Fluvoxamine: a review of its therapeutic potential in the management of anxiety disorders in children and adolescents

Acetyl-11-keto-beta boswellic acid(AKBA) modulates CSTC-pathway by activating SIRT-1/Nrf2-HO-1 signalling in experimental rat model of obsessive-compulsive disorder: Evidenced by CSF, blood plasma and histopathological alterations

Obsessive-Compulsive disorder (OCD) is a long-term and persistent mental illness characterised by obsessive thoughts and compulsive behaviours. Numerous factors can contribute to the development or progression of OCD. These factors may result from the dysregulation of multiple intrinsic cellular pathways, including SIRT-1, Nrf2, and HO-1. Inhibitors of selective serotonin reuptake (SSRIs) are effective first-line treatments for OCD. In our ongoing research, we have investigated the role of SIRT-1, Nrf2, and HO-1, as well as the neuroprotective potential of Acetyl-11-keto-beta boswellic acid (AKBA) against behavioural and neurochemical changes in rodents treated with 8-OH-DPAT. In addition, the effects of AKBA were compared to those of fluvoxamine (FLX), a standard OCD medication. Injections of 8-OH-DPAT into the intra-dorso raphe nuclei (IDRN) of rats for seven days induced repetitive and compulsive behaviour accompanied by elevated oxidative stress, inflammatory processes, apoptosis, and neurotransmitter imbalances in CSF, blood plasma, and brain samples. Chronic administration of AKBA at 50 mg/kg and 100 mg/kg p.o. restored histopathological alterations in the cortico-striatal-thalamo-cortical (CSTC) pathway, including the cerebral cortex, striatum, and hippocampal regions. Our investigation revealed that when AKBA and fluvoxamine were administered together, the alterations were restored to a greater degree than when administered separately. These findings demonstrate that the neuroprotective effect of AKBA can serve as an effective basis for developing a novel OCD treatment.

Excessive mood elevation and behavioral activation with antidepressant treatment of juvenile depressive and anxiety disorders: a systematic review

BACKGROUND

The prevalence, characteristics and implications of excessive arousal-activation in children and adolescents treated with antidepressants for specific illnesses have not been systematically examined.

METHODS

We compared reports of antidepressant trials (n = 6,767 subjects) in juvenile depressive (n = 17) and anxiety disorders (n = 25) for consensus-based indications of psychopathological mood elevation or behavioral activation.

RESULTS

Rates of excessive arousal-activation during treatment with antidepressants were at least as high in juvenile anxiety (13.8%) as depressive (9.79%) disorders, and much lower with placebos (5.22 vs. 1.10%, respectively; both p < 0.0001). The antidepressant/placebo risk ratio for such reactions in paired comparisons was 3.50 (12.9/3.69%), and the meta-analytically pooled rate ratio was 1.7 (95% confidence interval: 1.2-2.2; both p ≤ 0.001). Overall rates for 'mania or hypomania', specifically, were 8.19% with and 0.17% without antidepressant treatment, with large drug/placebo risk ratios among depressive (10.4/0.45%) and anxiety (1.98/0.00%) disorder patients.

CONCLUSIONS

Risks of excessive mood elevation during antidepressant treatment, including mania-hypomania, were much greater than with placebo, and similar in juvenile anxiety and depressive disorders. Excessive arousal-activation in children or adolescents treated with antidepressants for anxiety as well as depressive disorders calls for particular caution and monitoring for potential risk of future bipolar disorder.

Pharmacotherapy for anxiety disorders in children and adolescents

BACKGROUND

Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders.

OBJECTIVES

To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%).

AUTHORS' CONCLUSIONS

Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

Child and adolescent psychopharmacology update

Understanding pediatric psychopharmacology often is an important part of the practice of a general psychiatrist, as a substantial number of children and adolescents are affected by a major psychiatric illness. A general psychiatrist should consider some key issues before he or she begins prescribing psychotropic medications to children and adolescents. Some agents that are effective in adults may not be effective in youths, and similarly, medications that are well tolerated in adults may be associated with accentuated or additional risks when prescribed to young people. This article is an effort to summarize the recent advances in medication therapy of the pediatric population and bring the general psychiatrist up to date on the evidence-based psychopharmacologic treatment of children and adolescents.

Serotonin syndrome following a single 50 mg dose of sertraline in a child

OBJECTIVE

To report a case of serotonin syndrome associated with a single, 50 mg dose of sertraline in a child and discuss the findings in context with previous relevant literature involving other selective serotonin reuptake inhibitors used in children.

CASE SUMMARY

A nine-year old male with chronic behavioral problems was prescribed oral sertraline 50 mg daily. After the first dose, the patient presented with abdominal pain, seizure-like activity, and change in mental status. He was admitted to a tertiary-care pediatric hospital and was treated for serotonin syndrome. Laboratory findings of elevated creatine kinase and serum creatinine were consistent with rhabdomyolysis as result of continued hypertonicity. Sertraline was discontinued and treatment with lorazepam and cyproheptadine was initiated. Clinical status, creatine kinase, and serum creatinine improved over 5 days of hospitalization. The Adverse Drug Reaction Probability Scale by Naranjo et al was applied to assess causality. The scale indicated the association of a single dose of sertraline and serotonin syndrome as "probable."

CONCLUSION

To our knowledge this is the first reported case of serotonin syndrome associated with a single dose of sertraline in a child using a validated causality scale. The sertraline 50 mg dose given to the child was higher than usual recommended initial doses (25 mg). This potential adverse reaction should be considered when selecting antidepressant therapy for children.