The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.
Autism Spectrum Disorder , Child , Humans , Autism Spectrum Disorder/drug therapy , Autism Spectrum Disorder/psychology , Off-Label Use , Prevalence
AIMS: To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults. BACKGROUND: Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013. METHOD: This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice. RESULTS: Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered. CONCLUSIONS: Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.
Over the years, there have been numerous studies linking acne to depression and suicidal thoughts. Although the exact relationship between the two is still unclear, the stigma associated with acne can have a significant impact on an individual's mental health. The critical appraisal of empirical evidence reveals a lack of understanding of the relationship between acne and suicide. Several studies have demonstrated an association between acne and suicide without causal links. Thus, it is clinically important to review the risks associated with isotretinoin and obtain informed consent regarding potential harm. The use of isotretinoin should be limited to cases of severe acne. There have been reports of an increased risk of suicide six months after the completion of isotretinoin treatment, so it is recommended that follow-up monitoring continue for up to one year following the completion of the treatment.
Objective To study the etiological profile of pediatric headaches (PH) in a tertiary child neurology clinic and to determine the utility of diagnostics, interventions, and long-term prognosis. Methods Children (ages 4-15) observed over four years were recruited retrospectively. In primary headaches, the headache frequency and impact on quality of life (QOL) parameters at pre-treatment (T1) were compared post-treatment at follow-up (T2). Results Of the 311 eligible patients, 285 had primary headaches (Tension-Type Headache {TTH}: 156; Migraine: 129), and 26 had secondary headaches. The mean (±SD) onset age was 10 (±3) years with a male-to-female ratio of 2.3:1. Migraine was more common in children aged less than seven years (17/28) and TTH in older patients (146/283). The most common causes of secondary headache were intracranial hypertension (ICH) in 11/26 patients (four idiopathic intracranial hypertension (IIH), four following aseptic meningitis, three with cortical vein thrombosis), and ophthalmologic causes in 7/26 (of these five had convergence insufficiency). Hypertension was a rare cause of secondary headaches (2/26 patients). Neuroimaging was performed in 173/311 (56%), primarily for parental anxiety (160/173; 92%), and was abnormal in only four. At T2 (Median time to follow-up: 29 months; Interquartile range: 22-37 months), data were collected in 207/285 patients with primary headaches (TTH: 109; Migraine: 98). In both migraine and TTH groups, there were statistically significant reductions (p-value <0.0001) in headache frequency and QOL parameters. Conclusion In our study, TTH was the most common cause of PH. Neuroimaging was normal in most cases. Psychological interventions were effective but underutilized. The symptoms of primary headaches improved significantly over time, despite poor adherence to prophylactic medications.
As a type of psychotherapy, play therapy entails using play and creative activities as a means to help children express their thoughts and emotions, and to work through their challenges. A wide range of issues can be addressed through play therapy, including behavioral issues, anxiety, depression, trauma, and difficulties in relationships. Through this case report, we aim to discuss the history and evolution of play therapy concepts. We will review the core principles of child-centered therapy (CCT), non-directive child-centered play (NDCCP), and cognitive behavior play therapy. We will discuss clinically helpful approaches and the evidence supporting the efficacy of play therapy in anxiety, depression, trauma, and other behavioral difficulties in children.
The systemic oppression of women and gender-based discrimination has deep roots in human civilization. As evident in both written texts and widespread practices, conscious and unconscious biases associated with patriarchy have been and continue to be interlaced with power struggles, control, and conformity enforced by the male-dominant cultures of the time. Brought into bold relief in this pandemic, recent dramatic events (the tragic murder of George Floyd and the overturning of Roe v. Wade, for example) have heightened social outrage against bias, racism, and bigotry and have also brought us to an inflection point demanding our better understanding of the pernicious and long-term mental health effects of patriarchy. There are compelling grounds to further expand their construct, but efforts to do so in psychiatric phenomenology have, until now, failed to gain momentum and substantive attention. The resistance may in part lie in misconceptions that patriarchy is supported by archetypal endowments of the collective unconscious constitutive of shared societal beliefs. While many continue to live with the adverse experiences associated with patriarchy within the current times, critics have argued that our concepts about patriarchy are not empirical enough. Empirically supported deconstruction is necessary to debunk misinformed notions that undermine women's equality.
Borderline personality disorder (BPD) has seen significant advances in the knowledge of its developmental phenomenology during late childhood and adolescence. Various genetic, neurobiological, psychological, and social factors are implicated in the etiology of BPD. With emerging evidence on BPD development in adolescence, the review focused on recent literature to understand the role of psychosocial risk factors. The effects of adverse familial environment, physical, emotional, verbal, and sexual abuse, intergenerational transmission of psychopathological traits, maternal neglect and rejection, low socioeconomic status, bullying victimization, and dating violence were reviewed to understand their role in the development of BPD. BPD is a highly complex, serious, and enduring mental illness that has now been widely accepted to have symptoms that onset in early adolescence and could be diagnosed as early as age 12. BPD symptoms are stable, phenomenologically distinct from externalizing and internalizing disorders, and often present with co-occurring disorders, which during assessment could not explain impairments associated with BPD. New measures like the Difficulties in Emotion Regulation Scale (DERS), detailed developmental histories, understanding of psychosocial risks, shared decision-making, and psychoeducation could assist in early diagnosis and improvement of long-term outcomes. The implementation of evidence-based treatments is a challenge given higher costs and access to services; therefore, modifications in the treatment based on the core principles of these strategies should be considered. It is imperative to screen for psychosocial factors early in higher-risk groups. The assessment of familial factors, parental histories of psychopathologies, and histories of childhood abuse is important in context with impairing symptoms of clinical presentation and dimensional aspects of self-functioning. The role of family therapies, parental psychoeducation, and the integration of trauma-informed care approaches are important for clinical outcomes. Also, coordinated efforts with multiple stakeholders like school awareness programs, anti-bullying policies, legislation, and enforcement of existing laws might be instrumental in addressing issues related to victimization by peers.
Mental health conditions have been linked closely to an imbalance of microbiota in the gut, leading to disruption of the microbiome (dysbiosis). Several neurotransmitters, such as GABA (gamma-aminobutyric acid), serotonin, and glutamate, are produced in the gut, which are associated with anxiety and depressive symptoms. Mental health and the gut have been linked closely, and many mental illnesses have been associated with gut dysbiosis. Probiotics are marketed to improve gut health, act as mood enhancers, and be effective in reducing stress as unregulated over-the-counter supplements. Given healthcare disparities and patient-doctor gaps across the globe, this review aims to appraise the literature on probiotics for the prevention and treatment of mental disorders. PubMed and Google Scholar databases were searched till March 2023 using the MeSH words "prebiotics," "probiotics," "synbiotics," and "psychobiotics." Out of 207 studies, 26 studies met the inclusion criteria and were included in the review. Studies suggest probiotics could be an effective and economical adjunct therapy; however, due to weak study design and low power, the results are inconclusive. Their use is not without risks, and healthcare providers need close supervision until more robust longitudinal studies are conducted to appraise their efficacy and safety profiles.
Diagnostic overshadowing (DO) is identified as a contributor to the missed diagnosis of individuals with an autism spectrum disorder (ASD). It has been used predominantly in the scientific literature and clinical settings to describe a phenomenon where a person's symptoms and behaviors are attributed solely to their primary diagnosis, rather than being recognized due to co-occurring conditions. DO is seen across many developmental disorders; however, females with autism may have a more difficult time getting diagnosed than males with autism because traditional diagnostic criteria for autism are often based on research that has primarily focused on males with autism. Likewise, the efficacy of approved psychopharmacological like selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) in individuals with ASD is not well established. Amidst these challenges, it's imperative to underscore the need for screening these disorders and provide informed evidence-based treatment alternatives for shared decision-making. Mirtazapine has low but promising findings, though modified CBT has superior empirical support in the treatment of co-occurring conditions associated with ASD.
Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.
The aim of this systematic review is to appraise the current evidence on the efficacy and safety of buspirone in core symptoms of autism spectrum disorder (ASD), co-occurring anxiety, and other associated symptoms. Major medical literature databases were searched for randomized controlled trials (RCTs), open-label trials, and any other relevant studies or clinical trials reporting on pediatric (age < 18 years) patients with ASD treated with buspirone for any reason. A total of 310 abstracts were screened, and six clinical trials were selected for inclusion. Out of these six clinical trials, two were RCTs (n =166 and 40), two open-label trials (n= 26 and 4), and one cross-over study (n = 1). We also included one retrospective chart review (n=31). Meta-analysis was not performed due to a lack of homogeneity in the two RCTs. Although most of the studies reported improved overall symptoms, they had different outcome measures. The quality of evidence available is low, and there is a need for higher-power studies in the future. Most studies suggested that buspirone was well tolerated and safe in pediatric patients with ASD. Based on the data, there is insufficient evidence to make conclusive recommendations on buspirone for improvement in core symptoms of ASD or cooccurring anxiety, irritability, or hyperactivity symptoms in the pediatric population. Given there are limited approved therapies for co-occurring anxiety, buspirone could be used as a safe off-label option due to the lack of behavioral activation and any serious adverse reactions.
Parkinson's disease (PD) is a complex neurodegenerative disorder with heterogeneous clinical presentations. Given the ambiguity of its overlapping symptomatology and concomitant atypical motor and neuropsychological symptoms its early diagnosis is clinically challenging. It is often missed since low mood, anhedonia, lack of motivation, and psychomotor retardation are commonly reported in individuals with PD. When alexithymia is the predominant symptom, the knowledge to discriminate between apathy, anhedonia, and alexithymia is critical to avoid misdiagnosis.
Anti-Anxiety Agents , Autistic Disorder , Humans , Buspirone/therapeutic use , Autistic Disorder/complications , Autistic Disorder/drug therapy , Anxiety Disorders/complications , Anxiety Disorders/drug therapy , Anxiety Disorders/epidemiology , Anxiety/complications , Anxiety/drug therapy , Comorbidity , Anti-Anxiety Agents/therapeutic use , Double-Blind Method
Cyproheptadine is a widely prescribed first-generation antihistamine, and due to its unique chemical structure, it has a popular off-label choice for a range of clinical conditions. Its efficacy is widely debated in the literature, but there are reports of hepatotoxicity as a rare adverse effect. Its benefits in migraine prophylaxis and appetite stimulation also underscore a highly overlapping clinical pathway that requires additional assessment and evaluation. The evidence suggests a baseline metabolic profile before initiation and assessment for co-occurring mental health conditions may improve overall response with evidence-based mental health interventions.
Bullying is an omnipresent problem with high prevalence in children and adolescents. There are many antibullying state laws and practices in place however its real level impact is ambiguous at best. We studied the prevalence of bullying in the United States, examine the practices, laws, and interventions in place to prevent bullying and its real-life impact. Various studies have reported that the ground-level change brought about by these policies and programs varies and is not quite significant. The effectiveness of existing policies and legislations remains unclear and measurable objective change or impact is not yet observed. Therefore, a rethink of the strategies is needed. The focus must be on community-level programs and interventions with inclusive approaches involving all the stakeholders are critical for addressing this menace.
Bullying , Child , Adolescent , Humans , United States/epidemiology , Bullying/prevention & control , Policy
The rural areas have been at the receiving end amidst mental health disparity across the USA. There is a serious and concerning divide among ones with autism spectrum disorders (ASDs) living in underserved areas as compared to urban residents. With the higher than ever prevalence of ASD as per the recent reports of the Centers for Disease Control and Prevention; there is a need for a closer look at the prevailing issues. The trends are reflecting marked underdiagnosis, late diagnosis, lack of evidence-based diagnostic measures and interventions. These factors interplay in worsening the mental health crisis and there is an urgent need for corrective measures to address these highly modifiable problems.
Autism Spectrum Disorder , Autistic Disorder , Humans , Public Health , Autism Spectrum Disorder/diagnosis , Autism Spectrum Disorder/epidemiology , Prevalence
Epidemiological trends in global suicides have been of serious concern in the last decade. The burden of higher expectations in the assessment of suicidal behaviors on mental health professionals is mounting. However, the suicidal risk assessment has many evolving and moving parts, and is one of the most heavily researched fields in psychiatry. Although it is clear from current empirical research that suicide cannot accurately be predicted, the standard of care from regulatory bodies and professional organizations dictates the use of established measures and following consensus guidelines. However, the legal system has different parameters to assess for the deviation from these standards and views it from a different vantage point. Therefore, it is imperative to know these critical multifaceted panoramas of suicide assessment. Considering the gaps within suicide risk assessment tools, we propose that appropriate documentation and thorough treatment planning are key to navigating the complex medicolegal risks. These approaches are useful for risk management and improve clinical outcomes, quality of care, and overall patient safety.
Psychiatry , Suicide , Humans , Risk Management , Suicidal Ideation , Consensus
