CA Calarge et al. J Pediatr 2018; 201: 245-51. This study analyzed data from 4 separate trials with a total of 267 boys treated with risperidone. In this cohort, 71% had taken an SSRI.
Key finding: The duration and cumulative dose of SSRI was inversely associated with height z score, especially during Tanner 3 and 4 stages. The effect was approximately 1 cm for every year of treatment.
The authors speculate that SSRIs could “alter serotonin signaling, which is known to control GH secretion.”
- This study shows an association between SSRIs and linear growth but it remains unclear if this affects adult height (could postpone growth).
- This potential adverse effect needs to be considered in the clinical picture of the severe impairment and distress that can occur due to untreated depression and anxiety.
Related blog post: Brave New World: Psychotropic Manipulation and Pediatric Functional GI Disorders
Lake Louise, Banff
A recent study (C AM Zar-Kessler et al. JPGN 2017; 65: 16-21) retrospectively reviewed a single center’s 8 year experience (2005-2013) using antidepressant medications to treat nonorganic abdominal pain. Of 531 cases, 192 initiated treatment with either a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).
- 63 of 84 (75%) of SSRI-treated patients improved; 56 of 92 (61%) of TCA-treated patients improved. The higher response rate to SSRIs persisted after control for psychiatric factors.
- A much higher percentage of SSRI-treated patients, compared to TCA-treated patients, had anxiety (49% vs 22%); an additional 15% and 5%, respectively, had combined anxiety/depression.
- The most common SSRI in this study was citalopram with median dose of 10 mg (range 5-60 mg).
- The most common TCA in this study was nortriptyline with median dose of 20 mg (range 10-50).
- Similar numbers of patients in each group had adverse effects, include 21 (25%) of SSRI-treated patients and 20 (22%) of TCA-treated patients. 14% of SRRI-treated patients discontinue medication due to adverse effects, compared with 17% of TCA-treated patients.
- Mood disturbances were higher in this study among TCA-treated patients: 14% compared with 6% of SSRI-treated patients
- TCAs were prescribed by gastroenterologists in 88% of cases; with SSRIs, only 39% of prescriptions were from gastroenterologists.
In the discussion, the authors note that “all patients who experienced GI adverse effect were prescribed medications that would worsen their underlying bowel complaint…these issues may have been mitigated if more attention was paid” to this. “Specifically, TCAs should be used cautiously in those with constipation, whereas SSRIs should be avoided in those with diarrhea.”
My take: This study shows that both classes of antidepressants were associated with improvement. The conclusions about effectiveness are limited as this is a retrospective study and could not control/evaluate many variables. That being said, particularly if there is coexisting anxiety, as was frequent in this study population, a SSRI may be more effective.
Related blog posts:
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Tynn Church, Prague
When I visited MIT, one of the slogans I heard was “Getting an Education from MIT is like taking a drink from a Fire Hose.” While this is a ridiculous notion, it is also true that the amount of information to consume, not just at MIT, but in so many areas is tremendous in quantity. As such, one has to figure out what to read and what to toss. For GI physicians, a recent summary (DA Drossman. Gastroenterol 2016; 1262-80) is worth a read due to the ubiquitous nature of the problems discussed.
Here were some key points:
- “The possibility that passions or emotions could lead to the development of medical disease was first proposed by the Greek physician Claudius Galen.”
- “Rome IV is a compendium of knowledge accumulated since Rome III” –10 years ago.
Some of the Changes:
- New diagnoses: Narcotic bowel syndrome, opioid-induced constipation, cannabinoid hyperemesis syndrome
- Removal of functional terminology when possible…functional abdominal pain syndrome has been changed to centrally mediated abdominal pain syndrome
- Threshold changes for diagnostic criteria
- Addition of reflux hypersensitivity diagnosis.
- Revision of Sphincter of Oddi dysfunction disorder… “driven by evidence that debunks the value of sphincterotomy for type III SOD.”
- Emphasis that functional disorders exist on a spectrum with linked pathogenesis, particularly with regard to irritable bowel syndrome (IBS) subtypes.
- Removal of the term discomfort for IBS criteria and using pain as the key criterion.
Approach to Patients with Functional GI Disorders:
- The author discusses ways to engage patient to create partner-like interaction.
- “Determine the immediate reason for the patient’s visit (eg. What led you to see me at this time?)” Potential reasons: exacerbating factors, concern for serious disease, stressors, emotional comorbidity, impairment in daily functioning or hidden agenda (eg. disability, narcotics, litigation)
- “Determine what the patient understands of the illness…What do you think is causing your symptoms?”
- Provide a thorough explanation of the disorder. “For example: ‘I understand you believe you have an infection that has been missed; as we understand it, the infection is gone but your nerves have even affected by the infection to make you feel like it is still there, similar to phantom limb.”
- “Identify and respond realistically to the patient’s expectations for improvement (e.g. How do you feel I can be helpful to you?)”
- Explain ways that stress can be associated. “I understand you do not see stress as causing your pain, but you have mentioned how severe and disabling your pain is. How much do you think that is causing you emotional distress?”
- “Set consistent limits..narcotic medication is not indicated because it can be harmful.”
- “Involve patient in treatment plan (e.g. Let me suggest some treatments for you to consider).”
- With regard to use of TCAs, the author explains that antidepressants can be used “to turn down the pain, and pain benefit occurs in doses lower than that used for depression.” “Tricyclic antidepressants or the serotonin-norepinephrine reuptake inhibitors help control pain via central analgesia as well as provide relief of associated depressive symptoms. The selective serotonin reuptake inhibitors are less effective for pain but can help reduce anxiety and associated depression.”
- Establish an ongoing relationship. “Whatever the result of this treatment, I am prepared to consider other options, and I will continue to work with you through this.”
My take: This summary provides a succinct update on a 6-year effort of 117 investigators/clinicians from 23 countries. After reading this article, you will probably want to glance at the other articles in the same issue.
Vik Muniz Collage
A closer look at the front wheel