Adolescent Psychiatry Unit Research Articles

Which Aspects of Long-Term Outcome Are Predicted by Positive and Negative Symptoms in Early-Onset Psychosis? An Exploratory Eight-Year Follow-Up Study

Background: Early-onset psychoses show substantial variability of diagnostic and functional outcome. Finding reliable prognostic factors may allow to allocate resources to those with the worst prognosis. The aim of the study was to gain new insights regarding the potential value of baseline negative and positive symptoms as predictors of outcome in psychoses of early onset. Method: Sixty-three patients with early-onset schizophrenia spectrum psychosis hospitalized in an adolescent psychiatry unit were assessed with the Positive and Negative Syndrome Scale during the index admission. Associations with diagnosis, illness course and functional outcome were analysed in mean 8 years of follow-up (range 3.4-13.5 years). Results: The mean age at the index admission and the follow-up was 16.6 ± 1.2 and 24.5 ± 3.0 years, respectively. A significant majority of subjects continued psychiatric treatment (95%) and had been readmitted (71%). The mortality rate was 3% (suicide and accident). Negative symptoms were related to mental health service utilization during the follow-up. General severity of symptoms, specifically positive and cognitive factors were associated with the diagnosis of schizophrenia and inversely with diagnostic shift outside the schizophrenia spectrum at the catamnesis. Poor impulse control at baseline was associated with worse functional outcome. The drug-free subgroup with no occupational/educational activity compared with the drug-treated subjects showed lower levels of baseline negative symptomatology. Conclusion: The study findings suggest that in patients with early-onset psychosis negative and positive symptoms show a differential prognostic value. Pharmacotherapy may attenuate the effect of symptoms on functional outcome. These hypotheses need to be tested in future studies using confirmatory approaches.

Treatment-Resistant Juvenile Bipolar Disorder with Psychosis

13-year-old white male was admitted to the child and adolescent psychiatry unit at our institution. He was referred to us by his outpatient therapist. He had become increasingly aggressive (both verbally and physically), agitated, unable to sit still, and was pacing and talking incessantly. His speech was pressured, rapid, and mumbled. He was acting out sexually by masturbation. He also had auditory hallucinations (was hearing a “good voice”) but no visual hallucinations. He had paranoid ideations that someone was breaking into his home, and he was talking to himself and responding to internal stimuli. His sleep and concentration were reduced but his appetite was adequate. Suicidal and homicidal ideations were absent. His symptoms had been getting worse in the weeks prior to

Predictors of eating disorders outcomes in Polish teenage patients

Aim of the studyThe aim of this study was to assess factors associated with outcome of eating disorders in Polish teenage patients.Subject or material and methodsAnalyses covered the data of 47 patients diagnosed with any of the eating disorders according to DSM IV consulted for the first time in the outpatients clinic of the Child and Adolescent Psychiatry Unit between 2002/2004 in Krakow (DGN1), Poland and then followed-up between 2009/2011 (DGN2). The influence of the number of variables collected at DGN1 on outcomes were analysed.ResultsThe outcomes of anorexia nervosa and bulimia nervosa are influenced by some aspects of clinical picture, patients’ objective family situation, their self-image and the perception they have of their family relations. The co-occurrence of depressive symptoms and younger age of parents proved to be the most clinically important negative outcome predictors in whole group of eating disorders.DiscussionSmall size of group in the follow-up study is the most important limitating factor.ConclusionsConclusion: Outcomes in eating disorders are affected by several psycho-bio-social factors common for all patients and specific for diagnosis type they initially present.

Outcome of Polish teenage patients with eating disorders

Aim of the studyThe aim of the study was to assess outcome of patients with eating disorders in the Polish socio-cultural context.Subject or material and methodsRe-assessed after 6.72 years (SD 0.99 years, min 4.58 years, max 8.81 years) 47 of 112 patients consulted initially in the outpatient clinic of the Child and Adolescent Psychiatry Unit between 2002/2004 in Krakow, Poland with one of the eating disorders.ResultsComplete remission (absence of symptoms for three months) took place in 55% of patients from the restrictive anorexia nervosa group, 27.3% patients from the bulimia nervosa group. A full range of symptoms was observed in 10% of patients from the restrictive anorexia nervosa group and 36.4% of patients from the bulimia nervosa group. In both groups, the longer the follow-up study, the worse outcome was observed.DiscussionSmall size of group in the follow-up study caused a significant limitation.ConclusionsConclusion: The remission rates indices for restrictive anorexia nervosa are similar to these presented in other follow-up studies. In the case of bulimia nervosa they are lower than average. An analysis of diagnosis variability between the initial and the follow up assessment indicates low cross-over rate from anorexia nervosa to bulimia nervosa group.

Suivi thérapeutique d’un adolescent de 16 ans souffrant de schizophrénie précoce avec symptômes catatoniques

The aim of this paper is to underline the need of a systematic monitoring (1) of atypical antipsychotics and (2) of catatonic symptoms in child psychiatry. We present in this paper the clinical history of a 16-year-old adolescent inpatient needing a prescription of atypical antipsychotic drug. We present the most relevant results of our clinical monitoring over 7 months.A 16-year-old Caucasian male adolescent, by the name of Paul, was admitted in August 2009 to an Adolescent University Psychiatry Unit for an acute psychotic disorder. On admission, he presented paranoid delusion, auditory hallucinations and impulsive movements. The score on the Bush-Francis Catatonia Rating Scale (BFCRS) was 17 (the threshold score for the diagnosis of catatonic symptoms is 2). Laboratory tests showed the lack of blood toxic levels, creatine phosphokinase (CPK) level was 684 IU/L. Paul was treated with clonazepam (0.05 mg/kg/d). This particular day was considered to be day #1 of the clinical drug monitoring. Immediately after, regular follow-up of catatonic symptoms was performed. On day #15, the CPK level returned to normal with improvement of clinical catatonia but with still a score of 4 on the BFCRS scale. Auditory hallucinations and delusion persisted. Risperidone treatment was begun (1mg/d and 1.5mg/d after 24 hours), associated with oral clonazepam (0.05 mg/kg/d). On day #17, after 48 hours of improvement of delusion, the catatonic symptoms rapidly worsened. Risperidone was stopped; Paul was transferred to intensive care where he was treated with clonazepam IV (0.1mg/kg/d). The score on BFCRS scale was 20, Paul presented no fever and the CPK level was below 170 IU/L. The diagnosis was a relapse of the catatonic episode, which was caused by the administration of risperidone. On day #24, no improvement in the state of catatonia was obtained. The treatment was changed with the following combination of medicine: clonazepam (0.1mg/kg/d)-lorazepam (5mg/d)-carbamazepine (10mg/kg/d). With this combination, the state of catatonia improved quickly and on day #31, he was transferred to the adolescent psychiatry unit. However, delusion and hallucinations persisted; a treatment with olanzapine was started at 5mg/d and then progressively increased to 20mg/d for 10 days. On day #115, after 3 months with olanzapine, no improvement of the hallucinatory and delusional symptoms was observed; the diagnosis of early-onset refractory schizophrenia was established. The Therapeutic Drug Monitoring (TDM) confirmed the good compliance; clozapine was introduced and progressively increased up to 250 mg/d. On day #199, after 3 months under clozapine (250 mg/d), the speech was coherent and delusion was rare. During this period, no relapse of the catatonic state was observed.In this case, the BFCRS scale was sensitive to catatonic symptom diagnosis. CPK levels vary differently for each atypical antipsychotic and are not a specific complication indicator. In complex cases, the TDM seems useful when choosing atypical antipsychotics.The association of two benzodiazepines (clonazepam-lorazepam) with carbamazepin allowed the improvement of catatonic symptoms. Plasma levels of atypical antipsychotics helped the practitioner in deciding the type of care required: plasma levels confirmed the patient's treatment adherence and thus reinforced the choice of clozapine.

À propos de la chambre d’isolement en pédopsychiatrie. Étude au sein d’une unité d’hospitalisation pour adolescents

BackgroundThe aim of this study is to examine characteristics associated with the use of locked seclusion in an adolescent in-patient unit. MethodsWe studied the seclusion room records of an adolescent in-patient unit for a six-year period. The demographic and clinical data related to all seclusions that occurred between 2005 and 2010 at an adolescent psychiatric unit were analyzed. Characteristics of adolescents who were placed in seclusion were compared to characteristics of all other adolescents at the unit. Information was abstracted from their case records and seclusion logs. ResultsThe study included 175 adolescent in-patients. The six-year prevalence of use of seclusion was 13% (23 seclusions), 57% of secluded patients were boys and the average length of stay was 59 days. Adolescents with conduct disorder diagnosis and who were admitted on an emergency basis were more likely to undergo seclusion. They consumed more drugs too (alcohol, tobacco). The most frequent behaviours leading to seclusion were agitation and hetero-aggressive behaviours. Seclusion was most frequent in the first days of hospitalization (26% occurred the first day). The average duration of seclusion (16 days) was much more than reported by other investigators. Medication was used in conjunction with the seclusion in 91% of cases and intramuscular injection was necessary in 35% of cases. A physical restraint was necessary in 22% of cases. For two adolescents, seclusion time was stopped due to the deterioration of their clinical condition. ConclusionThe use of seclusion in child and adolescent psychiatry units is particularly poorly documented in France. The prevalence of conduct disorder diagnosis indicates a need for guidelines for seclusion which takes into account the adolescent's need for protection from his own impulsive, the psychopathologic context and possible traumatic history. In this in-patient unit, seclusion is not used as a method of behaviour control. The time spends in seclusion tends to create a need for an intensive therapeutic care. The implications of the findings for practice need to be completed by further studied.

Pediatric bipolar disorder in a Spanish sample: Results after 2.6 years of follow-up

IntroductionBipolar disorder (BD) often starts in childhood or adolescence. There is considerable scepticism outside the United States over the validity, stability and prevalence of BD in children and adolescents. Persistence of course lends support to the validity of a diagnosis. ObjectivesTo describe the longitudinal course of pediatric BD in a Spanish sample over a median follow-up period of 2.6years and to examine risk factors associated with outcome. MethodsWe retrospectively reviewed the medical records of all children and adolescents (N=38) with DSM-IV-TR BD-I, II and NOS evaluated in the Child and Adolescent Psychiatry Unit, University of Navarra (Pamplona, Spain) from 1999 to 2005. We used the NIMH Lifetime Mood Chart and the Clinical Global Impression-Severity Scale to assess clinical course. Results79% (N=30) were boys and 21% (N=8) were girls; 44.7% (N=17) had BD-I, 5.3% (N=2) BD-II, and 50% (N=19) BD-NOS. Median (inter-quartile range: IQR: Q25; Q75) age at diagnosis was 13.9 (10.64; 15.84). Median follow-up period was 2.6years (0.91; 3.66). Mean percentage of time in an episode was 46.17% (23.36; 75.26), and it was longer in younger children (p<0.05). 2.6% had rapid cycling. At the end of follow-up, only 47% achieved remission or recovery. Younger children showed a worse treatment response (p<0.05). We found higher rates of hospitalization in children with ADHD (21%) (p<0.05). ConclusionChildren with BD had a chronic course with little interepisodic recovery. BD can be diagnosed in children using DSM-IV-TR criteria. An early age of onset and ADHD comorbidity are risk factors for worse prognosis.

Why do Adolescents Return to an Acute Psychiatric Unit?

The aim of this paper is to determine potentially modifiable factors associated with the high proportion of patients who are readmitted to adolescent psychiatric units. The case notes of 112 adolescents admitted over 1 year to an acute adolescent psychiatry unit were reviewed. Socio-demographic and clinical variables were compared between those who were readmitted over a 12-month period post discharge and those who were not. The readmission rate over a 12-month period was 31%. Males were significantly more likely to be readmitted. No other statistically significant predictors of readmission were identified. There was a trend towards readmission for those with bipolar disorder and a trend away from readmission for those with adjustment disorders. A history of sexual abuse and cluster B personality traits were significantly related to a history of previous admission, but not with subsequent readmission. Readmission is influenced by a number of factors, which may not be easily identified by a chart review. Prospective studies which follow-up adolescents for several years after discharge are needed.

Pediatric bipolar disorder in a Spanish sample: Features before and at the time of diagnosis

Introduction Bipolar disorder (BD) often starts in childhood or adolescence. Diagnostic delay is common and may have a negative impact on treatment response and outcome. Objectives To describe the clinical characteristics and symptoms of children with BD prior to their diagnosis and at the time of diagnosis in a sample in Spain. Methods We retrospectively reviewed the medical records of all children and adolescents ( N = 38) with a DSM-IV diagnosis of BD evaluated in the Child & Adolescent Psychiatry Unit, University of Navarra, over a 6-year period. We collected the DSM-IV symptoms of BD prior and at the time of diagnosis using the K-SADS-PL interview template. Results BD was diagnosed in close to 4% of clinic patients. Thirty (79%) were boys and 8 (21%) were girls; 17 (44.7%) had BD-1, 2 (5.3%) BD-2, and 19 (49.9%) BD-NOS. Median age at diagnosis was 13.9 (10.6;15.9). Delay of diagnosis was 1.5 (0.7;3.4) years. Symptoms of BD were similar to those reported in U.S. samples with high rates of severe irritability (94.6%) and psychiatric comorbidity: 92.1% of the BD children had at least one comorbid disorder and 18.4% had three comorbidities, most frequently ADHD (21%) and substance abuse (18.4%). Conclusions Clinical findings in this Spanish sample of children with BD closely resembles those described in U.S. clinics. Diagnostic delay, as in the U.S., and frequent misdiagnosis may explain low prevalence estimates found outside the U.S.

Obstetric complications as a risk factor for first psychotic episodes in childhood and adolescence

There are reports of significant association between obstetric complications (OC) and childhood psychosis. Authors conducted a case-control study of 102 children and adolescents with a first episode psychosis (FEP) and 94 healthy controls (HC), using the obstetric complications scale (OCS) and their medical records, to examine the risk of FPE. Patients were recruited from child and adolescent psychiatry units at six university hospitals and controls from publicly-funded schools of similar characteristics and from the same geographic areas. A logistic regression was performed to quantify the risk of psychosis in childhood and adolescence, based on OC, adjusting for potential confounding factors like socio economic status (SES) and family psychiatric history (FPH). OC appeared more frequently in the records of patients. Significant differences between patients and controls were found in Prenatal OC (15.7% vs. 5.3%, P < 0.05) and among them, bleeding in pregnancy showed the greatest difference between groups (12.7% vs. 2.1%, P < 0.01). In the logistic regression, bleeding in pregnancy showed a crude odds ratio (OR) of 6.7 (95%CI = 1.4-30.6) and 5.1 (CI 95% = 1.0-24.9) adjusted for SES and FPH. Therefore, bleeding in pregnancy is a likely risk factor for early-onset psychosis.

Inpatient and emergency child and adolescent psychiatry units in Sweden do not use restraint and seclusion: what we have learned

The Swedish Health and Medical Services Act states that health and medical care for all children, youth and adults shall: Be of a high standard and satisfy the patients need for security; Be easily accessible; Be based respect for the patients right to self-determination and integrity; Promote good communication between the patient and health and medical care personnel. The use of restraint and seclusion in psychiatric care is regulated by the same law compulsory psychiatric care (the current version was passed in 1991) for all ages. It states that coercive measures should be used only when there were no other alternatives. A court decision is needed and compulsory care includes: Compulsory medication; To be held with force; Isolation; Ban of visitors; Forbidden objects can be taken into custody. A caring attitude at wards based upon the UN Declaration of the Rights of the Child together with the paragraphs from above on respect for the patients right to self-determination and integrity and to promote good communication between the patient and health and medical care personnel including the child and his/her parents/legal guardians has minimized the use of restraint and seclusion in child and adolescent psychiatric care. Quiet rooms do not exist and the needs to use compulsory medication and to hold children with force have been rare occasions. To create a caring attitude of this kind is essentially depending how the staff is selected and their awareness and education.

Deletion 22q11.2 und schizophrene Störungen im Kindes- und Jugendalter

22q11.2 deletion is the most common microdeletion in humans and one of the most important risk factors for schizophrenia. Nevertheless, case reports of children or adolescents with 22q11.2 deletion and schizophrenia are very rare. After a review of the current knowledge about physical, developmental, behavioural and psychiatric problems in 22q11.2 deletion, the case of a 12;10-year-old boy with schizophrenia and the microdeletion is reported. About three years after the first symptoms, and only after medication with several neuroleptics, the patient reached his pre-morbid functioning level under treatment with risperidone. Under medication with clozapine he had experienced a single event of seizures which were due to hypocalcemia. This case report illustrates the importance of serum calcium controls at regular intervals for patients with 22q11.2 deletion and schizophrenia who are on neuroleptic medication. Ideally, children and adolescents with the deletion and co-morbid psychiatric problems should be treated in child and adolescent psychiatry units specialized in problems associated with the deletion. A good cooperation with other medical services is absolutely necessary.

Électroconvulsivothérapie et schizophrénie

Cette étude de cas a pour but d’enrichir la littérature sur la prise en charge de la schizophrénie précoce compliquée de symptômes catatoniques et de montrer l’intérêt d’un suivi thérapeutique. La catatonie est un symptôme grave avec une forte mortalité, il est sous-diagnostiqué en psychiatrie de l’enfant et de l’adolescent. La population pédiatrique présente une plus grande vulnérabilité à développer des événements indésirables sévères sous antipsychotiques atypiques comme la catatonie. Ce cas clinique complexe souligne la nécessité du suivi thérapeutique systématisé en psychiatrie de l’enfant et de l’adolescent avec des paramètres cliniques et biologiques adaptés. Après l’exposition clinique détaillée du cas et de sa prise en charge, nous présentons les résultats du suivi les plus pertinents obtenus sous rispéridone, olanzapine et clozapine. Puis, nous discutons de l’intérêt de protocoliser le suivi thérapeutique dans notre discipline avec évaluation systématisée des symptômes catatoniques et suivi pharmacologique des antipsychotiques atypiques. La mise en place d’un suivi thérapeutique avec des paramètres adaptés comme l’échelle Bush-Francis Catatonia Rating Scale (BFCRS) peut permettre d’optimiser le soin. À ce jour en France, aucune recommandation ne permet au praticien de s’appuyer sur un cadre fiable.The aim of this paper is to underline the need of a systematic monitoring (1) of atypical antipsychotics and (2) of catatonic symptoms in child psychiatry. We present in this paper the clinical history of a 16-year-old adolescent inpatient needing a prescription of atypical antipsychotic drug. We present the most relevant results of our clinical monitoring over 7 months.A 16-year-old Caucasian male adolescent, by the name of Paul, was admitted in August 2009 to an Adolescent University Psychiatry Unit for an acute psychotic disorder. On admission, he presented paranoid delusion, auditory hallucinations and impulsive movements. The score on the Bush-Francis Catatonia Rating Scale (BFCRS) was 17 (the threshold score for the diagnosis of catatonic symptoms is 2). Laboratory tests showed the lack of blood toxic levels, creatine phosphokinase (CPK) level was 684 IU/L. Paul was treated with clonazepam (0.05 mg/kg/d). This particular day was considered to be day #1 of the clinical drug monitoring. Immediately after, regular follow-up of catatonic symptoms was performed. On day #15, the CPK level returned to normal with improvement of clinical catatonia but with still a score of 4 on the BFCRS scale. Auditory hallucinations and delusion persisted. Risperidone treatment was begun (1 mg/d and 1.5 mg/d after 24 hours), associated with oral clonazepam (0.05 mg/kg/d). On day #17, after 48 hours of improvement of delusion, the catatonic symptoms rapidly worsened. Risperidone was stopped; Paul was transferred to intensive care where he was treated with clonazepam IV (0.1 mg/kg/d). The score on BFCRS scale was 20, Paul presented no fever and the CPK level was below 170 IU/L. The diagnosis was a relapse of the catatonic episode, which was caused by the administration of risperidone. On day #24, no improvement in the state of catatonia was obtained. The treatment was changed with the following combination of medicine: clonazepam (0.1 mg/kg/d)–lorazepam (5 mg/d)–carbamazepine (10 mg/kg/d). With this combination, the state of catatonia improved quickly and on day #31, he was transferred to the adolescent psychiatry unit. However, delusion and hallucinations persisted; a treatment with olanzapine was started at 5 mg/d and then progressively increased to 20 mg/d for 10 days. On day #115, after 3 months with olanzapine, no improvement of the hallucinatory and delusional symptoms was observed; the diagnosis of early-onset refractory schizophrenia was established. The Therapeutic Drug Monitoring (TDM) confirmed the good compliance; clozapine was introduced and progressively increased up to 250 mg/d. On day #199, after 3 months under clozapine (250 mg/d), the speech was coherent and delusion was rare. During this period, no relapse of the catatonic state was observed.In this case, the BFCRS scale was sensitive to catatonic symptom diagnosis. CPK levels vary differently for each atypical antipsychotic and are not a specific complication indicator. In complex cases, the TDM seems useful when choosing atypical antipsychotics.The association of two benzodiazepines (clonazepam–lorazepam) with carbamazepin allowed the improvement of catatonic symptoms. Plasma levels of atypical antipsychotics helped the practitioner in deciding the type of care required: plasma levels confirmed the patient's treatment adherence and thus reinforced the choice of clozapine.

A Systematic Chart Review of Inpatient Population with Childhood Dissociative Disorder

Objective: To study the socio-demographic factors, clinical characteristics, and long-term outcome of dissociative disorders in inpatient children and adolescents. Methods: Chart data of forty-four subjects (8-15 years) with a diagnosis of dissociative disorder admitted to a specialist Child and Adolescent Psychiatry (CAP) unit between September 2001 and August 2002 were reviewed. Results: Eighty-nine percent of the subjects were above 10 years of age, and 61% were females. Difficult or anxious temperament was found in half of the subjects. Precipitating stressors were present in a majority (82%) and half of the subjects had an acute onset of symptoms. Mean duration of illness was 3.6 weeks. The most common symptom was pseudoseizure. Sixty-eight percent of patients had a co-morbid psychiatric diagnosis, the commonest being a depressive disorder. Remission in symptoms was seen in about 80% of subjects at the time of discharge. Two-thirds of the twenty-four subjects available for follow-up had resumed academics and had good global functioning. Conclusions: Inpatient children and adolescents with dissociative disorders had an acute onset, with obvious precipitating stressors and had a favourable short- and medium-term outcome. Majority of the subjects had psychiatric co-morbidity. Early diagnosis and presence of precipitating factors determined a favourable outcome.

Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review.

Several studies have reported that patient ethnicity influences psychiatric diagnosis, although this has only been examined in adolescents in two prior studies. One study was based on an outpatient sample and the other was a retrospective study involving a relatively small sample of inpatients. We hypothesized that, as reported in adults, African American adolescents would be diagnosed with schizophrenic spectrum disorders more frequently than Caucasians, and Caucasians correspondingly would receive more affective disorders diagnoses. We retrospectively examined the charts of all adolescents (ages 12-18 years) admitted to the Adolescent Psychiatry Unit at Cincinnati Children's Hospital Medical Center (n = 1,001) between July 1995 and June 1998 for demographic information and discharge diagnoses. We used insurance status as a proxy for socioeconomic status. African American males were more commonly diagnosed with schizophrenic spectrum disorders than were African American women, Caucasian women, and Caucasian men. There were significantly more African Americans diagnosed with conduct disorder than Caucasians. In contrast, Caucasians were diagnosed with alcohol use disorders and major depression more often. Patient race and sex may influence clinical psychiatric diagnoses of hospitalized adolescents. Further investigations using structured interviews are necessary to determine whether the disparity in clinical diagnosis is secondary to actual gender and racial differences in the rates of illnesses in hospitalized adolescents or due to other factors that may contribute to diagnostic practices.

Psychomotorische Entwicklung einer kinderpsychiatrischen Population überprüft anhand der Movement-ABC-Checkliste und des Movement-ABC-Tests

Research was done about the agreement between test results and checklist information concerning psychomotor development. The Movement ABC checklist and the Movement-ABC-test were administered in 34 children from the child and adolescent psychiatry unit of the UZ Gasthuisberg, of Leuven, Belgium. The children were 25 boys and 9 girls aged 4 to 12 years. There was a moderate association between the test results of the children and the judgements of the carepersons, suggesting that use of the checklist instead of testing cannot be deemed a good alternative.

Relationship between psychotic disorders in adolescence and criminally violent behaviour. A retrospective examination.

The interaction between psychosis and violence in adults is an important area of research receiving attention. To date there is little available data examining this relationship in adolescence. To investigate the possible relationships between criminally violent types of behaviour, and psychopathology and social factors, among adolescents suffering from a psychotic disorder. A retrospective case note study of 39 in-patients diagnosed as having a psychotic disorder and admitted to one of two adolescent psychiatry units (one secure, one open). Cases were divided into a 'violent' and a 'non-violent' group, and these two groups were then compared for social and psychopathological variables. There was no association between recorded psychopathology and criminally violent behaviour. Criminally violent behaviour was associated with a history of emotional or physical abuse, contact with social or mental health services, and previous criminal behaviour. These findings fail to echo results of studies in adult schizophrenia; they suggest that violent behaviour in psychosis is associated more closely with social factors than with specific symptoms of the psychotic illness. Potential explanations are discussed.

Measuring patient symptom change on rural psychiatry units: utility of the symptom checklist-90 revised.

Mental health service providers have seen an increased need for demonstrating symptom reductions during the past decade. This change has been particularly evident to those working in inpatient psychiatry facilities where there is considerable need for a brief, easily administered, and low-cost means of tracking symptom change. The current study evaluated the utility of using the Symptom Checklist-90 Revised for tracking symptom reductions in patients admitted to rural adolescent and adult psychiatry units. Consecutive admissions to adolescent (N = 104) and adult (N = 125) psychiatry units located in a rural community hospital served as subjects. The mean length of stay was 8 days for adolescents and 7 days for adults. Patients were administered the Symptom Checklist-90 Revised at admission and just prior to discharge. Psychiatrists provided a DSM-IV primary diagnosis for each patient. Principal component analyses on both the adolescent and adult admission and discharge Symptom Checklist-90 Revised subscales resulted in a 1-factor solution. Repeated-measures ANOVAs demonstrated the Global Severity Index to be a sensitive measure of clinically significant admission-to-discharge symptom change. Analyses using psychiatrist-assigned diagnoses revealed that all diagnostic categories evinced significant admission-to-discharge symptom reductions. Implications for using the Symptom Checklist-90 Revised to evaluate clinically significant symptom changes on rural inpatient psychiatry units are discussed.

Psychiatric Diagnoses of Previous Suicide Attempters, First-Time Attempters, and Repeat Attempters on an Adolescent Inpatient Psychiatry Unit

To compare psychiatric diagnoses of hospitalized adolescents who (a) have made previous but no recent suicide attempts, (b) have recently made their first suicide attempt, (c) have recently made a second or subsequent attempt, or (d) have never made an attempt. Semistructured psychiatric diagnostic interviews were used to determine psychiatric diagnoses and history of recent and previous suicidal behavior of 269 consecutively admitted adolescents to an inpatient psychiatric facility. Forty-nine previously suicidal youths, 28 first-time attempters, and 33 repeat attempters were compared with 159 nonsuicidal youths in prevalence of Axis I psychiatric disorders and psychiatric comorbidity with affective disorder. Previous attempters and repeat attempters both reported more affective disorders, whereas first-time attempters reported more adjustment disorders than nonsuicidal youths. Previous attempters and nonsuicidal youths reported the most externalizing disorders. Previous attempters on an inpatient unit have multiple psychiatric problems. Like repeat attempters, they often are depressed, but like nonsuicidal youths, they also exhibit significant externalizing behaviors. Interventions with these adolescents should focus not only on immediate presenting problems, but also on ameliorating their long-term risk of posthospitalization suicidal behavior.

Paediatric assessment in a residential child and adolescent psychiatry unit.

To document the health status, comorbidity and functional impairments experienced by a group of psychiatrically disturbed children and adolescents. A detailed study of consecutive admissions to a residential unit over a two-year period was undertaken. All admissions had a comprehensive paediatric, speech pathology and psychiatric assessment. Compared to the general population, there was a significant history of developmental delay and low birthweight, but only a slightly greater prevalence of antenatal problems. Clumsiness (37%), severe speech and language disorder (32%), and hearing loss (15%) were prominent. Only 25% had no history of comorbid medical or neurological disorders. Children and adolescents presenting with moderate to severe mental health morbidity may have pre-existing comorbid medical problems, as well as unrecognised difficulties and impairments in other skills areas. Multidisciplinary assessment and intervention should be an integral part of the residential programme.