The black hole of the transition process: dropout of care before transition age in adolescents.

Recent evidence confirms the risks of discontinuity of care when young people make a transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS), although robust data are still sparse. We aimed to identify when and how patients get lost to care during transition by tracking care pathways and identifying factors which influence dropping out of care during transition. This is a retrospective observational study of 760 patients who reached the transition age boundary within 12 months before transition time and being treated at CAMHS for at least during preceding 18 months. Data were collected at two time points: last visit to CAHMS and first visit to AHMS. Socio-demographic, clinical and service utilization variables on CAMHS treatment were collected. In the 12 months leading up to the transition boundary, 46.8% of subjects (n = 356) withdrew from CAHMS without further contact with AHMS, 9.3% withdrew from CAHMS but were referred to AHMS by other services, 29% were transferred from CAHMS to AHMS, 10% remained at CAHMS and 5% patients were transferred to alternative services. Fifty-six percent of subjects experience cessation of care before the transition age. The risk of dropout increases with shorter contact time in CAMHS, is greater in subjects without pharmacological treatment, and decreases in subjects with psychosis, bipolar disorder, eating disorders, mental retardation, and neurodevelopmental disorders. This study confirms that a large number of people drop out of care as they approach the CAMHS transition and experience discontinuity of care during this critical period.

Predictors of Bipolar Disorder Versus Schizophrenia Diagnosis in a Multicenter First Psychotic Episode Cohort: Baseline Characterization and a 12-Month Follow-Up Analysis.

OBJECTIVE: The aim of this study was to identify predisposing factors and clinical features at baseline that might help predict diagnosis of bipolar disorder vs schizophrenia in a first-episode psychosis (FEP) cohort. METHODS: In this prospective, naturalistic study, we evaluated a cohort of 335 subjects with FEP recruited from April 2009 to April 2012. Baseline features were compared between subjects with a final DSM-IV diagnosis of bipolar disorder and schizophrenia at 12-month follow-up. A binary logistic regression model was used to assess predictors of diagnosis of bipolar disorder at follow-up. RESULTS: At 12-month follow-up, 47 of the 335 subjects included in the study received the diagnosis of bipolar disorder and 105, of schizophrenia. Subjects with a final diagnosis of bipolar disorder had a higher prevalence of family history of mood disorders (38.2% vs 18.0%, P = .02), better baseline premorbid adjustment (Premorbid Adjustment Scale [PAS]: 38.4 vs 50.6, P < .01) and psychosocial functioning (Functional Assessment Short Test [FAST]: 23.6 vs 33.7, P = .001), better cognitive flexibility (number of perseverative errors on the Wisconsin Card Sorting Test [WCST]: 14.2 vs 19.7, P = .01), more manic symptoms (Young Mania Rating Scale [YMRS]: 14.1 vs 7.3, P < .01), lesser negative symptoms (Positive and Negative Syndrome Scale negative scale [PANSS-N]: 15.0 vs 22.3, P < .001), and shorter duration of untreated psychosis (144.2 vs 194.7 days, P < .01) than subjects with a schizophrenia diagnosis. Binary logistic regression model revealed that lower FAST scores (odds ratio [OR] = 0.956; P = .015), lower PANSS-N scores (OR = 0.93; P = .048), and lower number of perseverative errors on the WCST (OR = 0.946; P = .035) were significantly related to diagnosis of bipolar disorder at follow-up. CONCLUSIONS: In our FEP cohort, better psychosocial functioning, lesser negative symptoms, and better cognitive flexibility were related to diagnosis of bipolar disorder at 12-month follow-up.

Findings of proton magnetic resonance spectometry in the dorsolateral prefrontal cortex in adolescents with first episodes of psychosis.

Knowledge of the neurobiology of early onset psychosis is limited. We used proton magnetic resonance spectroscopy to investigate the possible existence of dorsolateral prefrontal brain biochemical abnormalities in adolescents with psychosis and to determine possible differential effects related to specific psychotic diagnoses. We measured the ratios of N-acetyl-aspartate (NAA), choline (Cho), and creatine (Cr) to water in two groups of adolescents with a first episode of psychosis (schizophrenia n=8; non-schizophrenia n=15) and in 32 healthy controls matched for age, gender, and years of education. Proton magnetic resonance spectroscopy at 1.5 T was used to study two 6.75-cc voxels placed in the left and right dorsolateral prefrontal region. The schizophrenia patients presented statistically significant reductions in NAA/water levels in the left dorsolateral prefrontal voxel as compared with non-schizophrenia patients and healthy controls. No significant differences were detected between groups for NAA/water in the right dorsolateral prefrontal voxel or for Cho/water and Cr/water levels in any hemisphere. A reduction of the NAA/water level in the left dorsolateral prefrontal region may be selectively present at the onset of psychosis during adolescence in patients who later progress to schizophrenia, but not in those who later progress to other psychotic disorders.

Neurological soft signs in adolescents with first episode psychosis.

The purpose of this study is to determine the decrease of neurological soft signs (NSS) during adolescence and to compare this evolutionary process in two groups of adolescents with first episode psychosis: a) schizophrenia and b) non-schizophrenia patients. The structured neurological evaluation scale (NES) was administered to 24 adolescents with first episode psychosis. The number of NSS, the total and subscales scores were correlated with age in patients and in 39 healthy controls. Adolescents with first-episode psychosis had a higher prevalence of NSS than healthy controls; the schizophrenia patients (N=9) scored higher than non-schizophrenia patients (N=15). The number of NSS, total score and the scores on three of the four NES subscales correlated inversely with age in the healthy control group. No correlation was found for the schizophrenia group. For the non-schizophrenia group, a significant negative correlation was found only in one subscale. The decrease of NSS during adolescence in the healthy population but not in the patient groups with psychosis may be an indicator of a disturbance of brain processes that occurs during development. We did not find a clear pattern of NSS that distinguished schizophrenia from other psychoses.

Clinical effectiveness of new generation antipsychotics in adolescent patients.

In addition to management of symptoms of disease, pharmacological interventions in adolescents with psychotic disorders must be clinically effective to provide the best possible outcome in terms of well-being, functioning, and disease burden. Six outcome domains should be considered: symptoms of disease, tolerability, everyday functioning, subjective well-being, family/career burden, and treatment adherence. To date, few studies have compared the clinical effectiveness of the different new generation antipsychotics in adolescents. However, clear differences exist between available agents, particularly in terms of tolerability profile. This review will focus on the particular issues that clinicians need to consider in order to maximise the clinical effectiveness of the new generation antipsychotics in adolescent patients with psychosis. For example, adolescents are not only more susceptible to the side effects of antipsychotic medication than adults, but they are also more likely to be sensitive to the negative impact of side effects on appearance, body image, and self-esteem. Data available in children and adolescents will be reviewed, and the practical implications for patient management will be highlighted. The importance of dosing the new generation antipsychotics appropriately will also be discussed.