Antidepressants for cognitive impairment in schizophrenia - A systematic review and meta-analysis

Background: Cognitive impairment in schizophrenia is disabling, but current treatment options remain limited. Objective: To meta-analyze the efficacy and safety of adjunctive antidepressants for cognitive impairment in schizophrenia. Data sources and study selection: PubMed, MEDLINE, PsycINFO, and Cochrane Library databases were searched until 12/2013 for randomized controlled trials comparing antidepressant augmentation of antipsychotics with placebo regarding effects on cognitive functioning in schizophrenia. Data extraction: Two authors independently extracted data. Standardized mean differences (SMDs) were calculated for continuous outcomes and risk ratios for categorical outcomes. SMDs of individual cognitive tests were pooled on a study level within domains (primary outcome) and across domains. When results were heterogeneous, random instead of fixed effects models were used. Results: We meta-analyzed 11 studies (duration=8.7 +/- 3.7 weeks) including 568 patients (mean age=39.5 +/- 6.9 years, males=67.2%, illness duration=12.5 +/- 8.0 years). Antidepressants included mirtazapine (4 studies; n=126), citalopram (2 studies; n=231), fluvoxamine (1 study; n=47), duloxetine (1 study; n=40), mianserin (1 study; n=30), bupropion (1 study; n=61), and reboxetine (1 study; n=33). Statistically significant, but clinically negligible, advantages were found for pooled antidepressants compared to placebo in executive function (Hedges\u27 g=0.17, p=0.02) and a composite cognition score (Hedges\u27 g=0.095, p=0.012). Depression improved with serotonergic antidepressants (p=0.0009) and selective serotonin reuptake inhibitors (p=0.009), but not with pooled antidepressants (p=0.39). Sedation was more common with pooled antidepressants (p=0.04). Conclusion: Adjunctive antidepressants do not demonstrate clinically significant effects on cognition in schizophrenia patients, however, larger studies, preferably in euthymic schizophrenia patients and using full neurocognitive batteries, are needed to confirm this finding. (C) 2014 Elsevier B. V. All rights reserved

Characteristics and disposition of youth referred from schools for emergency psychiatric evaluation

We aimed to describe the characteristics and disposition of youth referred from schools to the emergency department (ED) for psychiatric evaluations. Consecutive 12-month records of ED psychiatric consultations at a large urban hospital from 07.01.2009 to 06.30.2010 were retrospectively analyzed. School-initiated referrals were deemed inappropriate if youth were discharged from the ED without any recommended mental health follow-up. Of the 551 psychiatric ED evaluations, 243 (44.1 %) were initiated by schools. Of all school referrals, only 19 (7.8 %) children were psychiatrically hospitalized, 108 (44.4 %) were discharged from the ED with a follow-up appointment; and 116 (47.7 %) were discharged without arranged follow-up. Those with a chief complaint of suicidality (n = 109, 44.9 %) were more likely to be discharged without arranged follow-up than youth with other presenting complaints (56.0 vs. 41.0 %, p = 0.021). Altogether, only 37 (18.5 %) of 200 school-referred youth with information were evaluated by a school nurse, social worker, or other professional before being sent to the ED. Students without in-school screening were significantly more frequently discharged without follow-up than students with in-school evaluations prior to the ED referral (51.5 vs. 27.0 %, p = 0.0070; odds ratio = 2.87 (95 % CI 1.30-6.31). Multivariate predictors of inappropriate school referrals of youth discharged without any outpatient follow-up were higher Children\u27s Global Assessment Scale score (p \u3c 0.0001), absent in-school evaluation (p = 0.0069), absent prior psychiatric history (p = 0.011) and absent current psychotropic medication treatment (p = 0.012) (r 2 = 0.264 %, p \u3c 0.0001). Altogether 44.1 % of ED consultations were school referred, of which 47.7 % were potentially inappropriate for the emergency setting. In-school screening, which occurred infrequently, reduced unnecessary evaluations by 52 %

Suicidality and hospitalization as cause and outcome of pediatric psychiatric emergency room visits

The aim of this study was to identify predictors of suicidality in youth presenting to a pediatric psychiatric emergency room service (PPERS). To this end, we conducted a retrospective cohort study of youth aged01.01.2002-12.31.2002, using a 12-page semi-structured institutional evaluation form and the Columbia Classification Algorithm for Suicide Assessment. Multivariate regression analyses were conducted to identify correlates of suicidal thoughts and attempts/preparation and their relationship to outpatient/inpatient disposition. Of 1,062 youth, 265 (25.0 %) presented with suicidal ideation (16.2 %) or attempt/preparation (8.8 %). Suicidal ideation was associated with female sex, depression, adjustment disorder, absent referral by family/friend/self, school referral, precipitant of peer conflict, and no antipsychotic treatment (p \u3c 0.0001). Suicidal attempt/preparation was associated with female sex, depression, lower GAF score, past suicide attempt, precipitant of peer conflict, and no stimulant treatment (p \u3c 0.0001). Compared to suicidal attempt/preparation, suicidal ideation was associated with school referral, and higher GAF score (p \u3c 0.0001). Of the 265 patients with suicidality, 58.5 % were discharged home (ideation = 72.1 % vs. attempt/preparation = 33.7 %, p \u3c 0.0001). In patients with suicidal ideation, outpatient disposition was associated with higher GAF score, school referral, and adjustment disorder (p \u3c 0.0001). In patients with suicidal attempt/preparation, outpatient disposition was associated with higher GAF score, lower acuity rating, and school referral (p \u3c 0.0001). Suicidality is common among PPERS evaluations. Higher GAF score and school referral distinguished suicidal ideation from suicidal attempt/preparation and was associated with outpatient disposition in both presentations. Increased education of referral sources and establishment of different non-PPERS evaluation systems may improve identification of non-emergent suicidal presentations and encourage more appropriate outpatient referrals

ROHHAD and Prader-Willi syndrome (PWS): clinical and genetic comparison

Abstract Background Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) is a very rare and potentially fatal pediatric disorder, the cause of which is presently unknown. ROHHAD is often compared to Prader-Willi syndrome (PWS) because both share childhood obesity as one of their most prominent and recognizable signs, and because other symptoms such as hypoventilation and autonomic dysfunction are seen in both. These phenotypic similarities suggest they might be etiologically related conditions. We performed an in-depth clinical comparison of the phenotypes of ROHHAD and PWS and used NGS and Sanger sequencing to analyze the coding regions of genes in the PWS region among seven ROHHAD probands. Results Detailed clinical comparison of ROHHAD and PWS patients revealed many important differences between the phenotypes. In particular, we highlight the fact that the areas of apparent overlap (childhood-onset obesity, hypoventilation, autonomic dysfunction) actually differ in fundamental ways, including different forms and severity of hypoventilation, different rates of obesity onset, and different manifestations of autonomic dysfunction. We did not detect any disease-causing mutations within PWS candidate genes in ROHHAD probands. Conclusions ROHHAD and PWS are clinically distinct conditions, and do not share a genetic etiology. Our detailed clinical comparison and genetic analyses should assist physicians in timely distinction between the two disorders in obese children. Of particular importance, ROHHAD patients will have had a normal and healthy first year of life; something that is never seen in infants with PWS