Trends for Electroconvulsive Therapy Utilization in Children and Adolescents in the United States From 2002 to 2017: A Nationwide Inpatient Sample Analysis.

OBJECTIVES: Electroconvulsive therapy (ECT) is controversial in children and adolescents (C/A). The primary objective of this study was to evaluate baseline characteristics of C/A in the utilization of ECT compared with the non-ECT group with the same primary indication. The secondary objective was to assess the trends in ECT utilization over 16 years and explore the predictors of length of stay. METHODS: Using the Nationwide Inpatient Sample database from the years 2002 to 2017, we identified patients (age ≤18 years) undergoing ECT in the United States using International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification/Procedure Coding System codes and compared with non-ECT C/A patients with the same primary diagnosis. Baseline clinical characteristics were assessed using descriptive analysis methods. Multilevel regression analysis and trend analysis were performed. RESULTS: Children and adolescent patients (n = 159,158) receiving (ECT: n = 1870) were more likely to be men (43.3% vs 36.7%) and of White race (58% vs 49%) (P < 0.001). The hospital stay was longer (19 days vs 6 days, P < 0.001) for the ECT group than controls. ECT receiving C/A patients were more likely to have private insurance (72% vs 42%, P < 0.001). African American patients undergoing ECT treatment increased in number over the course of years (2002 to 2017), whereas the privately insured C/A patients receiving ECT decreased over the same period (P < 0.001). There was an upward trend in ECT utilization for small bed size hospitals (P < 0.001). Length of stay for C/A receiving ECT was longer for males (P < 0.001) and patients with nonprivate insurance (p: 0.003). CONCLUSIONS: Electroconvulsive therapy is not optimally used in C/A; therefore, formulated treatment guidelines are required.

White matter tract integrity is associated with antidepressant response to lurasidone in bipolar depression.

OBJECTIVES: Patients with bipolar disorder spend the most time in the depressed phase, and that phase is associated with the most morbidity and mortality. Treatment of bipolar depression lacks a test to determine who will respond to treatment. White matter disruptions have been found in bipolar disorder. Previous reports suggest that white matter disruptions may be associated with resistance to antidepressant medication, but this has never been investigated in a prospective study using a Food and Drug Administration (FDA)-approved medication. METHODS: Eighteen subjects with bipolar disorder who were in a major depressive episode and off all medications were recruited. Magnetic resonance imaging was acquired using a 64-direction diffusion tensor imaging sequence on a 3T scanner. Subjects were treated with 8 weeks of open-label lurasidone. The Montgomrey-Asberg Depression Rating Scale (MADRS) was completed weekly. Tract-Based Spatial Statistics were utilized to perform a regression analysis of fractional anisotropy (FA) data with treatment outcome as assessed by percent change in MADRS as a regressor while controlling for age and sex, using a threshold of P (threshold-free cluster enhancement-corrected) <.05. RESULTS: FA was positively correlated with antidepressant treatment response in multiple regions of the mean FA skeleton bilaterally, including tracts in the frontal and parietal lobes. CONCLUSIONS: Greater disruptions in the white matter tracts in bipolar disorder were associated with poorer antidepressant response to lurasidone. The disruptions may potentially indicate treatment with a different antidepressant medication class. These results are limited by the open-label study design, sample size and lack of a healthy control group.

Modafinil Treatment of Cocaine Dependence: A Systematic Review and Meta-Analysis.

BACKGROUND: Currently, there is none FDA-approved medication to treat cocaine dependency. Studies conducted with various medications, including antipsychotics, antidepressants, anticonvulsants, and others, revealed inconsistent results. OBJECTIVES: To meta-analytically investigate the efficacy and safety of modafinil in the treatment of cocaine-dependent patients. METHODS: Randomized controlled trials with ≥20 subjects comparing the numerical therapeutic outcomes of modafinil with placebo were identified in databases, such as PUBMED, psycINFO, EMBASE, and Clinicaltrials.gov. Relevant data on efficacy and safety were extracted. Relative risk (RR) and standardized mean difference were applied for reporting dichotomous and continuous outcomes respectively. Random effects, subgroup, and meta-regression analyses were conducted to further explore the results and evaluate for any moderators. RESULTS: In total, 11 studies (participants = 896, duration = 6.7 ± 1.9 weeks) comparing modafinil with placebo were systematically analyzed, which indicated that modafinil was not superior to placebo in improving the treatment retention rate (studies = 11, participants = 891, RR = 1.030, 95% CI = 0.918-1.156, p = .613). Similarly, data from 7/11 studies did not evidence superiority of modafinil in achieving cocaine abstinence (participants = 696, RR = 1.259, 95% CI = 0.813-1.949, p = .302). However, subgroup analysis of six studies conducted in the United States demonstrated superiority of modafinil in cocaine abstinence rate (studies = 6, participants = 669, 95% CI = 1.027-2.020, p = 0.035). In addition, no evidence suggested modafinil-related discontinuation or specific adverse events than placebo. CONCLUSIONS: Overall, there is no evidence to conclude superiority of modafinil in increasing cocaine abstinence and treatment retention rate. However, promising result in subgroup analysis of cocaine abstinence, secondary outcomes, and good safety profile urged the need of larger studies to derive more conclusive results.

Sexual Abuse and Its Impact on Suicidal Ideation and Attempts and Psychiatric Illness in Children and Adolescents With Posttraumatic Stress Disorder.

Objective: Sexual abuse in minors aged 6-17 years is a significant public health concern. Victims of sexual abuse are at risk of developing complex psychopathology and chronic suicidal thoughts. Posttraumatic stress disorder (PTSD) develops in one-third of minors with a history of sexual abuse. The primary objective of this study was to assess the baseline characteristics of minors with PTSD and a history of sexual abuse (PTSD+S) compared with minors with PTSD without sexual abuse (PTSD only). The secondary objective was to evaluate the psychiatric comorbidities and suicidal ideation/attempts between the groups.Methods: The National Inpatient Sample database from 2006 to 2014 was analyzed using the ICD-9 code for PTSD and history of sexual abuse. PTSD+S (n = 251) subjects were compared with those with PTSD only (n = 24,243) using t test and χ2 test. Univariate and multivariate logistic regression analyses were performed with suicidal behavior (suicidal ideation/attempt) as the outcome and PTSD with and without sexual abuse, sex, age, and other psychiatric comorbid conditions as independent variables.Results: More patients in the PTSD+S group were nonwhite (52% vs 42%, P < .001) and female (81% vs 66%, P < .001) compared to PTSD only patients. Also, more patients were Hispanic in the PTSD+S group compared to the PTSD only group (28% vs 13%). Major depressive disorder (MDD; 23% vs 14%, P < .001) and substance use disorder (SUD; 20% vs 11%) were more commonly diagnosed psychiatric comorbidities in the PTSD+S group (P < .001). Suicidal behavior (suicidal ideation/attempt) was higher in the PTSD+S group than in PTSD only patients (36% vs 30%, P = .05). Overall, the risk of suicidal behavior was 29% higher in the PTSD+S group than in PTSD only patients (odds ratio [OR] = 1.29, P = .05). In the multivariate analysis, after controlling for age and sex, comorbid diagnosis of MDD (OR = 1.66, P < .001) and SUD (OR = 1.18, P < .001) was associated with increased suicidal behavior. However, PTSD+S showed no association with suicidality (OR = 1.16, P = .29) in the multivariate analysis.Conclusions: Sexual abuse is associated with PTSD and higher risk of comorbid psychiatric illnesses, including MDD, SUD, and suicidal behavior. In-depth research on the relationship between child and adolescent sexual abuse and chronic suicidality is warranted.

Human Umbilical Cord Blood Infusions in the Management of Autism Spectrum Disorder.

Objective: To provide an overview of the role of umbilical cord blood (UCB) in managing autism spectrum disorder (ASD) symptoms in children aged 4-8 years.Data Sources: A systematic literature search was conducted using the terms (autism OR autism spectrum disorder AND umbilical cord blood infusion UCB OR umbilical cord blood). The review was limited to articles published in the English language from 1945 to September 2020. The database search included PubMed, Scopus, and EMBASE.Study Selection: The initial search revealed 165 hits of potential relevance.Data Extraction: The articles were analyzed to obtain clinical information relevant to meeting the review objectives.Data Synthesis: After title, abstract, and full article review, 3 UCB studies were selected for analysis.Results: The systematic review showed mixed results. In the first study, improvements were seen in the socialization and communication domains and adaptive behavior with UCB infusion. The Pervasive Developmental Disorder Behavior Inventory composite T score and Expressive One-Word Picture Vocabulary Test (EOWPVT) score also improved. Symptomatic improvement was seen in half of the patients. The second study showed no improvement in the EOWPVT, Receptive One-Word Picture Vocabulary Test, Clinical Global Impressions scale, or Vineland Adaptive Behavior Scales (VABS), second edition. The third study showed nonsignificant improvement in the VABS, third edition socialization scale scores; however, major improvement in the communication domain was seen for those with nonverbal IQ ≥ 70. No serious adverse events were reported in any of the studies.Conclusion: Few studies have evaluated the role of UCB infusion in addressing symptoms of ASD. Due to the limited number of studies, more research is warranted.

Clozapine for Management of Childhood and Adolescent-Onset Schizophrenia: A Systematic Review and Meta-Analysis.

Background: Schizophrenia at a young age deserves investigation because of the greater severity and burden of illness on individuals and health care than its adult onset. For this study, we included both childhood-onset schizophrenia and early-onset schizophrenia. We used the common term "childhood and adolescent-onset schizophrenia (CAOS)" for either type. This systematic review provides an overview of the clinical use, efficacy, and safety of clozapine treatment in managing CAOS. Methods: We conducted a systematic literature search in PubMed, Embase, and PsycINFO databases. We searched for randomized controlled trials (RCTs), open-label studies (OLSs), review articles, meta-analytic and observational studies. Our literature search resulted in 1242 search results. After the title, abstract, and full article review, 18 studies qualified (double-blind RCTs n = 4; OLS n = 4; observational studies n = 7; case reports n = 3). Results: Clozapine use in CAOS was generally well tolerated and not associated with any fatalities. Clozapine use in the short term (6 weeks) and long term (2-9 years) was superior in efficacy than other antipsychotics in CAOS management. Improvement in overall symptoms was maintained during long-term follow-up over the years in OLSs. Clozapine appeared to have a favorable clinical response and shorter hospital stays. Sedation and hypersalivation were commonly reported (90%), constipation was next in frequency (13%-50%). Neutropenia was seen in 6%-15% of cases and agranulocytosis (<0.1%). Although weight gain was common (up to 64%), followed by metabolic changes (8%-22%), treatment-onset diabetes was less frequent (<6%). Akathisia, tachycardia, and blood pressure changes were less commonly seen. Conclusions: Limited studies indicate that clozapine is a safe and efficacious option for CAOS management. We need large-scale and well-designed long-term RCTs for the use of clozapine in the management of CAOS.

How Are Attention-deficit Hyperactivity and Internet Gaming Disorders Related in Children and Youth?

OBJECTIVES: This review addresses important practical questions facing clinicians regarding internet gaming disorder (IGD) and attention-deficit/hyperactivity disorder (ADHD) in children and youth (C-Y). The authors investigated data concerning the risk that C-Y who have ADHD will develop IGD, whether effective treatment of ADHD positively influences the course of IGD in C-Y who have both, and other findings that might be of benefit to clinicians who treat C-Y with these conditions. METHODS: We conducted a literature review using 4 databases: PubMed, Scopus, PsychInfo, and Embase. RESULTS: C-Y with ADHD are at greater risk for developing IGD than those without ADHD. A close association exists between the severity of ADHD symptoms and the severity of IGD. It is unknown what proportion of C-Y with ADHD will develop IGD during their developmental trajectory; however, C-Y with IGD are at risk for developing ADHD, and ADHD can also increase the vulnerability of C-Y to IGD. Adolescents with ADHD and IGD have greater deficits in social skills than those with ADHD but no IGD. Lower parental occupational and socioeconomic status and poor family relationships are associated with more severe IGD symptoms. Atomoxetine and methylphenidate are equally effective in alleviating IGD symptoms comorbid with ADHD. CONCLUSIONS: C-Y with ADHD are at increased risk for developing IGD compared with C-Y without ADHD, but it has not been determined at what developmental stage IGD is likely to emerge. Since IGD and ADHD are strongly associated, it is imperative to consider ADHD as a significant risk factor for IGD and vice versa, which can help psychiatrists be alert for early signs of IGD and manage them accordingly.

Psychopharmacology of Pediatric Anxiety Disorders: A Narrative Review.

Anxiety disorders are common among children and adolescents; almost one-third of this population has an anxiety disorder. The most common anxiety disorders in this population are specific phobia (19.3%), social anxiety disorder/ social phobia (9.1 %), and separation anxiety disorder (7.6 %). Pediatric anxiety disorders are often associated with poor psychosocial functioning, academic underachievement, learning difficulties, substance abuse, relationship problems, and suicide behaviors. Psychotherapy, particularly cognitive behavioral therapy as a stand-alone treatment or in combination with medication, is found to be efficacious in the treatment of various anxiety disorders. The early recognition and treatment of anxiety disorders result in better long-term outcomes in children and adolescents. This article summarizes the evidence-based pharmacologic treatments for anxiety disorders in youth, including social anxiety disorder generalized anxiety disorder, separation anxiety disorder, and panic disorder.

A systematic review on treatment of tardive dyskinesia with valbenazine and deutetrabenazine.

Recent reports state that the prevalence of tardive dyskinesia (TD) is 32% with typical antipsychotics, and 13% with atypical antipsychotics. Current evidence-based recommendations determine an unmet need for efficacious treatment of TD. This systematic review was planned to update the evidence for TD treatment, comparing two vesicular monoamine transporter 2 (VMAT2) inhibitors, deutetrabenazine (DBZ), and valbenazine (VBZ). Of 75 PubMed search results, 11 studies met the review criteria. Efficacy and tolerability were demonstrated in a series of randomized, placebo-controlled clinical trials in our review study, and the Abnormal Involuntary Movement Scale response of ⩾50% reduction in score was robust for VBZ 80 mg/day in short-term and long-term studies. On the contrary, DBZ was equally efficacious at 12 mg twice daily, but additional information about long-term efficacy and persistence of effect is needed.