Relative safety of single versus divided dose imipramine in adolescent major depression

Management of suicidal behavior in children and adolescents

Many therapeutic approaches to managing suicidal behavior among youth have been used, including in-school education programs, screening programs, telephone hotlines, cognitive behavioral therapies, medication management, and inpatient milieux treatment programs. These interventions have been applied based on educational and therapeutic principles drawn from prior work with adolescents in varied scholastic and psychiatric settings. This article reviews: the assessment of risk factors among suicide attempters, emotional states, family, social isolation, interpersonal loss, substance and alcohol abuse, and treatment strategies.

Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and adolescents

OBJECTIVE

Tricyclic antidepressants (TCAs) play an important role in the treatment of pediatric psychiatric disorders. Despite widespread clinical use, concerns about their possible cardiovascular risk have arisen following several published reports of sudden death associated with their use in children. Accordingly, available evidence concerning TCA-associated cardiovascular effects in children and adolescents was surveyed.

METHOD

A systematic literature search from 1967 to 1996 identified relevant pediatric studies that evaluated cardiovascular effects of TCAs.

RESULTS

Twenty-four studies involving 730 children and adolescents given imipramine, amitriptyline, desipramine, or nortriptyline were found. TCA treatment was associated with minor increases in systolic and diastolic blood pressure, in heart rate, and in the electrocardiographic (ECG) conduction parameters, PR, QRS, and QTc. Holter ECG monitoring and exercise testing also revealed minor treatment effects. Some ECG changes related to specific TCAs emerged. Few age-related ECG differences in TCA-treated children, adolescents, or adults were detected. Associations of ECG abnormalities and relatively higher serum TCA levels were found.

CONCLUSION

TCA treatment in children and adolescents, like that in adults, is associated with cardiovascular changes of uncertain, but probably minor, clinical significance. More information is needed on the contribution of other physiological conditions on the cardiovascular system during exposure to TCAs. Guidelines for using TCAs in children and adolescents are presented.

Another sudden death in a child treated with desipramine

The sudden death of three children receiving the tricyclic antidepressant medication desipramine for behavioral disorders was reported in 1990. We now provide new information about these children and describe a fourth case. Because desipramine is a useful medication for many children, these deaths pose clinical dilemmas for physicians and families. The cardiac long QT syndrome has been proposed as a mechanism for these sudden deaths. Considerable uncertainty remains about the basis of the apparent association between the use of desipramine and the sudden deaths.

Antidepressant treatments in children and adolescents: II. Anxiety, physical, and behavioral disorders

Part II of this review critically evaluates antidepressants' (AD) efficacy in children and adolescents with anxiety, physical, and behavioral disorders as well as AD's side-effect spectrum. AD are administered increasingly to youths with specific anxiety syndromes phenomenologically paralleling those in adults which are responsive to AD (e.g., panic, obsessive-compulsive disorders). While several trials have not substantiated earlier theoretical considerations suggesting their usefulness in separation anxiety, their recent success in ameliorating obsessive-compulsive symptoms is encouraging. Systematic drug treatment studies however are limited because of the common overlap of anxiety syndromes with each other and other prominent psychiatric disturbances. More consistent benefits with AD are seen in the physical (e.g., enuresis, bulimia nervosa) and behavioral disorders (e.g., attention deficit-hyperactivity disorder). The wide-ranging benefits of AD in nonaffective disorders suggest AD are more appropriately viewed as broad spectrum pharmacotherapeutics.

A retrospective study of serum levels and electrocardiographic effects of nortriptyline in children and adolescents

OBJECTIVE

We retrospectively evaluated a large pediatric population treated with nortriptyline (NT) in an outpatient psychopharmacology clinic to assess pharmacokinetic and electrocardiographic (EKG) effects.

METHODS

A systematic search revealed 82 children and adolescents treated naturalistically with NT. All patients with available EKGs and serum NT levels were included in the series with the exception of those receiving concomitant antipsychotic agents. Forty-three percent of subjects were receiving medications in addition to NT.

RESULTS

Patients received an average (+/- SE) NT dose of 2.0 +/- 0.1 mg/kg yielding mean serum NT levels of 105.5 +/- 7.4 ng/mL. There was a linear relationship of NT dose (mg/kg) to serum NT levels (r = 0.50, p < 0.0001). NT treatment resulted in small increases in heart rate, and PR, QRS, and QTc intervals (all ps < 0.01), of similar magnitude in children and adolescents. Individuals with the highest baseline EKG indices had the least amount of change in those indices with NT treatment. There were only a few statistically significant associations between NT dose or serum NT levels and EKG parameters. NT treatment was significantly associated with the onset of asymptomatic sinus tachycardia (heart rate > 100 beats per minute), and prolongation of the EKG QRS (> 100 msec) and QTc (> 440 msec) intervals.

CONCLUSIONS

These findings suggest: (1) NT has a predictable dose to level relationship, (2) the effect of NT on the EKG in this age group is mild and similar to that reported with other tricyclic antidepressants, and (3) there are few age-specific differences in NT-induced EKG changes.

Pediatric psychopharmacotherapy: a review of recent research

In the past 5 years, we have witnessed the continuation of important trends in clinical research that began earlier in the decade. With regard to the treatment of specific disorders in children and adolescents, the most significant developments have been the examination of the tricyclics for the treatment of depression and the initiation of controlled studies for the treatment of Tourette syndrome. Unfortunately, the findings from the depression studies have been uniformly negative, and the results of research on both depression and tic disorders show a relatively high rate of placebo responsivity, which raises nagging questions about the role of case reports and open trials. Another important trend in pediatric psychopharmacotherapy is the search for substitutes for the neuroleptics. Potential candidates include agents such as lithium, naltrexone, fenfluramine, clonidine, and carbamazepine. The most underresearched disorders are a combination of the least common (e.g. schizophrenia, mania) and those that are apparently perceived as less serious (e.g. sleep disorders, certain anxiety disorders). Not surprisingly, the most studied disorder and treatment is hyperactivity and stimulant medication, respectively. Considerable progress has been made in understanding the social implications of the associated symptoms and their response to stimulant drugs, aided greatly by the use of direct observation procedures. Researchers are beginning to attend to the implications of comorbidity for assessing response to medication. There has been additional confirmation of efficacy of stimulant treatment for preschoolers and adolescents. Dose-response issues remain to some extent unresolved, the primary impediments being interpretive misconceptions associated with trend analysis, an overreliance on the syndromal perspective and too little attention to target behaviors and their clinical implications, and the failure to operationalize the minimal effective dose with regard to the normalization and supranormalization of target and collateral behaviors. Disagreement over whether hyperactivity is a learning or a behavior disorder (or both) and what academic underproductivity means clinically and socially is also impeding progress. With regard to developmental disorders, controlled studies indicate that fenfluramine and naltrexone are effective for managing associated symptoms in some individuals. However, given the limited amount of research on these agents, their status as clinically useful palliatives must be considered tentative.(ABSTRACT TRUNCATED AT 400 WORDS)

The effects of age and sex on depression ratings in children and adolescents

The self-reports of depressive symptomatology of the 89 children and the parental reports of 62 parents whose children had such symptoms from a sample of 220 children, aged 6 to 23 years, in a family-genetic study of children at high and low risk of depression were examined for the effects of the age and sex of the child. The age of the child at interview proved to have a significant effect upon the dating of the onset of dysphoric episodes and the dating of the worst ever episode of dysphoria. The older girls reported about two more depressive symptoms on average than the younger girls. This finding was obscured unless account was taken of the age at which the subjects were interviewed. However, these effects did not apply to a group of melancholia-related symptoms. There were no consistent effects of age at interview or age at episode on the symptom reports of the boys or in the reports from the parents about both their male and female children.

A double-blind placebo controlled study of desipramine in the treatment ADD: II. Serum drug levels and cardiovascular findings

In a 6-week study of children and adolescents with attention deficit disorder with hyperactivity (ADDH) in which desipramine (DMI) was highly effective and well tolerated, the mean maximal daily oral dose in the DMI-treated patients (N = 31) was 4.6 +/- 0.2 mg/kg. Additional data were obtained for 27 placebo nonresponders given DMI openly for 6 additional weeks following a nearly identical protocol and mean daily doses (total N = 58). Individual serum drug concentration varied widely at a given dose. The overall median serum DMI level was 152 ng/ml and in 6 of 56 cases with assayed serum (DMI), the level exceeded 500 ng/ml. Serum tended to be higher with older age and greater clinical improvement. Only small, clinically unimportant but statistically significant increases in diastolic blood pressure, heart rate, and electrocardiographic conduction parameters occurred. DMI-treated patients showed higher incidence during DMI treatment of sinus tachycardia and ECG evidence of intraventricular conduction defect (IVCD) of the right bundle branch block type, with two of these patients developing complete IVCD. Increases in ventricular rate and in ECG conduction parameters, as well as the incidence of IVCD, were higher in patients attaining serum levels of DMI above the median. These findings suggest that, although treatment with DMI at daily doses above 3.5 mg/kg may be needed in some cases of childhood ADDH, such doses require caution and monitoring of serum drug levels and ECG when they are used in the pediatric population.