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Gupta N, Gupta M. Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians. CNS Spectr 2024; 29:10-25. [PMID: 37539695 DOI: 10.1017/s1092852923002389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.
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Affiliation(s)
| | - Mayank Gupta
- Southwood Psychiatric Hospital, Pittsburgh, PA, USA
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2
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Salazar de Pablo G, Pastor Jordá C, Vaquerizo-Serrano J, Moreno C, Cabras A, Arango C, Hernández P, Veenstra-VanderWeele J, Simonoff E, Fusar-Poli P, Santosh P, Cortese S, Parellada M. Systematic Review and Meta-analysis: Efficacy of Pharmacological Interventions for Irritability and Emotional Dysregulation in Autism Spectrum Disorder and Predictors of Response. J Am Acad Child Adolesc Psychiatry 2023; 62:151-168. [PMID: 35470032 DOI: 10.1016/j.jaac.2022.03.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 02/13/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Emotional dysregulation and irritability are common in individuals with autism spectrum disorder (ASD). We conducted the first meta-analysis assessing the efficacy of a broad range of pharmacological interventions for emotional dysregulation and irritability in ASD and predictors of response. METHOD Following a preregistered protocol (PROSPERO: CRD42021235779), we systematically searched multiple databases until January 1, 2021. We included placebo-controlled randomized controlled trials (RCTs) and evaluated the efficacy of pharmacological interventions and predictors of response for emotional dysregulation and irritability. We assessed heterogeneity using Q statistics and publication bias. We conducted subanalyses and meta-regressions to identify predictors of response. The primary effect size was the standardized mean difference. Quality of studies was assessed using the Cochrane Risk of Bias Tool (RoB2). RESULTS A total of 2,856 individuals with ASD in 45 studies were included, among which 26.7% of RCTs had a high risk of bias. Compared to placebo, antipsychotics (standardized mean difference = 1.028, 95% CI = 0.824-1.232) and medications used to treat attention-deficit/hyperactivity disorder (ADHD) (0.471, 0.061-0.881) were significantly better than placebo in improving emotional dysregulation and irritability, whereas evidence of efficacy was not found for other drug classes (p > .05). Within individual medications, evidence of efficacy was found for aripiprazole (1.179, 0.838-1.520) and risperidone (1.074, 0.818-1.331). Increased rates of comorbid epilepsy (β = -0.049, p = .026) were associated with a lower efficacy. CONCLUSION Some pharmacological interventions (particularly risperidone and aripiprazole) have proved efficacy for short-term treatment of emotional dysregulation and irritability in ASD and should be considered within a multimodal treatment plan, taking into account also the tolerability profile and families' preferences.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom; Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Carolina Pastor Jordá
- University of Pittsburgh Medical Center, Pittsburgh, the Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania, and Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Julio Vaquerizo-Serrano
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Carmen Moreno
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | | | - Celso Arango
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | - Patricia Hernández
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain
| | | | - Emily Simonoff
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom; University of Pavia, Italy, and OASIS service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom
| | - Samuele Cortese
- Centre for Innovation in Mental Health, Academic Unit of Psychology, Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, United Kingdom, the New York University Child Study Center, New York, Solent NHS Trust, and the Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, United Kingdom
| | - Mara Parellada
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, Madrid, Spain.
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Correll CU, Solmi M, Cortese S, Fava M, Højlund M, Kraemer HC, McIntyre RS, Pine DS, Schneider LS, Kane JM. The future of psychopharmacology: a critical appraisal of ongoing phase 2/3 trials, and of some current trends aiming to de-risk trial programmes of novel agents. World Psychiatry 2023; 22:48-74. [PMID: 36640403 PMCID: PMC9840514 DOI: 10.1002/wps.21056] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/15/2023] Open
Abstract
Despite considerable progress in pharmacotherapy over the past seven decades, many mental disorders remain insufficiently treated. This situation is in part due to the limited knowledge of the pathophysiology of these disorders and the lack of biological markers to stratify and individualize patient selection, but also to a still restricted number of mechanisms of action being targeted in monotherapy or combination/augmentation treatment, as well as to a variety of challenges threatening the successful development and testing of new drugs. In this paper, we first provide an overview of the most promising drugs with innovative mechanisms of action that are undergoing phase 2 or 3 testing for schizophrenia, bipolar disorder, major depressive disorder, anxiety and trauma-related disorders, substance use disorders, and dementia. Promising repurposing of established medications for new psychiatric indications, as well as variations in the modulation of dopamine, noradrenaline and serotonin receptor functioning, are also considered. We then critically discuss the clinical trial parameters that need to be considered in depth when developing and testing new pharmacological agents for the treatment of mental disorders. Hurdles and perils threatening success of new drug development and testing include inadequacy and imprecision of inclusion/exclusion criteria and ratings, sub-optimally suited clinical trial participants, multiple factors contributing to a large/increasing placebo effect, and problems with statistical analyses. This information should be considered in order to de-risk trial programmes of novel agents or known agents for novel psychiatric indications, increasing their chances of success.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Marco Solmi
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikkel Højlund
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, Department of Psychiatry Aabenraa, Aabenraa, Denmark
| | - Helena C Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Cupertino, CA, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Daniel S Pine
- Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Sciences, and Department of Neurology, Keck School of Medicine, and L. Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
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4
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Cortese S, Singh MK, Novins DK. The Neuroscience-based Nomenclature Child & Adolescent (NbN C&A) for Psychotropic Medications: Innovation in Progress. J Am Acad Child Adolesc Psychiatry 2022; 61:1317-1318. [PMID: 35697264 DOI: 10.1016/j.jaac.2022.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/03/2022] [Indexed: 11/27/2022]
Abstract
To address the issues with the current nomenclature of psychotropic agents, which may be misleading or confusing, the Neuroscience-based Nomenclature (NbN) started being developed in 2009. It was introduced as one approach to the classification of pharmacological treatments based on a medication's putative psychopharmacological mechanisms of action derived from preclinical and clinical studies. In 2018, the NbN-Child & Adolescent (NbN C&A) was released. Since then, the NbN C&A has been refined, and its website and app (https://nbnca.com/) have been implemented. JAACAP encourages its authors and readers to consider utilizing the NbN C&A and to keep abreast of its developments over time. This is in line with the core missions of the Journal: to contribute to the translation and implementation of the most up-to-date science into real-world clinical practice. DIVERSITY & INCLUSION STATEMENT: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science.
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Zohar J, Levy DM. Neuroscience-based nomenclature of psychotropics: Progress report. Eur Neuropsychopharmacol 2022; 57:36-38. [PMID: 35077943 DOI: 10.1016/j.euroneuro.2022.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/04/2022] [Accepted: 01/09/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Joseph Zohar
- Department of Psychiatry, Sheba Medical Center, Tel-Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Strawn JR, Lu L, Peris T, Levine A, Walkup JT. Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years? J Child Psychol Psychiatry 2021; 62:114-139. [PMID: 32500537 PMCID: PMC7718323 DOI: 10.1111/jcpp.13262] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment. METHODS For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized. FINDINGS Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). CONCLUSIONS Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lu Lu
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, Ohio,Huaxi MR Research Center, Dept. of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Tara Peris
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Amir Levine
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY
| | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Lurie Children’s Hospital, Chicago, Illinois
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7
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Jack RH, Joseph RM, Coupland C, Butler D, Hollis C, Morriss R, Knaggs RD, Cipriani A, Cortese S, Hippisley-Cox J. Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database. BMC Med 2020; 18:93. [PMID: 32349753 PMCID: PMC7191694 DOI: 10.1186/s12916-020-01560-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care. METHODS The study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years). RESULTS In total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%). CONCLUSIONS The results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.
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Affiliation(s)
- Ruth H Jack
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Rebecca M Joseph
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol Coupland
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Debbie Butler
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Chris Hollis
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
- National Institute of Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Morriss
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
- National Institute of Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Samuele Cortese
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Center for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Department of Child and Adolescent Psychiatry, Hassenfeld Children's Hospital at NYU Langone, New York, NY, USA
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Boaden K, Tomlinson A, Cortese S, Cipriani A. Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment. Front Psychiatry 2020; 11:717. [PMID: 32982805 PMCID: PMC7493620 DOI: 10.3389/fpsyt.2020.00717] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/07/2020] [Indexed: 01/04/2023] Open
Abstract
Antidepressants are prescribed for the treatment of a number of psychiatric disorders in children and adolescents, however there is still controversy about whether they should be used in this population. This meta-review aimed to assess the effects of antidepressants for the acute treatment of attention-deficit/hyperactivity disorder (ADHD), anxiety disorders (ADs), autistic spectrum disorder (ASD), enuresis, major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) in children and adolescents. Efficacy was measured as response to treatment (either as mean overall change in symptoms or as a dichotomous outcome) and tolerability was measured as the proportion of patients discontinuing treatment due to adverse events. Suicidality was measured as suicidal ideation, behavior (including suicide attempts) and completed suicide. PubMed, EMBASE, and Web of Science were systematically searched (until 31 October 2019) for existing systematic reviews and/or meta-analyses of double-blind randomized controlled trials. The quality of the included reviews was appraised using AMSTAR-2. Our meta-review included nine systematic reviews/meta-analyses (2 on ADHD; 1 on AD; 2 on ASD; 1 on enuresis; 1 on MDD, 1 on OCD and 1 on PTSD). In terms of efficacy this review found that, compared to placebo: fluoxetine was more efficacious in the treatment of MDD, fluvoxamine and paroxetine were better in the treatment of AD; fluoxetine and sertraline were more efficacious in the treatment of OCD; bupropion and desipramine improved clinician and teacher-rated ADHD symptoms; clomipramine and tianeptine were superior on some of the core symptoms of ASD; and no antidepressant was more efficacious for PTSD and enuresis. With regard to tolerability: imipramine, venlafaxine, and duloxetine were less well tolerated in MDD; no differences were found for any of the antidepressants in the treatment of anxiety disorders (ADs), ADHD, and PTSD; tianeptine and citalopram, but not clomipramine, were less well tolerated in children and adolescents with ASD. For suicidal behavior/ideation, venlafaxine (in MDD) and paroxetine (in AD) were associated with a significantly increased risk; by contrast, sertraline (in AD) was associated with a reduced risk. The majority of included systematic reviews/meta-analyses were rated as being of high or moderate in quality by the AMSTAR-2 critical appraisal tool (one and five, respectively). One included study was of low quality and two were of critically low quality. Compared to placebo, selected antidepressants can be efficacious in the acute treatment of some common psychiatric disorders, although statistically significant differences do not always translate into clinically significant results. Little information was available about tolerability of antidepressants in RCTs of OCD and in the treatment of ADHD, ASD, MDD, and PTSD. There is a paucity of data on suicidal ideation/behavior, but paroxetine may increase the risk of suicidality in the treatment of AD and venlafaxine for MDD. Findings from this review must be considered in light of potential limitations, such as the lack of comparative information about many antidepressants, the short-term outcomes and the quality of the available evidence.
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Affiliation(s)
- Katharine Boaden
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Anneka Tomlinson
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Samuele Cortese
- Center for Innovation in Mental Health, Faculty of Environmental and Life Sciences and Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, School of Psychology, University of Southampton, Southampton, United Kingdom.,Solent NHS Trust, Southampton, United Kingdom.,Division of Psychiatry and Applied Psychology, School of Medicine and National Institute for Health Research MindTech Mental Health MedTech Cooperative and Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom.,New York University Child Study Center, New York, NY, United States
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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9
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Garfunkel D, Anagnostou EA, Aman MG, Handen BL, Sanders KB, Macklin EA, Chan J, Veenstra-VanderWeele J. Pharmacogenetics of Metformin for Medication-Induced Weight Gain in Autism Spectrum Disorder. J Child Adolesc Psychopharmacol 2019; 29:448-455. [PMID: 31188026 DOI: 10.1089/cap.2018.0171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives: We recently found that metformin attenuated weight gain due to mixed dopamine and serotonin receptor antagonists, commonly termed atypical antipsychotics, in children and adolescents with autism spectrum disorder (ASD). Previous studies have found that genetic variation predicts response to metformin in diabetes. In this study, we aimed to assess whether response to metformin for weight gain in this population is associated with variants in five genes previously implicated in metformin response in diabetes. Methods: Youth with ASD who experienced significant weight gain while taking mixed receptor antagonist medications were randomly assigned to metformin or placebo for 16 weeks, followed by open-label metformin treatment for 16 weeks. In the 53 participants with available DNA samples, we used a linear, mixed model analysis to assess response in the first 16 weeks of metformin treatment, whether in the randomized or open-label period, based upon genotypes at polymorphisms in five genes previously associated with metformin response in diabetes: ATM, SLC2A2, MATE1, MATE2, and OCT1. Results: In the primary analysis, both ATM and OCT1 showed significant effects of genotype on change in body mass index z-scores, the primary outcome measure, during the first 16 weeks of treatment with metformin. No other polymorphism showed a significant difference. Conclusion: As has been shown for metformin treatment in diabetes, genetic variation may predict response to metformin for weight gain in youth with ASD treated with mixed receptor antagonists. Further work is needed to replicate these findings and evaluate whether they can be used prospectively to improve outcomes.
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Affiliation(s)
- Danielle Garfunkel
- 1Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - Evdokia A Anagnostou
- 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.,3Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Michael G Aman
- 4Nisonger Center, The Ohio State University, Columbus, Ohio
| | - Benjamin L Handen
- 5Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin B Sanders
- 6Department of Psychiatry, Vanderbilt University, Nashville, Tennessee
| | - Eric A Macklin
- 7Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts.,8Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - James Chan
- 7Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeremy Veenstra-VanderWeele
- 1Department of Psychiatry, Columbia University Medical Center, New York, New York.,9Center for Autism and the Developing Brain, NewYork-Presbyterian Hospital, White Plains, New York.,10New York State Psychiatric Institute, New York, New York
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