Development Of Mental Disorders Research Articles

Child and Adolescent Psychosocial Care Center service use profile in Brazil: 2008 to 2012.

Objective:To describe the service use profile of Child and Adolescent Psychosocial Care Centers (Centro de Atenção Psicossocial Infanto-Juvenil [CAPSi]) in Brazil regarding diagnostic categories, sociodemographic aspects, and care modalities between 2008 and 2012.Methods:A descriptive, ecological study was performed using data from the Unified Health System regarding high-complexity procedure authorizations (Autorização de Procedimentos de Alta Complexidade [APAC]) for the period from 2008-2012. The variables sex, age, diagnosis (F00-F99 of ICD-10), and type of care provided were examined. The data were processed using TabWin and STATA version 12.Results:A total of 837,068 records were examined, each representing one visit to CAPSi. Most visits were by male users (68.8%). The most common diagnoses were hyperkinetic disorders (13%), pervasive developmental disorders (12.4%), and conduct disorders (8.4%).Conclusions:Behavioral and emotional disorders that usually appear during childhood or adolescence and psychological development disorders were frequent, with more than 50% of the latter comprising autism spectrum disorders. Regional differences were observed, with a higher presence of this diagnosis in the Southeast, while the North and Northeast had a high percentage of visits due to mental retardation.

Demographic and diagnostic profiles of older people with intellectual disability and prescription of antipsychotics

PurposeTo describe demographic and diagnostic profiles in a national cohort of older people with intellectual disability (ID) who were prescribed antipsychotics.MethodsUsing national registers, we identified people with ID who were 55 + years in 2012 (n = 7936), as well as a subcohort with complete information on demographic factors (sex, year of birth, severity of ID, presence of behavior impairment, and residence in special housing; n = 1151). Data regarding diagnoses and prescription of antipsychotics were added for the time period 2006–2012. The potential effects of demographic factors and diagnoses on the prescription of sedating and less-sedating antipsychotics, respectively, were assessed in separate models by estimating the relative risks (RRs) of prescription.ResultsOf the demographic factors, severe/profound ID (RR 1.17), behavior impairment (RR 1.34), and living in special housing (RR 1.25) were associated with prescription of sedating antipsychotics, whereas only behavior impairment (RR 1.42) was associated with prescription of less-sedating antipsychotics. For both sedating and less-sedating antipsychotics, the diagnoses with the largest association (i.e., highest relative risk) were schizophrenia (RR 2.17 for sedating and RR 1.81 for less-sedating) and ID (RR 1.84 and RR 1.68, respectively), followed by disorders of psychological development (for sedating antipsychotics, RR 1.57) and organic mental disorders (for less-sedating antipsychotics, RR 1.55).ConclusionsThe associations between prescription of antipsychotics and demographic factors and non-psychotic diagnoses, respectively, suggest that older people with ID may be prescribed antipsychotic medication without thorough psychiatric diagnosing. If so, there is a need for improving the abilities of health care professionals to properly diagnose and manage psychiatric illness in this population.

Aural and nasal foreign bodies in children – Epidemiology and correlation with hyperkinetic disorders, developmental disorders and congenital malformations

ObjectivesForeign body incorporation in children is often a serious situation. Attention deficit hyperactivity disorder (ADHD) could be a risk factor for self-insertion of foreign bodies. Large cohort analyses are missing. MethodsThis was a retrospective analysis of patients’ records from a health insurance company representing 2.19% of the German population and 1.75% of German children and adolescents. According to the International Classification of Diseases, children in the age range between 1 and 18 years have been screened for foreign bodies in ear, nasal sinus and nostrils as well as for hyperkinetic disorders (F90), disorders of psychological development (F80–F89), and congenital malformations, deformations and chromosomal abnormalities (Q00–Q99). ResultsIn total, 12887 children (6609 male; 6278 female) have been treated in 16929 cases. The majority (n = 10041 (77.9%)) presented with foreign body incorporation on a single occasion. On average, 1.31 cases of foreign body treatment were recorded per child; 14.1% of children with foreign body treatment (FBT) also had a record of hyperkinetic disorder, 52.7% had a disorder of psychological development, and 50.8% a congenital malformation. Mean occurrence of FBT was 174.8 days before the diagnosis of a hyperkinetic disorder but 517.2 days after the diagnosis of a psychological development disorder and 683.1 days after the diagnosis of a congenital malformation, deformation or chromosomal abnormality. ConclusionPatients with disorders of psychological development as well as children with congenital malformations are high-risk patients for nasal and aural foreign bodies. The prevalence of a hyperkinetic disorder in patients with FBT is much higher than in the normal population. ADHD is a risk factor for foreign bodies.

SU56 - DIFFERENTIAL DNA METHYLATION AT BIRTH ASSOCIATED WITH MENTAL DISORDER IN INDIVIDUALS WITH 22Q11.2 DELETION SYNDROME

Background Individuals with 22q11.2 Deletion Syndrome (DS) have an increased risk of comorbid mental disorders including schizophrenia, attention deficit hyperactivity disorder, depression, as well as intellectual disability. While most 22q11.2 deletion carriers have the long 3 Mb form of the hemizygous deletion, there remains a large variation in the development and progression of psychiatric disorders, which suggests that alternative factors contribute to the pathogenesis. In this study, we investigated whether neonatal DNA methylation signatures in individuals with the 22q11.2 deletion associate with mental disorder later in life. Methods Subjects with 22q11.2 deletion were selected from The Danish Cytogenetic Central Register. DNA methylation was measured genome-wide with the use of Infinium HumanMethylation450 BeadChip from neonatal dried blood spots in a cohort of 164 individuals with 22q11.2DS, including 48 diagnosed with a psychiatric disorder. Epigenome-Wide Association Study (EWAS) was performed to determine differential DNA methylation among 22q11.2 deletion carriers diagnosed with mental disorder compared to carriers with no current or past mental disorder diagnosis. Most associated sites were used for Gene Ontology pathway enrichment analysis. Moreover, we evaluated four sub-classes of most commonly observed psychiatric diagnoses (intellectual disability: F70-79, behavioral disorders: F90-98, disorders of psychological development: F80-89 and schizophrenia spectrum disorders: F20-29) in the cohort and compared their methylome profiles to the non-psychiatric controls. Regression models, adjusted for sex, type of 22q11.2 deletion, and age of the blood spot card, were used for all EWAS analyses to identify differentially methylated sites. Results Among several CpG sites with p-value Discussion In conclusion, our study suggests an association of DNA methylation differences at birth with development of mental disorder later in life in 22q11.2DS individuals. Differentially methylated sites were located in genes enriched in those involved in neurogenesis, nervous development, and neuron projection development, what supports previous studies that suggested mental disorders to have an early neurodevelopmental component.

O važnosti društvenog i porodičnog konteksta u razumevanju nastanka i razvoja psihičkih poremećaja, u epidemiologiji i prevenciji

O važnosti društvenog i porodičnog konteksta u razumevanju nastanka i razvoja psihičkih poremećaja, u epidemiologiji i prevenciji

Art therapy in treatment, rehabilitation, micro- and macrosocial adaptation of children with autism spectrum disorders by means of a special rehabilitation and adaptation program "Art therapy (drama therapy): 'Because You are Needed…' for children with general disorders of psychological development and other mental disorders"

For the first time, the effectiveness of art therapy (drama therapy) in children with mental disorders has been studied on substantial clinical data. Psychotherapeutic work involved certain form of drama therapy that included patients watching Moscow theaters performances and then discussing them with family and in group therapy sessions with psychologists. Researchers have developed drama therapy methods for children with mental disorders, determined indications and contraindications for this treatment. The study shows effects of art therapy on the child adaptation to the conditions of the micro-social environment, particularly on his family adaptation, formation of harmonious, supportive, rehabilitative family relations. It is noted that art therapy influences adolescent's adaptation to the conditions of the macrosocial environment, particularly his adaptation in a peer group, behavior in various situations and formation of normal behavioral patterns in different environmental conditions.

PMH27 - RETROSPECTIVE HEALTHCARE CLAIMS DATA ANALYSIS FOR CHILDREN/ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVITY DISORDER RECEIVING SECOND-LINE PHARMACOTHERAPY IN GERMANY, EVALUATING PATIENT CHARACTERISTICS AND HEALTHCARE COSTS

Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous neurodevelopmental disorder associated with persistent and cross-situational occurring symptoms, including inattention, hyperactivity and/or impulsivity. The study aimed to evaluate healthcare claims data (demographics, co-occurring disorders and healthcare costs) for children/adolescents with ADHD treated with second-line lisdexamfetamine (LDX) or atomoxetine (ATX) in Germany. This was a retrospective claims data analysis conducted using the InGef research database containing anonymized healthcare claims of approximately 4 million individuals covered by statutory health insurance in Germany. Children/adolescents (6–17 years) with an ADHD diagnosis and first prescription of second-line LDX or ATX after methylphenidate treatment were included in the study. Demographic characteristics, co-occurring mental and behavioural disorders (by ICD-10-GM code groups) and direct healthcare costs were analysed in an individual 1-year post-index period after identification in 2014. A total of 451 children/adolescents with ADHD treated with LDX and 176 treated with ATX were identified (81% and 79% male patients, respectively). The LDX cohort was statistically significantly older (mean age 11.4 vs 10.9 years; p=0.0065). Behavioural/emotional disorders (F91-98) with specific childhood/adolescence onset were reported for 55% and 58% patients in the LDX and ATX cohorts, respectively. Disorders of psychological development (F80-89) were reported for 47% and 52%, respectively. Lower mean inpatient costs were reported in the LDX cohort compared with the ATX cohort (€1979 vs €3189; p=0.0028). The difference in inpatient costs led to significantly lower mean overall 1-year direct healthcare costs per patient in the LDX than ATX cohorts (€4485 vs €6018; p=0.0004). There may be a need for an individualized approach to the treatment of children/adolescents with ADHD, particularly considering common co-occurring mental and behavioural disorders reported. In Germany, children/adolescents treated with second-line ATX compared with LDX incurred significantly higher overall direct healthcare costs. Further multivariate analyses are needed to validate the study outcomes.

Mental health and disability of children managed by child welfare services in the Bouches-du-Rhone department

To describe the mental health and disability of foster children in the Bouches-du-Rhône (BDR) department. ESSPER-ASE 13 studied the physical and mental health of children managed by Child Welfare Services (CWS) of the BDR department. This descriptive cross-sectional survey was carried out from April 2013 to April 2014 and included 1,092 children placed in foster homes or in the custody of child care assistants. This survey explored the physical and mental health of the children and the characteristics of their medical follow-up. This article focuses on the mental health and disability of foster children. Psychiatric disorders were identified in 22% of foster children, predominantly consisting of anxiety disorders (44%), behavioural disorders (44%), and attention deficit hyperactivity disorders (16%). 20% of children received MDPH (French Departmental Home for Disabled Persons) notification. The two main types of disability were psychological development disorders (61%) and emotional disorders (20%). The over-representation of severe psychiatric disorders and disabilities among foster children calls for enhanced diagnosis and optimization of care.

An exploration of moderator effect of Negative Mood Regulation Expectancies (NMRE) in the association of Looming Cognitive Style (LCS) with trait anxiety

Negative Mood Regulation Expectancies (NMRE) refer to the beliefs that one has concerning his/her ability to control and regulate a negative mood state. NMRE play an important role in development of psychological disorders since it is known to buffer the negative impact of various risk factors for emotional distress. The present study aims to test the interaction of NMRE with Looming Cognitive Style (LCS), a cognitive vulnerability factor specific for anxiety disorders and the role this interaction plays in subjectively felt anxiety. Data were collected from 326 university students (251 female) through self-report questionnaires assessing LCS, NMRE, anxiety and depression. The results showed that both LCS and NMRE are significantly associated with anxiety scores while controlling for the overlap between anxiety and depression. Moreover, NMRE was found to be significantly able to moderate the association between LCS and anxiety. That is; tendency to generate looming cognitions appeared to be linked to higher anxiety when the individuals have low levels of confidence in their capacities for mood regulation and coping.

Need For Long-Term Care in Children is Increasingly Caused by Disorders of Psychological Development. Changes in the Care Causing Diagnoses According to German Social Code (SGB XI) Between 2009-2014.

There is an ongoing discussion on the increasing number of children with mental and developmental disorders, with some even needing long-term care according to the German Social Code XI. This study was performed to identify the main diagnoses justifying such care in children and to analyse their prevalence over time. The diagnoses justifying long-term care were evaluated using care assessments of Bavarian children and adolescents between 2009 to 2014 by the medical service of statutory health insurance. Over the years investigated, the percentage of assessments due to a mental and behavioural disorder rose significantly from 36.2 to 42.2%. Since 2012, the most common diagnose changed from Down's syndrome to pervasive developmental disorders with marked increase of also mixed specific developmental disorders. In new applications for nursing insurance services the proportion of pervasive developmental disorders rose gradually from 151 in 2010 to 254 in 2014. During the whole period of time, the overall care dependency in children seemed to be stable. These observations might rather be influenced by altered awareness of health and illness, increasing readiness to seek help with psychological or developmental impairments as well as changed diagnostic criteria than by a steady increase in affected individuals.

Psychiatric diagnoses of children affected by their parents’ traumatic brain injury: the 1987 Finnish Birth Cohort study

ABSTRACTObjective: To investigate whether parental TBI increases the overall risk for psychiatric disorders and the risk for specific psychiatric diagnoses in the children affected by parental TBI.Methods: The 1987 Finnish Birth Cohort (n = 59 476) were followed up through national registers from birth to the end of 2008. The diagnoses of cohort members and their parents were obtained from the Care Register of Health Care, provided by the National Institute of Health and Welfare.Results: During the 21-year follow-up, the likelihood for psychiatric diagnoses being assessed in psychiatric care was significantly increased in males with any mental disorder (odds ratio (OR) = 1.43), substance-use-related disorders (OR = 1.71) and behavioural and emotional disorders (OR = 1.75), and in females with disorders of psychological development (OR = 1.85).Conclusions: Children affected by parental TBI are at increased risk for psychiatric disorders: males for externalizing disorders and females for developmental disorders. Observed gender interactions in the association between parental TBI and the psychiatric disorders of children warrant further study.

Barriers to special care patients with mental illness receiving oral healthcare. A cross sectional study in the Holy City of Makkah, Saudi Arabia.

Objectives:To assess barriers to patients with mental illness receiving oral healthcare in Makkah city, Saudi Arabia.Methods:This was a 3-month cross-sectional study from the Department of Psychiatry at Al-Noor, Specialist Hospital in Makkah city, Saudi Arabia, between January 2017 and April 2017. A structured questionnaire with closed-ended questions was considered. A total of 161 psychiatric patients were recruited, made up of 81 male (50.3%) and 80 female (49.7%) participants. Simple descriptive statistics were used to define the characteristics of the study variables, through a form of counts and percentages. The chi-square test was also used to evaluate the distribution of the nominal variables.Results:Of the 161 psychiatric patients, 51 were aged 26-35 years old (31.7%). Most participants (n=73) had psychological development disorders (45.3%). Ninety-one (56.5%) were unemployed, and among them, 25 (15.5%) reported problems with access to oral health and dental care. Participants also suffered from dry mouth (64%) and dental anxiety (23%).Conclusions:This study suggested that dental anxiety is considered the major barrier to dental care, followed by the cost of dental treatments and accessibility. Most belonged to the group of psychological development disorder and reported having the most barriers to oral healthcare.

The understanding of the text and images by teenagers with different levels of intelligence with eye tracking using

The aim of this study was to identify and compare the characteristics of the recognition and understanding of verbal and nonverbal stimuli in the form of a text and drawing images of various degrees of definition applicable to students with mild mental retardation. The objects of the comparative study were graduates of schools with a varying degree of the intelligence decline (F83 – mixed specific disorders of psychological development and F70 – mild mental retardation). 85 subjects were participants. There were 49% boys and 51% girls. The study revealed specific features of perception and understanding of the texts and images of different degree of visual complexity by students with mild mental retardation. In the analysis of the visual information, they preferred to focus on the emotional aspect of the content both of the texts and pictures. Students with mild mental retardation demonstrated a lower level of cognitive development and volitional activity when viewing a stimulus of a high degree of visual complexity. A specific feature in the perception and understanding of the texts and images by these students is the lack of cognitive orientation on the procedural side event analysis.

Potential Use of Transspinal Direct Current Stimulation For Cerebral Circulation Correction

Research objective: to prove the potential use of Trans spinal direct current stimulation for treatment of brain systems functioning disturbance attached with regulation of vasal tonus. Identify the most effective localizations and exposure regimens, so that in the future they can be used purposefully, for the treatment of cerebral blood flow disorders.
 Materials and methods. 38 children aged 4-12 years were examined who were treated with TSDCS and who had EEG at the beginning of the course of treatment – signs of hemolytic dysfunction with ICD-10 diagnoses as mental retardation (F70-F79), disorders of psychological development (F80-F89) or as behavioural and emotional disorders with onset usually occurring in childhood and adolescence (F90-F98). The following examinations were performed: an electroencephalogram, a neurological examination. The trans spinal direct current stimulation was carried out by a constant current of 100-200 μA, during 30-40 min. At the same time, the cathode was located lateral from the spinous process of the seventh cervical vertebra C7, and the anode counterlaterally to the cathode in the lumbosacral region at the level of the spinous processes L5-S1. A total of 3 to 5 sessions of TSDCS were conducted. A repeat EEG examination with the determination of Hemolucleodynamics Coefficient (HC) was performed 7-10 days after the last TSMP session.
 Result. After the course of TSDCS, all patients significantly decreased the HC score. In 27 patients (71%) patients, HC decreased to the norm value (≤1,2). In 23 patients (29%), HC values corresponded to the first degree of hemolytic dysfunction.

Optimism, hope, and attention for emotional stimuli

Optimism and hope are individual difference factors that protect against the development of psychological disorders. They also are associated with more positive cognitive processes, such as positive appraisal of ambiguous events. Attention to emotional information is a cognitive process that has been implicated in the development and maintenance of emotional disorders, but there is a relative dearth of information investigating the relationships between hope, optimism, and attention to emotional information. In the current study, participants (n=104) completed measures of hope and optimism and completed an eye-tracking task to measure attention to emotional scenes. Optimism and hope were associated with less sustained attention to dysphoric information and threatening information. Optimism was associated with increased attention to positive information. Additional indirect effects models were explored. These findings demonstrate a relationship between optimism, hope, and attention to emotional information and suggest a potential mechanism by which these factors may reduce psychological distress.

Differential DNA methylation at birth associated with mental disorder in individuals with 22q11.2 deletion syndrome

Individuals with 22q11.2 deletion syndrome (DS) have an increased risk of comorbid mental disorders including schizophrenia, attention deficit hyperactivity disorder, depression, as well as intellectual disability. Although most 22q11.2 deletion carriers have the long 3-Mb form of the hemizygous deletion, there remains a large variation in the development and progression of psychiatric disorders, which suggests that alternative factors contribute to the pathogenesis. In this study we investigated whether neonatal DNA methylation signatures in individuals with the 22q11.2 deletion associate with mental disorder later in life. DNA methylation was measured genome-wide from neonatal dried blood spots in a cohort of 164 individuals with 22q11.2DS, including 48 individuals diagnosed with a psychiatric disorder. Among several CpG sites with P-value<10−6, we identified cg23546855 (P-value=2.15 × 10−7) mapping to STK32C to be associated with a later psychiatric diagnosis. Pathway analysis of the top findings resulted in the identification of several Gene Ontology pathways to be significantly enriched (P-value<0.05 after Benjamini–Hochberg correction); among them are the following: neurogenesis, neuron development, neuron projection development, astrocyte development, axonogenesis and axon guidance. In addition, we identified differentially methylated CpG sites in LRP2BP (P-value=5.37 × 10−8) to be associated with intellectual disability (F70–79), in TOP1 (P-value=1.86 × 10−7) with behavioral disorders (F90–98), in NOSIP (P-value=5.12 × 10−8) with disorders of psychological development (F80–89) and in SEMA4B (P-value=4.02 × 10−7) with schizophrenia spectrum disorders (F20–29). In conclusion, our study suggests an association of DNA methylation differences at birth with development of mental disorder later in life in 22q11.2DS individuals.

CASPR2 autoantibodies are raised during pregnancy in mothers of children with mental retardation and disorders of psychological development but not autism

Background, Methods and ObjectivesMaternal autoantibodies to neuronal proteins may be one cause of neurodevelopmental disorders. This exploratory study used the Danish archived midgestational sera and their nationwide registers to search...

Maternal CASPR2 antibodies and neurodevelopmental disorders in the offspring: epidemiological findings and an animal model

BackgroundCNS disorders can be caused by IgG antibodies to neuronal surface proteins, and these antibodies have the potential to cross the placenta. Since some of them target proteins involved in neurodevelopment, such as contactin-associated protein-2 (CASPR2), we hypothesised that they could alter developing neuronal circuits in utero and lead to neurodevelopmental disorders in the children. MethodsA dual approach to the study was undertaken. First, we studied pregnancy serum samples from two population-based Danish cohorts: a cohort of women with postpartum psychosis and a cohort of mothers of children with mental retardation and other disorders of psychological development (MR–DPD), each with individually matched controls. We screened them for the presence of antibodies to CASPR2. Then, we assessed the effects of in-utero exposure to the antibodies in a mouse maternal-to-fetal model. FindingsThe combined results from these two cohorts showed that maternal antibodies to CASPR2 were associated with an increased risk of MR–DPD in the children: eight (4·4%) of 182 mothers of MR–DPD children had CASPR2 antibodies compared with only three (0·9%) of 347 mothers of children without this diagnosis (p=0·01). This association was explored by injection of mouse dams with IgG purified from CASPR2-antibody-positive patients, or from healthy controls. The mouse offspring had long-term behavioural sequelae, manifested as deficits in social interaction and social activities, and increased repetitive, non-social behaviours. When they were culled at 12 months, their brains showed abnormal migration of cortical projection neurons, increased microglial activation, and reduction in the number of glutamatergic synapses, confirming that there had been long-term changes in neurodevelopment. InterpretationCASPR2 was identified as a specific target for maternal antibodies that can alter brain development in utero, resulting in long-term behavioural deficits and permanent abnormalities at the cellular and synaptic level. These results should encourage further epidemiological and experimental studies to confirm and explore further how CASPR2 and other maternal antibodies can lead to neurodevelopmental disorders in children. FundingEC was funded by the Programme for Advanced Medical Education at the Calouste Gulbenkian Foundation. This work was also supported by the Stanley Medical Research Institute. Resources were provided by the Nuffield Department of Clinical Neurosciences.

Epidemiology of psychological development disorders in adolescents: use of alcohol and other drugs

Objective: to identify the personal and clinical characteristics of adolescents alcohol and other drugs’ users with PsychologicalDevelopment Disorders. Methods: this retrospective study analyzes the care of the Psychosocial Care III Center. Results: fromthe 415 adolescents treated, 52.3% were female; 89.9% were between 12 to 14 years old, 51.6% attended by court order,28.2% had “Unspecified Disorder of Psychological Development”; 32.3% used multiple drugs. Being between 12 and 14 yearsof age meant 2.5 and 1.5 times more risk of having Psychological Development Disorders, respectively. Cocaine/crack userswere more likely (4.27 times) to receive the diagnosis of “Psychoactive Substance Use.” Conclusion: adolescents are treated inaccordance with the law, which requires treatment for social living inadequacies due to high use of cannabinoids, and there isa difficulty of professionals in treating Psychological Development Disorders.

Mental disorder diagnoses of offspring affected by parental cancer before early adulthood: the 1987 Finnish Birth Cohort study.

The purpose of this study is to investigate psychiatric diagnoses given to children affected by parental cancer in psychiatric and somatic specialized health care settings. The 1987 Finnish Birth Cohort data (n = 59476) were followed up through national registers from birth of cohort members up to the end of 2008. The health-related data of cohort members and their parents were obtained from the Care Register of Health Care provided by the National Institute of Health and Wellbeing. By the age of 21years 7711 of the cohort members had used specialized psychiatric outpatient care and, of them, 549 (7.1%) were affected by parental cancer. Of affected offspring a mental disorder diagnosis was made in 424 (77.2%), while 125 (22.8%) children had not been given any specific mental disorder diagnosis. In females the likelihood for a mental disorder diagnosis assessed in outpatient care was significantly increased by up to 1.2 fold in cases of parental cancer. In males with a father having cancer, psychological development disorders were significantly increased whether assessed in outpatient (OR 1.5) or inpatient (OR1.9) settings. The prevalence of psychiatric diagnoses in children with parental cancer does not seem to differ from those of children with parents without cancer. However, evidence was found that children affected by parental cancer are at increased risk for some specific psychiatric disorders. Quarter of affected offspring who were referred to specialized psychiatric outpatient care only received diagnoses related to use of health care services or crises or received no psychiatric diagnosis at all. Copyright © 2016 John Wiley & Sons, Ltd.