Psychiatry - October 2008 - (Page 39)

sporadic, isolated core hypomanic symptoms.6 Figure 1 provides an example of a patient diagnosed with a bipolar disorder and a patient diagnosed with a mood disorder NOS. Patients were included if they returned for at least one follow-up visit after the start of pharmacotherapy. In general, patients were started on pharmacotherapy immediately after the initial evaluation, were scheduled for a return visit one month later, and were subsequently seen for follow-up visits every two to three months. Follow-up visits included both patients and parents to review progress, side effects, mental status, and the medication regimen. As part of every follow-up visit, a Global Assessment of Functioning (GAF) score was determined. Data were documented in a standardized chart format. Patients were treated with mood stabilizers/anti-aggression medications, most commonly aripiprazole.10 The decision to treat with mood stabilizers was made with informed consent/assent of the parent and the patient. The chart review included historical information obtained during the initial evaluation and “followed back” the treatment course until either the patient dropped out of treatment or until the last visit within the first year after the initial evaluation. As such, data were only obtained for a maximum of one year of treatment. Information extracted from the records included age at initial evaluation, gender, DSM-IV-TR diagnoses, including initial GAF, family history of bipolar disorder, number of prior psychiatric hospitalizations, highest level of care ever required (1=outpatient psychotherapy, 2=wraparound or family-based therapy, 3=partial hospitalization program, 4=residential care/hospitalization), previous number and type of medications used, risk factors for suicidality routinely collected in this clinic (e.g., past or present suicidal ideation, past or present suicidal BIPOLAR DISORDER The patient reports periods of feeling high and full of energy. He reports needing less sleep, feeling significantly irritable, talking too much, racing thoughts, distractibility and dangerous behavior. Other times, he reports low mood, feeling uninterested in normal activities, and ambivalence regarding spending time with friends and family. The patient reports that his mood will fluctuate and cycle about 2 to 3 times per week. High and low episodes last 2 to 3 days at a time. MOOD DISORDER NOS The patient is described as chronically irritable. Irritability leads to aggressive and violent behavior. Examples include biting his brother to the point of bleeding, and hitting and biting children in school. At times, the patient presents as somewhat overconfident such as “telling the school teacher how stupid she was”. No significant hypomanic symptoms such as euphoria, decreased need for sleep, racing thoughts and pervasive grandiosity are reported. No significant depressed mood or anhedonia are reported. FIGURE 1. Example of a patient diagnosed with a bipolar disorder and a patient diagnosed with a mood disorder NOS TABLE 1. Baseline characteristics PATIENT CHARACTERISTICS Age Gender (male) Diagnoses (n) ADHD present + Family history Risks (n) Past inpatient Past medications (n) Mood Disorder NOS Bipolar Disorder P value N=22 11.3±3.1 15 2.4±1.1 18 14 1.0±1.2 9 2.7±2.7 N=19 15.0±2.4 12 2.1±0.7 11 11 1.6±1.3 10 3.7±3.2 0.0002 >0.5 0.218 >0.1 >0.5 0.133 >0.5 0.309 + Family history = for bipolar disorder; Risks = risks for suicidal behavior; Past inpatient = number of patients with psychiatric hospitalizations; Past medications = number of reported past psychiatric medication trials behavior, family history of suicidal behavior, exposure to suicidal behavior, history of physical or sexual abuse, history of psychiatric hospitalization, and substance use), medications prescribed after the evaluation, changes made in the prescription, number of medications used during the treatment, and final GAF. A Clinical Global ImpressionImprovement Score (CGI) was extracted from the report of the last treatment visit, compared to the initial evaluation. Statistical comparisons were done with Student’s t-test for continuous variables and Chi-square test for categorical variables. Tests were twotailed and significance was put at the 0.05 level. RESULTS Twenty-two patients were identified as having been diagnosed with mood disorder NOS and 19 patients with bipolar disorder. Characteristics of both groups are listed in Table 1. Patients with bipolar disorder were about four years older, had more risk factors for suicidality (63% of patients with past suicidality versus 45%), more [OCTOBER] Psychiatry 2008 39

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Psychiatry - October 2008

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