Assessing sexual symptoms and side effects in adolescents

Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) and, to a lesser extent, serotonin-norepinephrine reuptake inhibitors (SNRIs) are the cornerstone of pharmacotherapy for children and adolescents with anxiety and depressive disorders. These medications alleviate symptoms and restore function for many youths; however, they are associated with a distinct adverse effect profile, and their tolerability may complicate treatment or lead to discontinuation. Yet, SSRI/SNRI tolerability has received limited attention in the pediatric literature.

METHODS

This review examines the early- (e.g., activation, gastrointestinal symptoms, sedation) and late-emerging (e.g., weight gain) adverse effects of SSRIs and some SNRIs in pediatric patients.

RESULTS

We provide a framework for discussing SSRI/SNRI tolerability with patients and their families and describe the pharmacologic basis, course, and predictors of adverse events in youth. Strategies to address specific tolerability concerns are presented. For selected adverse events, using posterior simulation of mean differences over time, we describe their course based on Physical Symptom Checklist measures in a prospective, randomized trial of anxious youth aged 7-17 years who were treated with sertraline (n = 139) or placebo (n = 76) for 12 weeks in the Child/Adolescent Anxiety Multimodal Study (CAMS).

MAIN RESULTS

In CAMS, the relative severity/burden of total physical symptoms (p < 0.001), insomnia (p = 0.001), restlessness (p < 0.001), nausea (p = 0.002), abdominal pain (p < 0.001), and dry mouth (p = 0.024) decreased from baseline over 12 weeks of sertraline treatment, raising the possibility that these symptoms are transient. No significant changes were observed for sweating (p = 0.103), constipation (p = 0.241), or diarrhea (p = 0.489). Finally, we review the antidepressant withdrawal syndrome in children and adolescents and provide guidance for SSRI discontinuation, using pediatric pharmacokinetic models of escitalopram and sertraline-two of the most used SSRIs in youth.

CONCLUSION

SSRI/SNRIs are associated with both early-emerging (often transient) and late-emerging adverse effects in youth. Pharmacokinetically-informed appraoches may address some adverse effects and inform SSRI/SNRI discontinuation strategies.

Talking About Sexuality With Youth: A Taboo in Psychiatry?

BACKGROUND

Young people who have psychiatric problems are more likely than their peers to endure difficulties during their sexual and gender identity development.

AIM

This study aims to examine the communication between mental health care providers and their patients about the topics of relations, sexuality and gender identity, including a description of professionals' attitudes toward these topics and the factors that contribute to and inhibit communication.

METHODS

Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors, parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on communication about sexuality and gender identity with their young patients (age 12-21 years).

OUTCOMES

Sexuality and gender identity are infrequently discussed by mental health care providers with their young patients or their patients' parents.

RESULTS

Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. However, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%) of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infrequently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimulants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own feelings of discomfort, and the patients' supposed feelings of shame. There was no gender differences observed.

CLINICAL IMPLICATIONS

Recommendations for professionals include to be aware of these topics, initiating age-appropriate conversation and use inclusive language.

STRENGTHS AND LIMITATIONS

The present study included a diverse and representative group of mental health care professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias.

CONCLUSION

Despite a recognized need to engage in age-appropriate communication about sexuality and gender identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics. Bungener SL, Post L, Berends I, et al. Talking About Sexuality With Youth: A Taboo in Psychiatry?. J Sex Med 2022;19:421-429.

Sexual Functioning in Adolescents With Major Depressive Disorder: A Prospective Study

Objective: To examine the association between sexual functioning, depression and anxiety severity, and selective serotonin reuptake inhibitor (SSRI) use in adolescents.

Methods: From September 2010 to December 2014, 15- to 20-year-old participants, either unmedicated or within a month of beginning SSRI treatment, completed the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Changes in Sexual Functioning Questionnaire (CSFQ) at baseline and every 4 months for up to 2 years. The DSM-IV-TR was used to determine presence of psychiatric disorders. Data regarding use of medications and hormonal contraception were collected. Polymorphisms of the HTR2A and ABCB1 genes were genotyped. Linear mixed-effects regression models examined the association between depression and anxiety symptom severity, SSRI use, and sexual functioning, accounting for relevant covariates.

Results: A total of 263 participants (59% female, mean ± SD age = 18.9 ± 1.6 years, 70% with major depressive disorder) contributed to this analysis. After adjusting for age, sex, and duration in the study, depression severity, but not anxiety severity, was associated with lower CSFQ total scores (β = -0.13, P < .0001) and lower arousal, orgasm, and pleasure subscale scores (all β = -0.03, P < .003). Higher SSRI doses were associated with lower orgasm subscale scores (β = -0.30, P < .03). Hormonal contraceptive use was associated with higher CSFQ total scores (β = 0.97, P < .003) and higher arousal (β = 0.25, P < .009), desire (β = 0.24, P < .001), orgasm (β = 0.27, P < .02), and pleasure (β = 0.15, P < .004) subscale scores. No significant genetic moderating effect was found.

Conclusions: In adolescents, depression is associated with lower sexual functioning while SSRI use impairs orgasm.

Management of Adverse Effects of Psychotropic Medications

Psychotropic medications are an essential component of treating pediatric mental health disorders, and pediatricians are increasingly likely to prescribe them. Commonly used psychotropic medications include stimulants and nonstimulants used in the treatment of attention-deficit/hyperactivity disorder (ADHD); antidepressants used in the treatment of anxiety and depression; and antipsychotics indicated for use in autism, schizophrenia, mood disorders, severe impulsivity, and aggression. Stimulants are commonly associated with appetite suppression and initial insomnia and nonstimulants for ADHD are associated with sedation. Antidepressants are generally well tolerated; adverse effects include behavioral activation early in treatment and, rarely, treatment-emergent mania and suicidal ideation. Potential adverse effects of atypical antipsychotics include weight gain and metabolic syndrome. Monitoring strategies are reviewed. [Pediatr Ann. 2020;49(10):e431-e435.].