The results of the study, based on the Global Assessment of Functioning (GAF) scale, will be used to identify patients who are more likely to have or develop significant disabilities related either to the severity of their tics, or to the psychiatric disorders associated with TS, such as obsessive-compulsive disorder, mood disorders and drug or alcohol abuse.

Results were presented today (June 17) at the 14th International Congress on Parkinson’s Disease and Movement Disorders, being held in Buenos Aires, Argentina, June 14-17.

David G. Lichter, MD, professor of clinical neurology in the University at Buffalo’s School of Medicine and Biomedical Sciences, is first author.

“Our study identified the most significant predictors of disability, says Lichter. “Now having identified these at-risk patients, we can follow them more closely and begin appropriate interventions as early as possible.”

Lichter also noted that the finding of anxiety/panic disorder as the most-disabling psychiatric disorder associated with TS was unexpected.

“The main surprise was that depression was not a major predictor of psychosocial or occupational disability in these patients,” says Lichter. “Depression has been identified as an important predictor of quality of life in TS.

Tics, both motor and vocal, are the primary symptoms of Tourette syndrome. Vocal tics are involuntary sounds, such as whistles, hums, or throat clearing. Complex vocal tics can be repeating words or phrases or involuntary swearing. Motor tics are muscle spasms, such as involuntary eye blinks, shoulder shrugs, repetitive kicking, head jerks, eye darts and nose twitches.

In most patients, tics wane after mid-to-late adolescence. However, the study data indicates that in those patients whose tics persist into adulthood, tic severity remains the primary factor contributing to global psychosocial and occupational disability, according to Lichter.

“In many TS adults, motor tics remain more enduring and prominent than vocal tics and, in our study, motor tics were more severe overall than vocal tics and were more closely correlated with GAF scale score,” says Lichter.

The study involved 66 patients — 45 male and 21 female — who had been followed for an average of 8.2 years at a UB-based TS clinic. They ranged in age from 20 to 80.

Results showed that nearly 32 percent were diagnosed with obsessive-compulsive disorder (OCD), while 62 percent showed OCD behavior. Nearly 29 percent had anxiety/panic disorder with another 21 percent exhibiting anxiety symptoms.

Prevalence of other TS-associated conditions were depression (16.7 percent), depressed mood (12.1 percent), bipolar disorder (12.1 percent), rage attacks and severe self-injury behavior (4.5 percent), childhood ADHD history (33.3 percent), adult ADD (18.2 percent), substance-use disorder (22.7 percent) and psychosis and restless legs syndrome (1.5 percent).

In the future Lichter and colleagues plan to collect prospective data on both quality of life and psychosocial and occupational functioning in TS patients.

“We will look more closely at the interactions of tic severity, mood disorders, substance abuse and social support systems and determine how these issues relate to personal and social/occupational adjustment,” Lichter says.

“We hope this information will help us improve the lives of our TS patients, especially those who are at highest risk for a poor outcome.”

Sarah G. Finnegan, MD, PhD, UB assistant professor of neurology, is co-author of the study.

Note that they are looking at adult occupational and psychosocial functioning. My hypothesis is still that ADHD is the most disabling co-morbid disorder for school-age individuals with Tourette’s Syndrome.

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