Gender differences in transdiagnostic domains and function of adults measured by DSM-5 assessment scales at the first clinical visit: a cohort study.

BACKGROUND: Measurement-based care has been called for as best practice in psychiatric care and learning health systems and use of transdiagnostic measures was suggested as part of the DSM-5. Our objective is to examine gender differences in first visit socioeconomic, transdiagnostic, and functional characteristics of a dynamic, real-world measurement-based care cohort. METHODS: Transdiagnostic, functional, and clinical measures were collected from 3,556 patients at first visit in an ambulatory psychiatric clinic. All patients were evaluated at the first visit by board-certified psychiatrists or licensed clinical psychologists. Demographic variables and clinical diagnoses were collected from the Electronic Medical Record. Self-report measures were collected that assessed transdiagnostic symptoms (DSM-5 Level 1 Cross-cutting Measure and Level 2 symptom scales), disability, alcohol use, attention deficit hyperactivity disorder (ADHD) symptoms, depression, anxiety, mania, suicidal thoughts and behaviors, and trauma exposure. RESULTS: Men and women did not differ in age, BMI, household income, high school graduation rate, race, or ethnicity, but women were more likely to be formerly married and less likely to have commercial insurance. Compared to men, women reported significantly higher overall psychopathology on the transdiagnostic Level 1 Cross-cutting measure and had higher depression, anxiety, sleep, anger, ADHD combined presentation, and suicidality severity. Women also had higher disability scores than men. However, men reported higher alcohol, tobacco and substance use, and more risky behavior than women. Trauma exposure differed significantly by gender; men reported more exposure to accidents, war-related trauma, serious accidents, and major disasters and women reported more unwanted sexual contact. CONCLUSIONS: This cross-sectional study of a transdiagnostic, ecologically-valid real-word measurement-based care cohort demonstrates gender differences in socioeconomic factors, trauma exposure, transdiagnostic symptoms, and functioning.

Urban vs. rural differences in psychiatric diagnoses, symptom severity, and functioning in a psychiatric sample.

OBJECTIVE: Identifying whether certain groups of people experience elevated rates or severities of psychiatric symptoms provides information to guide healthcare allocation. People living in urban areas have higher rates of some psychiatric disorders relative to people living in rural settings, however, it is unclear if psychiatric severity is more elevated in urban vs. rural settings. This study investigates the urban vs. rural differences in rates of psychiatric disorders and severity of psychiatric symptoms. METHOD: A cohort of patients (63% women, 85% White) presenting to an outpatient psychiatric treatment center in the U.S. completed patient-reported outcomes at all clinic visits as part of standard care. Rurality was determined by municipality population density. Sociodemographic characteristics, psychiatric diagnoses, trauma exposure, psychiatric symptom severity, functioning, and suicidality were compared by rural vs. urban municipality. RESULTS: There were virtually no differences between patients living in rural vs. urban municipalities on rates of psychiatric disorders, severity of psychiatric symptoms, functional impairment, and suicidality (ps≥.09). The only difference was that patients living in rural municipalities had higher exposure to serious accidents than patients living in urban municipalities (p < .01); exposure to nine other traumatic events did not differ between groups (p≥.07). CONCLUSIONS: People living in urban and rural municipalities have a similar need for mental health treatment. Access to care may be one explanatory factor for the occasional rural-urban differences in rates of psychiatric disorders. In other words, if people living in rural areas can access care, their symptom presentations appear unlikely to differ from those of people living in urban areas.

Screening for ADHD in a general outpatient psychiatric sample of adults.

Adults (n = 805) seeking outpatient psychiatric care completed the Adult ADHD Self-Report Scale (ASRS) and measures of impairment and co-occurring psychopathology as part of a measurement-based care initiative. Diagnostic indicators of ADHD (i.e., formal diagnosis and/or medication treatment) were recorded from the electronic medical record (EMR). Agreement between screening positive for ADHD and EMR indicators for the diagnosis was explored, and clinical characteristics of adults identified with ADHD using these indicators were examined. Lastly, the contribution of ADHD to functional impairment was examined, controlling for the contribution of other demographic and psychiatric comorbidities. In the full sample, 54.78% of adults screened positive for ADHD based on the ASRS, and using EMR indicators, only 11.93% of adults were identified with ADHD. Agreement emerged between self-reported ADHD and ADHD EMR indicators, although adults screening positive for ADHD generally reported greater psychiatric complexity relative to adults identified with ADHD in the EMR. ADHD was associated with clinical impairment even when controlling for other psychiatric comorbidities. The considerable difference in prevalence of ADHD based on self-report screening versus EMR indicators suggests that ADHD may be overlooked in adult psychiatric care. Findings point to the importance of assessing adult ADHD in routine psychiatric care.

Transdiagnostic and functional predictors of depression severity and trajectory in the Penn state psychiatry clinical assessment and rating evaluation system (PCARES) registry.

BACKGROUND: Timely, accurate diagnosis and subsequent identification of risk factors for depression that is difficult-to-treat can aid in decreasing the burden of depressive illness and reducing probability of future disability. We aimed to identify sociodemographic, clinical, and functional factors that predict depression severity over one year in a real-world, naturalistic, transdiagnostic clinical sample. A subset sample with moderate depression was examined to determine the magnitude of improvement. METHODS: The Penn State Psychiatry Clinical Assessment and Rating System (PCARES) Registry houses data from systematically-structured patient-reported outcomes and clinical data from an Electronic Medical Record (EMR) gathered during routine clinical care of patients seeking mental health care at a mid-Atlantic clinic. Self-report symptom and functional measures were obtained, and sociodemographic features and clinical diagnoses were extracted from the EMR from 1,766 patients between 2/6/2016 to 9/30/2019. The Patient Health Questionnaire 9 (PHQ-9) depression scale was obtained at each visit. Using a discrete mixture clustering model, the study population was divided into five longitudinal trajectory groups, termed depression severity groups, based on intra-individual PHQ-9 score trajectories over one year. Multinomial logistic regression models were estimated to evaluate associations between characteristics and the likelihood of depression severity group membership. To determine the magnitude of improvement, predictors of the slope of the PHQ-9 trajectory were examined for patients with moderate depression. RESULTS: The strongest predictors of high depression severity over one year were poor functioning, high transdiagnostic DSM-5 Level 1 crosscutting symptom score, diagnosis of Post-Traumatic Stress Disorder (PTSD), public/self-pay insurance, female gender, and non-White race. Among the subset of patients with moderate depression, strong predictors of improvement were commercial insurance and exposure to trauma; the strongest predictors of worsening were high functional impairment, high transdiagnostic Level 1 symptom score, diagnosis of PTSD, diagnosis of bipolar disorder, and marital status of single or formerly married; depression-specific symptom measures were not predictive. LIMITATIONS: Limitations include inferring education and income status from zip code level-data, the non-random missingness of data, and the use of diagnoses collected from the electronic medical record. CONCLUSION: Functional impairment, transdiagnostic measures of symptom burden, and insurance status are strong predictors of depression severity and poor outcome.

Initial Investigation of the Psychometric Properties of the Limited Prosocial Emotions Questionnaire (LPEQ).

Callous-unemotional traits, which include lack of remorse or guilt, callousness/lack of empathy, unconcern about performance, and shallow/deficient affect, were included as a specifier of conduct disorder in the current (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders under the rubric Limited Prosocial Emotions (LPEs). The purpose of this study was to examine the psychometric properties of a new rating scale, the Limited Prosocial Emotions Questionnaire (LPEQ). Caregivers (n = 1,050) of children (Mage = 8.42, SD = 2.31) completed the LPEQ and other measures. Results provide support for a single factor model of the LPEQ, with measurement invariance supported across child and informant sex. Both the reliability and validity of the LPEQ as a measure of LPEs were also well supported. Children identified with LPE had significantly greater average impairment and need for treatment relative to children without LPE. Children with conduct problems (i.e., conduct disorder or oppositional defiant disorder), as well those without conduct problems, had significantly more impairment if they were identified as having LPE. Our findings fit with the mounting evidence of the clinical utility of assessing LPEs in children. Future research should look to replicate our findings in clinical samples of youth.

Predictors of diagnostic delay: Assessment of psychiatric disorders in the clinic.

BACKGROUND: Diagnostic delay contributes to morbidity in psychiatric disorders. METHODS: Patients in an ambulatory psychiatry clinic were given patient-reported outcome measures at an initial visit, and a subset (N = 493) were given a structured interview (MINI International Neuropsychiatric Interview, MINI), in addition to the clinical encounter (CLIN). Diagnostic agreement between MINI and CLIN was assessed at an initial and follow-up visit. Diagnostic delay was identified if diagnostic disagreement between MINI and CLIN occurred at the initial visit and changed to an agreement at a follow-up visit. Registry data was compiled by an honest broker. RESULTS: Significant agreement occurred between MINI and CLIN diagnoses for major depressive disorder (MDD), bipolar disorder (BD), generalized anxiety disorder, and panic disorder. Diagnostic agreement for MDD occurred at initial visit for 63% of patients, and at follow-up for 87% of those with initial diagnostic disagreement; for BD, 75% at initial visit and 28% at follow-up. No demographic, socioeconomic, symptom severity or functioning measures predicted diagnostic agreement for the MDD group at the first visit, however initial psychopathological symptom complexity predicted diagnostic agreement in the diagnostic delay group. Initial diagnostic agreement for BD was predicted by lower symptom burden and better social, physical, and occupational functioning. No factors predicted additional diagnostic agreement at the second visit in the diagnostic delay group. CONCLUSION: Initial assessment by a structured interview aided physicians in identifying MDD by the second visit in patients with complex psychopathology. Patients with high complexity/severity of symptoms and more difficulty with functioning were less commonly identified with BD even with the assistance of a structured interview. Use of structured assessment tools may improve the detection of psychiatric illness by clinicians at the first visit.

Sleep Disturbances Increase the Impact of Working Memory Deficits on Learning Problems in Adolescents with High-Functioning Autism Spectrum Disorder.

Sleep disturbances (SD) are prevalent in individuals diagnosed with Autism Spectrum Disorder (ASD). Less is known about the effects of SD on cognition and learning in adolescents with high-functioning ASD (HF-ASD). Adolescents with HF-ASD (N = 96) were evaluated for the relationships of SD to working memory and learning problems. Results found SD to modify the relationship between working memory and learning problems. Working memory deficits were associated with learning problems among those with SD, while not among those without SD. SD and working memory deficits should be targeted in interventions for these adolescents with HF-ASD (e.g., cognitive behavior therapy for insomnia, pharmacological treatments). Future studies should examine if improvement in SD reduces the impact of working memory deficits on learning problems.

Risk Factors for Emergency Department Utilization Among Adolescents with Autism Spectrum Disorder.

This study reaffirms our previous work documenting a higher number of Emergency Department (ED) visits by adolescent females with Autism Spectrum Disorder (ASD) as compared to adolescent males with ASD, as well as significantly more ED visits by older adolescents than younger adolescents with ASD. Combined externalizing and internalizing psychiatric co-morbidities as well as internalizing conditions alone predict a higher number of ED visits in this study. Illness severity as demonstrated by patterns of visits to primary care physicians and psychiatric referrals prior to ED visits and the prescription of two or more classes of psychotropic medications also predict higher number of ED visits. Finally, as expected, previous ED visits predict future ED visits. The identification of these factors may prove helpful in determining adequacy of current supports and resources for teens with ASD navigating the challenges of adolescence.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders.

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325-332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825-830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227-235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

Cognitive-behavioral treatment of a second-generation child of Pakistani descent: ethnocultural and clinical considerations.

Ethnocultural variables in cognitive behavioral therapy (CBT) are gaining an increasing amount of attention. This is a welcome development since cultural responsiveness is a core element in ethical and effective CBT practice. However, the literature is sparse and generally silent regarding CBT with children of Pakistani descent. Accordingly, this case based article attempts to close the knowledge gap by reviewing the extant literature pertaining to the role of religion, help seeking behavior, and emotional expression in Pakistani families. The literature review is followed by a case discussion of an 11 year old second generation Pakistani male living in the United Kingdom who is struggling with posttraumatic stress disorder (PTSD). The case presentation highlights the importance of culturally informed case conceptualization and individually tailored interventions. The case illustrates the way cognitive behavioral psychotherapy balanced empirically based procedures with a sensitive appreciation of cultural context.

Assessing adolescent social competence using the Social Responsiveness Scale: should we ask both parents or will just one do?

There is a paucity of instruments designed to measure social competence of adolescents with autism spectrum disorders. The Social Responsiveness Scale is one of a few that can be used. This study compared differences between mother and father reports of social competence of adolescents. Data were collected from parents of 50 adolescents with and without an autism spectrum disorder diagnosis between the ages of 12 and 17 years. The Social Responsiveness Scale demonstrated high interrater reliability between parents. These results suggest that the Social Responsiveness Scale is an efficient and valuable tool for researchers and clinicians to obtain a more comprehensive understanding of an individual's social skills deficits. Additionally, given the extremely high agreement between mothers and fathers on the ratings of their children's social competence, obtaining data from either parent is sufficient to provide an accurate reflection of social competence at home.

Supervising Child Psychiatry Fellows in Cognitive Behavioral Therapy: Crucibles and Choices.

Child psychiatric fellows enter cognitive behavioral therapy (CBT) training experiences with a wide variety of backgrounds and experiences in this area of treatment. Although some child fellows have fundamental knowledge of cognitive-behavioral theory, most struggle with the CBT model and even more so, subsequently using this model to guide treatment. Unlike supervising early career mental health professionals, child residents often possess a skill set apt for CBT including using a problem-oriented focus, a tendency to use structured methods in treatment, the use of psychoeducation, and basic clinical skills including genuineness, understanding, and empathy. On the other hand, child psychiatric fellows find several areas of CBT challenging because it is often vastly different from previous experience, including more frequent and longer sessions, the use of collaborative empiricism, developing case conceptualizations, and tolerating negative affective arousal. Moreover, training climates in psychiatry departments may shape the supervision experiences. Various specific recommendations are offered to manage these crucibles. Overall, although there are significant challenges when supervising child residents in CBT rotations, having knowledge of these crucibles and access to choices for addressing these supervisory tests enhances both supervisor and supervisee competence.

Engaging parents in preventive parenting groups: do ethnic, socioeconomic, and belief match between parents and group leaders matter?

The authors evaluate the relation of ethnic, socioeconomic status (SES), and belief match between parents and group leaders and engagement in a preventive intervention for parents of preschoolers. Engagement was assessed through attendance, retention, and quality of participation in sessions with 171 parents and 11 group leaders. SES match predicted attendance, retention, and quality of participation. Parents attended more sessions, remained longer in the program, and participated more actively when their group leader came from comparable SES backgrounds. Ethnic match predicted retention only, with parents attending longer when their ethnicity matched their group leader's. Engagement was unrelated to the extent of match across different characteristics, nor was the link between ethnic match and retention mediated by SES or belief match. Results suggest that social, cultural, and belief similarities between parents and group leaders may be less salient in preventive parenting interventions than is assumed. Implications for research and practice are discussed.