Children of Parents With Mental Illnesses: When to Intervene: Potential Implications for Mental Health Clinicians

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Author's Note: The commentary below is the first in a 3-part series highlighting and providing perspective on select topics from the 32nd International Congress on Law and Mental Health, held under the auspices of the International Academy of Law and Mental Health at Humboldt University in Berlin, Germany, from July 17-23, 2011. Specifically, part 1 will cover experiences of children of individuals with mental illnesses, part 2 will look at therapeutic jurisprudence and mental health courts, and part 3 will address behavioral genetics and the antisocial personality spectrum, though the Congress covered a much broader array of topics than just these few.

Children of Parents With Mental Illnesses: Introduction

Presenters from New Zealand, Canada, and the United Kingdom discussed "Moving the Agenda Forward on Services for Parents With Mental Illness and Their Children."^[1] Grant Duncan (Massey University, New Zealand) discussed his qualitative research with adults who had been raised by a parent with a serious mental illness like schizophrenia.

Although a substantial amount of research on such children's risk of developing mental illnesses has accumulated, he feels that more important questions pertain to how such children cope, their resilience strengths, and what we can learn from their experiences. At least 5 themes were apparent in his presentation. First, a parent having schizophrenia is not a necessary or sufficient reason for separating a parent and child. However, he noted that secure attachment may be disrupted as some affected parents may not respond well emotionally to their children (though separation would obviously be even more detrimental to attachment). Whereas abuse or neglect may justify separation, a mental illness diagnosis alone does not, though it should warrant an increase in supports available to the family. "Separation should be a last resort," Duncan noted.

Third, disruption to the family resulting from the mental illness may be much more damaging than the mental illness itself. Sole custody by the parent with a mental illness, without the stability and support of the other parent, may convey a higher risk for problems among children. It should also be recognized that signs/symptoms witnessed by children are highly variable (eg, ranging from being intrusive to being very distant).

Fourth, children feel a heightened sense of responsibility, though they usually receive very little age-appropriate information from clinicians, which may be growing even more problematic in light of privacy laws and misunderstandings about such laws by clinicians. Fifth, Duncan's research participants nearly never mentioned stigma per se, though they did speak about feelings of embarrassment.

 

How Do Children Perceive Stigma?

Regarding the latter concern, Elaine Mordoch, from the University of Manitoba, presented a study of how children of parents with various mental illnesses (eg, depression, posttraumatic stress disorders, attention-deficit/hyperactivity disorder, borderline personality disorder) perceive stigma, in particular, stigma by association, or "courtesy" stigma (ie, stigma acquired as a result of being related to a person with a stigmatized condition).^[1] She noted that according to recent epidemiologic statistics, 17% of Canadian children are parented by a person with a mental illness, which may be an underestimate. Thus, the magnitude of this issue is considerable. In interviewing youths 6-18 years of age, she found that children (6-11 years old) spoke most commonly about concerns related to observable differences that could cause them to be treated differently. On the other hand, older youths seemed to be more aware of possible stigma tied to the mental illness and became aware that the illness could affect family income, job security, and, thus, going to college in the future.

Children as Caregivers?

From Loughborough University in the United Kingdom, Jo Aldridge presented on a study involving children who serve as caregivers for parents with mental illnesses.^[1] She conducted qualitative research using photography as a medium for discovery (a method she had found useful in research involving adults with learning disabilities). That is, she gave children disposable cameras for 2 weeks and asked them to photograph their lives with their parents (and ideally to also provide narrative commentary on the photographs). Although she didn't find evidence of clear parentification of the children, her rich data revealed that they often want to help in caring for their parents but may lack the supports to do so.

Potential Implications for Mental Health Clinicians

Clinicians working with adult patients with serious mental illnesses should inquire specifically about their children and potentially meet with those children to answer questions and provide support. The presence of a serious mental illness is not grounds for separation, though it does indicate a need for additional supports as secure attachment may be disrupted. Children should be provided with age-appropriate information and given the opportunity to talk about their care-giving roles, perceptions of stigma or embarrassment, and concerns about the family's well-being.

 

How Can PCPs and Pain Docs Curb Opioid Abuse?

Charles E. Argoff, MD

Authors and Disclosures

Posted: 08/22/2011

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Hi. I am Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York. Today, I want to talk about how prescription drug abuse continues to be a significant and growing problem in this country, with all that we have learned about it, even in the last couple of years.

The Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the federal government, has recently released a report regarding this matter. This report looks at treatment admissions for substance abuse. Of great interest to all of us who are involved in the care of patients, and specifically patients on opioids, is the significant increase in the number of treatment admissions for opioid prescription abuse. This is of great importance. The report highlighted the 5 most commonly abused substance groups, accounting for 96% of the treatment admissions: (1) alcohol, (2) opioids, (3) marijuana, (4) cocaine, and (5) methamphetamine or amphetamine. Those accounted for the 5 most commonly reported substances in the treatment admission group.

This report makes clear that we have not yet turned the corner in terms of trying to curb prescription drug abuse, specifically prescription opioid abuse. It really points to the need to work in a more collaborative way. Not infrequently, a primary care provider will refer a patient to me because of a concern about overuse of opioids. However, when I question that particular primary care provider, all too often, the prescriptions are being written by that same provider and no one else. We must collaborate earlier, before starting a patient on a path towards prescription opioid abuse. We are and should be in control of who we treat and what we do when we treat somebody. Certainly opioids may be an effective component of someone's treatment regimen, but as this report reminds us, the use of prescription opioids is still a huge issue with respect to substance abuse matters, and we really need to start to do what we can as prescribers to help curb this and actually start to see a decrease, if not at least stabilization.

I want to remind all of us that we are one medical community, and that it would be best to try to control this problem by working together before it consumes us. I'm Dr. Charles Argoff. Thank you for listening. I do understand that this is a very difficult topic, and it is difficult to change behaviors, but it's a topic that we really need to tackle together.

 

Pharmacotherapy for the treatment of acute bipolar II depression: current

Pharmacotherapy for the treatment of acute bipolar II depression: current evidence.

J Clin Psychiatry.  2011; 72(3):356-66 (ISSN: 1555-2101)

Swartz HA; Thase ME
Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. swartzha@upmc.edu

OBJECTIVE: Bipolar II disorder is a common, recurrent, and disabling psychiatric illness, and yet little is known about how best to treat it. The pressing clinical need for evidence-based approaches to the treatment of bipolar II disorder, coupled with recent publication of pertinent studies, calls for an updated review of this literature. This review focuses on a critical examination of the evidence supporting the efficacy of treatments for acute depressive episodes in bipolar II disorder.

DATA SOURCES: A MEDLINE (via Ovid) search of journals, covering the period from January 1950 to January 2009, was performed to identify relevant studies. Keywords used were bipolar II disorder, bipolar disorder, bipolar depression, and pharmacotherapy. Studies were further limited to those that were in adult samples, published in peer-reviewed journals, and written in English.

STUDY SELECTION: We examined all randomized trials evaluating the use of pharmacotherapy in the treatment of acute bipolar II depression. Studies with mixed samples of bipolar I and II or bipolar II and unipolar depression were examined as well. Twenty-one randomized trials were identified and reviewed.

DATA EXTRACTION: Therapeutic agents were rated according to the quality of evidence supporting their efficacy as treatments for bipolar II depression.

DATA SYNTHESIS: Ninety percent of relevant trials were published after 2005. Quetiapine was judged as having compelling evidence supporting its efficacy. Lithium, antidepressants, and pramipexole were judged as having preliminary support for efficacy. Lamotrigine was considered to have mixed support.

CONCLUSIONS: Although progress has been made, further research on bipolar II depression is warranted.

Major Subject Heading(s)	Minor Subject Heading(s)	CAS Registry / EC Numbers
	Acute Disease Antidepressive Agents [therapeutic use] Antimanic Agents [therapeutic use] Benzhydryl Compounds [therapeutic use] Benzothiazoles [therapeutic use] Bipolar Disorder [drug therapy] Dibenzothiazepines [therapeutic use] Humans Lithium Compounds [therapeutic use] Triazines [therapeutic use]	0  (Antidepressive Agents) 0  (Antimanic Agents) 0  (Benzhydryl Compounds) 0  (Benzothiazoles) 0  (Dibenzothiazepines) 0  (Lithium Compounds) 0  (Triazines) 0  (quetiapine) 104632-26-0  (pramipexol) 68693-11-8  (modafinil) 84057-84-1  (lamotrigine)

• PreMedline Identifier: 20816033

Can Genes Predict Response to Antipsychotics?: Viewpoint

Authors and Disclosures

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Analysis of Gene Variants Previously Associated With Iloperidone Response in Patients With Schizophrenia Who Are Treated With Risperidone

Fijal BA, Stauffer VL, Kinon BJ, et alJ Clin Psychiatry. July 12, 2011. [Epub ahead of print]

Study Summary

Six single nucleotide polymorphisms (SNPs) previously reported to be associated with response to iloperidone therapy were tested for association with response to risperidone therapy. Data were obtained during a 12-week randomized controlled trial in patients with schizophrenia in which all participants received risperidone 2-6 mg/d for the first 2 weeks. After 2 weeks, responders to risperidone (defined as ≥ 20% improvement in the Positive and Negative Syndrome Scale [PANSS] total score) continued risperidone treatment, but nonresponders were randomly assigned to either risperidone or olanzapine treatment (10-20 mg/d) for an additional 10 weeks. Associations between change in PANSS and the 6 SNPs were examined in risperidone-treated patients (N = 145). Two SNPs, XKR4 rs9643483 and GRIA4 rs2513265, were significantly associated with change in PANSS total response (adjusted P < .05 for both), with the same direction of effect as reported for iloperidone.

Viewpoint

Regarding change in PANSS total scores, the positive and negative predictive values were 52% and 56%, respectively, for XKR4 rs9643483, and were 57% and 62%, respectively, for GRIA4 rs251326. The authors further remark that the positive predictive values for response to risperidone treatment were very similar to that found for iloperidone, but the negative predictive values were inferior by 7%-18%. They conclude that genetic models that reliably predict response to atypical antipsychotics will most likely include numerous SNPs that individually provide little predictive power but, when considered together, account for a substantial portion of variation in response. Should this be true, the ever-decreasing cost of genetic testing may perhaps soon put personalized medicine within the reach of routine clinical practice. The authors correctly point out that much larger datasets than are usually available in individual trials of patients with schizophrenia will be required. This illustrates the need for joint collaboration on this type of work among all the manufacturers of antipsychotic medications.

Who Benefits From Lumbar Steroid Injections?

Joseph K. Lee, MD

Authors and Disclosures

Posted: 08/24/2011

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Predictors of a Favorable Response to Transforaminal Injection of Steroids in Patients With Lumbar Radicular Pain Due to Disc Herniation

Ghahreman A, Bogduk N
Pain Med. 2011;12:871-879

Study Summary

Lumbar transforaminal epidural steroid injections (TF-ESIs) are a common type of treatment for radicular pain caused by a disc herniation. Predictors of favorable response (> 50% pain reduction beyond the first month of treatment), however, have not been well delineated in the literature.

Ghahreman and Bogduk examined 71 patients who were treated with a lumbar TF-ESI due to a disc herniation.^[1]Radiologic review of MRI imaging revealed an inverse relationship between severity of nerve compression and response to a TF-ESI. Favorable response to a lumbar TF-ESI was seen in 75% of patients with low-grade nerve compression and in only 26% of patients with high-grade nerve compression. No association was seen with factors such as location, morphology, or size of disc herniation. Clinical features, such as duration of symptoms, sensory abnormalities, and presence of neurologic changes did not predict a favorable response either.

Viewpoint

Lumbar TF-ESIs are routinely used as nonsurgical treatment for radicular lumbar pain caused by a disc herniation. This is the first such article to evaluate factors that can predict clinical response to single level lumbar TF-ESIs. From these results, gradation of nerve compression severity theoretically becomes a pertinent part in determining the potential success and limitations of such treatments.

Radiologic severity of nerve compression alone, however, may not fully explain or predict treatment response. Degenerative stenosis showing similar degrees of nerve compression by the same thought process should also give clinically similar symptoms, but it is often asymptomatic. Furthermore, in many cases, clinical and radiologic films may indicate potential involvement of more than one nerve level. Future comparative studies focused on additional predictive factors may provide more answers to such questions.

Abstract

References

 

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When Is Foot Drop Recoverable?

Justin M. Brown, MD

Authors and Disclosures

Posted: 08/23/2011

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This is Dr. Justin Brown from the Division of Neurosurgery at the University of California at San Diego. My specialty is spine and peripheral nerve disorders. Today, I will be discussing foot drop. Foot drop, as we know, results from a number of etiologies: stroke and spinal cord injuries and, more commonly, injury to the lumbar nerve root or to the peroneal nerve distally.

Patients can develop foot drop immediately following a trauma or they can develop it spontaneously, in a painless situation. There can be a number of presentations, but when a patient comes to your office and cannot dorsiflex the foot, it's very important to be able to determine the source of this and whether it's recoverable.

As we know, the L5 nerve root contributes to the dorsiflexion of the foot as does the peroneal nerve. Thus, a skilled electrodiagnostician is an important part of the team for determining the source of the foot drop. The muscles [innervated by] the peroneal nerve and the L5 myotome do overlap, but there are differences, and EMG [electromyography] can help us determine whether the source is the back or the leg. But sometimes this is more difficult to discern.

When the spine is the source and patients have no accompanying pain, they are often told to wait and this will recover. But we have found that if, in serial examinations, we are not seeing improved motor units, then decompressing the nerve at the level of the spine can recover function for a large number of patients with foot drop who might not otherwise have recovered.

When the source is the leg, a peroneal nerve compression operation is a very simple procedure much like a carpal tunnel release but at the knee. Patients who have diabetes, swollen legs, or a poor outcome after knee replacement surgery often will recover almost instantaneously after an operation like this.

This outcome is related to the types of nerve injuries that are involved. Nerve injuries necessarily progress, from a neurapraxia, where the nerve is intact but not conducting, to axon loss, which over time becomes irrecoverable. But we have found that for many patients who present as long as a year or more after the development of the foot drop, if we can stimulate the nerve distal to the point of injury and we see those muscles contract, we know this injury is accounted for in part by a neurapraxia, and therefore, if it's decompressed, it will recover fully.

In the more advanced forms of nerve injury, sometimes a graft is required. If this is at the level of the leg, this can be successful. If it is at the level of the spine, it is much more difficult to obtain a good recovery. In this case, we can consider what's called nerve transfers, in which branches of the tibial nerve, which push the foot down and curl the toes, can be moved over and plugged into the peroneal nerve to bring the foot up. This requires a substantial retraining on the patients' part, but it can be a successful approach.

Lastly, if patients come years after with no function whatsoever in that nerve distribution and the muscles cannot be stimulated, and if it seems clear that the muscle is irretrievable, we refer them to our orthopaedic colleagues to undertake tendon transfer operations. A tendon transfer involves moving the tendons that push the foot down or curl the toes, to the front of the foot to pull it up. I've seen a number of cases in which this has been a very successful approach.

To summarize, foot drop is related to several etiologies and will respond to a number of potential interventions. It is important to get these patients to a treating physician as soon as possible after their injury.

I am Justin Brown at the University of California in San Diego. Thank you.

Addiction a Brain Disease, ASAM Says

Deborah Brauser

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August 31, 2011 — For the first time, the American Society of Addiction Medicine (ASAM) has officially recognized that addiction is not solely related to substance misuse and is, in fact, a chronic brain disease.

"At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas," ASAM Past President Michael Miller, MD, said in a news release.

"The disease is about brains, not drugs. It's about underlying neurology, not outward actions," added Dr. Miller, who oversaw the development of the new addiction definition.

Findings from brain circuitry studies prompted more than 80 experts to come together 4 years ago to begin the process of developing a new definition of addiction.

Previous research has shown that addiction affects neurotransmission in the reward area of the brain, triggers craving of addictive behaviors based on memories of previous experiences, and alters areas that govern impulse control and judgment.

Chronic Condition

Although ASAM adopted aspects of its new definition internally in April, it was recently released to the public with final tweaks based on subsequent discussion by board members.

Highlights include its description of addiction as a primary disease, which means "it's not the result of other causes such as emotional or psychiatric problems." ASAM also notes that addiction is a chronic condition, and so should be "treated, managed, and monitored over a life-time."

Raju Hajela, MD, chair of the ASAM new definition committee and past president of the Canadian Society of Addiction Medicine, said in the release that this disease drives behaviors that others might not understand.

"Simply put, addiction is not a choice[, but] choice still plays an important role in getting help. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary," added Dr. Hajela.

David Kupfer, MD, chair of the American Psychiatric Association's Task Force for the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), told Medscape Medical News that "a number of mental disorders" that are currently in the DSM-4 and that will be in the DSM-5 are considered chronic and persistent.

"Addictive disorders, anxiety disorders, certainly depressive or bipolar disorders, schizophrenia, some of the neurocognitive disorders such as Alzheimer's — they are disorders that are no different than cardiovascular disease, or diabetes, or even asthma in many ways," said Dr. Kupfer.

"Thinking about it that way has helped a lot of people trying to revise the current DSM to realize that what we are seeking to do is try and find out the underlying physiology and the underlying psychopathology and etiology of these disorders. There's no question that you have this interaction of what's going on in the brain and what's going on in terms of expression of behavior," he added.

Definition Reduces Stigma

He noted that the new definition is consistent with "parallel developments" currently going on in other areas of psychiatry.

"We're running into the same exciting areas. It doesn't mean we have the answers. It means we have our work cut out for us in terms of how to integrate what we're learning about how the brain functions with what we learn about behavior," said Dr. Kupfer.

"It's very nice to see this society endorsing the fact that in many ways addiction may very well be a chronic brain disorder, and not simply a behavioral disorder. And that I totally agree with."

Overall, he said, it is important to get this information out to the public, to let those affected know that it is okay to come in for treatment.

"The only way that we will really get rid of stigma is to continue to point out and show again and again, hopefully with more science, that these disorders are no different than any of the other disorders that we are treating throughout the rest of medicine. So anything like this new definition helps."

The new, full definition of addiction is available on the ASAM Web site.

 

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