Making the case for the family model in in-patient child and adolescent mental healthcare.

Within paediatrics, young children experiencing physical and emotional distress are admitted to hospital with their parents as a matter of course, recognising the trauma associated with parting children from their carers. Much of this practice is underpinned by our understanding of attachment theory, which also sits as a fundamental tenet of child psychiatry. Yet the culture in psychiatric in-patient hospitals remains to admit young children without their parents, often to units that are geographically distant from the family home. We argue that the practice of admitting lone children to psychiatric in-patient units is likely to be traumatising as well as less effective. We believe this culture requires challenge and change.

Clinical characteristics associated with the prescribing of SSRI medication in adolescents with major unipolar depression.

Unipolar major depressions (MD) emerge markedly during adolescence. National Institute for Health and Care Excellence (NICE) UK recommends psychological therapies, with accompanying selective serotonin reuptake inhibitors (SSRIs) prescribed in severe cases only. Here, we seek to determine the extent and rationale of SSRI prescribing in adolescent MD before entering a randomised clinical trial. SSRI prescribing, together with their clinical characteristics was determined in 465 adolescent patients with MD prior to receiving a standardised psychological therapy as part of the Improving mood with psychoanalytic and cognitive therapies (IMPACT) clinical trial. Overall, 88 (19 %) had been prescribed antidepressants prior to psychological treatment. The clinical correlates varied by gender: respectively, depression severity in boys and self-harming behaviours in girls. Prescribing also differed between clinical research centres. Medical practitioners consider severity of depression in boys as an indicator for antidepressant prescribing. Self-injury in girls appears to be utilised as a prescribing aid which is inconsistent with past and current revised UK NICE guidelines.

Inflammation and immunity in schizophrenia: implications for pathophysiology and treatment.

Complex interactions between the immune system and the brain might have important aetiological and therapeutic implications for neuropsychiatric brain disorders. A possible association between schizophrenia and the immune system was postulated over a century ago, and is supported by epidemiological and genetic studies pointing to links with infection and inflammation. Contrary to the traditional view that the brain is an immunologically privileged site shielded behind the blood-brain barrier, studies in the past 20 years have noted complex interactions between the immune system, systemic inflammation, and the brain, which can lead to changes in mood, cognition, and behaviour. In this Review, we describe some of the important areas of research regarding innate and adaptive immune response in schizophrenia and related psychotic disorders that, we think, will be of interest to psychiatric clinicians and researchers. We discuss potential mechanisms and therapeutic implications of these findings, including studies of anti-inflammatory drugs in schizophrenia, describe areas for development, and offer testable hypotheses for future investigations.

Antidepressants and the adolescent brain.

Major unipolar depression is a significant global health problem, with the highest incident risk being during adolescence. A depressive illness during this period is associated with negative long-term consequences including suicide, additional psychiatric comorbidity, interpersonal relationship problems, poor educational performance and poor employment attainment well into adult life. Despite previous safety concerns, selective serotonin reuptake inhibitors (SSRIs) remain a key component of the treatment of moderate to severe depression episodes in adolescents. The impact of SSRIs on the developing adolescent brain, however, remains unclear. In this review we first consider what is currently known about the developing brain during adolescence and how these development processes may be affected by a depressive illness. We then review our understanding of the action of SSRIs, their effects on the brain and how these may differ between adults and adolescents. We conclude that there is currently little evidence to indicate that the human adolescent brain is at developmental risk from SSRIs. Furthermore, there is no clear-cut evidence to support the concerns of marked suicidal adverse side effects accruing in depressed adolescents being treated with SSRIs. Neither, however, is there irrefutable evidence to dismiss all such concerns. This makes SSRI prescribing a matter of medical judgement, ensuring the benefits outweigh the risks for the individual patients, as with so much in therapeutics. Overall, SSRIs show clinical benefits that we judge to outweigh the risks to neurodevelopment and are an important therapeutic choice in the treatment of moderate to severe adolescent depression.

Eosinophilic bowel disease controlled by the BB rat-derived lymphopenia/Gimap5 gene.

BACKGROUND & AIMS: Many models of autoimmunity are associated with lymphopenia. Most involve a T-helper cell (Th)1-type disease, including the diabetic BioBreeding (BB) rat. To investigate the roles of identified susceptibility loci in disease pathogenesis, we bred PVG-RT1(u), lymphopenia (lyp)/lyp rats, congenic for the iddm1 (RT1(u)) and iddm2 (lyp, Gimap5(-/-)) diabetes susceptibility loci on the PVG background. Surprisingly, these rats developed a spontaneous, progressive, inflammatory bowel disease. To understand the disease pathogenesis, we undertook investigations at the genetic, histologic, and cellular levels. METHODS: Genetically lymphopenic rats and congenic wild-type partners were compared for gross pathologic, histologic, and immunologic parameters, the latter including cytokines and autoantibodies. RESULTS: Genetic analysis demonstrated that homozygosity at the lyp locus was required for disease. All rats developed disease, and the median age at humane killing was approximately 36 weeks. This panintestinal disease showed a conspicuous eosinophilic infiltrate in the submucosa and muscle layers, but the villi were unaffected. Diseased rats showed splenomegaly and massive enlargement of the mesenteric lymph nodes. This pathology resembles human eosinophilic gastroenteritis, and several further features indicate a Th2 basis. The rats developed high serum IgE and made IgG autoantibodies that detected a nonleukocytic cell present in the intestinal wall of all rats (including germ free). CONCLUSIONS: The T-lymphopenic state associated with GIMAP5 deficiency renders rats generally susceptible to T-cell-mediated autoimmunity, but the immunoregulatory bias (Th1/Th2) of any disease depends on other genetic (or environmental) factors. In the present model, we suggest that defective peripheral tolerance to an intestine-specific autoantigen leads to uncontrolled inflammation of the intestinal wall.

How do DCs interact with intestinal antigens?

Recent evidence demonstrates that dendritic cells (DCs) can insert dendrites between the epithelial cells that form the barrier protecting the body from the gut contents. Although first observed almost a decade ago, this is a controversial area of DC biology and the physiological importance of this phenomenon is only now being clarified. A recent study by Niess and colleagues shows that this behaviour enables efficient sampling of both invasive and non-invasive bacteria and might enhance the ability of an organism to resist infections by a pathogenic strain of Salmonella.

Uptake of antigens from the intestine by dendritic cells.

The intestinal immune system responds to ingested antigens in a variety of ways, ranging from tolerance to full immunity. How T cells are instructed to make these differential responses is still unclear. Dendritic cells (DCs) sample enteric antigens in the lamina propria and Peyer's patches, and transport them within the patch or to mesenteric nodes where they are presented to lymphocytes. It is probable that DCs also transmit information that influences the outcome of T cell activation, but the nature of this information and the factors in the intestine that regulate DC behavior and properties are far from clear. We have developed a model in the rat that permits analysis of DCs actually in the process of migration from the intestine to mesenteric nodes. In this paper we will review those aspects of our research that relate to antigen uptake and discuss these in the context of other experimental systems.