Emotions and behaviours of child and adolescent psychiatric patients during the COVID-19 pandemic.

BACKGROUND: Previous pandemics have had negative effects on mental health, but there are few data on children and adolescents who were receiving ongoing psychiatric treatment. AIMS: To study changes in emotions and clinical state, and their predictors, during the COVID-19 pandemic in France. METHOD: We administered (by interview) the baseline Youth Self-Report version of the CoRonavIruS Health Impact Survey v0.3 (CRISIS, French translation) to 123 adolescent patients and the Parent/Caregiver version to evaluate 99 child patients before and during the first 'lockdown'. For 139 of these patients who received ongoing treatment in our centre, treating physicians retrospectively completed longitudinal global ratings for five time periods, masked to CRISIS ratings. RESULTS: The main outcome measure was the sum of eight mood state items, which formed a single factor in each age group. Overall, this score improved for each age group during the first lockdown. Clinician ratings modestly supported this result in patients without intellectual disability or autism spectrum disorder. Improvement of mood states was significantly associated with perceived improvement in family relationships in both age groups. CONCLUSIONS: Consistent with previous studies of clinical cohorts, our patients had diverse responses during the pandemic. Several factors may have contributed to the finding of improvement in some individuals during the first lockdown, including the degree of family support or conflict, stress reduction owing to isolation, limitations of the outcome measures and/or possible selection bias. Ongoing treatment may have had a protective effect. Clinically, during crises additional support may be needed by families who experience increased conflict or who care for children with intellectual disability.

Changes in the Use of Emergency Care for the Youth With Mental Health Problems Over Decades: A Repeated Cross Sectional Study.

To understand whether changes exist in the types of youths mental health problems addressed in emergency in a context of increasing demand, we conducted a retrospective chart review in an emergency care outpatient unit. Data from children and adolescents admitted at four different time periods (years 1981, 1992, 2002, and 2017) were compared to determine trends in terms of patients' characteristics, nature of the mental health problems and final care decisions. Between 1981 and 2017 there was a 3.85 times increase in the annual number of patients presenting to the emergency consultations. The proportion of youths being referred for anxiety or depressive symptoms sharply increased over time, while no differences were found for the proportion of aggressive behaviors and suicidal attempts. Anxiety disorders became the most frequent discharge psychiatric disorder in youths admitted in the emergency unit, rising from 5% in 1981 to 34% in 2017. Significant changes were also observed in the source of referral to the emergency unit; in particular emergency consultations in 2017 were about twice as likely as in 1981 to be requested directly by the family. This data suggested that the increased use of emergency services observed over the last decades is associated with significant changes in the patient and his/her family's demands about mental health difficulties. Such findings are worth considering for mental health interventions that aim to address the emergency overcrowding issue.

Early interventions for youths at high risk for bipolar disorder: a developmental approach.

In recent decades, ongoing research programmes on primary prevention and early identification of bipolar disorder (BD) have been developed. The aim of this article is to review the principal forms of evidence that support preventive interventions for BD in children and adolescents and the main challenges associated with these programmes. We performed a literature review of the main computerised databases (MEDLINE, PUBMED) and a manual search of the literature relevant to prospective and retrospective studies of prodromal symptoms, premorbid stages, risk factors, and early intervention programmes for BD. Genetic and environmental risk factors of BD were identified. Most of the algorithms used to measure the risk of developing BD and the early interventions programmes focused on the familial risk. The prodromal signs varied greatly and were age dependent. During adolescence, depressive episodes associated with genetic or environmental risk factors predicted the onset of hypomanic/manic episodes over subsequent years. In prepubertal children, the lack of specificity of clinical markers and difficulties in mood assessment were seen as impeding preventive interventions at these ages. Despite encouraging results, biomarkers have not thus far been sufficiently validated in youth samples to serve as screening tools for prevention. Additional longitudinal studies in youths at high risk of developing BD should include repeated measures of putative biomarkers. Staging models have been developed as an integrative approach to specify the individual level of risk based on clinical (e.g. prodromal symptoms and familial history of BD) and non-clinical (e.g. biomarkers and neuroimaging) data. However, there is still a lack of empirically validated studies that measure the benefits of using these models to design preventive intervention programmes.

Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia.

We aimed to (1) describe the treatment used in a large sample of young inpatients with catatonia, (2) determine which factors were associated with improvement and (3) benzodiazepine (BZD) efficacy. From 1993 to 2011, 66 patients between the ages of 9 and 19 years were consecutively hospitalized for a catatonic syndrome. We prospectively collected sociodemographic, clinical and treatment data. In total, 51 (77%) patients underwent a BZD trial. BZDs were effective in 33 (65%) patients, who were associated with significantly fewer severe adverse events (p = 0.013) and resulted in fewer referrals for electroconvulsive therapy (ECT) (p = 0.037). Other treatments included ECT (N = 12, 18%); antipsychotic medications, mostly in combination; and treatment of an underlying medical condition, when possible. For 10 patients, four different trials were needed to achieve clinical improvement. When all treatments were combined, there was a better clinical response in acute-onset catatonia (p = 0.032). In contrast, the response was lower in boys (p = 0.044) and when posturing (p = 0.04) and mannerisms (p = 0.008) were present as catatonic symptoms. The treatment response was independent of the underlying psychiatric or systemic medical condition. As in adults, BZDs should be the first-line symptomatic treatment for catatonia in young patients, and ECT should be a second option. Additionally, the absence of an association between the response to treatment and the underlying psychiatric condition suggests that catatonia should be considered as a syndrome.

Patients' perspectives on residual symptoms in bipolar disorder: a focus group study.

Euthymic bipolar patients are often impacted by residual symptoms (RSs) that increase the risk of relapse or low functioning. We aimed to identify the perceptions of RSs, barriers to management, and service needs in euthymic bipolar patients. A qualitative methodology (focus group) was used. The interviews were investigated using a semistructured guide, tape-recorded, transcribed verbatim, and analyzed thematically. Twenty-three bipolar patients expressed concern about several RSs, such as emotional dysregulation, circadian rhythm disruption, cognitive impairment, low self-esteem, and physical symptoms. They reported concern about the impact of RSs on their functioning and about the need for more systematic assessment of RSs during interepisode visits. Selection bias may have occurred because the recruitment was limited to France and there may be cultural differences in the perceptions of RSs. Bipolar patients experienced bipolar disorder as a chronic disorder because they frequently continued to suffer from RSs associated with a functional impact.

Residual symptoms and functional performance in a large sample of euthymic bipolar patients in France (the OPTHYMUM study).

BACKGROUND: Some residual symptoms were found to be associated with impaired functioning in euthymic bipolar patients, but their impact and relevance are unclear in clinical practice. We re-examined the functional influence of a large set of residual symptoms in 525 euthymic bipolar outpatients using self- and clinician-rated questionnaires (OPTHYMUM study). METHODS: This was a multi-centre, cross-sectional, non-interventional study of adult bipolar outpatients. All patients were euthymic at the time of assessment (YMRS score <8 and BDRS ≤8). Patients with low functioning (GAF score <60) were compared with the rest of the sample. Patients filled in specific questionnaires concerning their perceptions of different residual and subsyndromal symptoms. RESULTS: Ninety-seven (97) psychiatrists included 525 patients. Of them, 35 patients had a GAF score <60. These "low functioning patients" were more frequently unemployed, had presented more manic episodes and psychotic symptoms, used more atypical antipsychotics or benzodiazepines and received less adjunctive psychotherapy. Concerning residual symptoms, they had more frequent emotional subsyndromal symptoms, disruption of circadian rhythms and sexual disorders. They perceived some cognitive deficits and suffered more social and family stigma. LIMITATIONS: Our study used an arbitrary GAF cut-off score (60) to separate bipolar patients in two groups (low and satisfactory functioning). CONCLUSIONS: Residual symptoms are associated with functional impairment and may represent specific treatment targets. A personalized approach through specific psychotherapeutic programs may lead to more efficient support by the clinician.

Circadian abnormalities as markers of susceptibility in bipolar disorders.

Chronobiological models have contributed to a better understanding of the pathophysiology of bipolar disorders. Circadian functions dysregulations are associated with bipolar disorders, including biochemical (melatonin and cortisol profiles), actigraphic (sleep/wake patterns), and dimensional (chronotypes) circadian markers. These associations are observed not only during acute episodes but also during euthymic periods. Most markers that are associated with bipolar disorders are also found in the healthy relatives of patients, suggesting a strong degree of heritability. As such, they may serve as trait markers of the disorder. Several circadian genes have been found to be associated with bipolar disorders: at least three studies have reported positive associations for each of CLOCK, NPAS2, ARNTL1, NR1D1, PER3, RORB and CSNK1epsilon. Thus the clock machinery may contribute to the genetic susceptibility to bipolar disorders. The circadian model theory has also led to the development of novel therapeutic strategies such as InterPersonal and Social Rhythms Therapy and chronotherapeutics. Additionally, the circadian model theory may help explain how mood stabilizers (in particular lithium carbonate) bring about their therapeutic effects.

Circadian biomarkers, circadian genes and bipolar disorders.

Bipolar disorders are associated with circadian deregulations both during acute mood episodes and during euthymic periods, suggesting that these circadian rhythms may represent trait markers of the disease. Several arguments demonstrate that deregulations of circadian rhythms may be part of the pathophysiology of bipolar disorders. Abnormal quantitative and qualitative circadian disturbances have been repeatedly showed in bipolar patients, both during euthymic periods and acute phases, using different assessment tools such as actigraphy, polysomnography, and blood melatonin monitoring. In addition, many circadian physiological functions have been demonstrated to be altered in bipolar patients, such as secretion of hormones and other endogenous substances, core temperature, and fibroblasts activity. Furthermore, mood stabilizers efficiency could partially be explained by their impact on the regulation of the circadian rhythms. The implication of genetic vulnerability factors has long been demonstrated in bipolar disorders and several circadian genes have been tested for association in bipolar disorders. Although preliminary, interesting results have been obtained in several independent studies.