1
|
Stimpfl JN, Walkup JT, Robb AS, Alford AE, Stahl SM, McCracken JT, Stancil SL, Ramsey LB, Emslie GJ, Strawn JR. Deprescribing Antidepressants in Children and Adolescents: A Systematic Review of Discontinuation Approaches, Cross-Titration, and Withdrawal Symptoms. J Child Adolesc Psychopharmacol 2024. [PMID: 39469761 DOI: 10.1089/cap.2024.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2024]
Abstract
Background: Antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly used to treat depressive, anxiety, and obsessive-compulsive disorders in youth. Yet, data on discontinuing these medications, withdrawal symptoms, and strategies to switch between them are limited. Methods: We searched PubMed and ClinicalTrials.gov through June 1, 2024, to identify randomized controlled trials assessing antidepressant discontinuation in youth. We summarized pediatric pharmacokinetic data to inform tapering and cross-titration strategies for antidepressants and synthesized these data with reports of antidepressant withdrawal. Results: Our search identified 528 published articles, of which 28 were included. In addition, 19 records were obtained through other methods, with 14 included. The corpus of records included 13 randomized, double-blind, placebo-controlled trials (3026 patients), including SSRIs (K = 10), SNRIs (K = 4), and TCAs (K = 1), ranging from 4 to 35 weeks. Deprescribing antidepressants requires considering clinical status, treatment response, and, in cross-titration cases, the pharmacokinetics and pharmacodynamics of both medications. Antidepressant withdrawal symptoms are related to the pharmacokinetics of the medication, which vary across antidepressants and may include irritability, palpitations, anxiety, nausea, sweating, headaches, insomnia, paresthesia, and dizziness. These symptoms putatively involve changes in serotonin transporter expression and receptor sensitivity, impacting the serotonin, dopamine, and norepinephrine pathways. Conclusions: Although approaches to deprescribing antidepressants in pediatric patients are frequently empirically guided, accumulating data related to the course of relapse and withdrawal symptoms, as well as the pharmacokinetic and pharmacodynamic properties of medications, should inform these approaches. Recommendations within this review support data-informed discussions of deprescribing-including when and how-that are critically important in the clinician-family-patient relationship.
Collapse
Affiliation(s)
- Julia N Stimpfl
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - John T Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Adelaide S Robb
- Department of Psychiatry and Behavioral Sciences, Children's National Hospital, George Washington University School of Medicine, Washington DC, USA
| | - Alexandra E Alford
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, California, USA
| | - James T McCracken
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Stephani L Stancil
- Department of Pediatrics, Schools of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Laura B Ramsey
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Pediatrics, Schools of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Graham J Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey R Strawn
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
2
|
Mills JA, Mendez E, Strawn JR. The Impact of Development on Antidepressant and Placebo Response in Anxiety Disorders: A Bayesian Hierarchical Meta-Analytic Examination of Randomized Controlled Trials in Children, Adolescents, and Adults. J Child Adolesc Psychopharmacol 2024; 34:302-309. [PMID: 38800869 DOI: 10.1089/cap.2024.0016] [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: 05/29/2024]
Abstract
Background: Understanding how development influences medication and placebo responses in anxiety disorders could inform treatment decisions, including age-specific first- versus second-line psychopharmacological interventions. Objective: To meta-analytically compare the trajectory of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and placebo response in youth and adults with anxiety disorders. Methods: Weekly symptom severity data were extracted from prospective, randomized, parallel-group, placebo-controlled trials of SSRIs and SNRIs in children, adolescents, and adults with anxiety disorders (generalized, separation, and social anxiety disorders as well as panic disorder). Treatment response was modeled for the standardized change in continuous measures of anxiety using a Bayesian hierarchical model. Change in symptom severity was evaluated as a function of time, and post hoc analyses were conducted to determine the sensitivity of these results across sample heterogeneity and alternative functional forms. Results: Data were included from 11 trials of youth (SSRI, κ = 7; SNRI, κ = 4) and 71 studies of adults (SSRI, κ = 46; SNRI, κ = 25). In total, 1067 youth participated in SSRI trials and 1024 in SNRI trials. In total, 10,826 adults participated in SSRI trials (placebo, n = 5367; SSRI n = 5,459) and 6232 in SNRI trials (placebo, n = 3,128; SNRI n = 3,094). A logarithmic model best described the response. Placebo response was similar in youth and adults (mean difference = -1.98 ± 6.21, 95% credible interval [CrI]: -10.2 to 14.2, p = 0.750), and statistically significant improvement from baseline emerged by week 2 in both adults (mean difference: -18.34 + 1.017, 95% CrI: -20.3 to 16.3, p < 0.001) and youth (mean difference: -23.74 + 3.736, 95% CrI: -31.1 to -16.4, p < 0.001). SSRIs produced similar improvements for youth and adults (p = 0.129), but SNRIs produced slower improvement in youth than adults (p = 0.018). Conclusions: Antidepressant-related improvement occurs early in youth and adults with anxiety disorders. SSRI response is similar in adults and youth; however, SNRIs produce greater responses in adults than youth, potentially representing a developmental effect.
Collapse
Affiliation(s)
- Jeffrey A Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Eric Mendez
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jeffrey R Strawn
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Divisions of Clinical and Translational Pharmacology and Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Zhang Y, Peng Z, Tang N, Zhang Y, Liu N, Lv R, Meng Y, Cai M, Wang H. Efficacy of MRI-guided rTMS for post-traumatic stress disorder by modulating amygdala activity: study protocol for a randomised controlled trial. BMJ Open 2024; 14:e081751. [PMID: 38960463 PMCID: PMC11227799 DOI: 10.1136/bmjopen-2023-081751] [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] [Received: 11/06/2023] [Accepted: 06/17/2024] [Indexed: 07/05/2024] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) is a prevalent and severe psychiatric disorder. Repetitive transcranial magnetic stimulation (rTMS) targeting the dorsolateral prefrontal cortex provides limited relief for symptoms of PTSD. This study will be conducted to validate the efficacy of MRI-guided rTMS in targeting the sites most closely associated with the amygdala for patients with PTSD. We hypothesise that the intervention will improve clinical symptoms by decreasing amygdala activity in patients. METHODS AND ANALYSIS A randomised, double-blind, sham-controlled trial will be conducted. Forty-eight eligible patients with PTSD will be randomly assigned to receive either active or sham MRI-guided rTMS for 10 consecutive days after the initial MRI scans. MRI scans will be recollected at the end of the intervention. Clinical assessments will be performed at baseline, treatment day 5, treatment day 10, and 2 weeks, 4 weeks, 8 weeks after completion of the intervention to monitor changes in clinical symptoms. The primary assessment outcome is the change in PTSD symptoms between baseline and treatment day 10, as measured by the PTSD Checklist for DSM-5. Repeated measures analysis of variance will be performed using statistical software SPSS V.26.0. The significance level will be set at 0.05. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethics Committee of Xijing Hospital in Xi'an, China (KY20222176-X-1), and the trial has been registered on ClinicalTrials.gov. The findings of this trial will be disseminated at academic conferences or published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT05544110.
Collapse
Affiliation(s)
- Yaochi Zhang
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Zhengwu Peng
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Nailong Tang
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Yuyu Zhang
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Nian Liu
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Runxin Lv
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Yumeng Meng
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Min Cai
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| | - Huaning Wang
- Department of Psychiatry, Xijing Hospital of Air Force Military Medical University, Xian, Shaanxi, China
| |
Collapse
|
4
|
Yang Y, Xu W, Wang Y, Cao H, Yao X, Zhang T, Xie X, Hua Q, Cheng W, Shen L, He K, Tian Y, Wang K, Ji GJ. Heterogeneous Brain Atrophy Sites in Anxiety Disorders Map to a Common Brain Network. Depress Anxiety 2024; 2024:1-9. [DOI: 10.1155/2024/3827870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2024] Open
Abstract
Background. Heterogeneous findings among anxiety disorder studies have hindered elucidation of the underlying pathophysiology and the development of mechanism-based therapies. Purpose. To determine whether structural MRI findings in anxiety disorder studies converge on a common network with therapeutic significance. Materials and Methods. In this retrospective study, a systematic literature search of PubMed and Web of Science databases was performed to identify coordinates of gray matter atrophy in patients with anxiety disorder. Atrophy coordinates were then mapped to an anxiety network constructed from the resting-state functional MRI (rs-fMRI) data of 652 healthy participants using “coordinate network mapping” and validated by specificity tests. The causal association of this network to anxiety symptoms was tested in a cohort of patients with brain lesions and emergent anxiety symptoms. The potential therapeutic utility of this anxiety network was then assessed by examining the clinical efficacy of network-targeted repetitive transcranial magnetic stimulation (rTMS) among a separate anxiety disorder cohort. Statistical analyses of images were performed using nonparametric tests and corrected for family-wise error. Results. Sixteen studies comprising 453 patients with anxiety (245 females; , years) and 460 healthy controls (238 females; years) were included in the analysis. Atrophy coordinates were mapped to an anxiety network with a hub region situated primarily within the superficial amygdala. Lesions associated with emergent anxiety symptoms exhibited stronger connectivity within this anxiety network than lesions not associated with anxiety (; ). Moreover, the connectivity strength of rTMS targets in the anxiety network was correlated with the improvements of anxiety symptom after treatment (, ). Conclusions. Heterogeneous gray matter atrophy among patients with anxiety disorder localize to a common network that may serve as an effective therapeutic target.
Collapse
Affiliation(s)
- Yinian Yang
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
- School of Mental Health and Psychological Sciences, Anhui Medical University, 81 Meishan Road, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Centre of Neuropsychiatric Disorder and Mental Health, Hefei, China
| | - Wenqiang Xu
- School of Mental Health and Psychological Sciences, Anhui Medical University, 81 Meishan Road, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Centre of Neuropsychiatric Disorder and Mental Health, Hefei, China
| | - Yingru Wang
- School of Mental Health and Psychological Sciences, Anhui Medical University, 81 Meishan Road, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Centre of Neuropsychiatric Disorder and Mental Health, Hefei, China
| | - Hai Cao
- School of Mental Health and Psychological Sciences, Anhui Medical University, 81 Meishan Road, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Centre of Neuropsychiatric Disorder and Mental Health, Hefei, China
| | - Xiaoqing Yao
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Ting Zhang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Xiaohui Xie
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Qiang Hua
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Wen Cheng
- Key Laboratory of Computational Medicine and Intelligent Health of Anhui Higher Education Institutes, Bengbu Medical College, Bengbu, China
| | - Longshan Shen
- Bengbu Hospital of Shanghai General Hospital, China
- The Second Affiliated Hospital of Bengbu Medical University, China
| | | | - Yanghua Tian
- Department of Psychology and Sleep Medicine, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
- Hefei Comprehensive National Science Center, Institute of Artificial Intelligence, Hefei, China
- Anhui Institute of Translational Medicine, Hefei, China
| | - Gong-Jun Ji
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University, Hefei, China
- School of Mental Health and Psychological Sciences, Anhui Medical University, 81 Meishan Road, Hefei 230032, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
- Collaborative Innovation Centre of Neuropsychiatric Disorder and Mental Health, Hefei, China
- Hefei Comprehensive National Science Center, Institute of Artificial Intelligence, Hefei, China
| |
Collapse
|
5
|
Shapiro M. Psychodynamic Formulation and Psychodynamic Psychotherapy for Pediatric Anxiety Disorders. Child Adolesc Psychiatr Clin N Am 2023; 32:559-572. [PMID: 37201967 DOI: 10.1016/j.chc.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Psychodynamic psychotherapy can be an effective treatment of pediatric anxiety disorders. Psychodynamic formulation can be easily integrated with other conceptualizations of anxiety (eg, biological/genetic, developmental, and social learning theory). Psychodynamic formulation helps determine whether anxiety symptoms represent innate biological responses, learned responses from early experiences, or defensive reactions to intrapsychic conflict. Child and Adolescent Anxiety Psychodynamic Psychotherapy and Psychoanalytic Child Therapy are two evidence-based manualized psychodynamic approaches to treating pediatric anxiety disorders.
Collapse
Affiliation(s)
- Michael Shapiro
- Department of Psychiatry, University of Florida, 1149 Newell Drive, Suite L4-100, Gainesville, FL 32610, USA.
| |
Collapse
|
6
|
Abstract
Both pharmacologic and psychotherapeutic treatment-related changes increase activity in brain regions implicated in prefrontal regulatory circuits, and the functional connectivity of these regions with the amygdala is enhanced following pharmacological treatment. This may suggest overlapping mechanisms of action across therapeutic modalities. The existing literature is best viewed as a partially constructed scaffold on which to construct a vigorous understanding of biomarkers in pediatric anxiety syndromes. As the field approaches leveraging "fingerprints" in neuroimaging with "outputs" in neuropsychiatric tasks and scale, we can move beyond one-size-fits-all selection of psychiatric interventions toward more nuanced therapeutic strategies that recognize individual differences.
Collapse
Affiliation(s)
- W Thomas Baumel
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Box 670559, 260 Stetson Street, Suite 3200, Cincinnati, OH 45267-0559, USA.
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Box 670559, 260 Stetson Street, Suite 3200, Cincinnati, OH 45267-0559, USA; Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
7
|
Strawn JR, Moldauer L, Hahn RD, Wise A, Bertzos K, Eisenberg B, Greenberg E, Liu C, Gopalkrishnan M, McVoy M, Knutson JA. A Multicenter Double-Blind, Placebo-Controlled Trial of Escitalopram in Children and Adolescents with Generalized Anxiety Disorder. J Child Adolesc Psychopharmacol 2023; 33:91-100. [PMID: 37074330 DOI: 10.1089/cap.2023.0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Objective: Generalized anxiety disorder (GAD) in children and adolescents is associated with substantial morbidity and increases the risk of future psychopathology. However, relatively few psychopharmacologic studies have examined treatments for GAD in pediatric populations, especially in prepubertal youth. Methods: Children and adolescents aged 7-17 years of age with a primary diagnosis of GAD were treated with flexibly dosed escitalopram (10-20 mg daily, n = 138) or placebo (n = 137) for 8 weeks. Efficacy measures included the Pediatric Anxiety Rating Scale (PARS) for GAD, Clinical Global Impression of Severity (CGI-S) scale, Children's Global Assessment Scale (CGAS); safety measures included the Columbia-Suicide Severity Rating Scale (C-SSRS) as well as adverse events (AEs), vital signs, and electrocardiographic and laboratory monitoring. Results: Escitalopram was superior to placebo in reducing anxiety symptoms of GAD, as seen in the difference in mean change from baseline to week 8 on the PARS severity for GAD score (least squares mean difference = -1.42; p = 0.028). Functional improvement, as reflected by CGAS score, was numerically greater in escitalopram-treated patients compared with those receiving placebo (p = 0.286), and discontinuation owing to AEs did not differ between the two groups. Vital signs, weight, laboratory, and electrocardiographic results were consistent with previous pediatric studies of escitalopram. Conclusions: Escitalopram reduced anxiety symptoms and was well tolerated in pediatric patients with GAD. These findings confirm earlier reports of escitalopram efficacy in adolescents aged 12-17 years and extend the safety and tolerability data to children with GAD aged 7-11 years. ClinicalTrials.gov Identifier: NCT03924323.
Collapse
Affiliation(s)
- Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Child & Adolescent Psychiatry and Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | | | | | | | | | - Molly McVoy
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | |
Collapse
|
8
|
Seewoo BJ, Rodger J, Demitrack MA, Heart KL, Port JD, Strawn JR, Croarkin PE. Neurostructural Differences in Adolescents With Treatment-Resistant Depression and Treatment Effects of Transcranial Magnetic Stimulation. Int J Neuropsychopharmacol 2022; 25:619-630. [PMID: 35089358 PMCID: PMC9380715 DOI: 10.1093/ijnp/pyac007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/11/2022] [Accepted: 01/26/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Despite its morbidity and mortality, the neurobiology of treatment-resistant depression (TRD) in adolescents and the impact of treatment on this neurobiology is poorly understood. METHODS Using automatic segmentation in FreeSurfer, we examined brain magnetic resonance imaging baseline volumetric differences among healthy adolescents (n = 30), adolescents with major depressive disorder (MDD) (n = 19), and adolescents with TRD (n = 34) based on objective antidepressant treatment rating criteria. A pooled subsample of adolescents with TRD were treated with 6 weeks of active (n = 18) or sham (n = 7) 10-Hz transcranial magnetic stimulation (TMS) applied to the left dorsolateral prefrontal cortex. Ten of the adolescents treated with active TMS were part of an open-label trial. The other adolescents treated with active (n = 8) or sham (n = 7) were participants from a randomized controlled trial. RESULTS Adolescents with TRD and adolescents with MDD had decreased total amygdala (TRD and MDD: -5%, P = .032) and caudal anterior cingulate cortex volumes (TRD: -3%, P = .030; MDD: -.03%, P = .041) compared with healthy adolescents. Six weeks of active TMS increased total amygdala volumes (+4%, P < .001) and the volume of the stimulated left dorsolateral prefrontal cortex (+.4%, P = .026) in adolescents with TRD. CONCLUSIONS Amygdala volumes were reduced in this sample of adolescents with MDD and TRD. TMS may normalize this volumetric finding, raising the possibility that TMS has neurostructural frontolimbic effects in adolescents with TRD. TMS also appears to have positive effects proximal to the site of stimulation.
Collapse
Affiliation(s)
- Bhedita J Seewoo
- Experimental and Regenerative Neurosciences, School of Biological Sciences, The University of Western Australia, WA, Australia
- Brain Plasticity Group, Perron Institute for Neurological and Translational Science, WA, Australia
- Centre for Microscopy, Characterisation and Analysis, Research Infrastructure Centre, The University of Western Australia, Perth, WA, Australia
| | - Jennifer Rodger
- Experimental and Regenerative Neurosciences, School of Biological Sciences, The University of Western Australia, WA, Australia
- Brain Plasticity Group, Perron Institute for Neurological and Translational Science, WA, Australia
| | - Mark A Demitrack
- Mayo Clinic, Rochester, Minnesota, USA; Trevena, Inc. Chesterbrook, Pennsylvania, USA
| | | | - John D Port
- Department of Radiology
Chesterbrook, Pennsylvania, USA
- Department of Psychiatry and Psychology
Chesterbrook, Pennsylvania, USA
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paul E Croarkin
- Department of Psychiatry and Psychology
Chesterbrook, Pennsylvania, USA
| |
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: 0.7] [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
|
Baumel WT, Mills JA, Schroeder HK, Specht AM, Rothenberg R, Peris TS, Strawn JR. Executive Functioning in Pediatric Anxiety and Its Relationship to Selective Serotonin Reuptake Inhibitor Treatment Response: A Double-Blind, Placebo-Controlled Trial. J Child Adolesc Psychopharmacol 2022; 32:215-223. [PMID: 35532982 PMCID: PMC9145261 DOI: 10.1089/cap.2022.0012] [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: 11/13/2022]
Abstract
Objective: To characterize executive function in adolescents with generalized anxiety disorder (GAD) and its relationship to treatment. Methods: Using data from a double-blind, placebo-controlled trial of escitalopram in adolescents (N = 51) 12-17 years of age with GAD, we used the self-report version of the Behavior Rating Inventory of Executive Function (BRIEF-SR) to assess executive function, at baseline, and examined its relationship to treatment response as measured by the Pediatric Anxiety Rating Scale (PARS). Results: For all baseline subscores of the BRIEF-SR, T-scores were significantly elevated in adolescents with GAD compared to an age- and sex-matched normative healthy sample. In escitalopram-treated patients, baseline BRIEF-SR scores for Emotional Control (β = 0.256, 95% credibility interval [CrI]: 0.367 to 0.146, p < 0.001), Working Memory (β = 0.204, CrI: 0.2952 to 0.1134, p < 0.001), Planning/Organizing (β = -0.223, CrI: -0.1021 to -0.3436, p = 0.004), and Task Completion (β = -0.152, CrI: 0.075 to 0.228, p = 0.002) predicted the trajectory of improvement in PARS score over the 8-week trial. For youth who received placebo, only the Inhibit score was significantly, but weakly, associated with response trajectory (β = -0.081, CrI: -0.0167 to -0.1461, p = 0.015). For adolescents who had clinically significant impairment in Emotional Control, Working Memory, Planning/Organizing, and Task Completion (i.e., T-score >65), the trajectory of improvement significantly differed from patients without scores in the clinically significant range. Conclusions: Taken together, these findings point to the potential value of assessing executive function in youth with anxiety disorders as one strategy for guiding treatment selection. These data suggest that executive function may predict treatment response to psychopharmacologic treatment and point to numerous avenues for further personalizing treatment.
Collapse
Affiliation(s)
- W. Thomas Baumel
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Heidi K. Schroeder
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ashley M. Specht
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Richard Rothenberg
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tara S. Peris
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
11
|
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: 0.3] [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
|
12
|
Baumel WT, Lu L, Huang X, Drysdale AT, Sweeny JA, Gong Q, Sylvester CM, Strawn JR. Neurocircuitry of Treatment in Anxiety Disorders. Biomark Neuropsychiatry 2022; 6. [PMID: 35756886 PMCID: PMC9222661 DOI: 10.1016/j.bionps.2022.100052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Methods: Results: Conclusions:
Collapse
Affiliation(s)
- W. Tommy Baumel
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Correspondence to: University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA. (W.T. Baumel)
| | - Lu Lu
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
- Psychoradiology Research Unit of Chinese Academy of Medical Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaoqi Huang
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
- Psychoradiology Research Unit of Chinese Academy of Medical Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Andrew T. Drysdale
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St Louis, MO, USA
| | - John A. Sweeny
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Qiyong Gong
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
- Psychoradiology Research Unit of Chinese Academy of Medical Sciences, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chad M. Sylvester
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St Louis, MO, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
13
|
Tools to Address Children's Mental Health. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:222-223. [PMID: 37153134 PMCID: PMC10153506 DOI: 10.1176/appi.focus.22020006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
|
14
|
Stancil SL, Tumberger J, Strawn JR. Target to Treatment: a charge to develop biomarkers of response and tolerability in child and adolescent psychiatry. Clin Transl Sci 2021; 15:816-823. [PMID: 34913258 PMCID: PMC9010264 DOI: 10.1111/cts.13216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/04/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022] Open
Abstract
The current pediatric mental health crisis is characterized by staggering rates of depression, anxiety, and suicide. Beyond this, first‐line pharmacologic interventions for depressive and anxiety disorders in children and adolescents produce variable responses with two in five youths failing to respond. Given the heterogeneity of treatment response in pediatric depressive and anxiety disorders, pharmacodynamic biomarkers are necessary to develop precision therapeutics by identifying clear targets to guide treatment. This mini‐review summarizes candidate biomarkers and their development in pediatric mental health conditions. A framework for how these biomarkers may relate to safety, efficacy (e.g., surrogates for clinical endpoints), tolerability or target engagement (i.e., drug action) in children and adolescents is also presented. Taken together, accumulating data suggest that, in children and adolescents with myriad psychiatric disorders, pharmacodynamic biomarkers could facilitate developing drugs with well‐defined targets in specific populations, could inform treatment decisions, and hasten patients’ recovery.
Collapse
Affiliation(s)
- Stephani L Stancil
- Division of Adolescent Medicine, Children's Mercy Kansas City.,Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation.,Department of Pediatrics, University of Missouri-Kansas City
| | - John Tumberger
- Division of Adolescent Medicine, Children's Mercy Kansas City.,Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation
| | - Jeffrey R Strawn
- Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA.,Divisions of Clinical Pharmacology and Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati Ohio, USA
| |
Collapse
|
15
|
Jonassen R. Editorial: The Cognitive Neuropsychological Hypothesis in Pediatric Anxiety and the Advantage of Revealing Early Changes in Brain Mechanisms Associated With Therapeutic Effects. J Am Acad Child Adolesc Psychiatry 2021; 60:1187-1189. [PMID: 33600936 DOI: 10.1016/j.jaac.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022]
Abstract
There is a pressing need to improve treatment, and clinical trials should not only focus on efficacy, but also on identifying the underlying mechanisms through which treatments operate.1 Treatment with a serotonergic antidepressant is commonly used to treat pediatric anxiety disorders, including generalized anxiety disorder (GAD). Serotonergic antidepressants require considerable time to induce clinically observed responses, and tolerability and efficacy are difficult to predict. Risk and precautions have been widely discussed and are weighed against urgent needs for interventions early in life that may prevent recurrent mental health complaints. Drug-induced molecular, cellular, and chemical effects result in neurocognitive changes, which are believed to occur before behavioral changes. Assessments of early neurocognitive changes may therefore be a powerful tool to reveal key mechanisms through which antidepressants work. When the neurofunctional mechanisms believed to cause the symptoms are restored, the clinical manifestation of symptom improvement is expected. The degree of symptom improvement should also follow the degree of positive changes in neurocognitive function. Many patients do not respond early enough in the course of symptom evolution,2,3 and thus assessments of early neurocognitive mechanisms may guide treatment individualization during titration of doses and effects.
Collapse
Affiliation(s)
- Rune Jonassen
- Faculty of Health Sciences, Oslo Metropolitan University, Norway.
| |
Collapse
|