Pharmacology of the selective serotonin reuptake inhibitors in children and adolescents

Treatment of Functional Abdominal Pain With Antidepressants: Benefits, Adverse Effects, and the Gastroenterologist's Role

OBJECTIVES

Pediatric functional abdominal pain is often treated with tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). The aim is investigating antidepressant use for treatment efficacy, correlation of response to psychiatric factors, and impact of adverse effects in regard to physicians' prescribing patterns.

METHODS

Retrospective review (2005-2013) children (5-21 years old) with functional abdominal pain treated with SSRI or TCA. Of the 531 cases with functional abdominal pain, 192 initiated SSRIs or TCAs while followed by gastroenterology. Charts reviewed for symptoms, adverse effects, and response: decreased pain or increased daily functioning.

RESULTS

Sixty-three of 84 (75%) SSRI patients improved, 56 of 92 (61%) TCA patients improved (P = 0.03). Logistic regression controlling for psychiatric factors: SSRI remained significant over TCA (P = 0.04). Thirty-two of 67 (48%) patients with constipation received TCAs and 26 of 45 (58%) patients with diarrhea received SSRIs (P = 0.64). Three SSRI patients reported gastrointestinal effects, all diarrheal-type symptoms, and 2 TCA patients reported gastrointestinal effects, both constipation, in all it led to discontinuation. Thirteen (29%) of diarrheal-type patients reported adverse effects causing discontinuation as compared to 7 (8%) in the constipation group (P = .01). Twenty-one (25%) SSRI patients reported adverse effects with 5 (6%) mood disturbances. Twenty (22%) TCA patients reported adverse effects, 13 (14%) with mood disturbances (P = .07). Overall, 12 (14%) SSRI patients discontinued medication due to adverse effects, whereas 16 (17%) TCA patients (P = 0.24) did.

CONCLUSIONS

Patients had significantly greater response to SSRIs than TCAs, remaining significant after controlling for psychiatric factors. Little significance is given to patient's associated gastrointestinal symptoms, frequently resulting in adverse effects and termination of medication.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals.

METHODS

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles.

RESULTS

Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported.

CONCLUSIONS

Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

Paroxetine induced mania in pre-adolescence

Selective serotonin reuptake inhibitor induced mania has been described in adults, and more recently in adolescents. To the authors' knowledge a case in pre-adolescents has not yet been published in the literature. The authors would like to report two cases of SSRI-induced mania. Both cases were pre-adolescent girls, A and B, who had a DSM-IV diagnosis of panic disorder, and were treated with paroxetine.

Ecstasy use and serotonin syndrome: a neglected danger to adolescents and young adults prescribed selective serotonin reuptake inhibitors

BACKGROUND

At present, there are scarce clinical and basic lab data concerning the risk of acute serotonin toxicity from selective serotonin reuptake inhibitors (SSRIs) and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) co-administration. The health care community can strongly benefit from efforts to address the high risks associated with serotonin syndrome from this specific drug combination.

OBJECTIVE

The aim of this work is to review the risk of serotonin syndrome in adolescents and young adults prescribed with SSRIs and are concurrently using ecstasy.

DATA SOURCES

An electronic search of the major behavioral science bibliographic databases (Pubmed, PsycINFO, Medline) was conducted to retrieve peer-reviewed articles, which detail the clinical characteristics, biological mechanisms and social implications of SSRIs, MDMA, and their potential synergism in causing serotonin syndrome in the pediatric and young adult population. Search terms included "serotonin syndrome", "ecstasy", "MDMA", "pediatric", and "SSRI". Additional references were incorporated from the bibliographies of these retrieved articles.

RESULTS

MDMA, in combination with the widely-prescribed SSRI antidepressant class, can lead to rapid, synergistic rise of serotonin (5-HT) concentration in the central nervous system, leading to the acute medical emergency known as serotonin syndrome. This review addresses such complication through an exploration of the theoretical mechanisms and clinical manifestations of this life-threatening pharmacological interaction.

CONCLUSION

The increasing incidences of recreational ecstasy use and SSRI pharmacotherapy among multiple psychiatric disorders in the adolescent population have made this an overlooked yet increasingly relevant danger, which poses a threat to public health. This can be curbed through further research, as well as greater health care provision and attention from a regulatory body owing.

Early onset major depressive disorder

The present paper provides an overview of the clinical diagnosis and presentation, epidemiology, coexisting problems, and treatment issues of child and adolescent depressive disorders, with a focus on major depressive disorder (MDD). Depression is a common and potentially debilitating disorder for youth; has significant comorbid, behavioural and systemic sequelae; and is associated with a significant suicidal risk. Although rigorous study of psychosocial and pharmacological treatment modalities is in its infancy, current treatment is also informed by judicious and patient-specific clinical judgment. In view of the duration of MDD, remission and recurrence rates, morbidity, and potential chronicity of impaired psychosocial functioning, both active treatment and research involving MDD are indicated.

Disinhibition as a side effect of treatment with fluvoxamine in pediatric patients with obsessive-compulsive disorder

Selective serotonin reuptake inhibitors (SSRIs) are usually well tolerated in the pediatric population, and widely used in the treatment of obsessive-compulsive disorder (OCD). Of the 51 pediatric patients with obsessive-compulsive disorder seen in our outpatient clinic between January 2009 and July 2009, 3 of them developed behavioral disinhibition after treatment with fluvoxamine. These cases are described and discussed in relation to the use of CYP2D6 and CYP2C19 pharmacogenetic testing in patients treated with serotonin-selective reuptake inhibitors.

Depressive symptoms and SSRI use in pediatric oncology patients

This review of depressive symptoms in pediatric cancer patients describes the challenge of recognizing depression in this group, prevalence, risk factors, and treatment, primarily with the selective serotonin reuptake inhibitors (SSRIs). Pediatric oncologists prescribe SSRIs, but there is limited data regarding their use in this setting. Adverse effects, pharmacokinetics and metabolism of SSRIs are reviewed to provide a reference for physicians and inform choices for SSRI prescription. Ongoing research includes incorporation of routine screening measures for depression and future studies might focus on physician recognition and prospectively evaluating treatment for children with cancer and depressive symptoms.

Social anxiety disorder in children and adolescents: epidemiology, diagnosis, and treatment

Social anxiety disorder (SOC) is characterized by marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny. The person fears that she or he might act in a way that will be humiliating or embarrassing. Children and adolescents with this disorder often have great impairment in their academic performance, social skills, peer relationships, and family life. Early diagnosis is vital. Primary care providers are in a unique situation to first diagnose and treat SOC in children and adolescents. There is evidence of successful pharmacologic and psychosocial treatment in pediatric SOC. Serotonin reuptake inhibitors, which are considered first-line medications for SOC, have shown promising results in open-label and double-blind trials. Studies have demonstrated that psychosocial treatments, specifically cognitive-behavioral therapy and group therapy, are efficacious in pediatric SOC. There is some evidence that the use of combination therapy, both pharmacology and psychosocial treatment, is beneficial in the management of pediatric SOC.

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders

This practice parameter describes the epidemiology, clinical picture, differential diagnosis, course, risk factors, and pharmacological and psychotherapy treatments of children and adolescents with major depressive or dysthymic disorders. Side effects of the antidepressants, particularly the risk of suicidal ideation and behaviors are discussed. Recommendations regarding the assessment and the acute, continuation, and maintenance treatment of these disorders are based on the existent scientific evidence as well as the current clinical practice.

Venlafaxine ER for the treatment of pediatric subjects with depression: results of two placebo-controlled trials

OBJECTIVE

The safety, efficacy, and tolerability of venlafaxine extended release (ER) in subjects ages 7 to 17 years with major depressive disorder were evaluated in two multicenter, randomized, double-blind, placebo-controlled trials conducted between October 1997 and August 2001.

METHOD

Participants received venlafaxine ER (flexible dose, based on body weight; intent to treat, n = 169) or placebo (intent to treat, n = 165) for up to 8 weeks. The primary efficacy variable was the change from baseline in the Children's Depression Rating Scale-Revised score at week 8.

RESULTS

There were no statistically significant differences between venlafaxine ER and placebo on the Children's Depression Rating Scale-Revised in either study. A post hoc age subgroup analysis of the pooled data showed greater improvement on the Children's Depression Rating Scale-Revised with venlafaxine ER than with placebo (-24.4 versus -19.9; p = .022) among adolescents (ages 12-17), but not among children (ages 7-11). The most common adverse events were anorexia and abdominal pain. Hostility and suicide-related events were more common in venlafaxine ER-treated participants than in placebo-treated participants. There were no completed suicides.

CONCLUSIONS

Venlafaxine ER may be effective in depressed adolescents. However, its safety and efficacy in pediatric patients has not been established. Prescribers should monitor for signs of suicidal ideation and hostility in pediatric patients taking venlafaxine ER.

Psychopharmacologic treatment of pediatric major depressive disorder

RATIONALE

The role of pharmacotherapy in the treatment of major depressive disorder (MDD) in youth has received much attention in recent years due to concerns of efficacy and safety of the antidepressants for the treatment of MDD in youth.

OBJECTIVES

This review describes the existing published and unpublished literature regarding the efficacy and short-term safety of the antidepressants and decision-making process required for the use of these medications for youth with MDD. In addition, current continuation and maintenance treatments are discussed.

RESULTS

In general, nine depressed youth must be treated with an antidepressant to obtain one clinical response above that achieved with placebo. To date, fluoxetine has showed the most consistent positive treatment effects. Depressed youth had also acutely responded to other antidepressants, but the response to placebo has also been high. Overall, the antidepressants are well tolerated, but 1-3 children and adolescents of 100 taking antidepressants showed onset or worsening of suicidal ideation and, more rarely, suicide attempts.

CONCLUSIONS

There is a positive risk-benefit ratio for the use of antidepressants in the acute treatment of depressed youth. First-line antidepressant treatment with-or without-specific types of psychotherapy is indicated for youth with MDD of at least moderate severity. All youth taking antidepressants must be closely monitored for suicidality and medication side effects. Many youth will likely require psychotherapy or additional medication treatments to address comorbid disorders. Treatments to prevent relapses and recurrences require further study.

[Safety of selective serotonin reuptake inhibitor antidepressants in children and adolescents]

Some behavioral side effects of selective serotonin reuptake inhibitor (SSRI) antidepressants have been known for a long time. Since the introduction of these drugs in the 1990s, publications have regularly reported behavioral side effects in children and adolescents, including excitation, motor restlessness, social disinhibition, and above all self-injurious ideation and behavior. Clinical trials provide only limited data. Although these data suggest that some self-injurious and suicidal behavior may indeed occur in children and adolescents receiving SSRIs, they are too disparate to specify the frequency of these acts. Clinical trials provide useful data about drug efficacy, but their methodology is inappropriate for determining the frequency of such side effects. SSRI and suicidality: the data are difficult to read. Although some epidemiologic data suggest that SSRIs may increase the risk of occurrence of self-injurious and suicidal behavior in children and adolescents, other epidemiologic data show that the rate of suicide mortality in children and adolescents has decreased since the introduction of SSRIs. No known mechanism explains how SSRIs might increase the risk of these behavioral side effects. It is clear, however, that these effects are not particular to children and adolescents but may also be observed among adults. SSRIs must be used rationally and carefully in children and adolescents. They should not be administered routinely in youth with obsessive-compulsive or depressive disorders. Their use should be reserved for severe disorders or when psychotherapy alone has been shown to be inadequate, and when they are used, efficacy and side effects must be monitored carefully and frequently.

Psychopharmacology in pediatric critical care

Psychopharmacologic treatment in pediatric critical care requires a careful child or adolescent psychiatric evaluation, including a thorough review of the history of present illness or injury, any current or pre-existing psychiatric disorder, past history, and laboratory studies. Although there is limited evidence to guide psychopharmacologic practice in this setting, psychopharmacologic treatment is increasing in critical care, with known indications for treatment, benefits, and risks; initial dosing guidelines; and best practices. Treatment is guided by the knowledge bases in pediatric physiology, psycho-pharmacology, and treatment of critically ill adults. Pharmacologic considerations include pharmacokinetic and pharmcodynamic aspects of specific drugs and drug classes, in particular elimination half-life, developmental considerations, drug interactions, and adverse effects. Evaluation and management of pain is a key initial step, as pain may mimic psychiatric symptoms and its effective treatment can ameliorate them. Patient comfort and safety are primary objectives for children who are acutely ill and who will survive and for those who will not. Judicious use of psychopharmacolgic agents in pediatric critical care using the limited but growing evidence base and a clinical best practices collaborative approach can reduce anxiety,sadness, disorientation, and agitation; improve analgesia; and save lives of children who are suicidal or delirious. In addition to pain, other disorders or indications for psychopharmacologic treatment are affective disorders;PTSD; post-suicide attempt patients; disruptive behavior disorders (especially ADHD); and adjustment, developmental, and substance use disorders. Treating children who are critically ill with psychotropic drugs is an integral component of comprehensive pediatric critical care in relieving pain and delirium; reducing inattention or agitation or aggressive behavior;relieving acute stress, anxiety, or depression; and improving sleep and nutrition. In palliative care, psychopharmacology is integrated with psychologicapproaches to enhance children's comfort at the end of life. Defining how best to prevent the adverse consequences of suffering and stress in pediatric critical care is a goal for protocols and for new psychopharmacologic research [23,153].

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.

Selective serotonin reuptake inhibitors and suicidality in juveniles: review of the evidence and implications for clinical practice

This article reviews the existing evidence regarding whether selective serotonin reuptake inhibitors increase suicidal behaviors in children and examines the implications of the findings for clinical practice and research. When balanced against the fact that depression in the young is a serious, recurring condition that produces personal suffering and can lead to suicide, the overall weight of the evidence favors pharmacologic treatment over nontreatment in moderate to severe depression. Nevertheless, the need for careful clinical monitoring of suicidality and attention to behavioral activation, manic switching, and medication compliance or withdrawal are clearly warranted.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.

The Food and Drug Administration's deliberations on antidepressant use in pediatric patients

On February 2, 2004, the Food and Drug Administration organized a joint meeting of the Neuro-Psychopharmacologic Advisory Committee and Pediatric Subcommittee of the Anti-Infective Drugs Advisory Committee to examine the occurrence of suicidality in clinical trials that investigate the use of the newer antidepressant drugs in pediatric patients. Committee members reconvened on September 13-14, 2004, and concluded that there was a causal link between the newer antidepressants and pediatric suicidality. This article provides a summary of the Food and Drug Administration deliberations for the pediatric clinician. We also provide research, regulation, education, and practice implications for care for children and adolescents who may be eligible for treatment with these medications.

An open trial of citalopram in children and adolescents with depression

OBJECTIVE

The aim of this study was to collect pilot data on the magnitude of effect and tolerability of citalopram in early-onset major depressive disorder (MDD).

METHOD

This study was performed in two academic child and adolescent psychiatric clinics (2000 through 2002). Thirty children and adolescents, 8-17 years of age (mean age, 13.57 +/- 2.5), of both sexes (53.3% girls; 46.7% boys) and diagnosed with MDD by means of clinical psychiatric evaluation, Diagnostic Interview for Children and Adolescents (DICA) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, were studied in an open-label clinical trial with 10-40 mg/day of citalopram for 6 weeks. The outcome measures were the Hamilton Depression Rating Scale (HDRS), the Children Global Assessment Scale (CGAS), and the New York State Psychiatric Institute side-effect form.

RESULTS

Moderate (50%-70% change in HDRS and CGAS) to large (> 70% change in HDRS and CGAS) effect were seen in 91.7% of children (22/24). There were significant changes on HDRS (X = 22.78; t = -14.12; p < 0.000) and CGAS (X = 26.02; t = 9.68; p < 0.000) between baseline and the 6th week. Mild side effects were reported in 2 patients (8.3%). Adverse effects that contributed to discontinuation were nausea and vomiting in 3.3% (n = 1) of patients and unexpectedly switching to mania in 16.7% (n = 5) of patients.

CONCLUSION

Citalopram may be an efficatious treatment in early-onset MDD. However, the high switch rate to mania warrants further investigations, as well as cautions, in using it.

Child & Adolescent Depression: Review of the Latest Evidence-Based Treatments

(1) Depression is a serious mental health problem particularly in children and adolescents that requires early identification and intervention. (2) Cognitive-behavioral therapy is a highly effective treatment that decreases symptoms within 3 months and maintains gains at 2 years posttreatment. It works by changing cognitive distortions and teaching problem solving and coping strategies. (3.)Interpersonal psychotherapy demonstrates effectiveness by teaching adolescents how to self-monitor feelings, problem solve, link affect to events, and foster communication skills within the context of a supportive relationship. 4(.)Psychopharmacological treatment has shown moderate effectiveness in treating depression in children and adolescents, but close monitoring is required to evaluate for adverse events, including suicidal behavior and agitation.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review

OBJECTIVE

To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents.

METHOD

A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports.

RESULTS

Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found.

CONCLUSIONS

Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Pharmacological treatment of adolescent major depression

Antidepressant agents are widely prescribed for adolescents, although specific data regarding their efficacy in this age range are limited. The aims of the present article are to review research findings regarding the use of antidepressant drugs for adolescent depression and to discuss the main results in light of our clinical experience. Only 13 controlled trials on the use of antidepressant drugs for adolescent major depression are available in the literature. Six studies evaluated the efficacy of tricyclic antidepressants, yet they only included 196 adolescents altogether. Seven studies, including a total of 1,403 patients, evaluated the efficacy of three specific serotonin reuptake inhibitors: fluoxetine, paroxetine, and sertraline. Based on published data, serotonin reuptake inhibitors appear to be the first-line psychopharmacologic treatment for adolescent depression, as three compounds (fluoxetine, paroxetine, and sertraline) appeared to be effective in this indication. Conversely, all published studies failed to demonstrate that the tricyclic antidepressants were superior to placebo. Several questions remain open and are discussed: How should we use available scientific data in clinical practice? Are there nonspecific factors implicated in treatment response? Is there a serotonin hypothesis for juvenile depression? What are the priorities for future research?

Diagnosis and treatment of dysthymia in children and adolescents

Dysthymic disorder is a chronic depressive condition occurring in 0.6-4.6% of children and 1.6-8.0% of adolescents. Although symptoms are less severe than those observed in major depression, childhood-onset dysthymic disorder is characterised by a persistent and long-term depressed or irritable mood (mean episode duration 3-4 years), a worse outcome than major depression and, frequently, comorbid disorders (in around 50% of patients). Long-lasting depressive symptoms seem responsible for long-term disabling consequences on social skill learning, psychosocial functioning and consequent professional life, probably contributing to a higher risk of relapse or development of major depression. Consistently, the first episode of major depression occurs 2-3 years after the onset of dysthymic disorder, suggesting that the latter is one of the gateways to recurrent mood disorders. The primary aims of treatment for dysthymic disorder should be to resolve depressive symptoms, reduce the risk of developing other mood disorders over time and strengthen psychosocial functioning, especially in children and adolescents, in order to prevent the potentially serious sequelae of this disorder. As children with dysthymia often have multiple problems, interventions should involve multiple levels and measures: individual psychotherapy, family therapy/education and pharmacological treatment. Psychotherapeutic techniques, such as cognitive-behaviour therapy and interpersonal therapy, have been found to be efficacious interventions in treating children and adolescents with mild to moderate depression in studies including patients with either dysthmia or double depression. SSRIs are the first-line drug treatment for children and adolescents because of their safety, adverse effect profile and ease of use (the safety of paroxetine is currently under investigation). Several nonblind studies have shown the efficacy and good tolerability of SSRIs in children and adolescents with dysthymic disorder, but further research is needed to confirm their efficacy and that of newer antidepressants in the treatment of this disorder. Regardless of whether psychotherapeutic or medical treatments are planned, according to clinical experience, psychoeducational interventions and psychosocial support should be provided to parents and other caregivers during the acute treatment phase to help manage the child's irritable mood and foster a therapeutic alliance and better compliance with treatment. Unfortunately, no studies have focused on continuation treatment of paediatric dysthymic disorder. Given the chronicity, recurrence, psychosocial consequences and peculiar response pattern to treatment of dysthymic disorder, establishing effective 'acute' and 'continuation' interventions in this group of patients should be a priority in mental health management.

The pediatric obsessive-compulsive disorder treatment study: rationale, design, and methods

Obsessive-compulsive disorder (OCD), which has a prevalence of 1 in 200 in children and adolescents, carries with it significant functional morbidity. A growing empirical literature supports the efficacy of short-term treatment with OCD-specific cognitive-behavior therapy (CBT) or medication management with a selective serotonin reuptake inhibitor. These and other studies also identify a substantial probability of partial response and, possibly, differences in durability when treatment is discontinued between medication and CBT. The Pediatric OCD Treatment Study is a multicenter, randomized, masked clinical trial designed to evaluate the relative benefit and durability of four treatments for children and adolescents with OCD: sertraline, CBT, combination of sertraline and CBT, and pill placebo. Stage 1 (12 weeks) is a balanced randomized comparison of these four treatments. Responders at the end of stage 1 advance to 4 months of open follow-up in their assigned arm during which all treatment is discontinued. At the end of stage 2 (if not before), nonresponders to any treatment at the end of stage 1, any patient relapsing in stage 2, and all stage 1 placebo patients receive open treatment that is tailored to the patient's needs. A volunteer sample of 120 subjects between the ages of 7 and 17 inclusive with a primary Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of OCD enters the study. All patients, regardless of responder status, return for all scheduled assessments. This report describes the design of the trial, the rationale for the design choices made, and the methods used to carry out the trial.

Depression in children and adolescents

Depression is a common problem in children and adolescents. The disorder may be overlooked because of the prominent irritability seen in children with depression and because of the perception that moodiness is a normal phase of childhood. Depression frequently is associated with other psychiatric problems and neurologic disorders. Therapy consists of psychotherapy and medication, with SSRIs the first choice for pharmacotherapy.

Anxiety disorders in the child and teen

Several disorders have been reviewed (Table 1). Based upon review of the literature, an algorithm has been developed, supporting the initial use of cognitive behavioral therapy, followed by a psychopharmacology algorithm if treatment is not successful. In this algorithm, severely anxious patients initially may require psychopharmacologic treatment to be able to participate in cognitive behavioral treatment. Nonspecific measures of parent education, general support, and illness education to parents and patients are overarching principles. In this algorithm, the SSRIs are perceived to be first-line interventions, with tricyclic antidepressants and venlafaxine as second-line agents. Buspirone is considered a second- or third-line agent, as are the benzodiazepines. Table 2 reviews psychopharmacologic agents shown to be useful in the management of anxiety disorders in youth. Although much research remains to be done, there is evidence of efficacy of several interventions for anxiety disorders in children and adolescents. There is a need for a holistic and comprehensive management plan. Particular attention must be given to specific psychopharmacologic and psychotherapy needs, family matters, abuse issues, freedom from substance abuse, the use of peer support groups, and the encouragement of healthier lifestyle choices such as exercise. A rising number of well-done, large, placebo-controlled studies are providing increased support for medication and psychotherapy to inform evidence-based treatment. There is a need for teamwork and effective communication among team members in addressing pediatric and adolescent anxiety disorders.

The relevance of prolonged QTc measurement to pediatric psychopharmacology

OBJECTIVE

To consider the relevance of prolonged QTc (QT interval corrected for rate) to pediatric psychopharmacology.

METHOD

The authors reviewed publications on QTc prolongation and publications on sudden death in Medline from 1968 to November 2002.

RESULTS

The search yielded more than 20,000 publications. Review manuscripts with clinical recommendations outnumber the few pediatric studies of QTc duration during treatment. Most reviews have been published in the past 5 years, during a time when the Food and Drug Administration restricted five psychotropic medications because of QTc prolongation (sertindole: not approved; thioridazine, mesoridazine, and droperidol: black-box warning; and ziprasidone: bolded warning) and nine somatic medications because of QTc prolongation.

CONCLUSION

Pretreatment screening, careful selection of psychotropic and/or somatic medication combinations, and recognition of QTc prolongation in electrocardiographic tracings during treatment with medications that prolong QTc are important components of clinical practice.

Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study

BACKGROUND

An 8-week placebo-controlled study, the Research Units on Pediatric Psychopharmacology Anxiety Study, documented beneficial effects of fluvoxamine in the treatment of pediatric social anxiety, separation anxiety, or generalized anxiety disorders. Following completion of this study, participants were invited to enter a 6-month open-label treatment phase designed to examine three issues: (a) long-term maintenance of response in fluvoxamine responders, (b) acute response to fluoxetine in fluvoxamine nonresponders, and (c) acute response to fluvoxamine in placebo nonresponders.

METHODS

Participants aged 6-17 years meeting criteria for social anxiety, separation anxiety, or generalized anxiety disorders previously treated in an 8-week placebo-controlled trial (n = 128) were offered open treatment. Changes in symptoms of anxiety during open treatment were assessed in three groups: (a) fluvoxamine responders maintained on fluvoxamine, (b) fluvoxamine nonresponders changed to fluoxetine, and (c) placebo nonresponders changed to fluvoxamine. Response was defined based on Clinical Global Impression criteria.

RESULTS

During 6 months of continued open treatment, anxiety symptoms remained low in 33 of 35 (94%) subjects who initially responded to fluvoxamine. Among 14 fluvoxamine nonresponders switched to fluoxetine, anxiety symptoms appeared significantly improved in 10 (71%) subjects. Finally, among 48 placebo nonresponders, 27 (56%) showed clinically significant improvement in anxiety on fluvoxamine.

CONCLUSION

The current findings concerning extended treatment of pediatric anxiety disorders are only preliminary, because treatment was uncontrolled. Results suggest that an initial fluvoxamine response is likely to be retained with continued treatment, that some fluvoxamine nonresponders may respond to fluoxetine, and that some placebo nonresponders may respond to fluvoxamine.

Diagnosis and measurement of adolescent depression: a review of commonly utilized instruments

We surveyed 160 recent studies of adolescent depression (publication dates ranged from March 1996 to August 2000) and identified 33 different diagnostic and symptom measurement instruments being used by various investigators. We also found that more than one in three of the studies measuring depressive symptom severity in adolescents relied on instruments designed for use with adults. We then reviewed in detail the design features and psychometric properties of the 12 instruments most commonly used in studies of adolescent depression and attempted to characterize their strengths and weaknesses. Our main conclusions are as follows: Too many different instruments are being used by investigators, presumably due to a lack of consensus as to which are the most valid and reliable tools. Instruments designed for use in adults and never validated in adolescent populations are frequently used with no evidence for their developmental sensitivity. Many studies are using instruments that demonstrate substantial weaknesses in validity and/or reliability. The need for a parsimonious, easily administered, valid, and reliable tool(s) to diagnose and measure symptom severity in adolescent depression has not yet been met.

Efficacy of newer antidepressants for childhood anxiety disorders

Anxiety disorders as a whole are the most common psychiatric disorders in children and adolescents, with a reported prevalence ranging from 6 to 18%. Childhood anxiety disorders predict adult disorders and the majority of adult anxiety disorders are antedated by childhood anxiety. Furthermore, social dysfunction may result from misdiagnosis of these early-onset disorders. Anxiety disorders can be managed using nonpharmacological and pharmacological options, or a combination of them. Different classes of medications have been used in pediatric anxiety disorders, including benzodiazepines, tricyclics and buspirone. Newer antidepressants (SSRIs and beyond) have fewer side effects, lower toxicity in overdose and a broader range of indications. This review will focus on the efficacy of these new drugs in the management of anxiety disorders in children and adolescents (obsessive-compulsive disorder, panic disorder, separation anxiety disorder/school refusal, generalized anxiety disorder, social phobia, post-traumatic stress disorder).

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Management of Depression in Children and Adolescents

Depression is increasingly recognized as an illness that causes functional impairment and diminished quality of life for all age groups, including children. One to two percent of children and between 4% and 8% of adolescents meet Diagnostic Statistical Manual of Mental Disorders(4th ed.) (DSM-IV-TR) criteria for major depression. Psychotherapy, particularly cognitive-behavioral therapy, is effective, with 70% response rates. Antidepressants are effective according to limited controlled trials; however, concern exists over the gap between research and clinical practice, as most antidepressants are not well-studied in youth. Nevertheless, pharmacotherapy has gained greater acceptance in pediatric psychiatry, and prescriptions for antidepressants in youth have increased dramatically over the past 5 to 10 years. In 1995, 1.08 million selective serotonin reuptake inhibitor prescriptions were written for children and adolescents. Scientific evidence for the safety and effectiveness of antidepressants in youth is reviewed along with data on nondrug interventions such as cognitive-behavioral therapy. Recommendations for promoting the safe and effective management of depression in children and adolescents is provided.

Understanding and caring for the child with Asperger syndrome

Nurses in a variety of settings encounter children with the unfamiliar diagnosis of Asperger syndrome (AS). This disorder, which falls clinically along the autism spectrum, is receiving increasing attention because of its inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as one of the pervasive developmental disorders. The characteristic features of AS include deficits in social skills, atypical understanding of and use of pragmatic language, behavior problems, and a restricted set of interests. Cognitive abilities vary, and some children with AS have high intelligence. In addition, many children with AS have other conditions, such as attention deficit hyperactivity disorder, Tourette's syndrome, obsessive-compulsive disorder, and depression. The disorder can result in significant functional difficulties in the home, school, and community contexts. A case study highlights the features of AS, and a related individualized school health care plan demonstrates the school nurse's role in family and staff education, monitoring for comorbidities, behavioral management, medication management, support to family members, and referral.

Selective serotonin re-uptake inhibitors for children and adolescents

OBJECTIVES

1) To briefly review the scientific basis for the use of selective serotonin re-uptake inhibitors (SSRIs) in children and adolescents. 2) To review the current data on the efficacy, safety and tolerability in children and adolescents.

METHOD

A Medline search back to 1990 was conducted. Review articles and double blind, placebo controlled trials were critically reviewed. Additional hand searches were performed with key journals and in specific areas of interest for this paper.

RESULTS

Most of the published papers are from North America. There is an increasing use of SSRIs in child and adolescent psychiatry. The main disorders studied are mood and anxiety disorders. The data supporting efficacy is still limited. The most robust data is in the treatment of OCD and depression.

CONCLUSION

Taking the limited data together with clinical experience and with adult studies, there is a valuable role for SSRIs as a component of treatment for various child and adolescent psychiatric disorders.

Obsessive-complusive disorder: pharmacological treatment

Obsessive-compulsive disorder (OCD) in children and adolescents is often a disabling condition, which demands treatment with medication. Research shows that serotonin is involved in the disorder and empirical treatment studies show that antidepressants with serotonin activity are effective. The first choice of treatment in the psychopharmacological approach to OCD in children and adolescents are the SSRI agents, which have been documented as being effective as well as well-tolerated in children and adolescents. The best-documented SSRI to this point is sertraline. However, fluoxetine and fluoxamine have also undergone systematic studies in children and adolescents. Clomipramine has been proven effective, however, side effects caused by this agent would suggest that an SSRI is a better choice. Treatment with an SSRI seems to have effect in approximately 75 % of patients with OCD. There are still no systematic studies analyzing augmenting medication for children and adolescents with OCD. Research indicates that the combination of medication and psychotherapy (cognitive behavioural therapy) is important in most cases. Based on a few long-term follow-up studies on OCD children and adolescents there is not evidence that all children and adolescents suffer a lifetime course of the disease. It is therefore recommended that discontinuation is attempted after 1-1.5 years of successful treatment.

The selective serotonin reuptake inhibitor sertraline: its profile and use in psychiatric disorders

The naphthylamine derivative sertraline is a potent and selective inhibitor of serotonin reuptake into presynaptic terminals. Sertraline has a linear pharmacokinetic profile and a half-life of about 26 h. Its major metabolite, desmethylsertraline does not appear to inhibit serotonin reuptake. Sertraline mildly inhibits the CYP2D6 isoform of the cytochrome P450 system but has little effect on CYP1A2, CYP3A3/4, CYP2C9, or CYP2C19. It is, however, highly protein bound and may alter blood levels of other highly protein bound agents. Sertraline is a widely used serotonin reuptake inhibitor that has been shown to have both antidepressant and antianxiety effects. Many clinical trials have demonstrated its efficacy in depression compared with both placebo and other antidepressant drugs. Its efficacy has also been demonstrated in randomized, controlled trials of patients with obsessive-compulsive disorder, panic disorder, social phobia, and premenstrual dysphoric disorder. In short-term, open-label studies it has appeared efficacious and tolerable in children and adolescents and in the elderly, and data are positive for its use in pregnant or lactating women. Typical side effects include gastrointestinal and central nervous system effects as well as treatment-emergent sexual dysfunction; withdrawal reactions may be associated with abrupt discontinuation of the agent. The safety profile of sertraline in overdose is very favorable. Sertraline's efficacy for both mood and anxiety disorders, relatively weak effect on the cytochrome P450 system, and tolerability profile and safety in overdose are factors that contribute to make it a first-line agent for treatment in both primary and tertiary care settings.

An open trial of citalopram in adolescents with post-traumatic stress disorder

In this preliminary, 12-week open-label study, eight adolescents with moderate to severe post-traumatic stress disorder (PTSD) were treated with citalopram (the most selective of the selective serotonin reuptake inhibitors) in a fixed daily dose of 20 mg, and rated at 2-week intervals. The Clinician-Administered PTSD Scale (Child and Adolescent Version) was the primary measure used to assess treatment outcome. Core PTSD symptoms (re-experiencing, avoidance, and hyperarousal symptoms) showed statistically significant improvement at week 12 on the Clinician-Administered PTSD Scale (Child and Adolescent Version) (CAPS-CA), with a 38% reduction in total CAPS scores between baseline and endpoint. Citalopram failed to effect improvement on self-reported depressive symptoms. All seven adolescent completers were rated as much improved or very much improved on Clinical Global Impression Improvement scores. Citalopram was well-tolerated overall with reported adverse experiences being relatively benign. However, larger, controlled trials are needed to consolidate these preliminary results.

Fenfluramine challenge in anxious children

The study objective was to determine if serotonergic challenge with oral racemic fenfluramine would differentiate between childhood anxiety disorders in comparison to normal controls. Subjects were 24 children with anxiety diagnoses (DSM-IIIR) by structured interview, and 14 normal controls (ages 7 - 14 years) matched for age and sex. All subjects were given a standard challenge dose of d,1-fenfluramine (1 mg/kg) followed by serial assessments of cardiovascular, neurohormonal, and mood parameters over a five hour period. In response to fenfluramine, controls demonstrated increases in subjective anxiety and systolic blood pressure relative to anxious subjects. Fenfluramine was safely tolerated and did not induce panic symptoms in any subject. Exaggerated prolactin response to fenfluramine differentiated an obsessive - compulsive disorder (OCD) subset from both controls and other anxiety disorders. Fenfluramine challenge differentiates anxious children from healthy controls by elevated anxiety ratings and systolic blood pressure in controls. Increased prolactin response to fenfluramine discriminates children with obsessive - compulsive disorder from both healthy children and children with other anxiety diagnoses. As adults with OCD appear to demonstrate a blunted prolactin response to fenfluramine challenge, the serotonin pathways involved may differ between 'early' and 'late' onset disorder, or the serotonin substrates tapped by this challenge may change over time. Copyright 2000 John Wiley & Sons, Ltd.