Leo J. Bastiaens, MD

We invite you to answer the following question after reading the Case Vignette. Discussion follows on the next page. 

On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why?

Betty is a 10-year-old girl who initially presented to outpatient psychiatric care for severe temper outbursts-rages precipitated by minor issues. These lasted for 1 to 2 hours and included destruction of property, physical aggression, and suicidal threats. Bipolar disorder was diagnosed. She was initially treated with quetiapine and later with a combination of quetiapine and valproic acid. The medical record did not mention symptoms related to major depression, mania, ADHD, or anxiety.

Several months later, the Betty was hospitalized because of ongoing destructive psychiatric episodes. During the hospitalization, she was given a diagnosis of major depressive disorder and treatment with an antidepressant in conjunction with quetiapine was started. The hospital psychiatrist did not consider the outbursts as an indication of bipolar disorder; there was no record of manic symptoms.

Subsequent to the hospitalization, the patient was evaluated with the Mini International Neuropsychiatric Interview (MINI). During the evaluation, the presence of significant depressive symptoms, including low mood, reduced interest level in several activities, insomnia and fatigue, self-derogatory thinking, and poor concentration, were identified. Betty and her mother described a 5-day episode of clear hypomanic symptoms that had occurred 8 months earlier: euphoria, decreased need for sleep, grandiosity, very fast speech, and an increased activity level. A similar episode, of 2 days’ duration, occurred 4 months after the initial episode.

There were no symptoms of ADHD and no psychosis, trauma, PTSD, significant anxiety, or substance use. The family history was positive for bipolar disorder, although this could not be verified.

On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why? 

Poor Practice, Managed Care, and Magic Pills: Have We Created a Mental Health Monster?

-I attributed the overdiagnosis of pediatric bipolar disorder to poor diagnostic practices and contemporary insurance and societal pressures.

 The responsibility for improvement was placed on psychiatrists: diagnostic skills had to be improved and patients and their families and caregivers as well as the general public needed to be better educated about the disorder and treatment options. Here, I will discuss how diagnostic accuracy can be significantly enhanced through the use of structured psychiatric interview tools, such as the MINI.

This case clearly demonstrates that with clinical interviewing only, the correct diagnosis was made, but for the wrong reason (bipolar disorder diagnosis made because of rages), while the wrong diagnosis was made because of the right reason (major depressive disorder; rages not considered as symptom for bipolar disorder). However, a structured approach with a validated clinical tool identified major depressive symptoms and at least 1 hypomanic episode, which indicated a bipolar spectrum condition, regardless of severe angry outbursts.

Severe temper dysregulation, angry outbursts, and rages are not part of the diagnostic criteria for bipolar disorder, which requires a cyclical condition that includes core manic symptoms.

 Although outbursts can be part of bipolar disorder, they also occur in depressive disorders, ADHD, conduct disorder, and anxiety disorders and thus are not diagnostic in their own right. Structured interviews force the clinician to evaluate core symptoms of different disorders. In this case, neither the outpatient nor the inpatient psychiatrist identified core manic symptoms with unstructured clinical interviewing. In addition, benefits of using a structured interview include systematic evaluation of comorbidity and homogeneity of diagnostic assessments.

It is becoming increasingly important to differentiate pediatric bipolar disorder from other mood dysregulation syndromes. Ongoing research shows that in children who have mood disorders without core manic symptoms, bipolar disorder does not develop in later years, despite the severe impairment related to their temper dysregulation episodes.

There is ongoing research to evaluate whether different treatment approaches, other than mood stabilizers, are more effective in children with nonbipolar mood disorders. Thus, correctly diagnosing severe mood-related symptoms in youths is not an academic exercise; it is needed to help make correct treatment decisions-behavioral and pharmacological.

Weigh in with your comments below. Dr Bastiaens will review your responses and give his feedback in coming weeks.

Articles

The responsibility for improvement was placed on psychiatrists: diagnostic skills had to be improved and patients and their families and caregivers as well as the general public needed to be better educated about the disorder and treatment options.

Severe Temper Outbursts in a 10-Year-Old Girl

Anyone working in the mental health field will recognize that in patients with extreme irritability, explosive behavior, or quick mood changes, bipolar disorder (BD) is often unquestionably diagnosed. Thus, it is no surprise that a recent US study indicated a 10-year 40-fold increase in BD diagnosis in pediatric patients.

Three factors are largely responsible for the phenomenon described in the 

 poor practice, managed care, and a pill-pushing society.

 Even though the standard of care in psychiatry is structured around standardized assessments and measurement-based practice, this may not be adhered to in community clinics, private practices, and even academic centers. In addition, residents and fellows in training may not have been exposed to structured interviewing. Clearly, this perpetuates unstructured interviewing and impressionistic diagnostic assessments in clinical settings.

 Many managed care companies do not allow those patients who are clearly a danger to self or others to be admitted to acute psychiatric units with diagnoses such as substance use disorders, conduct disorders, and intermittent explosive disorders. Combined with impressionistic diagnostic practices, this phenomenon makes BD the diagnosis of choice to get reimbursement for evaluation and treatment.

 Rather than taking responsibility for interpersonal and family dynamics, or going through labor-intensive psychotherapeutic interventions, many parents opt for the quick fix of a BD diagnosis. A diagnosis of BD not only justifies psychopharmacological interventions, but it also arguably absolves the family of personal responsibility. The fact that managed care has led to pharmacotherapy being less expensive than intensive psychotherapy has enhanced the “McDonaldization” of mental health care.

The overdiagnosis of BD in children, adolescents, and adults has lost its utility, because it encompasses patients with “true” BD and a variety of other disorders (eg, attention-deficit/hyperactivity disorder, conduct disorder, substance use disorders, personality disorders). This state of affairs will continue until the psychiatric field and its practitioners take a strong stance for evidence-based medicine.

Police have brought a 15-year-old boy with severe agitation to the emergency department (ED). He trashed his room and threatened to kill his parents. He has a long history of explosive behavior. Police are willing to drop charges if he is admitted to the hospital. The patient’s parents express their concern to the ED physician that their son may have BD.

After taking a rudimentary history, the hospital admits the patient with a diagnosis of BD. The ED physician knows that the patient’s managed care organization will not allow inpatient admission with a diagnosis of conduct disorder. No standardized/structured psychiatric evaluation is performed on patients admitted to the inpatient unit.

Doctors give the patient an atypical antipsychotic and discharge him. He is referred to a busy outpatient clinic, where the admitting and discharge diagnosis of BD is taken at face value, no further evaluation is done, and the patient’s regimen of an atypical antipsychotic is continued. No specific psychotherapy or parent management training is instituted. The parents insist on maintaining their son’s current pharmacotherapy regimen. Because of their son’s diagnosis, the parents have begun the process of applying for Social Security benefits on his behalf.

The prime responsibility to correct this state of affairs rests on psychiatrists and the psychiatric field. At the present time, there is sufficient evidence to support structured interviewing and measurement-based practice. Several studies have shown the feasibility of these practices, even in busy community clinics.

 There is sufficient evidence to show that explosiveness, mood lability, and extreme irritability do not necessarily equal BD.

A 2008 study underscores the validity of structured interviewing and outcome assessments in busy community clinics.

 The study shows a significant differential response to treatment in children with BD versus non-bipolar mood disorders characterized by extreme irritability and explosiveness. In fact, a growing line of research shows that in children with severe irritability but without core features of mania, BD does not develop in later life.

It is therefore paramount that the correct diagnosis is made.

A diagnosis has treatment and prognostic implications. Even though the treatment of youths with severe mood disorder without BD is currently not well researched, it is hoped that future studies will elucidate more specific treatments for these children. The consideration in DSM-5 of a new diagnostic category for youths with severe mood disorders without BD may help in this regard. The following suggestions are offered to help remedy this problem:

 There are several advantages to this tool. It forces the evaluator to focus on core symptoms of specific syndromes, thereby avoiding impressionistic and incomplete assessments. The core symptoms of BD during a manic episode include developmentally inappropriate euphoria, developmentally inappropriate grandiosity, decreased need for sleep, racing thoughts and flight of ideas, and hypersexual behavior.

 Explosiveness, anger, low frustration tolerance, and quick mood changes are not part of the core symptoms of mania.

Structured interviewing forces the evaluator to explore comorbidity, which helps in the differential diagnostic formulation. For example, the uncovering of psychotic symptoms in an extremely irritable adolescent has a totally different meaning than the uncovering of conduct disorder symptoms in the same individual.

Diagnosis-specific screening tools and rating scales. 

Currently, several clinician-friendly structured interviews are available. Repeated use of available diagnosis-specific rating scales as screening tools or outcome measures will help in an ongoing differential diagnostic process. The Mood Disorder Questionnaire (MDQ) and the Parent Version of the Young Mania Rating Scale (P-YMRS) are helpful tools for differentiating core manic symptoms from other severe mood-disordered symptoms.

Psychiatric trainees should be educated about the use of structured interviews, rating scales, and outcome measures beginning in their first postgraduate year. In our clinic, medical students rotating through the outpatient program are exposed to structured interviewing of patients and are encouraged to participate in this activity. Social work and psychology students should be trained in evidence-based psychotherapy so that diagnosis-specific psychosocial treatments can be implemented.

Psychiatric associations should do a much better job educating the public and insurance companies about what constitutes proper psychiatric practice (eg, diagnostic tools, practices, criteria).

Various forces have created an enormous problem with the BD diagnosis. This problem affects many patients, families, and society at large. Patients may be inappropriately treated with medications, parents may not obtain the proper treatment for their children, and society may be paying a hefty price in the form of pharmacy costs, disability costs, and Social Security benefits without proper justification.

As physicians, we need to take up our responsibility and institute state-of-the-art evaluation and treatment methods based on the best available evidence.

 Moreno C, Laje G, Blanco C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. 

 Bastiaens L. Adolescents’ response to antidepressant treatment in a community mental health center. 

 Bastiaens L. Both atomoxetine and stimulants improve quality of life in an ADHD population treated in a community clinic. 

 Rich BA, Schmajuk M, Perez-Edgar KE, et al. Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. 

 Bastiaens L, Bastiaens J. Severely mood-disordered youth respond less well to treatment in a community clinic than youth with bipolar disorder. 

 Brotman MA, Schmajuk M, Rich BA, et al. Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. 

 Geller B, Zimerman B, Williams M, et al. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality. 

 Youngstrom E, Meyers O, Demeter C, et al. Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings. 

 Anyone working in the mental health field will recognize that in patients with extreme irritability, explosive behavior, or quick mood changes, bipolar disorder (BD) is often unquestionably diagnosed. 

The increase in youth violence and aggression in the past 50 years has been called an "epidemic."

 This epidemic has had a tremendous impact on society. From an economic and public health perspective, primary prevention of youth violence is obviously desirable. From a clinical perspective, evaluation and treatment of aggression is a primary concern. In this review, we discuss the economic impact of youth aggression, with an emphasis on the rationale for primary prevention; the use of current knowledge to guide evaluation and treatment of aggression in the clinical setting; and recent reports on pharmacotherapy in aggressive youths.

Before taking into account the costs of juvenile justice programs and institutions, youth violence alone costs the United States more than $158 billion each year.

 Violent crime peaks in the late teenage years, despite spending nearly 15% of the gross domestic product on the upbringing and education of children.

 Obviously, juvenile violence remains a serious societal issue with a significant financial burden. Perhaps it is necessary to both reallocate resources and readjust attitudes to combat, prevent, and treat youth violence and delinquency in a sustainable and efficient manner.

 investigated the trade-off between imprisonment funding and potential social spending. They explained that if they could "identify and treat the worst 6% of delinquents and reduce their crime rate by 20%, [their] thought experiment of shifting resources from imprisonment to social programs would likely reduce crime or maintain it at the same level."

It is important to note that the 20% was derived from an adjustment made to the hypothetical result of a preschool intervention program that modeled the Perry Preschool Program (which generated a 40% reduction in crime among its participants).

 The social spending in Donohue and Siegelman's investigation

 could hypothetically be applied to large-scale programs modeled on current small but successful organizations that reduce juvenile crime and improve socialization, self-esteem, and school and family functioning. Today, all smaller, successful programs contain the following components: starting at a young age; involving the family in teaching discipline and care skills; and being "small scale, high quality, and high cost."

 However, replicating these programs on a macro-level creates high cost curves that could rise exponentially with size. Also, providing the same quality of care on a large scale will be challenging.

Youth violence is not only a criminal justice concern, but also a public health issue. Welsh

 explained the role of prevention in public health, including classes dealing with aggression; public information campaigns; emergency department treatment and intervention; and early recognition of at-risk warning signs by families, physicians, school administrators, nurses, and teachers.

US cities lose nearly $50 billion a year because of crime and violence.

 Such large, negative externalities demand government attention and societal action. Reallocation of resources, new social spending initiatives, programs with a higher quality of care, and a better public health perspective would change the lives of our youths and cut the social cost of juvenile crime in the United States.

While primary prevention falls in the public health domain, the treatment of aggressive youth is a concern for every health practitioner involved in the provision of care to children and adolescents.

Aggression is a complex behavior with several subtypes. 

 violent behavior appears more persistent than 

 aggression and may be associated with more neuropsychiatric problems.

 aggression (eg, bullying and fighting) may come to clinical attention more often than 

 antisocial behavior (eg, stealing and vandalism). 

Another subtyping supported by animal research divides aggression into 

 Psychiatrists are most often called on to evaluate and treat childhood-onset, overt, and reactive aggression because of the link to identifiable biopsychosocial disturbances and their responsiveness to treatment.

Knowledge of the research findings on the causes and pathogenesis of aggressive behavior in youth should guide the assessment of the individual patient (

). Many children and adolescents with aggressive behaviors suffer from psychiatric disorders. A study evaluating juvenile delinquents in a detention center reported that over 60% had a diagnosed psychiatric disorder, excluding conduct disorder.

 Disruptive behavior disorders, substance use disorders, and mood disorders were particularly common.

Cutting across psychiatric diagnoses are maladaptive traits that appear to play a major role in overt and reactive aggression, such as impulsivity and the tendency to interpret benign social cues as hostile.

There is a significant amount of evidence that suggests aggressive behavior is the result of an interaction between individual and environmental factors. Thus, parental practices are important. Environmental issues, such as abuse and discipline, are paramount in understanding the individual with aggressive behavior.

 In addition, parental psychiatric disorders, including substance use disorders, are important in the assessment of a violent child or adolescent.	

Because children spend a lot of time in school, this environment can substantially influence--either negatively or positively--aggressive tendencies.

 Association with a deviant peer group is also important to recognize, but on the other hand, being ostracized by peers has been related to the increased likelihood of aggressive behavior.

 Other environmental factors, such as excessive exposure to violence in the media and living in an impoverished neighborhood, clearly play a role.

Taking into account the numerous variables (many of which are external to the individual) that play a role in shaping aggressive behavior, some form of "outreach" into the home and community appears to be necessary to deliver effective treatment. Many of the factors involved in aggression are not readily observed in a clinical setting and may not be known or discussed by the parent or child. In-home visits can help clinicians more readily identify hostile interactions between family members, inconsistent discipline, evidence of abuse, evidence of substance use, excessive involvement with television and video games, and inappropriate involvement or noninvolvement with peers. Therapists who are able to visit the school and take the patient into the community, can continue their observations and treatment. It appears, then, that some form of in-home/family-based therapy is the best way to impact the psychosocial environment of the young patient who is aggressive.

Evidence shows that this type of outreach treatment is effective. An 18-month follow-up in young people involved in the juvenile justice system who were treated with multisystemic therapy showed improvement in arrest rates and level of functioning, compared with a treatment-as-usual cohort.

 Since this type of in-home therapy may not always be available, other models that try to impact many aggression-related factors are being developed.

Such a treatment plan can address known and observed factors of aggressive behavior. A psychiatric disorder can be treated with pharmacotherapy or psychotherapy depending on the nature and severity of the disorder. Maladaptive traits can be treated with cognitive behavioral techniques such as problem-solving steps, social skills training, and anger management.

 Parental factors can be addressed through parent management training, psychiatric treatment, referral to child protective services, or parenting classes.

 School personnel can be involved in the generalization of skills learned in therapy and in providing a more prosocial environment for the patient.

 Peer factors can be targeted through social skills training and academic counseling to promote success. Parent management training and education could reduce the amount of exposure to the desensitizing effects of mechanistic violence in the media.

While there is significant evidence available for intensive psychosocial programs to reduce aggressive behavior in youth, the psychiatrist is most commonly involved in the pharmacologic part of treatment.

 However,  evidence in randomized controlled trials for drug treatment of aggression in youth is sparse.

 Traditional mood stabilizers, such as lithium, divalproex, and atypical antipsychotics, are often used to treat violent behavior in adults, regardless of a diagnosis of bipolar disorder or psychosis. At this time, there is insufficient evidence of the effectiveness of one type of medication over another to treat violence in children and adolescents. While some recent controlled data are available for divalproex therapy to treat aggression in conduct disorder,

 most studies have focused on atypical antipsychotics.

Diagnosis-specific pharmacotherapy should be the first-line treatment to target aggressive behavior, including

: stimulantsor atomoxetinefor attention-deficit/hyperactivity disorder (ADHD), antidepressants for depressive disorders, mood stabilizers for bipolar disorders, and antipsychotic agents for psychotic disorders. However, additional pharmacologic interventions are often needed in patients who are seriously aggressive.

 conducted an open-label study in 24 adolescents with ADHD, oppositional defiant disorder, or conduct disorder who exhibited severe aggressive outbursts, according to the Modified Overt Aggression Scale. The initial treatment consisted of 3 weeks of 54 mg/d of extended-release methylphenidate monotherapy, followed by 9 weeks of a combination of extended-release methylphenidate and quetiapine. Quetiapine was given at dosages up to 600 mg/d. After 12 weeks, verbal aggression and physical aggression toward self, others, and property declined significantly. Both the diagnosis-specific medication and the atypical antipsychotic appeared to contribute to improvement. However, this was an open-label study without placebo or active control. It is unclear how much of a placebo effect, monotherapy with methylphenidate, or the combination treatment contributed to the results.

 conducted a randomized, placebo-controlled monotherapy study with quetiapine treatment for aggressive conduct disorder. Nineteen adolescents participated in this 7-week study. Dosing was flexible; the average dosage of quetiapine at study end point was 300 mg/d 6 168 mg/d. Eight of 9 patients on medication improved, compared with 1 of 10 on placebo, according to a clinical global impression (CGI) score of 2. Quetiapine appeared to be well tolerated, although data on weight and metabolic parameters were not reported. 

Atypical antipsychotics have become the mainstay of pharmacotherapy for aggression, and their use in children and adolescents has increased significantly in the last decade.

 Reasons for this increase may be their effectiveness; their fast onset of action, which makes them useful in acute settings; and their improved neurologic safety profile. Recently, however, significant concern has been raised about their metabolic side effects.

The American Psychiatric Association and the American Diabetes Association have ranked the atypical antipsychotics based on their likelihood to induce metabolic abnormalities. Aripiprazole and ziprasidone were characterized as being least likely to induce weight gain and metabolic side effects. Because of these potential advantages, an open nonrandomized trial of aripiprazole or ziprasidone in a community clinic population of aggressive children and adolescents was performed.

 Forty-six patients (mean age of 11.9 6 2.6) were administered the Mini International Neuropsychiatric Interview and the Child/Adolescent Symptom Inventory. Conduct, bipolar, and depressive disorders were the most common diagnoses. The primary outcome measure was the Overt Aggression Scale. Patients with significant aggressive behaviors were started on aripiprazole (n = 24) or ziprasidone (n = 22). Eighteen patients were taking concomitant anti-ADHD medication. 

After 2 months, 34 patients remained in treatment, with an average dosage of aripiprazole of 4.5 mg/d 6 2.3 mg/d and of ziprasidone of 42.9 mg/d 618 mg/d. The average rating on the Overt Aggression Scale improved 63% and the average CGI score was 2.1 (much improved). There were no statistically significant differences between the aripiprazole group and the ziprasidone group in the primary outcome measure at baseline and after 2 months of treatment. However, 3 times more patients on ziprasidone than those on aripiprazole dropped out because of sedation. No other side effects were prominent, although weight change and metabolic indices require further study.

Aggression in youth has an enormous societal impact--economically, clinically, and in terms of human suffering. While primary prevention is clearly desirable, the clinician is more involved with secondary and tertiary prevention and treatment efforts. Controlled studies are needed to sort out which medications or combinations of medications are most effective in controlling aggression in young patients. Treatment that impacts the many biological, psychological, and social factors related to aggression--and is delivered within the patient's environment--may be the most clinically effective and economically sound modality.

Dr Bastiaens is associate clinical professor of psychiatry at the University of Pittsburgh and is associated with Family Services of Western Pennsylvania. He reports that he is on the speakers' bureau and is a consultant for Bristol- Myers Squibb, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Pfizer, and Takeda. He has received research honoraria from Forest Laboratories, McNeil Consumer Healthcare, and Janssen.

Ms Bastiaens is an undergraduate student at Davidson College, Davidson, NC. She reports no conflicts of interest regarding the subject matter of this article. 

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 Welsh BC. Prevention of juvenile violence: the role of public health. Presented at: Annual Conference of the Committee on Industrial Theory and Assessment; November 7-9, 2002; Lowell, Mass.


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Lifetime Effects. The High/Scope Perry Preschool Study Through

 Ypsilanti, Mich: High/Scope Press; 2005.


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 Conger RD, Neppl T, Kim KJ, Scaramella L. Angry and aggressive behavior across three generations: a prospective, longitudinal study of parents and children. 

 McEvoy A, Welker R. Antisocial behavior, academic failure, and school climate: a critical review. 

 Miller-Johnson S, Coie JD, Maumary-Gremaud A, et al. Peer rejection and aggression and early starter models of conduct disorder. 

 Johnson JG, Cohen P, Smailes EM, et al. Television viewing and aggressive behavior during adolescence and adulthood. 

 Timmons-Mitchell J, Bender MB, Kishna MA, Mitchell CC. An independent effectiveness trial of multisystemic therapy with juvenile justice youth. 

 Smith EP, Gorman-Smith D, Quinn WH, et al. Community-based multiple family groups to prevent and reduce violent and aggressive behavior: the GREAT Families Program. 

 van Manen TG, Prins PJ, Emmelkamp PM. Reducing aggressive behavior in boys with a social cognitive group treatment: results of a randomized, controlled trial. 

The increase in youth violence and aggression in the past 50 years has been called an "epidemic." This epidemic has had a tremendous impact on society. From an economic and public health perspective, primary prevention of youth violence is obviously desirable.

Youth Aggression: Economic Impact, Causes, Prevention, and Treatment

The Child and Adolescent Service System Program (CASSP) model launched by the National Institute of Mental Health stated that youth with emotional disturbances should be treated in the least restrictive setting (Stroul and Friedman, 1986). However, clinicians often encounter children and adolescents with severe psychiatric illnesses who require 24-hour supervised treatment. At the same time that long-term state hospital beds have been significantly reduced, managed care has led to a sharp reduction in the length of stay of acute admissions (Pottick et al., 2000). As a result, pediatric patients who fail to respond to repeated brief hospitalizations and intensive outpatient programs are referred to residential treatment facilities (RTFs) (Wells, 1991). Patients in RTFs have severe and chronic disorders, have received a variety of treatments in the past and are often taking several psychotropic medications (Connor et al., 1998).

During brief hospital stays, medications are often used to quickly stabilize patients. During repeated admissions, medications often accumulate. New medications are added, while past medications may be continued for no apparent reason. For example, Connor et al. (1997) found polypharmacy in 60.3% of patients admitted to an RTF. One factor associated with polypharmacy was the number of previous psychiatric placements.

Despite the CASSP principles, many youth continue to be in need of residential treatment due to insufficient quality and quantity of outpatient services; overwhelming psychosocial adversity; and significant illness severity. Advantages of RTFs are the ability to treat the patient in a safe and structured environment with a multidisciplinary team (milieu therapy, individual and group psychotherapy, pharmacotherapy, family therapy, special education) over a longer period of time. In this context, a minimum of pharmacotherapy need be instituted. Ideally, treatment in RTFs should lead to a reduction in medications.

This hypothesis was evaluated through a retrospective chart review of 24 male patients (mean age=12.8 plus/minus 2.5 with a range from 9 years to 17 years) consecutively treated in an RTF over an 18-month period. Seventy-five percent of patients were white, 17% were African-American, and 8% were Hispanic. Patients with mental retardation or significant substance use were not admitted.

On admission, all patients were interviewed with the Mini-International Neuropsychiatric Interview for children and adolescents (MINI-KID) (Sheehan et al., 1998). Collateral information was obtained from parents, past records and social agencies. Physical examinations were routinely performed. Diagnoses were made according to 

along the five axes; these can be found in Table 1. The mean Global Assessment of Functioning (GAF) score on admission was 34.4±4.5.

On entry into the RTF, patients were taking an average of 2.6±1.4 medications (range=0 to 5). The numbers of medication taken can be found in the Figure and the types in Table 2. The number of prior medication trials, not including the admission medications, was 2.1±1.6.

The mean number of hospitalizations before the RTF placement was 3.1±2.4, with a range from 0 to 10. Statistically significant correlations existed between the number of prior hospitalizations and both the number of pre-RTF medication trials (R=0.64; 

=0.0008; df 22) and the number of medications on admission (R=0.47; 

Throughout the RTF stay (mean length of stay=279.3 days±163.1 days), progress was measured with the Child Behavior Rating Form-Abbreviated (CBRF) (Van Egeren et al., 1999), filled out twice per day by staff. Diagnosis-specific rating scales, such as attention-deficit/hyperactivity disorder scales in the classroom, were used as well. School and parent reports were reviewed twice per week. Mental status examinations were performed on a weekly basis by a board certified child and adolescent psychiatrist. Based on this information, GAF scale scores on Axis V were adjusted.

During the treatment, 17 patients (71%) had the number of their medications reduced. Five patients remained on the same number and two patients were treated with an increased number of medications. Overall, the total number of medications prescribed decreased from 63 on admission to 38 on discharge, a 40% decrease. Alpha-2 agonists, antipsychotics and antidepressants were stopped most frequently. Patients were taking an average of 1.6±1.3 medications at discharge (range=0 to 4) (Figure). At the same time, the mean GAF score showed a 27% increase from 34.4±4.5 to 43.8±8.9.

Conclusions from this project are very preliminary, mainly because of the absence of a control group not admitted to an RTF. It might be argued that these patients would have improved over the same amount of time while receiving treatment in less-restrictive environments, and while decreasing their medications as well. However, considering their pre-RTF records with numerous hospitalizations, intensive outpatient treatments and several medication trials, it appears unlikely that a similar outcome would have occurred. Many of these patients were referred because of serious concern for ongoing suicidal and aggressive behavior, despite repeated hospitalizations and intensive outpatient treatment.

Despite the small number of patients, strong correlations were found between the number of hospitalizations and the number of medications used before and on admission. These findings are a replication of the 1997 Connor et al. study. It appears that severely ill youth accumulate psychiatric medications during repeated acute admissions without much benefit, thus ending up in RTFs. This study continued to follow the patients throughout their RTF treatment. With more time for multidisciplinary psychosocial treatments to take effect, medications were reduced by 40%. Patients left on average with one less medication. Polypharmacy decreased from 79% to 63%. Yet, patients improved, as evidenced by increased GAF scores.

A tentative conclusion appears to point to a subgroup of children and adolescents with severe psychiatric disorders who do not get better with repeated brief hospitalizations and who accumulate medications. These patients do get better with long-term residential treatment at the same time that medications are significantly reduced.

If replicated in more controlled studies, several questions are raised by these findings. How are non-responding patients best identified, when, and after how many hospitalizations? What are the economic implications of these findings? What role do brief hospitalizations play in the treatment of severe and chronic psychiatric illnesses? What is the role of polypharmacy in this treatment? The answers are important in the current climate of managing cost by insurances, of limited resources to provide treatment and of ongoing controversy about the role of medications to treat problems in youth.

 Connor DF, Ozbayrak KR, Harrison RJ et al. (1998), Prevalence and patterns of psychotropic and anticonvulsant medication use in children and adolescents referred to residential treatment. J Child Adolesc Psychopharmacol 8(1):27-38.
 

 Connor DF, Ozbayrak KR, Kusiak KA et al. (1997), Combined pharmacotherapy in children and adolescents in a residential treatment center. J Am Acad Child Adolesc Psychiatry 36(2):248-254 [see comment].
 

 Pottick KJ, McAlpine DD, Andelman RB (2000), Changing patterns of psychiatric inpatient care for children and adolescents in general hospitals, 1988-1995. Am J Psychiatry 157(8):1267-1273.
 

 Sheehan DV, Lecrubier Y, Sheehan KH et al. (1998), The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(suppl 20):22-23; quiz 34-57.
 

 Stroul BA, Friedman RM (1986) A system of care for children and youth with severe emotional disturbances. (Revised edition.) Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center.
 

 Van Egeren LA, Frank SJ, Paul JS (1999), Daily behavior ratings among child and adolescent inpatients: the abbreviated Child Behavior Rating Form. J Am Acad Child Adolesc Psychiatry 38(11):1417-1425.
 

 Wells K (1991), Placement of emotionally disturbed children in residential treatment: a review of placement criteria. Am J Orthopsychiatry 61(3):339-347.

There appears to be a subgroup of children and adolescents who, despite repeated brief hospitalizations, do not improve, but along the way, these patients accumulate medications. During long-term residential treatment, however, these patients do improve and their medications are reduced.

Author | Leo J. Bastiaens, MD

Articles

Severe Temper Outbursts in a 10-Year-Old Girl

Poor Practice, Managed Care, and Magic Pills: Have We Created a Mental Health Monster?

Youth Aggression: Economic Impact, Causes, Prevention, and Treatment

Does Residential Treatment Impact Pharmacotherapy in Children and Adolescents?