Functional Impairment Rating Research Articles

Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score

IntroductionThird degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. Material and methodsA retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. ResultsFifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3–10) and 9 (range: 4–50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DiscussionIt became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. Level of evidenceIV: retrospective or historical series.

AUGMENTATION STRATEGIES FOR TREATMENT-RESISTANT ANXIETY DISORDERS: A SYSTEMATIC REVIEW AND META-ANALYSIS.

A systematic review and meta-analysis was conducted to explore the efficacy of medication augmentation strategies compared to control treatments in patients who have had a partial or no response to initial treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder. Double-blind controlled trials of medication augmentation in adult treatment-resistant anxiety disorders conducted between January 1990 and January 2015 were systematically reviewed and evaluated by two independent raters. The search identified 625 articles; 610 were excluded following abstract review and 15 had full-text screening. Studies had to include a definition of treatment resistance, exclude concomitant medications, and have a parallel or crossover design. Data extraction forms were completed in duplicate. Six studies were included in the meta-analysis. Effect estimates were calculated using random effects modeling; heterogeneity was assessed and subgroup and sensitivity analyses were completed. Primary outcome was response, defined by Clinical Global Impression-Improvement score of ≤2. Augmentation was not associated with an increased risk of response, as compared with placebo (RR = 1.08, 95% CI = 0.94-1.24). A small significant effect was found in reduction in symptom severity: standard mean difference = -0.32, 95% CI = -0.56 to -0.08. No significant differences between augmentation with medication versus placebo were found in ratings of functional impairment and dropouts due to adverse events. Augmentation does not appear to be beneficial in treatment-resistant anxiety disorders. These results may be limited by small study samples, and a small number of overall studies in the analysis.

Mental health, life functioning and risk factors among people exposed to frequent natural disasters and chronic poverty in Vietnam.

BackgroundPeople living in low- and middle-income countries (LMIC) are at increased risk for exposure to major natural disasters, which places them at increased risk for mental health problems. Evidence is less clear, however, regarding the effects of less severe but more frequent natural disasters, which are likely to increase due to global climate change.AimsTo examine the mental health and life functioning, and their predictors, of people living in central coastal Vietnam – an area characterised by high risk for natural disasters and poverty.MethodOne thousand individuals were randomly selected from five provinces in central coastal Vietnam. Individuals were assessed cross-sectionally for exposure to major storms and other traumatic events (Post-traumatic Diagnostic Scale, or PDS), financial stress (Chronic Financial Stress Scale), depression (PHQ-9), anxiety (GAD-7), post-traumatic stress disorder (PTSD) (PDS), somatic syndrome (SCL-90-R), alcohol dependence (ICD-10), self-perceived general physical health (SF-36), and functional impairment (PDS life functioning section); caseness was determined using the various measures’ algorithms.Results22.7% of the sample (n=227) met caseness criteria in one or more mental health domains, and 22.1% (n=221) reported moderate to severe functional impairment. Lifetime exposure to typhoons and other major storms was 99% (n=978), with 77% (n=742) reporting traumatic major storm exposure. Moderate to high levels of financial stress were reported by 30% (n=297). Frequency of exposure to major storms was not associated with increased risk for mental health problems but traumatic exposure to a major storm was. Overall, the strongest predictor of mental health problems was financial stress. Number of traumatic typhoons and other major storms in turn were significant predictors (r2=0.03) of financial stress. The primary predictor of alcohol dependence was male gender, highlighting the importance of gender roles in development of alcohol abuse in countries like Vietnam.ConclusionsIndividuals living in central coastal Vietnam have elevated rates of PTSD, somatic syndrome, and functional impairment but not depression or anxiety. Financial stress was the strongest predictor of mental health problems. Results suggest the importance of conducting broad assessments when providing mental health support for disaster-impacted communities. Study results suggest that one indirect consequence of predicted global climate change may be increased prevalence of mental health problems in communities such as that assessed in the present study, due to increased risk for traumatic storm-related exposure and through indirect effects on financial stress, but not through a general increased risk for major storms. Such results also indicate that when supporting LMIC communities that have experienced natural disasters, it will be important to consider the broader community context including poverty, in addition to the direct effects of the disaster.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Clinical outcomes associated with comorbid posttraumatic stress disorder among patients with bipolar disorder.

To assess clinical outcomes associated with the presence of a lifetime history of comorbid posttraumatic stress disorder in subjects with bipolar disorder. This cross-sectional study of 284 subjects with bipolar disorder (DSM-IV) assessed the association between lifetime comorbid posttraumatic stress disorder (DSM-IV) and clinical characteristics. Participants were included from January 2006 to June 2009. We assessed age at onset, number of mood episodes, presence of rapid cycling, first drug use, suicide attempts, hospitalizations, functional impairment, and quality of life. Diagnostic, clinical, and functional assessments were carried out using the Structured Clinical Interview for DSM-IV Axis I Disorders, patient edition (SCID-I/P), the Functioning Assessment Short Test, and the World Health Organization Quality of Life scale. The number of manic episodes as assessed by SCID-I/P was the primary outcome. The prevalence of lifetime comorbid posttraumatic stress disorder was 19.7% (56 subjects). Subjects with bipolar disorder and posttraumatic stress disorder had an accelerated course of illness, with a lower age at onset of manic/hypomanic episodes (P = .009) and earlier initiation of illicit drug use (P = .008). In addition, they were more likely to be younger when they received the diagnosis of bipolar disorder (P = .036) and had a higher number of manic/hypomanic episodes (P = .01). Quality of life was worse in all domains among subjects who presented the comorbidity, and rates of functional impairment were higher. Comorbid posttraumatic stress disorder was associated with increased morbidity and accelerated illness progression among subjects with bipolar disorder.

Disruptive Mood Dysregulation Disorder at Ages 13-18: Results from the National Comorbidity Survey-Adolescent Supplement.

"Disruptive mood dysregulation disorder" (DMDD) has been introduced into the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. but the utility of this new label and the clinical correlates of the children it describes are yet to be determined. A proxy for the DMDD diagnosis was extracted from the National Comorbidity Survey - Adolescent Supplement (NCS-A) data on 6483 adolescents (51.4% female) including Composite International Diagnostic Interview (CIDI) diagnoses and measures of impaired functioning from the Sheehan Disability Scale. Cross tabulations and logistic regression were used to assess for prevalence and comorbidity. A total of 310 (5.26%) adolescents met the criteria for DMDD when diagnostic hierarchy and frequency of outbursts were not considered. At the low end of prevalence estimation, only nine adolescents (0.12%) met the most stringent proxy diagnosis, and they also met criteria for a number of comorbid disorders and functional impairment. The rates of comorbidity and functional impairment in adolescents with bipolar disorder were the same, irrespective of their meeting criteria for DMDD. The DMDD diagnosis captures a small group of adolescents with multiple other psychiatric and neurologic conditions. The specificity of this diagnostic label, therefore, at least in adolescents, remains an open question.

Psychometric validation of the Weiss Functional Impairment Rating Scale-Parent Report Form in children and adolescents with attention-deficit/hyperactivity disorder.

BackgroundMeasurement properties of the Weiss Functional Impairment Rating Scale-Parent Report Form (WFIRS-P), which assesses attention-deficit/hyperactivity disorder (ADHD)-related functional impairment in children/adolescents (6–17 years), were examined.MethodsData from seven randomized, controlled trials were pooled. Analyses were conducted in two random half-samples. WFIRS-P conceptual framework was evaluated using confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach’s alpha) and test–retest reliability methods. Convergent validity was assessed using correlations between WFIRS-P domain scores and the ADHD-RS-IV and Clinical Global Impression–Severity (CGI–S) scales. Responsiveness was tested by comparing mean changes in WFIRS-P domain scores between responders and non-responders based on clinical criteria.ResultsCFA adequately confirmed the item-to-scale relationships defined in the WFIRS-P conceptual framework. Cronbach’s alpha coefficient exceeded 0.7 for all domains and test–retest reliability exceeded 0.7 for all but Risky Activities. With few exceptions, WFIRS-P domains correlated significantly (p < 0.05) with ADHD-RS-IV Total, Inattention and Hyperactivity-Impulsivity scores and CGI–S at baseline and follow-up in both random half-samples. Mean changes in WFIRS-P domain scores differed significantly between responder and non-responder groups in the expected direction (p < 0.001).ConclusionsStudy results support the reliability, validity and responsiveness of the WFIRS-P. Findings were replicated between two random samples, further demonstrating the robustness of results.Electronic supplementary materialThe online version of this article (doi:10.1186/s12955-015-0379-1) contains supplementary material, which is available to authorized users.

Does Guanfacine Extended Release Impact Functional Impairment in Children with Attention-Deficit/Hyperactivity Disorder? Results from a Randomized Controlled Trial.

BackgroundIn clinical trials of medications to treat attention-deficit/hyperactivity disorder (ADHD) in children, effects on functional impairment have been less well-studied than changes in ADHD symptoms.ObjectiveData regarding functional impairment were analyzed from a multicenter, double-blind, placebo-controlled study of guanfacine extended release (GXR) in children with ADHD, using the Weiss Functional Impairment Rating Scale–Parent Report (WFIRS-P). The correspondence of changes in WFIRS-P scores with symptomatic and global response to GXR treatment was also examined, with treatment response defined by scores on both the ADHD Rating Scale IV (ADHD-RS-IV) and the Clinical Global Impressions–Improvement Scale (CGI-I).MethodsIn this 8-week, double-blind, placebo-controlled, dose optimization study at 47 sites across the USA and Canada, children aged 6–12 years with a diagnosis of ADHD [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria, and an ADHD-RS-IV score ≥28 and CGI–Severity of Illness Scale score ≥4 at baseline], were randomized 1:1:1 into three groups: GXR am [GXR (1–4 mg/day) in the morning, placebo in the evening], GXR pm [placebo in the morning, GXR (1–4 mg/day) in the evening], or twice-daily placebo. Parents rated their children on the WFIRS-P at screening, baseline, the end of dose optimization, and at the final on-treatment assessment.ResultsThe efficacy population was composed of 333 subjects (GXR am: n = 107; GXR pm: n = 114; placebo: n = 112). At the final on-treatment assessment, there were significant improvements from baseline in the placebo-adjusted difference in least-squares (LS) mean (95 % confidence interval) WFIRS-P Total scores for both GXR treatment groups combined [GXR all-active: −0.16 (−0.25, −0.07), effect size (ES) = 0.448, P <0.001] and separately [GXR am: −0.15 (−0.26, −0.05), ES = 0.417, P = 0.004; GXR pm: −0.18 (−0.28, −0.07), ES = 0.478, P = 0.001]. Significant improvements in WFIRS-P domain scores for Family, Learning and School (including Academic Performance and Behavior in School), Social, and Risky Behavior were found for both GXR cohorts compared with placebo. However, the Life Skills and Self-Concept domain scores of the WFIRS-P did not improve with GXR treatment. Post hoc stratification by responder status revealed that significant (P <0.001) improvements in WFIRS-P Total and all domain scores were associated with symptomatic treatment response in the GXR all-active group.ConclusionsGXR treatment in children with ADHD was associated with reductions in WFIRS-P functional impairment scores compared with placebo, regardless of time of GXR administration. Changes in WFIRS-P scores were congruent with clinical response, as determined by both ADHD symptom reduction and CGI-I scores.ClinicalTrials.gov identifierNCT00997984.

Predictors of psychiatric readmission among patients with bipolar disorder at an academic safety-net hospital.

Even with treatment, approximately one-third of patients with bipolar disorder relapse into depression or mania within 1 year. Unfavorable clinical outcomes for patients with bipolar disorder include increased rates of psychiatric hospitalization and functional impairment. However, only a few studies have examined predictors of psychiatric hospital readmission in a sample of patients with bipolar disorder. The purpose of this study was to examine predictors of psychiatric readmission within 30 days, 90 days and 1 year of discharge among patients with bipolar disorder using a conceptual model adapted from Andersen's Behavioral Model of Health Service Use. In this retrospective study, univariate and multivariate logistic regression analyses were conducted in a sample of 2443 adult patients with bipolar disorder who were consecutively admitted to a public psychiatric hospital in the United States from 1 January to 31 December 2013. In the multivariate models, several enabling and need factors were significantly associated with an increased risk of readmission across all time periods examined, including being uninsured, having ⩾3 psychiatric hospitalizations and having a lower Global Assessment of Functioning score. Additional factors associated with psychiatric readmission within 30 and 90 days of discharge included patient homelessness. Patient race/ethnicity, bipolar disorder type or a current manic episode did not significantly predict readmission across all time periods examined; however, patients who were male were more likely to readmit within 1 year. The 30-day and 1-year multivariate models showed the best model fit. Our study found enabling and need factors to be the strongest predictors of psychiatric readmission, suggesting that the prevention of psychiatric readmission for patients with bipolar disorder at safety-net hospitals may be best achieved by developing and implementing innovative transitional care initiatives that address the issues of multiple psychiatric hospitalizations, housing instability, insurance coverage and functional impairment.

A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder

Despite the continuity of attention-deficit/hyperactivity disorder (ADHD) into adolescence, little is known regarding use of nonstimulants to treat ADHD in adolescents. This phase 3 trial evaluated the safety and efficacy of guanfacine extended release (GXR) in adolescents with ADHD. This 13-week, multicenter, randomized, double-blind, placebo-controlled trial evaluated once-daily GXR (1-7 mg per day) in adolescents with ADHD aged 13 to 17 years. The primary endpoint was the change from baseline in the ADHD Rating Scale-IV (ADHD-RS-IV) total score; key secondary endpoints included scores from the Clinical Global Impressions-Severity of Illness (CGI-S), and Learning and School domain and Family domain scores from the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) at week 13. A total of 314 participants were randomized (GXR, n = 157; placebo, n = 157). The majority of participants received optimal doses of 3, 4, 5, or 6 mg (30 [22.9%], 26 [19.8%], 27 [20.6%], or 24 [18.3%] participants, respectively), with 46.5% of participants receiving an optimal dose above the currently approved maximum dose limit of 4 mg. Participants receiving GXR showed improvement in ADHD-RS-IV total score compared with placebo (least-squares mean score change, -24.55 [GXR] versus -18.53 [placebo]; effect size, 0.52; p <.001). More participants on GXR also showed significant improvement in CGI-S scores compared with placebo (50.6% versus 36.1%; p = .010). There was no statistically significant difference between treatments at week 13 in the 2 WFIRS-P domains. Most treatment-emergent adverse events were mild to moderate, with sedation-related events reported most commonly. GXR was associated with statistically significant improvements in ADHD symptoms in adolescents. GXR was well tolerated, with no new safety signals reported. Dose-Optimization in Adolescents Aged 13-17 Diagnosed With Attention-Deficit/Hyperactivity Disorder (ADHD) Using Extended-Release Guanfacine HCl; http://ClinicalTrials.gov/; NCT01081132.

Functional impairment and mental health functioning among Vietnamese children.

Functional impairment is a key indicator of need for mental health services among children and adolescents, often a stronger predictor of service usage than mental health symptoms themselves. Functional impairment may be of particular importance in low- and middle-income countries (LMIC) because of its potential to focus policy on treatment of child mental health problems which is generally given low priority in LMIC. However, few studies have assessed functional impairment in LMIC. The present study assessed rates of functional impairment among children in Vietnam, as a case example of an LMIC, as well as effects of other risk/protective factors of particular relevance to LMIC (e.g., whether the family lived in an urban or rural area; family structure variables such as grandparents living with the family). 1314 parents of children 6-16years old from 10 Vietnamese provinces were interviewed. The overall rate of functional impairment among Vietnamese children was 20%, similar to rates in high-income countries such as Germany and the United States, suggesting that LMIC status may not be associated with dramatic increases in functional impairment in children. Functional impairment was significantly greater among mental health cases than non-cases, with increases of over 550% associated with mental health caseness. A number of other risk factors (e.g., marital status) had smaller but significant effects. Mental health problems are a major but not the sole contributor to functional impairment among Vietnamese children. The pragmatic significance of this research lies in its potential to affect public awareness and policy related to child mental health in LMIC.

Validation of DSM-5 age-of-onset criterion of attention deficit/hyperactivity disorder (ADHD) in adults: Comparison of life quality, functional impairment, and family function

The newly published Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) elevates the threshold of the ADHD age-of-onset criterion from 7 to 12 years. This study evaluated the quality of life and functional impairment of adults with ADHD who had symptoms onset by or after 7 years and examined the mediation effect of family function and anxiety/depression symptoms between ADHD diagnosis and quality of life and functional impairment. We assessed 189 adults with ADHD and 153 non-ADHD controls by psychiatric interview and self-administered reports on the Adult ADHD Quality of Life Scale, Weiss Functional Impairment Rating Scale, Family APGAR, and Adult Self Report Inventory-4. The ADHD group was divided into early-onset ADHD (onset <7 years, n=147) and late-onset ADHD (onset between 7 and 12 years, n=42). The mediation analysis was conducted to verify the mediating factors from ADHD to functional impairment and quality of life. The late-onset ADHD had more severe functional impairment at work and poorer family support than early-onset ADHD while they had comparable impairment at other domains. Less perceived family support and current anxiety/depressive symptoms partially mediated the link between ADHD diagnosis and quality of life/functional impairment both in early- and late-onset ADHD. Our data support decreased quality of life and increased functional impairment in adult ADHD, regardless of age of onset, and these adverse outcomes may be mediated by family support and anxiety/depression at adulthood. Our findings also imply that the new DSM-5 ADHD criteria do not over-include individuals without impairment.

Trastornos de ansiedad relacionados con traumas y otros factores de estrés

Anxiety disorders are the most common group of mental diseases, with an overall prevalence of 2-8% and a 10-12% rate in primary care consultations. The DSM-5 differentiates the category “trauma and stressor-related disorders”, in which the main diagnosis is post-traumatic stress disorder (PTSD). This article is devoted to the update of this category. The prevalence of PTSD is 6.4-6.8%, usually starts in the twenties and is more common among women. PTSD is associated with high rates of functional impairment, sleep complaints, a risk of suicide and other comorbid psychiatric disorders. Early diagnosis is important to identify individuals who can benefit from treatment, which generally includes psychoeducation for patients and families, as well as psychotherapy and psychoactive drugs, with selective serotonin reuptake inhibitors as the first choice. Patients are referred to psychiatrists when there are comorbidities, a risk of suicide or a poor response to treatment.

Staging Models and Functional Outcomes in Bipolar Disorder: Clinical Implications

Prognostic staging has been gaining traction in psychiatry in the past few years. The heterogeneity of clinical presentations in bipolar disorder has been an important challenge to clinicians and researchers. Staging models attempt to overcome this problem by identifying clusters of patients with bipolar disorder who have a differential course of illness and response to treatments. There is an emerging body of knowledge suggesting that staging models based on functional outcomes (functional staging) may provide clinicians with a useful tool to predict the course of illness and organize treatment strategies to individual patients. For instance, it has been widely accepted that earlier interventions in BD are likely to be associated with a better response to treatment, and lower rates of functional impairment. Also, while treatments such as lithium monotherapy, cognitive behavioral therapy, and psychoeducation seem to be better suited to prevent further recurrences within patients with few episodes, complex pharmacological strategies and functional remediation might be considered in more severe patients. Therefore, the aim of the present work is to review the evidence related to the clinical use of functional staging models in bipolar disorder.

Home visits and the housebound

Home visits remain an important and integral part of general practice. Many home visits are on an unscheduled acute basis, but for permanently housebound patients home visits are often the only way of seeing a GP. Housebound patients have higher rates of co-morbidity, functional impairment and mortality than their non-housebound counterparts. As the elderly population and potentially the number that are housebound continues to rise; the value and importance of home visits to enable continuity of care to this frail subset of patients is also likely to grow. Home visits can undoubtedly be difficult but they offer many advantages that can easily be overlooked, including gaining valuable insight into the home life of the patient. This article aims to improve awareness of the needs of the housebound as well as highlighting the advantages of home visiting in general. It gives useful advice on how to get the most out of a home visit.

Further Validation of the Female Sexual Function Index: Specificity and Associations With Clinical Interview Data

Female sexual function is a multi-faceted psychophysiological construct. The Female Sexual Function Index (FSFI) is considered a “gold standard” self-report instrument that assesses the various aspects of sexual function. However, researchers have recently proposed potential limitations of the FSFI, highlighting the need for continued validation research. The aims of the current analyses were (a) to assess the correlations between FSFI scores and information regarding specific rates of functional impairment gained via clinical interview; and (b) to assess the specificity of FSFI subscale scores in reflecting corresponding aspects of sexual function (e.g., whether the Sexual Desire subscale reflects sexual desire specifically rather than sexual arousal, orgasm, etc.). The participants were 97 sexually active women who reported impairments in sexual function. Clinical interview data exhibited moderate-to-strong correlations with FSFI scores. Additionally, FSFI subscales generally exhibited adequate specificity in terms of reflecting their corresponding aspects of sexual function more strongly than other aspects. The results generally supported the validity of the FSFI. Implications for the measurement and conceptualization of female sexual function are discussed.

The Use of Cholinesterase Inhibitors Across All Stages of Alzheimer's Disease.

Current pharmacological therapy for Alzheimer's disease (AD) includes the cholinesterase inhibitors (ChEIs) donepezil, rivastigmine, and galantamine and the N-methyl D-aspartate receptor antagonist memantine. Based on the results of randomized controlled trials and several meta-analyses, ChEIs appear to show modest but statistically significant improvements on several measures, including cognition and global functioning. Given their modest effects, there is a lack of consensus among clinicians regarding issues related to initiation, optimal duration, and discontinuation of ChEI therapy across the spectrum of AD. There is evidence from long-term observational controlled studies that early initiation and persistent exposure to AD therapy lead to delays in nursing home admission and significantly slower rates of cognitive and functional impairment. In the moderate to severe stages of AD, therapeutic trials of higher dose ChEIs and the addition of memantine are recommended for patients who are no longer responding to lower doses. While side effects are generally mild and gastrointestinal in nature, these events can lead to significant morbidity in more susceptible patients with advanced disease. Patients should thus be regularly monitored for any potential serious side effects of ChEI therapy, which also may include syncope and bradycardia. At the terminal stages of AD, such as when patients become hospice eligible, attempts to cautiously discontinue all medications not necessary for quality of life, including AD drugs, should be made.

Functional outcomes from a head-to-head, randomized, double-blind trial of lisdexamfetamine dimesylate and atomoxetine in children and adolescents with attention-deficit/hyperactivity disorder and an inadequate response to methylphenidate.

Attention-deficit/hyperactivity disorder (ADHD) is associated with functional impairments in multiple domains of patients’ lives. A secondary objective of this randomized, active-controlled, head-to-head, double-blind, dose-optimized clinical trial was to compare the effects of lisdexamfetamine dimesylate (LDX) and atomoxetine (ATX) on functional impairment in children and adolescents with ADHD. Patients aged 6–17 years with an ADHD Rating Scale IV total score ≥28 and an inadequate response to methylphenidate treatment (judged by investigators) were randomized (1:1) to once-daily LDX or ATX for 9 weeks. Parents/guardians completed the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) at baseline and at week 9 or early termination. p values were nominal and not corrected for multiple comparisons. Of 267 randomized patients, 200 completed the study (LDX 99, ATX 101). At baseline, mean WFIRS-P total score in the LDX group was 0.95 [standard deviation (SD) 0.474; 95 % confidence interval (CI) 0.87, 1.03] and in the ATX group was 0.91 (0.513; 0.82, 1.00). Scores in all WFIRS-P domains improved from baseline to endpoint in both groups, with least-squares mean changes in total score of −0.35 (95 % CI −0.42, −0.29) for LDX and −0.27 (−0.33, −0.20) for ATX. The difference between LDX and ATX was statistically significant (p < 0.05) for the Learning and School (effect size of LDX vs ATX, 0.43) and Social Activities (0.34) domains and for total score (0.27). Both treatments reduced functional impairment in children and adolescents with ADHD; LDX was statistically significantly more effective than ATX in two of six domains and in total score.Electronic supplementary materialThe online version of this article (doi:10.1007/s00787-015-0718-0) contains supplementary material, which is available to authorized users.

Cardiovascular risk factors and metabolic syndrome in people with established psychotic illnesses: baseline data from the IMPaCT randomized controlled trial.

The aims of the study were to determine the prevalence of cardiometabolic risk factors and establish the proportion of people with psychosis meeting criteria for the metabolic syndrome (MetS). The study also aimed to identify the key lifestyle behaviours associated with increased risk of the MetS and to investigate whether the MetS is associated with illness severity and degree of functional impairment. Baseline data were collected as part of a large randomized controlled trial (IMPaCT RCT). The study took place within community mental health teams in five Mental Health NHS Trusts in urban and rural locations across England. A total of 450 randomly selected out-patients, aged 18-65 years, with an established psychotic illness were recruited. We ascertained the prevalence rates of cardiometabolic risk factors, illness severity and functional impairment and calculated rates of the MetS, using International Diabetes Federation (IDF) and National Cholesterol Education Program Third Adult Treatment Panel criteria. High rates of cardiometabolic risk factors were found. Nearly all women and most men had waist circumference exceeding the IDF threshold for central obesity. Half the sample was obese (body mass index ≥ 30 kg/m2) and a fifth met the criteria for type 2 diabetes mellitus. Females were more likely to be obese than males (61% v. 42%, p < 0.001). Of the 308 patients with complete laboratory measures, 57% (n = 175) met the IDF criteria for the MetS. In the UK, the prevalence of cardiometabolic risk factors in individuals with psychotic illnesses is much higher than that observed in national general population studies as well as in most international studies of patients with psychosis.

Visual impairment and unmet eye care needs among homeless adults in a Canadian city.

The ocular status of homeless populations remains largely unknown. Given that visual acuity has been shown to be heavily correlated with reduced well-being and decreased earning potential, findings of poor vision could have important health implications for people experiencing homelessness. To assess the prevalence of visual impairment and to identify unmet eye care needs in an adult homeless population. For this cross-sectional study, we recruited 100 homeless persons using a stratified random sampling technique from January to March 2014. Recruitment took place at 10 randomly selected adult shelters in Toronto, Ontario, Canada. All English-speaking persons older than 18 years of age were eligible to participate. Information was obtained on sociodemographic characteristics, ocular history, and subjective visual acuity. A comprehensive vision screening and an undilated retinal examination were performed for each participant. Rates of functional visual impairment and prevalence of nonrefractive eye pathology. The median age of participants was 48 years (interquartile range, 36-56 years), and 62% were men. The median lifetime duration of homelessness was 12 months (interquartile range, 5-36 months). Based on the participants' presenting visual acuity, the age-standardized rate of visual impairment was 25.2% (95% CI, 16.7%-33.7%). After pinhole occlusion, this number decreased to 15.2% (95% CI, 7.7%-22.7%). In total, 13.0% (95% CI, 7.8%-20.0%) of participants experienced visual impairment secondary to a correctable refractive error. Although the major problem for this demographic was limited access to refractive correction, a large degree of nonrefractive pathology was also observed. Of all the participants, 34.0% (95% CI, 24.7%-43.3%) had 1 or more abnormal findings during the vision screening, and 8% (95% CI, 2.7%-13.3%) required urgent referral to an ophthalmologist. A large majority of participants (89.0%) indicated interest in accessing free eye examinations. These data suggest that homeless adults have a high prevalence of visual impairment, even when living within a system of universal health insurance. Given the high level of interest in eye care among homeless persons, ongoing vision-screening programs and readily accessible free eye clinics may help address this need.

Validation of life-charts documented with the personal life-chart app - a self-monitoring tool for bipolar disorder.

BackgroundLong-term monitoring in bipolar affective disorders constitutes an important therapeutic and preventive method. The present study examines the validity of the Personal Life-Chart App (PLC App), in both German and in English. This App is based on the National Institute of Mental Health’s Life-Chart Method, the de facto standard for long-term monitoring in the treatment of bipolar disorders.MethodsMethods have largely been replicated from 2 previous Life-Chart studies. The participants documented Life-Charts with the PLC App on a daily basis. Clinicians assessed manic and depressive symptoms in clinical interviews using the Inventory of Depressive Symptomatology, clinician-rated (IDS-C) and the Young Mania Rating Scale (YMRS) on a monthly basis on average. Spearman correlations of the total scores of IDS-C and YMRS were calculated with both the Life-Chart functional impairment rating and mood rating documented with the PLC App. 44 subjects used the PLC App in German and 10 subjects used the PLC App in English. 118 clinical interviews from the German sub-sample and 97 from the English sub-sample were analysed separately.ResultsThe results in both sub-samples are similar to previous Life-Chart validation studies. Again statistically significant high correlations were found between the Life-Chart function rating assigned through the PLC App and well-established observer-rated methods. Again correlations were weaker for the Life-Chart mood rating than for the Life-Chart function impairment. No relevant correlation was found between the Life-chart mood rating and YMRS in the German sub-sample.ConclusionThis study gives further evidence for the validity of the Life-Chart method as a valid tool for the recognition of both manic and depressive episodes. Documenting Life-Charts with the PLC App (English and German) does not seem to impair the validity of patient ratings.