Psychiatric Dispatches

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Primary Psychiatry. 2009;16(8):17-18

Medication and Improved Test Scores in ADHD

Recent prevalence rates suggest that ~7.8% (4.4 million) of American children have been diagnosed with attention-deficit/hyperactivity disorder (ADHD), with ~56% of affected children receiving ADHD medication.

Richard Scheffler, PhD, from the University of California, Berkeley, and colleagues, recently published the findings of a 5-year naturalistic study evaluating the academic performance effects of medication—and of taking no medication—for children with ADHD. The study followed 594 children in five waves from kindergarten to 5th grade using data from a national childhood study. Children underwent five standardized math and reading assessments between kindergarten and 5th grade. Researchers relied upon parental report to ascertain ADHD diagnosis and medication status.

Mean mathematics scores for medicated children with ADHD were 2.9 points higher than those of unmedicated children with ADHD. Although the difference in mathematics scores was statistically significant, the difference in mean reading scores between the two groups was not. However, children receiving medication for a longer period (>2 waves) had reading scores 5.4 points higher than the mean score of unmedicated children with ADHD.

Despite the test score advantages of medicated children in this study, an additional 60% gain in those scores would be required in order for children with ADHD to achieve the same scores of peers without ADHD, suggesting that medication alone is not a sufficient treatment strategy for meeting educational challenges of children with ADHD; behavioral interventions and additional tutoring are recommended in conjunction with medication.

Funding for this research was provided by the National Institute of Mental Health (Pediatrics. 2009;123(5):1273-1279). –LS

Brain White Matter Disruptions Associated with Increased Psychosis Risk in Adolescents and Young Adults

In the search for clinical indicators and causal foundations for schizophrenia, researchers have shown that patients with the disorder have brain white matter microstructural disruptions not found in individuals without signs of psychosis. Research has also shown that the degree of white matter connectivity may be associated with the presence of psychosis and schizophrenia in affected patients. However, it is not clear if changes in white matter are present in at-risk patients or occur directly prior to disease onset.

In addition, as schizophrenia onset is typically in adolescence and early adulthood, studies examining white matter disruptions in patients in this age group or younger are key in determining how disruptions are related to disease progression. However, there have been few studies that have examined white matter disruption in this patient population, including studies with patients who do not currently have psychotic symptoms but are at risk due to family history or presence of symptomatic behavior. Katherine Karlsgodt, PhD, of the Semel Institute for Neuroscience and Human Behavior at the University of California in Los Angeles (UCLA), and colleagues, studied brain imaging results from 36 youths at risk for psychosis compared to 25 healthy controls to determine prevalence of white matter alterations and if a decline in white matter integrity was related to increased symptoms of psychosis in this patient population.

All patients included in the study were 12–26 years of age; symptoms of schizophrenia and psychosis have been shown to present in late adolescence and early adulthood. Patients were determined to be at risk for psychosis due to genetic factors or the presence of clinically recognized symptoms. Brain white matter for all patients was evaluated using diffusion tensor imaging at baseline. White matter scans were examined for fractional anisotropy (FA), or white matter density, in six major areas for brain white matter. For follow up, participants were clinically assessed ~6 months (26 patients) and ~15 months (13 patients) following the beginning of the study.

Karlsgodt and colleagues found that at-risk patients showed lower baseline FA in the superior longitudinal fasciculus, the major frontoparietal white matter connection, and the inferior longitudinal fasciculus, compared to healthy controls. In addition, when compared to healthy controls, at-risk patients showed delays in age-associated increases in FA leading to decreased FA in the inferior longitudinal fasciculus and the medial temporal lobe. Follow-up results showed that reduced FA was associated with deterioration in social functioning in at-risk patients.

The authors concluded that there is a difference in the brain development of adolescents and young adults shown to be at risk for schizophrenia and psychosis and those with no history or symptoms of these disorders. This difference may be caused by disrupted brain developmental mechanisms. However, causal mechanisms remain unclear. Regarding functional outcomes, the authors also found that level of white matter integrity may be predictive of later symptom development and worse long-term patient outcome.

Funding for this research was provided by the National Alliance for Research on Schizophrenia and Affective Disorders, the National Institutes of Health, and a private donation to UCLA. (Biol Psychiatry. In press). –CP

Care Managers Reduce Depression and Suicidal Thoughts in Older Primary Care Patients

Depression in older adults may lead to escalation of additional illness, unexplainable misery, and early death when it goes unrecognized and untreated. However, if a primary care physician (PCP) trained in mental health accompanies patients, the number of depression in these are reduced. A study conducted by George S. Alexopoulos, MD, from the Institute of Geriatric Psychiatry at New York-Presbyterian Hospital, Westchester Division, and colleagues, found that adding a trained depression care manager to primary care practices can increase the number of patients who receive the treatment, furthering a higher remission rate of depression and reducing suicidal thoughts.

Two groups were compared in the study, which was conducted in 2-year outcomes and headed by the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). The study included 599 patients >60 years of age diagnosed with depression at 20 primary care practices of varying sizes in New York and Pennsylvania.

Randomized treatment of either PROSPECT care or the usual care was administered to patients. Patients in the PROSPECT group were assigned a care manager, trained social worker, nurse, or psychologist. Physicians enabled PCPs to offer treatment according to accepted practice guidelines. Additionally, the care managers provided follow-up for the next 2 years. Within practice guidelines, citopalopram was as an option as were other psychotherapeutic drugs and therapy.

After ~2 years of being in the PROSPECT care management group, 90% of patients received depression treatment, compared to 62% of patients receiving the usual care. In addition to the favorable outcome from depression treatment,  PROSPECT patients also experienced decline in suicial ideation—2.2 times greater than the group of patients with the usual care.

Depression remission also occurred more rapidly within the PROSPECT intervention group, with remission rates increasing between 18 and 24 months compared to the usual care group, who showed no significant increase within the same time period. The PROSPECT intervention group also displayed favorable results in patients diagnosed with major depressive disorder (MDD). Patients with MDD and minor depressive disorders showed a high rate of remission of the disease.

Alexopoulos and colleagues believe that when elderly patients have an illness already, depression almost always further complicates it and results in the patient getting worse. Depression almost doubles the risk factor for death. By reducing depression factors, PCPs are able to reduce illness.

Funding for this research was provided by Forest Laboratories. (Am J Psychiatry. June 15, 2009 [Epub ahead of print]). –AC

Psychiatric dispatches is written by Amanda Cuomo, Carlos Perkins, Jr., and Lonnie Stoltzfoos.