Identification and Management of COVID-19 Related Child and Adolescent Mental Health Problems: A Multi-Tier Intervention Model.

Nepal is a low and medium-income country (LMIC), situated in South-east Asia, with a population of 29 million, of which, 40-50% are children and adolescents. The Coronavirus Disease 2019 (COVID-19) pandemic has affected the lives of people around the world, including Nepal. The child and adolescent mental health (CAMH) needs and services in Nepal have a significant gap. CAMH in Nepal suffers from lack of specialized training in this field as well as scarcity of human resources and services. There is only one full-time child and adolescent psychiatry (CAP) out-patient clinic in the country. Some recent activities have focused on CAMH in Nepal but the COVID-19 pandemic has produced new challenges. Access to mental health services for children and adolescents (C&A) across Nepal has been adversely affected. Factors such as closure of schools, confinement at home, lockdown, transportation problems, uncertainty, loss of usual routine and fear of infection have affected the mental health of C&A. This has highlighted a need to build capacity of available local human resources, enhance community support, teach measures of coping with stress and improve CAMH service delivery by strengthening the referral system, but these have to be addressed overcoming problems of travel restrictions and limited resources. To address these needs, online platform can be a suitable approach. With this view, a multi-tier CAMH intervention model was developed, which utilizes online platform for training mental health professionals across Nepal, who would then facilitate sessions for C&A, teachers, parents and caregivers; and link them to CAMH services locally, and remotely through teleconsultation. This started as a pilot from June 2020 and will continue till end of February 2021, with the aim to reach 40,000 C&A, parents, teachers and caregivers. As of Nov 2020, this model has been used to successfully conduct 1,415 sessions, with 28,597 population reached. Among them, 16,571 are C&A and 12,026 are parents, teachers and caregivers, across all 7 provinces of Nepal. In this paper, the multi-tier intervention to address the COVID-19 related CAMH problems has been discussed as a feasible framework for resource limited settings and LMICs like Nepal.

Parenting during the COVID-19 Pandemic.

Parenting is both an art and science of nurturing a child that comes very naturally to some. In today's world, the fundamentals of parenting are getting challenged but it has been even more magnified during the coronavirus 2019 (COVID-19) pandemic. The mental health of children is bound to be affected by the stress related to COVID-19 owing to loss of usual routine, unpredictability, uncertainty. Various other social, economic, and environmental factors also threaten their mental well-being. Parents are the child's first and longest-lasting context for development Positive parenting that involves sensitivity, responsivity, caring, communicating, and empowering would ensure positive developmental outcomes in children and adolescents. Positive parenting and self-care of parents would serve as a promotive and preventative intervention for child and adolescent mental health, especially during this crisis.

Child and adolescent mental health problems in Nepal: a scoping review.

INTRODUCTION: Globally, 10-20% of children and adolescents suffer from mental disorders, with half of all them starting by the age of 14 and three-quarters before the age of 25. In Nepal, 40% of the population is younger than 18 years of age, and as such there is a large proportion of the population that is at risk of developing a mental disorder. There has been a recent recognition of child and adolescent mental health problems in Nepal, although prior to this it had remained almost invisible on the health agenda. In response to growing concern, there is a need to conduct a review on children and adolescent mental health problems in Nepal. OBJECTIVE: To review the existing studies on child and adolescent mental health problems in Nepal. METHODOLOGY: A scoping review approach was used to identify studies on child and adolescent mental problems in Nepal. A search of Medline and PubMed databases for articles published from the database inception to August 2018 was conducted. RESULTS: Ten papers were identified, and they all together included 7876 participants. Two studies reported on Post traumatic Stress Symptoms (PTSS) and described a prevalence of 10.7% to 51% of earthquake-affected children and adolescents in the Kathmandu district of Nepal. Another study reported that 53.2% of former child soldiers met the cut-off score for PTSS. Two school surveys found that the prevalence of emotional and behavioural problems in school children ranged between 12.9 and 17.03%, whereas a study on emotional and behavioural disorders in homeless children reported a prevalence of 28.6%. The prevalence of Autism Spectrum Disorder (ASD) was estimated to be as high as three in every 1000 persons in Nepal by one study. The clinical prevalence of anxiety disorders was reported ranging from 18.8% to 24.4% while that of Attention Deficit Hyperactivity Disorder (ADHD) was 10-11.7% in various clinical samples of children and adolescents. CONCLUSION: Only a few studies on the prevalence of child and adolescent mental health in Nepal have been conducted. Clearly, there is a need for better study design and larger studies to understand more fully the prevalence of child and adolescent mental health disorders in Nepal, in order to adequately plan public health services accordingly.

Cortical gyrification in velo-cardio-facial (22q11.2 deletion) syndrome: a longitudinal study.

INTRODUCTION: Velo-cardio-facial syndrome (VCFS) has been identified as an important risk factor for psychoses, with up to 32% of individuals with VCFS developing a psychotic illness. Individuals with VCFS thus form a unique group to identify and explore early symptoms and biological correlates of psychosis. In this study, we examined if cortical gyrification pattern, i.e. gyrification index (GI) can be a potential neurobiological marker for psychosis. METHOD: GIs of 91 individuals with VCFS were compared with 29 siblings and 54 controls. Further, 58 participants with VCFS, 21 siblings and 18 normal controls were followed up after 3 years and longitudinal changes in GI were compared. Additionally, we also correlated longitudinal changes in GI in individuals with VCFS with prodromal symptoms of psychosis on the Scale of Prodromal Symptoms (SOPS). RESULT: Individuals with VCFS had significantly lower GIs as compared to their siblings and normal controls. Longitudinal examination of GI did not reveal any significant group-time interactions between the three groups. Further, longitudinal change in GI scores in the VCFS group was negatively correlated with positive prodromal symptoms, with the left occipital region reaching statistical significance. CONCLUSION: The study confirms previous reports that individuals with VCFS have reduced cortical folding as compared to normal controls. However over a period of three years, there is no difference in the rate of change of GI among both individuals with VCFS and normal controls. Finally, our results suggest that neuroanatomical alterations in areas underlying visual processing may be an early marker for psychosis.

A study of polypharmacy with second generation antipsychotics in patients with severe and persistent mental illness.

BACKGROUND: There is a paucity of empirical support for polypharmacy with second generation (atypical) antipsychotics (SGAs), especially in understudied populations. OBJECTIVE: To investigate the frequency, effectiveness, and safety of this practice in patients with severe and persistent mental illness who are chronically hospitalized. METHODS: A chart review was conducted at a state psychiatric hospital in Syracuse, NY. The study subjects (N=26) were chronically hospitalized individuals with DSM-IV diagnoses of schizophrenia or schizoaffective disorder who were initially prescribed at least one SGA and then received at least one other SGA during the study period. Demographic and clinical data were collected. Baseline and 6-month assessments were compared for statistical significance (p<0.05). RESULTS: Of the 117 chronically hospitalized inpatients at the study center, 22.2% (N=26) received treatment regimens involving polypharmacy with SGAs. These patients as a group achieved statistically significant reductions on their scores on the Brief Psychiatric Rating Scale (34.2 +/- 11.0 compared with 25.3 +/- 11.8; p=0.016) and the Clinical Global Impressions-Improvement Scale (5.5 +/- 0.6 compared with. 5.0 +/- 0.8; p=0.016) at 6 months. There was a significant decrease in the use of prn medications (7.6 +/- 19.6 compared with 1.6 +/- 2.6; p<0.04). However, the number of patients receiving anticholinergic medications increased from 5 to 8 (p<0.04). CONCLUSIONS: Polypharmacy with SGAs is quite frequent among chronic inpatients with severe and persistent mental illness despite a limited empirical database supporting its use. The results of our pilot study do not demonstrate the effectiveness and safety of this practice. However, methodological shortcomings may have contributed to our failure to detect a true, positive effect. Controlled studies are needed to accurately determine the risks and benefits of SGA polypharmacy.

Treating common psychiatric disorders associated with attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) often occurs along with other psychiatric disorders, with estimated comorbidity rates of 50--90%. Comorbidity greatly influences presentation, diagnosis and prognosis, complicates treatment and significantly increases the morbidity and disease burden of ADHD. Commonly co-occurring psychiatric disorders are disruptive behavior disorder, anxiety, depression, bipolar disorder and substance use disorders. This article provides a brief review of effective strategies for treating the most common psychiatric disorders associated with ADHD. This paper also discusses knowledge gaps in the understanding of treatment of comorbid disorders associated with ADHD, and directions for future research.

A retrospective study of weight changes and the contributing factors in short term adult psychiatric inpatients.

INTRODUCTION: The authors endeavored to determine if there is significant weight gain during acute psychiatric inpatient hospitalization for adults and, if so, what are the contributing factors. METHODS: A retrospective chart review was conducted of all patients admitted to the psychiatric inpatient unit of a University Hospital in the year 2001. The study was approved by the Institutional Review Board. RESULTS: Out of 535 charts reviewed, 96 patients met the inclusion criteria. The group on average gained 3.9 +/- 13.3 lbs. (P = 0.005; 95% CI = 1.2, 6.6). Lower admission body weight was associated with more weight gain. Patients with diagnoses of bipolar disorder and schizophrenia gained more compared to those diagnosed with major depressive disorder. Patients who were prescribed atypical antipsychotics gained more compared to those who were not prescribed such medications. Smokers gained more weight than nonsmokers, and males gained more than females. Weight at the time of the admission (inverse relationship) and Axis I diagnosis were the strongest predictors of weight gain. CONCLUSIONS: This study demonstrates that significant numbers of patients are at risk of gaining weight when they are admitted to a psychiatric inpatient unit. Patients with lesser degrees of overweight at the time of admission, patients with diagnoses of bipolar disorder and schizophrenia, and those receiving atypical antipsychotics may be more vulnerable to such effects.

How should psychiatrists dress?--a survey.

Personal attire is an important part of being a professional. This survey is an attempt to determine the patient's and psychiatrists view point about how a psychiatrist should dress to work. A human subjects research board approved survey of seven questions was offered to patients and a similar survey of nine questions was offered to psychiatrists. The replies obtained were combined and tabulated. One hundred patients and 77 psychiatrists responded to the survey. Both the patients and psychiatrists considered dress to be an important part of the doctor-patient relationship. The psychiatrists appear to be more concerned and critical about their dress as compared to patients.

Oxcarbazepine in the treatment of child psychiatric disorders: a retrospective chart review.

Though not considered a first-line treatment, oxcarbazepine has become an option in the expanding effort to ameliorate severely dysregulated mood and behavioral symptoms in youth. Like most pharmaceuticals in child and adolescent psychiatry, oxcarbazepine is not U.S. Food and Drug Administration (FDA)-approved for the treatment of psychiatric disorders. A search of the world literature found a single case report pertaining to this topic. This paper is a chart review of 14 children and adolescents treated with oxcarbazepine who presented with moderate to severe problems with anger and irritability associated with a range of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses. A majority (70%) of patients was treatment-resistant to prior psychopharmacologic efforts, and 70% were receiving combined treatment with other agents in addition to oxcarbazepine. Moderate clinical global improvement was reported in 50% of patients receiving oxcarbazepine; tolerability was good in 86%.

Acute myocardial infarction in a young male on methylphenidate, bupropion, and erythromycin.

The prevalence and treatment of behavioral and mental illnesses in the adolescent population are increasing, and many of the medications used are continued into adulthood. Increased vigilance is necessary when caring for this population to prevent side effects and drug interactions. In this short communication, we present a case of myocardial infarction in a male likely related to drug interactions between bupropion, erythromycin, and methylphenidate.

Resolution of risperidone-induced hyperprolactinemia with substitution of quetiapine.

OBJECTIVE: To report a case of risperidone-induced hyperprolactinemia that was successfully managed with quetiapine. CASE SUMMARY: A 30-year-old white woman with schizoaffective disorder, depressive type, and comorbid alcohol and cocaine abuse was treated successfully for her psychotic symptoms with risperidone until she developed adverse effects consistent with hyperprolactinemia. This was confirmed by laboratory blood tests, as her prolactin level was 186.9 ng/mL (normal for nonpregnant women 2.8-29.2). The woman had experienced similar effects in the past, which had led to noncompliance and subsequent psychotic relapse. Normalization of prolactin levels and associated adverse effects were achieved upon switching to quetiapine. No psychotic symptoms reoccurred. DISCUSSION: Dopamine type 2 (D(2)) receptor blockade in the mesolimbic tract is thought to mediate the therapeutic effects of antipsychotics. This action in the tuberoinfundibular system produces prolactin level elevation. Risperidone has a relatively higher affinity for the D(2) receptor in comparison with other atypical antipsychotics, which may explain why it is associated with a higher incidence of hyperprolactinemia. Quetiapine, which has one of the lowest D(2) receptor affinities, is not known to increase prolactin levels to any significant degree. This pharmacologic property allows quetiapine to be a reasonable treatment option for patients who develop risperidone-induced hyperprolactinemia. CONCLUSIONS: Quetiapine may be a suitable substitute when a patient taking risperidone develops hyperprolactinemia.