Pharmacological treatment of depression in children and adolescents

A double-blind, placebo-controlled study of selegiline transdermal system in depressed adolescents

OBJECTIVE

A randomized, double-blind, placebo-controlled flexible-dose, parallel group trial was conducted at 26 clinical investigational sites in the United States to examine the safety and efficacy of the selegiline transdermal system (STS) (EMSAM®) in adolescents (ages 12-17 years) meeting American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for moderate to severe major depressive disorder (MDD) without psychotic features.

METHODS

Adolescents (n=308) with moderate to severe MDD were randomized to either STS (n=152) or placebo (n=156). Two hundred and fifteen (69.8%) subjects completed the study and 17 (5.5%) reported discontinuation because of adverse events (AEs). The primary efficacy outcome measure was the mean change from baseline to end of study (week 12 last observation carried forward [LOCF]) in the Children's Depression Rating Scale-Revised (CDRS-R) total score. Secondary outcome measures included end-point Clinical Global Impressions - Severity (CGI-S) and Clinical Global Impressions - Improvement (CGI-I).

RESULTS

Patients on STS or placebo had a significant decline from baseline (p<0.001) on their CDRS-R total score with mean reductions±SD as follows: STS 21.4±16.6; placebo 21.5±16.5. Both groups had similar response rates (58.6% vs. 59.3%) defined as CGI-I of 1 or 2 at study end. However, these between-group efficacy findings were without statistical significance. The overall incidence of reported AEs was 62.5% for STS-treated patients and 57.7% for placebo-treated patients. Most commonly reported AEs in STS or placebo groups were application site reactions (STS=24.3%; placebo=21.8%), headache (STS=17.1%; placebo=16.7%), and nausea (STS=7.2%; placebo=7.7%). Treatment groups did not differ on any laboratory parameters, vital signs, or electrocardiogram (ECG) findings. No suspected hypertensive crises were reported in the trial.

CONCLUSIONS

These data demonstrated that the STS was safe and well tolerated in this adolescent sample. However, both STS-treated and placebo-treated subjects demonstrated a decline from baseline in depressive symptoms (CDRS-R total score) over the length of the study, without statistical superiority by either group.

Tricyclic antidepressants for autism spectrum disorders (ASD) in children and adolescents

BACKGROUND

Autism spectrum disorders (ASD) are a heterogeneous group of neurodevelopmental disorders, ranging in severity and characterised by early onset of delay and deviance in the development of social interaction, and verbal and nonverbal communication. ASD is associated with restricted and/or stereotyped interests or behaviours. Tricyclic antidepressants (TCAs) block noradrenaline and serotonin reuptake, increasing the availability of these neurotransmitters in the central nervous system. Via their impact on serotonin, TCAs have been used in the treatment of autistic symptoms and comorbidities in individuals with ASD.  

OBJECTIVES

To determine if treatment with tricyclic antidepressants:1) improves the core features of autism, including restricted social interaction, restricted communication, and stereotypical and repetitive behaviours; 2) improves non-core features such as challenging behaviours; 3) improves comorbid states, such as depression and anxiety; 4) causes adverse effects.

SEARCH METHODS

We ran the latest searches for this review on 23 May 2011. We searched: Cochrane Central Register of Controlled Trials (CENTRAL), 2011 Issue 2, MEDLINE (1948 to May Week 2, 2011), EMBASE (1980 to 2011 Week 2), PsycINFO (1887 to current), CINAHL (1937 to current). We also searched Dissertation Abstracts International via Dissertation Express, and the metaRegister of Controlled Trials.

SELECTION CRITERIA

Randomised controlled trials of any dose, duration and frequency of oral TCAs compared with placebo, in children and adolescents with a diagnosis of ASD, where at least one standardised outcome measure had been used.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and appraised the studies for inclusion and risk of bias. All data were continuous.

MAIN RESULTS

Three studies met the inclusion criteria for this review. Two studies used clomipramine and one used tianeptine. All three trials were small, with between 12 and 32 participants. One of the clomipramine trials involved children and young adults, while the other two trials enrolled only children. Due to heterogeneity in study participant characteristics, the TCA medications investigated and the outcome measures used, we were not able to perform any meta-analysis.In only one of the three studies was there any indication that giving children tianeptine could be effective in the short term. In this study, parents and teachers reported that it reduced irritability, hyperactivity, inadequate eye contact and inappropriate speech, but clinician ratings found no significant impact on these symptoms. There were also significant adverse effects, including increased drowsiness and reduced activity levels in these individuals while being treated with tianeptine. The evidence of the impact of clomipramine in the two studies is contradictory. There was evidence of improvement in autistic symptoms, irritability and obsessive-compulsive disorder type symptoms, but conflicting evidence in relation to hyperactivity across the two studies, and no significant changes found with inappropriate speech. There were also adverse effects reported with the use of clomipramine. Although side effect ratings were not significantly different to placebo, there were significant dropout rates in the clomipramine arm of one study.

AUTHORS' CONCLUSIONS

Clinicians considering the use of TCAs need to be aware of the limited and conflicting evidence of effect and the side effect profile when discussing this treatment option with people who have ASD and their carers. Further research is required before TCAs can be recommended for treatment of individuals with ASD.

Antidepressant-coincident mania in children and adolescents treated with selective serotonin reuptake inhibitors

Several factors have amplified concern about the possibility that antidepressant medication may contribute to induction of pediatric mania. These include the high rate of antidepressant medication prescription, the recent surge in the rate of diagnosis of pediatric bipolar disorder in the USA, and a growing number of case reports and clinical studies showing coincidence of manic symptoms with antidepressant pharmacotherapy in both youths and adults. However, the question of how medications and manic symptoms might be related is complicated, and decisive research studies with rigorous designs for evaluating the issues have not been published. The situation makes it difficult for practitioners to make good, evidence-based decisions. The scientific literature is ambiguous, and the stakes are high. We review the extant literature, offer seven different conceptual models of how medication and mania might be related, and comment on the evidence and clinical implications of each.

A cumulative meta-analysis of selective serotonin reuptake inhibitors in pediatric depression: did unpublished studies influence the efficacy/safety debate?

OBJECTIVE

The aim of this study was to assess whether unpublished trials of serotonin reuptake inhibitors in pediatric depression impacted efficacy or safety conclusions, and to examine the evolution of information contributing to the safety/efficacy debate.

METHOD

From 939 potentially relevant studies extracted from Medline, Cinahl, Biosis, and Cochrane databases, and from the United Kingdom's Committee on Safety of Medicines website, we examined 38 studies: Ten published and five unpublished randomized, controlled trials, 22 observational studies, and one crossover trial. We performed cumulative and non-cumulative meta-analyses and generated pooled relative rates of response and serious adverse events for high-quality randomized, controlled trials.

RESULTS

Unpublished studies did not substantially alter the risk-to-benefit determination. Cumulative meta-analyses of seven randomized, controlled trials for efficacy and 11 randomized, controlled trials for safety suggest an adverse safety/efficacy profile for selective serotonin reuptake inhibitors (SSRIs) overall. Fluoxetine and citalopram appear to offer favorable risk to benefit profiles, while shorter-acting agents pose greater risks and provide marginal benefit.

CONCLUSIONS

While simple meta-analysis across all SSRIs for treatment of pediatric depression provided general efficacy and safety information, meta-analysis of individual drugs and use of cumulative meta-analytic techniques may have expedited our ability to formulate conclusions about safety and efficacy of SSRIs in pediatric depression.

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.

Somatic treatment for depressive illnesses in children and adolescents

Numerous somatic interventions have been studied as potential treatments of depressive disorders in children and adolescents. These include antidepressant medications, light therapy, electro-convulsive therapy, and alternative therapies. The available evidence suggests that several somatic interventions hold promise as potentially safe and effective treatments for depressed youths; however, there is still much to be learned about these interventions. This article reviews what is known and what needs to be learned about the somatic treatment of pediatric depression.

Toward an integration of parent and clinician report on the Young Mania Rating Scale

BACKGROUND

The Young Mania Rating Scale (YMRS) has validity in the assessment of mania in adults. The purpose of this study was to examine how the YMRS might optimally be used in the assessment of youths.

METHODS

Children and adolescents between the ages of 5 and 17 years of age participated in this study. All youths were evaluated with the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). Based on the K-SADS results, subjects were then assigned to one of five groups: a bipolar I group, another bipolar spectrum group, a depressive disorders group, a disruptive behaviors disorders group, and a no diagnosis group. Guardians completed a version of the YMRS modified for parent reporting. Clinicians completed the YMRS on all participating youths.

RESULTS

Both parent and clinician ratings on the YMRS assigned patients (n=117) to the appropriate diagnostic group with 71-98% accuracy. Combining information from multiple informants did not significantly improve diagnostic group assignment.

LIMITATIONS

The same raters completed the clinician YMRS and the K-SADS interview involving the parent. Findings need replication in an independent sample with lower base rates of bipolar disorder, less rigorously trained and supervised raters, and using a prospective design to provide maximum generalizability of results. Current results should be interpreted as a 'best case' scenario.

CONCLUSIONS

These data suggest that the YMRS may be a useful adjunct in assessing the severity of mania in youths. Tentative cutting scores are proposed to maximize efficiency, sensitivity, and specificity.

Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention

Suicide is rare in childhood and early adolescence, and becomes more frequent with increasing age. The latest mean worldwide annual rates of suicide per 100 000 were 0.5 for females and 0.9 for males among 5-14-year-olds, and 12.0 for females and 14.2 for males among 15-24-year-olds, respectively. In most countries, males outnumber females in youth suicide statistics. Although the rates vary between countries, suicide is one of the commonest causes of death among young people. Due to the growing risk for suicide with increasing age, adolescents are the main target of suicide prevention. Reportedly, less than half of young people who have committed suicide had received psychiatric care, and thus broad prevention strategies are needed in healthcare and social services. Primary care clinicians are key professionals in recognizing youth at risk for suicide. This article reviews recent population-based psychological autopsy studies of youth suicides and selected follow-up studies of clinical populations and suicide attempters, analyzing risk factors for youth suicides. As youth suicides are rare, research on risk factors for youth suicidal ideation and attempted suicide is also briefly reviewed. The relationship between psychiatric disorders and adolescent suicide is now well established. Mood disorders, substance abuse and prior suicide attempts are strongly related with youth suicides. Factors related to family adversity, social alienation and precipitating problems also contribute to the risk of suicide. The main target of effective prevention of youth suicide is to reduce suicide risk factors. Recognition and effective treatment of psychiatric disorders, e.g. depression, are essential in preventing child and adolescent suicides. Research on the treatment of diagnosed depressive disorders and of those with suicidal behavior is reviewed. In the treatment of youth depression, psychosocial treatments have proved to be useful and efficacious. Although studies on the effectiveness of selective serotonin reuptake inhibitors are limited in number, evidence supports their use as first-line antidepressant medication in youth depression. Available evidence suggests that various treatment modalities are useful in the treatment of suicidal youths, e.g. cognitive behavioral therapy and specialized emergency room interventions. Much of the decrease in suicide ideation and suicide attempts seems to be attributable to nonspecific elements in treatment. For high-risk youth, providing continuity of care is a challenge, since they are often noncompliant and commonly drop out or terminate their treatment prematurely. Developing efficacious treatments for suicidal children and adolescents would offer better possibilities to prevent suicides.

Die selektiven Serotonin-Wiederaufnahmehemmer und die neueren Antidepressivasubstanzen in der Kinder- und Jugendpsychiatrie

Zusammenfassung: Fragestellung: Seit der ersten Publikation über einen selektiven Serotonin-Wiederaufnahmehemmer (SSRI) 1974 kam es nicht nur zur Weiterentwicklung der Wirkstoffe aus der Gruppe der SSRI, sondern es sind auch neue Substanzgruppen entwickelt worden. Zu diesen neueren Substanzgruppen gehören, gegliedert nach dem pharmakologischen Wirkmechanismus, die Serotonin2-Antagonisten/Serotonin-Wiederaufnahmehemmer (SARI), die noradrenergen und selektiv serotonergen Antidepressiva (NaSSA), die Noradrenalin- und Dopamin-Wiederaufnahmehemmer (NDRI) und die Serotonin- und Noradrenalin-Wiederaufnahmehemmer (SNRI). In dieser Übersichtsarbeit werden die Wirkmechanismen und Nebenwirkungssprofile der neuen Antidepressivasubstanzen dargestellt und mit den älteren Substanzgruppen wie trizyklischen Antidepressiva (TZA), MAO-Hemmern (MAOH) und SSRI verglichen. Es werden Studien mit Antidepressiva bei Kindern und Jugendlichen mit Depression vorgestellt und verglichen, ob es Unterschiede zwischen den älteren und neueren Antidepressiva gibt. Methode: Es wurde eine Medline Recherche bis einschließlich Januar 2002 durchgeführt. Schlussfolgerungen: Die bis jetzt durchgeführten Studien mit den neueren Antidepressiva sind vielversprechend. Allerdings sind weitere doppelblind, Placebo-kontrollierte Studien notwendig.

Pharmacologic treatment of adolescent depression

Depression is a disease entity that causes significant morbidity and mortality in the adolescent population. It is important for primary care providers to recognize the signs and symptoms associated with depression in adolescents. This article discusses the current literature addressing the pharmacologic treatment of adolescent depression. A brief review of diagnosing depression is included. Diagnosis of depression in the adolescent with normal and abnormal development is examined, along with risk factors associated with increased incidence of depression in this population. Past and present clinical trials of tricyclic, monoamine oxidase inhibitor, and selective serotonin reuptake inhibitor classes of antidepressants are reviewed. In addition, adverse effects and toxicity are briefly discussed. Currently, the selective serotonin reuptake inhibitors are the first-line pharmacologic intervention for adolescent depression, although only selected drugs have undergone controlled clinical trials in this age group. The high toxicity profile of other classes of antidepressants makes their choice less optimal. Newer antidepressants have also been studied recently in the adolescent population. Further pharmacotherapy research in this vulnerable cohort is needed.

Depression in adolescence

Major depression is a common mental health disorder in adolescents that predicts a significant risk for recurrence in adulthood. Suicide is the third most frequent cause of deaths in this age group, and depression is a significant risk factor for suicidal ideation and attempts. Risks for depression and suicidal ideation are reviewed, and subtypes of depression are discussed. Difficulties associated with identification of depression and suicidal ideation in adolescents and biologic therapies for adolescent depression are reviewed.

The use of electroconvulsive therapy in special patient populations

BACKGROUND

Despite its well-established efficacy and its increasing use, electroconvulsive therapy (ECT) remains a controversial treatment. Lack of clarity in the issues related to its use in special patient populations (for example, in children, in adolescents, in pregnant women, in the elderly, and in the medically ill) often contributes to the debate about the use of ECT.

METHOD

The literature on ECT use in special patient populations is reviewed, together with the commonly associated high-risk medical conditions in clinical practice. Specific reference is made in each case to the safety, tolerability, and efficacy of the procedure.

RESULTS

Much of the literature surveyed consists of case studies, although a few controlled trials are available. In general, ECT use in special populations is relatively safe and extremely effective. In small case series, ECT use in children and adolescents is effective but requires further systematic study. In pregnant women, ECT is very effective, and with proper medical care, it is relatively safe in all trimesters of pregnancy, as well as in the postpartum period. The frail elderly are particularly good candidates for ECT because they are often unresponsive to or intolerant of psychotropic medication. Medical conditions that should receive particular attention during a course of ECT are disorders of the central nervous system (CNS), cardiovascular, and respiratory system. With modern anesthesia techniques and careful medical management of each high-risk patient, most can successfully complete a course of ECT. The process of obtaining informed consent also requires special consideration in this group of patients because their capacity to consent to treatment may be compromised.

CONCLUSIONS

With careful attention to each patient's medical and anesthesia needs, ECT is an effective and relatively safe procedure in high-risk special patient populations.

Paediatric psychopharmacology: closing the gap between science and practice

Children and adolescents do not always respond to treatment with psychotropic agents in a similar fashion to adults. Differences in safety and therapeutic response may occur across the life cycle. For example, despite the fact that tricyclic antidepressants are traditionally the 'gold standards' of pharmacotherapy for depressed adults, it does not seem that youths with depression benefit from treatment with these agents [1]. Similarly, it appears that earlier age at onset is associated with a reduced propensity to respond to neuroleptics for patients with schizophrenia [2]. In addition, young patients have been noted to be at higher risk for developing neuroleptic-induced extrapyramidal side effects when compared to adults [3]. Simply put, what is known about the safety and effectiveness of psychotropic compounds in adults cannot necessarily be presumed to be applicable to teenagers or children.

Nefazodone pharmacokinetics in depressed children and adolescents

OBJECTIVE

To describe the pharmacokinetics and safety of nefazodone (NFZ) in depressed children and adolescents.

METHOD

Depressed youths aged 7 to 17 years were eligible to participate. Intensive sampling for pharmacokinetic analyses of NFZ and 3 of its active metabolites was performed after single and multiple dose administration. Treatment was continued for 6 more weeks and titrated to maximize clinical response.

RESULTS

Twenty-eight patients were enrolled. Systemic exposure to NFZ and 3 metabolites was generally higher in children than adolescents. NFZ and metabolite disposition profiles showed high intra- and interpatient variability. Compared to published data in adults, the half-life of NFZ and 2 of its metabolites appears shorter in children and adolescents. Meta-chlorphenylpiperazine pharmacokinetic parameters were different in 5 patients determined to be poor metabolizers of cytochrome P450 2D6 (CYP2D6). NFZ was well tolerated, and administration was associated with significant reductions (p < .001) in depressive symptoms.

CONCLUSIONS

The pharmacokinetics of NFZ in pediatric patients is highly variable. NFZ appears to be safe in this small, short-term study. Pediatric patients who are poor metabolizers of CYP2D6 do not appear to be at increased risk for NFZ-associated adverse events. Open-label treatment of NFZ is associated with reductions in depressive symptoms.