SSRIs Not Known to Promote Suicide Risk in Pediatric OCD

PARIS – Selective serotonin reuptake inhibitors have not been shown to increase suicide risk in children and adolescents with obsessive-compulsive disorder and should not be withheld from these patients, Dr. Martine F. Flament advised at the annual congress of the European College of Neuropsychopharmacology.

Individual studies and pooled analyses have shown SSRIs to be comparable with clomipramine in pediatric cases of obsessive-compulsive disorder (OCD), said Dr. Flament, a professor of psychiatry and research director of the youth program at the University of Ottawa Institute of Mental Health Research.

Both clomipramine and SSRIs have produced 20%–45% improvement in clinical trials conducted since 1985, according to Dr. Flament. Clomipramine at 141–150 mg per day has been shown to be superior to placebo and to desipramine.

Fluoxetine at 20–64 mg per day, sertraline at 160–167 mg per day, and fluvoxamine at 50–200 mg per day also were superior to placebo in randomized trials.

She also cited a meta-analysis that found a statistically significant but modest benefit for SSRIs in the treatment of pediatric OCD (Am. J. Psychiatry 2003;160:1919–28). “So there is evidence that medication works. It brings some improvement, but not complete remission,” she said.

Despite growing concern that SSRIs increase suicide risk in children and adolescents being treated for depression, Dr. Flament said no individual study has shown SSRIs are associated with more suicidal ideation or behavior than placebo in children being treated for OCD. Most recent studies have not identified any treatment-emergent suicidal behaviors, she added.

Pooled analyses of controlled studies in OCD and other anxiety disorders have shown other behavioral side effects, she said, listing activation, akathisia, disinhibition, impulsivity, and hyperactivity. Again, she said, no analysis has shown a significant risk for increased suicidal thoughts or behaviors.

“Rigorous clinical monitoring for suicidal ideation and behavior is advised in youth, as in older patients,” she said, adding that “in pediatric OCD, SSRI treatment is generally thought to show a favorable risk-to-benefit ratio.”

To optimize treatment response, Dr. Flament recommended assessing how a child with OCD responds to the first medication prescribed. If the patient does not respond in 10–12 weeks to one SSRI, she suggested trying another SSRI.

If, however, the child has a partial response, Dr. Flament offered two options. Combining medication with behavioral therapy has been shown to improve outcomes and decrease the relapse rate when medication is discontinued, she said.

The other option is augmentation either to enhance serotonin neurotransmission or to antagonize dopamine neurotransmission in children with comorbid tic disorders.

Augmentation has been shown to improve outcomes, Dr. Flament said, with the caveat that very few studies have been conducted and with very small numbers of children.

Clomipramine and SSRIs have produced 20%–45% improvement in clinical trials since 1985. DR. FLAMENT

PARIS – Selective serotonin reuptake inhibitors have not been shown to increase suicide risk in children and adolescents with obsessive-compulsive disorder and should not be withheld from these patients, Dr. Martine F. Flament advised at the annual congress of the European College of Neuropsychopharmacology.

Individual studies and pooled analyses have shown SSRIs to be comparable with clomipramine in pediatric cases of obsessive-compulsive disorder (OCD), said Dr. Flament, a professor of psychiatry and research director of the youth program at the University of Ottawa Institute of Mental Health Research.

Both clomipramine and SSRIs have produced 20%–45% improvement in clinical trials conducted since 1985, according to Dr. Flament. Clomipramine at 141–150 mg per day has been shown to be superior to placebo and to desipramine.

Fluoxetine at 20–64 mg per day, sertraline at 160–167 mg per day, and fluvoxamine at 50–200 mg per day also were superior to placebo in randomized trials.

She also cited a meta-analysis that found a statistically significant but modest benefit for SSRIs in the treatment of pediatric OCD (Am. J. Psychiatry 2003;160:1919–28). “So there is evidence that medication works. It brings some improvement, but not complete remission,” she said.

Despite growing concern that SSRIs increase suicide risk in children and adolescents being treated for depression, Dr. Flament said no individual study has shown SSRIs are associated with more suicidal ideation or behavior than placebo in children being treated for OCD. Most recent studies have not identified any treatment-emergent suicidal behaviors, she added.

Pooled analyses of controlled studies in OCD and other anxiety disorders have shown other behavioral side effects, she said, listing activation, akathisia, disinhibition, impulsivity, and hyperactivity. Again, she said, no analysis has shown a significant risk for increased suicidal thoughts or behaviors.

“Rigorous clinical monitoring for suicidal ideation and behavior is advised in youth, as in older patients,” she said, adding that “in pediatric OCD, SSRI treatment is generally thought to show a favorable risk-to-benefit ratio.”

To optimize treatment response, Dr. Flament recommended assessing how a child with OCD responds to the first medication prescribed. If the patient does not respond in 10–12 weeks to one SSRI, she suggested trying another SSRI.

If, however, the child has a partial response, Dr. Flament offered two options. Combining medication with behavioral therapy has been shown to improve outcomes and decrease the relapse rate when medication is discontinued, she said.

The other option is augmentation either to enhance serotonin neurotransmission or to antagonize dopamine neurotransmission in children with comorbid tic disorders.

Augmentation has been shown to improve outcomes, Dr. Flament said, with the caveat that very few studies have been conducted and with very small numbers of children.

Clomipramine and SSRIs have produced 20%–45% improvement in clinical trials since 1985. DR. FLAMENT

PARIS – Selective serotonin reuptake inhibitors have not been shown to increase suicide risk in children and adolescents with obsessive-compulsive disorder and should not be withheld from these patients, Dr. Martine F. Flament advised at the annual congress of the European College of Neuropsychopharmacology.

Individual studies and pooled analyses have shown SSRIs to be comparable with clomipramine in pediatric cases of obsessive-compulsive disorder (OCD), said Dr. Flament, a professor of psychiatry and research director of the youth program at the University of Ottawa Institute of Mental Health Research.

Both clomipramine and SSRIs have produced 20%–45% improvement in clinical trials conducted since 1985, according to Dr. Flament. Clomipramine at 141–150 mg per day has been shown to be superior to placebo and to desipramine.

Fluoxetine at 20–64 mg per day, sertraline at 160–167 mg per day, and fluvoxamine at 50–200 mg per day also were superior to placebo in randomized trials.

She also cited a meta-analysis that found a statistically significant but modest benefit for SSRIs in the treatment of pediatric OCD (Am. J. Psychiatry 2003;160:1919–28). “So there is evidence that medication works. It brings some improvement, but not complete remission,” she said.

Despite growing concern that SSRIs increase suicide risk in children and adolescents being treated for depression, Dr. Flament said no individual study has shown SSRIs are associated with more suicidal ideation or behavior than placebo in children being treated for OCD. Most recent studies have not identified any treatment-emergent suicidal behaviors, she added.

Pooled analyses of controlled studies in OCD and other anxiety disorders have shown other behavioral side effects, she said, listing activation, akathisia, disinhibition, impulsivity, and hyperactivity. Again, she said, no analysis has shown a significant risk for increased suicidal thoughts or behaviors.

“Rigorous clinical monitoring for suicidal ideation and behavior is advised in youth, as in older patients,” she said, adding that “in pediatric OCD, SSRI treatment is generally thought to show a favorable risk-to-benefit ratio.”

To optimize treatment response, Dr. Flament recommended assessing how a child with OCD responds to the first medication prescribed. If the patient does not respond in 10–12 weeks to one SSRI, she suggested trying another SSRI.

If, however, the child has a partial response, Dr. Flament offered two options. Combining medication with behavioral therapy has been shown to improve outcomes and decrease the relapse rate when medication is discontinued, she said.

The other option is augmentation either to enhance serotonin neurotransmission or to antagonize dopamine neurotransmission in children with comorbid tic disorders.

Augmentation has been shown to improve outcomes, Dr. Flament said, with the caveat that very few studies have been conducted and with very small numbers of children.

Clomipramine and SSRIs have produced 20%–45% improvement in clinical trials since 1985. DR. FLAMENT