Eur Child Adolesc Psychiatry (2009) 18:587595
DOI 10.1007/s00787-009-0018-7
ORIGINAL CONTRIBUTION
Medication adherence for children and adolescents
with first-episode psychosis following hospitalization
Robin E. Gearing Alice Charach
Received: 16 July 2008 / Accepted: 26 March 2009 / Published online: 21 April 2009
Springer-Verlag 2009
Abstract The objective of this study was to examine the
predictors associated with adherence to atypical antipsy-
chotic medication following discharge from hospital for
children and adolescents with first-episode psychosis. Sixty-
five children and adolescents, age 15.35 2.08 years, 59%
boys, who had participated in a longitudinal cohort study
examining relapse following first hospitalization for episode
of psychosis were included in this study. All those studied
were discharged on one of three atypical antipsychotics,
risperidone, quetiapine, or olanzapine between January 1999
and October 2003. Time 1 data were collected retrospec-
tively from medical charts using a standardized question-
naire; time 2 data were obtained using questionnaire mailed
to participants parents a minimum of 2 years post-dis-
charge, mean 3.9 1.3 years. Variables examined as pre-
dictors of adherence fell into broad categories of biological,
social and treatment variables. Discharge on concurrent
pharmacologic agent for affective symptoms in addition to
atypical antipsychotic, OR = 10.5 [95% confidence interval
(CI) = 2.0653.19] was a strong predictor of medication
adherence in adolescents. The results indicated that children
and adolescents discharged from their first hospitalization
following a psychotic episode may be more likely to stay on
prescribed antipsychotic medication if they are prescribed
concurrent medication for affective symptoms.
R. E. Gearing (&)
Columbia University, New York, USA
e-mail: rg2372@columbia.edu
A. Charach
The Hospital for Sick Children, Toronto, Canada
Keywords Medication adherence
Psychosis

First-episode
Schizophrenia
Mood disorders

Risk factors
Children
Adolescents
Introduction
Children and adolescents are diagnosed with psychotic
disorders and mood disorders with psychotic features
with increasing frequency. The average age of onset for
schizophrenia is between 15 and 25 years for males, and
25 and 35 years for females [1]. Thirty-nine percent of
males and 23% of females have their first-episode before
the age of 19 years [2]. Prevalence rates for adolescents,
1518 years old, are estimated at 0.23% compared with 1%
in adults, 18 years and older [3]. Psychotic disorders are
the primary reason for psychiatric hospitalizations, and
adolescents often require a length of stay from 25 to
45 days [4, 5]. Indirect, direct, and readmission costs
associated with schizophrenia extend into the tens of bil-
lions of dollars annually [68]. Increasingly the rising costs
associated with non-adherence to medications are being
recognized as the other drug problem [9]. The United
States National Institute of Mental Health [10] has
emphasized the importance of investigating the problem of
non-adherence in psychiatric populations.
Children and adolescents with psychosis experience a
chronic episodic course characterized by relapses, impaired
social adjustment and poor educational and occupational
functioning. Early onset of psychotic disorders and mood
disorders with psychotic features is associated with intel-
lectual decline reflected in lowered IQ scores [11] and
decreased quality of life marked by declines in daily
functioning, employment-related problems, and social
deficits [1215]. Adolescent onset results in poorer
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outcomes than adult onset [1618]. While only a limited
number of controlled studies have investigated children
and adolescents with psychotic disorders, the majority
report that less than 25% regained full recovery [1822].
Psychosis also results in hardships for the patients fami-
lies. The majority of patients reside with their families [12,
23, 24]. Parents frequently report personal stress, feelings
of anxiety, anger, and helplessness from the burden asso-
ciated with caring for their ill child [16, 2530].
Relapse rates following hospitalizations are high. Thirty
to 50% of patients with psychosis, schizophrenia, or major
mood disorders are readmitted within 1 year of discharge
[3133]. Over 80% of patients relapse within 5 years [34,
35]. In adult studies, the most common reason for relapse
and hospital readmission is discontinuing prescribed med-
ications. Thirty-three to 44% of patients with psychosis
adhere poorly to their medications and, consequently, are
up to six times more likely to be readmitted to hospital
[33, 36].
There is little information about medication use and
treatment adherence among children and adolescents with
psychosis. Increasingly, patients under 18 years of age are
being prescribed atypical antipsychotics [37]. Gearing
et al. [38] examined the relapse rate for children and
adolescents admitted to psychiatric inpatient units for
first-episode psychosis or mood disorders with psychotic
features. Fifty out of 87 youths (57%) experienced
symptom relapse requiring hospital readmission docu-
mented at a time point 25 years post-discharge [38].
Twenty-five percent of patients required readmission
within 7.4 months (95% CI = 2.112.6 months) and 50%
within 34.0 (19.367.1) months of the adolescents first
hospital discharge. Predictors of readmission were poor
adherence to medical treatment, female sex, currently in
clinical treatment and loss of social support prior to
hospitalization. Among predictors, poor adherence to
medication was particularly salient: non-adherent youths
relapsed three times more frequently than those who
adhered to treatment, with a hazard ratio of 0.33 (95%
CI = 0.180.61).
The current study is an exploratory study examining a
broad range of potential predictors associated with
adherence to atypical neuroleptic medication following
initial inpatient hospitalization for children and adoles-
cents with first-episode psychosis or mood disorders with
psychotic features. We hypothesized that some but not all
factors investigated in Gearing et al. [38] described above
would be associated with medication adherence. More
specifically, we anticipated that, controlling for age and
gender, social and family support would be associated
with improved adherence and severity of illness and
complexity of prescribed treatment with decreased
adherence.
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Eur Child Adolesc Psychiatry (2009) 18:587595
Methods
Design
The study was conducted with youths who had been dis-
charged from one of the six children and adolescent psy-
chiatric inpatient hospitals in Ontario, Canada. Using a
retrospective follow-up longitudinal cohort research
design, data were collected at two time points with a
minimum interval of 2 years, mean 3.9 1.3 years. Time
1 (T1) data were collected from the hospital charts for the
childs or the adolescents initial inpatient admission for
psychosis, with the hospital discharge occurring between
January 1, 1999, and October 31, 2003. Time 2 (T2) fol-
low-up data were collected using a questionnaire mailed to
parents after a minimum of 2 years post-discharge,
between April 1, 2004, and October 31, 2005.
Sixty-five of the 87 participants in the initial study
described above were prescribed an atypical antipsychotic
medication (risperidone, olanzepine, or quetiapine) upon
discharge and were included in this study. Parent report of
medication use identified those who were adherent or not.
Adherence was measured from the date of discharge (T1)
until relapse, identified by readmission to a hospital for a
minimum of 3 days for recurrence of psychotic symptoms,
or until follow up (T2), minimum 2 years post-discharge,
range 24 months to 6.8 years, mean 3.9 1.3 years.
Operationalizing relapse as readmission to hospital is an
established conservative quantifiable measure that captures
only severe episodic presentations but may exclude non-
episodic or mild symptom manifestations [31, 3944].
Medication adherence was defined as following the phy-
sicians directions regarding medication use.
Sample
Children and adolescents were eligible to participate in the
primary study if they were hospitalized for their first-epi-
sode of a primary psychotic disorder or a mood disorder
with psychotic features, under 18 years of age at the time
of admission, and at least one parent could communicate in
English.
Eligible subjects had Diagnostic and statistical manual,
Fourth Edition (DSM IV) diagnoses of schizophrenia,
schizophreniform disorder, schizoaffective disorder, brief
psychotic disorder, shared psychotic disorder, psychotic
disorder not otherwise specified, delusional disorder,
depressive disorders with psychotic features, or bipolar
disorders with psychotic features. All diagnoses were made
by a qualified child and adolescent psychiatrist during
the index hospital admission. Participants were excluded
if their psychotic symptoms were due to substance use
or general medical conditions (metabolic or physiologic
Eur Child Adolesc Psychiatry (2009) 18:587595
disorders) during index admission. Details to determine
diagnosis, inclusion, and exclusion criteria were extracted
from the medical record.
The sampling frame consisted of 229 youths admitted
with first-episode psychosis across six participating
adolescent inpatient units during the index time period.
Following ethics approval, the ethics protocol required that
all potential participants families be contacted by a clini-
cian who knew them prior to contact by research team.
Letters were sent to introduce the families and young people
to the study, followed by a telephone contact to solicit
participation. Fifty-eight (25%) declined participation.
Eighty-seven (38%) families returned the data collection
questionnaire and consent materials, and were enrolled in
the study. Another 84 (37%) agreed to participate by tele-
phone, but did not return the study materials.
Data collection instruments
Time 1 (T1): Hospital records from the index admission
were available for data extraction. The Chart Review Data
Instrument was developed to extract data following estab-
lished criteria [45, 46]. Variables of interest were identified
from those previously investigated in the literature, and
operationalized using input from clinical and scientific
experts in conjunction with a review of several hospital
cases. The instrument was supported by a set of standard
protocols and guidelines developed to instruct and guide
reviewers in the collection of the data. Two independent
reviewers piloted the instrument in a subset of 11 partici-
pants hospital charts. Agreement for variables, Kappa
coefficient or intraclass correlation coefficient (ICC)
depending on the level of measurement ranged between
0.74 and 1.00. The variable, discharge medication, had a
Kappa of 1.00 [47].
Time 2 (T2): The Information Update Profile Sheet was
mailed to the parent or caregiver to be completed and
returned along with the consent materials for participating
in the study. The questionnaire collected follow-up infor-
mation from parents (caregivers) covering a minimum of
2 years post-discharge from hospital. Parents were asked
to record the history of any medication changes for their
son or daughter since the index hospitalization, names of
medications, dose, frequency, start and stop dates, and
reasons for stopping medications. They also recorded
whether their child or adolescent was currently on medi-
cation(s) at the time of follow up. The instrument was
piloted in a subgroup of participants and parents were able
to provide the necessary data without apparent difficulty or
confusion. Wherever possible, data from the Information
Update Profile Sheet were compared to the adolescents
hospital and medical records to confirm accuracy. Youths
were non-adherent when they discontinued medication
589
without medical supervision as recorded in the Information
Update Profile Sheet. Where medication type was changed,
lowered or discontinued with the agreement and advice of
the physician, the participant was considered adherent.
Independent variables
Potential predictors of medication adherence were drawn
from variables previously evaluated as potential predictors
of symptom relapse following hospitalization [47]. Vari-
ables fell into broad biological, social, and treatment
categories. Information documenting each variable was
extracted from the hospital record. Biological variables
included gender, age at admission, gradual versus sudden
onset, length of time in weeks illness remained untreated
prior to admission, presence of medical diagnosis, diag-
nostic group categorized broadly into primary psychotic
disorders (including schizophrenia, schizophreniform dis-
order, brief psychotic disorder, psychotic disorder not
otherwise specified) or affective psychotic disorders
(schizoaffective, depressive disorder with psychotic fea-
tures or bipolar disorders), presence of negative symptoms
in addition to positive symptoms, presence of major
depressive disorder (MDD) by DSM IV criteria, presence
of mania by DSM IV criteria, history of alcohol use, and
history of illicit drug use. Social variables included foreign-
born, number of weekly parent visits during hospital
admission, decrease in social support prior to admission,
number of peer relationships, special education prior to
admission, documented presence of family criticism
toward patient (negative expressed emotion), family his-
tory of depression, family history of bipolar disorder, and
family history of schizophrenia.
Treatment variables included length of hospital stay in
days, and discharged from hospital with prescription for
atypical neuroleptic with or without concurrent medication
for affective symptoms.
Statistical analysis
All variables were first summarized using descriptive sta-
tistics such as mean and standard deviations, medians and
ranges, counts and percentages, as appropriate. Univariate
associations between adherence to atypical neuroloptic
medication and each of the other variables were investi-
gated. For this purpose the Chi-square and Fisher exact
tests were used for binary or categorical variables and
univariate logistic regression for continuous variables.
The effect of biological, social, and treatment variables
on adherence to medication was evaluated using logistic
regression. To maximize statistical power, candidate pre-
dictors were identified through a preliminary analysis. First,
variables with too much missing data were eliminated.
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Second, variables measuring similar underlying constructs
were collapsed, and finally variables with a P-value above
0.20 in the univariate analysis were eliminated. To avoid
multicollinearity in the final model, pair-wise correlations
were evaluated for the remaining variables. Finally, models
limited to two or three predictors at a time were explored in
the multiple logistic model. Variables with the highest
statistical significance were retained in the final model. All
analyses were performed using SAS Institute software for
Windows version 9.1 [48].
Results
Sixty-five (n = 65) child and adolescent participants
enrolled in this study were discharged on a single atypical
antipsychotic for treatment of psychosis, 39 (60%) were
male, age at admission was 15.35 2.08 years, and 49
(75%) were adherent to medication (see Table 1 for further
details).
The 65 youths on atypical antipsychotics included 27
(42%) children discharged on resperidone, 26 (40%) on
olanzepine, and 12 (18%) on quetiapine. Thirty-two
(n = 32) (49%) were discharged on an additional medi-
cation targeting mood symptoms, 16 on antidepressants
(Sertraline, Paroxetine, Fluoxetine and Venlafaxine), 15 on
mood stabilizers (Lithium, Divalproex Sodium and Car-
bamazepine), and 1 was on both an antidepressant and a
mood stabilizer (see Tables 2, 3 for further details). These
pharmacological agents were available and in common use
in Canada during 1999 to 2003.
The following eight variables were considered for
inclusion in the multivariate analysis: age at admission,
gender, decreased social support, length of untreated illness,
diagnostic group, family history of depression, presence of
MDD, and participant discharged on atypical neuroleptic
with or without medication for affective symptoms. Cor-
relations among variables were evaluated to identify
potential multi-collinearity (see Table 3 for further details).
Three variables, presence of MDD, Diagnostic group,
and discharged on medication for affective symptoms as
well as atypical neuroleptic, were found to be highly
associated with each other. The variable, depressive dis-
order, was dropped from further analysis as it was highly
correlated with diagnostic group, r = 0.76, P \ 0.0001.
Diagnostic group was also highly associated with discharge
on atypical neuroleptic with medication for affective
symptoms, r = 0.64, P \ 0.0001. Several variables were
not found to be significant: age at admission, gender,
family history of depression, and decreased social support.
In the multivariable model, the strongest predictor
of adherence to medication following discharge was dis-
charged on an atypical antipsychotic agent and at the same
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Eur Child Adolesc Psychiatry (2009) 18:587595
time, a medication for mood symptoms, either an antide-
pressant or a mood stabilizing agent. The statistical model
identified as most robust included two variables, discharge
on concurrent medication for mood symptoms, odds ratio
(OR) = 10.5 (95% CI = 2.0653.19, P = 0.005) and
fewer weeks of untreated illness prior to hospital admis-
sion, OR = 0.98 (95% CI = 0.951.01, P = 0.1).
Although the variable duration of untreated illness does not
formally reach statistical significance at a 0.05 alpha level,
it does show a trend toward statistical significance
(P = 0.1), so it was retained in the model.
Discussion
Of the 65 children and adolescents who participated in the
study, only 16 (25%), 9 males and 7 females were non-
adherent to medication treatment during the follow-up
period. This finding does not correlate with the literature on
adults, which routinely reports high non-adherence rates
[49]. For instance, Favre et al.s [32] study found that 75%
of patients were non-adherent by 18 months post-dis-
charge. Similarly, Olfsen et al.s [50] study found that 20%
did not remain compliant at 3-month post-hospital dis-
charge. Valenstein et al. [51] found that 3637% of patients
are poorly adherent to antipsychotic agents over time.
While it has been suggested in the literature that young
people may have higher non-adherence rates than adults
[52], the current study does not support this conclusion.
Rather, the findings suggest that a substantial proportion of
children and adolescents is likely to remain adherent to
medication following hospitalization.
The current study identifies two predictors of adherence
to atypical antipsychotic medication following discharge
from hospital. Youths discharged on an atypical antipsy-
chotic agent and an additional medication for affective
symptoms, either an antidepressant or a mood stabilizing
agent were 10 times more likely to remain adherent than
those discharged on atypical antipsychotic agent without a
second medication for mood symptoms. This finding was
strengthened when associated with shorter duration of
untreated illness prior to hospital admission. While these
results must be seen as exploratory, they are variables
related to the underlying condition and its treatment, and
may reflect the presence of an unidentified and undertreated
mood syndrome. Supporting this understanding of the data
is the observation that two variables, presence of major
depressive disorder and diagnosis of affective psychosis,
were highly associated with discharge on concurrent med-
ications. This is not surprising since the treating physician
who identified an affective disorder would also be likely to
prescribe treatment for the affective disorder. A possible
explanation for the current results is that where affective
Eur Child Adolesc Psychiatry (2009) 18:587595 591

Table 1 Sample characteristics

Variable Total (N = 65) Adherent (N = 49) Non-adherent (N = 16)
n (%) Mean (SD) n (%) Mean (SD) n (%) Mean (SD)

Gender
Male 39 (60) 30 (77) 9 (23)
Female 26 (40) 19 (73) 7 (27)
Type of onset
Sudden 17 (27) 12 (71) 5 (29)
Gradual 47 (73) 37 (79) 10 (21)
Duration of untreated illness
Weeks 62 (100) 20.76 (28.25) 47 (76) 23.47 (31.34) 15 (24) 12.27 (12.12)
Maintenance of social support
Decreased 39 (61) 27 (69) 12 (31)
Unchanged 25 (39) 21 (84) 4 (16)
Substance use
Illicit drug use
No 39 (60) 28 (72) 11 (28)
Yes 26 (40) 21 (81) 5 (19)
Alcohol use
No 41 (63) 30 (73) 11 (27)
Yes 24 (37) 19 (79) 5 (21)
Age at first-episode hospital admission 65 (100) 15.35 (2.08) 49 (75) 15.33 (2.26) 16 (25) 15.42 (1.46)
Type of symptoms
Positive only 17 (27) 12 (71) 5 (29)
Positive and negative 47 (73) 36 (77) 11 (23)
Presence of mania
Absent 50 (83) 39 (78) 11 (22)
Present 10 (17) 9 (90) 1 (10)
Presence of MDD
Absent 38 (62) 27 (71) 11 (29)
Present 23 (38) 21 (91) 2 (9)
Family history of depression
No 45 (69) 31 (69) 14 (31)
Yes 20 (31) 18 (90) 2 (10)
Family history of schizophrenia
No 57 (88) 14 (25) 43 (75)
Yes 8 (12) 2 (25) 6 (75)
Family history of bipolar
No 58 (89) 13 (22) 45 (78)
Yes 7 (11) 3 (43) 4 (57)
Length of stay (Days) 65 (100) 26.85 (36.62) 49 (75) 23.55 (19.45) 16 (25) 23.81 (13.54)

symptoms co-occur with psychosis, a conservative
approach to diagnosing and treating a possible early-onset
bipolar disorder may not be helpful and may contribute to
poor medication adherence and relapse. Indeed guidelines
[53] based on evidence drawn from the adult literature
recommend treatment starting with both antipsychotic and
mood stabilizing medications at the time of diagnosis for
early-onset bipolar disorder with psychosis.
The other factor potentially associated with improved
adherence was a shorter length of illness prior to hospital-
ization. Although a modest effect, not quite reaching sta-
tistical significance, this result is concordant with the
association in the literature of a shorter duration of untreated
illness with adherence [40, 43, 5467]. Since a history of
rapid onset of psychosis symptoms is classically linked with
bipolar disorder and consequently provides greater clinical

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Table 2 Medications
Atypical antipsychotic Additional medications Freq. Group % Total %

Olanzapine
Alone 8 30.8 12.3
Antidepressanta 6 23.1 9.2
b
Mood stabilizer 7 26.9 10.8
Mood stabilizerb and Benzodiazepinec 1 3.8 1.5
Mood stabilizerb and other medicationf 1 3.8 1.5
Typical antipsychoticd and Benzodiazepinec 2 7.7 3.1
Benzodiazepinec 1 3.8 1.5
Olanzapine subtotal 26 100 40
Quetiapine
Alone 3 25.0 4.6
Antidepressanta 4 33.3 6.2
Antidepressanta and mood stabilizerb 1 8.3 1.5
Mood stabilizerb, typical antipsychoticd and Benzodiazepinec 2 16.7 3.1
c
Benzodiazepine 1 8.3 1.5
Other medicationf 1 8.3 1.5
Quetiapine subtotal 12 100 18
Risperidone
Alone 14 51.9 21.5
a
Antidepressant 5 18.5 7.7
Antidepressanta, anticholinergice and Benzodiazepinec 1 3.7 1.5
Mood stabilizerb 2 7.4 3.1
Mood stabilizerb and anticholinergice 2 7.4 3.1
Typical antipsychoticd and anticholinergice 1 3.7 1.5
Anticholinergice 2 7.4 3.1
Risperidone subtotal 27 100 42
Total 65 100 100
a
Antidepressants include Sertraline, Paroxetine, Fluoxetine and Venlafaxine
b
Mood Stabilizers include Lithium, Divalproex Sodium and Carbamazepine
c
Benzodiazepines include Lorazepam and Clonazepam
d
Typical antipsychotic include Haloperidol, Perphenazine and Nozinan
e
Anticholinergics include Cogentin, Benztropine and Procyclidine
f
Other medications include Synthroid and Tri-cyclen

certainty in using that diagnosis, this second predictor sup-
ports the suggestion that lack of clear diagnosis led to poor
adherence and subsequent relapse. Also, it is possible that
those youths with the most puzzling symptom patterns and
therefore most difficult to diagnose disorders and also most
likely to require multiple hospitalizations.
Although we had anticipated that increased social sup-
port would be associated with improved adherence, this
hypothesis was not supported by the data. This may be
because our population was biased toward including those
with relatively high levels of family support reducing the
variability in this potential predictor. Likewise, we
hypothesized that those young people with more complex
disorders and complicated treatment regimens would show
poorer adherence. The current results may suggest that
those with more complicated medication regimens, that is,
two rather than one medication, actually appear to have
improved adherence. However, more study is required to
replicate this finding and to elucidate its significance.
It is important to note the limitations of this preliminary
study. The retrospective component of the research design
using data from health records could result in potential bias
from the way information was recorded, or from lack of the
completeness and inaccuracy of charts. Another limitation
was the lack of a semi-structured diagnostic interview
across all settings. Similarly, the retrospective follow-up
relied on parental memory about the treatment over the
period of follow up, 2 years or more. An additional limi-
tation of the study was the low response rate. Only 38% of
the eligible subjects in the sample frame participated,

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Table 3 Strengths of association matrix

Maintenance Duration of Psychosis Prescribed mood Age at Gender Depression Family
of social untreated diagnostic stabilizer or admission history of
support illness group antidepressant depression

Pearson correlation r r r r r r r r
Prob [ |r| under H0 P P P P P P P P
Rho = 0
Number of observations n n n n n n n n
Maintenance of social 0.205 -0.147 -0.185 -0.051 0.12 -0.058 -0.22
support 0.11 0.25 0.14 0.69 0.34 0.66 0.08
61 64 64 64 64 60 64
Duration of untreated -0.145 -0.211 0.128 0.06 -0.097 0.214
illness 0.26 0.1 0.32 0.64 0.47 0.09
62 62 62 62 58 62
Psychosis diagnostic 0.638 -0.045 -0.194 0.758 0.227
group \0.0001 0.72 0.12 \0.0001 0.07
65 65 65 61 65
Prescribed mood -0.21 -0.226 0.52 0.298
stabilizer or 0.09 0.07 \0.0001 0.02
antidepressant
65 65 61 65
Age at admission 0.268 -0.034 -0.106
0.03 0.79 0.4
65 61 65
Gender -0.135 -0.204
0.3 0.1
61 65
Depression 0.249
0.05
61
Family history of
depression

leading to potential bias because participants were often
those still connected to treatment and who had volunteered
to participate. Response and attrition rates have remained a
recognized limitation in first-episode schizophrenia and
adult studies on treatment adherence with psychotic dis-
orders [49, 68]. The response rate reported here, while low,
is within the range reported in other studies using compa-
rable samples [50, 69, 70]. As in many exploratory studies,
the sample size for this analysis was small and lack of
power likely contributed to modest effects of variables
such as duration of untreated illness.
Clinical implications
The strongest predictor of atypical antipsychotic medica-
tion adherence in youth following hospitalization for first-
episode psychosis was discharged on concurrent medica-
tion for affective symptoms. The information presented
here is hypothesis-generating, and limited by lack of sta-
tistical power. Further investigation is required to replicate
the findings and clarify the significance. The findings may
reflect difficulties in obtaining an accurate diagnosis of
early-onset bipolar disorder in the context of the initial
psychotic presentation in unselected community popula-
tions. Where patients are hard to diagnose, practitioners
sometimes use a conservative approach to prescribe med-
ication, using one agent initially rather than using two.
Hard to diagnose patients understandably may relapse and
require additional hospitalizations, both for further diag-
nostic clarification as well as treatment. However, active
treatment of affective symptoms at the time of initial
psychotic presentation using concurrent agents may
improve treatment adherence and relapse rate compared
with using an atypical antipsychotic alone. Further research
is required to clarify the best intervention approach for
youth with first-episode psychosis when diagnostic clarity
is elusive.

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