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What's New in Research
12/18/2013 12:00 AM

Children with brain injuries may be twice as likely to suffer from depression, say researchers of a new study who sought to identify the prevalence of depression in children with brain injuries, including concussions, in the United States, and describe their association. They presented the findings in a poster on October 25 at the American Academy of Pediatrics (AAP) National Conference and Exhibition in Orlando, Florida.

précis

• Children with brain injury, including concussions, are twice as likely to have depression as children without brain injury, according to a new study.

• This shouldn’t be surprising, as there is a proven association between brain injury and depression in adults.

• However, it is not clear whether the relationship is a causal one, since full details aren’t available in only an abstract.

• The data came from the National Survey of Children’s Health.

Children with brain injuries may be twice as likely to suffer from depression, say researchers of a new study who sought to identify the prevalence of depression in children with brain injuries, including concussions, in the United States, and describe their association. They presented the findings in a poster on October 25 at the American Academy of Pediatrics (AAP) National Conference and Exhibition in Orlando, Florida.

Of the preliminary results, researchers said they are currently working on a manuscript for submission to a peer-reviewed journal later this month. According to the abstract, “Depression in Children Diagnosed with Brain Injury or Concussion,” affective disorders are an important morbidity of head injury in adults, but less is known about the relationship between head injury and psychological disease in children.

Researchers analyzed data from parental interviews regarding 81,936 children ages 0–17 in the National Survey of Children’s Health (NSCH). The data was weighted to be nationally representative. The analytic sample was identified using responses to the following questions: 1) “Has [subject] ever been diagnosed with brain injury or concussion? and 2) “Has [subject] ever been diagnosed with depression?”

Candidate predictors of depression were chosen by literature review and bivariate analysis, according to the abstract.

Researchers identified more than 2,034 children with brain injuries, corresponding to a national prevalence of 1.9% in 2007. Likewise, there were 3,112 children with diagnosed depression, yielding a prevalence of 3.7%. In children diagnosed with brain injury or concussion, the prevalence of depression was 15%.

Compared to other participants, children with brain injuries had a nearly fivefold increase in odds of diagnosed depression. After an adjustment for age, race, ethnicity, family income and structure, maternal mental health, child health and developmental achievement, brain injury remained a significant predictor of depression.

‘No surprises’

“Given the robust association between brain injury and depression in adults, it was not too much of a surprise that an association existed in children,” said Matthew C. Wylie, M.D., affiliated with pediatric emergency medicine at the Alpert Medical School of Brown University in Providence, R.I., and lead author of the study.

Researchers said they are not sure why there hasn’t been more research on the link between head injuries and affective disease. “One reason is that the NSCH hasn’t always been around,” Wylie said. “I think the first was in 2003 and the scope of it has grown over the last few years to contain questions about brain injury in research, and this has spurred investigation of the consequences of childhood brain injury. We have conducted a similar study in a more recent iteration of NSCH and we’re currently seeking to publish this work.”

More details needed

“The details of the research need to be fleshed out in a full publication,” said Keith Yeates, Ph.D., professor of pediatrics at Ohio State University and chief of psychiatry and neuropsychiatry at Nationwide Children’s Hospital in Columbus, who was not involved in the study. Yeates acknowledged some reluctance to comment when only an abstract of the research is available. “With the kind of research they are doing, it doesn’t prove that there is a causal relationship between the two outcomes — brain injury and depression,” he said. Given the research and design of the study, it’s [not certain] whether the depression didn’t preexist before the injury,” he noted.

Yeates said that with adults, studies have revealed an increased risk for depression following a traumatic brain injury (TBI). The new study doesn’t suggest that clinical depression is as much of a risk in children as it is in adults, he said. “It’s worth stressing that while the risk [for depression] is elevated in the vast majority of brain injuries, children don’t end up with clinical depression,” said Yeates. “The same holds true for adults.” Yeates added, “The literature would support that high percentages of people with TBI end up with depression, but I don’t think that research would suggest that for the majority of adults.”

* * *

For the poster abstract, go to https://aap.confex.com/aap/2013/webprogram/Paper22515.html

ADHD
11/20/2013 12:00 AM

The percentage of children treated with stimulant medication for attention-deficit hyperactivity disorder (ADHD) varies greatly among states, and more widely among counties, according to a new study estimating the prevalence of stimulant treatment among both adults and children at national, state, and county levels. The findings are published in the November issue of Psychiatric Services.

According to the study, “Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008,” ADHD is associated with heightened risks of poor academic and vocational achievement, delinquency, and other comorbidities. Because stimulant treatment is effective in moderating these risks, geographic differences in identifying and treating the disorder that do not result from differences in prevalence of ADHD or other conditions treatable with stimulants are reasons for concern, the study stated.

précis

• The average rates of ADHD in children are 5–10%, but in some states fewer than 1% are in treatment.

• Other factors that indicate greater likelihood of treatment include living in an urban area, having a well-funded special needs program in the schools, and living in an area with higher poverty rates.

• Areas with more psychiatrists are more likely to have more children in treatment for ADHD.

• There is a great likelihood of significant undertreatment in some areas, the study shows.

The percentage of children treated with stimulant medication for attention-deficit hyperactivity disorder (ADHD) varies greatly among states, and more widely among counties, according to a new study estimating the prevalence of stimulant treatment among both adults and children at national, state, and county levels. The findings are published in the November issue of Psychiatric Services.

According to the study, “Geographic Variation and Disparity in Stimulant Treatment of Adults and Children in the United States in 2008,” ADHD is associated with heightened risks of poor academic and vocational achievement, delinquency, and other comorbidities. Because stimulant treatment is effective in moderating these risks, geographic differences in identifying and treating the disorder that do not result from differences in prevalence of ADHD or other conditions treatable with stimulants are reasons for concern, the study stated.

Although the study only makes available information about treatment prevalence, it is distinct from other studies that have examined this issue, said Douglas McDonald, Ph.D., principal associate at Abt Associates, a public policy consulting firm, and lead author.

“We sought not only to document the extent and range of variation in stimulant treatment among states but also among counties,” McDonald told CPU. “Because we had information about 24 million prescriptions, we could develop estimates at the county level, unlike other studies that used smaller samples.”

McDonald said that he and coauthor Sarah Kuck Jalbert also explored the reasons for this observed variation in treatment. “We examined rates of treatment and their association with a number of characteristics of county populations,” he said. Those characteristics included education levels, poverty rates, ethnicity, funding for special education, percentage of population living in urban areas, percentage uninsured, existence of a prescription monitoring program, and availability of prescribers. “The third distinctive factor was that we examined treatment rates not just of children but of children and adults,” he added.

Study details

The study stated that an estimated 4.5% of children and 1.2% of adults purchased at least one stimulant prescription during 2008, but only half of them (2.5% of children and 0.6% of adults) were classified according to the researchers’ measure as being in treatment. Researchers obtained records from IMS Health for 24.1 million prescriptions for methylphenidate (Ritalin), dexmethylphenidate (Focalin XR), dextroamphetamine (Dexedrine), combined dextroamphetamine and amphetamine, and lisdexamfetamine (dimesylate). These prescriptions were written by 300,795 prescribers to 6,031,622 unique patients that included commercially insured, Medicaid and cash purchases. Nonstimulants prescribed for ADHD, such as atomoxetine (Strattera), were not included.

Retail pharmacies dispensed 97% of all stimulants sold in the United States during 2008, according to the study. The sample included all stimulant prescriptions dispensed that year by approximately 37,000 retail pharmacies, about 76% of all pharmacies in the United States.

Results

The study found that wide variation in treatment prevalence existed among states, in both children and adults. For example, among children, rates ranged between 0.4% (Alaska) and 5.1% (Delaware). For adults, the difference ranged from 0.2% in Alaska to 1.2% in Delaware.

There were small differences in regional treatment rates — the rates among children were slightly higher in the South (2.4%) and were lowest in the Midwest (2.2%).

Regional rates for adults were highest in the South (0.5%) and were 0.4% elsewhere. Within regions, however, rates differed significantly. In Maryland, for example, 2.7% of children were estimated to have been in treatment compared with 5.1% in neighboring Delaware, 3.6% in West Virginia, and 4.4% in Kentucky. Child treatment prevalence of ADHD was higher in more urban counties and in counties with larger proportions of non-Hispanic white residents, less-educated populations, higher poverty rates, higher average expenditures for special education programs in schools and higher prevalence of adults in treatment.

The rates of children in treatment were positively correlated with the county supply of pediatricians and, to a lesser extent, of family medicine practitioners, according to the study. Only 34% of children in treatment obtained any of their prescriptions from a psychiatrist, and 4% obtained them from a neurologist. Nearly all others got them from primary care providers. “Our analysis found that the strongest determinant of the prescription rate per 1,000 county residents was the availability of prescribers in that county, especially for children — primary care doctors and pediatricians, but not psychiatrists,” said McDonald. “Among adults, the availability of psychiatrists and family medicine practitioners was strongly correlated with prescription rate.” It’s not surprising that in counties with more psychiatrists, the rate of adult treatment by stimulant medications is higher, added McDonald. “If you don’t have many psychiatrists in an area, you are less likely to be treated, and probably less likely to be diagnosed with ADHD or another condition where stimulant treatment can be useful.”

Implications

The estimated rates for children with ADHD range from 5% to 10%, said McDonald. The study found that in California the estimated rates of treatment prevalence were 1%, he said. “If that’s the case, [based on] the 1% in California, that suggests substantial undertreatment,” McDonald said. The national average indicates that 2.5% of all children in the United States are being treated for ADHD. Several states are way below 1%, including California, Colorado, and Hawaii.

“There’s a huge variation state to state and when you look at counties, even greater,” he said. “I think differences this large cannot be explained by the prevalence of ADHD,” he added. “This has to be about treatment.”

McDonald added, “If treatment differs so greatly, the conclusion has to be [about] gaps in established clinical practice guidelines and actual guidelines, especially in primary care practices.”

“We assume this is the case because it is highly unlikely that the prevalence of ADHD varies widely from one county to the next,” he said. “Because we observe very wide variation in treatment rates among counties, this must indicate that diagnostic and treatment practices of clinicians differ — probably from one clinician to the next.”

Researchers concluded that better education and training for physicians may improve identification and treatment of ADHD, thereby reducing disparities in care for ADHD and other disabling conditions.

* * *

McDonald DC, Jalbert SK. Geographic variation and disparity in stimulant treatment of adults and children in the United States in 2008. Psychiatr Serv 2013, Aug 2. Epub ahead of print. E-mail: doug_mcdonald@abtassoc.com.

What's New in Research
10/23/2013 12:00 AM

Teens with bipolar disorder (BP) should be followed for substance abuse, because their first substance abuse makes them likely to develop a diagnosable substance use disorder (SUD) in four years, according to an article in the current issue of the Journal of the American Academy of Child & Adolescent Psychiatry. Based on data from the Course and Outcome of Bipolar Youth (COBY) study, the researchers, led by Benjamin Goldstein, M.D., of the University of Toronto and the University of Pittsburgh, found that 32% of 167 youth ages 12 to 17 developed abuse or dependence of alcohol or drugs — mainly, marijuana — within four years of follow-up. Any so-called recreational use of alcohol or drugs is like “playing with fire” for teens with BP, says Goldstein.

précis

• One in three teens with bipolar disorder develop substance abuse or dependence within four years of first trying a drug or alcohol.

• Marijuana was the most frequently abused substance, followed by alcohol.

• Early alcohol use, oppositional defiant disorder, family history of substance abuse, and family discord predicted an SUD.

• Adolescents who were taking antimanic or antidepressant medication at intake were less likely to develop an SUD.

Teens with bipolar disorder (BP) should be followed for substance abuse, because their first substance abuse makes them likely to develop a diagnosable substance use disorder (SUD) in four years, according to an article in the current issue of the Journal of the American Academy of Child & Adolescent Psychiatry. Based on data from the Course and Outcome of Bipolar Youth (COBY) study, the researchers, led by Benjamin Goldstein, M.D., of the University of Toronto and the University of Pittsburgh, found that 32% of 167 youth ages 12 to 17 developed abuse or dependence of alcohol or drugs — mainly, marijuana — within four years of follow-up. Any so-called recreational use of alcohol or drugs is like “playing with fire” for teens with BP, says Goldstein.

Study details

The COBY study, funded by the National Institute of Mental Health, enrolls participants at Brown University, the University of California at Los Angeles, and the University of Pittsburgh. COBY is a longitudinal study which will continue to follow these adolescents into adulthood. The participants had no substance use disorder (SUD) at intake, but some had experimented with alcohol or drugs.

The COBY study included 400 children and adolescents aged 7 through 17 years 11 months. For this study, only 167 subjects aged 12 through 17 years 11 months at intake, who did not have an SUD, and who had at least one follow-up assessment, were used. The researchers determined first-onset SUD based on the first week in which the subject met threshold criteria in DSM-IV for abuse or dependence of alcohol or drugs. Nicotine dependence was not included as an SUD.

The participants were interviewed about seven times during the course of the four-year follow-up.

Results

Overall, 32.3% of the participants developed an SUD within four years of intake. On average, abuse or dependence developed 2.7 years from the start of the study, at a mean age of 18 years. The most common SUDs were cannabis (16.8% abuse, 5.4% dependence) followed by alcohol (15.6% abuse, 4.8% dependence). Other drug abuse and dependence did not exceed 1.2%.

The strongest predictor of later substance abuse was repeated early alcohol use, followed by use of marijuana. Other predictors were oppositional defiant disorder, panic disorder, family history of substance abuse, low family cohesiveness, and absence of antidepressant treatment. More than half (54.7%) of teens with three or more risk factors developed substance abuse, compared to 14.1% of teens with two or fewer risk factors.

Adolescents who were taking antimanic or antidepressant medications at intake were less likely to develop SUDs. And the adolescents who did develop SUDs were also significantly more likely to have a family history of mania/hypomania, anxiety, and SUDs.

Implications

While SUDs are a cause for concern in all patients, it is particularly important to pay attention to them among adolescents with BP, as the combination is associated with more treatment nonadherence, suicide attempts, legal problems, and academic failure, the authors write.

Family cohesiveness mitigates the risk of SUD among youth with BP, which aligns with previous research finding that family conflict is associated with initiation of substance abuse in adolescents, they note. “Prevention of SUD in this population is a matter of tremendous clinical and public health importance.” They recommend strategies such as “assertive treatment of adolescents with BP, early identification of substance use via repeated screening beginning in late childhood, family-focused preventive interventions, and motivation-enhancing interventions targeting subthreshold substance use.”

Variables researchers should take into account when studying first-onset SUD among patients with BP are mood symptoms, inadequate treatment, recreational alcohol use, and familial factors, the researchers conclude. “These findings, albeit tentative, further suggest that treatment of psychiatric comorbidity, both internalizing and externalizing, and incorporating family therapy may confer benefits with regard to SUD,” they write. “Mood exacerbations, particularly those of hypo/manic polarity, may comprise an interval of risk for escalating substance use, and in such circumstances increased vigilance for excessive substance use appears warranted.” While experimenting with substances is often viewed as developmentally appropriate, and parents and clinicians are “reluctant to promote abstinence,” this study “may help to resolve ambivalence among some clinicians, parents, and perhaps adolescents,” they write. Deferring the first onset of substance use could mitigate the risk of a full-blown SUD in patients with BP, they write. “In addition to yielding a greater understanding of why the prevalence of SUD in BP is so high, advances regarding the neurobiological underpinnings of comorbid SUD in BP may identify novel treatment strategies that may ameliorate the substantial psychiatric burden experienced by these doubly affected patients.”

In an accompanying editorial, Robert Milin, M.D., wrote that the findings suggest that treatment of BP could help mediate against the development of substance use disorder (SUD). “From the study findings of Goldstein et al., one can arrive at the clinical importance of assessing and monitoring for likely high-risk factors, such as recreational alcohol and marijuana use, immediate family history of SUD, and the presence of oppositional-defiant disorder, and providing suitable treatment for BP in adolescents,” he wrote. In addition to treating the BP, clinicians should consider treatment interventions for adolescents’ substance abuse problems, including motivational enhancement therapy, psychoeducational therapy, and specific psychosocial therapies, he said, adding that “the development of SUD is a highly prevalent and serious problem in adolescents in the early course of BP that requires clinical attention and further research.”

“It stands to reason that to provide the requisite treatment for BP in adolescents, it is meaningful to use reliable and valid diagnostic criteria and evidence-based pharmacotherapy/treatment for pediatric BP,” Milin continued. “Likewise, one can turn to the existing literature on effective early intervention and treatment of adolescents with substance use-related problems and SUD for strategies that might be introduced and integrated as clinically relevant into the early course of treatment for adolescents with BP. Such treatment interventions include motivational enhancement therapy, psychoeducational therapy, and specific psychosocial therapies for adolescent SUD.”

* * *

Goldstein BI, Strober M, Axelson D, et al. Predictors of first-onset substance use disorders during the prospective course of bipolar spectrum disorders in adolescents. J Am Acad Child Adolesc Psychiatry 2013 Oct; 52(10):1026–1037. Epub 2013 Jul 31. E-mail: benjamin.goldstein@sunnybrook.ca.

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  • Meet the Editor

    Jeffrey I. Hunt
    Editor

    Jeffrey I. Hunt, M.D. is Professor of Psychiatry and Human Behavior; Director of Training of the Child and Adolescent Psychiatry Fellowship and Combined Program in Pediatrics, Psychiatry and Child Psychiatry, Department of Psychiatry and Human Behavior, at the Alpert Medical School of Brown University.
    Alison Knopf
    Managing Editor

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