Mirtazapine in the treatment of adolescents with major depression: an open-label, multicenter pilot study

Prescribing Psychotropic Medications for Justice-Involved Juveniles

Psychiatric disorders are exceedingly common in justice-involved youth. Relevant justice systems are varied, evolving, complex, and underserved. The intent of this article is to highlight the research and best practices related to managing the psychiatric disorders of justice-involved youths with a particular focus on pharmacotherapy. We review relevant features of the justice system and related case law, how prescribing for these individuals varies from both community settings and for incarcerated adults, effective assessment and medication selection, informed consent, management of nonadherence and medication diversion, and applied evidence for specific psychiatric problems common in these patients. Psychiatrists caring for justice-involved youth will benefit from tools, like this article, for training and orientation to provide timely and effective treatment services and consultation in these settings.

Controversies In The Pharmacotherapy Of Adolescent Depression

BACKGROUND

Although fluoxetine and, in the USA, escitalopram are approved for depression in adolescence, substantial concern surrounds antidepressant use in youth. Major controversies regarding efficacy and safety (increased suicidality).

INTRODUCTION

The cathegory of depression is very broad and overinclusive, in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity, not fully controlled considered in Randomized Controlled Trials (RCTs), may account for the disappointing results on both efficacy and safety.

METHOD

Based on the available literature, we will address the following topics: a) controversies regarding the definition of depression as a unique homogeneous condition with a unique type of pharmacological treatment; b) controversies about the interpretation of data from Randomized Controlled Trials (RCTs) on the efficacy of pharmacological treatments in adolescent depression; c) the interpretation of data regarding the safety of antidepressant treatment in adolescent depression, particularly in terms of increased suicidal risk.

RESULTS

According to RCTs, antidepressants are minimally to moderately more effective than placebo, principally based on very high placebo responses, and only fluoxetine showed more evidence of efficacy. These differences in meta-analyses are sometimes statistically, but not clinically significant. Depression is a heterogeneous condition in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity may partly explain the low drug-placebo difference and the high placebo response (possibly related to a high level of natural recovery of the adolescent depression). In the National Institute of Mental Health (NIMH)-funded studies, including a lower number of study sites and more reliable enrollment procedures, lower placebo response rates and greater group differences between medication and placebo were found. Robust evidence supports an increased risk of emergent suicidality after starting antidepressants. A clear age effect on suicidal risk after antidepressants is supported by a comprehensive meta-analysis, showing that suicidal risk increased with decreasing age, being markedly greater in subjects aged between 18 and 25 years. However, the term suicidality is too broad, as it includes suicidal ideation, suicidal attempts, and completed suicide, with a hugely wide range of severity and pervasiveness. If emergent suicidality should be actively and carefully explored, empirical evidence, albeit weak, suggests that combined pharmacotherapy (antidepressant and/or lithium) associated with psychotherapy may be helpful in reducing pretreatment suicidal ideation and suicidal risk.

DISCUSSION

Moderate to severe depression should be treated with psychotherapy and/or fluoxetine, the best-supported medication, and treatment-resistant adolescents should always receive combined treatment with psychotherapy. Suicidal ideation, particularly with a plan, should be actively explored before starting an antidepressant, as a reason for the closest monitoring. Emergent suicidality after starting antidepressants, as well as antidepressant-related activation, should also be closely monitored and may lead to antidepressant discontinuation. Although no response to pharmacotherapy and psychotherapy may occur in up to 40% of depressed adolescents, possible predictors or mediators of poorer response in adolescents are uncertain, and only a few studies support possible treatment strategies. Finally, studies exploring the efficacy of antidepressants in specific depression subtypes, i.e., based on prevalent psychopathological dimensions (apathy, withdrawal, impulsivity), are warranted.

Effect of vitamin D deficiency on depressive symptoms in child and adolescent psychiatric patients: results of a randomized controlled trial

PURPOSE

While observational studies revealed inverse associations between serum vitamin D levels [25(OH)D] and depression, randomized controlled trials (RCT) in children and adolescents are lacking. This RCT examined the effect of an untreated vitamin D deficiency compared to an immediate vitamin D3 supplementation on depression scores in children and adolescents during standard day and in-patient psychiatric treatment.

METHODS

Patients with vitamin D deficiency [25(OH)D ≤ 30 nmol/l] and at least mild depression [Beck Depression Inventory II (BDI-II) > 13] (n = 113) were 1:1 randomized into verum (VG; 2640 IU vitamin D3/d) or placebo group (PG) in a double-blind manner. During the intervention period of 28 days, both groups additionally received treatment as usual. BDI-II scores were assessed as primary outcome, DISYPS-II (Diagnostic System for Mental Disorders in Childhood and Adolescence, Self- and Parent Rating) and serum total 25(OH)D were secondary outcomes.

RESULTS

At admission, 49.3% of the screened patients (n = 280) had vitamin D deficiency. Although the intervention led to a higher increase of 25(OH)D levels in the VG than in the PG (treatment difference: + 14 ng/ml; 95% CI 4.86-23.77; p = 0.003), the change in BDI-II scores did not differ (+ 1.3; 95% CI - 2.22 to 4.81; p = 0.466). In contrast, DISYPS parental ratings revealed pronounced improvements of depressive symptoms in the VG (- 0.68; 95% CI - 1.23 to - 0.13; p = 0.016).

CONCLUSION

Whereas this study failed to show a vitamin D supplementation effect on self-rated depression in adolescent in- or daycare patients, parents reported less depressive symptoms in VG at the end of our study. Future trials should consider clinician-rated depressive symptoms as primary outcome.

TRIAL REGISTRATION

"German Clinical Trials Register" ( https://www.drks.de ), registration number: DRKS00009758.

Psychopharmakotherapie bei Ein- und Durchschlafstörungen im Kindes- und Jugendalter: Eine Übersicht

Zusammenfassung. Ein- und Durchschlafstörungen sind mit einer Prävalenz von etwa 20 % eine relevante Symptomatik im Kindes- und Jugendalter. Aufgrund des mit Insomnien oftmals verbundenen verminderten psychosozialen Funktionsniveaus und des sich einstellenden Leidensdrucks ist eine suffiziente Behandlung notwendig. Zeigen sich Maßnahmen wie eine angemessene Schlafhygiene und andere nichtmedikamentöse Therapieansätze als nicht ausreichend, wird oftmals eine pharmakotherapeutische Behandlung in Betracht gezogen. Die vorliegende Arbeit bietet eine Literaturübersicht zum Einsatz verschiedener Substanzklassen in hypnotischer Indikation. Der Einsatz von Melatonin bei Kindern und Jugendlichen mit Autismus-Spektrum-Störungen ist zwischenzeitlich gut untersucht und ist mit einem positiven Effekt auf den Schlaf bei dieser Patientengruppe assoziiert. Hinsichtlich der Wirksamkeit und Verträglichkeit anderer Wirkstoffe bei primären Insomnien bzw. Schlafstörungen im Kontext anderer psychiatrischer Erkrankungen bei Minderjährigen besteht bislang eine geringe Evidenz. Daher sind zunächst nichtmedikamentöse Behandlungsstrategien vorzuziehen und eine Pharmakotherapie erst sekundär und nach kritischer Abwägung zu erwägen.

Effect of an vitamin D deficiency on depressive symptoms in child and adolescent psychiatric patients - a randomized controlled trial: study protocol

BACKGROUND

Depression is a significant health and economic burden worldwide affecting not only adults but also children and adolescents. Current treatment options for this group are scarce and show moderate effect sizes. There is emerging evidence that dietary patterns and specific nutritional components might play a role in the risk for developing depression. This study protocol focusses on the role of vitamin D which is for long known to be relevant for calcium and phosphorous homeostasis and bone health but might also impact on mental health. However, the assessment of the vitamin D status of depressed juvenile patients, or supplementation of vitamin D is currently not part of routine treatment. Controlled intervention studies are indispensable to prove whether a vitamin D deficiency ameliorates depressive symptoms.

METHODS/DESIGN

This double blinded, randomized controlled trial will enroll 200 inpatients from a child and adolescent psychiatric department with a vitamin D deficiency defined by a 25(OH)-vitamin D-level < 30 nmol/l (12 ng/ml) and a Beck Depressions Inventory (BDI-II) score > 13 (indicating at least: mild depression). Upon referral, all patients will be screened, checked for inclusion criteria, and those eligible will be randomized after written consent into a supplementation or placebo group. Both study-arms will receive treatment-as-usual for their psychiatric disorder according to established clinical guidelines. The participants of the vitamin D supplementation group will receive 2640 I.E. vitamin D3 q.d. for 28 days in accordance with best practice in pediatric endocrinology. We hypothesize that delaying supplementation of vitamin D in the placebo arm will affect the treatment success of the depressive symptomatology in comparison to the vitamin D supplementation group. Patients will be enrolled for a period of 28 days based on the mean length of hospitalization of juveniles with depression.

DISCUSSION

Randomized controlled trials in children and adolescents with depression are needed to elucidate the role of a vitamin D deficiency for mental disorders and to investigate the relevance of a routine assessment and supplementation of vitamin D deficits.

TRIAL REGISTRATION

DRKS00009758, 16/06/2016 (retrospectively registered).

Pharmacotherapy in depressed children and adolescents

In children and adolescents, antidepressants are used in the treatment of depressive symptoms and several other psychiatric conditions. In the treatment of mild and moderate depressive symptoms, non-pharmacological approaches such as psychotherapy play a major role, a severe symptomatology may demand a combination with antidepressants. As first-choice medication for the treatment of juvenile depression, the selective serotonin reuptake inhibitor (SSRI) fluoxetine is recommended, due to its efficacy and approval. As second-choice antidepressants the SSRIs sertraline, escitalopram and citalopram might be used. Other antidepressants - such as tricyclic antidepressants, α(2)-adrenoceptor antagonists, selective noradrenalin reuptake inhibitors (SNRI) - may be alternatively used, but not as first- or second-choice medications. In the case of "off-label" use, patients and parents have to be carefully informed prior to the start of medication, after a thorough risk-benefit analysis. In the following overview we address a general framework, therapeutic strategies and the issues of antidepressant pharmacotherapy for the treatment of unipolar depression in childhood and adolescence.

Psychiatric Co-morbidity and Efficacy of Mirtazapine Treatment in Young Subjects With Chronic or Cyclic Vomiting Syndromes: A Case Series

The aim of this case report was to evaluate the psychiatric co-morbidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes. This is a case series of 8 young subjects (age range of 6-16 years, 11.12 ± 3.52 years) who were referred or consulted to child psychiatry department. They were referred or consulted by pediatric gastroenterology or surgery departments for the presence of non-remitting and medically unexplained vomiting. They were investigated for co-morbid psychiatric disorders using a structured psychiatric interview. An open trial of mirtazapine was conducted for the treatment and/or prevention of vomiting. Primary outcome measure was Clinical Global Impression-Improvement scale. Subjects were diagnosed with chronic (n = 5) or cyclic (n = 3) vomiting syndromes. Duration of vomiting ranged from 6 months to 10 years (3.5 ± 3.2 years). All subjects received multiple psychiatric diagnoses with anxiety disorders being the most frequent. Maximum mirtazapine dosage was 7.5-30 mg/day (16.00 ± 6.16 mg/day). Three subjects showed complete remission and 5 subjects showed much to very much improvement in vomiting. Most frequent side effects were increased appetite, weight gain and sedation. Young subjects with chronic or cyclic vomiting may frequently suffer anxiety and/or depressive symptoms or disorders. Mirtazapine could be an effective treatment option for the treatment of vomiting and co-morbid anxiety or depressive disorders in these subjects. More systematic research are needed on this topic.

Patterns of antidepressant use in Quebec children and adolescents: trends and predictors

Antidepressants are highly prescribed in youth although most products have not been approved for use in this population. Furthermore, regulatory warnings have led to changes in antidepressant use that might have differed across various countries. Our study aimed at determining factors associated with antidepressant prescribing practices and at assessing trends in use from 1997 to 2005 in Quebec youth.A retrospective cohort study was conducted through claims databases of the Quebec public health care program (RAMQ). The study included 5094 children (age 2-14) and 11,121 adolescents (age 15-19) who were incident users of antidepressant between 1997 and 2005. The characteristics of users and prescribers were the main independent variables.Tricyclics were the most frequently dispensed products among children (50.9%) and selective serotonin reuptake inhibitors among adolescents (58.8%). Selection of an antidepressant class was associated with patient characteristics and with prescriber specialty. The number of antidepressant users increased from 1997 until 2001 then decreased thereafter.The selection of an antidepressant class was associated with clinical and non-clinical characteristics. Although antidepressant use decreased after regulatory warnings, there appears to be a care gap between the evidence generated by efficacy studies and the products prescribed in a real-life setting.

Optimizing emetic control in children receiving antineoplastic therapy: beyond the guidelines

Existing guidelines for the prevention of antineoplastic chemotherapy-induced nausea and vomiting (CINV) in children are constrained by the lack of robust evidence. Current guidelines recommend the use of a serotonin 5-HT(3) receptor antagonist plus a corticosteroid to prevent acute CINV. Consequently, antiemetic agents that are recommended for use in adult cancer patients do not appear in the current pediatric guidelines. In addition, there is no information to guide the selection of alternative antiemetic agents for children who either cannot receive the recommended agents or who do not respond adequately to the treatment. Possible barriers to adherence to the pediatric antiemetic selection guidelines that are currently available are discussed, and published pediatric experience with antiemetic agents recommended in the current adult antiemetic selection guidelines (dolasetron, tropisetron, palonosetron, aprepitant) is summarized in this review. The use of novel and emerging antiemetic therapeutic interventions {metopimazine, diphenhydramine (Benadryl)-lorazepam (Avitan)-dexamethasone (Decadron) [BAD], nabilone, acupuncture, midazolam, olanzapine, mirtazapine, gabapentin, droperidol} in children are explored.

MAOA gene polymorphisms and response to mirtazapine in major depression

BACKGROUND

Polymorphisms in the monoamine oxidase A (MAOA) gene may influence treatment outcomes in major depression disorder (MDD).

OBJECTIVE

To investigate the association of MAOA genetic polymorphisms and response to mirtazapine in patients with MDD.

METHOD

Fifty-eight adult patients in Taiwan who met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for MDD were given mirtazapine for 7 weeks and evaluated on days 0, 7, 14, 21, 49 using the 24-item Hamilton Rating Scale for Depression (HRSD). Remission was defined as a final HRSD <or= 10 and a 50% reduction in baseline HRSD score. Patients provided venous blood for DNA testing. The patients' response to mirtazapine treatment was compared between those who had the long-form polymorphism in the MAOA gene promoter and the short-form polymorphism.

RESULT

The total HRSD scores after mirtazapine treatment were significantly lower than baseline (p < 0.001). There were 10 cases (38.5%) in short from and 6 (18.8%) in long from group touched the remission stage. Patients with the short-form group had a greater response to mirtazapine (p < 0.001) than those with the long-form polymorphism after controlling for age, sex, and apolipoprotein E genetic (APOE) polymorphism.

CONCLUSION

The genetic polymorphisms in the MAOA promoter region may be associated with treatment response to mirtazapine.

Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia

Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.

A comparative meta-analysis of Clinical Global Impressions change in antidepressant trials

Two scales of the Clinical Global Impressions (CGI) Scale are frequently used in antidepressant trials. No research has systematically addressed how CGI change compares to change on established measures such as the Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale, or Beck Depression Inventory. The current meta-analysis examined 75 antidepressant trials in which the CGI was used along with at least one other popular depression measure. The CGI-Severity scale was significantly more conservative than the HAM-D in rating change in double-blind trials, but not in open trials. The Beck Depression Inventory was significantly more conservative than the CGI-Severity. The CGI-Improvement scale was significantly more liberal than the HAM-D or Montgomery-Asberg Depression Rating Scale. Rater bias or scale content may explain differences between measures. Given the often substantial differences between instruments, researchers should use a variety of measures rather than relying on any single tool in assessing treatment response.

Recognizing and treating depression in children and adolescents

PURPOSE

The clinical presentation and neurobiology of depression in youth and its appropriate treatment, as well as strategies for improving therapeutic benefit and preventing adverse outcomes, including suicide, are reviewed.

SUMMARY

Functionally impairing depression occurs in 2-10% of children and adolescents. A diagnosis of depression should be considered when a physically healthy child exhibits depressed mood or anhedonia, multiple somatic complaints, or behavioral changes, such as bullying, aggression, and social withdrawal. Risk factors for depression include childhood trauma, genetic susceptibility, and environmental stressors. Antidepressants and cognitive behavioral therapy are the most effective treatments for adolescents with depression. Youth are at risk for the same adverse effects as adults but have an increased risk of behavioral activation, or switch, to mania and suicidal thoughts and behaviors early in treatment. Compared with other antidepressants, fluoxetine has the most evidence for safety and efficacy, particularly in adolescents 12 years or older. There is very little evidence for the effectiveness of any antidepressant in children 11 years and younger. Youth receiving antidepressants should be monitored closely for new-onset or worsening suicidality, particularly during the first two weeks after starting medication, and for three months of therapy. Behavioral activation, aggression, worsening depression, anxiety, insomnia, or impulsivity can herald a switch to mania or suicidality.

CONCLUSION

Depression in youth is common and treatable and responds best to multimodal treatment combining patient and family education, cognitive behavioral therapy, and antidepressant medication. The potential benefits of antidepressants outweigh the risks for adolescents. Family and psychotherapeutic interventions are most effective for prepubertal children.

Mirtazapine treatment of social phobia in women: a randomized, double-blind, placebo-controlled study

Social phobia is an anxiety disorder characterized by extreme fear and phobic avoidance of social and performance situations and by a relatively poor health-related quality of life. The goal of this study was to compare the efficacy of mirtazapine versus placebo in the treatment of patients with social phobia. In 2004, we conducted a randomized, double-blind, placebo-controlled study of mirtazapine in 66 female subjects from the general population meeting the criteria for social phobia. The subjects were randomly assigned in a 1:1 manner to mirtazapine (n = 33) or placebo (n = 33). The treatment lasted 10 weeks. Seven patients dropped out. Primary outcome measures were self-reported changes on the Social Phobia Inventory, Liebowitz Social Anxiety Scale, and Health Survey (SF-36). In comparison with the placebo group and according to the intent-to-treat principle, significant differences on the Social Phobia Inventory and Liebowitz Social Anxiety Scale scales (all P < 0.001), as well as on most (5 from 8) scales of SF-36 (all P < 0.001), were observed in the mirtazapine-treated subjects. All patients tolerated mirtazapine relatively well. Mirtazapine appears to be an effective agent in the treatment of social phobia in women and in the improvement of their health-related quality of life.

Efficacy of antidepressants in child and adolescent depression: a meta-analytic study

OBJECTIVES

To examine whether antidepressant drugs are superior to placebo in the treatment of juvenile depression.

METHOD

Extensive literature search was done to retrieve all randomised controlled and all uncontrolled trials describing children and adolescents with a diagnosis of depression who underwent any antidepressant drug treatment. In order to combine results, separate analyses using random effect models were conducted first for controlled and then for both controlled and open studies.

RESULTS

18 controlled and 23 open trials were submitted to meta-analysis. Tricyclics showed no significant benefit over placebo. Odds ratios for SSRIs were 1.84 (95% CI 1.35-2.50) for controlled and 1.83 (95% CI 1.40-2.40) for controlled and uncontrolled studies suggesting a significant benefit over placebo. Combining all antidepressants also gave confidence interval excluding the value one.

CONCLUSIONS

Despite some promising data concerning the use of SSRIs in the treatment of adolescent depression, caution is warranted until the long-term safety of these agents can be demonstrated. Insufficient data are available to judge even the short term merits of these agents in prepubertal children. There is no evidence to support the use of tricyclics in this population.