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Honeycutt DC, Blom TJ, Ramsey LB, Strawn JR, Bruns KM, Welge JA, Patino LR, Singh MK, DelBello MP. Pharmacogenetic Factors Influence Escitalopram Pharmacokinetics and Adverse Events in Youth with a Family History of Bipolar Disorder: A Preliminary Study. J Child Adolesc Psychopharmacol 2024; 34:42-51. [PMID: 38377518 PMCID: PMC10880264 DOI: 10.1089/cap.2023.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Introduction: Escitalopram is an effective and generally well-tolerated antidepressant, but children of parents with bipolar disorder (BD) may be at increased risk for adverse events associated with antidepressants, including increased irritability, restlessness, impulsivity, and manic symptoms. This risk may be influenced by polymorphisms in genes encoding cytochrome P450 enzymes (CYP2C19 or CYP2D6), the serotonin transporter (SLC6A4), and the serotonin receptor 2A subtype (HTR2A). We explored whether gene-drug interactions influence the emergence of adverse events in depressed and/or anxious youth with a family history of BD. Materials and Methods: Children and adolescents aged 12-17 years with a first-degree relative with bipolar I disorder were treated with escitalopram and monitored for adverse effects, underwent pharmacogenetic testing, and provided serum escitalopram levels. Emergence of adverse events was determined by study clinicians, and symptoms were tracked using the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) and Pediatric Adverse Events Rating Scale. Clinical Pharmacogenetics Implementation Consortium guidelines were used to determine CYP2C19 and CYP2D6 phenotypes. Results: Slower CYP2C19 metabolizers had greater dose-normalized 24-hour area under the curve (AUC0-24; p = 0.025), trough concentrations (Ctrough; p = 0.013), and elimination half-lives (t1/2; p < 0.001). CYP2D6 phenotype was not significantly associated with any pharmacokinetic parameter. Slower CYP2D6 metabolizers had increased TEASAP akathisia (p = 0.015) scores. HTR2A A/A and A/G genotypes were associated with increased TEASAP "self-injury, suicidality, and harm to others" subscale scores (p = 0.017). Escitalopram maximum concentration, AUC0-24, CYP2C19 phenotype, and SLC6A4 genotype were not associated with adverse events. Conclusions: CYP2C19 phenotype influences escitalopram pharmacokinetics whereas CYP2D6 phenotype does not. Slower CYP2D6 metabolism was associated with increased akathisia, and HTR2A A/A or A/G genotypes were associated with increased risk of self-harm or harm to others. Larger cohorts are needed to identify associations between genetic test results and antidepressant-associated adverse events. Trial Registration: ClinicalTrials.gov identifier: NCT02553161.
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Affiliation(s)
- Duncan C. Honeycutt
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J. Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kaitlyn M. Bruns
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jeffrey A. Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Luis R. Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Manpreet K. Singh
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa P. DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Strawn JR, Mills JA, Poweleit EA, Ramsey LB, Croarkin PE. Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents. Pharmacotherapy 2023. [PMID: 36651686 PMCID: PMC10378577 DOI: 10.1002/phar.2767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Selective serotonin reuptake inhibitors (SSRIs) and, to a lesser extent, serotonin-norepinephrine reuptake inhibitors (SNRIs) are the cornerstone of pharmacotherapy for children and adolescents with anxiety and depressive disorders. These medications alleviate symptoms and restore function for many youths; however, they are associated with a distinct adverse effect profile, and their tolerability may complicate treatment or lead to discontinuation. Yet, SSRI/SNRI tolerability has received limited attention in the pediatric literature. METHODS This review examines the early- (e.g., activation, gastrointestinal symptoms, sedation) and late-emerging (e.g., weight gain) adverse effects of SSRIs and some SNRIs in pediatric patients. RESULTS We provide a framework for discussing SSRI/SNRI tolerability with patients and their families and describe the pharmacologic basis, course, and predictors of adverse events in youth. Strategies to address specific tolerability concerns are presented. For selected adverse events, using posterior simulation of mean differences over time, we describe their course based on Physical Symptom Checklist measures in a prospective, randomized trial of anxious youth aged 7-17 years who were treated with sertraline (n = 139) or placebo (n = 76) for 12 weeks in the Child/Adolescent Anxiety Multimodal Study (CAMS). MAIN RESULTS In CAMS, the relative severity/burden of total physical symptoms (p < 0.001), insomnia (p = 0.001), restlessness (p < 0.001), nausea (p = 0.002), abdominal pain (p < 0.001), and dry mouth (p = 0.024) decreased from baseline over 12 weeks of sertraline treatment, raising the possibility that these symptoms are transient. No significant changes were observed for sweating (p = 0.103), constipation (p = 0.241), or diarrhea (p = 0.489). Finally, we review the antidepressant withdrawal syndrome in children and adolescents and provide guidance for SSRI discontinuation, using pediatric pharmacokinetic models of escitalopram and sertraline-two of the most used SSRIs in youth. CONCLUSION SSRI/SNRIs are associated with both early-emerging (often transient) and late-emerging adverse effects in youth. Pharmacokinetically-informed appraoches may address some adverse effects and inform SSRI/SNRI discontinuation strategies.
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Affiliation(s)
- Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, Anxiety Disorders Research Program, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey A Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ethan A Poweleit
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
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Bai MS, Miao CY, Zhang Y, Xue Y, Jia FY, Du L. COVID-19 and mental health disorders in children and adolescents (Review). Psychiatry Res 2022; 317:114881. [PMID: 36252421 PMCID: PMC9550277 DOI: 10.1016/j.psychres.2022.114881] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/23/2022] [Accepted: 10/01/2022] [Indexed: 01/05/2023]
Abstract
The new coronavirus has been present for two years and has had a widespread and sustained impact worldwide. There is growing evidence in the literature that COVID-19 may have negative effects on mental illness in patients and in healthy populations. The unprecedented changes brought about by COVID-19, such as social isolation, school closures, and family stress, negatively affect people's mental health, especially that of children and adolescents. The purpose of this paper is to review the literature and summarize the impact of COVID-19 disorders on children's and adolescents' mental health, the mechanisms and risk factors, screening tools, and intervention and prevention. We hope that the mental dysfunction caused by the pandemic will be mitigated through appropriate and timely prevention and intervention.
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Affiliation(s)
| | | | | | | | | | - Lin Du
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Changchun, China.
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4
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A Double-Blind Randomized Trial to Investigate Mechanisms of Antidepressant-Related Dysfunctional Arousal in Depressed or Anxious Youth at Familial Risk for Bipolar Disorder. J Pers Med 2022; 12:jpm12061006. [PMID: 35743790 PMCID: PMC9225632 DOI: 10.3390/jpm12061006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Antidepressants are standardly used to treat moderate to severe symptoms of depression and/or anxiety in youth but may also be associated with rare but serious psychiatric adverse events such as irritability, agitation, aggression, or suicidal ideation. Adverse events are especially common in youth with a family history of bipolar disorder (BD) who are at heightened risk for dysfunction in neurobiological systems that regulate emotion and arousal. To further understand this phenomenon, this study will examine (a) baseline risk factors associated with dysfunctional arousal in a sample of youth at high-risk for BD treated with or without an antidepressant, (b) whether antidepressant-related changes in arousal are mediated by changes in prefrontal-limbic circuitry, and (c) whether pharmacogenetic factors influence antidepressant-related changes in arousal. High-risk youth (aged 12-17 years with moderate to severe depressive and/or anxiety symptoms and at least one first-degree relative with bipolar I disorder) will be randomized to receive psychotherapy plus escitalopram or psychotherapy plus placebo. Neuroimaging and behavioral measures of arousal will be collected prior to randomization and at 4 weeks. Samples for pharmacogenetic analysis (serum escitalopram concentration, CYP2C19 metabolizer phenotype, and HTR2A and SLC6A4 genotypes) will be collected at 8 weeks. Youth will be followed for up to 16 weeks to assess change in arousal measures.
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5
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Strawn JR, Poweleit EA, Mills JA, Schroeder HK, Neptune ZA, Specht AM, Farrow JE, Zhang X, Martin LJ, Ramsey LB. Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial. J Pers Med 2021; 11:1188. [PMID: 34834540 PMCID: PMC8621124 DOI: 10.3390/jpm11111188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022] Open
Abstract
Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.
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Affiliation(s)
- Jeffrey R. Strawn
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
| | - Ethan A. Poweleit
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Child & Adolescent Psychiatry, Cincinnati, OH 45219, USA
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, OH 45219, USA;
| | - Heidi K. Schroeder
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Zoe A. Neptune
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Ashley M. Specht
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Jenni E. Farrow
- Anxiety Disorders Research Program, Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (J.R.S.); (H.K.S.); (Z.A.N.); (A.M.S.); (J.E.F.)
| | - Xue Zhang
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Lisa J. Martin
- Cincinnati Children’s Hospital Medical Center, Division of Human Genetics, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA; (X.Z.); (L.J.M.)
| | - Laura B. Ramsey
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Clinical Pharmacology, Cincinnati, OH 45219, USA;
- Cincinnati Children’s Hospital Medical Center, Division of Research in Patient Services, College of Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
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6
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Sharma E, Jacob P, Dharmendra A, Reddy YCJ, Seshadri SP, Girimaji SC, Vijaysagar KJ. Preschool-onset OCD: A review of literature and clinical experience. Bull Menninger Clin 2021; 85:298-315. [PMID: 34468213 DOI: 10.1521/bumc.2021.85.3.298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Obsessive-compulsive disorder (OCD) has been described in preschool children as young as 2-3 years old. A preschool age onset of OCD has unique diagnostic and therapeutic challenges. In this article, the authors review published literature on preschool onset OCD and present data on preschool-onset OCD (age of onset ≤ 5 years) from clinical records at a tertiary care child and adolescent psychiatry center in India. Literature suggests that OCD that starts this early is phenomenologically similar to OCD in older individuals; however, it has very high rates of comorbidity and a family history of OCD. There is a paucity of data on course, treatment, and long-term outcome in this group. At their center, the authors found a 3% prevalence of preschool-onset OCD, with a male predominance (69%) and fairly high comorbidity rates (62%). Qualitative review highlighted delay in treatment seeking, poor follow-up rates, frequent use of pharmacological treatment, and a high remission rate in those treated adequately.
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Affiliation(s)
- Eesha Sharma
- Assistant professor, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Preeti Jacob
- Associate professor, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Apoorva Dharmendra
- PhD Scholar in Clinical Neurosciences in the Department of Clinical Neurosciences, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Y C Janardhan Reddy
- Professor in the Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Shekhar P Seshadri
- Senior professors, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Sathish C Girimaji
- Senior professors, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - K John Vijaysagar
- Professor and head in the Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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7
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Abstract
Preschoolers are presenting in increasing numbers to primary care providers and mental health clinics with emotional and behavioural impairment. Preschoolers in the US have the highest rates of school expulsion of all age groups. Because young children are limited in their capacity to convey distress and internal states, impairment is most often expressed behaviourally. Disruptive behaviour, frequently in the form of aggression or dysregulation, is a final common pathway for many disorders in this age group. Tools and training to diagnose pre-school disorders are limited, and while some effective non-medication interventions exist, the evidence base for medication use in this age group is extremely limited. This article reviews approaches to assessing common pre-school disorders including attention deficit hyperactivity disorder (ADHD), disruptive behaviour disorders, anxiety and mood disorders, perceptual disturbances and psychosis, and trauma related disorders. The evidence base for both therapeutic and psychopharmacologic interventions for these disorders is discussed.
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Affiliation(s)
- Nadia Zaim
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joyce Harrison
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital, Baltimore, MD, USA.,Department of Psychiatry, Kennedy Krieger Institute, Baltimore, MD, USA
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Schapir L, Weizman A, Golubchik P. The Impact of Prolonged, Selective, Serotonin Reuptake Inhibitor Treatment on Serum Lipid and Glucose Levels in Children and Adolescents: A Preliminary Prospective Study. J Child Adolesc Psychopharmacol 2018; 28:485-487. [PMID: 29874099 DOI: 10.1089/cap.2018.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Treatment with selective serotonin reuptake inhibitors (SSRIs) is common and is considered safe and effective in the treatment of anxiety and depressive disorders in pediatric populations. SSRI administration, however, is associated with adverse metabolic effects. The aim of this preliminary study was to evaluate the possible influence of a 6-month SSRI treatment on metabolic parameters in children and adolescents with depressive and/or anxiety disorders. METHODS Metabolic parameters (glucose, cholesterol, triglycerides, low-density lipoprotein [LDL], and high-density lipoprotein [HDL]) were monitored in 22 children and adolescents (16 boys and 6 girls, aged 8-18 years) at baseline and after 6 months of SSRI treatment for depression and/or anxiety. RESULTS Six months of SSRI treatment did not affect serum glucose, cholesterol, or triglycerides significantly, but a tendency (p = 0.06) toward elevation in serum LDL accompanied by a parallel reduction in HDL levels was detected. CONCLUSION It appears that the 6-month SSRI treatment is metabolically safe in children and adolescents and does not affect the glucose or lipid profile. Long-term large-scale studies in pediatric populations focusing on the possible impact of long-term SSRI treatment (>6 months) on metabolic parameters are warranted.
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Affiliation(s)
- Lior Schapir
- 1 Geha Mental Health Center , Petah Tikva, Israel .,2 Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
| | - Abraham Weizman
- 1 Geha Mental Health Center , Petah Tikva, Israel .,2 Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel .,3 Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University , Petah Tikva, Israel
| | - Pavel Golubchik
- 1 Geha Mental Health Center , Petah Tikva, Israel .,2 Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
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Luft MJ, Lamy M, DelBello MP, McNamara RK, Strawn JR. Antidepressant-Induced Activation in Children and Adolescents: Risk, Recognition and Management. Curr Probl Pediatr Adolesc Health Care 2018; 48:50-62. [PMID: 29358037 PMCID: PMC5828909 DOI: 10.1016/j.cppeds.2017.12.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The tolerability of antidepressants is poorly characterized in children and adolescents with depressive and anxiety disorders. Among adverse events that affect the tolerability of antidepressants in youth is activation, a cluster of symptoms that represent a hyperarousal event characterized by impulsivity, restlessness, and/or insomnia. This cluster of symptoms was first identified as a side effect of selective serotonin and selective serotonin norepinephrine inhibitors (SSRIs and SSNRIs) in the early 1990s; however, activation remains poorly characterized in terms of prevalence, risk factors, and pathophysiology. This article describes the pathophysiology of antidepressant-related activation, predictors of activation and its clinical management in youth with depressive and anxiety disorders who are treated with antidepressant medications.
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Affiliation(s)
- Marissa J Luft
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Martine Lamy
- Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Melissa P DelBello
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Robert K McNamara
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Jeffrey R Strawn
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
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10
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Current state of evidence for medication treatment of preschool internalizing disorders. ScientificWorldJournal 2014; 2014:286085. [PMID: 24600324 PMCID: PMC3926238 DOI: 10.1155/2014/286085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/10/2013] [Indexed: 11/18/2022] Open
Abstract
Psychotropic medications are being prescribed off-label by psychiatrists to treat preschool children diagnosed with internalizing disorders. In this review, the current state of evidence is presented for medications used to treat preschool children (ages 2-5 year olds) diagnosed with anxiety and/or depressive disorders. Eleven studies were systematically identified for this review based on a priori criteria. Overall, the available literature revealed that studies addressing the medication treatment of internalizing disorders in preschoolers are extremely limited and represent relatively weak research methodologies. Given the increasing prevalence of the use of psychotropic medications to treat preschool children and the unique challenges associated with working with this population, it is imperative that mental health practitioners are aware of the current, albeit limited, research on this practice to help make informed treatment decisions. Suggestions about how to monitor potential costs and benefits in those unique cases in which psychopharmacological treatments might be considered for young children are given. Moreover, areas of additional research for this population are discussed.
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11
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Offidani E, Fava GA, Tomba E, Baldessarini RJ. Excessive mood elevation and behavioral activation with antidepressant treatment of juvenile depressive and anxiety disorders: a systematic review. PSYCHOTHERAPY AND PSYCHOSOMATICS 2013; 82:132-41. [PMID: 23548764 DOI: 10.1159/000345316] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/12/2012] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Emanuela Offidani
- Laboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, Italy.
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12
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Luby JL. Treatment of anxiety and depression in the preschool period. J Am Acad Child Adolesc Psychiatry 2013; 52:346-58. [PMID: 23582866 PMCID: PMC3640809 DOI: 10.1016/j.jaac.2013.01.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/16/2013] [Accepted: 01/31/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Empirical studies have established that clinical anxiety and depressive disorders may arise in preschool children as young as 3.0 years. Because empirical studies validating and characterizing these disorders in preschoolers are relatively recent, less work has been done on the development and testing of age-appropriate treatments. METHOD A comprehensive literature search yielded several small randomized controlled trials of psychotherapeutic treatments for preschool anxiety and depression. The literature also contained case series of behavioral and psychopharmacologic interventions for specific anxiety disorders. However, to date, no large-scale randomized controlled trials of treatment for any anxiety or depressive disorder specifically targeting preschool populations have been published. RESULTS Several age-adapted forms of cognitive-behavioral therapy have been developed and preliminarily tested in small randomized controlled trials and appear promising for different forms of preschool anxiety disorders. Notably, these adaptations centrally involve primary caregivers and use age-adjusted methodology such as cartoon-based materials and co-constructed drawing or narratives. Modified forms of parent child interaction therapy have been tested and appear promising for anxiety and depression. Although preventive interventions that target parenting have shown significant promise in anxiety, these methods have not been explored in early childhood depression. Studies of the impact of parental treatment on infants suggest that direct treatment of the youngest children may be necessary to affect long-term change. CONCLUSIONS Recommendations are made for the clinical treatment of these disorders when psychotherapy is the first line of intervention.
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Preschool children with obsessive-compulsive disorder and fluoxetine treatment. Eur Child Adolesc Psychiatry 2012; 21:169-72. [PMID: 22271063 DOI: 10.1007/s00787-012-0244-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 01/11/2012] [Indexed: 10/14/2022]
Abstract
Obsessive-compulsive disorder (OCD) is an anxiety disorder which can substantially disable children's ability to function at home and school. Clinicians frequently rely on knowledge about symptoms that can be examined early in treatment to determine future treatment effectiveness. However, OCD in preschoolers has also received little attention in literature. To the best of our knowledge, there is only one retrospective chart review and one case report in the literature for preschool cases treated with SSRIs. Therefore, the effect of fluoxetine on preschool children was imprecisely understood. The aim of this case report was to examine the efficacy and safety of fluoxetine treatment for pediatric OCD. Four preschool children with OCD completed an 8-week fluoxetine (up to 20 mg) trial. We diagnosed OCD according to Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR) criteria and symptoms of OCD were assessed with the Childrens' Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Initial and post-treatment symptom severity and improvement were assessed by using the severity (S) and improvement (I) scales of Clinical Global Impressions Scale (CGI). The CY-BOCS total, obsessions and compulsions subscale scores and CGI-S scores were significantly improved for all of the cases at the end of the eighth week. In this case report four preschool children, with severe OCD and resistant to the previous non-psychopharmacologic treatment responded well to fluoxetine monotherapy. On the other hand, the usage of SSRIs in preschool children remains highly controversial, due to the lack of data on safety and efficacy.
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Better tolerability of St. John's wort extract WS 5570 compared to treatment with SSRIs: a reanalysis of data from controlled clinical trials in acute major depression. Int Clin Psychopharmacol 2010; 25:204-13. [PMID: 20568656 DOI: 10.1097/yic.0b013e328335dc1a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) like paroxetine have replaced older antidepressants mainly because of a more favorable safety profile, but they are still associated with burdensome side effects. We investigate the tolerability of St. John's wort extract WS 5570, a herbal antidepressant with proven efficacy, in comparison to paroxetine and other SSRIs and placebo. A reanalysis was performed based on the original data from four controlled clinical trials during which 1661 outpatients with major depression (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria) received between 600 and 1800 mg/day WS 5570 (n=1264), 20 or 40 mg/day paroxetine (n=126), or placebo (n=271) for 6 weeks. For single and grouped adverse events, the risk ratios for treatment group comparisons were determined along with their 95% confidence intervals, including comparisons with published data for SSRIs. Across the four trials, the percentage of patients with any adverse events under WS 5570 exposition was comparable with placebo [risk ratio (95% confidence interval): 1.1 (0.9-1.3) in favor of WS 5570] and significantly lower than for paroxetine [2.4 (2.1-2.8)]. Compared with the herbal extract adverse event rates under paroxetine were between 10 and 38-fold higher (point estimates) in five out of seven symptom clusters inspected. WS 5570 was devoid of effects of sedation, anticholinergic reactions, gastrointestinal disturbances, and sexual dysfunction often found during treatment with SSRIs and other synthetic antidepressants. In conclusion, WS 5570 exhibits substantially lower incidence rates of adverse events than paroxetine and other SSRIs.
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Brunelli SA, Aviles JA, Gannon KS, Branscomb A, Shacham S. PRX-00023, a selective serotonin 1A receptor agonist, reduces ultrasonic vocalizations in infant rats bred for high infantile anxiety. Pharmacol Biochem Behav 2009; 94:8-15. [DOI: 10.1016/j.pbb.2009.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 06/20/2009] [Accepted: 06/23/2009] [Indexed: 11/16/2022]
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Abstract
Although empirical evidence has recently validated clinical depression in children as young as age 3, few data are available to guide treatment of early childhood depression. Considering this gap in the literature, a novel dyadic psychotherapeutic model, Parent Child Interaction Therapy-Emotion Development, based on a well-known and effective manualized treatment for disruptive preschoolers, is currently being tested for use in depression. To balance safety and efficacy, dyadic developmental approaches are currently recommended as the first line of treatment for preschool depression. In the absence of data on the safety and efficacy of antidepressants in preschool depression, these agents are not recommended as a first- or second-line treatment at this time. This article provides an illustrative case example of preschool depression, outlines key considerations in differential diagnosis, and describes this novel form of treatment. It also clarifies parameters for the rare situations in which antidepressants may be tried when psychotherapeutic options fail and depression is severe and impairing.
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Affiliation(s)
- Joan L Luby
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid, Box 8134, St. Louis, MO 63110, USA.
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Coskun M, Zoroglu S. Efficacy and safety of fluoxetine in preschool children with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2009; 19:297-300. [PMID: 19519265 DOI: 10.1089/cap.2008.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the efficacy and safety of fluoxetine in the treatment of obsessive-compulsive disorder (OCD) in preschool children. METHOD Six preschool children (age range 40-61 months; mean 51.5 +/- 8.8 months) with severe, distressing symptoms of OCD were treated with an initial 5 mg/day oral dose of fluoxetine by mouth. Baseline and end-point symptom severity was assessed using the Clinical Global Impressions-Severity (CGI-S) scale. The data for this study were collected by reviewing medical records of the subjects. RESULTS CGI-S baseline scores were 6-7 (mean 6.66 +/- 0.5) and end-point scores were 3-7 (mean 4 +/- 1.54). The Wilcoxon nonparametric paired t-test revealed a significant difference between baseline and end-point CGI-S scores (Z = -2.121; p = 0.034). The range of fluoxetine dosage was 5-15 mg/day (mean 10 +/- 3.16). Fluoxetine was effective in treating OCD in this sample. Four subjects showed much and 1 subject showed very much improvement in OCD symptoms. One subject, who discontinued medication after 4 weeks due to side effects, did not show any improvement with 5 mg/day fluoxetine. Two subjects developed significant symptoms of behavioral disinhibition (SBD) that required dose reduction and addition of 0.25-0.5 mg/day risperidone in 1 subject and discontinuation of medication in the second subject. Side effects were mild to moderate in severity and did not require medication discontinuation or dosage reduction in the remaining three subjects. One subject did not report any side effects. Overall the most frequently reported side effects were SBD, decreased appetite and weight loss (n = 3; range: 0-1200 grams; mean, 466 +/- 546.5 grams), sleep disturbance, headache, and abdominal pain. CONCLUSIONS Fluoxetine may be effective in the treatment of OCD in preschool children. However side effects, particularly SBD, remain an important concern.
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Affiliation(s)
- Murat Coskun
- Istanbul University, Istanbul Medical Faculty, Child and Adolescent Psychiatry Department, Istanbul, Turkey.
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Ghuman JK, Aman MG, Ghuman HS, Reichenbacher T, Gelenberg A, Wright R, Rice S, Fort C. Prospective, naturalistic, pilot study of open-label atomoxetine treatment in preschool children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2009; 19:155-66. [PMID: 19364293 PMCID: PMC2857147 DOI: 10.1089/cap.2008.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The aim of this study was to report preliminary data regarding effectiveness and tolerability of atomoxetine in 3- to 5-year-old preschool children with attention-deficit/hyperactivity disorder (ADHD). METHODS Nine boys and 3 girls (mean age = 5.0 +/- 0.72 years) diagnosed with ADHD were treated with atomoxetine in an open-label pilot study. Atomoxetine was gradually titrated to a maximum dose of 1.8 mg/kg per day. RESULTS There was a significant effect of time from baseline to end point on the parent-rated hyperactivity/impulsivity Swanson Nolan and Pelham (SNAP-IV-HI) subscale ratings (F[9, 11] = 6.32, p < 0.0001). The mean difference between the baseline and end-point parent SNAP-IV-HI scores was 10.2 +/- 7.3 (p = 0.0005). The rate of positive response (defined as at least a 30% reduction in the end-point parent SNAP-IV-HI scores and a Clinical Global Impressions-Improvement [CGI-I] rating of Much Improved or Very Much Improved) was 75%. The Children's Global Assessment Scale scores improved significantly over time [F(9, 11) = 6.24 p < 0.001]. The mean end-point daily dose of atomoxetine was 1.59 +/- 0.3 mg/kg. A high proportion (66.7%) of the preschoolers experienced side effects with atomoxetine. Side effects of defiance, tantrums, aggression, and irritability were most disconcerting to parents, and gastrointestinal complaints were the most commonly reported adverse effects. One child was terminated from the study due to "chest ache." There were no changes in weight, height, or cardiovascular measures. CONCLUSION This open-label pilot study provides preliminary evidence of effectiveness and tolerability of atomoxetine for treating ADHD in preschool children, although double-blind, randomized, placebo-controlled studies are needed to confirm this.
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Affiliation(s)
- Jaswinder K Ghuman
- Department of Psychiatry, University of Arizona, Tucson, Arizona 85724-5002, USA.
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Abstract
PURPOSE OF REVIEW This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice. RECENT FINDINGS The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years. SUMMARY The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.
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Storch EA, Milsom VA, Merlo LJ, Larson M, Geffken GR, Jacob ML, Murphy TK, Goodman WK. Insight in pediatric obsessive-compulsive disorder: associations with clinical presentation. Psychiatry Res 2008; 160:212-20. [PMID: 18556071 DOI: 10.1016/j.psychres.2007.07.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 06/21/2007] [Accepted: 07/01/2007] [Indexed: 11/25/2022]
Abstract
Insight has emerged as a significant treatment outcome predictor in adult obsessive-compulsive disorder (OCD), with some suggesting that OCD with poor insight represents a distinct clinical subtype. Despite its clinical relevance, limited data exist on insight in pediatric OCD patients. The present study investigated the relation between poor insight and clinical characteristics among children and adolescents with OCD (N=78, ages 6-20 years). Forty-five percent of the sample (n=35) was considered to have low levels of insight into their symptoms, as determined by clinician rating on item 11 of the Children's Yale-Brown Obsessive-Compulsive Scale. Pearson product-moment correlations showed a significant, inverse relation between insight and OCD severity. Relative to the high insight group, parents of patients with low insight reported higher levels of OCD-related impairment and family accommodation. These findings suggest that OCD with poor insight may represent a distinct clinical feature that may require more intensive and multimodal treatment approaches.
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Affiliation(s)
- Eric A Storch
- Department of Psychiatry, University of Florida, Gainesville, FL, USA.
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Bailly D. Benefits and risks of using antidepressants in children and adolescents. Expert Opin Drug Saf 2008; 7:9-27. [DOI: 10.1517/14740338.7.1.9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Daniel Bailly
- Service hospitalo-universitaire de psychiatrie, Hôpital Sainte-Marguerite, 270 Boulevard de Sainte Marguerite, 13009 Marseille, France ;
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