Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial.

Importance: Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment. Objective: To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation. Design, Setting, and Participants: This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools. Interventions: In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9. Main Outcomes and Measures: The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. Results: A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity. Conclusions and Relevance: In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern. Trial Registration: ClinicalTrials.gov identifier: NCT03716869.

Manifestaciones somáticas en un grupo de adolescentes con ansiedad / Somatic manifestations in a group of adolescents with anxiety disorders

INTRODUCCIÓN: la ansiedad es el síntoma psiquiátrico más prevalente en la sociedad moderna, también en la infancia y adolescencia. OBJETIVO: caracterizar un grupo de adolescentes ansiosos, la intensidad de la ansiedad, las manifestaciones clínicas y las áreas de conflictos. MÉTODOS: se realizó un estudio descriptivo con técnicas cuanti-cualitativas en 30 adolescentes entre 11 y 16 años de edad, con ansiedad de más de 6 meses de evolución, seleccionado aleatoriamente, que dieron el consentimiento para ser incluidos en el estudio. Fueron atendidos por Psiquiatría Infantil del Hospital Pediátrico Universitario Centro Habana, entre enero y junio del año 2014. Las variables estudiadas fueron: edad, sexo, intensidad de la ansiedad, manifestaciones clínicas y áreas de conflictos. Se realizó historia social psiquiátrica, examen psiquiátrico, entrevista psicológica, test IDAREN y de Frases Incompletas de Rotter. RESULTADOS: 77 % tienen entre 11 y 14 años, 73 % es del sexo femenino, con nivel medio y alto para la ansiedad-estado (97 %) y ansiedad-rasgo del 83 %; predominaron las manifestaciones somáticas, como trastornos del sueño (83 %), hiperactividad-excitación (80 %), síntomas cardíacos (77 %), salto epigástrico (70 %), dolor abdominal (63 %) y sudoración (53 %); y las psicológicas, como inseguridad (70 %), sensación de amenaza (67 %), dificultad en la concentración y la memoria (63 %), sentimientos negativos (60 %) e irritabilidad (53 %). El 83 % tenía conflictos en área familiar, 70 % en las relaciones sociales, y 50 % en área escolar. CONCLUSIONES: predominan el sexo femenino, las edades entre 11 y 14 años, con niveles medio y alto para ansiedad-estado y ansiedad-rasgo, así como los síntomas somáticos de ansiedad y conflictos en el área familiar.

INTRODUCTION: anxiety is the most prevailing psychiatric symptom in the modern society and also in childhood and adolescence. Objective: to characterize a group of anxious adolescence, the intensity of anxiety, the clinical manifestations and the areas of conflict. METHODS: a descriptive study based on quantitative and qualitative techniques was performed in 30 adolescents aged 11 to 16 years, who presented anxiety disorders for over 6 months and randomly selected after giving their consent to be included in the study. These patients had been seen at the infantile psychiatry service of the university pediatric hospital Centro Habana from January to June 2014. The studied variables were: age, sex, intensity of anxiety, clinical manifestations and areas of conflicts. A psychiatric social history, psychiatric exam, psychological interview, IDAREN test and Rotter's incomplete phrase test were all applied. RESULTS: in the study group, 77 % were 11 to 14 years, 73 % were females, with middle and high level for anxiety-state (97 %) and anxiety-trait (83 %); somatic manifestations such as sleep disorders (83 %), hyperactivity-excitement (80 %), heart symptoms (77 %), epigastric_beat (70 %), stomachache (63 %), sweating (53 %), and psychological manifestations as insecurity (70 %), feeling of being threatened (67 %), difficult concentration and memorization (63 %), negative feelings (60 %) and irritability (53 %) predominated. Eighty three percent of them faced conflicts in their family setting, 70 % with their social relationships and 50 % at the school area. CONCLUSIONS: females, 11-14 years of age, middle and high levels for anxiety-state and anxiety-trait, somatic symptoms of anxiety and conflicts in the family setting are predominant.

Annual Research Review: Discovery science strategies in studies of the pathophysiology of child and adolescent psychiatric disorders--promises and limitations.

BACKGROUND: Psychiatric science remains descriptive, with a categorical nosology intended to enhance interobserver reliability. Increased awareness of the mismatch between categorical classifications and the complexity of biological systems drives the search for novel frameworks including discovery science in Big Data. In this review, we provide an overview of incipient approaches, primarily focused on classically categorical diagnoses such as schizophrenia (SZ), autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD), but also reference convincing, if focal, advances in cancer biology, to describe the challenges of Big Data and discovery science, and outline approaches being formulated to overcome existing obstacles. FINDINGS: A paradigm shift from categorical diagnoses to a domain/structure-based nosology and from linear causal chains to complex causal network models of brain-behavior relationship is ongoing. This (r)evolution involves appreciating the complexity, dimensionality, and heterogeneity of neuropsychiatric data collected from multiple sources ('broad' data) along with data obtained at multiple levels of analysis, ranging from genes to molecules, cells, circuits, and behaviors ('deep' data). Both of these types of Big Data landscapes require the use and development of robust and powerful informatics and statistical approaches. Thus, we describe Big Data analysis pipelines and the promise and potential limitations in using Big Data approaches to study psychiatric disorders. CONCLUSIONS: We highlight key resources available for psychopathological studies and call for the application and development of Big Data approaches to dissect the causes and mechanisms of neuropsychiatric disorders and identify corresponding biomarkers for early diagnosis.

Screening for depression in adolescents: validity of the patient health questionnaire in pediatric care.

BACKGROUND: This study examines the criterion validity of the Patient Health Questionnaire 9-item (PHQ-9) and 2-item (PHQ-2) version as a depression-screening instrument for adolescents. METHODS: Three hundred twenty-two adolescents aged 13-16 were recruited from pediatric hospitals. Criterion validity of the PHQ-9 and PHQ-2 was assessed against diagnoses of any depressive disorder provided by a structured diagnostic interview. Areas under the receiver operating characteristics curve (AUCs) and sensitivities and specificities at optimal cutoff points were computed for both versions of the PHQ. Besides the dimensional algorithm, a categorical algorithm was applied for the PHQ-9. Validity measures of both scoring procedures of the PHQ-9 as well as PHQ-2 were compared statistically. In addition, unaided clinical depression diagnoses by the attending pediatricians were evaluated. RESULTS: Using the dimensional algorithm, the AUCof the PHQ-9 (93.2%) was significantly higher than that of the PHQ-2 (87.2%). At optimal cutoffs, there was no significant difference in sensitivity (PHQ-9: 90.0%, PHQ-2: 85.0%), but in specificity (PHQ-9: 86.5%, PHQ-2: 79.4%). Although the categorical algorithm of the PHQ-9 was most specific (94.7%), sensitivity was just above chance (52.5%). The unaided clinical diagnoses yielded a sensitivity of 12.5% and a specificity of 96.0%. CONCLUSIONS: The dimensional algorithm of the PHQ-9 demonstrated high criterion validity, whereas the categorical algorithm should not be applied due to its low sensitivity. Even though the PHQ-2 performed well, validity of the PHQ-9 was still superior. Hence, the PHQ-9 can be recommended as depression screener for adolescents to improve recognition rates in pediatric care.

Calidad de vida en pacientes adolescentes con epilepsia en México / Quality of life in adolescent patients with epilepsy in Mexico

Antecedentes. La epilepsia afecta todas las áreas en la vida del niño que la padece. Hay pocos estudios al respecto en poblaciones latinoamericanas. Nuestro objetivo fue evaluar la calidad de vida de los pacientes adolescentes con epilepsia con el uso del cuestionario QOLIE-31 en un hospital de tercer nivel de atención, así como identificar los factores que influyen en la misma. Pacientes y métodos. Un total de 60 pacientes adolescentes entre 12 y 17 años de la consulta externa de neurología pediátrica del Hospital Infantil “Federico Gómez” cumplió los criterios de inclusión. Se les aplicó el cuestionario QOLIE-31 entre septiembre 2008 a mayo 2009. Resultados: El 58.3% de los pacientes reportó una mala calidad de vida y solo 6.7% muy buena calidad de vida, siendo más afectados la calidad de vida en general (98.3%) y la función cognitiva (65%). Un factor muy influyente fue el antecedente de epilepsia parcial y el uso de politerapia antiepiléptica. Conclusión. La calidad de vida en los adolescentes estudiados está muy afectada por la ocurrencia de epilepsias parciales, el inicio temprano y el uso de politerapia. Se requiere un programa de atención integral con más información sobre la enfermedad...

Hypnotherapy in child psychiatry: the state of the art.

Children are more easily hypnotized than adults, and hypnotherapy as a method responds to the general developmental needs of children by addressing their ability for fantasy and imagination. Hypnotherapy and self-hypnosis are tools with which to assess and develop protective factors, and enhance positive adjustment. Meta-analyses and overviews have demonstrated the effect of hypnotherapy in paediatric disorders like asthma, chronic and acute pain, and in procedure-related distress in cancer patients. We wanted to examine the use and benefits of hypnotherapy when applied to child psychiatric disorders. A review of a literature search from PubMed, PsychINFO and the Cochrane databases revealed 60 publications, mostly case reports based on 2-60 cases, addressing the use of hypnotherapy in various child psychiatric conditions. Findings indicate that hypnotherapy may be useful for a wide range of disorders and problems, and may be particularly valuable in the treatment of anxiety disorders and trauma-related conditions. In conclusion, knowledge of hypnosis is useful in clinical practice and hypnotherapy may play an important role as an adjunctive therapy in cognitive-behavioural treatment and family therapy. Additional qualitative and quantitative studies are needed to assess the place for hypnosis/hypnotherapy in child psychiatry.

Child and adolescent psychiatrists' practices in assisting their adolescent patients who smoke to quit smoking.

OBJECTIVE: This national study examined the practices and perceptions of smoking cessation activities among child and adolescent psychiatrists. METHOD: A random sample of child and adolescent psychiatrists was identified from the membership list of the American Academy of Child and Adolescent Psychiatry and was mailed a valid and reliable 34-item questionnaire. RESULTS: A total of 184 responses (47%) were received. A plurality (48%) of psychiatrists reported being self-taught in smoking cessation techniques. A majority (67%) of psychiatrists were in the maintenance stage for asking about smoking status. However, only 19% consistently made attempts to assess willingness to quit, and 30% consistently gave messages urging the smoker to quit. The perceived number of barriers for addressing smoking was negatively correlated with psychiatrists' levels of confidence (r = -0.35, p <.001) and preparedness (r = -0.39, p <.001) in addressing smoking cessation. Estimations by the psychiatrists of youths who smoked were 61% of those with conduct disorders, 46% of those with schizophrenia, and 40% of those with attention-deficit/hyperactivity disorder. CONCLUSION: Considering the perceived high rate of patient smoking and the lack of formal training in smoking cessation, more postgraduate education is needed to adequately prepare child and adolescent psychiatrists for addressing tobacco cessation.

[Age-appropriate communication and screening for exploratory behaviour during adolescence]. / Umgang mit jugendlichen Patienten zur Erfassung von Noxen in der Adoleszenz.

Age-appropriate communication style is a core condition in order to screen successfully for exploratory behaviours during adolescence. To offer the adolescent patient to see the doctor alone for some time and to provide assurance of confidentiality even with regard to their parents enhances the doctor-patient relationship and enables the communication about personal issues such as the consumption of psychoactive substances and other potentially harmful behaviours. In order to assure confidentiality even with regard to the adolescent's parents, an evaluation of the adolescent patient's rights for minor consent as well as the potential risk for self-harm and / or homicide has to be performed. Age-appropriate communication that includes conversation about psychoactive drugs and other harmful behaviours has the potential to improve the adolescents' health substantially.

Transparent criteria for specialist level adolescent psychiatric care.

BACKGROUND: Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0-100, with 50 as an entry threshold. OBJECTIVE: To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. METHOD: Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. RESULTS: Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. CONCLUSION: The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.

Comportamiento del intento suicida en un grupo de adolescentes y jóvenes / Attempted suicide in a group of adolescents and young people

Se realizó un estudio descriptivo de 80 pacientes que realizaron intento suicida en el período comprendido de enero de 1997 a diciembre del 2000, ingresados en el Servicio de Psiquiatría del Hospital Militar ôDr. Octavio de la Concepción y de la Pedrajaö. Predominó el grupo de edad de 17 a 23 años. El perfil psicopatológico destacó los síntomas de ansiedad, ideación suicida, tristeza e insomnio. El perfil de personalidad obtenido con la aplicación del 16 PF permitió caracterizar al grupo como emotivos con poca estabilidad emocional, inseguros, aprensivos, angustiados, tensos, frustrados, agobiados con niveles altos de ansiedad. La intoxicación por psicofármacos fue el método más empleado por los pacientes. La incidencia de antecedentes familiares de intento suicida y trastornos psiquiátricos fue alta. Dentro de las enfermedades psiquiátricas predominaron los trastornos situacionales depresivos y ansiosos

Análisis neuropsicológico de las características cognoscitivas de un grupo de adolescentes con trastorno por déficit de atención / Neuropsychological analysis of the cognitive characteristics of a group of teenagers with attention deficit disorder

De acuerdo con la literatura, es poco lo que se sabe sobre las características neuropsicológicas de los pacientes con trastorno por déficit de atención (TDA). La tendencia actual de la investigación se ha centrado en el estudio del funcionamiento ejecutivo, sin tomar en cuenta otros aspectos de la cognición. En este estudio se evaluaron, en un sentido más amplio, las habilidades cognoscitivas de un grupo de 30 pacientes adolescentes con TDA (media de edad = 17.1; DE = 2.1) por medio de la Escala de Inteligencia para Adultos de Wechsler (WAIS) y de la Figura Compleja de Rey. Se buscó analizar comparativamente las distintas funciones implicadas en la solución de problemas y generar un modelo que explicara las interrelaciones de las características cognoscitivas del grupo. Los pacientes obtuvieron un C.I. total promedio dentro del rango normal(media = 102.3, DE = 7.5), sin discrepancias significativas entre los valores de C.I. verbal y de ejecución. El análisis factorial de las 11 subescalas del WAIS generó 4 factores que explican el 74.1 por ciento de la varianza total, dos de los cuales correlacionaron significativamente con el valor del C.I. total. También se efectuó una análisis de trayectorias por medio de regresión lineal múltiple para establecer el modelo hipotético que se deseaba comprobar y un análisis estructural con el programa AMOS. El modelo obtenido presentó un buen porcentaje de ajuste con los datos empíricos (78.9 por ciento; con un error de 0.067). En la Figura Compleja de Rey, tanto el puntaje del ensayo de copia, como el del ensayo de memoria, se ubicó significativamente por debajo de los parámetros establecidos para la media de la población. Se concluye que el valor del C.I. del WAIS no discrimina al grupo de pacientes, pero sí las interrelaciones que guardan entre sí las distintas subescalas. También se encontraron defectos significativos en la habilidad gráfica que, al igual que los trastornos en el funcionamiento ejecutivo, pueden ser característicos de este tipo de pacientes, apoyando, a la vez, la hipótesis del compromiso en el funcionamiento del hemisferio cerebral derecho en el TDA.