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.

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.

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.

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.

Brain function in fetal alcohol syndrome assessed by single photon emission computed tomography.

This case series reports results of single photon emission computed tomography (SPECT) studies in three patients with fetal alcohol syndrome (FAS), who had previously undergone structural magnetic resonance imaging (MR). The MR studies revealed several brain anomalies, including microcephaly, agenesis or hypoplasia of corpus callosum and agenesis of hippocampal commissure. The SPECT data revealed that the CBF was reduced by at least 25% in the temporal region relative to the cerebellum in all three patients. By contrast, the temporal-cerebellar differences were between 4% and 7% in two controls. The functional abnormalities in FAS, like neuroanatomical abnormalities, are likely to be multiple and varied because of heterogeneity of this syndrome. Our findings suggest the need for a larger study to test the hypothesis that temporal lobe abnormalities are a notable occurrence in FAS. Discovery of specific regional brain dysfunctions (such as temporal lobe dysfunction) that are particularly vulnerable to alcohol's teratogenic effect may allow clinicians and researchers to look for markers useful in FAS screening and may have implications for prevention and treatment of FAS.