1
|
Vente T. Antidepressant Prescribing Practices of Pediatric Palliative Care Providers. J Palliat Med 2024. [PMID: 38471104 DOI: 10.1089/jpm.2023.0671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Background: Mental health diagnoses can co-occur with complex medical illness in pediatric patients. Pediatricians may not feel comfortable with managing psychopharmacology for patients and access to child psychiatrists can be limited. Palliative care (PC) providers follow patients with serious illness longitudinally to address burdensome symptoms that affect quality of life and may be responsible for evaluation and treatment of mental health concerns; however, education in managing psychologic distress for pediatric palliative care (PPC) providers is limited. Objective: This study seeks to describe the antidepressant prescribing practices of PPC providers and describe their level of training and comfort in assessing for anxiety and depression and prescribing psychotropic medications. Methods: An electronic survey approved by the American Academy of Hospice and Palliative Medicine was distributed nationally to PPC providers. Results: A total of 58 providers responded to the survey (response rate 12.3%). Most reported prescribing a variety of antidepressants (79%). Very few used formal assessment tools to screen for depression (7%) or anxiety (16%). Less than a third of providers consulted child psychiatry before prescribing antidepressants (29%). More than half of providers (54.5%) had no formal training in assessment and treatment of anxiety and depression in pediatric patients. Despite this, many providers (70%) reported feeling comfortable in prescribing antidepressants while also endorsing interest in more training for behavioral health evaluation and treatment (82.5%). Conclusions: Limited training in assessing mental health concerns, prescribing, and managing psychopharmacology suggests an opportunity for more targeted education for pediatric PC providers regarding antidepressant prescribing practices.
Collapse
Affiliation(s)
- Teresa Vente
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| |
Collapse
|
2
|
Honeycutt DC, Blom TJ, Ramsey LB, Strawn JR, Bruns KM, Welge JA, Patino LR, Singh MK, DelBello MP. Pharmacogenetic Factors Influence Escitalopram Pharmacokinetics and Adverse Events in Youth with a Family History of Bipolar Disorder: A Preliminary Study. J Child Adolesc Psychopharmacol 2024; 34:42-51. [PMID: 38377518 PMCID: PMC10880264 DOI: 10.1089/cap.2023.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Introduction: Escitalopram is an effective and generally well-tolerated antidepressant, but children of parents with bipolar disorder (BD) may be at increased risk for adverse events associated with antidepressants, including increased irritability, restlessness, impulsivity, and manic symptoms. This risk may be influenced by polymorphisms in genes encoding cytochrome P450 enzymes (CYP2C19 or CYP2D6), the serotonin transporter (SLC6A4), and the serotonin receptor 2A subtype (HTR2A). We explored whether gene-drug interactions influence the emergence of adverse events in depressed and/or anxious youth with a family history of BD. Materials and Methods: Children and adolescents aged 12-17 years with a first-degree relative with bipolar I disorder were treated with escitalopram and monitored for adverse effects, underwent pharmacogenetic testing, and provided serum escitalopram levels. Emergence of adverse events was determined by study clinicians, and symptoms were tracked using the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) and Pediatric Adverse Events Rating Scale. Clinical Pharmacogenetics Implementation Consortium guidelines were used to determine CYP2C19 and CYP2D6 phenotypes. Results: Slower CYP2C19 metabolizers had greater dose-normalized 24-hour area under the curve (AUC0-24; p = 0.025), trough concentrations (Ctrough; p = 0.013), and elimination half-lives (t1/2; p < 0.001). CYP2D6 phenotype was not significantly associated with any pharmacokinetic parameter. Slower CYP2D6 metabolizers had increased TEASAP akathisia (p = 0.015) scores. HTR2A A/A and A/G genotypes were associated with increased TEASAP "self-injury, suicidality, and harm to others" subscale scores (p = 0.017). Escitalopram maximum concentration, AUC0-24, CYP2C19 phenotype, and SLC6A4 genotype were not associated with adverse events. Conclusions: CYP2C19 phenotype influences escitalopram pharmacokinetics whereas CYP2D6 phenotype does not. Slower CYP2D6 metabolism was associated with increased akathisia, and HTR2A A/A or A/G genotypes were associated with increased risk of self-harm or harm to others. Larger cohorts are needed to identify associations between genetic test results and antidepressant-associated adverse events. Trial Registration: ClinicalTrials.gov identifier: NCT02553161.
Collapse
Affiliation(s)
- Duncan C. Honeycutt
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J. Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kaitlyn M. Bruns
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jeffrey A. Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Luis R. Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Manpreet K. Singh
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa P. DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Pruneti C, Guidotti S. Need for Multidimensional and Multidisciplinary Management of Depressed Preadolescents and Adolescents: A Review of Randomized Controlled Trials on Oral Supplementations (Omega-3, Fish Oil, Vitamin D 3). Nutrients 2023; 15:nu15102306. [PMID: 37242190 DOI: 10.3390/nu15102306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Depression is a serious health problem with a high cost for public administration. Epidemiological studies report that one in five children have a mental disorder and about 50% of mental health problems exacerbate in childhood and adolescence. Moreover, the antidepressant efficacy in children and adolescents is poorly demonstrated and can cause severe behavioral adverse events such as suicidal ideation. (2) Methods: This systematic literature review examined oral supplementations (Omega-3, fish oil, Vitamin D3) to treat depressed children, preadolescents, and adolescents. MEDLINE, Scopus, Embase, and PsycInfo were searched for articles published in the last five years. Six studies met the eligibility criteria. The inclusion criteria encompassed children, preadolescents, and adolescents, a diagnosis of depression, and an intervention of oral supplementations such as Omega-3, fish oil, and Vitamin D3. (3) Results: Most of the studies demonstrated that dietary intervention provides positive outcomes in terms of depression symptoms. (4) Conclusions: Overall, the results demonstrate a positive effect for oral supplementation suggesting an increase intake of Omega-3, fish oil, and Vitamin D3. However, only a few studies assess the effectiveness of diet recommendations, as a monotherapy or combined treatment, for the management of depression at developmental ages. Thus, there is still a need to further investigate these aspects and to look more specifically at adolescents and preadolescents.
Collapse
Affiliation(s)
- Carlo Pruneti
- Clinical Psychology, Clinical Psychophysiology, and Clinical Neuropsychology Laboratory, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Sara Guidotti
- Clinical Psychology, Clinical Psychophysiology, and Clinical Neuropsychology Laboratory, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| |
Collapse
|
4
|
Lester TR, Herrmann JE, Bannett Y, Gardner RM, Feldman HM, Huffman LC. Anxiety and Depression Treatment in Primary Care Pediatrics. Pediatrics 2023; 151:e2022058846. [PMID: 37066669 PMCID: PMC10691450 DOI: 10.1542/peds.2022-058846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review. METHODS We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices. RESULTS At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects. CONCLUSIONS When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.
Collapse
Affiliation(s)
- Talia R. Lester
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | | | - Yair Bannett
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | - Rebecca M. Gardner
- Stanford School of Medicine, Palo Alto, California
- Quantitative Science Unit, Department of Medicine
| | - Heidi M. Feldman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| | - Lynne C. Huffman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics
- Stanford School of Medicine, Palo Alto, California
| |
Collapse
|
5
|
Hua N, Tan X, He Y, Sun M, Wang X. Medical decision-making for adolescents with depression: A bibliometric study and visualization analysis via CiteSpace. Int J Ment Health Nurs 2023; 32:365-377. [PMID: 36317375 DOI: 10.1111/inm.13085] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
This study focussed on evaluating the status of recent research on medical decision-making for adolescents with depression and identifying research hotspots and frontiers via CiteSpace. We extracted studies that were concerned with medical decision-making for adolescents with depression from the Web of Science Core Collection (WoSCC), covering the period from 1 January 1999 to 20 September 2022. We used CiteSpace to generate online maps of worldwide cooperation among countries, institutions, and authors. Hotspots and frontiers were systematically summarized. A total of 368 papers related to medical decision-making for adolescents with depression were obtained from WoSCC. The most prolific author was Nick Midgley (seven papers). The United States and University College London were the leading country and institution in this research area, with 177 and 17 papers, respectively. Countries, institutions, and authors all actively collaborated. Main recent research trends include the preference or attitude towards medical treatment in adolescents with depression; approaches for adolescents with depression to seeking medical help; and the key role of parent, family, and primary care in medical decision-making for adolescents. Thus, further attention should be paid to determining how to promote the role of parents, families, and primary care in the decision-making process and create appropriate online help-seeking tools and decision aids to facilitate shared decision-making in the future.
Collapse
Affiliation(s)
- Nan Hua
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Xiangmin Tan
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Yuqing He
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Mei Sun
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Xiuhua Wang
- Xiangya School of Nursing, Central South University, Changsha, China
| |
Collapse
|
6
|
Strawn JR, Mills JA, Poweleit EA, Ramsey LB, Croarkin PE. Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents. Pharmacotherapy 2023. [PMID: 36651686 PMCID: PMC10378577 DOI: 10.1002/phar.2767] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Selective serotonin reuptake inhibitors (SSRIs) and, to a lesser extent, serotonin-norepinephrine reuptake inhibitors (SNRIs) are the cornerstone of pharmacotherapy for children and adolescents with anxiety and depressive disorders. These medications alleviate symptoms and restore function for many youths; however, they are associated with a distinct adverse effect profile, and their tolerability may complicate treatment or lead to discontinuation. Yet, SSRI/SNRI tolerability has received limited attention in the pediatric literature. METHODS This review examines the early- (e.g., activation, gastrointestinal symptoms, sedation) and late-emerging (e.g., weight gain) adverse effects of SSRIs and some SNRIs in pediatric patients. RESULTS We provide a framework for discussing SSRI/SNRI tolerability with patients and their families and describe the pharmacologic basis, course, and predictors of adverse events in youth. Strategies to address specific tolerability concerns are presented. For selected adverse events, using posterior simulation of mean differences over time, we describe their course based on Physical Symptom Checklist measures in a prospective, randomized trial of anxious youth aged 7-17 years who were treated with sertraline (n = 139) or placebo (n = 76) for 12 weeks in the Child/Adolescent Anxiety Multimodal Study (CAMS). MAIN RESULTS In CAMS, the relative severity/burden of total physical symptoms (p < 0.001), insomnia (p = 0.001), restlessness (p < 0.001), nausea (p = 0.002), abdominal pain (p < 0.001), and dry mouth (p = 0.024) decreased from baseline over 12 weeks of sertraline treatment, raising the possibility that these symptoms are transient. No significant changes were observed for sweating (p = 0.103), constipation (p = 0.241), or diarrhea (p = 0.489). Finally, we review the antidepressant withdrawal syndrome in children and adolescents and provide guidance for SSRI discontinuation, using pediatric pharmacokinetic models of escitalopram and sertraline-two of the most used SSRIs in youth. CONCLUSION SSRI/SNRIs are associated with both early-emerging (often transient) and late-emerging adverse effects in youth. Pharmacokinetically-informed appraoches may address some adverse effects and inform SSRI/SNRI discontinuation strategies.
Collapse
Affiliation(s)
- Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey A Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ethan A Poweleit
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
7
|
Ghosh P, Martinez J, Shah N, Kenan W, Fowler A, Limdi N, Burns L, Cogan ES, Gardiner A, Hain D, Johnson H, Lewis D, Shelton R, Liebelt E. Pharmacogenomic Profiling of Pediatric Patients on Psychotropic Medications in an Emergency Department. Pediatr Emerg Care 2023; 39:6-12. [PMID: 36413430 PMCID: PMC9815804 DOI: 10.1097/pec.0000000000002871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the ability of a combinatorial pharmacogenomic test to predict medication blood levels and relative clinical improvements in a selected pediatric population. METHODS This study enrolled patients between ages 3 to 18 years who presented to a pediatric emergency department with acute psychiatric, behavioral, or mental health crisis and/or concerns, and had previously been prescribed psychotropic medications. Patients received combinatorial pharmacogenomic testing with medications categorized according to gene-drug interactions (GDIs); medications with a GDI were considered "incongruent," and medications without a GDI were considered "congruent." Blood levels for escitalopram, fluoxetine, aripiprazole, and clonidine were evaluated according to level of GDI. Relative clinical improvements in response to the prescribed psychotropic medications were measured using a parent-rated Clinical Global Impression of Improvement (CGI-I) assessment, where lower scores corresponded with greater improvement. RESULTS Of the 100 patients enrolled, 73% reported taking ≥1 incongruent medication. There was no significant difference in CGI-I scores between patients prescribed congruent versus incongruent medications (3.37 vs 3.68, P = 0.343). Among patients who presented for depression or suicidal ideation, those prescribed congruent medications had significantly lower CGI-I scores compared with those taking incongruent medications ( P = 0.036 for depression, P = 0.018 for suicidal ideation). There was a significant association between medication GDI and blood levels for aripiprazole (n = 15, P = 0.01) and escitalopram (n = 10, P = 0.01). CONCLUSIONS Our preliminary findings suggest that combinatorial pharmacogenomic testing can predict medication blood levels and relative outcomes based on medication congruency in children presenting to an emergency department with acute psychiatric/behavioral crises. Additional studies will be needed to confirm these findings.
Collapse
Affiliation(s)
- Pallavi Ghosh
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
| | - Jesse Martinez
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Neurobiology, The University of Alabama at Birmingham Heersink School of Medicine
| | - Nipam Shah
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
| | - Will Kenan
- Department of Biomedical and Health Sciences, The University of Alabama at Birmingham, School of Health Processions, Birmingham, AL
| | - Andrew Fowler
- Pediatric Residency Program at Arkansas Children's Hospital, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR
| | - Nita Limdi
- Department of Neurology, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | | | | | | | | | | | | | - Richard Shelton
- Department of Psychiatry, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | - Erica Liebelt
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine
- Department of Pediatrics, Section of Pediatric Emergency Medicine and Pharmacology and Medical Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
8
|
Singer J, Daum C, Shen MJ, Zecha G, Kaplan L, Plakovic K, Blazey M, Arnold M, Silko B, Baker K, Loggers ET. Assessment of Oncology Advanced Practice Professional Willingness to Participate in Medical Aid in Dying. JAMA Netw Open 2022; 5:e2239068. [PMID: 36287559 PMCID: PMC9606841 DOI: 10.1001/jamanetworkopen.2022.39068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE In 2021, New Mexico passed legislation allowing nurse practitioners and physician assistants (referred to herein as advanced practice professionals [APPs]) to prescribe medications for medical aid in dying (MAID). Other US states with existing MAID laws (eg, Washington) are also considering expanding MAID prescribing authority to APPs. There is a lack of research exploring APP knowledge of, willingness to, and comfort with acting as a prescribing or consulting clinician for MAID. OBJECTIVE To assess perspectives of oncology APPs regarding MAID, including their willingness to prescribe and/or consult for MAID and factors associated with willingness. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, self-report survey study used data collected from APPs working at a comprehensive cancer center in Washington State in fall 2021. MAIN OUTCOMES AND MEASURES The primary survey question was whether APPs would be willing to participate in death with dignity, the term used for MAID in Washington. Survey questions evaluated how influential specific factors were on APP views on MAID as well as respondents' knowledge of and comfort with aspects of the MAID process. RESULTS Of 167 eligible APPs, 77 (46.1%) responded to the survey. Most respondents (68 [88.3%]) reported their race and ethnicity as White; 72 (93.5%) identified as a woman. Medical oncology (28 [36.4%]) was the most common field of practice, and 21 respondents (27.3%) reported having practiced as an APP for 6 to 10 years. Of all respondents, 61 (79.2%) reported having at least 1 patient who inquired about MAID; depending on the question, less than a third of respondents (5.0%-27.0%) endorsed feeling knowledgeable or very knowledgeable about any aspect of the MAID process. In this study, 39 APPs (50.6%) endorsed being willing to participate in MAID either as a consulting or prescribing clinician, whereas 31 (40.3%) were uncertain of whether they would participate. Willingness to participate was associated with having had more patients pursue MAID (33 of the 39 willing participants [84.6%] vs 15 of the 31 unsure participants [48.4%] reported having 1 or more patients pursue MAID). Higher knowledge and comfort scores were both significantly associated with increased odds of being willing to participate (odds ratio, 1.14 per 1-point score increase [95% CI, 1.03-1.27]; P = .01) vs unsure (1.18 [95% CI, 1.07-1.30; P = .001). CONCLUSIONS AND RELEVANCE The results of this survey study suggest that oncology APPs may require preparation for the addition of MAID to their scope of practice. This study also raises questions for future research regarding support for APPs who may be considering participation in MAID but question their role or want physician involvement.
Collapse
Affiliation(s)
- Jonathan Singer
- Department of Psychological Sciences, Texas Tech University, Lubbock
| | - Courtney Daum
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Megan J. Shen
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Louise Kaplan
- College of Nursing, Washington State University, Vancouver
| | | | | | - Molly Arnold
- Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Kelsey Baker
- Clinical Research Division, Department of Clinical Biostatistics, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth T. Loggers
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Oncology, University of Washington, Seattle
| |
Collapse
|
9
|
A Double-Blind Randomized Trial to Investigate Mechanisms of Antidepressant-Related Dysfunctional Arousal in Depressed or Anxious Youth at Familial Risk for Bipolar Disorder. J Pers Med 2022; 12:jpm12061006. [PMID: 35743790 PMCID: PMC9225632 DOI: 10.3390/jpm12061006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Antidepressants are standardly used to treat moderate to severe symptoms of depression and/or anxiety in youth but may also be associated with rare but serious psychiatric adverse events such as irritability, agitation, aggression, or suicidal ideation. Adverse events are especially common in youth with a family history of bipolar disorder (BD) who are at heightened risk for dysfunction in neurobiological systems that regulate emotion and arousal. To further understand this phenomenon, this study will examine (a) baseline risk factors associated with dysfunctional arousal in a sample of youth at high-risk for BD treated with or without an antidepressant, (b) whether antidepressant-related changes in arousal are mediated by changes in prefrontal-limbic circuitry, and (c) whether pharmacogenetic factors influence antidepressant-related changes in arousal. High-risk youth (aged 12-17 years with moderate to severe depressive and/or anxiety symptoms and at least one first-degree relative with bipolar I disorder) will be randomized to receive psychotherapy plus escitalopram or psychotherapy plus placebo. Neuroimaging and behavioral measures of arousal will be collected prior to randomization and at 4 weeks. Samples for pharmacogenetic analysis (serum escitalopram concentration, CYP2C19 metabolizer phenotype, and HTR2A and SLC6A4 genotypes) will be collected at 8 weeks. Youth will be followed for up to 16 weeks to assess change in arousal measures.
Collapse
|
10
|
Acute neurofunctional effects of escitalopram during emotional processing in pediatric anxiety: a double-blind, placebo-controlled trial. Neuropsychopharmacology 2022; 47:1081-1087. [PMID: 34580419 PMCID: PMC8938471 DOI: 10.1038/s41386-021-01186-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023]
Abstract
Anxiety disorders are the most common mental disorders in adolescents. However, only 50% of pediatric patients with anxiety disorders respond to the first-line pharmacologic treatments-selective serotonin reuptake inhibitors (SSRIs). Thus, identifying the neurofunctional targets of SSRIs and finding pretreatment or early-treatment neurofunctional markers of SSRI treatment response in this population is clinically important. We acquired pretreatment and early-treatment (2 weeks into treatment) functional magnetic resonance imaging during a continuous processing task with emotional and neutral distractors in adolescents with generalized anxiety disorder (GAD, N = 36) randomized to 8 weeks of double-blind escitalopram or placebo. Generalized psychophysiological interaction analysis was conducted to examine the functional connectivity of the amygdala while patients viewed emotional pictures. Full-factorial analysis was used to investigate the treatment effect of escitalopram on amygdala connectivity. Correlation analyses were performed to explore whether pretreatment and early (week 2) treatment-related connectivity were associated with treatment response (improvement in anxiety) at week 8. Compared to placebo, escitalopram enhanced emotional processing speed and enhanced negative right amygdala-bilateral ventromedial prefrontal cortex (vmPFC) and positive left amygdala-right angular gyrus connectivity during emotion processing. Baseline amygdala-vmPFC connectivity and escitalopram-induced increased amygdala-angular gyrus connectivity at week 2 predicted the magnitude of subsequent improvement in anxiety symptoms. These findings suggest that amygdala connectivity to hubs of the default mode network represents a target of acute SSRI treatment. Furthermore, pretreatment and early-treatment amygdala connectivity could serve as biomarkers of SSRI treatment response in adolescents with GAD. The trial registration for the study is ClinicalTrials.gov Identifier: NCT02818751.
Collapse
|
11
|
Strawn JR, Vaughn S, Ramsey LB. Pediatric Psychopharmacology for Depressive and Anxiety Disorders. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:184-190. [PMID: 37153132 PMCID: PMC10153505 DOI: 10.1176/appi.focus.20210036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Anxiety and depressive disorders are the most common psychiatric illnesses among children and adolescents. These disorders are associated with impairments in social, family, and educational functioning. This article summarizes the evidence base for psychopharmacologic interventions; the developmental pharmacology of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); and pharmacokinetic and pharmacodynamic differences between youths and adults that call for differences in dosage and affect response and tolerability. The authors also review the efficacy and tolerability of SSRIs and SNRIs in children and adolescents with depressive and anxiety disorder diagnoses, as well as data related to duration of therapy and SSRI/SNRI discontinuation in this population. Taken together, the current evidence suggests that SSRIs are the first-line psychopharmacologic intervention for youths with depressive and anxiety disorders, with SNRIs having a more limited role. These medications are safe and well tolerated, although emerging data and developmental pharmacologic concepts may help clinicians to choose from available SSRIs and to improve the efficacy and tolerability of these medications in children and adolescents.
Collapse
Affiliation(s)
- Jeffrey R Strawn
- Anxiety Disorders Research Program, Department of Psychiatry and Behavioral Neuroscience (Strawn), and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (Strawn, Vaughn); Division of Clinical Pharmacology (Strawn, Ramsey), Division of Child and Adolescent Psychiatry (Strawn, Vaughn), and Division of Research in Patient Services (Ramsey), Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Samuel Vaughn
- Anxiety Disorders Research Program, Department of Psychiatry and Behavioral Neuroscience (Strawn), and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (Strawn, Vaughn); Division of Clinical Pharmacology (Strawn, Ramsey), Division of Child and Adolescent Psychiatry (Strawn, Vaughn), and Division of Research in Patient Services (Ramsey), Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Laura B Ramsey
- Anxiety Disorders Research Program, Department of Psychiatry and Behavioral Neuroscience (Strawn), and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (Strawn, Vaughn); Division of Clinical Pharmacology (Strawn, Ramsey), Division of Child and Adolescent Psychiatry (Strawn, Vaughn), and Division of Research in Patient Services (Ramsey), Cincinnati Children's Hospital Medical Center, Cincinnati
| |
Collapse
|
12
|
Lester TR, Bannett Y, Gardner RM, Feldman HM, Huffman LC. Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study. Front Pediatr 2022; 10:794722. [PMID: 35372169 PMCID: PMC8970594 DOI: 10.3389/fped.2022.794722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network. STUDY DESIGN/METHODS We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample. RESULTS Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription. CONCLUSIONS In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.
Collapse
Affiliation(s)
- Talia R Lester
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Yair Bannett
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rebecca M Gardner
- Quantitative Science Unit, Department of Medicine, Stanford School of Medicine, Palo Alto, CA, United States
| | - Heidi M Feldman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lynne C Huffman
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
13
|
Strawn JR, Poweleit EA, Mills JA, Schroeder HK, Neptune ZA, Specht AM, Farrow JE, Zhang X, Martin LJ, Ramsey LB. Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial. J Pers Med 2021; 11:1188. [PMID: 34834540 PMCID: PMC8621124 DOI: 10.3390/jpm11111188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022] Open
Abstract
Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.
Collapse
Affiliation(s)
- Jeffrey R. Strawn
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
| | - Ethan A. Poweleit
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, OH 45219, USA;
| | - Heidi K. Schroeder
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Zoe A. Neptune
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Ashley M. Specht
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Jenni E. Farrow
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Xue Zhang
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Lisa J. Martin
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Laura B. Ramsey
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Division of Research in Patient Services, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| |
Collapse
|
14
|
Imfeld SM, Darang DM, Neudecker M, McVoy MK. Primary care pediatrician perceptions towards mental health within the primary care setting. Pediatr Res 2021; 90:950-956. [PMID: 33531675 DOI: 10.1038/s41390-020-01349-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mental health (MH) conditions are highly prevalent, yet only marginal portions of children receive adequate services. Access to specialized mental healthcare is limited and, consequently, pediatricians remain the source of management and care of children with MH disorders. Despite this, research suggests that pediatricians report lack of access to training and support regarding MH care of youth, leading to discomfort with managing the population they are asked to treat. An additional barrier to care that has less research is perceptions regarding MH disorders among pediatricians. This scoping review aims to describe the state of science regarding perceptions and possible stigma towards MH in pediatric primary care. METHODS PsychInfo, PubMed Medline, Ovid Medline, CINAHL, and Embase were searched with terms related to stigma, pediatricians, and MH disorders. New research articles were included after review, which addressed stigma in pediatricians treating youth with MH disorders. RESULTS Our initial search produced 457 titles, with 23 selected for full-text review, and 8 meeting inclusion criteria, N = 1571 pediatricians. CONCLUSIONS While a limited number of studies focus on physician-based perceptions/stigma, and even less data on pediatrician stigma towards MH, more studies are needed to explore how this impacts patient care. IMPACT In this scoping review, we sought to shed light on the limitations regarding MH care access, especially with the increasing need for care and not enough MH specialists, adding to an already tremendous burden pediatric primary care providers face daily. We also reviewed barriers to said care within pediatric primary care, including the potential for physician stigma towards MH diagnosis, treatment, and management. This review adds a concise summary of the current limited studies on stigma towards MH within primary care pediatricians and the importance of continued research into how perception and stigma affect patient care. This material is an original project and has not been previously published. This work is not submitted for publication or consideration elsewhere.
Collapse
Affiliation(s)
- Samantha M Imfeld
- Department of Child and Adolescent Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Dyan M Darang
- Department of Child and Adolescent Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mandy Neudecker
- Graduate Medical Education Department, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Molly K McVoy
- Department of Child and Adolescent Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Neurological and Behavioral Outcomes Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
15
|
Allen KB, Benningfield M, Blackford JU. Childhood Anxiety-If We Know So Much, Why Are We Doing So Little? JAMA Psychiatry 2020; 77:887-888. [PMID: 32401291 DOI: 10.1001/jamapsychiatry.2020.0585] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Margaret Benningfield
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer Urbano Blackford
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Veteran Affairs, Tennessee Valley Healthcare System, Nashville
| |
Collapse
|
16
|
Hughes KL, Roberts G. Who is prescribing psychotropic medications in a public developmental-behavioural clinical service and how often? J Paediatr Child Health 2020; 56:532-536. [PMID: 31721351 DOI: 10.1111/jpc.14676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/15/2019] [Accepted: 10/14/2019] [Indexed: 11/29/2022]
Abstract
AIM Psychotropic prescribing by paediatricians is increasingly common, and there is considerable variation in care provided. The aims of this study were to examine current rates of psychotropic prescribing in the developmental-behavioural outpatient clinics at the Royal Children's Hospital's Centre for Community Child Health, and to compare rates between paediatric consultants and advanced trainees. METHODS Data were extracted for appointment encounters from electronic medical records across 12 months in 2017. Patient demographics, provider and medication order data were analysed using Excel and STATA to calculate logistic regression, standard deviation, percentages and means. RESULTS From 5069 encounters, there were 847 (16.7%) that included psychotropic prescribing. Advanced trainees prescribed psychotropic medications in only 4.4% of their encounters compared with consultants who prescribed these medications in 23% of encounters (P < 0.001). Stimulants were the most commonly prescribed psychotropic medication (62%), either alone (86.3%) or in combination (13.7%). CONCLUSIONS Psychotropic prescribing rates were lower than expected. Advanced trainees may need more experience in psychotropic prescribing.
Collapse
Affiliation(s)
- Katherine L Hughes
- Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gehan Roberts
- Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia.,Population Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
17
|
Lai LL, Alvarez G, Dang L, Vuong D, Ngo V, Jo Y, Koh L. Prevalence and trend of potential drug–drug interaction among children with depression in U.S. outpatient settings. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2019. [DOI: 10.1111/jphs.12320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L. Leanne Lai
- Department of Sociobehavioral and Administrative Pharmacy College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Goar Alvarez
- College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Linh Dang
- College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Dung Vuong
- College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Vy Ngo
- College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Yailin Jo
- College of Pharmacy Nova Southeastern University Ft. Lauderdale FL USA
| | - Leroy Koh
- Department of Pharmacy Houston Methodist Hospital Houston TX USA
| |
Collapse
|
18
|
Strawn JR, Poweleit EA, Ramsey LB. CYP2C19-Guided Escitalopram and Sertraline Dosing in Pediatric Patients: A Pharmacokinetic Modeling Study. J Child Adolesc Psychopharmacol 2019; 29:340-347. [PMID: 30817183 PMCID: PMC6585169 DOI: 10.1089/cap.2018.0160] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: Cytochrome P4502C19 (CYP2C19) is a highly polymorphic gene that encodes an enzyme that metabolizes escitalopram and sertraline, two selective serotonin reuptake inhibitors (SSRIs) that are FDA approved for pediatric use and commonly used to treat anxiety and depressive disorders in youth. Using pharmacokinetic (PK) models in adolescents, we sought to (1) model SSRI dosing across CYP2C19 phenotypes to compare SSRI exposure (area under curve, AUC) and maximum concentration (Cmax), (2) evaluate the impact of b.i.d. dosing (in rapid metabolizers [RM] and ultrarapid metabolizers [UM]) on SSRI exposure and Cmax, and (3) determine pharmacogenomically-informed dosing strategies to provide similar exposure across CYP2C19 phenotypes in adolescents. Methods: Using PK parameters in CYP2C19 phenotype groups and previously reported pediatric PK data for escitalopram and sertraline, we modeled exposure (AUC0-24) and Cmax and determined CYP2C19-guided dosing strategies. Results: Compared with normal CYP2C19 metabolizers treated with either escitalopram or sertraline, Cmax and AUC0-24 were higher in slower metabolizers and lower in patients with increased CYP2C19 activity, although the magnitude of these differences was more pronounced for escitalopram than for sertraline. For escitalopram, poor metabolizers (PMs) require 10 mg/day and UMs require 30 mg/day to achieve an exposure that is equivalent to 20 mg/day in a normal metabolizer (NM). For sertraline, to achieve AUC0-24 and Cmax similar to NMs receiving 150 mg/day, PMs require 100 mg/day, whereas a dose of 200 mg/day was required in rapid and UMs. For UMs, b.i.d. escitalopram dosing was necessary to achieve comparable trough levels and exposure to NMs. Conclusions: This simulation study raises the possibility that achieving similar escitalopram and sertraline plasma concentrations could require dose adjustments in CYP2C19 poor metabolizers and UMs, although the magnitude of these differences were more pronounced for escitalopram than for sertraline. However, prospective trials of pharmacogenomically guided dosing in the pediatric population are needed to extend the findings of these modeling studies.
Collapse
Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ethan A. Poweleit
- Divisions of Research in Patient Services and Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Laura B. Ramsey
- Divisions of Research in Patient Services and Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
19
|
Wehry AM, Ramsey L, Dulemba SE, Mossman SA, Strawn JR. Pharmacogenomic Testing in Child and Adolescent Psychiatry: An Evidence-Based Review. Curr Probl Pediatr Adolesc Health Care 2018; 48:40-49. [PMID: 29325731 PMCID: PMC5828875 DOI: 10.1016/j.cppeds.2017.12.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Significant advances have been made in the application of pharmacogenomic testing for the treatment of patients with psychiatric disorders. Over the past decade, a number of studies have evaluated the utility of pharmacogenomic testing in pediatric patients with psychiatric disorders. The evidence base for pharmacogenomic testing in youth with depressive and anxiety disorders as well as attention/deficit hyperactivity disorder (ADHD) is reviewed in this article. General pharmacogenomic principles are summarized and functional polymorphisms in P450 enzymes (and associated metabolizer phenotypes), the serotonin transporter promoter polymorphisms, serotonin 2A receptor genes (e.g., HT2AR) and catecholamine pathway genes (e.g., COMT) are reviewed. These commonly tested pharmacogenomic markers are discussed with regard to studies of drug levels, efficacy and side effects. The translation of pharmacogenomics to individualized/precision medicine in pediatric patients with ADHD, anxiety and depressive disorders has accelerated; however, its application remains challenging given that there are numerous divergent pathways between medication/medication dose and clinical response and side effects. Nonetheless, by leveraging variations in individual genes that may be relevant to medication metabolism or medication target engagement, pharmacogenomic testing may have a role in predicting treatment response, side effects and medication selection in youth with ADHD, depressive and anxiety disorders.
Collapse
Affiliation(s)
- Anna M Wehry
- University of Cincinnati, College of Medicine, Box 0559, Cincinnati, OH 45267-0559
| | - Laura Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shane E Dulemba
- Division of Child and Adolescent, Cincinnati Children's Hospital, Cincinnati, OH
| | - Sarah A Mossman
- University of Cincinnati, College of Medicine, Box 0559, Cincinnati, OH 45267-0559
| | - Jeffrey R Strawn
- University of Cincinnati, College of Medicine, Box 0559, Cincinnati, OH 45267-0559.
| |
Collapse
|
20
|
Luft MJ, Lamy M, DelBello MP, McNamara RK, Strawn JR. Antidepressant-Induced Activation in Children and Adolescents: Risk, Recognition and Management. Curr Probl Pediatr Adolesc Health Care 2018; 48:50-62. [PMID: 29358037 PMCID: PMC5828909 DOI: 10.1016/j.cppeds.2017.12.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The tolerability of antidepressants is poorly characterized in children and adolescents with depressive and anxiety disorders. Among adverse events that affect the tolerability of antidepressants in youth is activation, a cluster of symptoms that represent a hyperarousal event characterized by impulsivity, restlessness, and/or insomnia. This cluster of symptoms was first identified as a side effect of selective serotonin and selective serotonin norepinephrine inhibitors (SSRIs and SSNRIs) in the early 1990s; however, activation remains poorly characterized in terms of prevalence, risk factors, and pathophysiology. This article describes the pathophysiology of antidepressant-related activation, predictors of activation and its clinical management in youth with depressive and anxiety disorders who are treated with antidepressant medications.
Collapse
Affiliation(s)
- Marissa J Luft
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Martine Lamy
- Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Melissa P DelBello
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Robert K McNamara
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Jeffrey R Strawn
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
| |
Collapse
|
21
|
Commentary: Pediatric Psychopharmacology for the Primary Care Clinician. Curr Probl Pediatr Adolesc Health Care 2017; 47:25-26. [PMID: 28089615 DOI: 10.1016/j.cppeds.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
22
|
Pascoe JM. Foreword: Pediatric Psychopharmacology for Primary Care Clinicians. Curr Probl Pediatr Adolesc Health Care 2017; 47:1-2. [PMID: 28089616 DOI: 10.1016/j.cppeds.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|