Trends in psychotropic drug use in a child psychiatric hospital from 1991-1998.

OBJECTIVE: This study was undertaken to analyze inpatient prescribing patterns of psychotropic drugs in a child psychiatric hospital from 1991-1998. METHODS: Hospital pharmacy dispensing data were reviewed. Total admissions, first admissions, and readmissions were identified, and medication status of all patients at admission and at discharge was ascertained. Patterns of total psychotropic drug use and proportionate use of each drug class (antidepressants, mood stabilizers, antipsychotics stimulants, and alpha-2 antagonists) were evaluated. RESULTS: Controlling for the 2.3-fold rise in hospital admissions, there was a 73.0% increase in the use of psychotropic drugs from 1991-1998. The greatest relative increase was in the use of alpha-2 antagonists (from 3.3% to 23.6%). Significant increases were also observed for antidepressants (from 35.6% to 77.3%), mood stabilizers (from 14.9% to 32.6%), and stimulants (from 10.5% to 20.6%). Antipsychotic use showed no net change, although use of atypical agents largely supplanted that of conventional drugs. CONCLUSIONS: These findings document a marked and continuing increase in psychotropic drug use in child psychiatric inpatients during the 1990s. This trend occurred against a background of increased hospital admissions and shorter lengths of stay. Most of the increased use is accounted for by newer agents, even though data supporting their efficacy and safety in this population are limited.

Psychiatric diagnoses and comorbidity in relation to suicidal behavior among psychiatrically hospitalized adolescents.

This study examined relations between suicidal behavior history (i.e., no suicidality, suicidal ideation, single attempters, and multiple attempters) and psychiatric functioning. Adolescents, aged 12-17, admitted to an inpatient psychiatric unit, were categorized by suicidal behavior history based on self- and clinician-report data. Groups were examined for differences in suicidal ideation and psychiatric diagnosis. Severity of suicidal ideation increased with severity of suicidal behavior history. Females were disproportionately represented among multiple attempters. Multiple attempters were more likely to be diagnosed with at least one externalizing disorder, particularly substance use disorders, and to have more than one comorbid diagnosis than adolescents with no suicidal behavior or a history of ideation only. Clinicians should be alerted to the particularly high-risk nature of adolescents with multiple suicide attempts.

Multimethod assessment of suicidality in adolescent psychiatric inpatients: preliminary results.

OBJECTIVE: To examine agreement among multiple assessments of adolescent suicidal ideation and suicidal behavior for adolescent psychiatric inpatients, including pencil/paper checklists; structured and unstructured interviews; and adolescent, clinician, and parent reports, and to provide suggestions for the accurate and reliable assessment of suicidality in adolescence. METHOD: Participants included 153 adolescent psychiatric inpatients (54 boys, 99 girls) between the ages of 12 and 17 years. Measurement of suicidal ideation and behavior included common assessment instruments and standard clinical practices, including the Suicidal Ideation Questionnaire, NIMH Diagnostic Interview Schedule for Children, clinician interview, and parent report (Behavior Assessment Scale for Children). RESULTS: Results revealed significantly different rates of suicidality across each instrument and poor to moderate agreement between similar measures of adolescent suicidal ideation and suicidal behavior. Agreement between measures was generally best for boys, for older adolescents, and for assessments relying on a single informant. Reporters were most likely to agree on the presence of suicidality for more severely suicidal adolescents; this finding suggests that agreement in itself may be a useful marker for adolescent suicide. CONCLUSIONS: Results of this preliminary study supported the use of multiple measurement approaches when examining adolescent suicidality, particularly those that rely on clinician judgment and adolescents' own reports. Implications for future research and for clinical practice are also discussed.

Peer functioning, family dysfunction, and psychological symptoms in a risk factor model for adolescent inpatients' suicidal ideation severity.

Examined models of suicidal ideation severity that include two psychosocial risk factors (i.e., peer and family functioning) and four domains of psychological symptoms (i.e., generalized anxiety, depression, conduct problems, and substance abuse/dependence). Participants were 96 psychiatric inpatients (32 boys, 64 girls), ages 12 to 17, who were hospitalized because of concerns of suicidality. Adolescents completed a structured diagnostic interview, measures of suicidal ideation, and several dimensions of family and peer functioning. Results supported a model in which greater levels of perceived peer rejection and lower levels of close friendship support were associated directly with more severe suicidal ideation. In addition, indirect pathways included deviant peer affiliation and global family dysfunction related to suicidal ideation via substance use and depression symptoms. The results are among the first to demonstrate relations between suicidal ideation and several areas of adolescent peer functioning, as well as divergent processes for peer and family predictors of suicidal ideation.

A behavioral comparison of female adolescent inpatients with and without borderline personality disorder.

Patients with borderline personality disorder (BPD) are thought to have problematic hospitalizations. This study seeks to examine this phenomenon in adolescence by documenting the specific problem behaviors exhibited by patients, and the staff interventions in response to these behaviors in patients with and without BPD. Data were collected from the charts of 81 hospitalized adolescent girls regarding restraints, seclusions, incidents of self-abuse and aggression, incidents of signing the intent-to-leave form, nonroutine drug and/or alcohol screens, and discharges against medical advice. The two groups were compared using the analysis of variance (ANOVA) statistic for continuous variables and the chi-square statistic for the categorical variable. A follow-up multivariate ANOVA (MANOVA) was performed using the length of stay as a covariate. The BPD group displayed significantly higher rates of certain behaviors per day, but not of others. The length of stay was significantly higher in the BPD group. Further analysis indicated that some of the behavioral differences between the two groups may be due to the effect of the difference in length of stay. The data also suggest that while most BPD patients behave similarly to other patients, there may be a subset of BPD patients who behave in an extreme manner while hospitalized. BPD patients may display more of certain problematic behaviors than non-BPD patients in the hospital. However, it is hypothesized that these differences in hospital behavior may be largely due to the different lengths of stay between the two groups or to an acting-out subgroup of BPD patients.

Borderline personality disorder in adolescents: affective and cognitive features.

OBJECTIVE: To examine systematically the affective and cognitive features of borderline personality disorder (BPD) in adolescence, using standardized measures of these constructs and controlling for depression. METHOD: Nineteen depressed female adolescents with BPD were compared with 21 non-BPD depressed inpatients on measures of affect and cognitive style. RESULTS: Both BPD and non-BPD adolescents endorsed significantly elevated levels of self-reported depression, anger, anxiety, hopelessness, self-deprecatory attributional style, and external locus of control. Adolescents with BPD endorsed significantly poorer self-concept than their non-BPD peers; this difference was not an artifact of depressive severity. CONCLUSIONS: The findings indicate that adolescents with BPD experience significant impairments in self-concept, suggestive of pervasive emptiness and identity disturbance associated with BPD.

Panic disorder in children and adolescents.

Undiagnosed panic disorder may be a significant health problem in children and adolescents. Some of the adolescents and children who have presented for years with school refusal or psychogenic somatic complaints may suffer from this disorder and may benefit significantly from appropriate treatment.

Is major depressive disorder in childhood a distinct diagnostic entity?

One approach to validation of the construct of major depressive disorder in childhood was examined. Multivariate analyses of parents' responses on the Child Behavior Checklist (CBCL) were undertaken to determine whether a depressive symptom component would emerge and whether a group of children with pure depressive disorder could be isolated. The study involved 284 children (91 inpatients and 193 outpatients) aged 6 to 11 years. Principal components analyses identified a weak depression component among the CBCL items. Other components were aggressive, anxious, withdrawn, and immature. Cluster analyses designed to isolate a group of children with pure depressive disorder did not accomplish that goal. The results suggest that current enthusiasm for the diagnosis of major depressive disorder in children may be misplaced, and that a dimensional dysthymic syndrome that accompanies many other problems may better explain patterns of symptoms in children. The importance of the use of multiple methods to validate important psychiatric diagnoses is discussed.

Is major depressive disorder in adolescence a distinct diagnostic entity?

The concept of major depressive disorder in childhood and adolescence is reviewed and it is suggested that contemporary enthusiasm for this diagnosis may have outrun the evidence that it is a distinct categorical entity. To test the hypothesis that major depression is not a qualitatively distinct disorder in adolescence, but rather a continuously distributed, noncategorical syndrome, the behavioral rating scales (CBCL-P) of 216 hospitalized adolescent patients were analyzed first by principal components analysis and then by cluster analysis. Three behavioral syndromes were isolated by principal components analysis. Of three groups of patients identified by a subsequent cluster analysis, one was consistent with the concept of a categorically distinct "nuclear" depression. However, a noncategorical continuously distributed depressive syndrome appears to affect a larger number of patients in this age group, and the "nuclear" disorder may be less prevalent than is currently assumed. One explanation of these findings would combine a categorical model of nuclear depression with a dimensional model of dysthymia.

The characterization of depressive disorders in serious juvenile offenders.

The authors systematically evaluated a selected population of juvenile offenders for the prevalence of affective disorders. Seventy-one (40 male, 31 female) serious juvenile offenders were interviewed using the Schedule for Affective Disorders and Schizophrenia (SADS). They were then diagnosed using the Research Diagnostic Criteria (RDC) and the DSM-III. The Hamilton Rating Scales (HRS), Carroll Self-Rating Scale (CSRS), and Global Rating Scale for Depression (GRS) were also obtained for each subject. Eleven (15%) subjects were diagnosed as having an active major depressive disorder (MDDa), 6 (8%) subjects were diagnosed as having a major depressive disorder in remission (MDDr), and 9 (13%) as having a minor depressive disorder (mDD). The HRS, CSRS, and GRS differentiated the MDDa from the other three groups including MDDr, mDD and all other psychiatric diagnoses. RDC subtypes of depressive disorders were identified in those juvenile offenders with active major depressive disorders (MDDa) and compared to a population of hospitalized adolescents with major depressive disorders. There were significant differences in the distribution of the subtypes identified. Secondary, agitated and endogenous subtypes occurred significantly more often. The diagnostic, prognostic and therapeutic significance of these findings are discussed.