With purpose of establishment of influence of success of functioning of family where child with time-lagged psychical development is educated, on psychical health of its members, 200 families where child grows with violation of psychical development are investigated. On criterion of success of functioning the inspected families were parted on two groups: basic (164 families) - disfunctional and comparisons (36 families) - functional.

Assessment tools: surveillance, clinical and diagnostic interview, objective psychometric scales and test methods to identify the studied trait. Data were subjected to quantitative analysis with subsequent qualitative interpretation and meaningful generalization.

For all of women from disfunctional families neurotic and highly emotional disorders are diagnosed depressed, anxiously-depressed and fobial spectrum. For children, educated in disfunctional families, negative psycho-emotional state is set with predominance of alarm, depression, nervousness and depression, sense of unscreenedness, outcast and lonelyness.

Women from successful families demonstrated absence of psychical violations, and children time-lagged psychical development from families with favourable psychological atmosphere is differed an optimistic emotional background and predominance of sense of protected.

There is necessity of development and introduction in practice, of complex system of medical-psychological rehabilitation of families, educative child with violation of psychical development, including measures, directed on strengthening of health of family and increase of success of domestic functioning. Such complex approach will be given by possibility both to heave up efficiency of rehabilitation of children and promote quality of life of parents of children with violation of psychical development.

This paper aims

1. a) to explore the difficulties in differential diagnosis between epileptic crises and psychogenic non epileptic seizures (pseudoseizures),

2. b) to suggest therapeutic guidelines for psychogenic non epileptic seizures. Our purpose is to present a literature review on this subject and to discuss the problems involved.

Typical systematic review of recent articles regarding this topic at the internet search engines of PubMed and Scopus. We used the following keywords: psychogenic seizures, psychogenic non epileptic seizures (PNES), pseudoseizures, conversion disorder, dissociative disorder.

A large percentage of the seizures are found to be psychogenic non epileptic. Most of the patients are firstly treated by neurologists and only a percentage of close to 1/3 of these are referred to psychiatrists for further therapy. The differential diagnosis is difficult because most of the patients actually suffer from both epileptic and non epileptic seizures and usually come to the emergency clinics with either. Video EEG and therapeutic hypnosis are considered to be helpful techniques.

In order to treat patients suffering from psychogenic non epileptic seizures there must be a close collaboration between the neurologists, the psychiatrists and the emergency physicians considering both the medication prescribed and the therapeutic guidelines followed.

Atypical features are common among depressed primary care patients, but clinical trials testing the efficacy of psychopharmacological and/or psychotherapeutic treatment are lacking. This paper examines the efficacy of sertraline and cognitive behavioural therapy (CBT) among depressed patients with atypical features.

Analyses involve a double-blind comparison of sertraline versus placebo (N=47) and a single-blind comparison between CBT versus a guided self-help group (GSG) (N=48), with primary efficacy endpoints being the Inventory of Depressive Symptomatology (IDSC) and Hamilton Depression Scale (HAMD-17).

In intent-to-treat (ITT) analyses, the decrease on the IDSC scale (and HAMD-17) was greater after CBT compared to GSG: p=0.01 (HAMD-17: p=0.01). The difference between SSRI versus placebo was not significant: p=0.22 (HAMD-17: p=0.36). At endpoint, the CBT versus GSG difference in mean change from baseline IDSc scores was 7.69 points (HAMD-17: 4.97 points), the sertraline versus placebo difference was 3.07 points (HAMD-17: 0.59 points).

The data provide a preliminary suggestion that the mix of patients with minor or mild major depression with atypical features may not be best treated with an SSRI, but that these conditions might be amenable to CBT. Although SSRI were not superior to placebo, it would be premature to rule out SSRI as efficacious in atypical depression.

Although the subgenual anterior cingulate cortex (Cg25: Brodmann area 25) is an important target area in the treatment of affective disorders, its involvement in the evaluation of emotional salience of visual stimuli during depressed episodes is not quite understood. Research regarding the neurocircuitry in mood disorders suggests an important role of this anatomical region for affective information processing.

In this study, we focused on Cg25 neuronal responses in depressed females using a paradigm in which emotions are elicited without explicit cognitive control, relying on the salient nature of the mood inducing stimuli eliciting approach-related emotions (like happiness) or withdrawal-related emotions (like disgust).

Twelve treatment-resistant melancholic depressed women and 12 age-matched healthy female control subjects were asked to passively view blocks of baby faces when undergoing functional magnetic resonance imaging (fMRI).

Compared to the healthy females, the depressed patients displayed significantly higher bilateral Cg25 neuronal activities in both emotional experiences. Whereas in melancholically depressed women, right-sided Cg25 activity was comparable for both emotional experiences, we found significantly less leftsided Cg25 neuronal activity during the withdrawal-related emotional experience.

Our results could indicate that in depressed women the left Cg25 modulates intense visceral emotional responses to aversive visual stimuli. Our observations could help to explain why in unipolar melancholic depression the left Cg25 provides a valid target region for antidepressant treatment strategies, such as deep brain stimulation and anterior cingulotomy and nervus vagus stimulation therapy, which all seem to correlate with decreases in left Cg25 activity.

Evaluate the effects of once-daily extended release quetiapine fumarate (quetiapine XR) monotherapy on sleep disturbance in patients with major depressive disorder (MDD).

Pooled data from four 6- or 8-week placebo-controlled quetiapine XR (50-300mg/day, administered in the evening) monotherapy studies (D1448C00001, D1448C00002, D1448C00003, D1448C00004) were analysed. Primary endpoint: change from randomisation in Montgomery-Åsberg Depression Rating Scale (MADRS) scores. Post-hoc analyses assessed changes in: MADRS item 4 (reduced sleep); Hamilton Rating Scale for Depression (HAM-D) items 4 (insomnia-early), 5 (insomnia-middle) and 6 (insomnia-late) and sleep disturbance factor (items 4+5+6); Pittsburgh Sleep Quality Index (PSQI) total and item scores. MADRS total score change was analysed for patients experiencing high (baseline HAM-D sleep disturbance factor score >=4) and low (baseline HAM-D sleep disturbance factor score < 4) sleep disturbance.

In total, 2,116 patients were randomised. At last assessment, quetiapine XR (all doses combined) significantly (p< 0.001) reduced MADRS item 4, HAM-D sleep disturbance factor and items 4, 5 and 6 and PSQI total scores from baseline versus placebo. Quetiapine XR significantly (p< 0.001) improved MADRS total score from baseline versus placebo at all time points in patients experiencing high sleep disturbance (n=865, quetiapine XR; n=514, placebo). Quetiapine XR improved MADRS total score versus placebo in patients with low sleep disturbance (n=252, quetiapine; n=121, placebo): difference significant at Weeks 2(p< 0.001), 4(p< 0.05) and 6(p< 0.05).

Quetiapine XR monotherapy improved symptoms of sleep disturbance in MDD and was effective against depressive symptoms in patients experiencing high and low sleep disturbance levels. AstraZeneca funded.

Changes in mature brain-derived neurotrophic factor (mBDNF) have been associated with the pathogenesis of depression. The present study employed isolation-rearing from weaning in normal Sprague Dawley (SD) and genetically depressed Flinders Sensitive Line (FSL), as a model of gene-environment interaction, to study mBDNF alterations in the plasma, hippocampus and frontal cortex (FC).

21-28 days old male SD (n=8) and FSL (n=10) rats were housed in groups or in isolation for 39 days and sacrificed on the last day of housing. The hippocampus and FC were immediately dissected and the trunk blood collected for plasma separation. Pro-BDNF (36 kDa) and mBDNF (14 kDa) were detected in plasma using ELISA and in the hippocampus and FC using Western Blot. The mBDNF data were normalized to those of pro-BDNF to have an accurate index of changes in mBDNF production.

I. Under basal conditions group-housed depressed FSL rats showed significantly (p< 0.05) higher mBDNF in plasma and lower in the hippocampus compared to normal SD rats. No differences were detected in the FC. II. Isolation-rearing in depressed FSL induced a decrease in mBDNF in plasma (p< 0.05) and an increase in the hippocampus (p< 0.01) compared to group-housed FSL, the FC was not affected. In contrast, isolation-rearing did not affect mBDNF in normal SD rats.

Isolation rearing differentially affected plasma and brain mBDNF only in depressed FSL rats, supporting the idea that gene-environment interaction is an important factor in determining specific changes in molecular correlates of depression.

Although the therapeutic efficacy of newer antidepressants has been demonstrated in various studies there is only little research available about patients fitness to drive under newer antidepressants.

A sample of 60 depressive inpatients diagnosed according to DSM-IV criteria were randomly assigned to treatment with either mirtazapine (n=20), escitalopram (n=20) or reboxetine (n=20). To control for retest effects 15 healthy controls were examined in the same time schedule. Participants were tested before pharmacologic treatment (t0), and on days 7 (t1) and 14 (t2) with computerized tests related to car driving skills. Data were collected with the Act and React Testsystem (ART 90) and the Wiener- Testsystem (WTS) measuring visual perception, reactivity, stress tolerance, concentration and vigilance.

Patients showed significant improvements in most functional domains related to driving ability skills after 14 days of treatment with newer antidepressants. Statistically significant differences between treatment groups could not be shown. However, controlling for retest-effects only in vigilance-measures significant group by time effects could be found indicating an improvement over practice effects.

Partly remitted depressive patients treated with mirtazapine, escitalopram or reboxetine showed a better test performance in driving related skills than untreated patients. However, as most of these laboratory driving tests have a large speed component, retest effects have to be considered when interpreting results of repeated examinations.

The purpose of this study is to identify factors associated with diagnostic stability of Bipolar Mood Disorder (BMD) with statistical and clinical interest.

Retrospective cohort study, in which the medical records of 916 individuals admitted to Coimbra University Hospital, between 1989 and 2008 with first diagnostic of BMD, were analysed for the following characteristics: age, gender, occupation, educational level, age at first diagnostic, number and types of hospital admissions, presence of suicide attempts, pharmacological treatments, time between first diagnostic and the new one (Schizophrenia, Delusional Disorder or Dementia), type of cognitive impairment, assessment examinations (TC-CE and EEG) and presence of co-morbidities.

The analysed sample was divided in two groups: one that kept the first diagnostic (BMD) and another that later received a different diagnostic.

Diagnostic criteria according to International Classification of Diseases- 10th edition.

4,7% of the total sample received a different diagnostic in a posterior assessment: 41,9% Schizophrenia, 4,7% Delusional Disorder and 53,5% Dementia. The factors were analyzed with traditional statistical methods and Mann-Whitney's test. The authors found five main factors with statistical significance between the two groups, namely, age, age at first diagnostic, total number of admissions and number of admissions for maniac episodes, and educational level.

The aim of the study was achieved. In clinical practice the reported characteristics must receive a special attention in patient's assessment, in order to verify the diagnostic stability and eventual evolution to another diagnostic.

To assess the prevalence and correlates of childhood and adolescence sexual and/or physical abuse (SPA) in bipolar I disorder (BD) patients treated for a first episode of psychotic mania.

The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 first episode psychosis (FEP) patients between 1998 and 2000. Data were collected from patients’ files using a standardized questionnaire. 704 files were available, 43 were excluded because of a non-psychotic diagnosis at endpoint and 3 due to missing data regarding past stressful events. Among 658 patients with available data, 118 received a final diagnosis of BD and were entered in this study.

80% of patients had been exposed to stressful life events during childhood and adolescence and 24.9% to SPA: in particular, 29.8% of female patients had been exposed to sexual abuse. Patients who were exposed to SPA had poorer pre-morbid functioning, higher rates of forensic history, were less likely to live with family during treatment period and were more likely to disengage from treatment

Sexual and/or physical abuse is highly prevalent in BD patients presenting with a first episode of psychotic mania; exposed patients have lower pre-morbid functional levels and poorer engagement with treatment. The context in which such traumas occur must be explored in order to define if early intervention strategies may contribute to diminish their prevalence. Specific psychological interventions must also be developed.

To identify predictors of remission with placebo treatment in double-blind randomized controlled trials (RCTs) in major depressive disorder (MDD) based on baseline characteristics.

989 placebo-treated MDD subjects with baseline Hamilton Depression Rating Scale total score (HAMDT17) ≥15 who completed 7-8 weeks of treatment from 8 duloxetine RCTs with placebo lead-in were included. Remission was defined as HAMDT17 endpoint score ≤7. Stepwise logistic regression and classification and regression tree (CART) methods were used to identify predictors of remission. Data were randomly split into training data (N=791, 80%) for model selection and test data (N=198, 20%) for validation. Predictive quality of models was assessed by ROC curves.

In the logistic regression analysis, out of >50 potential pre-treatment predictors, the HAMDT17 score, age, Hamilton Anxiety Scale item 14 (HAMA14: behavior at interview) and length of current MDD episode (length) were found to be most predictive for remission on placebo. These variables were also identified as top predictors by the CART method that identified 2 subgroups: “HAMA14=0 OR (HAMDT17< 22 AND length< 18 weeks)” (45% remitted), “HAMA14>0 AND (HAMDT17≥22 OR length≥18 weeks)” (21% remitted). However, the predictive power was weak for both methods with areas under the ROC curve (test data) of 67% and 56%, respectively.

Baseline risk factors for non-remission after 7-8 weeks of placebo treatment were older age, more severe depressive symptoms, apparent anxiety, and a longer duration of current MDD episode. These results are consistent with previous findings and may aid in the design of RCTs.

Although numerous studies agree that bipolar patients demonstrate extensive cognitive deficits, it is still unclear to which extent these impairments persist across different mood states, including euthymia. Given that the emotional and cognitive processes are closely intertwined, we aimed to examine selective attention, cognitive inhibition, and social cognition within different emotional context in the group of remitted bipolar outpatients.

80 euthymic bipolar outpatients and 66 healthy volunteers matched for sex, age and education participated in the study. Internal State Scale and Barratt Impulsiveness Scale were used to assess self-reported affective states and trait impulsivity. Computerised versions of Colour-Word Stroop, Emotional Stroop, Affective Go/NoGo and Ekman Recognition of Facial Expression task were administered to assess selective attention, inhibition of cognitive control and social cognition.

Several cognitive deficits in selective attention, inhibition of cognitive control and social cognition tasks have been identified in the group of euthymic bipolar outpatients. They revealed worse recognition of negative, positive and neutral affect than controls. Besides cognitive disruptions which were reflected in longer reaction times and more erroneous performance to different emotional stimuli and in different emotional contexts, also trait impulsivity was considerably elevated in the group of bipolar euthymic outpatients.

Bipolar outpatients in our study demonstrated relatively marked impairments in cognitive functioning within different emotional contexts also during the euthymia. Applied neuropsychological inventory proved as useful tool for assessing specific cognitive impairments in bipolar mood disorder, and could contribute to more effective diagnosing and treatment of patients.

Lithium has been used in the successful treatment of bipolar disorders since the 1950's. Advancements in neuroscience show that it has neuroprotective properties suggesting a possible efficacy in stroke, Alzheimer's and dementia. There is also evidence showing lithium protection of neurologic injury by changing GSK-3 inhibition in animals.

The Lithium Archives Project research design is a retrospective, random paper based chart review of patients with mood disorders. The charts are examined for over 100 variables including demographic, symptom, mood, biochemical, neurologic, and medical items. The current sample of over 700 charts was analyzed by a skilled statistician using standard SPSS statistical software. Mean, standard deviation and significance of cerebrovascular disease, myocardial infarction, brain tumors, stroke, seizures, and eye diseases of patients treated with lithium and patients treated without lithium were compared and analyzed. Multivariate analysis was performed to analyze group (lithium/no lithium) and incidence of disease. The means of disease incidence in the lithium versus non-lithium groups were then charted.

The Multivariate Analysis of Variance of the current data shows that group is a significant variable in the incidence of diseases analyzed (Pillai's Trace F = 2.926, df = 11,416, p=.004). The patients treated with lithium show less incidence of cerebrovascular disease (p=.053), myocardial infarction (p=.012), seizures (p=.091), eye diseases (p=.011), stroke (p=.014) and brain tumors (p=.072).

The current analysis is very promising and indicates that in this patient population, lithium may have played a role in protection from these diseases.

Assessing impact of treatment from the patient perspective provides additional information about treatment efficacy in major depressive disorder (MDD) trials.

Pooled data from three identically designed clinical trials showed aripiprazole adjunctive to antidepressant therapy (ADT) was effective in treating MDD.1

Patients who completed an 8-week prospective ADT phase with inadequate response were randomized double-blind to 6-weeks adjunctive treatment with aripiprazole or placebo. The Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) is a 16-item, self-report measure to evaluate daily functioning, with higher scores indicating better satisfaction. Comparisons of mean change from baseline (Week 8) to Week 14 in Q-LES-Q-SF items and general subscores were performed using ANCOVA (LOCF).

There was significant improvement in the Q-LES-Q-SF Overall-General subscore (total of items 1-14 expressed as a percentage of the maximum possible score) in the aripiprazole-treatment group (9.49% [n=507]) vs placebo (5.71% [n=492] p< 0.001). Placebo was significantly higher than aripiprazole in Physical Ability (placebo 0.13 vs aripiprazole 0.02, p=0.020). Aripiprazole was significantly higher than placebo in all other items except Physical Health and Vision. Aripiprazole also produced significant increases in both the Satisfaction with Medication (Item 15) (aripiprazole 0.36 vs placebo 0.20, p< 0.01) and Overall Satisfaction (Item 16) (aripiprazole 0.61 vs placebo 0.35, p< 0.001) scores.

Results emphasize that assessment of patient functioning and quality of life may have utility both in clinical trials and clinical practice.2

Age-of-onset (AO) seems to be a phenotypic variable with a strong genetic component and therefore useful in molecular analysis of bipolar disorder (BP). A debate about the cut-off point for defining early AO has developed over the last few years. Using an Expectation-Maximization algorithm Bellivier et al. (2001) found the best fit for a model with three onset-groups, proposing the age 20-21 as cut-off for early onset, while using the same algorithm Kennedy et al. (2005) found the best fit for a two onset-group model with age 40 as cut-off with an incidence peak for mania in the age-band 21-25. Based on segregation analysis, we proposed a two AO-group model with cut-off age 25 for early onset (Grigoroiu-Serbanescu et al. 2001). The present study aimed at investigating the best AO-model in 500 Romanian BPI and 1458 German BPI patients using commingling analysis (SAGEv6.01-software) (Elston et al, 2009). The best model was selected according to Akaike's Information Criterion (AIC).

The two AO-group and three AO-group models provided similar AIC-values both in the Romanian and the German sample. The Romanian early-onset group (40% cases) had means around 18 years, SDs=6-7, while in the German early-onset group the mean AO was around 20 years (SDs=9-11) (50% cases). Thus the cut-off for early-onset (X +1SD) was different.

Our results overlapped with the findings of Kennedy et al (2005) showing that two-curve and three-curve AO mixtures similarly fit the AO-distribution in BPI disorder and the cut-offs for early-onset differ by sample.

Neurocognitive impairments in depression have traditionally been regarded as epiphenomena of the illness. Increasing evidence for the stability of neurocognitive deficits outside of depressive episodes implicates their potential role as mechanisms for emotion dysregulation associated with depressive states. This study thus examined associations between neurocognition and emotion regulation in currently depressed patients.

Participants were thirty patients presenting with current DSM-IV major depression. Participants completed neurocognitive tasks assessing executive function, attention, working memory, and response control to emotional stimuli. The capacity to implement functional emotion regulation strategies was assessed using additive sub-scales from the ‘Cognitive Emotion Regulation Questionnaire’ (CERQ), while emotion regulation difficulties were assessed using the ‘Difficulties in Emotion Regulation Scale’ (DERS).

Neurocognitive performance was compared between sub-groups of patients identified via median split on combined CERQ and DERS items. Patients reporting greater difficulties in emotion regulation demonstrated impaired sustained attention and response control, and increased reaction time to negative stimuli, in comparison to those reporting fewer difficulties. In addition, patients with better access to functional strategies demonstrated better attentional performance and fewer errors of omission to positive stimuli on the response control task.

Neuropsychological impairments in attention and response inhibition may contribute to emotion dysregulation in depressive episodes. By implication, remediation of particular neurocognitive deficits may improve the capacity to implement context-appropriate emotion regulation strategies in affective disorders. Examination of associations between neurocognitive impairment and emotion dysregulation outside of acute illness episodes is necessary to determine the relevance of these associations for illness development.

Despite lithium has been used for the last 50 years as a maintenance treatment for bipolar disorder during pregnancy, there is limited information about perinatal clinical outcomes from fetal exposure to lithium.

1. 1. To quantify the rate of lithium placental passage

2. 2. To assess any association between plasma concentration of lithium at delivery and perinatal outcome.

Observational and prospective study. Subjects: Women in maintenance treatment with lithium, being attended during pregnancy at the Perinatal Psychiatry Programme of Hospital Clínic (Barcelona, Spain) between 2007 and 2009. Procedure: We assessed sociodemographical data; dose/day of lithium carbonate; other drugs doses; plasmatic concentration of lithium carbonate in maternal blood intrapartum and in the umbilical cord; obstetrical maternal complications; gestational age at delivery; weight at delivery; Apgar scores; congenital malformations; hospital stays, infant serum concetrations of thyroid-stimulating hormone.

Eight mother-child diads. Mean age of the mother (SD): 32.1 (4,7); 100% caucasian and married. Mean dose of maternal lithium (SD): 675mg (237,5mg). Premature rupture of membranes (%):25. Gestational mean age (in weeks) (SD): 39,9 (1). Birth weight (SD) : 3625gr (451,2gr); Mean Apgar1min (SD): 8,38 (1,1); Mean Apgar5min (SD): 9,75 (0,4). Loss of fetal intrapartum wellness (%): 12,5. Days of hospitalization (mean) (SD):9,5(16,6). Lithium plasmatic concentration (mEq/L), mean (SD): maternal 0,45(0,1), umbilical cord 0,33(0,1), lithium ratio uc/m 0,93 (0,3); infant TSH μU/mL mean (SD): 4,9(4,6).

Lithium placental passsage was 0,93 (0,63-1,07). ≤At umbilical cord lithium levels ≤ 0.60 mEq/L, we didn't have any preterm deliveries, low birth weight newborns, nor neonatal complications.

There is a substantial body of evidence that cognitive deficits in schizophrenia and bipolar disorder persist after the subsidence of active symptoms. The aim of the study was to assess and compare the cognitive functioning of patients with clinically stable schizophrenia and bipolar disorder.

Attention, memory, verbal learning ability, visuospatial ability, executive functions and social cognition were assessed in 21 patients with schizophrenia in remission, 23 euthymic bipolar-I patients, and 27 normal controls, using WAIS - Vocabulary, Block design, and Digit span, Stroop Test, Babcock Story Recall Test, Rey Auditory Verbal Learning Test (RAVLT), Trail Making Test (Trails A and B), Wisconsin Card Sorting Test (WCST), and Faux Pas Recognition Test. The three groups were matched for gender, age and education. One-way ANOVA with post hoc Bonferroni corrections was used for the between groups comparisons.

Both bipolar disorder and schizophrenia patients were significantly impaired on tests of working memory, learning abilities, and executive functions compared to control subjects. Patients with schizophrenia performed significantly worse than patients with bipolar disorder on attention and verbal memory tasks, whereas the latter performed worse than normal controls on visuospatial ability tasks.

Table 1

Comparison of neuropsychological function

Our results indicate that stable schizophrenia and euthymic bipolar disorder exhibit different but overlapping profiles of cognitive impairment.

Cognitive function seems to be impaired during both the acute and euthymic phases of bipolar disorder. The aim of the study was to determine the effect of remission on cognitive functioning in bipolar disorder.

Attention, memory, verbal learning ability, visuospatial ability, executive functions and social cognition were assessed in 19 patients with bipolar-I patients during an episode of the illness and in remission as well as in 16 normal controls, using WAIS - Vocabulary, Block design, and Digit span, Stroop Test, Babcock Story Recall Test, Rey Auditory Verbal Learning Test (RAVLT), Trail Making Test (Trails A and B), Wisconsin Card Sorting Test (WCST), and Faux Pas Recognition Test. The two groups were matched for gender, age and education. Paired t-test was used to compare patients’ neuropsycholigical performance in episode and euthimic states and one-way ANOVA with post hoc Bonferroni corrections for the between groups comparisons.

Patients showed cognitive dysfunction in verbal learning, visospatial ability, executive functions and social cognition during both the acute and the euthymic phases in relation to the comparison group. Poorer performance in attention and working memory tasks was observed only in the acute phase of the illness. Performance in verbal learning and executive function tasks was significantly improved but still impaired in remission.

Patients with bipolar disorder exhibit similar profiles of cognitive impairment during the acute and the euthymic phases of the illness.

To determine if utilization and expenditures differ between ADHD medication classes.

Prescription and medical claims for Texas Medicaid patients with an ADHD diagnosis newly initiated on an ADHD medication (no previous use for 180 days) between January 2006 and September 2007 were analyzed. Logistic and linear regression analyses were used to evaluate differences in adherence, persistence, switching, and expenditures during a 180-day post-initiation observation period across ADHD treatment classes [immediate-release methylphenidate (IR-M) and amphetamines (IR-A) and extended-release methylphenidate (ER-M) and amphetamines (ER-A)] with relevant demographic and pre-initiation period comorbidities, utilization, and expenditure variables as covariates. Because prior authorization was required, the non-stimulant medication atomoxetine was excluded.

The sample consisted of 15,055 subjects with 71% aged 6 to 12 years; 64.7% were initiated on ER-M and 25.4% on ER-A. Compared to the ER-A group, the IR-M (OR=0.56, 95%CI=0.45-0.69) and IRA (OR=0.60, 95%CI=0.46-0.78) groups were less likely to be adherent, more likely to discontinue therapy (OR=2.03, 95%CI=1.67-2.47; and OR=1.77, 95%CI=1.38-2.27; respectively) and more likely to switch medications (OR=2.44, 95%CI=2.05-2.90; and OR=2.85, 95%CI=2.28-3.56; respectively) (all p< 0.001). The ER-A group had significantly higher ADHD medication expenditures compared to other groups (all p≤0.001), but no significant differences in medical expenditures.

Utilization patterns differed across the ADHD medication classes. Most subjects were initiated on ER medications which demonstrated advantages in adherence, persistence, and less switching while the ER-A group, which included more complex patients as indicated by comorbidities, had higher ADHD medication expenditures but no difference in overall medical expenditures.

To determine if utilization and expenditures differ between a newly-marketed (at time of study) ADHD medication (lisdexamfetamine dimesylate [LDX]) and existing medications.

Prescription and medical claims for Texas Medicaid patients diagnosed with ADHD newly initiated on an ADHD medication (no previous use for 180 days) during August and September 2007 were analyzed. Logistic and linear regressions were used to evaluate differences in adherence, persistence, switching, and expenditures during a 180-day post-initiation period between the LDX group and existing medications (immediate-release methylphenidate [IR-M] and amphetamines [IR-A] and extended-release methylphenidate [ER-M] and amphetamines [ER-A, excluding LDX]) with relevant demographic and preinitiation period comorbidities, utilization, and expenditure variables as covariates. Because prior authorization was required, the non-stimulant atomoxetine was excluded.

The sample consisted of 1810 subjects with 69% aged 6 to 12 years; 58.0% were initiated on ER-M and 14.4% on LDX. Psychiatrists prescribed 60.5% of LDX prescriptions. A greater proportion of LDX patients had psychiatric-related comorbidities compared to the other medication groups. Logistic regression showed that compared to the LDX group, the IR-M group was more likely to discontinue therapy (OR=1.95, 95%CI=1.05-3.60, P=0.034), and the IR-A group was more likely to switch therapy (OR=2.39, 95%CI=1.22-4.69, P=0.012). ADHD medication expenditures were significantly lower for the LDX group than the ER groups (all P≤0.003). ADHD-related and total medical expenditures did not differ significantly.

Although used in more complex patients, LDX demonstrated advantages over IR-M on persistence, IR-A on therapy switching, and the ER groups on medication expenditures.