Ted Bosworth

BROOKLYN, N.Y. – Three steps in the progressive pathology of anxiety and other pediatric psychiatric disorders are important to recognize for their critical role in guiding treatment, John T. Walkup, MD, said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

After the onset of symptoms and over the course of time, those with untreated anxiety disorders are at risk for developing impairment in adaptation and coping, and also the development of maladaptive behaviors like substance abuse and suicidal behavior, said Dr. Walkup, chair of the department of psychiatry at Ann and Robert H. Lurie Children’s Hospital of Chicago.

The focus of his presentation was on the treatment of anxiety disorders in children, but Dr. Walkup said the impact of the three-tier progression is likely relevant to any psychiatric disorder that begins in childhood.

In essence, the scope of problems becomes more complicated over time, and without early treatment, children continue to be symptomatic. But they also develop a lifestyle based on avoidance coping and might engage in maladaptive behaviors, Dr. Walkup said. As a result, the complexity of treatment increases substantially beyond just symptom control.

Providing an example, Dr. Walkup described a child of 7 years of age with separation anxiety. If treated at the time symptoms begin, Dr. Walkup explained, cognitive-behavioral therapy and medication would be expected to be both straightforward and highly effective. If left untreated until age 14, the child might accumulate impairment in independent functioning (due to avoidance coping) at a particularly important time in development.

“In those kids, you can reduce their anxiety burden with acute treatments like [cognitive-behavioral therapy] or meds, but now you also have 7 or 8 years of accumulated impairment due to avoidance coping and parental accommodation,” Dr. Walkup said. “If those kids are going to catch up developmentally, they also need life skill support in addition to symptomatic treatment for their anxiety.”

In the case of any pediatric psychiatric disorder, early treatment has the potential to thwart progression to a more complex and treatment-resistant form, but anxiety is a particularly prominent example. In most children, anxiety is relatively easy to control if caught early but a greater challenge when fears are not contained and the child accumulates ongoing impairment.

The obstacle is that many children are not diagnosed at the time of onset, said Dr. Walkup. The solution, he suggested, is better training of pediatricians and other primary care physicians not only to identify those children but to initiate treatment in uncomplicated cases.

“The person who has that longitudinal relationship with the child is their primary care provider, and this is really the person who is going to do the best job in getting to these kids early and initiating treatment,” Dr. Walkup said.

“We have a program in Chicago where we have trained primary care physicians not only to treat anxiety and depression, but we have specifically focused them on the easiest cases in their caseload, the classic phenotypes,” Dr. Walkup reported. Using a collaborative care model, this approach has been effective in building the confidence of primary care clinicians and in reaching children when symptoms are easier to control.

Importantly, anti-anxiety medication delivered in primary care could be sufficient to help children to manage anxiety effectively when parents cooperate in helping their children manage their fears.

“People suggest that we always start with CBT, but there [are no data] to support that. I think it is a conclusion drawn from the fact that CBT works and medication has side effects,” Dr. Walkup said. He appreciates the evidence that CBT is effective, but he cautioned that this therapy is not available everywhere, and pharmacologic therapies may be as or potentially more effective for some anxiety symptoms like anxiety-related physical symptoms.
 

Conversely, some have expressed the opinion that drugs might be a better option in late adolescence, when the efficacy of CBT appears to diminish, but Dr. Walkup objected to that characterization as well.

“My sense is that if you treat a 7-year-old for symptoms that have lasted a year it’s very different from treating a 17-year-old who has had symptoms for a decade,” Dr. Walkup said. Referring back to the contention that psychiatric disease in children becomes more complicated with a longer duration, this might explain why “you don’t see as much immediate success” with CBT and medication in the older age groups even if this is an effective treatment tool.

Some psychiatric disorders in children, including anxiety, might resolve with age, but early recognition and treatment should be a goal because of the potential to reduce symptoms and avoidance coping, and improve long-term outcomes, Dr. Walkup reported. Ironically, it might not be just anxiety symptoms, but poor adaptation and coping that might be the most important driver of ongoing impairment.

Dr. Walkup has served as an unpaid adviser to the Anxiety Disorders of Association of America. In addition, he has received royalties from Wolters Kluwer for CME activity on childhood anxiety.

This story was updated 2/11/2019.

BROOKLYN, N.Y. – Three steps in the progressive pathology of anxiety and other pediatric psychiatric disorders are important to recognize for their critical role in guiding treatment, John T. Walkup, MD, said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

After the onset of symptoms and over the course of time, those with untreated anxiety disorders are at risk for developing impairment in adaptation and coping, and also the development of maladaptive behaviors like substance abuse and suicidal behavior, said Dr. Walkup, chair of the department of psychiatry at Ann and Robert H. Lurie Children’s Hospital of Chicago.

The focus of his presentation was on the treatment of anxiety disorders in children, but Dr. Walkup said the impact of the three-tier progression is likely relevant to any psychiatric disorder that begins in childhood.

In essence, the scope of problems becomes more complicated over time, and without early treatment, children continue to be symptomatic. But they also develop a lifestyle based on avoidance coping and might engage in maladaptive behaviors, Dr. Walkup said. As a result, the complexity of treatment increases substantially beyond just symptom control.

Providing an example, Dr. Walkup described a child of 7 years of age with separation anxiety. If treated at the time symptoms begin, Dr. Walkup explained, cognitive-behavioral therapy and medication would be expected to be both straightforward and highly effective. If left untreated until age 14, the child might accumulate impairment in independent functioning (due to avoidance coping) at a particularly important time in development.

“In those kids, you can reduce their anxiety burden with acute treatments like [cognitive-behavioral therapy] or meds, but now you also have 7 or 8 years of accumulated impairment due to avoidance coping and parental accommodation,” Dr. Walkup said. “If those kids are going to catch up developmentally, they also need life skill support in addition to symptomatic treatment for their anxiety.”

In the case of any pediatric psychiatric disorder, early treatment has the potential to thwart progression to a more complex and treatment-resistant form, but anxiety is a particularly prominent example. In most children, anxiety is relatively easy to control if caught early but a greater challenge when fears are not contained and the child accumulates ongoing impairment.

The obstacle is that many children are not diagnosed at the time of onset, said Dr. Walkup. The solution, he suggested, is better training of pediatricians and other primary care physicians not only to identify those children but to initiate treatment in uncomplicated cases.

“The person who has that longitudinal relationship with the child is their primary care provider, and this is really the person who is going to do the best job in getting to these kids early and initiating treatment,” Dr. Walkup said.

“We have a program in Chicago where we have trained primary care physicians not only to treat anxiety and depression, but we have specifically focused them on the easiest cases in their caseload, the classic phenotypes,” Dr. Walkup reported. Using a collaborative care model, this approach has been effective in building the confidence of primary care clinicians and in reaching children when symptoms are easier to control.

Importantly, anti-anxiety medication delivered in primary care could be sufficient to help children to manage anxiety effectively when parents cooperate in helping their children manage their fears.

“People suggest that we always start with CBT, but there [are no data] to support that. I think it is a conclusion drawn from the fact that CBT works and medication has side effects,” Dr. Walkup said. He appreciates the evidence that CBT is effective, but he cautioned that this therapy is not available everywhere, and pharmacologic therapies may be as or potentially more effective for some anxiety symptoms like anxiety-related physical symptoms.
 

Conversely, some have expressed the opinion that drugs might be a better option in late adolescence, when the efficacy of CBT appears to diminish, but Dr. Walkup objected to that characterization as well.

“My sense is that if you treat a 7-year-old for symptoms that have lasted a year it’s very different from treating a 17-year-old who has had symptoms for a decade,” Dr. Walkup said. Referring back to the contention that psychiatric disease in children becomes more complicated with a longer duration, this might explain why “you don’t see as much immediate success” with CBT and medication in the older age groups even if this is an effective treatment tool.

Some psychiatric disorders in children, including anxiety, might resolve with age, but early recognition and treatment should be a goal because of the potential to reduce symptoms and avoidance coping, and improve long-term outcomes, Dr. Walkup reported. Ironically, it might not be just anxiety symptoms, but poor adaptation and coping that might be the most important driver of ongoing impairment.

Dr. Walkup has served as an unpaid adviser to the Anxiety Disorders of Association of America. In addition, he has received royalties from Wolters Kluwer for CME activity on childhood anxiety.

This story was updated 2/11/2019.

BROOKLYN, N.Y. – Three steps in the progressive pathology of anxiety and other pediatric psychiatric disorders are important to recognize for their critical role in guiding treatment, John T. Walkup, MD, said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

After the onset of symptoms and over the course of time, those with untreated anxiety disorders are at risk for developing impairment in adaptation and coping, and also the development of maladaptive behaviors like substance abuse and suicidal behavior, said Dr. Walkup, chair of the department of psychiatry at Ann and Robert H. Lurie Children’s Hospital of Chicago.

The focus of his presentation was on the treatment of anxiety disorders in children, but Dr. Walkup said the impact of the three-tier progression is likely relevant to any psychiatric disorder that begins in childhood.

In essence, the scope of problems becomes more complicated over time, and without early treatment, children continue to be symptomatic. But they also develop a lifestyle based on avoidance coping and might engage in maladaptive behaviors, Dr. Walkup said. As a result, the complexity of treatment increases substantially beyond just symptom control.

Providing an example, Dr. Walkup described a child of 7 years of age with separation anxiety. If treated at the time symptoms begin, Dr. Walkup explained, cognitive-behavioral therapy and medication would be expected to be both straightforward and highly effective. If left untreated until age 14, the child might accumulate impairment in independent functioning (due to avoidance coping) at a particularly important time in development.

“In those kids, you can reduce their anxiety burden with acute treatments like [cognitive-behavioral therapy] or meds, but now you also have 7 or 8 years of accumulated impairment due to avoidance coping and parental accommodation,” Dr. Walkup said. “If those kids are going to catch up developmentally, they also need life skill support in addition to symptomatic treatment for their anxiety.”

In the case of any pediatric psychiatric disorder, early treatment has the potential to thwart progression to a more complex and treatment-resistant form, but anxiety is a particularly prominent example. In most children, anxiety is relatively easy to control if caught early but a greater challenge when fears are not contained and the child accumulates ongoing impairment.

The obstacle is that many children are not diagnosed at the time of onset, said Dr. Walkup. The solution, he suggested, is better training of pediatricians and other primary care physicians not only to identify those children but to initiate treatment in uncomplicated cases.

“The person who has that longitudinal relationship with the child is their primary care provider, and this is really the person who is going to do the best job in getting to these kids early and initiating treatment,” Dr. Walkup said.

“We have a program in Chicago where we have trained primary care physicians not only to treat anxiety and depression, but we have specifically focused them on the easiest cases in their caseload, the classic phenotypes,” Dr. Walkup reported. Using a collaborative care model, this approach has been effective in building the confidence of primary care clinicians and in reaching children when symptoms are easier to control.

Importantly, anti-anxiety medication delivered in primary care could be sufficient to help children to manage anxiety effectively when parents cooperate in helping their children manage their fears.

“People suggest that we always start with CBT, but there [are no data] to support that. I think it is a conclusion drawn from the fact that CBT works and medication has side effects,” Dr. Walkup said. He appreciates the evidence that CBT is effective, but he cautioned that this therapy is not available everywhere, and pharmacologic therapies may be as or potentially more effective for some anxiety symptoms like anxiety-related physical symptoms.
 

Conversely, some have expressed the opinion that drugs might be a better option in late adolescence, when the efficacy of CBT appears to diminish, but Dr. Walkup objected to that characterization as well.

“My sense is that if you treat a 7-year-old for symptoms that have lasted a year it’s very different from treating a 17-year-old who has had symptoms for a decade,” Dr. Walkup said. Referring back to the contention that psychiatric disease in children becomes more complicated with a longer duration, this might explain why “you don’t see as much immediate success” with CBT and medication in the older age groups even if this is an effective treatment tool.

Some psychiatric disorders in children, including anxiety, might resolve with age, but early recognition and treatment should be a goal because of the potential to reduce symptoms and avoidance coping, and improve long-term outcomes, Dr. Walkup reported. Ironically, it might not be just anxiety symptoms, but poor adaptation and coping that might be the most important driver of ongoing impairment.

Dr. Walkup has served as an unpaid adviser to the Anxiety Disorders of Association of America. In addition, he has received royalties from Wolters Kluwer for CME activity on childhood anxiety.

This story was updated 2/11/2019.

BROOKLYN, N.Y. – As a target of therapy in children with a psychiatric disorder, irritability expressed as grumpy mood or anger should be uncoupled from irritability expressed as threatening behavior, according to an exploration of this common clinical issue at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Ted Bosworth/MDedge News

“Irritability is like fever,” reported Gabrielle A. Carlson, MD, professor of psychiatry and pediatrics, State University of New York at Stony Brook. “It is a nonspecific symptom that only tells you that something is wrong.”

Irritability might be nothing more than a negative mood, but it also can be the source of explosive aggression, leading to tantrums and destructive behaviors, according to Dr. Carlson. She placed them into two different categories when considering treatment. Irritability leading to annoyance, grumpiness, withdrawal, or persistent anger is characterized as the “internalizing” or “tonic” form of the symptom. As opposed to the aggressive subtype, the tonic form is more closely associated with depression or anxiety. Irritability leading to extreme verbal outbursts or physical violence is characterized as the “externalizing” or “phasic” form, Dr. Carlson said. This type of irritability, defined by behavior more than mood, might signal disruptive mood dysregulation disorder (DMDD). But it is important to recognize that DMDD can overlap with other conditions, such as attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, oppositional defiant disorder (ODD), and autism spectrum disorders.

In defining the impact of treatments on tonic versus phasic symptoms of irritability within the context of the underlying diagnoses, studies have not done a good job in separating relative effects on the two key forms of irritability, Dr. Carlson said.

“Irritability needs to be measured not only by how one feels but what one does,” said Dr. Carlson, explaining that the impact of therapy has not always been adequately described in therapy studies.

For the tonic form, irritability is likely to improve or resolve with control of the underlying psychiatric condition. Although this might also be true of the phasic form, this type of irritability often accompanies conditions that are less readily controlled even through the threat of self-harm, harm to others, or other destructive behaviors invites intervention specifically targeted at this symptom.

Unfortunately, the best approach to irritability is unclear for many underling pathologies.

“Clinicians should recognize that empirical evidence is still lacking as to aggression-targeted treatments with favorable benefit-risk profiles for children and adolescents with ADHD and severe aggression,” said Dr. Carlson, providing ADHD as one of several examples.

Psychological interventions, such as dialectical behavior therapy in children (DBT-C), have been associated with control of both tonic and phasic forms of irritability, but Dr. Carlson cautioned that few studies have adequately differentiated improvement in irritability as measured by behavior relative to mood. In addition, the baseline severity and the degree to which improvement meant adequate control have been unclear.

“Many psychological treatments are school based or group delivered, making it likely that patients are less impaired than explosive kids in psychiatry clinics and hospitals,” Dr. Carlson said.

Providing some practical tips for addressing the phasic form of irritability, Dr. Carlson suggested keeping careful records of the frequency, intensity, number, and duration of disruptive outbursts. She advised clinicians to “maximize the treatment of the base condition” but to add pharmacologic therapies to psychological interventions if symptoms persist.

“Our pendulum has swung from dishing out atypicals to eschewing them completely,” Dr. Carlson noted. Although she agreed these are no longer appropriate as first-line therapies, she suggested they might be employed judiciously if weight gain is monitored carefully.

“If they don’t work, stop them. If they do work, try to limit the duration of use,” Dr. Carlson said.

She reported having no relevant financial relationships to disclose.

BROOKLYN, N.Y. – As a target of therapy in children with a psychiatric disorder, irritability expressed as grumpy mood or anger should be uncoupled from irritability expressed as threatening behavior, according to an exploration of this common clinical issue at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Ted Bosworth/MDedge News

“Irritability is like fever,” reported Gabrielle A. Carlson, MD, professor of psychiatry and pediatrics, State University of New York at Stony Brook. “It is a nonspecific symptom that only tells you that something is wrong.”

Irritability might be nothing more than a negative mood, but it also can be the source of explosive aggression, leading to tantrums and destructive behaviors, according to Dr. Carlson. She placed them into two different categories when considering treatment. Irritability leading to annoyance, grumpiness, withdrawal, or persistent anger is characterized as the “internalizing” or “tonic” form of the symptom. As opposed to the aggressive subtype, the tonic form is more closely associated with depression or anxiety. Irritability leading to extreme verbal outbursts or physical violence is characterized as the “externalizing” or “phasic” form, Dr. Carlson said. This type of irritability, defined by behavior more than mood, might signal disruptive mood dysregulation disorder (DMDD). But it is important to recognize that DMDD can overlap with other conditions, such as attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, oppositional defiant disorder (ODD), and autism spectrum disorders.

In defining the impact of treatments on tonic versus phasic symptoms of irritability within the context of the underlying diagnoses, studies have not done a good job in separating relative effects on the two key forms of irritability, Dr. Carlson said.

“Irritability needs to be measured not only by how one feels but what one does,” said Dr. Carlson, explaining that the impact of therapy has not always been adequately described in therapy studies.

For the tonic form, irritability is likely to improve or resolve with control of the underlying psychiatric condition. Although this might also be true of the phasic form, this type of irritability often accompanies conditions that are less readily controlled even through the threat of self-harm, harm to others, or other destructive behaviors invites intervention specifically targeted at this symptom.

Unfortunately, the best approach to irritability is unclear for many underling pathologies.

“Clinicians should recognize that empirical evidence is still lacking as to aggression-targeted treatments with favorable benefit-risk profiles for children and adolescents with ADHD and severe aggression,” said Dr. Carlson, providing ADHD as one of several examples.

Psychological interventions, such as dialectical behavior therapy in children (DBT-C), have been associated with control of both tonic and phasic forms of irritability, but Dr. Carlson cautioned that few studies have adequately differentiated improvement in irritability as measured by behavior relative to mood. In addition, the baseline severity and the degree to which improvement meant adequate control have been unclear.

“Many psychological treatments are school based or group delivered, making it likely that patients are less impaired than explosive kids in psychiatry clinics and hospitals,” Dr. Carlson said.

Providing some practical tips for addressing the phasic form of irritability, Dr. Carlson suggested keeping careful records of the frequency, intensity, number, and duration of disruptive outbursts. She advised clinicians to “maximize the treatment of the base condition” but to add pharmacologic therapies to psychological interventions if symptoms persist.

“Our pendulum has swung from dishing out atypicals to eschewing them completely,” Dr. Carlson noted. Although she agreed these are no longer appropriate as first-line therapies, she suggested they might be employed judiciously if weight gain is monitored carefully.

“If they don’t work, stop them. If they do work, try to limit the duration of use,” Dr. Carlson said.

She reported having no relevant financial relationships to disclose.

BROOKLYN, N.Y. – As a target of therapy in children with a psychiatric disorder, irritability expressed as grumpy mood or anger should be uncoupled from irritability expressed as threatening behavior, according to an exploration of this common clinical issue at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Ted Bosworth/MDedge News

“Irritability is like fever,” reported Gabrielle A. Carlson, MD, professor of psychiatry and pediatrics, State University of New York at Stony Brook. “It is a nonspecific symptom that only tells you that something is wrong.”

Irritability might be nothing more than a negative mood, but it also can be the source of explosive aggression, leading to tantrums and destructive behaviors, according to Dr. Carlson. She placed them into two different categories when considering treatment. Irritability leading to annoyance, grumpiness, withdrawal, or persistent anger is characterized as the “internalizing” or “tonic” form of the symptom. As opposed to the aggressive subtype, the tonic form is more closely associated with depression or anxiety. Irritability leading to extreme verbal outbursts or physical violence is characterized as the “externalizing” or “phasic” form, Dr. Carlson said. This type of irritability, defined by behavior more than mood, might signal disruptive mood dysregulation disorder (DMDD). But it is important to recognize that DMDD can overlap with other conditions, such as attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, oppositional defiant disorder (ODD), and autism spectrum disorders.

In defining the impact of treatments on tonic versus phasic symptoms of irritability within the context of the underlying diagnoses, studies have not done a good job in separating relative effects on the two key forms of irritability, Dr. Carlson said.

“Irritability needs to be measured not only by how one feels but what one does,” said Dr. Carlson, explaining that the impact of therapy has not always been adequately described in therapy studies.

For the tonic form, irritability is likely to improve or resolve with control of the underlying psychiatric condition. Although this might also be true of the phasic form, this type of irritability often accompanies conditions that are less readily controlled even through the threat of self-harm, harm to others, or other destructive behaviors invites intervention specifically targeted at this symptom.

Unfortunately, the best approach to irritability is unclear for many underling pathologies.

“Clinicians should recognize that empirical evidence is still lacking as to aggression-targeted treatments with favorable benefit-risk profiles for children and adolescents with ADHD and severe aggression,” said Dr. Carlson, providing ADHD as one of several examples.

Psychological interventions, such as dialectical behavior therapy in children (DBT-C), have been associated with control of both tonic and phasic forms of irritability, but Dr. Carlson cautioned that few studies have adequately differentiated improvement in irritability as measured by behavior relative to mood. In addition, the baseline severity and the degree to which improvement meant adequate control have been unclear.

“Many psychological treatments are school based or group delivered, making it likely that patients are less impaired than explosive kids in psychiatry clinics and hospitals,” Dr. Carlson said.

Providing some practical tips for addressing the phasic form of irritability, Dr. Carlson suggested keeping careful records of the frequency, intensity, number, and duration of disruptive outbursts. She advised clinicians to “maximize the treatment of the base condition” but to add pharmacologic therapies to psychological interventions if symptoms persist.

“Our pendulum has swung from dishing out atypicals to eschewing them completely,” Dr. Carlson noted. Although she agreed these are no longer appropriate as first-line therapies, she suggested they might be employed judiciously if weight gain is monitored carefully.

“If they don’t work, stop them. If they do work, try to limit the duration of use,” Dr. Carlson said.

She reported having no relevant financial relationships to disclose.

BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.

Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.

The problem is common among adults as well, but adolescents pose a greater challenge.

“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.

“Substance use disorder is a pediatric issue,” he emphasized.

The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.

Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”

Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.

“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.

Citing a correlation between parental and adolescent marijuana use, Dr. Wilens said the legalization of marijuana appears destined to exacerbate the already considerable challenge of substance use in children. He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.

A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.

As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.

In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.

Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.

Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
 

BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.

Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.

The problem is common among adults as well, but adolescents pose a greater challenge.

“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.

“Substance use disorder is a pediatric issue,” he emphasized.

The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.

Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”

Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.

“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.

Citing a correlation between parental and adolescent marijuana use, Dr. Wilens said the legalization of marijuana appears destined to exacerbate the already considerable challenge of substance use in children. He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.

A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.

As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.

In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.

Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.

Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
 

BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.

Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.

The problem is common among adults as well, but adolescents pose a greater challenge.

“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.

“Substance use disorder is a pediatric issue,” he emphasized.

The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.

Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”

Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.

“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.

Citing a correlation between parental and adolescent marijuana use, Dr. Wilens said the legalization of marijuana appears destined to exacerbate the already considerable challenge of substance use in children. He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.

A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.

As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.

In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.

Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.

Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
 

In the year 2016, female radiation oncologists received less money than did male radiation oncologists from industry across every type of compensation evaluated, according to an analysis of data from the Centers for Medicare & Medicated Services Open Payments program.

These sex disparities included a median $1,000 less for consulting (P = .005), $500 less for honoraria (P = .005) and $135 less for research payments, although the difference in this latter category fell short of statistical significance (P = .08), reported Julius K. Weng, department of radiation oncology, University of California, Los Angeles, and his colleagues, in JAMA Network Open.

The CMS Open Payments Program, which is part of the Physician Payments Sunshine Act, made the study possible. The CMS data were intended to allow evaluation of potential conflicts of interest, but they were amenable to compare payments by gender. For this purpose, the investigators determined gender by first name, which was confirmed by Internet search when ambiguous.

At least one industry payment in 2016 was made to 61.4% of 1,164 female and 70.4% of 3,319 male radiation oncologists included in this retrospective cross-sectional study.

Of research funding, only 20.7% went to women even though they represented 25.9% of radiation oncologists in the United States at that time. In other categories, such as honoraria or consulting, the proportion of compensation going to females was even lower, never exceeding 15%.

In the United States, about one-third of radiation oncologists are women, according to the authors of this study. This is substantially lower than the proportion in many other specialties and is far below that of current medical school enrollment, where women are now in a slight majority.

It cannot be ascertained from these data why industry compensation was lower for women, but the authors offered numerous potential explanations including the possibility that more female than male radiation oncologists do not elect to pursue relationships with industry. They labeled such relationships as “controversial” due to potential conflicts of interest.

Among the theories put forth are those that have been proposed to explain other sex disparities, including lower salaries and slower promotion, in medicine and elsewhere.

For one, it has been suggested that “agentic traits” of men might propel them to seek opportunities more aggressively, compared with women, who have “historically been associated with communal qualities,” according to the authors.

If due to gender bias, disparities may also accumulate over time as “downstream consequences of sex gaps experienced early in a female physician’s career,” the authors stated. They noted that women have a lower proportion of leadership positions in radiation oncology than predicted by their numbers in the specialty.

The disparity in industry partnerships and compensation is a relevant measure of sex disparity because these are associated with “substantial career advantages,” according to the authors of this study. In addition to the advantages of research funding, they believe these include association with important signs of success in academic clinical medicine, such being identified as a key opinion leader.

One limitation of the CMS data regarding industry payments is that the information is derived from self-reports. In 2016, the CMS Open Payments Program was in its fourth year, which the authors suggested had more complete information on industry payments than prior years because of initiatives to improve reporting compliance.

The lower payments from compensation are likely to be related to other gender disparities in radiation oncology, such as lower publication productivity and fewer patents held by women. It is unclear how non–career oriented activities, whether alone or together, particularly raising children, might interfere with both career advancement and compensation from industry, according to the authors.

Coauthor Ann C. Raldow, MD, also of the department of radiation oncology at UCLA, acknowledged in an interview that any of the potential explanations, such as the choice not to choose to pursue industry relationships, might be valid. However, she suggested that this issue deserves further exploration.

“Of greater concern is the possibility that this observed disparity may be a proxy for the systemic inequalities that female physicians have in radiation oncology. A first step in clarifying the origin of this gap could be incorporating industry-related questions into a workforce survey,” Dr. Raldow said.

If this step demonstrates a true disparity, “the most relevant metric may be female physicians receiving a percentage of total industry funding that corresponds to their representation in the field,” she added.

SOURCE: Weng JK et al. JAMA Netw Open. 2019 Jan. 25. doi: 10.1001/jamanetworkopen.2018.7377.

In the year 2016, female radiation oncologists received less money than did male radiation oncologists from industry across every type of compensation evaluated, according to an analysis of data from the Centers for Medicare & Medicated Services Open Payments program.

These sex disparities included a median $1,000 less for consulting (P = .005), $500 less for honoraria (P = .005) and $135 less for research payments, although the difference in this latter category fell short of statistical significance (P = .08), reported Julius K. Weng, department of radiation oncology, University of California, Los Angeles, and his colleagues, in JAMA Network Open.

The CMS Open Payments Program, which is part of the Physician Payments Sunshine Act, made the study possible. The CMS data were intended to allow evaluation of potential conflicts of interest, but they were amenable to compare payments by gender. For this purpose, the investigators determined gender by first name, which was confirmed by Internet search when ambiguous.

At least one industry payment in 2016 was made to 61.4% of 1,164 female and 70.4% of 3,319 male radiation oncologists included in this retrospective cross-sectional study.

Of research funding, only 20.7% went to women even though they represented 25.9% of radiation oncologists in the United States at that time. In other categories, such as honoraria or consulting, the proportion of compensation going to females was even lower, never exceeding 15%.

In the United States, about one-third of radiation oncologists are women, according to the authors of this study. This is substantially lower than the proportion in many other specialties and is far below that of current medical school enrollment, where women are now in a slight majority.

It cannot be ascertained from these data why industry compensation was lower for women, but the authors offered numerous potential explanations including the possibility that more female than male radiation oncologists do not elect to pursue relationships with industry. They labeled such relationships as “controversial” due to potential conflicts of interest.

Among the theories put forth are those that have been proposed to explain other sex disparities, including lower salaries and slower promotion, in medicine and elsewhere.

For one, it has been suggested that “agentic traits” of men might propel them to seek opportunities more aggressively, compared with women, who have “historically been associated with communal qualities,” according to the authors.

If due to gender bias, disparities may also accumulate over time as “downstream consequences of sex gaps experienced early in a female physician’s career,” the authors stated. They noted that women have a lower proportion of leadership positions in radiation oncology than predicted by their numbers in the specialty.

The disparity in industry partnerships and compensation is a relevant measure of sex disparity because these are associated with “substantial career advantages,” according to the authors of this study. In addition to the advantages of research funding, they believe these include association with important signs of success in academic clinical medicine, such being identified as a key opinion leader.

One limitation of the CMS data regarding industry payments is that the information is derived from self-reports. In 2016, the CMS Open Payments Program was in its fourth year, which the authors suggested had more complete information on industry payments than prior years because of initiatives to improve reporting compliance.

The lower payments from compensation are likely to be related to other gender disparities in radiation oncology, such as lower publication productivity and fewer patents held by women. It is unclear how non–career oriented activities, whether alone or together, particularly raising children, might interfere with both career advancement and compensation from industry, according to the authors.

Coauthor Ann C. Raldow, MD, also of the department of radiation oncology at UCLA, acknowledged in an interview that any of the potential explanations, such as the choice not to choose to pursue industry relationships, might be valid. However, she suggested that this issue deserves further exploration.

“Of greater concern is the possibility that this observed disparity may be a proxy for the systemic inequalities that female physicians have in radiation oncology. A first step in clarifying the origin of this gap could be incorporating industry-related questions into a workforce survey,” Dr. Raldow said.

If this step demonstrates a true disparity, “the most relevant metric may be female physicians receiving a percentage of total industry funding that corresponds to their representation in the field,” she added.

SOURCE: Weng JK et al. JAMA Netw Open. 2019 Jan. 25. doi: 10.1001/jamanetworkopen.2018.7377.

In the year 2016, female radiation oncologists received less money than did male radiation oncologists from industry across every type of compensation evaluated, according to an analysis of data from the Centers for Medicare & Medicated Services Open Payments program.

These sex disparities included a median $1,000 less for consulting (P = .005), $500 less for honoraria (P = .005) and $135 less for research payments, although the difference in this latter category fell short of statistical significance (P = .08), reported Julius K. Weng, department of radiation oncology, University of California, Los Angeles, and his colleagues, in JAMA Network Open.

The CMS Open Payments Program, which is part of the Physician Payments Sunshine Act, made the study possible. The CMS data were intended to allow evaluation of potential conflicts of interest, but they were amenable to compare payments by gender. For this purpose, the investigators determined gender by first name, which was confirmed by Internet search when ambiguous.

At least one industry payment in 2016 was made to 61.4% of 1,164 female and 70.4% of 3,319 male radiation oncologists included in this retrospective cross-sectional study.

Of research funding, only 20.7% went to women even though they represented 25.9% of radiation oncologists in the United States at that time. In other categories, such as honoraria or consulting, the proportion of compensation going to females was even lower, never exceeding 15%.

In the United States, about one-third of radiation oncologists are women, according to the authors of this study. This is substantially lower than the proportion in many other specialties and is far below that of current medical school enrollment, where women are now in a slight majority.

It cannot be ascertained from these data why industry compensation was lower for women, but the authors offered numerous potential explanations including the possibility that more female than male radiation oncologists do not elect to pursue relationships with industry. They labeled such relationships as “controversial” due to potential conflicts of interest.

Among the theories put forth are those that have been proposed to explain other sex disparities, including lower salaries and slower promotion, in medicine and elsewhere.

For one, it has been suggested that “agentic traits” of men might propel them to seek opportunities more aggressively, compared with women, who have “historically been associated with communal qualities,” according to the authors.

If due to gender bias, disparities may also accumulate over time as “downstream consequences of sex gaps experienced early in a female physician’s career,” the authors stated. They noted that women have a lower proportion of leadership positions in radiation oncology than predicted by their numbers in the specialty.

The disparity in industry partnerships and compensation is a relevant measure of sex disparity because these are associated with “substantial career advantages,” according to the authors of this study. In addition to the advantages of research funding, they believe these include association with important signs of success in academic clinical medicine, such being identified as a key opinion leader.

One limitation of the CMS data regarding industry payments is that the information is derived from self-reports. In 2016, the CMS Open Payments Program was in its fourth year, which the authors suggested had more complete information on industry payments than prior years because of initiatives to improve reporting compliance.

The lower payments from compensation are likely to be related to other gender disparities in radiation oncology, such as lower publication productivity and fewer patents held by women. It is unclear how non–career oriented activities, whether alone or together, particularly raising children, might interfere with both career advancement and compensation from industry, according to the authors.

Coauthor Ann C. Raldow, MD, also of the department of radiation oncology at UCLA, acknowledged in an interview that any of the potential explanations, such as the choice not to choose to pursue industry relationships, might be valid. However, she suggested that this issue deserves further exploration.

“Of greater concern is the possibility that this observed disparity may be a proxy for the systemic inequalities that female physicians have in radiation oncology. A first step in clarifying the origin of this gap could be incorporating industry-related questions into a workforce survey,” Dr. Raldow said.

If this step demonstrates a true disparity, “the most relevant metric may be female physicians receiving a percentage of total industry funding that corresponds to their representation in the field,” she added.

SOURCE: Weng JK et al. JAMA Netw Open. 2019 Jan. 25. doi: 10.1001/jamanetworkopen.2018.7377.

Brooklyn, N.Y. – A risk calculator for bipolar disorder that has reached late stages of development might merit a trial to test whether treating prodromal symptoms delays or prevents the disease from developing in young patients, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Clinicians often are confronted with children who have prodromal symptoms of bipolar disorder, but only about half of those children eventually convert to full disease expression. As a result, treatment is not routine practice, said Boris Birmaher, MD, Endowed Chair, Early Onset Bipolar Disease, at the University of Pittsburgh.

A risk calculator that more effectively identifies those at highest risk of converting might be a tool that could allow early intervention to be tested. Such a calculator has been in development for some years, and the most recent research suggests that it is nearing a degree of accuracy that is clinically meaningful (J Am Acad Child Adolesc Psychiatry. 2018;57:755-63).

“The accuracy of this risk calculator at this moment is 70%,” Dr. Birmaher reported.

Accuracy might improve further with the identification and incorporation of more predictive variables. High-risk features for conversion include a parent with bipolar disorder, particularly one with childhood onset, and specific clinical features, such as prominent episodes of mania.

“Once replicated, the risk calculator will be instrumental to predict personalized risk to develop bipolar disease,” Dr. Birmaher said. He compared it to risk calculators now in use in other fields of medicine, such as cancer and cardiovascular disease, which generate information used by patients and their physicians for treatment decisions.

In the most recent study with the risk calculator, which has been the topic of several previous publications, 140 children with a diagnosis of bipolar disorder not otherwise specified (BP-NOS) were assessed every 7 months for a median of 11.5 years. BP-NOS is the diagnosis of a prodromal syndrome that includes mood lability and other features of bipolar disorder but not at levels reaching DSM-5 diagnostic criteria. The primary outcome of the study was conversion from BP-NOS to bipolar I or II, which are DSM-5 categories.

At the end of follow-up, 53.6% of the population had converted to bipolar I or II, which is consistent with previous risk estimates in this population. In specific patients, the correlation between predicted and observed conversions was “excellent.” Furthermore, the risk calculator was reported to have provided “good” discrimination between converters and nonconverters.

The risk calculator already is accessible online (http://www.cabsresearch.pitt.edu/bpriskcalculator/). Dr. Birmaher invited clinicians to visit and “play around” with its features, but he also issued a warning. “Be careful because we need to further validate this, which we are doing now, to see if it’s truly accurate or not. If it is, it would be a very good tool for us,” he said.

There are many potential clinical applications of the risk calculator, but Dr. Birmaher emphasized its possible value in selecting at-risk patients for therapy studies. Although several therapy trials already have been conducted in high-risk children on the basis of clinical presentation alone, such as a double-blind trial in BP-NOS patients that associated aripiprazole with a reduction in mania (J Child Adolesc Psychopharmacol. 2017;27:864-74), Dr. Birmaher sees the risk calculator as potentially more precise in identifying candidates.

Brooklyn, N.Y. – A risk calculator for bipolar disorder that has reached late stages of development might merit a trial to test whether treating prodromal symptoms delays or prevents the disease from developing in young patients, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Clinicians often are confronted with children who have prodromal symptoms of bipolar disorder, but only about half of those children eventually convert to full disease expression. As a result, treatment is not routine practice, said Boris Birmaher, MD, Endowed Chair, Early Onset Bipolar Disease, at the University of Pittsburgh.

A risk calculator that more effectively identifies those at highest risk of converting might be a tool that could allow early intervention to be tested. Such a calculator has been in development for some years, and the most recent research suggests that it is nearing a degree of accuracy that is clinically meaningful (J Am Acad Child Adolesc Psychiatry. 2018;57:755-63).

“The accuracy of this risk calculator at this moment is 70%,” Dr. Birmaher reported.

Accuracy might improve further with the identification and incorporation of more predictive variables. High-risk features for conversion include a parent with bipolar disorder, particularly one with childhood onset, and specific clinical features, such as prominent episodes of mania.

“Once replicated, the risk calculator will be instrumental to predict personalized risk to develop bipolar disease,” Dr. Birmaher said. He compared it to risk calculators now in use in other fields of medicine, such as cancer and cardiovascular disease, which generate information used by patients and their physicians for treatment decisions.

In the most recent study with the risk calculator, which has been the topic of several previous publications, 140 children with a diagnosis of bipolar disorder not otherwise specified (BP-NOS) were assessed every 7 months for a median of 11.5 years. BP-NOS is the diagnosis of a prodromal syndrome that includes mood lability and other features of bipolar disorder but not at levels reaching DSM-5 diagnostic criteria. The primary outcome of the study was conversion from BP-NOS to bipolar I or II, which are DSM-5 categories.

At the end of follow-up, 53.6% of the population had converted to bipolar I or II, which is consistent with previous risk estimates in this population. In specific patients, the correlation between predicted and observed conversions was “excellent.” Furthermore, the risk calculator was reported to have provided “good” discrimination between converters and nonconverters.

The risk calculator already is accessible online (http://www.cabsresearch.pitt.edu/bpriskcalculator/). Dr. Birmaher invited clinicians to visit and “play around” with its features, but he also issued a warning. “Be careful because we need to further validate this, which we are doing now, to see if it’s truly accurate or not. If it is, it would be a very good tool for us,” he said.

There are many potential clinical applications of the risk calculator, but Dr. Birmaher emphasized its possible value in selecting at-risk patients for therapy studies. Although several therapy trials already have been conducted in high-risk children on the basis of clinical presentation alone, such as a double-blind trial in BP-NOS patients that associated aripiprazole with a reduction in mania (J Child Adolesc Psychopharmacol. 2017;27:864-74), Dr. Birmaher sees the risk calculator as potentially more precise in identifying candidates.

Brooklyn, N.Y. – A risk calculator for bipolar disorder that has reached late stages of development might merit a trial to test whether treating prodromal symptoms delays or prevents the disease from developing in young patients, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Clinicians often are confronted with children who have prodromal symptoms of bipolar disorder, but only about half of those children eventually convert to full disease expression. As a result, treatment is not routine practice, said Boris Birmaher, MD, Endowed Chair, Early Onset Bipolar Disease, at the University of Pittsburgh.

A risk calculator that more effectively identifies those at highest risk of converting might be a tool that could allow early intervention to be tested. Such a calculator has been in development for some years, and the most recent research suggests that it is nearing a degree of accuracy that is clinically meaningful (J Am Acad Child Adolesc Psychiatry. 2018;57:755-63).

“The accuracy of this risk calculator at this moment is 70%,” Dr. Birmaher reported.

Accuracy might improve further with the identification and incorporation of more predictive variables. High-risk features for conversion include a parent with bipolar disorder, particularly one with childhood onset, and specific clinical features, such as prominent episodes of mania.

“Once replicated, the risk calculator will be instrumental to predict personalized risk to develop bipolar disease,” Dr. Birmaher said. He compared it to risk calculators now in use in other fields of medicine, such as cancer and cardiovascular disease, which generate information used by patients and their physicians for treatment decisions.

In the most recent study with the risk calculator, which has been the topic of several previous publications, 140 children with a diagnosis of bipolar disorder not otherwise specified (BP-NOS) were assessed every 7 months for a median of 11.5 years. BP-NOS is the diagnosis of a prodromal syndrome that includes mood lability and other features of bipolar disorder but not at levels reaching DSM-5 diagnostic criteria. The primary outcome of the study was conversion from BP-NOS to bipolar I or II, which are DSM-5 categories.

At the end of follow-up, 53.6% of the population had converted to bipolar I or II, which is consistent with previous risk estimates in this population. In specific patients, the correlation between predicted and observed conversions was “excellent.” Furthermore, the risk calculator was reported to have provided “good” discrimination between converters and nonconverters.

The risk calculator already is accessible online (http://www.cabsresearch.pitt.edu/bpriskcalculator/). Dr. Birmaher invited clinicians to visit and “play around” with its features, but he also issued a warning. “Be careful because we need to further validate this, which we are doing now, to see if it’s truly accurate or not. If it is, it would be a very good tool for us,” he said.

There are many potential clinical applications of the risk calculator, but Dr. Birmaher emphasized its possible value in selecting at-risk patients for therapy studies. Although several therapy trials already have been conducted in high-risk children on the basis of clinical presentation alone, such as a double-blind trial in BP-NOS patients that associated aripiprazole with a reduction in mania (J Child Adolesc Psychopharmacol. 2017;27:864-74), Dr. Birmaher sees the risk calculator as potentially more precise in identifying candidates.

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

BROOKLYN, N.Y. – Intervening effectively for children and adolescents at suicide risk involves watching for triggers such as personal loss, sleep disturbances, or interpersonal conflict, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

It is important to distinguish the distal risks, which are factors known to increase suicidal ideation, and proximal risk factors, which predict attempts, according to Tina R. Goldstein, PhD, associate professor of psychiatry and psychology at the University of Pittsburgh. “We know that the optimal targets for preventing suicidal behavior are proximal,” Dr. Goldstein said. Treatment of distal risks, such as depression or substance use, is a foundation for risk management, but suicidal events are driven by acute crises that appear to require individualized intervention.

Dr. Goldstein said she had just “one sad slide” to summarize drug treatments aimed at controlling suicidal behavior. That slide included citations for studies associating neuroleptics and antidepressants with a reduction in aggressive or impulsive behavior in children. The only study associating a drug with a reduction in suicide attempts was performed with lithium in adults.

However, intensive cognitive and dialectical behavior interventions involving the family have been shown to reduce suicide attempts in randomized controlled trials, said Dr. Goldstein, who also is affiliated with the university’s Child and Adolescent Bipolar Spectrum Services Research Program. Those trials underscore the messages that personalizing therapy is essential, as are addressing specific triggers and helping patients develop defenses against suicidal thoughts.

Dr. Goldstein described a recently published, National Institutes of Health–funded study that focused on suicide reduction. The study was conducted in adolescents who were being discharged from a brief hospitalization for acute suicidal ideation or a suicide attempt (J Adolesc Health. 2018 Nov. 8. doi: 10.1016/j.jadohealth.2018.09.015). “We know that there is this really high-risk period after discharge from the hospital for which we could potentially do things better,” said Dr. Goldstein, whose center was involved in the study.

The tested intervention, called As Safe As Possible (ASAP), involved “front-loading some coping skills and giving [the patients] a good safety plan even before they are discharged,” Dr. Goldstein said. For risk management after discharge, the adolescents were provided with a smartphone app called BRITE that contained the safety plan as well as a summary of personalized coping skills, including reminders that the patients themselves had provided for reasons for living. The app was augmented as appropriate with favorite songs, photos of the patients’ pet, or other customized aids to provide support during the typical delay between the time of discharge and the next step in care.

In 6 months of follow-up, the rate of suicide attempts was 8.7% of those enrolled in the intensive outpatient program, compared with 27.3% (P = .08) for those who received treatment as usual. Dr. Goldstein called this trend promising, particularly in the context of other favorable results, including a significantly longer (P = .03) time to a suicide attempt in the ASAP group.

In patients at imminent risk of a suicide attempt, it is logical to assume that treatment must be personalized to the issues behind increased suicidal ideation. However, a study published by Dr. Goldstein and her associates several years ago suggested that evidence of deteriorating mental health can signal a need for intensification of suicide risk management (Arch Gen Psychiatry. 2012;69:1113-22). In one part of that study, risk factors for suicide were evaluated in the 8 weeks before a suicide attempt in 413 children with bipolar disorder. During that time, depression scores increased as did substance use, but, surprisingly, so did use of mental health services.

“The way we have come to think of these data is that the kids, their parents, and their providers were recognizing that things were getting worse and they needed more services,” Dr. Goldstein said. “The bad news is that the services we were giving them were not particularly effective.”

Those data underscore some of the challenges facing clinicians who treat pediatric patients with mental illness. “Our field has not yet developed ... gold standard treatments for preventing suicidal behavior in kids with mood disorder,” Dr. Goldstein said. However, she thinks that some progress has been made and that some of the personalized approaches are demonstrating efficacy – particularly in children and adolescents who exhibit signs of imminent risk.

BROOKLYN, N.Y. – There are studies demonstrating depression is more likely to resolve if depressed parents are also treated dating back more than 10 years, but new evidence suggests this effect may extend to children as young as 3 years of age, according to an update on current strategies for early intervention presented at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Of multiple triggers that can be caught and treated early to prevent children from progressing to chronic depression, addressing parental depression is an important target, according to Karen Dineen Wagner, MD, Director of the Division of Child and Adolescent Psychiatry at the University of Texas Medical Branch in Galveston.

In an overview of strategies for intervening early in children who have or are at risk for depression, Dr. Wagner looked at several targets. The purpose of recognizing and addressing such targets as parental depression is to get children well faster and avoid disease chronicity.

“If we want to intervene and potentially prevent the occurrence of depression, we need to look at disorders or triggers that may precede the depression and that, had they been treated, might have eliminated the stressors that tip the child into depression,” Dr. Wagner said.

Parental depression was just one of these factors, but along with others, such as child abuse of any kind and bullying, each poses a threat for chronic mood disorders, according to Dr. Wagner.

In the case of parental depression, Dr. Wagner cited numerous studies demonstrating a close correlation between remission in the parent and remission in the child. These trajectories interact, so children are less likely to get well if an affected parent does not get well.

“Make sure you consider depression in the parent when you are doing an evaluation, and it is not just depression in the parent who is there. Ask about the other partner who is not there,” Dr. Wagner advised. Parents reluctant to address their own depression should be informed that the mental health of their child is at risk.

The most recent evidence to show benefit from treating both child and parent was drawn from a controlled study that enrolled young children (Luby JL et al. Am J Psychiatry. 2018 Jun 20. doi: 10.1176/appi.ajp.2018.18030321).

In this study, 229 parent-child dyads were randomized to receive parent-child psychotherapy for early childhood depression or to a wait-list. The age range for the children was 3-6.2 years. The therapy was specifically designed to improve the parents’ ability to help young children cope with their feelings.

The parent-child interaction therapy “focused on emotional development which was designed to train parents to work with the child on developing emotional competence in which the child understands their emotions, understands how events affect how they are feeling, and controls emotional reactivity,” Dr. Wagner explained.

For the primary outcome of depression at the end of 18 weeks, the rates were significantly lower in those who participated in the interaction therapy than they were in those on the wait-list. Measures of parent depression and stress were also lower in the therapy group.

Currently, the U. S. Preventive Task Force recommends screening all children at age 12 for depression with the adolescent version of the Patient Health Questionnaire (PHQ-A), according to Dr. Wagner. Given the rising prevalence of depression in adolescents, which climbed 46% from 2005 (8.7%) to 2015 (12.7%) according to a published national survey, this screening is prudent, Dr. Wagner indicated. However, she further suggested that it is reasonable to screen children with risk factors, such as learning disorders or anxiety disorders, even earlier.

The reason is that there are effective therapies. Early treatment may prevent chronic and more severe forms of depression, according to Dr. Wagner. She suggested that there is a growing emphasis on not just treating depression at its early stages but also in recognizing the child at risk, identifying subsyndromal symptoms leading toward depression, and preventing children from ever reaching diagnostic criteria.

Indeed, an initiative for better and earlier detection and treatment of depression in children was begun by the AACAP when Dr. Wagner served recently as its president. Several parts of that program have now been launched. Dr. Wagner encouraged those with an interest to visit the AACAP website, where more information about this initiative can be accessed.

Dr. Wagner reported no potential conflicts of interest.

BROOKLYN, N.Y. – There are studies demonstrating depression is more likely to resolve if depressed parents are also treated dating back more than 10 years, but new evidence suggests this effect may extend to children as young as 3 years of age, according to an update on current strategies for early intervention presented at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Of multiple triggers that can be caught and treated early to prevent children from progressing to chronic depression, addressing parental depression is an important target, according to Karen Dineen Wagner, MD, Director of the Division of Child and Adolescent Psychiatry at the University of Texas Medical Branch in Galveston.

In an overview of strategies for intervening early in children who have or are at risk for depression, Dr. Wagner looked at several targets. The purpose of recognizing and addressing such targets as parental depression is to get children well faster and avoid disease chronicity.

“If we want to intervene and potentially prevent the occurrence of depression, we need to look at disorders or triggers that may precede the depression and that, had they been treated, might have eliminated the stressors that tip the child into depression,” Dr. Wagner said.

Parental depression was just one of these factors, but along with others, such as child abuse of any kind and bullying, each poses a threat for chronic mood disorders, according to Dr. Wagner.

In the case of parental depression, Dr. Wagner cited numerous studies demonstrating a close correlation between remission in the parent and remission in the child. These trajectories interact, so children are less likely to get well if an affected parent does not get well.

“Make sure you consider depression in the parent when you are doing an evaluation, and it is not just depression in the parent who is there. Ask about the other partner who is not there,” Dr. Wagner advised. Parents reluctant to address their own depression should be informed that the mental health of their child is at risk.

The most recent evidence to show benefit from treating both child and parent was drawn from a controlled study that enrolled young children (Luby JL et al. Am J Psychiatry. 2018 Jun 20. doi: 10.1176/appi.ajp.2018.18030321).

In this study, 229 parent-child dyads were randomized to receive parent-child psychotherapy for early childhood depression or to a wait-list. The age range for the children was 3-6.2 years. The therapy was specifically designed to improve the parents’ ability to help young children cope with their feelings.

The parent-child interaction therapy “focused on emotional development which was designed to train parents to work with the child on developing emotional competence in which the child understands their emotions, understands how events affect how they are feeling, and controls emotional reactivity,” Dr. Wagner explained.

For the primary outcome of depression at the end of 18 weeks, the rates were significantly lower in those who participated in the interaction therapy than they were in those on the wait-list. Measures of parent depression and stress were also lower in the therapy group.

Currently, the U. S. Preventive Task Force recommends screening all children at age 12 for depression with the adolescent version of the Patient Health Questionnaire (PHQ-A), according to Dr. Wagner. Given the rising prevalence of depression in adolescents, which climbed 46% from 2005 (8.7%) to 2015 (12.7%) according to a published national survey, this screening is prudent, Dr. Wagner indicated. However, she further suggested that it is reasonable to screen children with risk factors, such as learning disorders or anxiety disorders, even earlier.

The reason is that there are effective therapies. Early treatment may prevent chronic and more severe forms of depression, according to Dr. Wagner. She suggested that there is a growing emphasis on not just treating depression at its early stages but also in recognizing the child at risk, identifying subsyndromal symptoms leading toward depression, and preventing children from ever reaching diagnostic criteria.

Indeed, an initiative for better and earlier detection and treatment of depression in children was begun by the AACAP when Dr. Wagner served recently as its president. Several parts of that program have now been launched. Dr. Wagner encouraged those with an interest to visit the AACAP website, where more information about this initiative can be accessed.

Dr. Wagner reported no potential conflicts of interest.

BROOKLYN, N.Y. – There are studies demonstrating depression is more likely to resolve if depressed parents are also treated dating back more than 10 years, but new evidence suggests this effect may extend to children as young as 3 years of age, according to an update on current strategies for early intervention presented at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Of multiple triggers that can be caught and treated early to prevent children from progressing to chronic depression, addressing parental depression is an important target, according to Karen Dineen Wagner, MD, Director of the Division of Child and Adolescent Psychiatry at the University of Texas Medical Branch in Galveston.

In an overview of strategies for intervening early in children who have or are at risk for depression, Dr. Wagner looked at several targets. The purpose of recognizing and addressing such targets as parental depression is to get children well faster and avoid disease chronicity.

“If we want to intervene and potentially prevent the occurrence of depression, we need to look at disorders or triggers that may precede the depression and that, had they been treated, might have eliminated the stressors that tip the child into depression,” Dr. Wagner said.

Parental depression was just one of these factors, but along with others, such as child abuse of any kind and bullying, each poses a threat for chronic mood disorders, according to Dr. Wagner.

In the case of parental depression, Dr. Wagner cited numerous studies demonstrating a close correlation between remission in the parent and remission in the child. These trajectories interact, so children are less likely to get well if an affected parent does not get well.

“Make sure you consider depression in the parent when you are doing an evaluation, and it is not just depression in the parent who is there. Ask about the other partner who is not there,” Dr. Wagner advised. Parents reluctant to address their own depression should be informed that the mental health of their child is at risk.

The most recent evidence to show benefit from treating both child and parent was drawn from a controlled study that enrolled young children (Luby JL et al. Am J Psychiatry. 2018 Jun 20. doi: 10.1176/appi.ajp.2018.18030321).

In this study, 229 parent-child dyads were randomized to receive parent-child psychotherapy for early childhood depression or to a wait-list. The age range for the children was 3-6.2 years. The therapy was specifically designed to improve the parents’ ability to help young children cope with their feelings.

The parent-child interaction therapy “focused on emotional development which was designed to train parents to work with the child on developing emotional competence in which the child understands their emotions, understands how events affect how they are feeling, and controls emotional reactivity,” Dr. Wagner explained.

For the primary outcome of depression at the end of 18 weeks, the rates were significantly lower in those who participated in the interaction therapy than they were in those on the wait-list. Measures of parent depression and stress were also lower in the therapy group.

Currently, the U. S. Preventive Task Force recommends screening all children at age 12 for depression with the adolescent version of the Patient Health Questionnaire (PHQ-A), according to Dr. Wagner. Given the rising prevalence of depression in adolescents, which climbed 46% from 2005 (8.7%) to 2015 (12.7%) according to a published national survey, this screening is prudent, Dr. Wagner indicated. However, she further suggested that it is reasonable to screen children with risk factors, such as learning disorders or anxiety disorders, even earlier.

The reason is that there are effective therapies. Early treatment may prevent chronic and more severe forms of depression, according to Dr. Wagner. She suggested that there is a growing emphasis on not just treating depression at its early stages but also in recognizing the child at risk, identifying subsyndromal symptoms leading toward depression, and preventing children from ever reaching diagnostic criteria.

Indeed, an initiative for better and earlier detection and treatment of depression in children was begun by the AACAP when Dr. Wagner served recently as its president. Several parts of that program have now been launched. Dr. Wagner encouraged those with an interest to visit the AACAP website, where more information about this initiative can be accessed.

Dr. Wagner reported no potential conflicts of interest.

NEW YORK – Conflicts of interest, whether reported or unreported, are just one component of a broken system that has misaligned incentives with meaningful advances in breast cancer research, agreed a panel of experts who participated in an evening program sponsored by SHARE, a breast cancer patient advocacy group.

Ted Bosworth/MDedge News

“The issue of disclosures, while it is important, is not really the key issue. The key issue for me is about the amazing amount of money that is changing hands,” said Fran Visco, president of the National Breast Cancer Coalition, Washington. She contended not enough money in breast cancer research is being applied to save women’s lives rather than driving profits for institutions, physicians, and the pharmaceutical industry.

The other two participants in this panel, called Conflicts of Interest in Research and Treatment: What Breast Cancer Patients Should Know, largely agreed. In turn, they each explained that major sums of money in play for physicians and institutions collaborating with industry are earmarked for generating income much more than improving outcomes.

“Most of where this money is going is for these little tiny improvements and there is no association between the outcome increment that you get and what you pay for that outcome increment,” said Robert Cook-Deegan, MD, a bioethicist and a professor at the School for Innovation in Society, Arizona State University, Tempe.

Ted Bosworth/MDedge News

Ted Bosworth/MDEdge News

Ted Bosworth/MDEdge News

NEW YORK – Conflicts of interest, whether reported or unreported, are just one component of a broken system that has misaligned incentives with meaningful advances in breast cancer research, agreed a panel of experts who participated in an evening program sponsored by SHARE, a breast cancer patient advocacy group.

Ted Bosworth/MDedge News

“The issue of disclosures, while it is important, is not really the key issue. The key issue for me is about the amazing amount of money that is changing hands,” said Fran Visco, president of the National Breast Cancer Coalition, Washington. She contended not enough money in breast cancer research is being applied to save women’s lives rather than driving profits for institutions, physicians, and the pharmaceutical industry.

The other two participants in this panel, called Conflicts of Interest in Research and Treatment: What Breast Cancer Patients Should Know, largely agreed. In turn, they each explained that major sums of money in play for physicians and institutions collaborating with industry are earmarked for generating income much more than improving outcomes.

“Most of where this money is going is for these little tiny improvements and there is no association between the outcome increment that you get and what you pay for that outcome increment,” said Robert Cook-Deegan, MD, a bioethicist and a professor at the School for Innovation in Society, Arizona State University, Tempe.

Ted Bosworth/MDedge News

Ted Bosworth/MDEdge News

Ted Bosworth/MDEdge News

NEW YORK – Conflicts of interest, whether reported or unreported, are just one component of a broken system that has misaligned incentives with meaningful advances in breast cancer research, agreed a panel of experts who participated in an evening program sponsored by SHARE, a breast cancer patient advocacy group.

Ted Bosworth/MDedge News

“The issue of disclosures, while it is important, is not really the key issue. The key issue for me is about the amazing amount of money that is changing hands,” said Fran Visco, president of the National Breast Cancer Coalition, Washington. She contended not enough money in breast cancer research is being applied to save women’s lives rather than driving profits for institutions, physicians, and the pharmaceutical industry.

The other two participants in this panel, called Conflicts of Interest in Research and Treatment: What Breast Cancer Patients Should Know, largely agreed. In turn, they each explained that major sums of money in play for physicians and institutions collaborating with industry are earmarked for generating income much more than improving outcomes.

“Most of where this money is going is for these little tiny improvements and there is no association between the outcome increment that you get and what you pay for that outcome increment,” said Robert Cook-Deegan, MD, a bioethicist and a professor at the School for Innovation in Society, Arizona State University, Tempe.

Ted Bosworth/MDedge News

Ted Bosworth/MDEdge News

Ted Bosworth/MDEdge News

In response to chemoradiation, patients with stage I or II small cell lung cancer (SCLC) have a significantly longer overall survival than do those with stage III disease, according to a post hoc analysis of a randomized trial of chemoradiation in patients with early stages of SCLC.

The fact that overall survival is better in stage I and II than in stage III SCLC isn’t surprising. But the data confirm that stage I and II SCLC responds differently to chemoradiation than does stage III, providing a benchmark for safety and efficacy, according to the study authors.

The phase 3 CONVERT trial, from which the data were drawn, randomized patients with limited-stage SCLC to twice-daily (45 Gy in 30 fractions) or once-daily (66 Gy in 33 fractions) radiation after initiating cisplatin-etoposide chemotherapy (Lancet Oncol. 2017 Aug;18[8]:1116-25). Additional prophylactic cranial irradiation was permitted for those with an indication.

Contrary to the researcher’s hypothesis, once-daily radiation was not more effective for the primary outcome of overall survival in CONVERT, which limited enrollment to patients with local disease but did not stratify outcomes by SCLC stage. The purpose of the new post hoc analysis was to compare outcomes in those early-disease SCLC patients stratified by stage, which the authors noted is now recommended by several guidelines.

Because there were only four patients in CONVERT with stage I SCLC, those with either stage I or II SCLC, totaling 86 patients, were combined and then compared with the 423 with stage III SCLC.

At baseline, there were no significant differences between stage I/II and III groups for median age, smoking history, ECOG performance status, or dyspnea score at baseline. Similar proportions of patients completed the planned therapy.

However, the median survival was twice as long in the stage I/II group, compared with those with stage III SCLC (50 vs. 25 months), producing a hazard ratio for this outcome of 0.60 (P = .001). At 5 years, 49% of the stage I/II patients were alive, compared with 28% of the stage III patients (P = .001).

Other outcomes, such as progression-free survival at 5 years (47% vs. 26%; P = .003) also favored those with earlier-stage disease.

The incidence of adverse events associated with chemoradiation was not significantly different for the two groups, with the exception of acute esophagitis, which was less frequent in patients with earlier stage disease.

“The low incidence of severe toxic effects is a valid rationale to consider future radiotherapy dose intensification trials to improve outcomes” in patients with stage I/II disease, according to study author Ahmed Salem, MB, ChB, of the University of Manchester, England, and his coinvestigators.

The data from the post hoc analysis support guideline recommendations to stage even early and local SCLC when evaluating response to therapy in clinical trials, noted Howard (Jack) West, MD, of Swedish Cancer Institute, Seattle, in an accompanying editorial (JAMA Oncol. 2018 Dec 6. doi: 10.1001/jamaoncol.2018.5187). Dr. West suggested that such staging information might be useful when counseling patients about treatment options.

“These results imply that we may do our patients a disservice by dispensing with clinically relevant staging information that can lead to a more refined assessment of prognosis and optimal treatment,” Dr. West wrote.

SOURCE: Salem A et al. JAMA Oncol. 2018 Dec 6:e185335. doi: 10.1001/jamaoncol.2018.5335.

In response to chemoradiation, patients with stage I or II small cell lung cancer (SCLC) have a significantly longer overall survival than do those with stage III disease, according to a post hoc analysis of a randomized trial of chemoradiation in patients with early stages of SCLC.

The fact that overall survival is better in stage I and II than in stage III SCLC isn’t surprising. But the data confirm that stage I and II SCLC responds differently to chemoradiation than does stage III, providing a benchmark for safety and efficacy, according to the study authors.

The phase 3 CONVERT trial, from which the data were drawn, randomized patients with limited-stage SCLC to twice-daily (45 Gy in 30 fractions) or once-daily (66 Gy in 33 fractions) radiation after initiating cisplatin-etoposide chemotherapy (Lancet Oncol. 2017 Aug;18[8]:1116-25). Additional prophylactic cranial irradiation was permitted for those with an indication.

Contrary to the researcher’s hypothesis, once-daily radiation was not more effective for the primary outcome of overall survival in CONVERT, which limited enrollment to patients with local disease but did not stratify outcomes by SCLC stage. The purpose of the new post hoc analysis was to compare outcomes in those early-disease SCLC patients stratified by stage, which the authors noted is now recommended by several guidelines.

Because there were only four patients in CONVERT with stage I SCLC, those with either stage I or II SCLC, totaling 86 patients, were combined and then compared with the 423 with stage III SCLC.

At baseline, there were no significant differences between stage I/II and III groups for median age, smoking history, ECOG performance status, or dyspnea score at baseline. Similar proportions of patients completed the planned therapy.

However, the median survival was twice as long in the stage I/II group, compared with those with stage III SCLC (50 vs. 25 months), producing a hazard ratio for this outcome of 0.60 (P = .001). At 5 years, 49% of the stage I/II patients were alive, compared with 28% of the stage III patients (P = .001).

Other outcomes, such as progression-free survival at 5 years (47% vs. 26%; P = .003) also favored those with earlier-stage disease.

The incidence of adverse events associated with chemoradiation was not significantly different for the two groups, with the exception of acute esophagitis, which was less frequent in patients with earlier stage disease.

“The low incidence of severe toxic effects is a valid rationale to consider future radiotherapy dose intensification trials to improve outcomes” in patients with stage I/II disease, according to study author Ahmed Salem, MB, ChB, of the University of Manchester, England, and his coinvestigators.

The data from the post hoc analysis support guideline recommendations to stage even early and local SCLC when evaluating response to therapy in clinical trials, noted Howard (Jack) West, MD, of Swedish Cancer Institute, Seattle, in an accompanying editorial (JAMA Oncol. 2018 Dec 6. doi: 10.1001/jamaoncol.2018.5187). Dr. West suggested that such staging information might be useful when counseling patients about treatment options.

“These results imply that we may do our patients a disservice by dispensing with clinically relevant staging information that can lead to a more refined assessment of prognosis and optimal treatment,” Dr. West wrote.

SOURCE: Salem A et al. JAMA Oncol. 2018 Dec 6:e185335. doi: 10.1001/jamaoncol.2018.5335.

In response to chemoradiation, patients with stage I or II small cell lung cancer (SCLC) have a significantly longer overall survival than do those with stage III disease, according to a post hoc analysis of a randomized trial of chemoradiation in patients with early stages of SCLC.

The fact that overall survival is better in stage I and II than in stage III SCLC isn’t surprising. But the data confirm that stage I and II SCLC responds differently to chemoradiation than does stage III, providing a benchmark for safety and efficacy, according to the study authors.

The phase 3 CONVERT trial, from which the data were drawn, randomized patients with limited-stage SCLC to twice-daily (45 Gy in 30 fractions) or once-daily (66 Gy in 33 fractions) radiation after initiating cisplatin-etoposide chemotherapy (Lancet Oncol. 2017 Aug;18[8]:1116-25). Additional prophylactic cranial irradiation was permitted for those with an indication.

Contrary to the researcher’s hypothesis, once-daily radiation was not more effective for the primary outcome of overall survival in CONVERT, which limited enrollment to patients with local disease but did not stratify outcomes by SCLC stage. The purpose of the new post hoc analysis was to compare outcomes in those early-disease SCLC patients stratified by stage, which the authors noted is now recommended by several guidelines.

Because there were only four patients in CONVERT with stage I SCLC, those with either stage I or II SCLC, totaling 86 patients, were combined and then compared with the 423 with stage III SCLC.

At baseline, there were no significant differences between stage I/II and III groups for median age, smoking history, ECOG performance status, or dyspnea score at baseline. Similar proportions of patients completed the planned therapy.

However, the median survival was twice as long in the stage I/II group, compared with those with stage III SCLC (50 vs. 25 months), producing a hazard ratio for this outcome of 0.60 (P = .001). At 5 years, 49% of the stage I/II patients were alive, compared with 28% of the stage III patients (P = .001).

Other outcomes, such as progression-free survival at 5 years (47% vs. 26%; P = .003) also favored those with earlier-stage disease.

The incidence of adverse events associated with chemoradiation was not significantly different for the two groups, with the exception of acute esophagitis, which was less frequent in patients with earlier stage disease.

“The low incidence of severe toxic effects is a valid rationale to consider future radiotherapy dose intensification trials to improve outcomes” in patients with stage I/II disease, according to study author Ahmed Salem, MB, ChB, of the University of Manchester, England, and his coinvestigators.

The data from the post hoc analysis support guideline recommendations to stage even early and local SCLC when evaluating response to therapy in clinical trials, noted Howard (Jack) West, MD, of Swedish Cancer Institute, Seattle, in an accompanying editorial (JAMA Oncol. 2018 Dec 6. doi: 10.1001/jamaoncol.2018.5187). Dr. West suggested that such staging information might be useful when counseling patients about treatment options.

“These results imply that we may do our patients a disservice by dispensing with clinically relevant staging information that can lead to a more refined assessment of prognosis and optimal treatment,” Dr. West wrote.

SOURCE: Salem A et al. JAMA Oncol. 2018 Dec 6:e185335. doi: 10.1001/jamaoncol.2018.5335.

Methotrexate is effective for the control of pain produced by arthritis associated with Chikungunya virus infection, according to a retrospective review of outcomes in a series of 50 patients.

CDC/Cynthia Goldsmith

Joint pain and joint inflammation are commonly seen in the approximately 60% of patients who progress to the chronic phase of Chikungunya virus (CHIKV) infection, but there is no current consensus about how best to manage this complication, according to first author J. Kennedy Amaral, MD, of the department of infectious diseases and tropical medicine at the University of Minas Gerais (Brazil) and his colleagues, who published their experience in 50 patients in the Journal of Clinical Rheumatology.

In this study, the primary measure of efficacy was pain control because not all CHIKV infection patients with rheumatic symptoms demonstrate synovitis on radiological examination. The 50 patients included in this series all had joint symptoms persisting more than 12 weeks after onset of CHIKV infection.

All but four of the patients in this series were women. The mean age was 61.9 years. At baseline, 28 had a musculoskeletal disorder defined by presence of arthralgia, 11 had rheumatoid arthritis, seven had fibromyalgia, and four had undifferentiated polyarthritis.

On a 0-10 visual analog scale (VAS), the mean pain score at baseline was 7.7. All patients were initiated on a 4-week course of 7.5 mg of methotrexate administered with folic acid.

Four patients not examined after 4 weeks of treatment were excluded from analysis. Of those evaluated, 80% had achieved at least a 2-point reduction in VAS score, which is considered clinically meaningful. The mean reduction in VAS pain score at 4 weeks was 4.3 points (P less than .0001 vs. baseline). In 12 patients, symptoms were resolved, and they were not further evaluated.

Those with inadequate pain control at 4 weeks were permitted to begin a higher dose of methotrexate and to receive additional therapies. At 8 weeks, the reduction in VAS pain score was only modestly increased, reaching a mean 4.5-point reduction from baseline on a mean methotrexate dose of 9.2 mg/week. A substantial proportion of patients had added other medications, such as prednisone and hydroxychloroquine.

Only 20 patients had joint swelling and frank arthritis at baseline. In these, the mean swollen joint count decreased from 7.15 to 2.89 (P less than .0001). There was no further reduction at 8 weeks.

Over the course of the study, there was no evidence that methotrexate exacerbated CHIKV infection.

The data were collected retrospectively, and there was no control group, but the findings inform practitioners of the “possible benefit of low-dose methotrexate to treat both arthralgia and arthritis” in chronic CHIK-associated arthritis, according to Dr. Amaral and his coinvestigators.

The authors declared no potential conflicts of interest.

SOURCE: Amaral JK et al. J Clin Rheumatol. 2018 Dec 5. doi: 10.1097/RHU.0000000000000943.

Methotrexate is effective for the control of pain produced by arthritis associated with Chikungunya virus infection, according to a retrospective review of outcomes in a series of 50 patients.

CDC/Cynthia Goldsmith

Joint pain and joint inflammation are commonly seen in the approximately 60% of patients who progress to the chronic phase of Chikungunya virus (CHIKV) infection, but there is no current consensus about how best to manage this complication, according to first author J. Kennedy Amaral, MD, of the department of infectious diseases and tropical medicine at the University of Minas Gerais (Brazil) and his colleagues, who published their experience in 50 patients in the Journal of Clinical Rheumatology.

In this study, the primary measure of efficacy was pain control because not all CHIKV infection patients with rheumatic symptoms demonstrate synovitis on radiological examination. The 50 patients included in this series all had joint symptoms persisting more than 12 weeks after onset of CHIKV infection.

All but four of the patients in this series were women. The mean age was 61.9 years. At baseline, 28 had a musculoskeletal disorder defined by presence of arthralgia, 11 had rheumatoid arthritis, seven had fibromyalgia, and four had undifferentiated polyarthritis.

On a 0-10 visual analog scale (VAS), the mean pain score at baseline was 7.7. All patients were initiated on a 4-week course of 7.5 mg of methotrexate administered with folic acid.

Four patients not examined after 4 weeks of treatment were excluded from analysis. Of those evaluated, 80% had achieved at least a 2-point reduction in VAS score, which is considered clinically meaningful. The mean reduction in VAS pain score at 4 weeks was 4.3 points (P less than .0001 vs. baseline). In 12 patients, symptoms were resolved, and they were not further evaluated.

Those with inadequate pain control at 4 weeks were permitted to begin a higher dose of methotrexate and to receive additional therapies. At 8 weeks, the reduction in VAS pain score was only modestly increased, reaching a mean 4.5-point reduction from baseline on a mean methotrexate dose of 9.2 mg/week. A substantial proportion of patients had added other medications, such as prednisone and hydroxychloroquine.

Only 20 patients had joint swelling and frank arthritis at baseline. In these, the mean swollen joint count decreased from 7.15 to 2.89 (P less than .0001). There was no further reduction at 8 weeks.

Over the course of the study, there was no evidence that methotrexate exacerbated CHIKV infection.

The data were collected retrospectively, and there was no control group, but the findings inform practitioners of the “possible benefit of low-dose methotrexate to treat both arthralgia and arthritis” in chronic CHIK-associated arthritis, according to Dr. Amaral and his coinvestigators.

The authors declared no potential conflicts of interest.

SOURCE: Amaral JK et al. J Clin Rheumatol. 2018 Dec 5. doi: 10.1097/RHU.0000000000000943.

Methotrexate is effective for the control of pain produced by arthritis associated with Chikungunya virus infection, according to a retrospective review of outcomes in a series of 50 patients.

CDC/Cynthia Goldsmith

Joint pain and joint inflammation are commonly seen in the approximately 60% of patients who progress to the chronic phase of Chikungunya virus (CHIKV) infection, but there is no current consensus about how best to manage this complication, according to first author J. Kennedy Amaral, MD, of the department of infectious diseases and tropical medicine at the University of Minas Gerais (Brazil) and his colleagues, who published their experience in 50 patients in the Journal of Clinical Rheumatology.

In this study, the primary measure of efficacy was pain control because not all CHIKV infection patients with rheumatic symptoms demonstrate synovitis on radiological examination. The 50 patients included in this series all had joint symptoms persisting more than 12 weeks after onset of CHIKV infection.

All but four of the patients in this series were women. The mean age was 61.9 years. At baseline, 28 had a musculoskeletal disorder defined by presence of arthralgia, 11 had rheumatoid arthritis, seven had fibromyalgia, and four had undifferentiated polyarthritis.

On a 0-10 visual analog scale (VAS), the mean pain score at baseline was 7.7. All patients were initiated on a 4-week course of 7.5 mg of methotrexate administered with folic acid.

Four patients not examined after 4 weeks of treatment were excluded from analysis. Of those evaluated, 80% had achieved at least a 2-point reduction in VAS score, which is considered clinically meaningful. The mean reduction in VAS pain score at 4 weeks was 4.3 points (P less than .0001 vs. baseline). In 12 patients, symptoms were resolved, and they were not further evaluated.

Those with inadequate pain control at 4 weeks were permitted to begin a higher dose of methotrexate and to receive additional therapies. At 8 weeks, the reduction in VAS pain score was only modestly increased, reaching a mean 4.5-point reduction from baseline on a mean methotrexate dose of 9.2 mg/week. A substantial proportion of patients had added other medications, such as prednisone and hydroxychloroquine.

Only 20 patients had joint swelling and frank arthritis at baseline. In these, the mean swollen joint count decreased from 7.15 to 2.89 (P less than .0001). There was no further reduction at 8 weeks.

Over the course of the study, there was no evidence that methotrexate exacerbated CHIKV infection.

The data were collected retrospectively, and there was no control group, but the findings inform practitioners of the “possible benefit of low-dose methotrexate to treat both arthralgia and arthritis” in chronic CHIK-associated arthritis, according to Dr. Amaral and his coinvestigators.

The authors declared no potential conflicts of interest.

SOURCE: Amaral JK et al. J Clin Rheumatol. 2018 Dec 5. doi: 10.1097/RHU.0000000000000943.