Early Intervention in Mood and Anxiety Disorders: The First Episode Mood and Anxiety Program (FEMAP).

The First Episode Mood and Anxiety Program (FEMAP) was developed for youth with mood and/or anxiety concerns in London, Ontario, to provide early intervention for these disorders, similar to the first-episode psychosis programs across Ontario and Canada. The logic and causal models of the pathway to and through FEMAP are described and inclusion/exclusion criteria are delineated. Results of the process evaluation of the model and preliminary data from a treatment-effectiveness evaluation and ongoing cost-comparison evaluation are provided. Several characteristic quotes from youth utilizing the service are included, as is an overview of utilization statistics. Challenges and lessons learned are conveyed.

Mentoring and role models in recruitment and retention: a study of junior medical faculty perceptions.

PURPOSE: This study explored the views of junior faculty toward informing mentorship program development. METHOD: Mixed sampling methodologies including questionnaires (n = 175), focus groups (female, n = 4; male, n = 4), and individual interviews (female n = 10; male, n = 9) of junior faculty were conducted in clinical departments at one academic health sciences center. RESULTS: Questionnaire results indicated that having role models increased commitment to an academic career; mentorship experience during residency training was a high incentive to pursue an academic career; and junior faculty did have identifiable mentorship experiences. Focus group results revealed that mentoring as well as the presence of role models a few years ahead of the junior faculty would promote career development. Females preferred similar age role models who spoke the same language, particularly in the area of promotion. Females identified several challenges and issues including a lack of researcher role models, a range of perceptions regarding the merits of formal versus informal mentoring, and the idea that mentors should provide advice on promotion and grants. Males valued advice on finances while females wanted advice on work-life balance. CONCLUSIONS: Mentorship emerged as an important factor in academic faculty recruitment and retention, with varying perceptions of how it should be institutionalized. Role models were viewed as important for retention, and a paucity of mid-career, female researcher role models suggests a gap to be filled in future programmatic efforts.

Managing depression in primary care: community survey.

OBJECTIVE: To investigate family physicians' practice patterns for managing depression and mental health concerns among adolescent and adult patients. DESIGN: Cross-sectional survey. SETTING: London, Ont, a mid-sized Canadian city. PARTICIPANTS: One hundred sixty-three family physicians identified through the London and District Academy of Medicine. MAIN OUTCOME MEASURES: Practice patterns for managing depression, including screening, pharmacotherapy, psychotherapy, shared care, and training needs. RESULTS: Response rate was 63%. Family physicians reported spending a substantial portion of their time during patient visits (26% to 50%) addressing mental health issues, with depression being the most common issue (51% to 75% of patients with mental health issues). About 40% of respondents did routine mental health screening, and 60% screened patients with risk factors for depression. Shared care with mental health professionals was common (care was shared for 26% to 50% of patients). Physicians and patients were moderately satisfied with shared care, but were frustrated by long waiting lists and communication barriers. Most physicians provided psychotherapy to patients in the form of general advice. Differences in practice patterns were observed; physicians treated more adults than adolescents with depression, and they reported greater comfort in treating adults. Although 33% of physicians described using cognitive behavioural therapy (CBT), they reported having little training in CBT. Moderate interest was expressed in CBT training, with a preference for a workshop format. CONCLUSION: Although 40% of family physicians routinely screen patients for mental health issues, depression is often not detected. Satisfaction with shared care can be increased through better communication with mental health professionals. Physicians' management of adolescent patients can be improved by further medical training, consultation, and collaboration with mental health professionals. Training in evidence-based treatment of depression is particularly warranted given physicians' limited knowledge of CBT.

International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions.

Researchers and clinicians worldwide share concerns that many youngsters with attention-deficit/hyperactivity disorder (ADHD) and/or disruptive behaviour disorders (DBDs) do not receive appropriate treatment despite availability of effective therapies. At the request of Johnson and Johnson (sponsor), 11 international experts in child and adolescent psychiatry were selected by Professor Stan Kutcher (chair) to address these concerns. This paper describes the experts' consensus conclusions, including treatment practice suggestions for physicians involved in the early treatment of youngsters with ADHD (or hyperkinetic disorder, in countries preferring this classification) and/or DBDs internationally: suggested first-line treatment for ADHD without comorbidity is psychostimulant medication aided by psychosocial intervention. For ADHD with comorbid conduct disorder (CD), psychosocial intervention combined with pharmacotherapy is suggested. For primary CD, suggested first-line treatment is psychosocial intervention, with pharmacotherapy considered as an 'add-on' when aggression/impulsivity is marked and persistent. Pharmacotherapy requires careful titration; full-day coverage is the suggested goal. Regular long-term follow-up is recommended.

Long-term safety and efficacy of risperidone for the treatment of disruptive behavior disorders in children with subaverage IQs.

OBJECTIVE: The objective of this study was to investigate the long-term safety and efficacy of risperidone in disruptive behavior disorders in children with subaverage IQs. Disruptive behavior disorders were defined as oppositional defiant disorder, disruptive behavior disorder, and conduct disorder as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. METHODS: This was a 48-week open-label (OL) extension study of risperidone in 77 children diagnosed with a disruptive behavior disorder, and either borderline intellectual function or mild or moderate mental retardation who had participated in a previous 6-week, double-blind (DB) study and completed at least 2 weeks of DB therapy. Children, aged 5 to 12 years inclusive, who had: 1) a DSM-IV Axis I diagnosis of conduct disorder, oppositional defiant disorder, or disruptive behavior disorder- not otherwise specified; 2) a parent-assessed rating of > or =24 in the Conduct Problem Subscale of the Nisonger-Child Behavior Rating Form(28); 3) a DSM-IV Axis II diagnosis of mild or moderate mental retardation or borderline intellectual functioning with an IQ > or =36 and < or =84; and 4) a score of < or =84 on the Vineland Adaptive Behavior Scale. Participants received oral solution risperidone given at a once daily dose of between 0.02 and 0.06 mg/kg for a maximum of 48 weeks. Participants in the DB study who had been randomized would have had a maximum of 54 weeks of risperidone therapy. Study visits were scheduled at entry, weekly for the first month, and monthly for the remaining 11 months. RESULTS: Baseline scores on the conduct problem subscale at the start of the previous DB study were similar for both treatment groups: mean values of 33.5 and 33.3 were recorded for placebo- and risperidone-treated participants, respectively. At the time of the OL baseline visit, mean Conduct Problem Subscale scores were lower in those who had been treated with risperidone than in those who remained risperidone-naïve (17.5 and 26.1, respectively). Within 1 week of receiving daily risperidone therapy (mean daily dose: 1.38 mg), those participants who had been risperidone-naïve at OL entry showed a rapid improvement in the Conduct Problem Subscale score. At the week 1 assessment, the mean change from baseline for those who had been risperidone-naïve at OL entry was similar in magnitude to the change from DB baseline recorded for participants who had received risperidone in the DB study. This mean improvement was sustained in both groups throughout the remainder of the OL study. At study endpoint, those participants who had been risperidone-naïve at OL entry experienced a highly significant mean decrease from OL baseline in the mean Conduct Problem Subscale score of 10.6 +/- 2.18. The response to risperidone in the OL trial remained stable in those participants who had been treated with risperidone in the previous DB trial; in this group, the mean change at study endpoint from OL baseline was a nonsignificant decrease of 1.26 +/- 1.45. At DB baseline, 68% of participants had a Clinical Global Impression assessment rated as marked, severe, or extremely severe. By DB study endpoint, only 17% of participants (15% of whom had received placebo and 19% of whom had been treated with risperidone in the previous study) had this severe an assessment; 63% of participants had symptoms rated as either none, very mild, or mild. Similarly, highly significant decreases from baseline in the Vineland Adaptive Behavior Scale rating of the most troublesome symptom (often identified as either aggression (hitting, fighting, or temper tantrums) were observed by study endpoint after 48 weeks of risperidone therapy. For those participants who had received placebo in the previous study, a mean decrease of 47.1 +/- 4.87 mm from a DB baseline of 79.4 +/- 2.69 mm was observed. In those who had received risperidone, a mean decrease of 43.5 +/- 4.57 mm from a DB baseline of 79.3 +/- 3.66 mm was observed. Five subgroup analyses of the primary efficacy outcome were performed. These included analysis by diagnosis (conduct disorder, oppositional defiant disorder, and disruptive behavior disorder-not otherwise specified), degree of mental retardation (borderline, mild, moderate), and presence or absence of somnolence, attention-deficit/hyperactivity disorder, and psychostimulants. The results showed that the efficacy of risperidone was not affected by type of disorder, level of retardation, presence/absence of somnolence or attention-deficit/hyperactivity disorder, or use of psychostimulants. Adverse events were reported for 76 participants; none were serious and most were mild/moderate in severity. Somnolence (52%), headache (38%), and weight gain (36%) were the most common adverse events. The degree of sedation was mild and not associated with cognitive deterioration. In fact, for most parameters assessed on the modified California Verbal Learning Test (a test for verbal learning and memory), there were statistically significant improvements relative to both OL and DB baselines in the mean scores. In addition, statistically significant improvements over baseline were also seen for some Continuous Performance Task (which is a test for attention and impulsivity) parameters. Overall, no deterioration of cognitive function was observed while participants were treated with risperidone. Almost half of the 8.5 kg gained was attributable to normal growth. Asymptomatic peak prolactin levels were observed within 4 weeks of beginning risperidone treatment and declined over time to within normal range. At study endpoint, mean prolactin levels were statistically significantly greater than baseline only in male participants but still <20 ng/mL, which is within the normal range. Twenty participants experienced mild or moderate extrapyramidal symptoms, although none withdrew for this reason. CONCLUSIONS: Risperidone, administered as an oral solution at a mean dose of 1.38 mg/d (range: 0.02-0.06 mg/kg/d) for 1 year, was well tolerated, safe, and showed maintenance of effect in the treatment of disruptive behavior disorders in children aged 5 to 12 years with subaverage IQs.

Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs.

OBJECTIVE: To determine whether risperidone is effective in reducing symptoms of disruptive behaviors (such as aggression, impulsivity, defiance of authority figures, and property destruction) associated with conduct disorder, oppositional defiant disorder, and disruptive behavior disorder-not otherwise specified in children with subaverage IQs. METHOD: The trial consisted of a 1-week, single-blind, placebo run-in period and was followed by a 6-week, double-blind, placebo-controlled period. One hundred ten children (aged 5-12 years inclusive) with an IQ of 36-84 with a disruptive behavior disorder and a score of at least 24 on the Conduct Problem subscale of the Nisonger Child Behavior Rating Form (NCBRF) were enrolled. Eighty percent of subjects had comorbid attention-deficit/hyperactivity disorder (ADHD). Risperidone doses ranged from 0.02 to 0.06 mg/kg per day. Subjects were rated on the NCBRF, Aberrant Behavior Checklist, Behavior Problems Inventory, Clinical Global Impressions (CGI), modified California Verbal Learning Test (CVLT), and a continuous performance task (CPT). RESULTS: The intention-to-treat analysis of risperidone-treated subjects showed a significant (p < .001) reduction in mean scores (from 33.4 at baseline to 17.6 at end point; 47.3% reduction) versus placebo-treated subjects (mean baseline of 32.6 to 25.8 at end point; 20.9% reduction) on the Conduct Problem subscale of the NCBRF. Between-group differences in favor of risperidone were seen as early as week 1 and were significant at all post-baseline visits. Other subscales showed significant improvement with risperidone compared with placebo. CGI scale ratings of improvement showed highly significant gains for risperidone over placebo. A subanalysis demonstrated that the effect of risperidone was unaffected by diagnosis, presence/absence of ADHD, psychostimulant use, IQ status, and somnolence. Risperidone produced no changes on the cognitive variables (CPT/modified CVLT). The most common side effects included somnolence, headache, appetite increase, and dyspepsia. Side effects related to extrapyramidal symptoms were reported in 7 (13.2%) and 3 (5.3%) of the subjects in the risperidone and placebo groups, respectively (p = .245). CONCLUSIONS: Risperidone appears to be an adequately tolerated and effective treatment in children with subaverage IQs and severe disruptive behaviors such as aggression and destructive behavior.