How COVID-19 Phases Have Impacted Psychiatric Risk: A Retrospective Study in an Emergency Care Unit for Adolescents.

Dramatic events during the COVID-19 pandemic have acutely impacted the psychosocial environment worldwide, with negative implications for mental health, particularly for more vulnerable children and adolescents with severe psychiatric illnesses. Some data suggest that the pandemic waves may have produced different psychopathological consequences, further worsening in the second phase of the pandemic, compared to those in the first lockdown, soon after March 2020. To test the hypothesis of a further worsening of psychiatric consequences of COVID-19 in the second lockdown compared to the first lockdown, we focused our analysis on a consecutive sample of youth referred to a psychiatric emergency unit for acute mental disorders in the time period between March 2019-March 2021. The sample, consisting of 241 subjects (123 males and 118 females, ranging in age from 11 to 17 years), was divided into three groups: Pre-Lockdown Group (PLG, 115 patients); First Lockdown Group (FLG, 65 patients); and Second Lockdown Group (SLG, 61 patients). Patients in the SLG presented more frequently with non-suicidal self-injuries (NSSIs), suicidal ideation, and suicidal behavior, while no significant differences in self-harm were found between PLG and FLG. Eating disorders were more frequent in both the FLG and SLG, compared to the PLG, while sleep problems were higher only in the SLG. Furthermore, patients in the SLG presented with more frequent psychological maltreatments and neglect, as well as with psychiatric disorders in the parents. Adverse traumatic experiences and internalizing disorders were significantly associated with an increased risk of suicidality. Intellectual disability was less represented from the PLG to SLG, and similarly, the rate of ADHD was lower in the SLG. No differences were found for the other psychiatric diagnoses. This information may be helpful for a better understanding and management of adolescents with severe emotional and behavioral disorders after the exposure to long-lasting collective traumas.

Proposal for a continuous wave laser with linewidth well below the standard quantum limit.

Due to their high coherence, lasers are ubiquitous tools in science. We show that by engineering the coupling between the gain medium and the laser cavity as well as the laser cavity and the output port, it is possible to eliminate most of the noise due to photons entering as well as leaving the laser cavity. Hence, it is possible to reduce the laser linewidth by a factor equal to the number of photons in the laser cavity below the standard quantum limit. We design and theoretically analyze a superconducting circuit that uses Josephson junctions, capacitors and inductors to implement a microwave laser, including the low-noise couplers that allow the design to surpass the standard quantum limit. Our proposal relies on the elements of superconducting quantum information, and thus is an example of how quantum engineering techniques can inspire us to re-imagine the limits of conventional quantum systems.

A Comparison between Severe Suicidality and Nonsuicidal Self-Injury Behaviors in Bipolar Adolescents Referred to a Psychiatric Emergency Unit.

BACKGROUND: Severe suicide ideation or attempts and non-suicidal self-injury (NSSI) present both differences and relevant overlaps, including frequent co-occurrence and shared risk factors. Specific categorical diagnoses, namely bipolar disorder (BD), may affect clinical features and natural histories of suicidal or not suicidal self-harm behaviour. Our study aimed to compare suicidality (severe suicidal ideation or suicidal attempts) and NSSI in referred bipolar adolescents. METHODS: The sample included 95 bipolar adolescents (32 males, 63 females) aged 11 to 18 years. Thirty adolescents with suicide attempts/suicidal ideation and BD (SASIB) were compared with structured measures to 35 adolescents with NSSI and BD, without suicidal ideation or attempts (NSSIB), and to 30 adolescents with BD, without suicidal ideation or attempts or NSSI (CB). RESULTS: Compared to CB, suicidality and NSSI were both associated with female sex, borderline personality disorder and self-reported internalizing disorders, anxiety/depression and thought disorders. The NSSI were specifically associated with somatic problems. Severe suicidal ideation and suicide attempts were associated with adverse life events, immigration, bullying, eating disorders, social problems, depressive feelings, performance and social anxiety, and feelings of rejection. CONCLUSIONS: Both shared and differential features between suicidal and not suicidal adolescents may represent possible targets for diagnostic and preventative interventions.

A Naturalistic Study of Youth Referred to a Tertiary Care Facility for Acute Hypomanic or Manic Episode.

BACKGROUND: Bipolar Disorders (BD) in youth are a heterogeneous condition with different phenomenology, patterns of comorbidity and outcomes. Our aim was to explore the effects of gender; age at onset (prepubertal- vs. adolescent-onset) of BD; and elements associated with attention deficit hyperactivity disorder (ADHD) and Substance Use Disorder (SUD) comorbidities, severe suicidal ideation or attempts, and poorer response to pharmacological treatments. METHOD: 117 youth (69 males and 57 females, age range 7 to 18 years, mean age 14.5 ± 2.6 years) consecutively referred for (hypo)manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders, 54th ed (DSM 5) were included. RESULTS: Gender differences were not evident for any of the selected features. Prepubertal-onset BD was associated with higher rates of ADHD and externalizing disorders. SUD was higher in adolescent-onset BD and was associated with externalizing comorbidities and lower response to treatments. None of the selected measures differentiated patients with or without suicidality. At a 6-month follow up, 51.3% of the patients were responders to treatments, without difference between those receiving and not receiving a psychotherapy. Clinical severity at baseline and comorbidity with Conduct Disorder (CD) and SUD were associated with poorer response. Logistic regression indicated that baseline severity and number of externalizing disorders were associated with a poorer outcome. CONCLUSIONS: Disentangling broader clinical conditions in more specific phenotypes can help timely and focused preventative and therapeutic interventions.

Suicidal Ideation and Suicidal Attempts in Referred Adolescents with High Functioning Autism Spectrum Disorder and Comorbid Bipolar Disorder: A Pilot Study.

Suicidal ideation and attempts in adolescents are closely associated to bipolar disorders (BD). Growing evidence also suggests that high functioning autism spectrum disorders (HF-ASD) are at increased risk for suicidal ideation and behaviors. Although BD and HF-ASD are frequently comorbid, no studies explored suicidality in these individuals. This exploratory study addressed this issue in a clinical group of inpatient adolescents referred to a psychiatric emergency unit. Seventeen adolescents with BD and HF-ASD and severe suicidal ideation or attempts (BD-ASD-S), were compared to 17 adolescents with BD and HF-ASD without suicidal ideation or attempts (BD-ASD-noS), and to 18 adolescents with BD and suicidal ideation or attempts without ASD (BD-noASD-S), using a structured assessment methodology. Individuals with BD-ASD-S had a higher intelligence quotient, more severe clinical impairment, more lethality in suicide attempts, more internalizing symptoms, less impulsiveness, and lower social competence. Severity of ASD traits in individuals and parents did not correlate with suicidal risk. Some dimensions of resilience were protective in terms of repulsion by life and attraction to death. Main limitations are the small sample size, the lack of a control group of typically developing adolescents. However, a better understanding of the specificities of bipolar HF-ASD individuals with suicidality may improve prevention and treatment strategies.

Psychopathological features in referred adolescents with psychogenic nonepileptic seizures with or without epilepsy.

Psychogenic nonepileptic seizures (PNES) are episodic manifestations that mimic epileptic seizures (ES) although not associated with electroencephalogram (EEG) abnormalities. Psychogenic nonepileptic seizures and ES, however, can often cooccur. Emotional distress in adolescents can trigger PNES, but the psychopathological and personality features are still unknown. The aim of this study was to explore psychopathological features in a sample of referred youth with PNES, with or without ES, compared with a control group with ES. Thirty-four patients aged 12 to 21 years, 19 females and 15 males, were included in the study, 15 patients with PNES, 7 with PNES and ES, and 12 with ES. The three groups were compared according to psychiatric categorical diagnoses, psychopathological dimensions, life stressors, and personality traits, including alexithymia, interpersonal reactivity, and resilience, all assessed with structured measures. Patients with PNES, with or without ES, were more severely impaired, had a higher incidence of mood disorders, more frequent lifetime traumatic experiences, and lower resilience. All the three groups presented alexythimic traits and emotional dysregulation. Major limitations are the small sample size and the lack of a control group of healthy subjects. Disentagling psychopathological characteristics in PNES can help clinicians to focus diagnostic approaches and therapeutic interventions.

Suicidal ideation, suicidal attempts and non-suicidal self-injuries in referred adolescent s.

BACKGROUND: Specific risk factors may affect persistent suicidal ideation (SI) and suicide attempts (SA) in adolescence. Non-suicidal self-injuries (NSSIs) are possible antecedent or associated factors of suicidality. AIMS: To compare clinical features in adolescents with mood disorders referred for severe SI and for SA, and to explore differences in those with or without NSSIs. METHOD: 22 youth with severe SI (16 males [77.3%], mean age 14.86±1.86 years), and 19 with SA (16 males [84.2%], mean age 15.05±1.75 years) were assessed for familial psychiatric disorders/suicidal attempts, traumatic antecedents, diagnosis, impulsivity, hopelessness, attitude for life and death, resilience, and according to additional NSSIs. RESULTS: Patients with SI presented more frequent anxiety disorders, those with SA more severe suicidal ideation with plan and intention, and more duration of suicidal ideation. Resilience was lower in SI, while all the other features did not distinguish the two groups. NSSIs were found in 70.7% of the sample, without differences between groups; only impulsivity was more frequent in NSSI group. DISCUSSION: These specific features were frequently found in this high-risk sample, but only comorbid anxiety disorders, and more active, persistent and planned suicidal ideation differentiated the two groups. CONCLUSIONS: Patients with severe SI and SA may represent different variants of the same clinical entity. Given the high frequency of the explored features in the whole suicidal sample, this diagnostic methodology may be helpful and informative in all the high-risk adolescents with mood disorders, namely with NSSI.

Lithium treatment in bipolar adolescents: a follow-up naturalistic study.

BACKGROUND: Although lithium is currently approved for the treatment of bipolar disorders in youth, long term data, are still scant. The aim of this study was to describe the safety and efficacy of lithium in referred bipolar adolescents, who were followed up at the 4th (T1) and 8th (T2) month of treatment. METHODS: The design was naturalistic and retrospective, based on a clinical database, including 30 patients (18 males, mean age 14.2±2.1 years). RESULTS: Mean blood level of lithium was 0.69±0.20 mEq/L at T1 and 0.70±0.18 mEq/L at T2. Both Clinical Global Impression-Severity (CGI-S) and Children Global Assessment Scale (C-GAS) scores improved from baseline (CGI-S 5.7±0.5, C-GAS 35.1±3.7) to T1 (CGI-S 4.2±0.70, C-GAS 46.4±6.5; P<0.001), without significant differences from T1 to T2. Thyroid-stimulating hormone significantly increased from 2.16±1.8 mU/mL at baseline to 3.9±2.7 mU/mL at T2, remaining within the normal range, without changes in T3/T4 levels; two patients needed a thyroid hormone supplementation. Creatinine blood level did not change. No cardiac symptoms and electrocardiogram QTc changes occurred. White blood cell count significantly increased from 6.93±1.68 103/mmc at baseline to 7.94±1.94 103/mmc at T2, and serum calcium significantly increased from 9.68±0.3 mg/dL at baseline to 9.97±0.29 mg/dL at T2, both remaining within the normal range; all the other electrolyte levels were stable and normal during the follow-up. The treatment with lithium was well tolerated, probably due to the relatively low lithium blood levels. Gastrointestinal symptoms (16.7%), sedation (9.7%) and tremor (6.4%) were the most frequently reported side effects. CONCLUSION: Lithium was effective and safe in adolescent bipolar patients followed-up for eight months.

A NATURALISTIC EXPLORATORY STUDY OF OBSESSIVE-COMPULSIVE BIPOLAR COMORBIDITY IN YOUTH.

BACKGROUND: Growing evidence supports the comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) in children and adolescents. Our aim is to further explore clinical and treatment implications of this comorbidity, as it appears in clinical practice. METHOD: The sample included 429 consecutive patients with BD and/or OCD as primary diagnoses, followed for a mean period of 6 months (range 4-9 months), 172 with BD (102 males, mean age 13.7±2.9 years), 169 with OCD (118 males, mean age of 13.2±2.7 years) and 88 with comorbid BD+OCD (56 males, mean age 14.2±2.6 years, 52 with BD as the primary diagnosis), followed for a mean period of 6 months (range 4-9 months). The comorbid group was compared to pure BD and OCD groups, to explore differential clinical and treatment features. RESULTS: The BD-OCD comorbidity was found in 33.8% of the BD patients and in 34.2% of the OCD patients. Age at onset of BD and OCD were not different in pure and "comorbid" groups. The comorbid group presented a higher occurrence of BD type II and hoarding symptoms, and more frequently received a psychotherapy and second generation antipsychotics, but it presented the poorest outcome in terms of response to treatments. Severity at baseline (clinical severity and functional impairment), hoarding obsessions and compulsions, and conduct disorder comorbidity were associated with a treatment non-response. LIMITATIONS: A selection bias may have increased the rate of comorbidity, as most of the patients were referred to our tertiary hospital for severe BD and/or OCD and pharmacological treatment. We have used CGI-I as an outcome measure, not a specific measure of BD or OCD symptoms' severity and improvement. The short duration of the follow-up may limit our conclusions. CONCLUSIONS: The timely identification of BD-OCD comorbidity may have relevant clinical implications in terms of symptomatology, course, treatment and outcome.

Prevalence of Candida albicans, Candida dubliniensis and Candida africana in pregnant women suffering from vulvovaginal candidiasis in Argentina / Prevalencia de Candida albicans, Candida dubliniensis y Candida africana en mujeres gestantes con candidiasis vulvovaginal, en Argentina

Background. Vulvovaginal candidiasis (VVC) is a vulvovaginitis commonly diagnosed in gynecology care. In recent years, the taxonomy of the most important pathogenic Candida species, such as Candida albicans have undergone significant changes. Aims. This study examined the prevalence of C. albicans, Candida africana, and Candida dubliniensis in vaginal specimens from 210 pregnant women suffering from vulvovaginitis or having asymptomatic colonization. Methods. Phenotypic and molecular methods were used for the identification of the species. Results. During the studied period, 55 isolates of Candida or other yeasts were obtained from specimens collected from 52 patients suffering from vulvovaginitis (24.8%). C. albicans was the predominant Candida species in 42 isolates (80.7%), either alone or in combination with other species of the genus (5.7%, n=3). Additionally, nine isolates of C. albicans (50%) were obtained from asymptomatic patients (n=18). C. dubliniensis was the causative agent in 2 (3.8%) cases of VVC, and was also isolated in one asymptomatic patient. Molecular assays were carried out using specific PCR to amplify the ACT1-associated intron sequence of C. dubliniensis. The amplification of the HWP1 gene also correctly identified isolates of the species C. albicans and C. dubliniensis. No C. africana was isolated in this work. Some C. albicans isolates were either homozygous or heterozygous at the HWP1 locus. The distribution of heterozygous and homozygous C. albicans isolates at the HWP1 locus was very similar among patients suffering from VVC and asymptomatic patients (p=0.897). Conclusions. The presence of C. albicans and C. dubliniensis, and the absence of C. africana in pregnant is noteworthy (AU)

Antecedentes. La candidiasis vulvovaginal (CVV) es una vulvovaginitis comúnmente diagnosticada en la práctica ginecológica. En los años recientes la taxonomía de Candida albicans ha sufrido cambios significativos. Objetivos. En este estudio se examinó la prevalencia de C. albicans, Candida africana y Candida dubliniensis en las secreciones vaginales de 210 mujeres embarazadas con vulvovaginitis o colonización asintomática. Métodos. Se usaron métodos fenotípicos y moleculares para la identificación de las levaduras. Resultados. Un total de 55 aislamientos de Candida u otras levaduras se recuperaron a partir de muestras de 52 pacientes con vulvovaginitis (24,8%). La especie C. albicans fue predominante como especie única (42 aislamientos; 80,7%) o asociada con otras especies del género (5,7%, n=3). Nueve aislamientos de C. albicans (50%) se recuperaron de las pacientes asintomáticas (n=18). Se aisló C. dubliniensis en dos casos de CVV (3,8%) y en una paciente asintomática. Los estudios moleculares por PCR que amplifican la secuencia del intrón asociado al gen ACT1 confirmaron la presencia de esta especie. La amplificación del gen HWP1 confirmó la presencia de C. dubliniensis y C. albicans, y la ausencia de C. africana. Los aislamientos de C. albicans fueron homocigóticos o heterocigóticos en el locus HWP1; las pacientes con CVV y aquellas asintomáticas mostraron para esta especie una distribución similar de aislamientos homocigóticos o heterocigóticos en el locus HWP1 (p=0,897). Conclusiones. Destacamos la presencia de C. albicans y C. dubliniensis y la ausencia de C. africana en las CVV o en la colonización asintomática de las secreciones vaginales de las gestantes (AU)

Prevalence of Candida albicans, Candida dubliniensis and Candida africana in pregnant women suffering from vulvovaginal candidiasis in Argentina.

BACKGROUND: Vulvovaginal candidiasis (VVC) is a vulvovaginitis commonly diagnosed in gynecology care. In recent years, the taxonomy of the most important pathogenic Candida species, such as Candida albicans have undergone significant changes. AIMS: This study examined the prevalence of C. albicans, Candida africana, and Candida dubliniensis in vaginal specimens from 210 pregnant women suffering from vulvovaginitis or having asymptomatic colonization. METHODS: Phenotypic and molecular methods were used for the identification of the species. RESULTS: During the studied period, 55 isolates of Candida or other yeasts were obtained from specimens collected from 52 patients suffering from vulvovaginitis (24.8%). C. albicans was the predominant Candida species in 42 isolates (80.7%), either alone or in combination with other species of the genus (5.7%, n=3). Additionally, nine isolates of C. albicans (50%) were obtained from asymptomatic patients (n=18). C. dubliniensis was the causative agent in 2 (3.8%) cases of VVC, and was also isolated in one asymptomatic patient. Molecular assays were carried out using specific PCR to amplify the ACT1-associated intron sequence of C. dubliniensis. The amplification of the HWP1 gene also correctly identified isolates of the species C. albicans and C. dubliniensis. No C. africana was isolated in this work. Some C. albicans isolates were either homozygous or heterozygous at the HWP1 locus. The distribution of heterozygous and homozygous C. albicans isolates at the HWP1 locus was very similar among patients suffering from VVC and asymptomatic patients (p=0.897). CONCLUSIONS: The presence of C. albicans and C. dubliniensis, and the absence of C. africana in pregnant is noteworthy.

A prospective observational study of vulvovagintis in pregnant women in Argentina, with special reference to candidiasis.

To evaluate the frequency of yeast, bacteria or protozoa in pregnant women and to correlate the possible associations of these microorganisms and their relationships with vulvovaginitis (VV) and cervicitis. Vaginal specimens were collected and prepared for smears in microscope slides for the evaluation of yeast, Trichomonas vaginalis and bacteria. Samples were cultured in specific culture medium. Cervical specimens were used to investigate the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma spp. and Mycoplasma hominis. We enrolled 210 pregnant women, aged 10-42 years old. Of them, 38.1% were symptomatic. Symptoms were most prevalent in the second and third trimesters of pregnancy coincident with a major prevalence of microorganisms. In this study, 39.5% of pregnant women had normal microbial biota and symptoms of VV due to non-infectious causes were observed (6.2%). The occurrence of vulvovaginal candidiasis was 25% and Candida albicans with a prevalence of 80.7% was the dominant species (P = 0.005) while non-albicans Candida species and other yeast were more common in asymptomatic ones (P = 0.0038). The frequency of bacterial vaginosis, T. vaginalis, C. trachomatis and N. gonorrhoeae were 18.1%, 1.4, 1.4% and 0.5% respectively.

Pediatric social anxiety disorder: predictors of response to pharmacological treatment.

OBJECTIVE: Pediatric social anxiety disorder (SAD) is associated with an increased risk of comorbid mental disorders, with implications for prognosis and treatment strategy. The aim of this study is to explore predictors of treatment response, and the role of comorbidity in affecting refractoriness. METHODS: One hundred and forty consecutive youths (81 males, 57.9%), ages 7-18 years (mean age 13.7 ± 2.5 years, mean age at onset of SAD 10.6 ± 2.7 years) met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for SAD as primary diagnosis, according to a structured clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]). All received a pharmacological treatment with serotonin reuptake inhibitors (SSRIs) targeted to SAD, associated with additional medications for comorbidities (mood stabilizers in 27.1%, antipsychotics in 12.8%) and 57.9% received an additional psychotherapy. RESULTS: Eighty-nine patients (63.6%) responded to treatments after 3 months, namely 72.8% with psychotherapy plus medication and 50.8% with medication only. Nonresponders had more severe symptoms at baseline in terms of both clinical severity and functional impairment, and had more comorbid disruptive behavior disorders. The backward logistic regression indicated that clinical severity and functional impairment at baseline, comorbid disruptive behavior disorders, and bipolar disorders were predictors of nonresponse. CONCLUSION: Our data suggest that SSRIs can be effective in pediatric SAD, but that the more severe forms of the disorder and those with heavier comorbidity are associated with poorer prognosis.

Developmental pathways for different subtypes of early-onset bipolarity in youths.

OBJECTIVE: Two main patterns of comorbidity have been described in bipolar disorder in children and adolescents: the first including preexisting attention-deficit/hyperactivity disorder (ADHD) and related disruptive behavior disorders and the second including anxiety disorders, namely, the association of co-occurring multiple anxiety disorders, usually predating the onset of bipolarity. This study was aimed at exploring whether ADHD and multiple anxiety disorders may exhibit different pathways to specific bipolar phenotypes. METHOD: We compared 49 youths (7 to 18 years) with bipolar disorder + ADHD without anxiety, 76 youths with bipolar disorder + multiple anxiety disorders without ADHD, and 52 youths with bipolar disorder without ADHD or multiple anxiety disorders who were referred to a third-level hospital and diagnosed according to DSM-IV-TR in the period 2005-2011. Subjects were evaluated for current and lifetime Axis I psychiatric disorders by using a structured clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version) and followed up for at least 6 months. RESULTS: Compared to both patients with bipolar disorder + multiple anxiety disorders and patients with bipolar disorder without ADHD and multiple anxiety disorders, patients with bipolar disorder + ADHD without anxiety were more frequently male, were younger, had an earlier onset of bipolar disorder, had a prevalent chronic course and irritable mood, were more likely to present with a bipolar disorder not otherwise specified diagnosis, had a greater clinical severity and functional impairment, had a manic/mixed index episode, had a higher risk of conduct disorder, and were more resistant to treatments, according to the CGI-Improvement scores (P < .0001). Patients with bipolar disorder + multiple anxiety disorders were similar to those with bipolar disorder without ADHD or multiple anxiety disorders, except for a higher rate of diagnosis of bipolar II disorder, more use of antidepressants, and less use of atypical antipsychotics. CONCLUSIONS: The presence of comorbid ADHD versus anxiety disorders is indicative of fundamental differences in the phenomenology of bipolar disorder in youth. While ADHD prior to bipolar disorder is associated with a specific bipolar phenotype, bipolar patients with multiple anxiety disorders are similar to "typical" bipolar patients.

Managing bipolar youths in a psychiatric inpatient emergency service.

Among the youths referred to our Psychiatric Inpatient Emergency Service, we focused on bipolar disorder (BD), to explore predictive elements for the outcome. Fifty-one patients (30 males, 21 females, age range 8-18 years, mean age 14.2 ± 3.1 years) received a diagnosis of BD, according to historical information, prolonged observations, and a structured clinical interview (K-SADS-PL). Twenty-seven patients (52.9%) were responders at the end of hospitalization according to CGI-I 1 or 2 and 50% decrease of both Brief Psychiatric Rating Scale (BPRS) and Young Mania Rating Scale (YMRS). Responders received a longer hospitalization. Non responders were more severe at baseline, had higher scores at BPRS (namely positive symptoms), and were more aggressive. Environmental/social stressors and comorbidities were frequent, but they did not affect the outcome. In summary, BD in emergency settings may represent a subtype with clinical and therapeutic peculiarities, and specific challenges for mental health services.

Pharmacological response in juvenile bipolar disorder subtypes: A naturalistic retrospective examination.

This study reports on the naturalistic pharmacotherapy of 266 youths with bipolar disorder (BP), manic or hypomanic episode (158 males and 108 females, 13.8+/-2.8 years), first treated with monotherapy on valproic acid (VPA) (n=158, 59.4%), lithium (n=90, 33.8%) or atypical antipsychotics (n=18, 6.8%). Among the patients receiving mood stabilizers, 59.5% of those treated with VPA and 47.8% of those receiving lithium did not need other antimanic agents (mood stabilizers and/or atypical antipsychotics). Lower severity was associated with a greater persistence of both VPA and lithium monotherapy. Factors associated with greater persistence of VPA monotherapy were BP II and co-occurring generalized anxiety disorder, separation anxiety disorder and simple phobias. On the contrary, BP I and co-occurring psychotic symptoms and/or conduct disorder were associated with a lower persistence of VPA monotherapy. Factors associated with lower persistence of lithium monotherapy were younger age and the association with attention deficit hyper-activity disorder (ADHD). Type of BP and presence of psychotic symptoms and conduct disorder did not affect the lithium monotherapy. Overall, predictors of non-response (multiple stepwise logistic regression) in both VPA and lithium groups were baseline Clinical Global Impression (CGI) Severity score and comorbid conduct disorder; while psychotic symptoms and absence of comorbid generalized anxiety disorder were predictors of poorer treatment response only in the VPA group, and chronic course, comorbid ADHD and absence of comorbid panic disorder were predictors only in the lithium group. Such naturalistic data from an ordinary clinical setting have relevance to clinical practice.

A naturalistic exploratory study of the impact of demographic, phenotypic and comorbid features in pediatric obsessive-compulsive disorder.

BACKGROUND: Few studies have examined the impact of gender, age at onset, phenotype and comorbidity in pediatric obsessive-compulsive disorder (OCD) in children. In this naturalistic study we consider these characteristics of OCD in the framework of the 4 OCD phenotypes (contamination/cleaning, order/symmetry, obsessions/checking and hoarding) proposed by Leckman et al. SAMPLING AND METHODS: A consecutive series of 257 patients aged 13.6 +/- 2.8 years, diagnosed using a DSM-IV-based clinical interview (Schedule for Affective Disorders and Schizophrenia for School Age Children - Present and Lifetime Version), were included. RESULTS: Patients with OCD onset before 12 years of age presented a higher frequency of comorbid tic disorder and disruptive behavior disorders. The type of obsession varied with gender: order/symmetry was more frequent in males, contamination/cleaning in females. Order/symmetry had the highest comorbidity with tics, contamination/cleaning was the least severe according to the Clinical Global Impression Severity, and was associated with a high rate of comorbid anxiety and depression, similarly to sexual-religious obsessions. Hoarding was the severest according to the Clinical Global Impression Severity, and was associated with a high comorbidity with social phobia and bipolar disorder. Tic comorbidity was more prevalent in males, had an earlier onset, and a heavier comorbidity with attention deficit hyperactivity disorder and other disruptive behavior disorders. A comorbid attention deficit hyperactivity disorder was associated with an earlier onset of OCD and a poorer response to treatments. CONCLUSIONS: OCD phenotypes and comorbidities may have marked clinical and prognostic implications. Tertiary care population results may not generalize to less impaired juvenile populations.

Pharmacotherapy in paediatric obsessive-compulsive disorder: a naturalistic, retrospective study.

BACKGROUND: Pediatric obsessive-compulsive disorder (OCD) can cause substantial impairment in academic, social and family functioning. Even though cognitive-behavioural therapy (CBT) is an effective treatment, the pharmacological option has to be taken into consideration. Effectiveness of serotonin reuptake inhibitors (SRIs) has been supported by several double-blind, placebo-controlled studies. OBJECTIVE: To report the response to pharmacotherapy in children and adolescents with OCD naturalistically followed up and treated with SRIs. METHODS: From a consecutive series of 257 patients (174 males and 83 females; mean age 13.6+/-2.7 years) diagnosed with OCD following a clinical interview according to DSM-IV criteria, 37 children improved significantly after psychotherapy and were excluded. The remaining 220 patients were included in the study. RESULTS: Eighty-nine patients (40.5%) were managed with SRI monotherapy and 131 with an SRI in combination with another medication. Compared with those who needed polypharmacy, patients managed with SRI monotherapy were younger at the time of the first consultation, had less severe symptoms at baseline, and more frequently presented with co-occurring anxiety and depressive disorders, while patients receiving polypharmacy presented with higher rates of bipolar disorder, tic disorder and disruptive behaviour disorders. 135 patients (61.4%) achieved a positive clinical response and were considered responders. When differences between responders and nonresponders at the end of follow-up were considered, irrespective of the pharmacological treatment (monotherapy or polypharmacy), responders had less severe disease at baseline, were younger at the time of the first consultation, more frequently presented with the contamination/cleaning phenotype and less frequently presented with the hoarding phenotype. Treatment refractoriness was associated with higher rates of conduct disorder and bipolar disorder, and lower rates of generalized anxiety disorder and panic disorder. Forty-three children received therapy with an atypical antipsychotic as an augmenting strategy, and 25 of these children (58.1%) became responders. Responders to augmentation were less severely impaired at baseline, while different subtypes of OCD were similar between responders and nonresponders, as were patterns of co-morbidity. CONCLUSION: Our study suggests that putative variables associated with response to pharmacological treatment of paediatric OCD can be defined, and can help improve treatment strategies.