Complementary/Integrative Medicine Treatment and Prevention of Youth Psychosis.

The rationale for CIM treatments in youth psychoses is to optimize treatment by targeting symptoms not resolved by antipsychotics, such as negative symptoms (major drivers of disability). Adjunctive omega-3 fatty acids (ω-3 FA) or N-acetyl cystine (NAC usage for > 24-week) can potentially reduce negative symptoms and improve function. ω-3 FA or exercise may prevent progression to psychosis in youth (in prodromal stage). Weekly 90-minute moderate to vigorous physical activity or aerobic exercise can reduce positive and negative symptoms. Awaiting better research, CIM agents are also recommended because they are devoid of any serious side-effects.

Complementary and Integrative Treatments of Aggressiveness/Emotion Dysregulation: Associated with Disruptive Disorders and Disruptive Mood Dysregulation Disorder.

Youth with emotional dysregulation (ED) and irritability/aggression, common in disruptive disorders (frequently comorbid with attention-deficit/hyperactivity disorder), are underserved by conventional treatments. Anger dysregulation is usually the core feature of ED. Complementary and integrative Medicine (CIM) treatments for youth with disruptive disorders and ED are reviewed. Broad-spectrum micronutrient supplementation has a medium effect and is supported by two double-blind randomized controlled trials using similar formulations. Other CIM treatments supported by controlled data but needing further research, include omega-3 fatty acid supplementation, music therapy, martial arts, restricting exposure to media violence, decreasing sleep deprivation, and increased exposure to green-blue spaces.

Racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders.

OBJECTIVES: To compare the racial/ethnic differences in treatment quality among youth with primary care provider-initiated versus mental health specialist-initiated care for major depressive disorders (MDD). METHODS: A retrospective cohort study was conducted using the 2005-2007 Medicaid claims data from Texas. Youth aged 10-20 during the study period were identified if they had two consecutive MDD diagnoses and received either medications for MDD or psychotherapy. Patients who received ≥84 days of medications and/or ≥4 sessions of psychotherapy for MDD treatment during 4 months of follow-up were considered meeting the minimum adequacy of treatment. RESULTS: The generalized linear multilevel model (MLM) analysis revealed that both Hispanics and Blacks were approximately 30% less likely to receive adequate treatment (Hispanics - OR: 0.67; 95% CI: 0.6-0.8) (Blacks - OR: 0.66; 95% CI: 0.6-0.8) and Hispanic children were 50% more likely to undergo MH-related hospitalization (OR: 1.53; 95% CI: 1.1-2.2) compared to their White counterparts. The odds of meeting the minimum MDD treatment adequacy were comparable between pediatric MDD cases first identified by primary care providers (PCP-I) and psychiatrists (PSY-I) (PCP-I vs. PSY-I: OR: 0.97; 95% CI: 0.8-1.2), and slightly lower in those first identified by social workers/psychologists (SWP-I) as compared to PSY-I (SWP-I vs. PSY-I: OR: 0.81; 95% CI: 0.7-0.9). In all models, the interaction between race/ethnicity and type of provider who initiated MDD care was not statistically significant. CONCLUSIONS: Minority youths received less adequate MDD treatment compared to Whites. Hispanic children had the highest risk of having mental health-related hospitalization. The specialty of provider who initiated MDD care had limited impact on treatment quality and was not associated with the racial/ethnic variations in treatment completion and mental health-related hospitalizations.

Risk factors of psychotropic polypharmacy in the treatment of children and adolescents with psychiatric disorders.

OBJECTIVE: To examine patient and provider characteristics associated with the use of pediatric psychotropic polypharmacy. METHODS: A retrospective study was conducted on children with psychiatric disorder diagnosis and treatment using the 2013-2015 claims data from a Pediatric Medicaid Managed Care Plan. Psychotropic polypharmacy was defined as the receipt of ≥2 psychotropic medications from different drug classes concurrently for ≥60 days. Stratified logistic regression analyses based on the number of prescribers involved in the treatment, i.e. single prescriber (SP) and multiple prescribers (MP) were conducted to determine the risk factors associated with multiclass psychotropic polypharmacy. The Fairlie decomposition method was used to test the difference in receipt of psychotropic polypharmacy between patients with and without a psychiatrist visit. RESULTS: A total of 24,147 children and adolescents met the inclusion criteria. The prevalence of psychotropic polypharmacy was 20.09%. In addition to patients' demographics, diagnoses, number of comorbid psychiatric disorders (MP only), and the number of prescribers involved in the treatment (MP only), patients with a psychiatrist involved in the treatment had 5.3 times and 3.6 times higher odds of receiving psychotropic polypharmacy in SP and MP groups respectively (SP: OR = 5.32; 95% CI 4.62-6.14 & MP: OR = 3.57; 95% CI 3.20-3.99). Only a quarter of the prescribing practice variation between psychiatrists and PCPs was explained by the observed need factors. CONCLUSIONS: Pediatric psychotropic polypharmacy may be necessary and justified as it is mainly prescribed by the best-trained providers.

Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders.

BACKGROUND: Psychotropic polypharmacy is a concern in the management of pediatric mental disorders due to the lack of pediatric data to support the practice. Although seeing multiple providers has been identified as an important predictor of polypharmacy, no study has yet assessed the effect of care coordination between providers on receipt of psychotropic polypharmacy. OBJECTIVE: To examine the association between the intensity of care coordination within a patient's care team and the likelihood of the patient receiving multiclass psychotropic polypharmacy. METHODS: A retrospective study was conducted using the 2013-2015 administrative claims data from a Medicaid managed care organization (Texas Children's Health Plan). Children and adolescents aged 18 years or younger with a diagnosis of a mental/behavioral disorder and receipt of psychotropic prescriptions from multiple prescribers were included in the study. Psychotropic polypharmacy was defined as the receipt of 2 or more psychotropic medications from different drug classes concurrently for 60 days or more. Care coordination was measured using social network analysis (SNA), a new technique included in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas. Care density, an SNA surrogate for care coordination, was calculated as the ratio of the sum of patients shared by physician pairs within a patient's care team to the total number of physician pairs. The Andersen behavioral model was used to guide multivariate logistic regression analyses conducted to assess the association between care density and the likelihood of patients receiving psychotropic polypharmacy after controlling for predisposing and need factors. RESULTS: A total of 24,147 children and adolescents diagnosed with a mental/behavioral disorder were identified. About 34.0% (n = 8,092) of these individuals received psychotropic medications from multiple prescribers who were either primary care physicians (PCPs) or specialists. Logistic regression analysis showed a significant association between care density and the use of psychotropic polypharmacy. However, the direction of this relationship varied depending on the composition of the patient's care team. Among patients with only PCPs involved in their care team, patients in the higher care-density group were 28% less likely to receive psychotropic polypharmacy (OR = 0.72; 95% CI = 0.62-0.96) than those in the lower care-density group. In contrast, among patients who had both PCPs and specialists involved in their care team, those in the higher care-density group were 2 times more likely to experience psychotropic polypharmacy (OR = 2.01; 95% CI = 1.68-2.40). Care density was not significantly associated with the receipt of psychotropic polypharmacy in the specialist-only group. CONCLUSIONS: This study found significant associations between care density and prescription of psychotropic polypharmacy. This relationship varied depending on the patient's diagnosis, disease complexity, and composition of the patient's care team. DISCLOSURES: No outside funding supported this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. The abstract for part of this study, titled "Association Between Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders," was selected as a silver medal abstract and was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2017; March 27-30, 2017; Denver, CO.

Racial/ethnic differences in the treatment of adolescent major depressive disorders (MDD) across healthcare providers participating in the medicaid program.

BACKGROUND: To examine whether racial/ethnic differences in receipt of MDD treatment could be explained by the specialty of provider diagnosing the adolescent. METHOD: Adolescents (10-20 years-old) with ≥2 MDD diagnoses were identified using 2005-2007 Medicaid data from Texas. Patients were categorized based on the types of provider who gave the initial MDD diagnosis (psychiatrist (PSY-I), social worker/psychologist (SWP-I), and primary care physician (PCP-I)). Within the sub-cohorts identified by each type of provider, patients were further divided by racial/ethnic groups. RESULTS: Of the 13,234-new pediatric MDD cases diagnosed, 61% were SWP-I, 33% PSY-I and 6% PCP-I. Results of the analysis using general linear multi-level model showed that being first diagnosed by a psychiatrist was associated with higher chance of receiving MDD related treatment (PCP-I vs. PSY-I (OR: 0.54, 95%CI: 0.4-0.7) and SWP-I vs. PSY-I (OR: 0.17, 95%CI: 0.1-0.2)). Specifically, regarding the receipt of pharmacotherapy, an interaction effect was detected between types of identifying providers and patients' race/ethnicity. The analysis stratified by race/ethnicity found Whites received comparable treatment regardless being PCP-Is or PSY-Is, while for Hispanics, being first identified by a PCP was associated with lower likelihood of receiving treatment as compared to being first identified by a psychiatrist. Further analysis stratified by provider types showed that a significant racial/ethnic variation in medication utilization was observed in PCP-Is, but not in PSY-Is. CONCLUSION: For adolescents with MDD, being first diagnosed by a psychiatrist was associated with higher treatment rate and reduced racial/ethnic variation in the utilization of pharmacotherapy.

The Impact of Pharmacotherapy on Substance Use in Adolescents With Attention-Deficit/Hyperactivity Disorder: Variations Across Subtypes.

OBJECTIVE: The primary purpose of this study was to investigate the impact of attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy on the risk of substance use within each ADHD subtype. METHODS: The study used data from the National Comorbidity Survey-Adolescent supplement, a nationally representative sample of US adolescents (ages 13-18) collected from 6,483 adolescent-parent interviews conducted between 2001 and 2004. ADHD was categorized into three subtypes: ADHD-predominantly hyperactive-impulsive type (ADHD-H); ADHD-predominantly inattentive type (ADHD-I); and ADHD-combined type (ADHD-C) using Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Substance use information was obtained from the adolescents' interview. The impact of ADHD-pharmacotherapy on substance use was examined using multivariable logistic regression analysis. RESULTS: Among the adolescents with ADHD, ADHD pharmacotherapy significantly associated with reduced risk of substance use (OR = 0.53, 95%CI [0.31-0.90]); with regards to ADHD subtypes, ADHD pharmacotherapy is negatively associated with substance use in adolescents with ADHD-C (OR = 0.53, 95%CI [0.24-0.97]) and those with ADHD-H (OR = 0.23, 95% CI [0.07-0.78]), but it did not have statistically significant effect on risk of substance use in those with ADHD-I subtype (OR = 0.49, 95%CI [0.17-1.39]). Among the group who never received ADHD-pharmacotherapy before the interview, individuals with ADHD-H and ADHD-C had a similar risk of substance use compared to adolescents with ADHD-I (ADHD-C: OR = 1.5, 95%CI [0.77-2.95] and ADHD-H: OR = 2.10, 95%CI [0.87-4.95]). CONCLUSIONS: Adolescents with ADHD were equally susceptible to future substance use disregard their ADHD subtypes. Receipt of pharmacotherapy could decrease risk of substance use in adolescents with ADHD-H and ADHD-C, but it may not affect risk of substance use among individuals with ADHD-I.

Concurrent use of stimulants and second-generation antipsychotics among children with ADHD enrolled in Medicaid.

OBJECTIVE: This study examined the prevalence of and factors associated with concurrent use of long-acting stimulants (LAS) and second-generation antipsychotic agents among children and adolescents with attention-deficit hyperactivity disorder (ADHD). METHODS: The study involved retrospective longitudinal analysis of 2003-2007 Medicaid data from four states for children and adolescents between the ages of six and 17 years who were diagnosed as having ADHD and initiated LAS treatment. Concurrent use of LAS and second-generation antipsychotic medications was defined as simultaneous receipt of both medications for at least 14 days. On the basis of the conceptual framework of the Andersen behavioral model, multivariable logistic regression analysis was used to examine predisposing, enabling, and need factors associated with concurrent use. RESULTS: Among the 61,793 children who initiated LAS treatment for ADHD, 11,866 (19.2%) received LAS and second-generation antipsychotics concurrently for at least 14 days. Overall, the average length of concurrent use was 130±98 days. Multivariable logistic regression revealed that concurrent use was higher among boys, blacks, and foster care children compared with their respective counterparts. Comorbid psychiatric conditions, including disorders that are not approved indications for second-generation antipsychotic use, were associated with concurrent use of LAS and second-generation antipsychotics. CONCLUSIONS: Almost one in five children and adolescents who initiated LAS also received second-generation antipsychotics concurrently for at least 14 days. Approved and nonapproved indications of second-generation antipsychotics influenced concurrent use in pediatric ADHD.

Concomitant antipsychotic prescribing in US outpatient settings.

BACKGROUND: Clinicians use concomitant antipsychotic therapy for management of psychotic disorders despite a paucity of evidence for this practice. OBJECTIVE: To examine national patterns and determinants of concomitant antipsychotic therapy. METHODS: Concomitant antipsychotic therapy was defined as simultaneous use of 2 or more antipsychotic agents. Prescription data from the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey were used to characterize the prescribing of concomitant antipsychotic therapy and antipsychotic monotherapy (defined as use of a typical or atypical agent). Multiple logistic regression was applied to antipsychotic visits to examine the determinants of concomitant antipsychotic therapy based on patient and provider characteristics. RESULTS: Overall, concomitant antipsychotic therapy was documented in 9% of the visits involving antipsychotic agents, and monotherapy in 91% of the visits. The use of atypical agents, namely risperidone, olanzapine, and quetiapine, was common in both forms of therapy. Concomitant therapy was frequently used for psychoses and bipolar disorder. Logistic regression revealed that the odds of receiving concomitant antipsychotic therapy were higher for patients younger than 65 years, with greatest odds (odds ratio=6.52) for patients 40 to 64 years old. Having a diagnosis of psychosis quadrupled (odds ratio=4.33) the odds of receiving concomitant antipsychotic therapy. Physicians in metropolitan areas were more likely (odds ratio=2.17) to use concomitant antipsychotic therapy than physicians in non-metropolitan areas. CONCLUSIONS: Concomitant antipsychotic therapy continues to be prevalent and extensive in outpatient settings. With the use of concomitant antipsychotic therapy as a quality of care measure, there is a need to optimize prescribing of these potent combinations.

Pharmacotherapy with atomoxetine for US children and adolescents.

BACKGROUND: Atomoxetine, a non-stimulant medication, was approved for treatment of Attention Deficit/ Hyperactivity Disorder (ADHD) in 2002. However, there is a paucity of recent practice-based national data on the use of atomoxetine. This article compares the use of atomoxetine with that of stimulant medications in outpatient treatment of U.S. children and adolescents, and examines the predictors of atomoxetine use in this population. METHODS: The 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey were used to determine the utilization of atomoxetine and stimulants in youth<20 years. Bivariate analyses were used to examine the use of atomoxetine relative to that of stimulant medications in children and adolescents (n=1,133). Multiple logistic regression analysis was applied to visits involving youths with ADHD to examine predictors of atomoxetine use (n=1,361). RESULTS: An estimated 14.51 million visits involving psychotropic agents resulted in prescription of atomoxetine and stimulants during the years 2003 and 2004. The percentage of visits for atomoxetine, as a proportion of all psychotropic visits, was nearly 10% (versus 40% for stimulants). Analyses of visits involving atomoxetine and stimulants revealed age- and region-based differences in the use of atomoxetine. Among children with ADHD, approximately 15% of outpatient visits resulted in prescription of atomoxetine; and stimulant medications were prescribed in nearly 61% of these visits. Examination of predictors of ADHD treatments (atomoxetine vs. stimulants) revealed no variations in the use of atomoxetine across sex, race, psychiatric comorbidity, primary care status, and metropolitan location. However, atomoxetine was preferred in 10-to-14 year old children, and in patients with private insurance. Physicians in the Northeast region were less likely to prescribe atomoxetine than physicians in the South. CONCLUSIONS: Although stimulant drugs remain the most frequently prescribed class of psychotropic medications for ADHD in children and adolescents, atomoxetine has emerged as the leading stimulant alternative. Preferential use of atomoxetine in age group 10-to-14 years needs to be further evaluated. Additionally, the role of several factors, including patient preferences, physician-related factors, and psychiatric comorbidity warrant further investigation. Data on differential safety and efficacy of atomoxetine and stimulants are needed to optimize pharmacotherapy in children.

Patterns and determinants of antipsychotic prescribing in children and adolescents, 2003-2004.

OBJECTIVES: This study examined patterns and determinants of antipsychotic prescribing in children and adolescents receiving outpatient care in the United States. METHODS: Antipsychotic prescribing practices for patients younger than 20 years were examined using the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey. The analysis focused on outpatient visits involving 11 typical and six atypical antipsychotic agents. National visit estimates were used to characterize the nature and extent of antipsychotic prescribing for patients younger than 20 years. Multiple logistic regression analysis was applied to visits involving children and adolescents to examine the need, predisposing, and enabling factors associated with antipsychotic prescribing. RESULTS: Antipsychotic medications were prescribed in two million outpatient visits annually involving children and adolescents, representing 1% of overall visits by children and adolescents in 2003-2004. Most (99%) of these visits involved prescribing of atypical agents. The most frequently prescribed atypical agents were risperidone, quetiapine, and aripiprazole. The majority of the visits involving antipsychotic medications in children were seen in patients over 9 years, males, and whites. Factors positively associated with antipsychotic prescribing in children and adolescents included age over 9 years, diagnoses (bipolar disorder, psychoses, depression, disruptive behavior, and anxiety), and visits to specialists. Private insurance was negatively associated with antipsychotic prescribing. CONCLUSIONS: Although the findings were based on cross-sectional analyses of outpatient visit data, the study revealed that atypical antipsychotic medications are being commonly and extensively prescribed to children and adolescents despite the relatively limited scientific evidence to support their pediatric use. Well-designed studies are urgently needed in children and adolescents to address atypical antipsychotic use for a variety of psychiatric disorders.

Acceptability of a Web-based attention-deficit/hyperactivity disorder scale (T-SKAMP) by teachers: a pilot study.

BACKGROUND: The American Academy of Pediatrics (AAP) recommends that physicians obtain information directly from teachers or other school professionals as a part of the periodic assessment of children with attention-deficit/hyperactivity disorder (ADHD). This can be difficult for physicians, however, and despite the guideline, treatment decisions are often made without this key information. Hence, alternative means of obtaining data need to be considered. One alternative is using a Web-based instrument as described in this paper. PURPOSE: This pilot, qualitative study examined teacher acceptability of a Web-based version of an ADHD rating scale known as Swanson, Kotkin, Agler, M-Flynn and Pelham Scale-Teacher Version (T-SKAMP) for weekly monitoring of ADHD-impaired children relative to paper-based scales. METHODS: Following a 2-month clinical trial using the Web-based T-SKAMP, we conducted a qualitative semi-structured interview known as the Teacher Preference Interview (TPI) to 19 teachers. RESULTS: Seventeen of 19 teachers (89.5%) rated Web-based T-SKAMP to be easier, shorter, simpler, and more informative than paper-based scales. They further perceived this Web-based scale to be a time saver (both long and short term) and more flexible, efficient, and effective to use than paper-based scales. CONCLUSIONS: Teachers participating in this pilot study generally preferred a Web-based mechanism of relaying classroom behavioral data on ADHD-impaired children. Web-based T-SKAMP was found to be efficient and effective, and has the potential to improve communication between teachers and physicians. Enhanced communication and cooperation can facilitate increased adherence to established ADHD management guidelines and ultimately benefit affected children.

Association of attention deficit hyperactivity disorder and gestational alcohol exposure: an exploratory study.

OBJECTIVE AND METHODS: To explore association between prevalence of ADHD and levels of risk for gestational alcohol exposure, the authors reviewed the charts of 2,231 youth referred for fetal alcohol spectrum disorders. Participants were categorized into four groups by different levels of risk for gestational alcohol exposure. For each group, the prevalence rates of ADHD and other selected disorders were determined. RESULTS: The disorder ranking first in overall prevalence was ADHD (41%), followed by learning disorder (17%) and oppositional-defiant/conduct disorder (16%). Prevalence rates of ADHD across the groups generally were high risk > some risk > unknown risk > no risk. CONCLUSION: The frequency distribution of ADHD cases was according to the levels of risk for gestational alcohol exposure. These results add to a growing body of evidence supporting an association between ADHD and prenatal alcohol exposure. Findings need to be confirmed by definitive studies on ADHD and gestational alcohol exposure.

U.S. national trends in the use of antipsychotics during office visits, 1998-2002.

BACKGROUND: There is a paucity of studies on U.S. national trends in the use of antipsychotic medications in the 21st century. This study examined national trends in the prescribing of antipsychotic drugs in office-based physician practices. METHODS: National probability sample survey data from 1998-2002 National Ambulatory Medical Surveys were used to analyze the prescribing trends. The weighted visit estimates and percentages were compared across the years using z-test. RESULTS: The number of antipsychotic-related visits was found to increase significantly and nearly two-fold, from 4.6 million in 1998 to 8.6 million in 2002. During the same period, the number of visits for second-generation antipsychotic drugs nearly tripled. The proportion of visits for the second-generation agents, as a percentage of visits for all antipsychotic drugs, rose sharply from about 48% in 1998 to 84% in 2002. Correspondingly, the percentage of visits involving first-generation antipsychotic drugs declined. The growth in the number of visits involving antipsychotic drugs over the 5-year period was substantial (120%) in visits with non-psychiatrist physicians, but not in visits involving psychiatrists. CONCLUSIONS: The trend of growth in prescription of antipsychotic drugs in office visits, accounted by increased use of second-generation antipsychotics, has persisted into the 21st century. Increased prescribing of these agents by non-psychiatrists is also apparently fueling this trend. This trend of shift from first-to-second generation antipsychotic agents, though not unambiguously supported by extant safety and efficacy data, is endorsed by guidelines based on expert-consensus and limited data. Given the high-level use of second-generation drugs, more practical studies of these drugs, focusing on effectiveness or long-term outcomes, are needed.

National trends in concomitant psychotropic medication with stimulants in pediatric visits: practice versus knowledge.

OBJECTIVES: (1) To examine U.S. national trends in the use of concomitant pharmacotherapy with the stimulant class of psychotropic drugs in youth; and (2) to present these trends in the context of (a) extant safety and efficacy data, and (b) overall trends in concomitant pharmacotherapy with psychotropic drugs for youth. METHODS: Prescribing data for youths under age 18 years from National Ambulatory Medical Surveys from 1993 to 1998 were analyzed. The visits were categorized into monotherapy (only one psychotropic prescribed) and concomitant pharmacotherapy (>1 psychotropic prescribed). The proportions of these groups were computed as a percentage of all visits during which a psychotropic medication was prescribed. Differences in proportions between surveys were analyzed to determine trends. RESULTS: Between 1993--94 and 1997--98, the proportions of visits for concomitant pharmacotherapy in association with the stimulant class increased nearly five-fold. This increase paralleled an overall increase in the proportion of visits involving prescription of more than one psychotropic medication among youth. CONCLUSIONS: The growth in concomitant pharmacotherapy with the stimulants class has out-paced the increase in safety/efficacy data to inform the use of this practice, resulting in a mismatch between trends in prescribing and growth in knowledge. A simultaneous trend of note is the overall increase in the use of concomitant pharmacotherapy with all psychotropic drugs in youth. Controlled trials are particularly needed to support commonly used combinations of stimulants with antidepressants in youth. In the absence of definitive data, clinical guidelines based on expert consensus and limited data are available and are useful.

Coexistent hypothyroidism, psychosis, and severe obsessions in an adolescent: a 10-year follow-up.

UNLABELLED: This is the first longitudinal report on possible psychosis resulting from the juvenile onset of hypothyroidism. A 10-year follow-up in the case of a 13-year-old boy published in this journal in 1993 is presented. The patient presented with a diagnostic dilemma. Although psychosis resulting from hypothyroidism was the most parsimonious explanation of his symptoms (new-onset auditory hallucinations, severe obsessions, and severe hypothyroidism), a primary psychiatric disorder (obsessive-compulsive disorder [OCD] or psychotic depression) aggravated by hypothyroidism could not be excluded. The aim of this study was to illustrate that the diagnosis and clinical interrelationships can be clarified by longitudinal data. FOLLOW-UP DATA: The patient's symptoms responded optimally to a combination of fluvoxamine, risperidone, and levothyroxine (LT4, 300 microg daily). He was free from severe symptoms until age 21, when he discontinued all psychotropic medications while continuing with LT4. Over 2 months later, he was hospitalized for thoughts of hurting himself or others. In the hospital, his LT4 was discontinued and propranolol was started. He was discharged on multiple psychotropic medications, and was rehospitalized 6 days later for suicide risk. When LT4 (200 microg daily) was added to his psychotropic regimen, he partially responded and was discharged. The optimal response to treatment occurred only after he was placed on a combination of fluoxetine, risperidone, and LT4 (300 microg daily). The patient remained stable for up to 12 months of follow-up. CONCLUSIONS: This chronology suggests that the optimal treatment in this patient probably required three components: a Selective Serotonin Reuptake Inhibitor, (SSRI) risperidone, and LT4 (300 g daily). Each component was apparently necessary but not sufficient individually for the optimal response. The relapse after the discontinuation of fluvoxamine and risperidone (but not LT4) suggests the presence of a primary psychiatric disorder (OCD with depression). The failure to improve without an adequate dosage of LT4 suggests that hypothyroidism was probably an aggravating factor. This case illustrates the diagnostic difficulty in distinguishing between obsessions, depressive ruminations, and delusions in children and the need to consider hypothyroidism in the differential diagnosis of the sudden worsening of OCD, or in cases of new-onset psychosis in children and adolescents.