Editorial

Psychopharmakologische Behandlung von Depressionen im Kindes- und Jugendalter

Die psychopharmakologische Behandlung kann – je nach Schweregrad- eine wichtige Option in der Therapie depressiver Erkrankungen bei Kindern und Jugendlichen darstellen. Diese Überblicksarbeit gibt klinische Behandlungsempfehlungen mit einem Fokus auf den Umgang mit Suizidalität und therapieresistenten Patienten. Die Studienlage zur medikamentösen Therapie der depressiven Erkrankung im Kindes- und Jugendalter hat sich seit den Warnungen der amerikanischen Zulassungsbehörde zum Auftreten von Suizidalität unter Therapie mit Selektiven Serotonin Wiederaufnahmehemmern (SSRIs) deutlich verbessert. In der Versorgung von depressiven Kindern und Jugendlichen ist in den letzten Jahren in Deutschland ein Trend hin zu einer evidenzbasierten psychopharmakologischen Therapie zu erkennen.

[Medical teaching in the area of conflict between "Evidence-based Medicine" and "Experience-based Medicine"]

As a medical discipline Child and Adolescent Psychiatry and Psychotherapy has gained increasing importance within society since given the epidemiological importance of behavioural problems in childhood and adolescence, it has verifiably improved the developmental chances of children at high risk. Child and Adolescent Psychiatry and Psychotherapy therefore should be systematically integrated into the German Medical Curriculum. The bio-psycho-social model provides us with a comprehensive paradigm of psychiatric disorders and has to face the problem of hermeneutics. An equilibrium between Evidence-based Medicine and the individual clinical experience with patients (Experience-based Medicine) must be established within medical teaching, rather than playing one against the other. Ethical dilemmas of medical therapy have to be taken into account.

Fragwürdigkeit eines Gerichtsurteils zur Antidepressiva-Verordnung bei Jugendlichen

Zusammenfassung: Ein Sozialgericht (SG Dresden, S 16 KR 51/06) hat eine beklagte Krankenkasse dazu verurteilt, einer depressiven Jugendlichen stationär verordnetes Fluoxetin für die Zeit der Ausschleichphase weiter zu erstatten, aber die Klage auf generelle Kostenübernahme bei der Patientin für dieses Medikament ansonsten abgewiesen. Dabei wurden dem Gericht vorliegende Unterlagen, insbesondere die Stellungnahme der DGKJP, fehlerhaft rezipiert und das Gericht hat auf die Schaffung einer eigenen Sachkunde, beispielsweise durch ein Sachverständigengutachten, verzichtet. Eine Bezugnahme auf ein Urteil des Bundessozialgerichts zum off-label-Gebrauch zeigt ebenfalls Recherchemängel des erkennenden Gerichts auf und weist allgemein auf eine unklare Umsetzung dieses Urteils hin. Für den behandelnden Arzt resultiert aus dem SG-Urteil ein therapeutisches, ethisches und haftungsrechtliches Dilemma: ein Absetzen der Substanz gefährdet eventuell die Patientin, ist aber im Urteil so vorgesehen. Durch die mittlerweile erfolgte EMEA-Zulassung der Substanz für Minderjährige über 8 Jahren in Europa ist der Fall vielleicht geklärt - nicht jedoch die Implikationen von juristischen Eingriffen in die ärztliche Therapiefreiheit und wissenschaftlich gut begründbare Therapierationalen.

Medikamentöse Therapie der Depression bei Kindern und Jugendlichen

Pharmacological treatment of depression in minors is contested after some published warnings about suicide related behaviour among youths treated with SSRI. This paper examines the last developments concerning antidepressant use in minors, prescrition patterns and evidence of antidepressants used in minors. Reviewing the guidelines and practise parameters, metaanalyses and the TADS-study a recommendation for an evidence based use in minors can only be given for Fluoxetine. Safety aspects should be taken into consideration during the treatment and patients should be kept in close contact to their therapists to observe suicidal related behaviour and adherence.

[Child sexual abuse]

The present paper gives an overview on the development of professional discourse on sexual abuse over the last 20 years in the field of child protection. After the introduction, definitions from different professional perspectives (civil law, criminal law, psychotherapy, counseling, etc.) are given. Based on these definitions an epidemiological range of prevalence figures is described. In the literature, rates ranging from 6 to 25 % in girls and 2 to 8 % in boy as victims of sexual abuse can be observed. Psychiatric consequences of sexual abuse are described based on an overview of the literature. Diagnostic approaches to posttraumatic problems are discussed and distinguished from obsolete measures. Some neurobiological findings are presented. Finally the foundations of counseling, psychotherapy and pharmacotherapy of behavioral of symptoms and PTSD are discussed on the bases of a literature review of controlled clinical trials. In conclusion, further developments in psychotherapy and research are discussed for the German practical child protection field.

[The effects of the 12th and 14th amendments to the AMG (Medical Preparations Act) on paediatric pharmaceutical research--a survey of the new regulations]

OBJECTIVE

The 12th amendment to the German Medical Preparations Act (Arzneimittelgesetz, AMG) implements EU-Directive 2001/20EC in national law and introduces changes with regard to academic research in child and adolescent psychiatry. The 14th amendment implements labelling regulations for drugs.

METHOD

This article analyses the effects of these new regulations on safety aspects, on the performance of clinical trials with and without sponsoring (investigator-initiated trials, IITs), and on the development of paediatric drugs. The former regulatory directives are compared with the changes mandated by the 12th amendment, and their effects on off-label use, long-term safety, and so-called dose-finding studies will be pointed out.

RESULTS

Current law no longer allows post marketing surveillance studies ("Anwendungsbeobachtungen" and "Therapieoptimierungsstudien"). Requirements and procedural regulations are now standardized for all clinical trials with human beings. The term "group benefit" has now been introduced into German law, which excludes research without any direct or group benefit for children participating in a study.

CONCLUSION

While prerequisites for drug development in accordance with GCP guidelines on a high medical and ethical standard are now granted, due to multiple regulatory requirements, investigator-initiated studies in paediatric psychopharmacology will be more difficult to conduct. Moreover, because of the strict regulations, it is very improbable that academic research will be undertaken without sponsoring (IITs).

Serotoninwiederaufnahmehemmer im Kindes- und Jugendalter

Recent reports and recommendations from national and international health care regulatory authorities have informed us that serotonin reuptake inhibitors (SSRI) are contraindicated as new treatment for those under 18 years of age with depressive illness. They conclude that SSRI carry the risk of increased suicide-related behavior; although there was no completed suicide. The European Medicine Agency (EMEA) and German regulatory agency (BfArM) advise that these components generally should not be used in this age group except in their other, approved indications. However, it is acknowledged that they may sometimes be chosen, depending on individual clinical needs. Based on these data, the Commission for Child and Adolescent Developmental Psychopharmacology of the German Scientific Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy is trying to give recommendations for the use of SSRI in clinical practice. Recent studies demonstrate that combining SSRI with psychological treatment such as cognitive behavioral therapy may reduce the risk of suicidal behavior in depressed children and adolescents.

[Diagnosis and therapy of post-traumatic stress disorders in childhood and adolescence. Responsibilities of the child and adolescent psychiatric trauma outpatient clinic]

This article presents an overview of the etiology, clinical characteristics, assessment, and treatment of PTSD in children and adolescents. Diagnostic criteria of DSM-IV and ICD-10 for PTSD in adults may not adequately describe this disorder especially in toddlers and preschool children, because specific PTSD symptoms may vary according to the developmental stage of the child. Prevalence of PTSD in adolescence is similar to that in adulthood. Children who exhibit high degrees of psychopathology before traumatic exposure, who are exposed to high levels of trauma for an extended period, or who directly experienced the event face a high risk to develop PTSD and other later adverse outcomes. Parental support and other social factors also emerge as strong predictors of differential risk among traumatized children. Cognitive-behavioral therapy is a well-assessed intervention strategy recommended for children and adolescents with PTSD while there are no controlled trials of pharmacological treatments. The outpatient clinic for traumatized children and adolescents of the University Clinic of Aachen is introduced and clinical characteristics of children seeking help are described. In addition, the social network and cooperating services are illustrated.