Transcript Adolescent depression significantly predicted young adult

Prognostic Factors in Child
and Adolescent Psychiatry.
A. James
Oxford University.
Continuities.
Childhood and Adolescent
Psychiatric Disorders
as Predictors of Young Adult
Disorders
Copeland et al, Arch Gen
Psych 2009.
Childhood and Adolescent Psychiatric Disorders
as Predictors of Young Adult Disorders
Copeland, et al Arch Gen Psych, 66 2009

To study homotypic and heterotypic
continuities while controlling for
comorbidities, and examining child
and adolescent predictors separately.
Childhood and Adolescent Psychiatric Disorders
as Predictors of Young Adult Disorders
Copeland, et al Arch Gen Psych, 66 2009

Adolescent depression significantly
predicted young adult depression,
but this effect was entirely accounted
for by comorbidity of adolescent
depression with adolescent
oppositional defiant disorder, anxiety,
and substance disorders in adjusted
analyses.
Childhood and Adolescent Psychiatric Disorders
as Predictors of Young Adult Disorders
Copeland, et al Arch Gen Psych, 66 2009


Generalized anxiety and depression cross
predicted each other, and oppositional
defiant disorder (but not conduct disorder)
predicted later anxiety disorders and
depression.
Evidence of homotypic prediction was
supported for substance use disorders,
antisocial personality disorder (from
conduct disorder), and
anxiety disorders, although this effect was
primarily accounted for by DSM-III-R
overanxious disorder
Eating
Disorders
AN
BN
Transdiagnosis
EDNOS
Improvement or merely
change?
Early-Onset
Schizophrenia.
Factors associated with poor prognosis
in EOS

Compared with the adult-onset form
of schizophrenia EOS, and in
particular the most early onset
cases, may be associated with
worse prognosis
(Jacobsen et al, 1998).
Factors associated with poor prognosis
in EOS

Most follow up studies have found
the majority of young persons being
chronically ill, with very few having
good functioning, and the majority
showing poor or very poor outcomes
on clinical measures.

More optimistic outcomes have also
been reported (Asarnow et al, 1994;
Russell, 1994; Pencer et al, 2005)
with up to around 60% showing
significant improvement at follow up.
Factors associated with poor prognosis
in EOS

Premorbid developmental delay.

Premorbid function.

Mode and age of onset.

Degree of recovery and negative
symptoms.
Lay et al. (2000)
65 EOS patients over a period of more
than 10 years
 83% of the patients as having at
least one further episode needing
hospitalisation 74% being under
psychiatric treatment.
 At least moderate educational and
occupational impairment was noted
in 57% of this sample and serious
social disability was found in 66%.
Eggers and Bunk, 1997; Remschmidt et al,
2006

Eggers and Bunk 1977 44 EOS
patients,
50% were found to have continuous
symptoms and 25% to be in partial
remission.
Remschmidt et al (2006)






38 patients retrospective ICD-10 diagnosis
42 years after the initial presentation
The overall prognosis of this cohort was
poor:
less than a sixth have a favourable
outcome
60% have a poor outcome.
More than 70% did not graduate from
school and were unemployed at the time
of follow up.
Significantly raised total death rate.
ADAPT Study (Br J Psychiatry. 2009, 194:33441).




There is great heterogeneity of clinical
presentation and outcome in paediatric
depression.
Method
RCT 192 adolescents with unipolar major
Participants were treated for 28 weeks
with routine psychosocial care and
selective serotonin reuptake inhibitors
(SSRIs), with half also receiving cognitivebehavioural therapy (CBT).
ADAPT Study (Br J Psychiatry. 2009, 194:33441).

Depression at 28 weeks was
predicted by the additive effects of
severity, obsessive-compulsive
disorder and suicidal ideation at
entry together with presence of at
least one disappointing life event
over the follow-up period.
ADAPT Study (Br J Psychiatry. 2009, 194:33441).

CONCLUSIONS: Clinicians should
assess for severity, suicidality and
comorbid obsessive-compulsive
disorder at presentation and should
monitor closely for subsequent life
events during treatment.
The OPUS trial in Denmark and the
Lambeth Early Onset (LEO) in the UK




Trial compared specialist multidisciplinary teams with
standard care in community mental health settings.
OPUS trial, specialist care included assertive community
treatment, low-dose atypical antipsychotic medication,
social skills training, multifamily psychoeducation.
More of those randomized to specialist treatment had
independent living arrangements, and fewer were
homeless, better global functioning at 2-year follow-up.
More participants in the intervention group had resumed
formal education and there was a greater reduction in
positive and negative symptoms and less comorbid drug
and alcohol abuse or dependence.
Eating Disorders.(Steinhausen et al
2009).



In AN, there are an almost 18-fold
increase in mortality including a high
suicide rate.
Chronic courses in approximately 20 per
cent of the cases.
More than half of the patients show either
a complete or a partial eating disorder in
combination with another psychiatric
disorder or another psychiatric disorder
without an eating disorder.
Eating Disorders.(Steinhausen et al
2009).


Vomiting, bulimia and purgative
abuse, chronicity, and obsessivecompulsive features represent
unfavourable prognostic factors.
Mitigating factors of the outcome
include onset of the disorder during
adolescence and longer duration of
follow-up.
Eating Disorders (Papadopoulos et al, BJP
2009).





The overall SMR for anorexia nervosa was 6.2
(95% CI 5.5-7.0). Anorexia nervosa,
psychoactive substance use and suicide had the
highest SMR.
The SMR was significantly increased for almost all
natural and unnatural causes of death.
The SMR 20 years or more after the first
hospitalisation remained significantly high.
Lower mortality was found during the last two
decades.
Younger age and longer hospital stay at first
hospitalisation was associated with better
outcome, and psychiatric and somatic
comorbidity worsened the outcome
OCD.
Ginsburg et al, JAACAP 2009



Meta-analysis (6 cognitive-behavioral therapy, 13
medication, and 2 combination studies).
Among all of the studies, there was little evidence
that sex, age, or duration of illness (age at onset)
was associated with treatment response.
Baseline severity of obsessive-compulsive
symptoms and family dysfunction were
associated with poorer response to cognitivebehavioural therapy,
Comorbid tics and externalizing disorders were
associated with poorer response in medicationonly studies.
OCD: (Masi et al, 2009)




Paediatric obsessive-compulsive disorder (OCD)
can cause substantial impairment in academic,
social and family functioning.
Evaluation of cognitive-behavioural therapy
(CBT)+/- enhancement in a consecutive series of
257 patients (174 males and 83 females; mean
age 13.6+/-2.7 years) diagnosed with OCD.
37 children improved significantly after
psychotherapy and were excluded. The
remaining 220 patients were included in the
study.
Eighty-nine patients (40.5%) were managed with
SRI monotherapy and 131 with an SRI in
combination with another medication.
OCD


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.
Patients receiving polypharmacy
presented with higher rates of bipolar
disorder, tic disorder and disruptive
behaviour disorders.
OCD


135 patients (61.4%) achieved a positive
clinical response and were considered
responders.
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.
Cytochrome P450 2D6 Genotyping:
Potential Role in Improving Treatment
Outcomes in Psychiatric Disorders
Irritability: Stringaris et al, AGP
2009
Loeber




1. Factor analyses suggest that two ODD
factors exist, one of negative affect and
the other representing defiance.
2. The negative affect but not the defiant
component of ODD predicts later
depression.
3. ODD rather than CD may explain the
comorbidity between CD and depression.
4. It is not clear whether and how child
temperament may be distinguished from
ODD
symptoms.



Psychopathic features in childhood are
about as stable as ODD/CD symptoms,
but developmental changes have also
been noted.
Psychopathic features independently
predict later conduct problems and
antisocial behavior
beyond earlier initial conduct problem
severity.
Aetiological factors of psychopathic
features appear similar to those factors
associated
with ODD and CD, but there is a need to
document etiological factors that are







Research on developmental pathways shows that
ODD and CD symptoms appear to be stepping
stones to serious forms of delinquency.
Loeber’s pathway model shows three pathways
(overt, covert, and authority conflict) to serious
delinquency. Children can be on more than one
pathway.
Research on developmental trajectories often
shows four groups:
problem behavior remains high over time,
problem behavior remains low,
problem behavior increases,
behavior decreases between childhood and early
adulthood.



Most of the risk factors predicting
delinquency also predict symptoms of
disruptive behavior.
There is replicated evidence of a doseresponse relationship between children
and adolescents’ exposure to an
accumulation of risk factors across
multiple domains and an increased
probability of later adverse outcomes.
It is probable that the most salient risk
window of children’s exposure to risk
factors is prior to adolescence.




The sum of promotive and risk factors is a
better predictor of later problems
compared to knowledge of risk or
promotive factors only.
Promotive factors tend to buffer the
impact of risk factors.
The natural occurring balance between
risk and promotive factors may change
over time;
The prevalence of promotive factors
appears highest in middle childhood, and
risk compared to promotive factor tends
to be more dominant during adolescence.