Identifying clinically relevant agranulocytosis in people registered on the UK clozapine Central Non-Rechallenge Database: retrospective cohort study.

BACKGROUND: Clozapine is the most effective antipsychotic for treatment-resistant psychosis. However, clozapine is underutilised in part because of potential agranulocytosis. Accumulating evidence indicates that below-threshold haematological readings in isolation are not diagnostic of life-threatening clozapine-induced agranulocytosis (CIA). AIMS: To examine the prevalence and timing of CIA using different diagnostic criteria and to explore demographic differences of CIA in patients registered on the UK Central Non-Rechallenge Database (CNRD). METHOD: We analysed data of all patients registered on the UK Clozaril® Patient Monitoring Service Central Non-Rechallenge Database (at least one absolute neutrophil count (ANC) < 1.5 × 109/L and/or white blood cell count < 3.0 × 109/L) between May 2000 and February 2021. We calculated prevalence rates of agranulocytosis using threshold-based and pattern-based criteria, stratified by demographic factors (gender, age and ethnicity). Differences in epidemiology based on rechallenge status and clozapine indication were explored. The proportion of patients who recorded agranulocytosis from a normal ANC was explored. RESULTS: Of the 3029 patients registered on the CNRD with 283 726 blood measurements, 593 (19.6%) were determined to have threshold-based agranulocytosis and 348 (11.4%) pattern-based agranulocytosis. In the total sample (75 533), the prevalence of threshold-based agranulocytosis and pattern-based agranulocytosis was 0.8% and 0.5%, respectively. The median time to threshold-based agranulocytosis was 32 weeks (IQR 184) and 15 (IQR 170) weeks for pattern-based agranulocytosis. Among age groups, the prevalence of pattern-based agranulocytosis and threshold-based agranulocytosis was highest in the >48 age group. Prevalence rates were greatest for White (18%) and male individuals (13%), and lowest for Black individuals (0.1%). The proportion of people who were determined to have pattern-based agranulocytosis without passing through neutropenia was 70%. CONCLUSIONS: Threshold-based definition of agranulocytosis may over-diagnose CIA. Monitoring schemes should take into consideration neutrophil patterns to correctly identify clinically relevant CIA. In marked contrast to previous studies, CIA occurred least in Black individuals and most in White individuals.

A good investment: longer-term cost savings of sensitive parenting in childhood.

BACKGROUND: Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested. METHODS: Design: Longitudinal study with follow-up from 2012 to 2016. SETTING: UK multicentre study cohort (London, South-East England). PARTICIPANTS: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years). MEASURES: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction. RESULTS: Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security. CONCLUSIONS: This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. Savings are likely to increase as individuals grow older since early parenting quality predicts health, behavioural and occupational outcomes in adulthood. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

The cost of love: financial consequences of insecure attachment in antisocial youth.

BACKGROUND: Knowing that your parent or caregiver will be there for you in times of emotional need and distress is a core aspect of the human experience of feeling loved and being securely attached. In contrast, an insecure attachment pattern is found in many antisocial youth and is related to less sensitive caregiving. Such youth are often distrustful of adults and authority figures, and are at high risk of poor outcomes. As they become adults, they require extensive health, social and economic support, costing society ten times more than their well-adjusted peers. However, it is not known whether insecure attachment itself is associated with higher costs in at-risk youth, independently of potential confounders, nor whether cost differences are already beginning to emerge early in adolescence. METHODS: Sample: A total of 174 young people followed up aged 9-17 years (mean 12.1, SD 1.8): 85 recruited with moderate antisocial behaviour (80th percentile) from a school screen aged 4-6 years; 89 clinically referred with very high antisocial behaviour (98th percentile) aged 3-7 years. MEASURES: Costs by detailed health economic and service-use interview; attachment security to mother and father from interview; diagnostic interviews for oppositional and conduct problems; self-reported delinquent behaviour. RESULTS: Costs were greater for youth insecurely attached to their mothers (secure £6,743, insecure £10,199, p = .001) and more so to fathers (secure £1,353, insecure £13,978, p < .001). These differences remained significant (mother p = .019, father p < .001) after adjusting for confounders, notably family income and education, intelligence and antisocial behaviour severity. CONCLUSIONS: Attachment insecurity is a significant predictor of public cost in at-risk youth, even after accounting for covariates. Since adolescent attachment security is influenced by caregiving quality earlier in childhood, these findings add support to the public health case for early parenting interventions to improve child outcomes and reduce the financial burden on society.

Complementary and alternative medicine use in adults with autism spectrum disorder in Germany: results from a multi-center survey.

BACKGROUND: Complementary and Alternative Medicine (CAM) is widely used both in the general population and for the treatment of somatic and psychiatric disorders. Studies on CAM use among patients with autism spectrum disorder (ASD) have so far only focused on children and adolescents. The aim of this study was to investigate patterns of CAM use among adults with ASD. METHODS: A questionnaire survey concerning current and lifetime use of CAM was distributed to adults with ASD between November 2015 and June 2016. Participants diagnosed by experienced clinicians using the current diagnostic gold standard were recruited from four ASD outpatient clinics in Germany. Questionnaire data was then linked to supplementary clinical data. RESULTS: The final sample consisted of 192 adults (response: 26.8%) with a mean age of 31.5 years (80% male; diagnoses: Asperger's syndrome (58%), childhood autism (27%), atypical autism (12%)). 45% of the respondents stated that they were currently using or had used at least one CAM modality in their life. Among the participants with lifetime CAM use, almost half had used two or more different types of CAM. Alternative medical systems (e.g. homeopathy, acupuncture) were most frequently used, followed by mind-body interventions (e.g. yoga, biofeedback, animal assisted therapy). Overall, 20% of respondents stated that they would like to try at least one listed CAM modality in the future. CONCLUSIONS: This is the first study on CAM use in adults with ASD, demonstrating considerable CAM use in this population. Given the popularity of CAM, patients should be informed about the effectiveness and potentially dangerous side effects of CAM treatments, as evidence for the majority of CAM methods in ASD is still limited.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]. / Einfluss des sozioökonomischen Status auf Gesundheitskosten für Kinder und Jugendliche mit Störungen des Sozialverhaltens : Eine Analyse von Routinedaten einer gesetzlichen Krankenversicherung.

BACKGROUND: For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking. OBJECTIVES: To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES. MATERIALS AND METHODS: The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication. RESULTS: There was no significant functional association between SES and healthcare costs for any of the analysed cost types. CONCLUSIONS: In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Differences in healthcare costs in youths with conduct disorders in rural vs. urban regions: an analysis of German health insurance data.

BACKGROUND: For children and adolescents with mental health problems, there is a lack of data as to whether the type of residential area (urban vs. rural) influences healthcare costs for affected individuals. The aim of this study was therefore to explore potential urban vs. rural healthcare cost differences in children and adolescents with conduct disorder (CD), one of the most frequent and cost-intensive child and adolescent psychiatric disorders. Additionally, we aimed to compare healthcare costs of youths with CD, and of youths without this diagnosis. METHODS: We analysed data from a German health insurance company, extracting all youths with a CD diagnosis in 2011 (CD group; N = 6337), and an age- and sex-matched group without this diagnosis (control group). For both groups, annual costs per person for outpatient and inpatient healthcare were aggregated, stratified by area of residence (urban vs. rural). RESULTS: While mean annual overall costs in the CD group did not differ significantly between urban and rural areas of residence (2785 EUR vs. 3557 EUR, p = 0.253), inpatient treatment costs were significantly higher in rural areas (2166 EUR (60.9% of overall costs) vs. 1199 EUR (43.1% of overall costs), p < 0.0005). For outpatient healthcare costs, the reverse effect was found, with significantly higher costs in individuals from urban areas of residence (901 EUR (32.3% of overall costs) vs. 581 EUR (16.3% of overall costs), p < 0.0005). In the control group, no significant rural vs. urban difference was found for either overall health costs, inpatient or outpatient costs. Mean overall costs in the CD group were four times higher than in the control group (3162 (±5934) EUR vs. 795 (±4425) EUR). CONCLUSIONS: This study is the first to demonstrate urban vs. rural differences in healthcare costs among youths with CD. The higher costs of inpatient treatment in rural regions may indicate a need for alternative forms of service provision and delivery in rural settings.

Trends in psychopharmacologic treatment of tic disorders in children and adolescents in Germany.

Data on medical treatment of children and adolescents with tic disorders are scarce. This study examined the administrative prevalence of psychopharmacological prescriptions in this patient group in Germany. Data of the largest German health insurance fund were analysed. In outpatients aged 0-19 years with diagnosed tic disorder, psychotropic prescriptions were evaluated for the years 2006 and 2011. In 2011, the percentage of psychotropic prescriptions was slightly higher than in 2006 (21.2 vs. 18.6%). The highest prescription prevalence was found in Tourette syndrome (51.5 and 53.0%, respectively). ADHD drugs were most frequently prescribed, followed by antipsychotics. In 2011, prescriptions of second generation antipsychotics (SGA) were higher and prescriptions of first generation antipsychotics (FGA) lower than in 2006. Concerning prescribed antipsychotic substances, in 2011 risperidone prescriptions were higher and tiapride prescriptions lower. Paediatricians issued 37.4%, and child and adolescent psychiatrists issued 37.1% of psychotropic prescriptions. The FGA/SGA ratio was highest in GPs (1.25) and lowest in child and adolescent psychiatrists (0.96). From 2006 to 2011, there was only a slight increase in psychotropic prescriptions for children and adolescents with a diagnosis of tic disorder in Germany, which stands in contrast towards the significant increase in psychotropic prescriptions in other child and adolescent psychiatric disorders (e.g. ADHD). There were marked differences in treatment patterns by tic disorder subgroups, with Tourette syndrome patients receiving most frequently psychopharmacotherapy. Risperidone prescriptions increased, probably reflecting a switch in prescribing practice towards up-to-date treatment guidelines. In primary care physicians, dissemination of current tic disorder treatment guidelines might constitute an important educational goal.

Anti-NMDA receptor encephalitis presenting as atypical anorexia nervosa: an adolescent case report.

Since 2007, more than 600 patients have been diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, with almost 40 % of those affected being children or adolescents. In early phases of the illness, this life-threatening disease is characterized by psychiatric symptoms, such as depression, anxiety, obsessions, hallucinations or delusions. Consequently, a high percentage of patients receive psychiatric diagnoses at first, hindering the crucial early diagnosis and treatment of the anti-NMDA receptor encephalitis. We report on a 15-year-old girl initially presenting with pathological eating behaviour and significant weight loss resulting in an (atypical) anorexia nervosa (AN) diagnosis. Her early course of illness, diagnostic process, treatment and short-term outcome are described. This case report aims to raise awareness about the association between anorectic behaviour and anti-NMDA receptor encephalitis and highlight the importance of multidisciplinary teams in child and adolescent services.

Trends in antidepressant prescriptions for children and adolescents in Germany from 2005 to 2012.

PURPOSE: Longitudinal data on prescriptions of antidepressants (AD) in children and adolescents depression are scarce. This study aimed to examine AD prescription trends in children and adolescents in Germany. METHODS: Data of a large statutory health insurance company were analyzed for the period 2005-2012, and outpatients aged 0-19 years with AD prescriptions were identified. Prescriptions were evaluated with respect to age, sex, region of residence (East vs. West Germany) and substance class. RESULTS: Our study population comprised 1.4-1.6 million children and adolescents per year; between 4790 and 6849 of them received AD prescriptions. From 2005 to 2012, the prevalence of AD prescriptions rose from 0.32% to 0.48% (+49.2%), with a significant increase only in the age group 15-19 years (from 0.83% to 1.41%; +71.0%). The prevalence of AD prescriptions rose from 0.41% to 0.63% (+53.3%) for women and from 0.24% to 0.35% (+43.1%) for men. Regarding substance classes, serotonin reuptake inhibitors (SSRI) prescriptions increased from 37.7% to 54.4% of all AD prescriptions, whereas tricyclic antidepressants (TCA) significantly decreased (from 39.6% to 23.0%). In all years, fluoxetine was the substance most frequently prescribed (2005: 12.2% and 2012: 24.3% of all AD prescriptions). CONCLUSIONS: During an 8-year period, prescriptions of AD to children and adolescents in Germany have markedly increased, but almost exclusively in adolescents. Fortunately, in accordance with guidelines, both fluoxetine and SSRI prescriptions have risen over recent years. Yet, there still remain a significant proportion of TCA prescriptions.

Recognition and management of children and adolescents with conduct disorder: a real-world data study from four western countries.

BACKGROUND: Conduct disorders (CD) are among the most frequent psychiatric disorders in children and adolescents, with an estimated worldwide prevalence in the community of 2-4%. Evidence-based psychological outpatient treatment leads to significant improvement in about two-thirds of cases. However, there seems to be considerable variation in rates of CD diagnoses and implementation of evidence-based interventions between nations. The aim of this study was to compare administrative prevalence and treatment patterns for CD in children and adolescents seen in health care systems across four Western countries (Denmark, Germany, Norway, and the USA). METHODS: Cross-sectional observational study using healthcare data to identify children and adolescents (aged 0-19 years) with an ICD-10 code for CD within the calendar year 2018. Within each country's study population, the prevalence of CD, psychiatric comorbidity, psychopharmacological treatment, and psychiatric hospitalisation was calculated. RESULTS: The prevalence of diagnosed CD differed 31-fold between countries: 0.1% (Denmark), 0.3% (Norway), 1.1% (USA) and 3.1% (Germany), with a male/female ratio of 2.0-2.5:1. The rate of psychiatric comorbidity ranged from 69.7 to 86.1%, with attention-deficit/hyperactivity disorder being most common. Between 4.0% (Germany) and 12.2% (USA) of youths with a CD diagnosis were prescribed antipsychotic medication, and 1.2% (Norway) to 12.5% (Germany) underwent psychiatric hospitalisation. CONCLUSION: Recognition and characteristics of youths diagnosed with CD varied greatly by country. In some countries, the administrative prevalence of diagnosed CD was markedly lower than the average estimated worldwide prevalence. This variation might reflect country-specific differences in CD prevalence, referral thresholds for mental health care, diagnostic tradition, and international variation in service organisation, CD recognition, and availability of treatment offers for youths with CD. The rather high rates of antipsychotic prescription and hospitalisation in some countries are remarkable, due to the lack of evidence for these therapeutic approaches. These findings stress the need of prioritising evidence-based treatment options in CD. Future research should focus on possible reasons for inter-country variation in recognition and management of CD, and also address possible differences in patient-level outcomes.

Prevalence, comorbidities and outpatient treatment of anorexia and bulimia nervosa in German children and adolescents.

OBJECTIVE: This study aimed at investigating the prevalence, psychiatric comorbidity and outpatient treatment in a sample of German children and adolescents with eating disorders (EDs). METHOD: Data of a large German statutory health insurance company were analysed and outpatients aged between 10 and 21 years with an ED diagnosis in 2009 were identified. RESULTS: Of 248,558 insured children and adolescents, 1,404 patients (79.9 % females, mean age: 16.7; SD: 3.3 years) matched the inclusion criteria. The large majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) were females (94.7 and 92.7 %), on which we focus in the following analyses. The prevalence in females was 0.28 % (AN) and 0.20 % (BN). Psychiatric comorbidity was diagnosed in 59.8 % (AN) and 64.1 % (BN) of patients, respectively. Most patients were treated with psychotherapy (AN: 75.7 %, BN: 78.5 %), 16.4 % (AN) and 20.2 % (BN) of our patients received pharmacotherapy with either antidepressants or antipsychotics. 23.5 % (AN) and 21.1 % (BN) received no treatment with psychotherapy, antidepressants or antipsychotics. DISCUSSION: This naturalistic study suggests that in young ED outpatients, EDs seem to be underdiagnosed and treatment does not necessarily comply with current guidelines. Therefore, dissemination of state-of-the-art knowledge on diagnosis and treatment in children and adolescents with EDs constitutes an important educational goal.

[Maintaining a comprehensive provision of inpatient child and adolescent mental health services in the years to come-a German perspective]. / Wie kann auch zukünftig eine gute stationäre Versorgung im Fachgebiet Kinder- und Jugendpsychiatrie gewährleistet werden? Ein Diskussionsbeitrag aus deutscher Perspektive.

BACKGROUND: A considerable number of child and adolescent psychiatry inpatient units in Germany suffer from a significant shortage of doctors, which endangers the current system of nation-wide availability of high-quality child and adolescent inpatient services. METHODS: Drawing on recent data, this article pictures the status quo of child and adolescent psychiatry inpatient services in Germany. The authors then discuss the pros and cons of different suggestions of how to cope with the doctor shortage crisis in child and adolescent psychiatry. RESULTS: The following options for action are suggested: reduction of service provision across the board, shift from personnel-intensive inpatient towards home-based treatment, trans-sectoral cooperation by means of tele-psychiatry, delegation of clinical responsibilities to psychologists, limiting ward physicians' tasks to mere medical care of patients, improvement of working conditions in inpatient units, recruitment of doctors from abroad, and increased recruiting efforts at medical school level. From the authors' viewpoint, the latter option offers the best chance of lasting success; however, this requires a long-term, nationwide approach and considerable efforts of all departments involved.

Characteristics and outcomes of cases with methylphenidate abuse, dependence or withdrawal: an analysis of spontaneous reports in EudraVigilance.

Methylphenidate (MPH) is a central nervous stimulant, which is mainly used in attention deficit hyperactivity disorder (ADHD) and narcolepsy. In recent years, rising MPH prescription volumes have drawn attention to possible misuse. We analyzed data on suspected MPH abuse, dependence or withdrawal reported to the EudraVigilance database (1996-2019), comparing case characteristics (e.g. age, indications and outcome). In 1531 cases from 35 countries (median: 29 years, 57.6% male), 42.3% had been diagnosed with ADHD and 8.0% with narcolepsy. Narcolepsy cases were older than ADHD cases (mean age: 47 vs. 22 years), and used co-medications more frequently (79.4 vs. 47.8%). Intravenous MPH administration was most common among individuals not diagnosed with ADHD or narcolepsy. A history of abuse, dependence or withdrawal of any substance was more often documented in fatal than in nonfatal cases (49.0 vs. 22.5%), whereas differences regarding the route of administration were less pronounced. Minors, who presumably received MPH for ADHD treatment, presented less frequently with serious outcomes than older cases or those without an approved indication. Prescribers should exercise caution in adult MPH users and should make a thorough co-medication assessment. Finally, more research on substance abuse in narcolepsy patients is required, which should include comorbidities and co-medication.

Secure attachment predicts lower societal cost amongst severely antisocial adolescents.

BACKGROUND: Social and economic costs associated with antisocial behaviour are well-established, but little is known about the potential costs savings/benefits of secure attachment in this high-risk group. We aimed to provide the first test of attachment quality as a distinct predictor of economic costs. METHODS: 111 adolescents (10-17 years of age, M = 15.0, SD = 1.6; 71% male) referred to young offender services due to high levels of antisocial behaviour were included. Costs were measured by detailed service-use interview, and attachment security to mother and father elicited through the Child Attachment Interview. The level of antisocial behaviour and callous-unemotional traits were assessed. Cost predictors were calculated using generalised linear models. RESULTS: Mean 12-months service costs were £5,368 (sd 5,769) per adolescent, with justice system and educational service costs being the main components. After adjusting for covariates, economic costs were predicted by attachment quality to fathers, with a difference of £2,655 per year between those with secure (£3,338) versus insecure attachment (£5,993); significant cost effects were not found for attachment quality to mothers. Higher levels of callous-unemotional traits, lower verbal IQ, higher levels of antisocial behaviour, and older age were also significant cost predictors. CONCLUSIONS: Secure attachment to fathers is a predictor of reduced public cost in adolescents with severe antisocial behaviour. This novel finding for severely antisocial youth extends previous findings in less antisocial children and underscores the public health and policy benefits of good caregiving quality and the value of population-level dissemination of evidence-based interventions that improve caregiving quality.

Trends in antipsychotic use among children and adolescents in Germany: a study using 2011-2020 nationwide outpatient claims data.

Introduction: We aimed to provide an update on trends in antipsychotic (AP) use among children and adolescents in Germany. Materials and methods: Based on nationwide outpatient claims data from Germany, we conducted a cross-sectional study. For each year from 2011 to 2020, we determined the prevalence of AP use, defined as the proportion of children and adolescents with at least one AP dispensation. We evaluated trends in AP use by age, sex, and AP class (typical vs. atypical). Additionally, we assessed trends in the specialty of AP prescribers and the frequency of psychiatric diagnoses among AP users. Results: Overall, data from more than 12 million children and adolescents were included for each calendar year (2011: 12,488,827; 2020: 13,330,836). From 2011 to 2020, the overall prevalence of pediatric AP use increased from 3.16 to 3.65 per 1,000, due to an increase in use of both typical APs (from 1.16 to 1.35 per 1,000) and atypical APs (from 2.35 to 2.75 per 1,000). The largest increase in AP use was found among 15- to 19-year-old females, with an increase from 3.88 per 1,000 in 2011 to 7.86 per 1,000 in 2020 (+103%), mainly due to rising quetiapine use (from 1.17 to 3.46 per 1,000). Regarding prescribers' specialty, the proportion of APs prescribed by child and adolescent psychiatrists increased during the studied period (2011: 24.8%; 2020: 36.4%), whereas prescriptions by pediatricians (2011: 26.0%; 2020: 19.9%) and general practitioners (2011: 18.0%; 2020: 12.4%) decreased. Risperidone was the most commonly used AP in males, and quetiapine was the leading AP in females, each with the highest prevalence in 15- to 19-year-olds. In male risperidone users in this age group, the most frequent diagnosis was attention-deficit/hyperactivity disorder (50.4%), while in female quetiapine users it was depression (82.0%). Discussion: Use of APs among children and adolescents in Germany has continued to increase over the last decade. The sharp increase in AP use among 15- to 19-year-old females, which is largely due to an increased use of quetiapine, is remarkable. Potential reasons for this increase-e.g., limited access to psychosocial treatments-should be carefully analyzed. Also, the introduction of more restrictive prescribing guidelines might be considered.

Which treatments do children with newly diagnosed non-organic urinary incontinence receive? An analysis of 3,188 outpatient cases from Germany.

AIMS: Objectives of this study were to examine the administrative incidence of urinary incontinence in children and to assess related outpatient health services utilization in this cohort. METHODS: Data of a statutory health insurance company were analyzed and outpatients from 1 to 18 years of age with a first recorded ICD-10 code for non-organic urinary incontinence during a 1-year-period (2007) were identified. For this cohort, the prescription of desmopressin, antispasmodics, non-selective monoamine reuptake inhibitors, alarm devices, and incontinence pads in the quarter of the first diagnosis and in the following one (i.e., 6 months) was evaluated with respect to age and gender. RESULTS: 3,188 patients (59.4% male; mean age 6.8 years) matched the inclusion criteria, of whom 25.4% were under 5 years old. 7.9% were prescribed desmopressin, 7.4% received urinary antispasmodics, and 7.0% were treated with alarm devices. For 77.9% of patients, no specific incontinence-related treatments were prescribed. We found considerable differences in treatment patterns between age groups, with patients ≥ 7 years receiving desmopressin more frequently than alarm devices. Regarding gender differences, the proportion of males treated with alarm devices (prevalence ratio [PR] 1.46; 95% confidence interval [95%CI] 1.11-1.92) and at least one specific treatment (PR 1.19; 95%CI 1.04-1.35) remained statistically significantly higher, even after adjusting for age. CONCLUSIONS: In our study, we found evidence that treatment modalities only partly comply with the current guidelines for treatment of children and adolescents with non-organic urinary incontinence. Therefore, the dissemination of current guidelines remains a major educational goal.

Outpatient treatment in German adolescents with depression: an analysis of nationwide health insurance data.

PURPOSE: Data on medical treatment of adolescents with depression are scarce. This study aimed to examine outpatient health services utilisation of depressive disorders in adolescents. METHODS: Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years old with diagnosed depression during a 1-year period (2009) were identified. For this cohort, the prescription of antidepressants and psychotherapy was evaluated with respect to age and sex. RESULTS: A total of 4295 patients (41.2% males; mean age, 15.5 years) matched the inclusion criteria. Of the patients, 29.7% consulted a child and adolescent psychiatrist. A total of 59.6% were treated with psychotherapy only, 9.6% were treated with a combination of psychotherapy and antidepressants, and 1.9% received only antidepressants. For 28.8% of patients, no specific depression-related treatment was prescribed. A total of 1357 packages of antidepressants were analysed, of which fluoxetine (24.4% of prescriptions), citalopram (14.0%), and mirtazapine (9.7%) were the most frequently prescribed substances. Regarding substance classes, selective serotonin reuptake inhibitors (SSRIs; 55.6%), tricyclic antidepressants (TCAs; 17.9%), and hypericum (St. John's wort; 8.5%) were most common. CONCLUSIONS: Although the underlying data were coded for insurance purposes, which might result in some data impreciseness, this naturalistic study furnishes evidence that outpatient treatment of adolescents with depressive disorders in Germany only partly complies with guideline recommendations for first-line treatment: Although the prescriptions of SSRI for adolescent depression have risen over recent years, still, a quarter of antidepressant prescriptions for adolescents with depression were TCA or hypericum. Therefore, dissemination of knowledge on state-of-the-art treatment for adolescent depression remains a major educational goal.

Prevalence and comorbidities of adolescent depression in Germany. An analysis of Health Insurance Data.

OBJECTIVE: Data on the prevalence of depressive disorders in adolescents are scarce. We aimed to examine the administrative prevalence of depressive disorders and related comorbidities in German adolescents. A second objective of was to assess potential regional (East vs. West Germany) differences in depression prevalence. METHOD: Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years of age with diagnosed depression during a one-year-period (2009) were identified. RESULTS: The population at risk consisted of 140,563 adolescents. Of these, 4,295 (41.2% male; mean age: 15.5 years) had a diagnosis of depression. This equates to a prevalence of 3.1% (females: 3.7%, males: 2.5%). There were no significant differences between East and West Germany. Of all adolescents with depression, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%) and posttraumatic stress disorder (10.0%) being most frequently diagnosed. CONCLUSIONS: The depression prevalence in this sample was lower than that in studies of clinical samples. There was a marked prevalence of psychiatric comorbidities, especially of internalizing disorders. In adolescents, the risk of depression seems to be comparable in both East and West Germany.

Subjective and biological weight-related parameters in adolescents and young adults with schizophrenia spectrum disorder under clozapine or olanzapine treatment.

OBJECTIVE: Administration of atypical antipsychotics often induces significant weight gain and metabolic changes. Little is known about subjective weight-related parameters in adolescent patients. Therefore, this cross-sectional, explorative study aimed to assess these parameters and their relationship with biological weight-related parameters. METHOD: 74 patients (mean age: 19.9 [SD ± 2.3] years; 66.2% male) with schizophrenia under clozapine or olanzapine treatment were examined. Subjective well-being, eating behavior, body perception and social functioning were assessed, using the Three-Factor-Eating-Questionnaire, FKB-20 Body Perception Questionnaire, Subjective Well-being under Neuroleptics, Short Form and Global Assessment of Functioning. Patients' biological weight-related parameters were measured as well. Gender differences as well as associations between subjective and biological weight-related parameters were evaluated. RESULTS: Female patients reported significantly worse negative body appraisal and physical functioning than males. An elevated BMI was associated with impaired physical functioning in females and with negative body appraisal and hunger in males. CONCLUSIONS: In our sample of young patients with schizophrenia unter treatment with atypical antipsychotics, an elevated BMI was associated with impaired physical functioning and negative body appraisal, respectively. Bearing in mind the high risk of obesity in this population, the mentioned impairments should be accounted for, especially in terms of compliance and quality of life.

[What do medical students expect of lectures in child and adolescent psychiatry?]. / Was erwarten medizinstudierende von vorlesungen in der kinder- und jugendpsychiatrie?

OBJECTIVE: In child and adolescent psychiatry (CAP) lectures are the most common teaching format for medical students. Besides conveying basic knowledge and skills related to the medical management of children and adolescents with mental health problems, lectures also play a decisive role in the recruitment of future residents for this discipline. Thus, knowledge of the expectations of medical students of lectures is a crucial factor. METHOD: 1,029 medical students at ten German medical schools were surveyed with a questionnaire in a cross-sectional design. RESULTS: Items perceived as most important were knowledge of disorders (73 %), medical skills in handling children and adolescents (61 %), and differential diagnosis of normal and abnormal child behaviour in children and adolescents (59 %). 71 % set a high value on patient presentation, while 41 % expressed ethical concerns about presenting mentally ill minors in lectures. CONCLUSIONS: The expectations of medical students toward CAP lectures are mainly related to the transfer of specialty-related knowledge and generic skills. The important area of teaching attitudes could best be covered via patient presentations, which are desired by most students. However, ethical concerns over patient presentation also need to be discussed with students.