For most folks the words psychotic and or schizophrenic bring to mind the idea of a floridly disruptive, agitated, and disorganized individual who is experiencing persistent auditory hallucinations, bizarre thinking,  delusional belief system(s), and a break down in their capacity to interact appropriately with others—all core features of a schizophrenic illness.  The more typical course of an evolving schizophrenic disorder, however, is more subtle with gradual onset of the prodromal symptoms of social withdrawal, subtle cognitive declines (decreased concentration, disorganized thinking), and social and functional impairments including irritability, suspiciousness, a decline in functioning.

With recognition of these early signs and symptoms, a primary care provider can contribute to the more formal multidisciplinary diagnostic phase of intervention in three important ways, by.

• Considering the differential diagnoses that may be underlying the youth’s clinical presentation: Is this schizophrenia, or is it a substance-induced psychosis, a psychosis associated with severe depression or mania, an atypical presentation of another psychiatric condition (such as severe PTSD), or a symptom of an identifiable organic (metabolic or neurologic) disorder?
• Conducting a comprehensive physical exam and obtaining relevant laboratory studies, to include CBC, CMP, TSH, electrolytes, ceruloplasmin, ANA, ESR, VDRL, HIV, B12, folate, U/A and urine toxicology—these to rule out organic etiologies and to establish baseline levels to allow for prompt medication treatment when indicated.
• Encouraging the patient and family to seek evaluation and services from child/adolescent psychiatrist or a multidisciplinary behavioral program.

Interviewing the Patient:  Interviewing an individual with suspected psychotic features can at times be challenging, but when feasible, doing so can aid in clarifying a diagnosis and is important in ruling out acute risk considerations and interventions.  Minimally, it is important to explore whether the individual is a potential danger to themselves or others and inquiry as to whether they are having thoughts of hurting themselves or others and/or if they are hearing auditory hallucinations of a derogatory nature or which entail commands to act in a dangerous manner.  Likewise, a history of significant impulsivity or agitation should be noted.  If present, further risk assessment is warranted and may entail referral to an urgent care or other emergency service.

As with any patient experiencing distress or dysfunction, an empathic approach that acknowledges the youth’s distress and communicates your interest in learning more about their condition is most helpful.   Learning about the time of onset of symptoms, their impact, and how the patient is coping are good initial steps. Inquiry as to issues of trauma, abuse, bullying and substance abuse should be made. Exploring for and learning about the presence or absence of overt symptoms of psychosis, such as hallucinations and delusional thinking, can feel awkward but prefacing the content inquiry with a statement to the effect that “Sometimes when people are having difficulties, they may hear or see things differently than usual.  So, I am wondering if you have experienced times when you hear voices or find yourself thinking about things in an unusual way?”

Involving the Family:   Engaging the family is also critical as they can provide important information as to the youth’s developmental history and baseline profile prior to symptom onset; the timeline of symptom progression and impact on functioning; the family history of mental health and substance use problems; and, the presence or absence of major life stressors.

Referral Options:

• If, as discussed above, high risk features are clearly present a referral to a psychiatric emergency setting will be appropriate. If these concerns are less overt, a referral to the Rady’s Behavioral Urgent Care clinic might be considered—a call to the program to discuss the referral concerns would be advisable.  (858) 966-5484
• If there are no imminent risk issues, referral to a child psychiatrist, another qualified behavioral health specialist who works collaboratively with a psychiatrist, or a multidisciplinary clinic program would be appropriate
• SmartCare can be a resource to assist parents in making the recommended connection to care.                                                                     The SmartCare Family Support line is (858) 956-5900.
• Long term treatment resources
  1. Kickstart
• Who they work with: insured and uninsured adolescents and young adults ages 10 to 25
• What they do: 12 to 18 months of interdisciplinary treatment involving multiple therapy modalities, including psychotherapy, group therapy, occupational therapy, education and employment support, peer support, and much more
• When to refer: if there is possible risk of first episode psychosis or psychotic-like symptoms present in your patient, you can refer them to Kickstart for an initial consultation and evaluation. They will determine if your patient is eligible for their services, as well as conduct assessments for psychosis risk. Their focus is on early intervention and prevention of psychosis, so early referral to this program is paramount for a patient to utilize their resources
• How to refer: there is a referral form on the Kickstart website that can be completed by the clinician, patient, and parent, and submitted to Kickstart in-person or via mail or fax. Phone (619) 481-3790    858 966-5484
•     2. CARE Program
• Who they work with: insured adolescents and young adults experiencing psychotic-like symptoms or first episode psychosis
• What they do: clinical services include collaborative care with patients and their families to create a unique treatment plan that best addresses patient needs. This could include medication management, psychotherapy, group therapy, intensive outpatient care, peer support, and inpatient care. Patients ages 12 to 35 can also enroll in research studies conducted at CARE.
• When to refer: if your patient is insured and presents with first episode psychosis or psychosis-related symptoms, they can be referred to CARE for further evaluation and assessment. They will collaborate to determine the level of care necessary and create a treatment plan to address the patient’s needs.
• How to refer: contact CARE as (619) 543-7745 or email: ucsdcareprogram@gmail.com

References

CARE Program | UC San Diego Department of Psychiatry. (n.d.). UC San Diego School of Medicine. Retrieved December 5, 2021, from https://medschool.ucsd.edu:443/som/psychiatry/research/CARE/pages/default.aspx

Hua, L. L. (2021). Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics, 147(6). https://doi.org/10.1542/peds.2021-051486

Kickstart San Diego | Mental Health Prevention and Early Intervention. (n.d.). Kickstart San Diego. Retrieved December 5, 2021, from https://www.kickstartsd.org

*****

Thanks to Sheridan Chappelle of the UC San Diego School of Medicine, Class of 2024 under the guidance and supervision of Desiree Shapiro, M.D., Associate Clinical Professor of Psychiatry University of California, San Diego Department of Psychiatry – Division of Child and Adolescent Psychiatry, Medical Director, UC San Diego Child and Adolescent Psychiatry Inclusive Excellence Program

What is Psychosis?
Psychosis is characterized by impairments in thought, behavior and emotion so severe that the ability to discern reality from non-reality is lost, for a significant a period of time that can range from days to a full lifetime.

The onset of many psychotic disorders peaks between ages 15 to 25, making the pediatric interface with these patients an opportunity to promote early recognition and intervention. Each year, nearly 100,000 adolescents and young adults in the US experience a first-episode psychosis (FEP). The good news is that early interventions to support these individuals are believed to reduce the likelihood of progression to long term illness by roughly 50%.

The underlying etiology and diagnostic profiles of individuals experiencing psychosis can vary considerably as the range of underlying disorders impacting people under the age of 25 or so year is broad and can include schizophrenia, major depressive disorder, delusional disorders, bipolar disorder, PTSD, substance use disorders, neurological and other medical conditions. Co-morbidities amongst these disorders is also not uncommon, potentially complicating diagnostic and treatment efforts, though regardless of the causation, early intervention is critical in reducing both acute and long-term morbidity.

Treatment with psychopharmacologic agents with concurrent attention to physical health and with psychosocial and behavioral health supports of many kinds is the ideal response and these interventions can foster optimal prognostic evolution. Patient safety and long-term functionality during a patient’s lifespan are typical aspirations defining their care and early recognition and intervention are hallmarks of quality care.

Schizophrenia:
The typical profile for a patient who progresses to have schizophrenia, perhaps the most devastating of psychotic illnesses, experiences a prodrome during which an individual may experience changes in thoughts, perceptions, feelings and behaviors but are without symptoms of hallucinations, delusions or overtly disorganized thinking. This in mind, all individuals with evidence of new onset or evolving functional challenges should be assessed for underlying concerns, regardless as to whether they appear to be psychotic.

Pediatricians or family practice practitioners are almost universally an early point of contact for many adolescents and young adults, so that familiarity and comfort in evaluating for, identifying, assessing and ultimately referring patients to mental health specialists for more detailed evaluation and care is a public health function that they can readily provide in their routine practice.

Symptoms and Symptom Presentation

• Prodromal Symptomatology:
  ··reduced concentration and attention, disorganized thoughts
  ··reduced motivation, changes in energy level, less interest in usual activities
  ··social withdrawal
  ··sleep disturbance
  ··suspiciousness
  ··irritability, anxiety, depressed mood
  ··no longer going to school or work, or performance deteriorating
  ··intense focus on particular ideas, which may seem odd or disturbing to others.
• Acute Phase Symptomatology:
  ··Delusions: false, fixed beliefs that do not change even if evidence shows the contrary of the belief to be true
  ··Hallucinations: experiences involving perceptions of something in the absence of any external stimulus (auditory hallucinations are most common, although visual, gustatory tactile and olfactory hallucinations can also occur)
  ··Disorganized thinking (speech): jumping from topic to topic, inability to answer questions or answering them in a tangential manner, word salad
  ··Disorganized behavior: abnormal motor behaviors that result in a difficulty performing goal-directed behavior. The most dramatic of the behavioral profiles that can emerge is catatonia which is manifest an overall decreased reactivity to the environment, resulting in an absence of motion, mutism and stupor. It may also include repeated stereotyped movements or echolalia.
  ··Negative symptoms: absence of typical behaviors, including diminished emotional expression, a lack of motivation, poverty of speech, anhedonia and asociality.
• Chronic Symptomatology: Negative Symptoms
  If not self-remitting, the long term course of patients with a schizophrenic illness is typically manifest by a significant degree of dysfunction and disability as manifest by a persistence and further development of the negative symptoms as identified above. These symptoms and the dysfunction they often cause can be devastating for the individual and the family.
• Confounding Considerations in Assessing Children:
  Although many children who report psychotic-like symptoms do not go on to develop psychosis in adulthood, these symptoms have been shown to be associated with the presence or the later development of other psychiatric disorders in adulthood. Therefore, it is important to recognize when a child or adolescent describes psychotic-like symptoms that may be distressing to them. Timing is also an important consideration. Hallucinations, for example, are common in children and often do not signify any sort of pathology; however, if hallucinations persist into adolescence, the risk of developing psychosis is 5-6x greater.

Here are some ways that psychotic like symptoms could present in a pediatric visit:
• Feeling “off” or a vague feeling that something is wrong
• A recent drop in grades/work performance
• Increased isolation
• Decreased hygiene or self-care
• Difficulty communicating or confused speech
• New-onset difficulty concentrating
• Trouble separating fantasy from reality
• Cognitive delays not previously in evidence

Future articles in this series will address the elements and processes of assessment appropriate for the pediatric setting and information about referral and intervention services available within San Diego County.

*****

Thanks to Sheridan Chappelle of the UC San Diego School of Medicine, Class of 2024 under the guidance and supervision of Desiree Shapiro, M.D., Associate Clinical Professor of Psychiatry University of California, San Diego Department of Psychiatry – Division of Child and Adolescent Psychiatry, Medical Director, UC San Diego Child and Adolescent Psychiatry Inclusive Excellence Program

When compared to non-stimulant FDA approved medications (atomoxetine, alpha agonists) stimulants, such as methylphenidate and amphetamine have a larger effect size (1.0 vs. ~0.7). As a result, these medications are often first line treatment for ADHD.  When prescribed and monitored appropriately, stimulant medications rarely induce major psychiatric side effects such as psychosis and/or exacerbate other disorders, but for some vulnerable youth, particularly adolescents, and in circumstances where the medications are misused (including in combination with illicit substances such as other stimulants or high potency marijuana, amongst others) serious problems can arise.

Whether the ongoing stressors associated with the Covid pandemic, including familial loss, financial strain and other issues, either on their own or in combination with co-occurring substance use  (legal as with ADHD stimulant agents or with illicit drugs) will lead to increased incidence of psychotic and/or other major potentially persisting psychiatric disorders remains to be evaluated.  Clearly as the pandemic has gone on there have been increased symptoms of anxiety and depression in children and adolescents generally (Zeytinoglu et al., 2021; Twenge, 2021) and those challenged with attentional difficulties have been additionally stressed by the challenges of remote learning and the distanced interpersonal environment.

While for some, efforts to enhance the capacities of youth who have challenges with focusing and attentiveness with prescriptions for stimulant or other ADHD medications, ongoing careful oversight, reassessment and monitoring for risk behaviors are recommended approaches.  What impact the pandemic has had and will have on the emergence of psychotic and/or major affective symptoms and pathologies in youth remains to be studied and better understood.  Historically, stressful life changes can exacerbate psychosis and other emotional disorders in vulnerable and at-risk populations, and we likely have seen and will continue to see instances of this among our youth in 2021 and beyond.

In summary, stimulant misuse and abuse is a common cause of psychotic symptoms (Henning et al., 2019) and it is important to consider that stimulant overuse, including higher therapeutic doses of FDA approved stimulants, can also cause these symptoms, as Henning, Kurtom and Espiridion’s referenced case below.  This also reminds us to screen for family history of psychotic and other mental illness in all of our ADHD patients.  Caution with the use of stimulants with youth at risk of experiencing psychotic symptoms is strongly recommended, and psychiatric consultation would be recommended for situations of concern.

References:

Henning, A., Kurtom, M., & Espiridion, E. D. (2019). A Case Study of Acute Stimulant-induced Psychosis. Cureus, 11(2), e4126. https://doi.org/10.7759/cureus.4126

Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. Pediatrics. 2020 Mar;145(3):e20193997. doi: 10.1542/peds.2019-3997. Erratum for: Pediatrics. 2019 Oct;144(4): PMID: 32111626.

Zeytinoglu, S., Morales, S., Lorenzo, N. E., Chronis-Tuscano, A., Degnan, K. A., Almas, A. N., Henderson, H., Pine, D. S., Fox, N. A. (2021) A Developmental Pathway from Early Behavioral Inhibition to Young Adults’ Anxiety During the COVID-19 Pandemic. Journal of the American Academy of Child and Adolescent Psychiatry. doi: 10.1016/j.jaac.2021.01.021

Twenge, J; The mental health of youth and their parents during the pandemic; presentation at 6^th Annual CICAMH conference, 3/19/21; San Diego

Postpartum Blues: Symptoms of mood lability, irritable mood, interpersonal hypersensitivity and tearfulness are common in the postpartum period and are commonly known as the postpartum “blues”. The incidence is up to 75% and the symptoms typically arise and resolve within 7-14 days after the delivery.

The following conditions are of more concern: depression during pregnancy (known as antepartum depression), postpartum depression (PPD) and postpartum psychosis.

Antepartum depression: The prevalence of depression during pregnancy ranges from 10-15% and it may persist into the first postpartum year. Depression during pregnancy is linked to birth complications like pre-eclampsia, low birth weight, premature delivery, and small for gestational age infants.

Postpartum depression: The prevalence of PPD is 10-15%. The postpartum year is one of the highest risk periods for first-onset depression for women with approximately 50% of women experiencing their first episode of depression during that time. In addition 25% of women with a history of Major Depressive Disorder will experience PPD and 50% of women who have had PPD will have a recurrence. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. In addition to depressive symptoms, women with PPD typically also present with prominent anxiety symptoms that involve distressing and intrusive thoughts about infant safety and feelings of guilt and inadequacy about mothering. Infants of depressed mothers have been found to be less responsive and more irritable than infants of non-depressed mothers. Infants of depressed mothers are also more likely to develop an insecure attachment because of (unintentional) maternal rejection of the baby. If one suspects PPD it is important to rule out medical conditions, like thyroid dysfunction and iron-deficiency anemia, as these are more common during pregnancy and in the postpartum period.

Postpartum psychosis: Postpartum psychosis is rare and occurs in 1-2 women per 1000. The onset is typically within 2 weeks of delivery. The psychotic symptoms typically accompany affective symptoms of depression and anxiety, rather than represent a psychotic first break. Postpartum psychosis is more common in women who have a history of bipolar disorder. In addition to auditory and visual hallucinations, patients may present with cognitive impairment, confusion, and olfactory and tactile hallucinations. Many mothers are distressed because they experience command hallucinations to harm their infants. If postpartum psychosis is suspected, it is important to seek immediate psychiatric attention and to consider psychiatric hospitalization for the mother for her safety and for the infant’s safety. Antipsychotic medications are helpful for treating postpartum psychosis but it is more appropriate for the treatment to take place in a psychiatric hospital.

Treatment considerations for depression related to pregnancy will be discussed in the next e-Weekly.

Attached are a JAMA article about the timing of symptoms and the  Edinburgh Postnatal Depression Scale (EPDS) screening tool.

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1666651

https://pc2education.files.wordpress.com/2012/05/edinburghscale.pdf

There has been a clear and steady increase in the number of adults reporting use of cannabis since 2000. Interestingly and fortunately, there is not an increase in the number of teens using cannabis, nor are there findings of teens starting to use at younger ages, but teens who are using are using more frequently than in the past and the potency of current supplies are greater than in the past, raising significant risk concerns.

Following are suggested harm reduction recommendations that seem appropriate to use with patients of any age to minimize potential negative consequences of cannabis use.

1. Using it less frequently and avoiding daily use
2. Delaying starting it until adulthood
3. Using safer sources and routes
4. Avoiding driving or being driven by someone under the influence

Although research findings are still somewhat limited, several studies have looked into the negative effects of cannabis use in adolescence which include: increased risk of psychosis, increased risk of substance dependence, and reduction of cognitive skills. Regular cannabis use can increase the risk of subclinical psychotic symptoms, and these symptoms can persist even after a long period of abstinence. Additionally, for patients with schizophrenia, using cannabis can move up the onset of schizophrenia up to 3 years earlier than for patients who do not use cannabis. Regular and heavy cannabis use in adolescence can lead to a permanent loss of IQ points, something that is not seen with cannabis use that starts in adulthood. Regular cannabis use in teens has been shown to impair learning, problem-solving skills and short-term and long-term memory. Studies also suggest downward socioeconomic mobility in people who started to use cannabis at a young age. The take home message is that if a teenager is using or at risk of using cannabis, they should be encouraged ideally to wait until adulthood or, absent abstinence, to avoid using it routinely because of these risks.

It is important for all patients, regardless of their age, to be aware of the sources of cannabis they are using and the route they are ingesting it by. It is particularly important for them to avoid products that are very high in THC (trans-Δ9-tetrahydrocannabino) and to avoid concentrates, which can be made in unsafe environments, and especially synthetic cannabinoids, which can be very potent and can have significant negative psychological impacts. Edibles and vaporized cannabis can be safer routes, because they do not irritate the respiratory system, but again, psychological impacts remain an obvious concern as dosing may be higher than anticipated, especially for new users.

It is recommended that providers discuss these issues in a fact oriented and non-judgmental manner just as one might inquire about alcohol or other substance use/abuse.  In the face of the changes in social attitudes and the change toward the legality of using cannabis for those over the age of 21, establishing and maintaining an active dialogue with all patients about substance use issues is recommended as part of routine care.

Patients acknowledging problems with dependence or misuse of cannabis should be referred for treatment to a mental health provider or a cannabis specific treatment program.

The San Diego Access and Crisis Line can offer options for your patients seeking treatment.  1-888-724-7240

References:

http://www.psychcongress.com/article/managing-cannabis-use-and-its-potential-risks

Postpartum Blues: Symptoms of mood lability, irritability, interpersonal hypersensitivity and tearfulness are common in the postpartum period and are commonly known as the postpartum “blues”. The incidence is up to 75% and the symptoms typically arise and resolve within 7-14 days after the delivery.  The following conditions are of more concern:

Antepartum depression: The prevalence of depression during pregnancy ranges from 10-15% and it may persist into the first postpartum year. Depression during pregnancy is linked to birth complications like pre-eclampsia, low birth weight, premature delivery, and small for gestational age infants.

Postpartum depression: The prevalence of PPD is 10-15%. The postpartum year is one of the highest risk periods for first-onset depression for women with approximately 50% of women experiencing their first episode of depression during that time. In addition 25% of women with a history of Major Depressive Disorder will experience PPD and 50% of women who have had PPD will have a recurrence. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. Women with PPD will typically present with prominent anxiety symptoms that involve distressing and intrusive thoughts about infant safety and feelings of guilt and inadequacy about mothering. Infants of depressed mothers have been found to be less responsive and more irritable than infants of non-depressed mothers. Infants of depressed mothers are also more likely to develop an insecure attachment because of (unintentional) maternal rejection of the baby. If one suspects PPD it is important to rule out medical conditions, like thyroid dysfunction and iron-deficiency anemia.

Postpartum psychosis: Postpartum psychosis is rare and occurs in 1-2 women per 1000. The onset is typically within 2 weeks of delivery. The psychotic symptoms typically accompany affective symptoms of depression and anxiety, rather than represent a psychotic first break. Postpartum psychosis is more common in women who have a history of bipolar disorder. In addition to auditory and visual hallucinations, patients may present with cognitive impairment, confusion, and olfactory and tactile hallucinations. Many mothers are distressed because they experience command hallucinations to harm their infants. If postpartum psychosis is suspected, it is important to seek immediate psychiatric attention and to consider psychiatric hospitalization. Antipsychotic medications are helpful, but it is more appropriate for the treatment to take place in a psychiatric hospital for the safety of mother and baby.

Treatment: Medication can be an important treatment for antepartum depression, if it is moderate-severe and/or not responding to non-medication approaches, like support groups and light therapy. SSRIs are the first line agents, in particular sertraline because of its relatively short half-life and availability of low doses (can be dosed as low as 12.5 mg per day). Paroxetine is pregnancy category D. There is evidence that it increases the risk of birth defects. There is also a possible connection between SSRI use in the 3rd trimester of pregnancy and development of persistent pulmonary hypertension of the newborn. While there are some reports of the risk of limb malformations with the tricyclic antidepressants, like amitriptyline and nortriptyline, these have not been confirmed. There have been reports of newborns experiencing temporary discontinuation symptoms at birth, including jitteriness and irritability when a woman is treated with antidepressants during pregnancy.

Currently, there are no FDA approved medications for PPD, mostly because it is difficult to conduct research. Of the SSRIs, sertraline and paroxetine are the least detectable in breast milk. Several case reports note an association between fluoxetine and citalopram use in lactating women and infant irritability, poor sleep, poor feeding, crying, and restlessness. This might be related to their relatively longer half-life. Other case reports have not noted any adverse effects in infants of mothers taking fluoxetine and citalopram.  If one is considering treating PPD with a medication, sertraline is a good first line agent because of its relatively short half-life and ability to dose in smaller doses, as low as 12.5 mg per day. If a woman is already on an antidepressant like fluoxetine with a good response, it is okay to continue with the medication and monitor closely for side effects in the mother and infant.

The important take home point for treating depression related to pregnancy is to first consider a non-medication treatment if that is a viable option. If it is determined medication is needed, it is important to have a careful discussion about the risks and benefits and to try to use the smallest possible dose for the shortest length of time.