Child Psychiatry Consult

In the realm of screening routinely offered to our patients in primary care, colon cancer screening stands with cervical cancer screening with a grade A recommendation from the U.S. Preventive Services Task Force. As such, our systems have been set up to gently remind us of colon cancer screening when it is due. If your practice is like mine, it has been almost exclusively colonoscopy. As such, I hear a lot of patient complaints about the colonoscopy prep.

Recently, one of our patients had uncontrolled vomiting with one of the commonly used polyethylene glycol (PEG) 3350 preparations. Many of us may have been aware of the Miralax and Gatorade (M-G) colon prep, and I considered recommending it to my patient. But is it just as good?

Dr. Sameer Siddique of the University of Missouri, Columbia, and colleagues published a systematic review evaluating the comparability of the M-G prep (238-255 g in 1.9 L) to PEG (3.8-4 L) (Am. J. Gastroenterol. 2014;109:1566-74).

The investigators identified five articles and observed that the M-G prep was associated with significantly fewer satisfactory bowel preparations, compared with PEG (odds ratio, 0.65; 95% confidence interval, 0.43-0.98; P = .04). In a subgroup analysis, split-dose M-G was inferior to split-dose PEG in the number of satisfactory preparations.

Patients, however, had a greater willingness to repeat the preparation (OR, 7.32; 95% CI, 4.88-10.98; P <.01). No significant differences were observed with polyp detection or in side effects such as nausea, cramping, or bloating.

The study authors point out that the dose of Miralax in the M-G prep is not FDA approved (because it is 15 times higher than the dose for constipation), and that the solution is hypotonic and can potentially cause hyponatremia. Furthermore, the cost of a colonoscopy ranges from $600 to more than $5,400. At those prices, patient agreeableness to repeat the test does not mean the health care system can bear a deluge of re-do’s.

Remember that split-dose PEG (one half the day before and one half the day of) has been shown to be superior to the night-before preparation, and it can increase tolerability. If a patient has time to get the job done the day of the colonoscopy, maybe this is the way to go.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

In the realm of screening routinely offered to our patients in primary care, colon cancer screening stands with cervical cancer screening with a grade A recommendation from the U.S. Preventive Services Task Force. As such, our systems have been set up to gently remind us of colon cancer screening when it is due. If your practice is like mine, it has been almost exclusively colonoscopy. As such, I hear a lot of patient complaints about the colonoscopy prep.

Recently, one of our patients had uncontrolled vomiting with one of the commonly used polyethylene glycol (PEG) 3350 preparations. Many of us may have been aware of the Miralax and Gatorade (M-G) colon prep, and I considered recommending it to my patient. But is it just as good?

Dr. Sameer Siddique of the University of Missouri, Columbia, and colleagues published a systematic review evaluating the comparability of the M-G prep (238-255 g in 1.9 L) to PEG (3.8-4 L) (Am. J. Gastroenterol. 2014;109:1566-74).

The investigators identified five articles and observed that the M-G prep was associated with significantly fewer satisfactory bowel preparations, compared with PEG (odds ratio, 0.65; 95% confidence interval, 0.43-0.98; P = .04). In a subgroup analysis, split-dose M-G was inferior to split-dose PEG in the number of satisfactory preparations.

Patients, however, had a greater willingness to repeat the preparation (OR, 7.32; 95% CI, 4.88-10.98; P <.01). No significant differences were observed with polyp detection or in side effects such as nausea, cramping, or bloating.

The study authors point out that the dose of Miralax in the M-G prep is not FDA approved (because it is 15 times higher than the dose for constipation), and that the solution is hypotonic and can potentially cause hyponatremia. Furthermore, the cost of a colonoscopy ranges from $600 to more than $5,400. At those prices, patient agreeableness to repeat the test does not mean the health care system can bear a deluge of re-do’s.

Remember that split-dose PEG (one half the day before and one half the day of) has been shown to be superior to the night-before preparation, and it can increase tolerability. If a patient has time to get the job done the day of the colonoscopy, maybe this is the way to go.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

In the realm of screening routinely offered to our patients in primary care, colon cancer screening stands with cervical cancer screening with a grade A recommendation from the U.S. Preventive Services Task Force. As such, our systems have been set up to gently remind us of colon cancer screening when it is due. If your practice is like mine, it has been almost exclusively colonoscopy. As such, I hear a lot of patient complaints about the colonoscopy prep.

Recently, one of our patients had uncontrolled vomiting with one of the commonly used polyethylene glycol (PEG) 3350 preparations. Many of us may have been aware of the Miralax and Gatorade (M-G) colon prep, and I considered recommending it to my patient. But is it just as good?

Dr. Sameer Siddique of the University of Missouri, Columbia, and colleagues published a systematic review evaluating the comparability of the M-G prep (238-255 g in 1.9 L) to PEG (3.8-4 L) (Am. J. Gastroenterol. 2014;109:1566-74).

The investigators identified five articles and observed that the M-G prep was associated with significantly fewer satisfactory bowel preparations, compared with PEG (odds ratio, 0.65; 95% confidence interval, 0.43-0.98; P = .04). In a subgroup analysis, split-dose M-G was inferior to split-dose PEG in the number of satisfactory preparations.

Patients, however, had a greater willingness to repeat the preparation (OR, 7.32; 95% CI, 4.88-10.98; P <.01). No significant differences were observed with polyp detection or in side effects such as nausea, cramping, or bloating.

The study authors point out that the dose of Miralax in the M-G prep is not FDA approved (because it is 15 times higher than the dose for constipation), and that the solution is hypotonic and can potentially cause hyponatremia. Furthermore, the cost of a colonoscopy ranges from $600 to more than $5,400. At those prices, patient agreeableness to repeat the test does not mean the health care system can bear a deluge of re-do’s.

Remember that split-dose PEG (one half the day before and one half the day of) has been shown to be superior to the night-before preparation, and it can increase tolerability. If a patient has time to get the job done the day of the colonoscopy, maybe this is the way to go.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.

Case Summary

Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.

Discussion

Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.

The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.

Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.

The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.

The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.

Case follow-up

Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.

I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.

Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).

What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.

As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.

“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.

Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.

Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.

Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.

Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.

Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.

Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.

Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.

An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.

Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.

“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.

[email protected]


On Twitter @mitchelzoler

NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.

“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.

Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.

Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.

Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.

Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.

Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.

Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.

Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.

An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.

Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.

“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.

[email protected]


On Twitter @mitchelzoler

NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.

“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.

Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.

Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.

Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.

Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.

Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.

Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.

Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.

An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.

Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.

“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.

[email protected]


On Twitter @mitchelzoler

NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.

“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.

Dr. Amsel is on the faculty of the REACH Institute.

[email protected]

On Twitter@mitchelzoler

NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.

“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.

Dr. Amsel is on the faculty of the REACH Institute.

[email protected]

On Twitter@mitchelzoler

NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.

“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.

Dr. Amsel is on the faculty of the REACH Institute.

[email protected]

On Twitter@mitchelzoler

NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.

But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.

“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.

Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.

“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.

Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.

Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.

Dr. Amsel had no disclosures aside from his work for the REACH Institute.

[email protected]

On Twitter @mitchelzoler

NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.

But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.

“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.

Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.

“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.

Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.

Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.

Dr. Amsel had no disclosures aside from his work for the REACH Institute.

[email protected]

On Twitter @mitchelzoler

NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.

But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.

“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.

Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.

“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.

Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.

Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.

Dr. Amsel had no disclosures aside from his work for the REACH Institute.

[email protected]

On Twitter @mitchelzoler

One out of every 10 adults in the United States has diabetes, and the percentage of Americans aged 65 years or older who have diabetes continues to increase. The treatment of diabetes consumes an enormous amount of health care and personal resources. This would palatable if such expenditures did nothing but improve outcomes and reduce morbidity and mortality.

But they don’t.

Compared with young healthy patients with diabetes, older patients with diabetes and complex medical conditions may derive little benefit from intensive management but may incur harm. Hypoglycemia is associated with significant medical costs and adverse health consequences among older patients. Hypoglycemic agents (oral and injectable) are implicated in one-fourth of emergency hospitalizations for adverse drugs events in this population.

Dr. Kasia J. Lipska of Yale University, New Haven, Conn., and her colleagues evaluated the potential overtreatment of diabetes in older patients (at least 65 years) by examining participants in the National Health and Nutrition Examination Survey from 2001 through 2010 who had an HbA_1c measurement. Participants were grouped into different health status categories using available data: very complex/poor, complex/intermediate, and relatively healthy (JAMA Intern. Med. 2015 [doi:10.1001/jamainternmed.2014.7345]).

The investigators found that almost two-thirds of this population had an HbA_1c less than 7% (i.e., tight control), which did not differ across health status categories. Of the adults with an HbA_1c less than 7%, more than one-half were treated with insulin or sulfonylureas, and this was similar across health status categories. During the 10 study years, no changes were observed in the proportion with an HbA_1c less than 7% or the proportion of patients with an HbA_1c less than 7% who were treated with insulin or a sulfonylurea.

These data tell us we are not racheting our care back when patients reach an age when aggressive care does more harm than good. We may feel hamstrung by quality metrics, a limited ability to manage large populations using health management approach, algorithmic approaches to facilitate appropriate de-escalations in medication management, and lack of time to engage in these discussions with our patients. What we tend to do is decrease these medications after patients have an office or emergency department visit for a hypoglycemic event or complication.

Moving forward, we need to embrace more liberal HbA_1c goals for our patients at least 65 years of age. Most important, yet most challenging, we need to have ongoing goals of care discussions with our patients, and comorbidities need to be considered when setting such goals. Decision aids would be helpful tools in this space.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

One out of every 10 adults in the United States has diabetes, and the percentage of Americans aged 65 years or older who have diabetes continues to increase. The treatment of diabetes consumes an enormous amount of health care and personal resources. This would palatable if such expenditures did nothing but improve outcomes and reduce morbidity and mortality.

But they don’t.

Compared with young healthy patients with diabetes, older patients with diabetes and complex medical conditions may derive little benefit from intensive management but may incur harm. Hypoglycemia is associated with significant medical costs and adverse health consequences among older patients. Hypoglycemic agents (oral and injectable) are implicated in one-fourth of emergency hospitalizations for adverse drugs events in this population.

Dr. Kasia J. Lipska of Yale University, New Haven, Conn., and her colleagues evaluated the potential overtreatment of diabetes in older patients (at least 65 years) by examining participants in the National Health and Nutrition Examination Survey from 2001 through 2010 who had an HbA_1c measurement. Participants were grouped into different health status categories using available data: very complex/poor, complex/intermediate, and relatively healthy (JAMA Intern. Med. 2015 [doi:10.1001/jamainternmed.2014.7345]).

The investigators found that almost two-thirds of this population had an HbA_1c less than 7% (i.e., tight control), which did not differ across health status categories. Of the adults with an HbA_1c less than 7%, more than one-half were treated with insulin or sulfonylureas, and this was similar across health status categories. During the 10 study years, no changes were observed in the proportion with an HbA_1c less than 7% or the proportion of patients with an HbA_1c less than 7% who were treated with insulin or a sulfonylurea.

These data tell us we are not racheting our care back when patients reach an age when aggressive care does more harm than good. We may feel hamstrung by quality metrics, a limited ability to manage large populations using health management approach, algorithmic approaches to facilitate appropriate de-escalations in medication management, and lack of time to engage in these discussions with our patients. What we tend to do is decrease these medications after patients have an office or emergency department visit for a hypoglycemic event or complication.

Moving forward, we need to embrace more liberal HbA_1c goals for our patients at least 65 years of age. Most important, yet most challenging, we need to have ongoing goals of care discussions with our patients, and comorbidities need to be considered when setting such goals. Decision aids would be helpful tools in this space.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

One out of every 10 adults in the United States has diabetes, and the percentage of Americans aged 65 years or older who have diabetes continues to increase. The treatment of diabetes consumes an enormous amount of health care and personal resources. This would palatable if such expenditures did nothing but improve outcomes and reduce morbidity and mortality.

But they don’t.

Compared with young healthy patients with diabetes, older patients with diabetes and complex medical conditions may derive little benefit from intensive management but may incur harm. Hypoglycemia is associated with significant medical costs and adverse health consequences among older patients. Hypoglycemic agents (oral and injectable) are implicated in one-fourth of emergency hospitalizations for adverse drugs events in this population.

Dr. Kasia J. Lipska of Yale University, New Haven, Conn., and her colleagues evaluated the potential overtreatment of diabetes in older patients (at least 65 years) by examining participants in the National Health and Nutrition Examination Survey from 2001 through 2010 who had an HbA_1c measurement. Participants were grouped into different health status categories using available data: very complex/poor, complex/intermediate, and relatively healthy (JAMA Intern. Med. 2015 [doi:10.1001/jamainternmed.2014.7345]).

The investigators found that almost two-thirds of this population had an HbA_1c less than 7% (i.e., tight control), which did not differ across health status categories. Of the adults with an HbA_1c less than 7%, more than one-half were treated with insulin or sulfonylureas, and this was similar across health status categories. During the 10 study years, no changes were observed in the proportion with an HbA_1c less than 7% or the proportion of patients with an HbA_1c less than 7% who were treated with insulin or a sulfonylurea.

These data tell us we are not racheting our care back when patients reach an age when aggressive care does more harm than good. We may feel hamstrung by quality metrics, a limited ability to manage large populations using health management approach, algorithmic approaches to facilitate appropriate de-escalations in medication management, and lack of time to engage in these discussions with our patients. What we tend to do is decrease these medications after patients have an office or emergency department visit for a hypoglycemic event or complication.

Moving forward, we need to embrace more liberal HbA_1c goals for our patients at least 65 years of age. Most important, yet most challenging, we need to have ongoing goals of care discussions with our patients, and comorbidities need to be considered when setting such goals. Decision aids would be helpful tools in this space.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.

Introduction

In the last 20 years there has been a marked rise in the number of children and adolescents receiving the diagnosis of bipolar disorder (BD) – a mood disorder that, classically, involves cycling between episodes of elevated mood and episodes of low mood (Arch. Gen. Psychiatry 2207;64:1032-9). The increase in diagnosis is partly explained by the inclusion of children with chronic irritability being diagnosed with BD. This has led to concern about the subsequent use of approved second-generation antipsychotics for chronically irritable children, with the resultant side effects.

A new diagnosis called disruptive mood dysregulation disorder (DMDD) was introduced into the DSM-5 to describe these chronically irritable children and, in part, to reduce the number of children receiving a bipolar diagnosis. So, how does one know whether a child has BD, DMDD, or something else? The two brief cases that follow distinguish the difference between BD and DMDD.

Case 1 summary

Joseph is a 15-year-old boy with a history of childhood depression. About 1 year ago, he began to appear more irritable and anxious. Despite his parents’ prohibition, he was going out at night and was intoxicated on several occasions when he came home – something he had never done before. After about 2 weeks of this, he began going to bed at midnight, but would be up again by 4 a.m. talking to himself, playing music, or exercising. He was hanging out with a different crowd. He began to talk about the possibility of becoming part of a motorcycle gang – at some point perhaps the leader of Hells Angels. Slowly, this resolved. However, these symptoms recurred about 1 month ago with progressive worsening, again, and 2 days ago he stopped sleeping at all. He has been locking himself in his room, talking rapidly and excessively about motorcycles, complaining that he “just needed to get his thoughts together.” He was very distractible and was not eating. His mother called his primary care clinician who advised her to bring him to the ED, which she could do only by police because he refused to leave the home, complaining of the “noises” outside.

Case 1 discussion

Joseph most likely has bipolar I disorder, although a substance-induced mania will have to be ruled out. His symptoms are classic for what we think of as “narrow phenotypic” mania – elated and irritable mood, grandiosity, flight of ideas, decreased need for sleep, hypertalkativeness, increase in goal-directed activity, severe distractibility, and excessive involvement in activities that are likely to have painful consequences. These episodes are a clear change from baseline. Here, Joseph has been previously depressed, but never had symptoms like this that came, went, and then returned. If these manic symptoms continue for 1 week or longer, or are so severe as to require him to be hospitalized, these are a manic episode, which, essentially, makes the diagnosis of bipolar I disorder. Most clinicians have seen mania in late adolescence and early adulthood and can distinguish when these episodes occur in childhood. There is less ambiguity about this diagnosis when it occurs with frank mania.

Case 2 summary

Henry is a 12-year-old boy. His parents say that he’s been difficult since he was “in the womb.” Starting at about the age of 4 years, they started to notice that he would frequently become moody – lasting almost all day in a way that was noticed by everyone. He remains almost constantly irritable. He responds extremely to negative emotional stimuli, like when he got so upset about striking out at a Little League game last year that he had a 15-minute temper outburst that couldn’t be stopped. When his father removed him from the field to the car, he kicked out a window. These types of events are not uncommon, occurring four to five times per week, and are associated with verbal and physical aggression. There have been no symptom-free periods since age 4 years. There have been no clear episodes, and nothing that could be described as elation.

Case 2 discussion

Henry would very likely meet the criteria for the DSM-5 diagnosis of disruptive mood dysregulation disorder. DMDD requires that there be severe and recurrent temper outbursts that can be verbal or physical and are grossly out of proportion to the situation, happening at least three times a week for the past year. In between these outbursts, the child’s mood is angry or irritable, most of the day, nearly every day with no time longer than 3 months in the last year without symptoms. There cannot be symptoms of mania or hypomania. DMDD should be distinguished from oppositional-defiant disorder (ODD), which cannot be diagnosed concurrently. ODD has similar characteristics, but the temper outbursts are not as severe, frequent, or chronic. The mood symptoms in DMDD predominate, while oppositionality predominates in ODD. Note the chronicity of irritable mood in DMDD. This is the distinguishing characteristic of the disorder – chronic, nonepisodic irritability.

General discussion

The distinction between BD and DMDD does matter, but it is sometimes quite hard to draw a clear line – even for the experts. It can be easy to be frustrated with yourself as a clinician when you’re unable to come to a clear decision about the diagnosis. With mood disorders in children, however, it’s important not to attribute the field’s lack of clarity to your own lack of knowledge. In these difficult cases, it’s highly likely that even the experts would disagree. Making the distinction between bipolar disorder and DMDD becomes even more complex in the situation of “other specified bipolar and related disorders,” which allows for short or subsyndromal hypomanic episodes with major depression, hypomania without depression, or short-duration cyclothymia. These cases, formerly called “bipolar, not otherwise specified,” are more likely to progress to adult bipolar disorder I or II. DMDD, on the other hand, is more likely to progress to adult depression (Biol. Psychiatry 2006;60:991-7).

Why does the distinction matter? Because the treatment for bipolar disorder is likely to involve one of the traditional mood stabilizers or the second-generation antipsychotics that are Food and Drug Administration–approved for bipolar disorder along with family education and cognitive-behavioral therapy. However, there is no evidence at this time that the management of DMDD should consist of these same treatments. In fact, a trial of lithium for DMDD (actually, its research predecessor severe mood dysregulation) was negative (J. Child. Adolesc. Psychopharmacol. 2009;19:61-73). While we are still working out how to help children with DMDD, the current trials being done are examining the use of antidepressants and psychostimulants (either serially or in combination) along with family-based interventions similar to those used for ODD. These are tough cases, and frequently a consult with a child psychiatrist or psychologist will be helpful.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, the Research Center for Children, Youth, and Families, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations. E-mail him at [email protected].

Introduction

In the last 20 years there has been a marked rise in the number of children and adolescents receiving the diagnosis of bipolar disorder (BD) – a mood disorder that, classically, involves cycling between episodes of elevated mood and episodes of low mood (Arch. Gen. Psychiatry 2207;64:1032-9). The increase in diagnosis is partly explained by the inclusion of children with chronic irritability being diagnosed with BD. This has led to concern about the subsequent use of approved second-generation antipsychotics for chronically irritable children, with the resultant side effects.

A new diagnosis called disruptive mood dysregulation disorder (DMDD) was introduced into the DSM-5 to describe these chronically irritable children and, in part, to reduce the number of children receiving a bipolar diagnosis. So, how does one know whether a child has BD, DMDD, or something else? The two brief cases that follow distinguish the difference between BD and DMDD.

Case 1 summary

Joseph is a 15-year-old boy with a history of childhood depression. About 1 year ago, he began to appear more irritable and anxious. Despite his parents’ prohibition, he was going out at night and was intoxicated on several occasions when he came home – something he had never done before. After about 2 weeks of this, he began going to bed at midnight, but would be up again by 4 a.m. talking to himself, playing music, or exercising. He was hanging out with a different crowd. He began to talk about the possibility of becoming part of a motorcycle gang – at some point perhaps the leader of Hells Angels. Slowly, this resolved. However, these symptoms recurred about 1 month ago with progressive worsening, again, and 2 days ago he stopped sleeping at all. He has been locking himself in his room, talking rapidly and excessively about motorcycles, complaining that he “just needed to get his thoughts together.” He was very distractible and was not eating. His mother called his primary care clinician who advised her to bring him to the ED, which she could do only by police because he refused to leave the home, complaining of the “noises” outside.

Case 1 discussion

Joseph most likely has bipolar I disorder, although a substance-induced mania will have to be ruled out. His symptoms are classic for what we think of as “narrow phenotypic” mania – elated and irritable mood, grandiosity, flight of ideas, decreased need for sleep, hypertalkativeness, increase in goal-directed activity, severe distractibility, and excessive involvement in activities that are likely to have painful consequences. These episodes are a clear change from baseline. Here, Joseph has been previously depressed, but never had symptoms like this that came, went, and then returned. If these manic symptoms continue for 1 week or longer, or are so severe as to require him to be hospitalized, these are a manic episode, which, essentially, makes the diagnosis of bipolar I disorder. Most clinicians have seen mania in late adolescence and early adulthood and can distinguish when these episodes occur in childhood. There is less ambiguity about this diagnosis when it occurs with frank mania.

Case 2 summary

Henry is a 12-year-old boy. His parents say that he’s been difficult since he was “in the womb.” Starting at about the age of 4 years, they started to notice that he would frequently become moody – lasting almost all day in a way that was noticed by everyone. He remains almost constantly irritable. He responds extremely to negative emotional stimuli, like when he got so upset about striking out at a Little League game last year that he had a 15-minute temper outburst that couldn’t be stopped. When his father removed him from the field to the car, he kicked out a window. These types of events are not uncommon, occurring four to five times per week, and are associated with verbal and physical aggression. There have been no symptom-free periods since age 4 years. There have been no clear episodes, and nothing that could be described as elation.

Case 2 discussion

Henry would very likely meet the criteria for the DSM-5 diagnosis of disruptive mood dysregulation disorder. DMDD requires that there be severe and recurrent temper outbursts that can be verbal or physical and are grossly out of proportion to the situation, happening at least three times a week for the past year. In between these outbursts, the child’s mood is angry or irritable, most of the day, nearly every day with no time longer than 3 months in the last year without symptoms. There cannot be symptoms of mania or hypomania. DMDD should be distinguished from oppositional-defiant disorder (ODD), which cannot be diagnosed concurrently. ODD has similar characteristics, but the temper outbursts are not as severe, frequent, or chronic. The mood symptoms in DMDD predominate, while oppositionality predominates in ODD. Note the chronicity of irritable mood in DMDD. This is the distinguishing characteristic of the disorder – chronic, nonepisodic irritability.

General discussion

The distinction between BD and DMDD does matter, but it is sometimes quite hard to draw a clear line – even for the experts. It can be easy to be frustrated with yourself as a clinician when you’re unable to come to a clear decision about the diagnosis. With mood disorders in children, however, it’s important not to attribute the field’s lack of clarity to your own lack of knowledge. In these difficult cases, it’s highly likely that even the experts would disagree. Making the distinction between bipolar disorder and DMDD becomes even more complex in the situation of “other specified bipolar and related disorders,” which allows for short or subsyndromal hypomanic episodes with major depression, hypomania without depression, or short-duration cyclothymia. These cases, formerly called “bipolar, not otherwise specified,” are more likely to progress to adult bipolar disorder I or II. DMDD, on the other hand, is more likely to progress to adult depression (Biol. Psychiatry 2006;60:991-7).

Why does the distinction matter? Because the treatment for bipolar disorder is likely to involve one of the traditional mood stabilizers or the second-generation antipsychotics that are Food and Drug Administration–approved for bipolar disorder along with family education and cognitive-behavioral therapy. However, there is no evidence at this time that the management of DMDD should consist of these same treatments. In fact, a trial of lithium for DMDD (actually, its research predecessor severe mood dysregulation) was negative (J. Child. Adolesc. Psychopharmacol. 2009;19:61-73). While we are still working out how to help children with DMDD, the current trials being done are examining the use of antidepressants and psychostimulants (either serially or in combination) along with family-based interventions similar to those used for ODD. These are tough cases, and frequently a consult with a child psychiatrist or psychologist will be helpful.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, the Research Center for Children, Youth, and Families, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations. E-mail him at [email protected].

Introduction

In the last 20 years there has been a marked rise in the number of children and adolescents receiving the diagnosis of bipolar disorder (BD) – a mood disorder that, classically, involves cycling between episodes of elevated mood and episodes of low mood (Arch. Gen. Psychiatry 2207;64:1032-9). The increase in diagnosis is partly explained by the inclusion of children with chronic irritability being diagnosed with BD. This has led to concern about the subsequent use of approved second-generation antipsychotics for chronically irritable children, with the resultant side effects.

A new diagnosis called disruptive mood dysregulation disorder (DMDD) was introduced into the DSM-5 to describe these chronically irritable children and, in part, to reduce the number of children receiving a bipolar diagnosis. So, how does one know whether a child has BD, DMDD, or something else? The two brief cases that follow distinguish the difference between BD and DMDD.

Case 1 summary

Joseph is a 15-year-old boy with a history of childhood depression. About 1 year ago, he began to appear more irritable and anxious. Despite his parents’ prohibition, he was going out at night and was intoxicated on several occasions when he came home – something he had never done before. After about 2 weeks of this, he began going to bed at midnight, but would be up again by 4 a.m. talking to himself, playing music, or exercising. He was hanging out with a different crowd. He began to talk about the possibility of becoming part of a motorcycle gang – at some point perhaps the leader of Hells Angels. Slowly, this resolved. However, these symptoms recurred about 1 month ago with progressive worsening, again, and 2 days ago he stopped sleeping at all. He has been locking himself in his room, talking rapidly and excessively about motorcycles, complaining that he “just needed to get his thoughts together.” He was very distractible and was not eating. His mother called his primary care clinician who advised her to bring him to the ED, which she could do only by police because he refused to leave the home, complaining of the “noises” outside.

Case 1 discussion

Joseph most likely has bipolar I disorder, although a substance-induced mania will have to be ruled out. His symptoms are classic for what we think of as “narrow phenotypic” mania – elated and irritable mood, grandiosity, flight of ideas, decreased need for sleep, hypertalkativeness, increase in goal-directed activity, severe distractibility, and excessive involvement in activities that are likely to have painful consequences. These episodes are a clear change from baseline. Here, Joseph has been previously depressed, but never had symptoms like this that came, went, and then returned. If these manic symptoms continue for 1 week or longer, or are so severe as to require him to be hospitalized, these are a manic episode, which, essentially, makes the diagnosis of bipolar I disorder. Most clinicians have seen mania in late adolescence and early adulthood and can distinguish when these episodes occur in childhood. There is less ambiguity about this diagnosis when it occurs with frank mania.

Case 2 summary

Henry is a 12-year-old boy. His parents say that he’s been difficult since he was “in the womb.” Starting at about the age of 4 years, they started to notice that he would frequently become moody – lasting almost all day in a way that was noticed by everyone. He remains almost constantly irritable. He responds extremely to negative emotional stimuli, like when he got so upset about striking out at a Little League game last year that he had a 15-minute temper outburst that couldn’t be stopped. When his father removed him from the field to the car, he kicked out a window. These types of events are not uncommon, occurring four to five times per week, and are associated with verbal and physical aggression. There have been no symptom-free periods since age 4 years. There have been no clear episodes, and nothing that could be described as elation.

Case 2 discussion

Henry would very likely meet the criteria for the DSM-5 diagnosis of disruptive mood dysregulation disorder. DMDD requires that there be severe and recurrent temper outbursts that can be verbal or physical and are grossly out of proportion to the situation, happening at least three times a week for the past year. In between these outbursts, the child’s mood is angry or irritable, most of the day, nearly every day with no time longer than 3 months in the last year without symptoms. There cannot be symptoms of mania or hypomania. DMDD should be distinguished from oppositional-defiant disorder (ODD), which cannot be diagnosed concurrently. ODD has similar characteristics, but the temper outbursts are not as severe, frequent, or chronic. The mood symptoms in DMDD predominate, while oppositionality predominates in ODD. Note the chronicity of irritable mood in DMDD. This is the distinguishing characteristic of the disorder – chronic, nonepisodic irritability.

General discussion

The distinction between BD and DMDD does matter, but it is sometimes quite hard to draw a clear line – even for the experts. It can be easy to be frustrated with yourself as a clinician when you’re unable to come to a clear decision about the diagnosis. With mood disorders in children, however, it’s important not to attribute the field’s lack of clarity to your own lack of knowledge. In these difficult cases, it’s highly likely that even the experts would disagree. Making the distinction between bipolar disorder and DMDD becomes even more complex in the situation of “other specified bipolar and related disorders,” which allows for short or subsyndromal hypomanic episodes with major depression, hypomania without depression, or short-duration cyclothymia. These cases, formerly called “bipolar, not otherwise specified,” are more likely to progress to adult bipolar disorder I or II. DMDD, on the other hand, is more likely to progress to adult depression (Biol. Psychiatry 2006;60:991-7).

Why does the distinction matter? Because the treatment for bipolar disorder is likely to involve one of the traditional mood stabilizers or the second-generation antipsychotics that are Food and Drug Administration–approved for bipolar disorder along with family education and cognitive-behavioral therapy. However, there is no evidence at this time that the management of DMDD should consist of these same treatments. In fact, a trial of lithium for DMDD (actually, its research predecessor severe mood dysregulation) was negative (J. Child. Adolesc. Psychopharmacol. 2009;19:61-73). While we are still working out how to help children with DMDD, the current trials being done are examining the use of antidepressants and psychostimulants (either serially or in combination) along with family-based interventions similar to those used for ODD. These are tough cases, and frequently a consult with a child psychiatrist or psychologist will be helpful.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, the Research Center for Children, Youth, and Families, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations. E-mail him at [email protected].

Like many groups, our practice shares backup call on a rotational basis. This week-long pleasure cruise is characterized by phone calls throughout the night (“Why are we checking a temperature on a comfortably sleeping 85-year-old at 2 a.m. again?”), dubious requests (“I am still unclear why you were cleaning out your medicine cabinet at 4 a.m. Even so, I cannot refill the oxycodone you just flushed down the toilet.”), and fragmented sleep associated with clinically significant carbohydrate cravings.

In the old days, this indispensable community service could be handled without the need for remoting into the practice. But most calls these days require that our computers be close at hand. As such, we find ourselves in the wee hours of morning staring at computer screens that, we are increasingly aware, emit melatonin-killing blue wavelengths of light. This makes it that much harder to go back to sleep after triaging colonoscopy-preps-gone-wrong calls.

Several months ago, one of my patients gave me orange-tinted, blue light–blocking (BB) glasses as a gift. These glasses are designed to filter out the blue wavelength (480 nm), which most strongly impacts alertness, cognitive performance, and circadian physiology.

They have collected dust on my desk. … until last week while on call.

In a recently published study, Stéphanie van der Lely of the University of Basel, Switzerland, and colleagues evaluated the impact of blue-blocker glasses as a countermeasure to evening computer screen time among adolescents (J. Adolesc. Health 2015;56:113-9). Thirteen adolescents with a mean age of 16 years participated in this crossover study over 16 days. Blue blockers were provided from 6 p.m. to sleep onset. Glasses reduced the blue light transmission to 30%.

Compared with clear lenses, BB significantly attenuated LED-induced melatonin suppression in the evening. BB glasses also decreased vigilant attention and subjective alertness before bedtime.

This article would suggest that my melatonin is not being suppressed while I wear the glasses as I do my evening article writing and answer phone calls. The color shifts take some getting used to, but the glasses are comfortable. In addition to sleeping in the attic, my backup call routine will include these glasses.

Now, if we can just find something to filter out midnight acetaminophen requests. At least I’ll fall back asleep quickly after telling them to take two and call me in the morning.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Like many groups, our practice shares backup call on a rotational basis. This week-long pleasure cruise is characterized by phone calls throughout the night (“Why are we checking a temperature on a comfortably sleeping 85-year-old at 2 a.m. again?”), dubious requests (“I am still unclear why you were cleaning out your medicine cabinet at 4 a.m. Even so, I cannot refill the oxycodone you just flushed down the toilet.”), and fragmented sleep associated with clinically significant carbohydrate cravings.

In the old days, this indispensable community service could be handled without the need for remoting into the practice. But most calls these days require that our computers be close at hand. As such, we find ourselves in the wee hours of morning staring at computer screens that, we are increasingly aware, emit melatonin-killing blue wavelengths of light. This makes it that much harder to go back to sleep after triaging colonoscopy-preps-gone-wrong calls.

Several months ago, one of my patients gave me orange-tinted, blue light–blocking (BB) glasses as a gift. These glasses are designed to filter out the blue wavelength (480 nm), which most strongly impacts alertness, cognitive performance, and circadian physiology.

They have collected dust on my desk. … until last week while on call.

In a recently published study, Stéphanie van der Lely of the University of Basel, Switzerland, and colleagues evaluated the impact of blue-blocker glasses as a countermeasure to evening computer screen time among adolescents (J. Adolesc. Health 2015;56:113-9). Thirteen adolescents with a mean age of 16 years participated in this crossover study over 16 days. Blue blockers were provided from 6 p.m. to sleep onset. Glasses reduced the blue light transmission to 30%.

Compared with clear lenses, BB significantly attenuated LED-induced melatonin suppression in the evening. BB glasses also decreased vigilant attention and subjective alertness before bedtime.

This article would suggest that my melatonin is not being suppressed while I wear the glasses as I do my evening article writing and answer phone calls. The color shifts take some getting used to, but the glasses are comfortable. In addition to sleeping in the attic, my backup call routine will include these glasses.

Now, if we can just find something to filter out midnight acetaminophen requests. At least I’ll fall back asleep quickly after telling them to take two and call me in the morning.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Like many groups, our practice shares backup call on a rotational basis. This week-long pleasure cruise is characterized by phone calls throughout the night (“Why are we checking a temperature on a comfortably sleeping 85-year-old at 2 a.m. again?”), dubious requests (“I am still unclear why you were cleaning out your medicine cabinet at 4 a.m. Even so, I cannot refill the oxycodone you just flushed down the toilet.”), and fragmented sleep associated with clinically significant carbohydrate cravings.

In the old days, this indispensable community service could be handled without the need for remoting into the practice. But most calls these days require that our computers be close at hand. As such, we find ourselves in the wee hours of morning staring at computer screens that, we are increasingly aware, emit melatonin-killing blue wavelengths of light. This makes it that much harder to go back to sleep after triaging colonoscopy-preps-gone-wrong calls.

Several months ago, one of my patients gave me orange-tinted, blue light–blocking (BB) glasses as a gift. These glasses are designed to filter out the blue wavelength (480 nm), which most strongly impacts alertness, cognitive performance, and circadian physiology.

They have collected dust on my desk. … until last week while on call.

In a recently published study, Stéphanie van der Lely of the University of Basel, Switzerland, and colleagues evaluated the impact of blue-blocker glasses as a countermeasure to evening computer screen time among adolescents (J. Adolesc. Health 2015;56:113-9). Thirteen adolescents with a mean age of 16 years participated in this crossover study over 16 days. Blue blockers were provided from 6 p.m. to sleep onset. Glasses reduced the blue light transmission to 30%.

Compared with clear lenses, BB significantly attenuated LED-induced melatonin suppression in the evening. BB glasses also decreased vigilant attention and subjective alertness before bedtime.

This article would suggest that my melatonin is not being suppressed while I wear the glasses as I do my evening article writing and answer phone calls. The color shifts take some getting used to, but the glasses are comfortable. In addition to sleeping in the attic, my backup call routine will include these glasses.

Now, if we can just find something to filter out midnight acetaminophen requests. At least I’ll fall back asleep quickly after telling them to take two and call me in the morning.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.