Psychiatry - October 2008 - (Page 40)

TABLE 2. Treatment results MOOD DISORDER NOS BIPOLAR DISORDER TREATMENT P VALUE N=19 7.8±3.7 2.1±1.3 2.5±1.9 46.6±5.0 56.9±8.0 10.3±10.7 2.6±1.2 0.953 0.718 0.97 0.326 0.014 0.131 0.211 N=22 Follow-up (m) Level of care Medications (n) GAF baseline GAF endpoint Change in GAF CGI 7.8±3.8 2.0±1.3 2.5±1.4 45.0±5.1 50.3±8.4 5.3±10.2 3.1±1.3 Level of care = highest level of care ever required (1=outpatient psychotherapy, 2=Family based therapy/wrap-around, 3=partial program, 4=residential care/hospitalization); medications = total number of medications used during this study. TABLE 3. Medications to treat primary condition MOOD DISORDER NOS Initial (n) Aripiprazole Risperidone Quetiapine Ziprasidone Perphenazine Lamotrigine Divalproex None 13 6 0 0 1 1 0 1 MOOD DISORDER NOS Endpoint (n) 13 3 1 0 0 1 0 3 BIPOLAR DISORDER Initial (n) 13 0 0 1 0 2 2 1 BIPOLAR DISORDER Endpoint (n) 9 1 0 2 0 5 3 0 MEDICATION inpatient hospitalizations (53% of patients vs. 41%), and had more past medication trials. Patients with mood disorder NOS had more ADHD diagnoses (82% vs. 58%), more overall diagnoses, and more family histories of bipolar disorder (64% vs. 58%). The only statistically significant difference between the two groups was in age. After approximately eight months of follow-up, patients diagnosed with bipolar disorder improved significantly more as manifested by their endpoint GAF. Even though not statistically significant, their CGI and change in GAF were much better as well. Patients were treated with an average of 2.5 medications, while 40 Psychiatry 2008 [ O C T O B E R ] their highest level of care did not differ. Table 2 summarizes these findings. In Table 3, the medications to treat the primary disorder, initially and at endpoint, are listed. The overwhelming majority was treated with atypical antipsychotic monotherapy for the mood problems, although many were prescribed antiADHD medications as well (mood disorder NOS: seven treated with stimulants and seven with atomoxetine; bipolar disorder: two treated with stimulants and five with atomoxetine). DISCUSSION The results of this study need to be interpreted in light of its limitations. Sample sizes were small, which more than likely reduced the statistical power to find significant differences. Treatment was uncontrolled and data were collected retrospectively. Adherence to treatment was unchecked. Many patients received concomitant psychosocial treatments. On the other hand, these realworld patients were diagnosed with standardized assessment tools, enhancing diagnostic accuracy. The authors believe that this latter issue goes to the heart of the current controversy in youth bipolar disorder. In many settings, where diagnostic accuracy is less than desirable, numerous patients may be diagnosed with bipolar disorder without clearly meeting preestablished criteria. The explosion in bipolar disorder diagnoses in youth is probably in large part related to inadequate diagnostic workups. Emerging data show that it will be important to increase diagnostic precision, since, among other things, diagnosis predicts prognosis.5 Researchers are starting to show that the longitudinal course, family history, and pathophysiology of bipolar disorder versus mood disorder NOS is quite different.11,12 The present study also shows that it is important, in real-world settings, to differentiate both conditions: Patients with mood disorder NOS improved significantly less than patients with bipolar disorder, despite similar treatment intensity and pharmacotherapy. In this clinic, bipolar disorder patients were significantly older. Both groups had comorbidity, although ADHD was much more common in mood disorder NOS patients, a finding that is also discussed in research studies.13 These latter two observations, the age difference and the comorbidity difference, may be related: Mood disorder NOS patients are reported to have a high comorbidity with ADHD and oppositional defiant disorder, both of which have an earlier onset than bipolar disorder.13 Patients with bipolar disorder

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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