Psychiatric Dispatches

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Primary Psychiatry. 2009;16(7):16-18

 

Risk of Psychotic Symptom Development Increased for School-aged Children Who Experience Peer Victimization

In prior studies, psychotic symptoms (ie, hallucinations, delusions, and other thought disorders) in adults have been linked to past childhood experience of trauma, including abuse. Although studies have shown that both children and adults in nonclinical populations commonly experience some psychotic symptoms, those who have experienced trauma, particularly in childhood, are at increased risk for developing full-blown psychosis. In this patient population, these symptoms have also been linked to the later development of schizophreniform disorders. Researchers at the Health Sciences Research Institute at Warwick Medical School in Coventry, England, studied whether bullying—or peer victimization—is associated with psychotic symptoms in a school-age population.

Andrea Schreier, PhD, and colleagues studied 6,437 adolescents for presence of psychotic symptoms and whether increased prevalence of peer victimization led to increased childhood psychotic symptoms. All participants (mean age=12.9 years) were gathered from the Avon Longitudinal Study of Parents and Children, which evaluated a cohort of children in Bristol, England from pregnancy, with parents completing annual written questionnaires on the health of their child. Children in the study then participated in annual evaluations of physical and psychological health beginning at 7 years of age.

In the present study, psychotic symptoms present during the past 6 months were measured using the Psychosis-like Symptoms Interview, a structured interview conducted by trained researchers developed for this study from the National Institute of Mental Health Diagnostic Interview Schedule for Children, Version 4 and the Schedules for Clinical Assessment in Neuropsychiatry. Incidence of peer victimization, defined as negative actions by peers with the intent to hurt another peer, was reported by participants, their mothers, and school teachers.
Approximately 46% of children in the study were found to have been victimized by 8 and/or 10 years of age, while 53.8% were reported to not have been victimized by those ages. Among those children who were victimized, Schreier and colleagues found that the risk of psychotic symptoms was approximately double than in those children who were not victimized. In addition, those who experienced chronic or severe victimization showed increased presence of psychotic symptoms. This finding persisted after researchers controlled for prior psychopathology, family adversity, or the IQ score of the child.

These results were also similar when researchers used only mother and teacher reports to assess victimization. Overall, 5.6% of participants had narrow symptoms with ≥1 symptoms present; 11.5% showed moderate symptoms with ≥1 symptoms suspected or present outside of sleep, substance use, and other factors; and 13.7% of participants had general psychosis-like symptoms.

The authors concluded that the association between childhood victimization and development of psychotic symptoms remains unclear; some children could be genetically predisposed to psychotic symptoms and/or schizophrenia while traumatic incidents may affect cognitive processing for others. They added that these results do show that continued bullying and victimization has consequences that persist beyond childhood, and those effects should be evaluated by primary care physicians.

“Peer victimization, to the best of our knowledge, is not a factor that general practitioners are very much aware of as a potential risk factor for psychotic symptoms,” Dr. Schreier said. “However, this study demonstrated the potentially strong effects, especially if peer victimization is chronic or happened via different means (ie, directly and relational).”

This study implies that doctors should be aware of these damaging effects and routinely explore adverse peer relationships when children present with health problems (not just psychotic symptoms). Health symptoms could well be an indicator of problematic peer relationships.

“To some degree, conflicts among children are normal and children learn from them,” he said. “But, bullying is repeated, systematic, and an abuse of power with the intent to hurt.”

Efforts to reduce victimization and stress for school-age children may provide an intervention to the development of early psychotic symptoms. Additional studies have been conducted to assess interventions that provide children who have been victimized with tools to limit further bullying.

“Children could learn in computer games how to deal with bullies,” Dr. Schreier said. “[Related studies] were able to demonstrate that this intervention helped victims to escape from further victimization.”

Funding for this research was provided by The Wellcome Trust. (Arch Gen Psychiatry. 2009;66(5):527-536). –CP

Baseline Symptom Severity of PMDD and Duration of Sertraline Treatment

Several antidepressants are approved for the treatment of premenstrual dysphoric disorder (PMDD). A recent 18-month survival study tested the ideal length of treatment period for PMDD treated with sertraline.

Ellen W. Freeman, PhD, at the University of Pennsylvania School of Medicine, and colleagues randomized 174 female participants with premenstrual syndrome or PMDD to 4 months (short-term) or 12 months (long-term) of double-blinded, placebo-controlled sertraline treatment (50 mg/day; 100 mg/day for poor response). They were interested specifically in whether duration of active treatment influences time to relapse, with relapse defined as baseline level symptom severity of PMDD. The short-term group (n=87) received sertraline for 4 months, followed by 14 months of placebo. The long-term group (n=87) received sertraline for 12 months followed by placebo for 6 months.

The relapse rate associated with short-term treatment (60%) was significantly greater than that of long-term treatment (41%), with a median time to relapse of 4 months (short-term treatment) versus 8 months (long-term) (.58 h, 95% CI, .34-.98; P=.4). More severe baseline symptoms predicted greater likelihood of relapse. Treatment duration was of little consequence for women with lower baseline symptom severity (P=.50), and those who demonstrated remission were least likely to experience relapse (.22 hazard ratio, 95% CI, .10-.45; P<.001).

To determine length of antidepressant treatment of PMDD, Freeman and colleagues suggest considering the baseline symptom severity of PMDD and symptom remission during treatment.

Funding for this research was provided by the Institute of Child Health and Human Development. (Arch Gen Psychiatry. 2009;66(5):537-544). –LS

Cortical Brain Stimulation Proves Effective for Major Depressive Disorder Symptoms

According to a study conducted by the World Health Organization, major depressive disorder (MDD) is rated as the primary cause of disability in the world; 340 million people suffer from a major depressive episode annually. Of those who suffer from MDD, the suicide rate is at least 15%.

Despite combined treatments of psychotherapy and medication that often provide MDD patients with alleviation, the reaction of most MDD patients is poor—20% fail to respond effectively. Electroconvulsive therapy (ECT) is used to treat many MDD symptoms. However, while ECT is effective in ~70% of cases in which antidepressants are insufficient, it has an extremely high relapse rate within a 6-month period. Because of the recurrent symptoms and relapse, ECT is frequently repeated in order for patients to maintain better stability.

An advantage of cortical brain stimulation is the flexibility of the procedure. It can be reversible and less interfering in comparison to other forms of stimulation. Once transplanted, it can be modified in its stimulator modes. However, one of the main concerns is the likelihood of many patients relapsing after several months of stimulation. Because the therapy results in relapses in patients from time to time, the treatment requires periodic maintenance, leaving ~20% to 50% routinely seeking treatment.

According to Emad Eskandar, MD, from Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues, the left dorsolateral prefrontal cortex section of the brain is significantly related to MDD symptoms in patients. Eskandar and colleagues analyzed patients by using the Montgomery-Asberg Depression Rating Scale, the Hamilton Rating Scale for Depression (HAM-D), and the Global Assessment of Functioning. Twelve patients were randomized to blind medicinal and/or placebo stimulation procedures for 8 weeks. Initially, the treatment was withheld before conductors of the study actively prompted patients through epidural cortical stimulation. The procedure proved to be a last resort for at least 29 patients who failed to respond effectively to 9–10 different medications prescribed. The procedure consisted of electrodes being placed epidurally, outside the dura (a tough membrane that covers the brain), through a small craniotomy.

Although there was a steady improvement in patients over the course of 6 months, the decrease was 20% within the HAM-D, eventually escalating to 33% by the end of 1 year. All patients showed at least some sort of improvement after 6- and 12-month follow-ups. Patients whose electrodes were implanted near the precentral sulcus at 22 mm displayed even better results. Conversely, patients who had electrodes placed <22 mm from the precentral sulcus showed a lower percentage of improvement (only 12%). By 8 weeks, scores on the HAM-D progressed by 22% in the active treatment group compared with just 3% in the sham treatment group. The proportional improvements on the Montgomery-Asberg Depression Rating Scale were 22% and 8%, respectively, and on the Global Assessment of Functioning were 23% and 12%, respectively.

Funding for this study was provided by Northstar Neuroscience. (77th Annual Meeting of the American Association of Neurological Surgeons; San Diego, California; Abstract 803). –AC


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