Psychopharmacology of pediatric obsessive-compulsive disorder: three case reports

Preschool-onset OCD: A review of literature and clinical experience

Obsessive-compulsive disorder (OCD) has been described in preschool children as young as 2-3 years old. A preschool age onset of OCD has unique diagnostic and therapeutic challenges. In this article, the authors review published literature on preschool onset OCD and present data on preschool-onset OCD (age of onset ≤ 5 years) from clinical records at a tertiary care child and adolescent psychiatry center in India. Literature suggests that OCD that starts this early is phenomenologically similar to OCD in older individuals; however, it has very high rates of comorbidity and a family history of OCD. There is a paucity of data on course, treatment, and long-term outcome in this group. At their center, the authors found a 3% prevalence of preschool-onset OCD, with a male predominance (69%) and fairly high comorbidity rates (62%). Qualitative review highlighted delay in treatment seeking, poor follow-up rates, frequent use of pharmacological treatment, and a high remission rate in those treated adequately.

Polypharmacy with antidepressants in children and adolescents

The aim of this study was to review current epidemiological data on the use of antidepressants in co-prescription with other psychotropic drugs in children and adolescents, as well as available efficacy and safety information. A Medline search from inception until February 2012 was performed to identify epidemiological and clinical studies, reviews and reports containing potentially relevant information on polypharmacy with antidepressants in young people. There has been an increase in polypharmacy in children and adolescents involving antidepressants in recent years. Antidepressants have become one of the drug classes most frequently prescribed in combination and are commonly co-prescribed with stimulants and antipsychotics. Most information regarding efficacy and safety of polypharmacy patterns was provided by case series and open-label studies. Efficacy studies gave some support for the use of a combination of antidepressants and antipsychotics in the management of refractory obsessive-compulsive disorder and some residual symptoms in major depressive disorder. Even less empirical support was found for a combination of stimulants and antidepressants in co-morbid attention deficit hyperactivity disorder and mood or anxiety disorders. Adverse events were similar to those found with individual medication groups, with severe adverse events mostly reported by individual case reports. The use of polypharmacy with antidepressants has become a regular practice in clinical settings. Although there is still little efficacy and safety information, preliminary evidence points to the potential clinical usefulness of some polypharmacy patterns. Further research on patients with co-morbidities or more severe conditions is needed, in order to improve knowledge of this issue.

The use of antipsychotics in preschoolers: a veto or a sensible last option?

Recent reports have illustrated a dramatic rise in the use of antipsychotics in preschool children, medications originally designed and licensed for the treatment of adult psychotic disorders. Within this context, the current usage and the associated diagnoses are reviewed and compared with official guidelines and licensing for such use, highlighting a controversial challenge for clinicians. A review of the evidence base of the relative efficacy of such medications for a range of disorders is given. Associated safety and side effects are discussed, with compelling evidence for increased adverse events associated with use of antipsychotics in preschoolers, and neurodevelopmental hypotheses are used to guide predictions of long-term risk. An apparent gap in the literature and evidence base supporting such use and elucidating the risks and benefits leaves a challenge for clinicians and researchers and hinders the development of appropriate guidelines. Pragmatism in clinical practice, mindful of the limited evidence base that does exist and the propensity for harm, is necessary; far more research is required in this important area.

Current state of evidence for medication treatment of preschool internalizing disorders

Psychotropic medications are being prescribed off-label by psychiatrists to treat preschool children diagnosed with internalizing disorders. In this review, the current state of evidence is presented for medications used to treat preschool children (ages 2-5 year olds) diagnosed with anxiety and/or depressive disorders. Eleven studies were systematically identified for this review based on a priori criteria. Overall, the available literature revealed that studies addressing the medication treatment of internalizing disorders in preschoolers are extremely limited and represent relatively weak research methodologies. Given the increasing prevalence of the use of psychotropic medications to treat preschool children and the unique challenges associated with working with this population, it is imperative that mental health practitioners are aware of the current, albeit limited, research on this practice to help make informed treatment decisions. Suggestions about how to monitor potential costs and benefits in those unique cases in which psychopharmacological treatments might be considered for young children are given. Moreover, areas of additional research for this population are discussed.

Preschool children with obsessive-compulsive disorder and fluoxetine treatment

Obsessive-compulsive disorder (OCD) is an anxiety disorder which can substantially disable children's ability to function at home and school. Clinicians frequently rely on knowledge about symptoms that can be examined early in treatment to determine future treatment effectiveness. However, OCD in preschoolers has also received little attention in literature. To the best of our knowledge, there is only one retrospective chart review and one case report in the literature for preschool cases treated with SSRIs. Therefore, the effect of fluoxetine on preschool children was imprecisely understood. The aim of this case report was to examine the efficacy and safety of fluoxetine treatment for pediatric OCD. Four preschool children with OCD completed an 8-week fluoxetine (up to 20 mg) trial. We diagnosed OCD according to Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR) criteria and symptoms of OCD were assessed with the Childrens' Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Initial and post-treatment symptom severity and improvement were assessed by using the severity (S) and improvement (I) scales of Clinical Global Impressions Scale (CGI). The CY-BOCS total, obsessions and compulsions subscale scores and CGI-S scores were significantly improved for all of the cases at the end of the eighth week. In this case report four preschool children, with severe OCD and resistant to the previous non-psychopharmacologic treatment responded well to fluoxetine monotherapy. On the other hand, the usage of SSRIs in preschool children remains highly controversial, due to the lack of data on safety and efficacy.

Trends in antipsychotic drug use by very young, privately insured children

OBJECTIVE

This study describes recent trends and patterns in antipsychotic treatment of privately insured children aged 2 through 5 years.

METHOD

A trend analysis is presented of antipsychotic medication use (1999-2001 versus 2007) stratified by patient characteristics. Data are analyzed from a large administrative database of privately insured individuals. Participants were privately insured children, aged 2 through 5 years, with 12 months of continuous service enrollment in 1999-2001 (N = 400,196) or 2007 (N = 755,793). The main outcomes are annualized rates of antipsychotic use and adjusted rate ratios (ARR) of year effect on rate of antipsychotic use adjusted for age, sex, and treated mental disorder.

RESULTS

The annualized rate of any antipsychotic use per 1,000 children increased from 0.78 (95% confidence interval [CI] 0.69-0.88) (1999-2001) to 1.59 (95% CI 1.50-1.68) (2007) (ARR 1.76, 95% CI 1.56-2.00). Significant increases in antipsychotic drug use were evident for boys (ARR 1.66, 95% CI 1.44-1.90) and girls (ARR 2.26, 95% CI 1.70-3.01) and for children diagnosed with several different psychiatric disorders. Among antipsychotic-treated children in the 2007 sample, pervasive developmental disorder or mental retardation (28.2%), attention deficit/hyperactivity disorder (ADHD) (23.7%), and disruptive behavior disorder (12.9%) were the most common clinical diagnoses. Fewer than one-half of antipsychotic-treated young children received a mental health assessment (40.8%), a psychotherapy visit (41.4%), or a visit with a psychiatrist (42.6%) during the year of antipsychotic use.

CONCLUSIONS

Despite increasing rates of antipsychotic use by very young children, provision of formal mental health services remains sparse. These service patterns highlight a critical need to improve the availability of specialized and well integrated mental health care for very young children with serious mental health problems.

Psychopharmacology and preschoolers: a critical review of current conditions

Rates of prescriptions for very young children have increased notably in the last 20 years. These changes have occurred in the context of increasing attention to early childhood mental health, availability of medications perceived to be safer than older medications, application of the medical model to the mental health care of young children, as well as other cultural shifts. Psychopharmacological treatment for any patient, but especially very young children, requires consideration of central nervous system (CNS) and metabolic development and issues of diagnostic validity and should be guided by an empirical literature. In young children, this literature is quite limited. In this article, the authors review developmental issues involved in psychopharmacological treatment and present existing literature and practical guidelines for common preschool diagnoses, recognizing that for some disorders, the extant literature does not support even consideration of medications.

Internalizing disorders in early childhood: a review of depressive and anxiety disorders

This article reviews the use of the broad category of internalizing disorders and data on young children using this definition. It also reviews the emerging support for more specific internalizing diagnoses in very young children. The current empiric database on nosology and treatment of mood and anxiety disorders in young children is examined, and a clinical case example is included. Identification of recent advances in the understanding and treatment of anxiety disorders in young children and areas in which future studies are needed also are explored.