Synopsis of Psychiatry

Objectives:To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise cli

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Irritability in child and adolescent psychopathology: An integrative review for ICD-11

Objective Persistent irritability and behavior outbursts in disruptive mood dysregulation disorder (DMDD) are associated with severe impairment in childhood and with negative adolescent and adult outcomes. There are no empirically established treatments for DMDD. This study examined the feasibility and preliminary efficacy of dialectical behavior therapy adapted for preadolescent children (DBT-C) with DMDD. Method Children 7 to 12 years old with DMDD (N = 43) were randomly assigned 1:1 to DBT-C or treatment as usual (TAU). The 6 domains of feasibility included recruitment, randomization, retention, attendance, participants’ satisfaction, and therapist adherence. Blinded raters assessed participants at baseline, after 8, 16, 24, and 32 weeks, and at 3-month follow-up. The primary efficacy outcome was the positive response rate on the Clinical Global Impression–Improvement scale. Improvements in behavior outbursts and angry/irritable mood were assessed by the Clinical Global Impression–Severity scale. Results Mean number of participants randomized per month was 2.53 ± 2.72. Participants in DBT-C (n = 21) attended 89% of sessions compared with 48.6% in TAU (n = 22). Eight TAU participants (36.4%) dropped out compared with none in DBT-C. Parents and children in DBT-C expressed significantly higher treatment satisfaction than those in TAU. The rate of positive response was 90.4% in DBT-C compared with 45.5% in TAU, despite 3 times as many participants in TAU receiving psychiatric medications. Remission rates were 52.4% for DBT-C and 27.3% for TAU. Improvements were maintained at 3-month follow-up. Therapists showed adherence to DBT-C. Conclusion DBT-C demonstrated feasibility in all prespecified domains. Outcomes also indicated preliminary efficacy of DBT-C. Clinical trial registration information—Adapting DBT for Children With DMDD: Pilot RCT; http://clinicaltrials.gov/ ; NCT01862549 .

Randomized Clinical Trial of Dialectical Behavior Therapy for Preadolescent Children With Disruptive Mood Dysregulation Disorder: Feasibility and Outcomes.

OBJECTIVE
To evaluate the efficacy and safety of aripiprazole versus placebo in preventing relapse of irritability symptoms associated with autistic disorder in pediatric patients.


METHOD
This multicenter, double-blind, randomized, placebo-controlled, relapse-prevention trial enrolled patients (6-17 years) who met the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DMS-IV-TR) criteria for autistic disorder and who also had serious behavioral problems (ie, tantrums, aggression, self-injurious behavior, or a combination of these behavioral problems) between March 2011 and June 2012. In phase 1, single-blind aripiprazole was flexibly dosed (2-15 mg/d) for 13-26 weeks. Patients with a stable response (≥ 25% decrease in Aberrant Behavior Checklist-irritability subscale score and a rating of "much improved" or "very much improved" on the Clinical Global Impressions-Improvement scale) for 12 consecutive weeks were randomized into phase 2 to continue aripiprazole or switch to placebo. Treatment was continued until relapse or up to 16 weeks. The primary end point was time from randomization to relapse.


RESULTS
Eighty-five patients were randomized in phase 2. The difference in time to relapse between aripiprazole and placebo was not statistically significant (P = .097). Kaplan-Meier relapse rates at week 16 were 35% for aripiprazole and 52% for placebo (hazard ratio [HR] = 0.57; number needed to treat [NNT] = 6). The most common adverse events during phase 1 were weight increase (25.2%), somnolence (14.8%), and vomiting (14.2%); and, during phase 2 (aripiprazole vs placebo), they were upper respiratory tract infection (10.3% vs 2.3%), constipation (5.1% vs 0%), and movement disorder (5.1% vs 0%).


CONCLUSIONS
In this study, there was no statistically significant difference between aripiprazole and placebo in time to relapse during maintenance therapy. However, the HR and NNT suggest some patients will benefit from maintenance treatment. Patients receiving aripiprazole should be periodically reassessed to determine the continued need for treatment.


TRIAL REGISTRATION
ClinicalTrials.gov identifier: NCT01227668.

Safety and Efficacy of Aripiprazole in the Long-Term Maintenance Treatment of Pediatric Patients with Irritability Associated with Autistic Disorder

OBJECTIVE: DSM-5 has added a new developmentally appropriate child and adolescent mood disorder subtype called disruptive mood dysregulation disorder (DMDD). The core features of DMDD are temper outbursts (manifested by either verbal rages and/or physical aggression) and unrelenting irritability or anger. Currently, the literature is lacking a thorough review of the possible treatment options for the cardinal symptoms constituting DMDD. The objective of this article is to provide a thorough review of peer-reviewed studies on the subject of pharmacological treatment options for children and adolescents with the cardinal symptoms of DMDD. METHODS: Relevant articles for this study were obtained through Pubmed, Medline, PsychINFO and PsychINDEXplus using the key words: "adolescents," "children," "paediatric," "youth," "irritability," "temper outbursts," "aggression," "rage," "disruptive behaviour," "treatment," "dysphoria," "autism," "mental retardation/intellectual disability," "impulsivity," "ADHD," "oppositional defiant disorder," and "conduct disorder." A total of 823 studies were generated; only English studies focusing on pharmacological treatment were retained. RESULTS: Currently there are no established guidelines or thorough reviews summarizing the treatment of DMDD. Pharmacotherapeutic treatment options of both aggression and chronic irritability include: antidepressants/selective norepinephrine reuptake inhibitors, mood stabilizers, psychostimulants, antipsychotics, and alpha-2 agonists. CONCLUSION: Treatment options of severe, persistent irritability in youth are numerous, and a consensual treatment algorithm has not yet emerged from the literature. Further studies and clinical trials are warranted to determine efficacious and safe treatment modalities. KEYWORDS: aggression; bipolar disorder; depression; disruptive mood dysregulation; irritability; mood stabilizers Language: en

/pdf/treatment-options-for-the-cardinal-symptoms-of-disruptive-3mlfxcgdjf.pdf

Jean Jacques Breton

Papers

Treatment Options for the Cardinal Symptoms of Disruptive Mood Dysregulation Disorder

Are youths with disruptive mood dysregulation disorder different from youths with major depressive disorder or persistent depressive disorder