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The missing psychotic disorders
JOURNAL OF ADOLESCENT HEALTH 2004;35:432– 433
LETTER TO THE EDITOR
The Missing Psychotic Disorders
To the Editor: We read with great interest the recent article by Les B. Whitbeck and colleagues [1], which is a worthwhile article regarding the efforts of the authors to assess mental disorders and comorbidity in a community sample of homeless adolescents. However, theoretical and methodological concerns render the interpretation of their findings incomplete. Our main concern involves the absence of psychotic disorders among the mental disorders that are assessed and discussed. In effect, as numerous previous studies have shown, psychotic disorders are much more prevalent among homeless persons than in the general population. The rate of schizophrenia in homeless persons reported in 33 published reports ranges from 2% to 45% [2]. Although less common than in the adult population, psychotic disorders frequently begin in adolescence. Moreover, the adolescents in the present study are relatively “old,” which therefore raises the likelihood of observing psychotic disorders. The diagnosis of psychotic disorders in adolescents is often complex and challenging, given the symptomatic overlap between different psychotic conditions and other emotional, behavioral, and developmental disorders [3]. Comorbid conditions such as conduct disorders, substance abuse, and mood disorders may mask the presence of a psychotic disorder. The diagnosis of psychotic disorders therefore requires a careful and accurate assessment that only an experienced clinician is in a position to provide. Beyond the nonprobability sample and the self-reports’ nature of the adolescents’ diagnosis that are mentioned in the study limitations, the fact that the interviewers are nonclinicians may explain the absence of psychotic disorders’ detection, which constitutes, according to us, the most serious limitation of this study. As detection and early intervention have become a major concern in the field of severe mental disorders, especially in schizophrenia, it is surprising that this condition has not been taken into account in an important study investigating the prevalence of mental dis1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2004.09.009
orders in adolescents. This is all the more regrettable because the five mental disorders studied often constitute comorbidities with psychotic disorders. An investigation of psychotic disorders undoubtedly would have identified adolescents with psychotic disorders among the 428 adolescents assessed. On the other hand, the significant levels of mental disorders among homeless and runaway adolescents have been pointed out by the authors and remain a challenge in adolescents’ health. However, the important category of psychotic disorders is missing. This gap has to be filled in; professionals involved in adolescent health must be sensitized to psychotic disorders. Adolescence is an at-risk period for psychotic disorders [4], and early detection and intervention are widely recommended. In effect, duration of untreated psychosis may have several deleterious consequences and should be reduced as much as possible. This aim will be reached only if all professionals involved in adolescent health are aware of the psychotic risk and its expression in adolescence. Therefore, the missing psychotic disorders in an important study on adolescent mental health such as this one must be recognized and underlined in order not to be forgotten. Laurent Holzer, M.D. Francesca Schwarz, M.D. Service Universitaire de Psychiatrie de l’Enfant et de l’Adolescent (SUPEA) Centre Thérapeutique de Jour pour Adolescents Lausanne, Switzerland
References 1. Whitbeck LB, Johnson KD, Hoyt DR, Cauce AM. Mental disorder and comorbidity among runaway and homeless adolescents. J Adolesc Health 2004;35:132– 40. 2. Folsom D, Jeste DV. Schizophrenia in homeless persons: A systematic review of the literature. Acta Psychiatr Scand 2002; 105:404 –13. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
December 2004
3. Reimherr JP, McClellan JM. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry 2004;65(Suppl 6):5–11. 4. Walker E, Bollini AM. Pubertal neurodevelopment and the emergence of psychotic symptoms. Schizophr Res 2002;54:17–23.
Response To the Editor: We read with interest the letter to the editor from Drs. Holzer and Schwartz. We appreciate their concern regarding our lack of screening for psychotic disorders in our study of homeless and runaway adolescents. In a study of this size and complexity we had to make some difficult choices. Our baseline interviews with the adolescents required two contacts and we were very apprehensive about subject fatigue and compliance, especially given the informal interview settings the design required. For this reason we had to limit the length of the interviews and hence the number of diagnoses we could realistically screen. We relied on earlier research and selected the diagnoses we believed would be most prevalent. Cauce and colleagues [1] reported that about 10% of homeless adolescents of similar ages met criteria for schizophrenia. A second consideration was the number of psychotic disorders and the complexity of screening for all of them. We wish now
LETTER TO THE EDITOR
433
that we had included a screener for psychoses that, although not diagnostic, would have given an approximation of the prevalence of psychotic symptoms. We agree that psychoses are an important consideration in adolescence, particularly among this population, and concur with Holzer and Schwartz that this is a significant limitation of our study. We hope that future research with homeless adolescents will use longitudinal designs to empirically investigate their contention that many of the disorders of adolescence mask emerging psychotic disorders. Les B. Whitbeck, Ph.D. Kurt D. Johnson, Ph.D. Dan R. Hoyt, Ph.D. University of Nebraska-Lincoln Lincoln, Nebraska Ana Mari Cauce, Ph.D. University of Washington Seattle, Washington
References 1. Cauce AM, Paradise M, Ginzler JA, et al. The characteristics and mental health of homeless adolescents: age and gender differences. J Emot Behav Dis 2000;8:230 – 44.
LETTER TO THE EDITOR
The Missing Psychotic Disorders
To the Editor: We read with great interest the recent article by Les B. Whitbeck and colleagues [1], which is a worthwhile article regarding the efforts of the authors to assess mental disorders and comorbidity in a community sample of homeless adolescents. However, theoretical and methodological concerns render the interpretation of their findings incomplete. Our main concern involves the absence of psychotic disorders among the mental disorders that are assessed and discussed. In effect, as numerous previous studies have shown, psychotic disorders are much more prevalent among homeless persons than in the general population. The rate of schizophrenia in homeless persons reported in 33 published reports ranges from 2% to 45% [2]. Although less common than in the adult population, psychotic disorders frequently begin in adolescence. Moreover, the adolescents in the present study are relatively “old,” which therefore raises the likelihood of observing psychotic disorders. The diagnosis of psychotic disorders in adolescents is often complex and challenging, given the symptomatic overlap between different psychotic conditions and other emotional, behavioral, and developmental disorders [3]. Comorbid conditions such as conduct disorders, substance abuse, and mood disorders may mask the presence of a psychotic disorder. The diagnosis of psychotic disorders therefore requires a careful and accurate assessment that only an experienced clinician is in a position to provide. Beyond the nonprobability sample and the self-reports’ nature of the adolescents’ diagnosis that are mentioned in the study limitations, the fact that the interviewers are nonclinicians may explain the absence of psychotic disorders’ detection, which constitutes, according to us, the most serious limitation of this study. As detection and early intervention have become a major concern in the field of severe mental disorders, especially in schizophrenia, it is surprising that this condition has not been taken into account in an important study investigating the prevalence of mental dis1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2004.09.009
orders in adolescents. This is all the more regrettable because the five mental disorders studied often constitute comorbidities with psychotic disorders. An investigation of psychotic disorders undoubtedly would have identified adolescents with psychotic disorders among the 428 adolescents assessed. On the other hand, the significant levels of mental disorders among homeless and runaway adolescents have been pointed out by the authors and remain a challenge in adolescents’ health. However, the important category of psychotic disorders is missing. This gap has to be filled in; professionals involved in adolescent health must be sensitized to psychotic disorders. Adolescence is an at-risk period for psychotic disorders [4], and early detection and intervention are widely recommended. In effect, duration of untreated psychosis may have several deleterious consequences and should be reduced as much as possible. This aim will be reached only if all professionals involved in adolescent health are aware of the psychotic risk and its expression in adolescence. Therefore, the missing psychotic disorders in an important study on adolescent mental health such as this one must be recognized and underlined in order not to be forgotten. Laurent Holzer, M.D. Francesca Schwarz, M.D. Service Universitaire de Psychiatrie de l’Enfant et de l’Adolescent (SUPEA) Centre Thérapeutique de Jour pour Adolescents Lausanne, Switzerland
References 1. Whitbeck LB, Johnson KD, Hoyt DR, Cauce AM. Mental disorder and comorbidity among runaway and homeless adolescents. J Adolesc Health 2004;35:132– 40. 2. Folsom D, Jeste DV. Schizophrenia in homeless persons: A systematic review of the literature. Acta Psychiatr Scand 2002; 105:404 –13. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
December 2004
3. Reimherr JP, McClellan JM. Diagnostic challenges in children and adolescents with psychotic disorders. J Clin Psychiatry 2004;65(Suppl 6):5–11. 4. Walker E, Bollini AM. Pubertal neurodevelopment and the emergence of psychotic symptoms. Schizophr Res 2002;54:17–23.
Response To the Editor: We read with interest the letter to the editor from Drs. Holzer and Schwartz. We appreciate their concern regarding our lack of screening for psychotic disorders in our study of homeless and runaway adolescents. In a study of this size and complexity we had to make some difficult choices. Our baseline interviews with the adolescents required two contacts and we were very apprehensive about subject fatigue and compliance, especially given the informal interview settings the design required. For this reason we had to limit the length of the interviews and hence the number of diagnoses we could realistically screen. We relied on earlier research and selected the diagnoses we believed would be most prevalent. Cauce and colleagues [1] reported that about 10% of homeless adolescents of similar ages met criteria for schizophrenia. A second consideration was the number of psychotic disorders and the complexity of screening for all of them. We wish now
LETTER TO THE EDITOR
433
that we had included a screener for psychoses that, although not diagnostic, would have given an approximation of the prevalence of psychotic symptoms. We agree that psychoses are an important consideration in adolescence, particularly among this population, and concur with Holzer and Schwartz that this is a significant limitation of our study. We hope that future research with homeless adolescents will use longitudinal designs to empirically investigate their contention that many of the disorders of adolescence mask emerging psychotic disorders. Les B. Whitbeck, Ph.D. Kurt D. Johnson, Ph.D. Dan R. Hoyt, Ph.D. University of Nebraska-Lincoln Lincoln, Nebraska Ana Mari Cauce, Ph.D. University of Washington Seattle, Washington
References 1. Cauce AM, Paradise M, Ginzler JA, et al. The characteristics and mental health of homeless adolescents: age and gender differences. J Emot Behav Dis 2000;8:230 – 44.