Long chain omega-3 polyunsaturated fatty acids in the treatment of psychiatric illnesses in children and adolescents

Omega-3 fatty acid supplementation for depression in children and adolescents

BACKGROUND

Mental health disorders including major depressive disorder (MDD) are well recognized as major contributors to the global burden of disease among adolescents. The prevalence of adolescent depression is estimated to have increased by at least 25% during the COVID-19 pandemic, compounding the already challenging problem of insufficient mental health service and service accessibility that existed prepandemic. Omega-3 polyunsaturated fatty acid (PUFA) supplementation is currently recommended as a preventive treatment for depression in high-risk adults as well as a second-line monotherapy for adults with mild to moderate MDD, and adjunctive to antidepressants for adults with moderate to severe MDD. The benefits of omega-3 PUFA intake on depressive illness have been hypothesized to occur as a result of their effect on neurotransmission, maintenance of membrane fluidity, and anti-inflammatory action. A comprehensive synthesis and quantification of the existing evidence on omega-3 PUFA's efficacy in treating depression among children and adolescents is essential for clinicians to provide informed guidance to young people and their families, especially considering the absence of current guidelines for this age group.

OBJECTIVES

Primary objective To determine the impact of omega-3 PUFA supplementation versus a comparator (e.g. placebo, wait list controls, no treatment/supplementation, or standard care) on clinician-diagnosed depression or self-reported depression symptoms in children and adolescents. Secondary objectives To estimate the size of the effect of omega-3 PUFAs on depression symptoms. To estimate the effect of each type of omega-3 PUFA (EPA or DHA), compared with placebo, on depression. To determine if the effect is modified by dosage, format (capsule or liquid), sex, or age. To determine compliance and attrition for omega-3 PUFAs as an intervention for depression in children and adolescents. To determine the safety of omega-3 PUFAs as an intervention for depression in children and adolescents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, reference lists of included studies, grey literature, and relevant reviews. The latest search date was 18 May 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving males and females aged 19 years or younger with diagnosed depression comparing omega-3 PUFA supplementation to placebo, wait list control, no treatment/supplementation, or standard care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were self-reported depression symptoms and clinically diagnosed resolution of depression. Our secondary outcomes were attrition, adverse effects, and compliance with the intervention. We used GRADE to assess the certainty of evidence for key outcomes.

MAIN RESULTS

We included five trials with 228 participants in our meta-analysis. All trials used a placebo comparator; intervention duration ranged from 10 to 16 weeks (median: 12 weeks). Omega-3 PUFA supplementation compared to placebo may reduce self-reported depression symptoms, but the evidence is very uncertain (standardized mean difference [SMD] -0.34, 95% confidence interval [CI] -0.85 to 0.17; lower SMD means greater improvement in depression due to omega-3 PUFA; 5 trials, 185 participants; very low-certainty evidence). Omega-3 PUFA supplementation may have little to no effect on remission of depression symptoms compared to placebo, but the evidence is very uncertain (omega-3 PUFA versus placebo: 50% versus 48%; odds ratio [OR] 1.11, 95% CI 0.45 to 2.75; 4 trials, 127 participants; very low-certainty evidence). Omega-3 PUFA supplementation may result in little to no difference in attrition (dropouts) compared to placebo (omega-3 PUFA versus placebo: 18% versus 19%; OR 0.94, 95% CI 0.46 to 1.90; 5 trials, 228 participants; low-certainty evidence). Omega-3 PUFA supplementation may result in little to no difference in adverse effects, with one study reporting more muscle cramps in the fish oil group (13/27 participants) compared to the placebo group (6/29 participants); one study reported more frequent defecation in the omega-3 group (1/29 participants) and one study identified mild skin rash and unusual/manic behavior in the placebo group (2/27 participants). None of the included studies reported serious adverse effects.

AUTHORS' CONCLUSIONS

Based on five small studies, omega-3 PUFA supplementation may reduce self-reported depression symptoms, but the evidence is very uncertain. Omega-3 PUFA supplementation may have little to no effect on depression remission compared to placebo, but the evidence is very uncertain. Omega-3 PUFA supplementation may result in little to no difference in attrition or adverse effects. The studies observed no serious adverse effects. This review highlights early-stage research on omega-3 PUFA and depression in young people. The evidence on the effects of omega-3 PUFA supplementation in improving self-reported depression symptoms or achieving depression remission in children and adolescents is very uncertain. While no harms are evident, more data are needed to confirm potential risks. Addressing current limitations in the evidence base through the design and conduct of methodologically rigorous studies - larger sample sizes, varied dosages, eicosapentaenoic acid/docosahexaenoic acid ratios, treatment durations, and safety profiles - is crucial to advance our understanding of the role of omega-3 PUFA supplementation for depression in children and adolescents.

Docosahexaenoic Acid (DHA) Supplementation Alters Phospholipid Species and Lipid Peroxidation Products in Adult Mouse Brain, Heart, and Plasma

The abundance of docosahexaenoic acid (DHA) in phospholipids in the brain and retina has generated interest to search for its role in mediating neurological functions. Besides the source of many oxylipins with pro-resolving properties, DHA also undergoes peroxidation, producing 4-hydroxyhexenal (4-HHE), although its function remains elusive. Despite wide dietary consumption, whether supplementation of DHA may alter the peroxidation products and their relationship to phospholipid species in brain and other body organs have not been explored sufficiently. In this study, adult mice were administered a control or DHA-enriched diet for 3 weeks, and phospholipid species and peroxidation products were examined in brain, heart, and plasma. Results demonstrated that this dietary regimen increased (n-3) and decreased (n-6) species to different extent in all major phospholipid classes (PC, dPE, PE-pl, PI and PS) examined. Besides changes in phospholipid species, DHA-enriched diet also showed substantial increases in 4-HHE in brain, heart, and plasma. Among different brain regions, the hippocampus responded to the DHA-enriched diet showing significant increase in 4-HHE. Considering the pro- and anti-inflammatory pathways mediated by the (n-6) and (n-3) polyunsaturated fatty acids, unveiling the ability for DHA-enriched diet to alter phospholipid species and lipid peroxidation products in the brain and in different body organs may be an important step forward towards understanding the mechanism(s) for this (n-3) fatty acid on health and diseases.

A Review of Recruitment, Adherence and Drop-Out Rates in Omega-3 Polyunsaturated Fatty Acid Supplementation Trials in Children and Adolescents

INTRODUCTION

The influence of n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) supplementation on health outcomes has been studied extensively with randomized controlled trials (RCT). In many research fields, difficulties with recruitment, adherence and high drop-out rates have been reported. However, what is unknown is how common these problems are in n-3 LCPUFA supplementation studies in children and adolescents. Therefore, this paper will review n-3 LCPUFA supplementation studies in children and adolescents with regard to recruitment, adherence and drop-out rates.

METHODS

The Web of Science, PubMed and Ovid databases were searched for papers reporting on RCT supplementing children and adolescents (2-18 years) with a form of n-3 LCPUFA (or placebo) for at least four weeks. As a proxy for abiding to CONSORT guidelines, we noted whether manuscripts provided a flow-chart and provided dates defining the period of recruitment and follow-up.

RESULTS

Ninety manuscripts (reporting on 75 studies) met the inclusion criteria. The majority of the studies did not abide by the CONSORT guidelines: 55% did not provide a flow-chart, while 70% did not provide dates. The majority of studies provided minimal details about the recruitment process. Only 25 of the 75 studies reported an adherence rate which was on average 85%. Sixty-five of the 75 studies included drop-out rates which were on average 17%.

CONCLUSION

Less than half of the included studies abided by the CONSORT guidelines (45% included a flow chart, while 30% reported dates). Problems with recruitment and drop-out seem to be common in n-3 LCPUFA supplementation trials in children and adolescents. However, reporting about recruitment, adherence and dropout rates was very heterogeneous and minimal in the included studies. Some techniques to improve recruitment, adherence and dropout rates were identified from the literature, however these techniques may need to be tailored to n-3 LCPUFA supplementation studies in children and adolescents.

Polyunsaturated fatty acid supplementation for drug-resistant epilepsy

BACKGROUND

An estimated 1% to 3% of all individuals will receive a diagnosis of epilepsy during their lives, which corresponds to approximately 50 million affected people worldwide. The real prevalence is possibly higher because epilepsy is underreported in developing countries. Although most will achieve adequate control of their disease though the use of medication, approximately 25% to 30% of all those with epilepsy are refractory to pharmacological treatment and will continue to have seizures despite the use of two or more agents in adequate dosages. Over the last decade, researchers have tested the use of polyunsaturated fatty acid (PUFA) supplements for the treatment of refractory epilepsy, with inconsistent results. There have also been some concerns about the use of omega-3 PUFA compounds because they reduce platelet aggregation and could, in theory, cause bleeding.

OBJECTIVES

To assess the effectiveness and tolerability of omega-3 polyunsaturated fatty acids (eicosapentaenoic acid-EPA and docosahexanoic acid-DHA) in the control of seizures in people with refractory epilepsy.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialised Register (from inception up to November 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, issue 11), MEDLINE (1948 to November 2015), EMBASE (1980 to November 2015), SCOPUS (1823 to November 2015); LILACS (Literatura Latino-Americana e do Caribe de Informação em Ciências da Saúde) (1982 to November 2015); ClinicalTrials.gov; World Health Organization (WHO) International Clinical Trials Registry Platform (November 2015). No language restrictions were imposed. We contacted study authors for additional and unpublished information and screened the reference lists of retrieved citations for potentially eligible studies not identified through the electronic search.

SELECTION CRITERIA

All randomised and quasi-randomised studies using PUFAs for the treatment of drug-resistant epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors were involved in study selection, data extraction and quality assessment of the included trials. The following outcomes were assessed: seizure freedom, seizure reduction, improvement in quality of life, potential adverse effects, gastrointestinal effects, drop-out rates and changes in plasma lipid profile. Primary analyses were by intention to treat.

MAIN RESULTS

Eight studies were identified as potentially relevant; three fulfilled the selection criteria and were included in the review. Two placebo-controlled, double blind trials involving adult participants were conducted in developed countries, while one placebo-controlled, single blind trial involving children was conducted in a developing country (Egypt). Bromfield 2008 randomised 27 American adults to receive 2.2 g/day of omega-3 PUFAs (EPA:DHA in a 3:2 ratio) or placebo. Yuen 2005 randomised 58 people in the UK to approximately 1.7 g/day omega-3 PUFAs (1g EPA and 0.7g DHA) or placebo. Reda 2015 randomised 70 Egyptian children to receive 3 ml/day of 1200 mg fish oil (providing 0.24 g DHA and 0.36 g EPA) or placebo. The three studies recruited a total of 155 subjects (85 adults and 70 children); 78 of them (43 adults and 35 children) were randomised to PUFAs and 77 (42 adults and 35 children) to placebo. All participants were followed for up to 12 weeks. Seizure freedom was reported by only one study, with a high risk of bias, involving exclusively children. The risk estimate for this outcome was significantly higher in the children receiving PUFA compared to the control group (risk ratio (RR) 20.00, 95% confidence interval (CI) 2.84 to 140.99, 1 study, 70 children). Similarly, PUFA supplementation was associated with a significant difference in the proportion of children with at least 50% reduction in seizure frequency (RR 33.00 95% CI 4.77 to 228.15, 1 study with a high risk of bias, 70 children). However, this effect was not observed when the data from two studies including adult participants were pooled (RR 0.57, 95% CI 0.19 to 1.75, I² 0%, 2 studies, 78 participants, low-quality evidence). One of our three primary outcomes (adverse effects related to bleeding) was not assessed in any of the studies included in this review. There were no significant differences between the PUFA and control groups in relation to gastrointestinal effects (RR 0.78, 95% CI 0.32 to 1.89, 2 studies, 85 participants, low-quality evidence).Supplementation with PUFA did not produce significant differences in mean frequency of seizures, quality of life or other side effects.

AUTHORS' CONCLUSIONS

In view of the limited number of studies and small sample sizes, there is not enough evidence to support the use of PUFA supplementation in people with refractory epilepsy. More trials are needed to assess the benefits of PUFA supplementation in the treatment of drug-resistant epilepsy.

A randomized, placebo controlled trial of omega-3 fatty acids in the treatment of young children with autism

Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder affecting more than 1% of children. It is characterized by social communication deficits and repetitive behaviors/restricted interests. In the absence of any medications known to improve core symptom domains, parents often use complementary alternative treatments, including omega-3 fatty acid supplements.

Methods

We conducted a 6-month, randomized, placebo controlled trial of omega-3 fatty acid supplements (1.5 g) vs placebo in children 2 to 5 years of age with ASD. Primary outcome measures included the autism composite score of the Pervasive Developmental Disorders Behavioral Inventory (PDDBI) and the externalizing problems score of the Behavior Assessment System for Children (BASC-2). Secondary outcome measures included clinical global improvement (Clinical Global Impression-Improvement (CGI-I)), adaptive function (Vineland Adaptive Behavior Scale (VABS-II)), and language gains (Preschool Language Scale (PLS-4)), as well as safety. Exploratory analysis investigated potential correlations between changes in cytokine profiles and treatment response.

Results

Thirty-eight participants were randomized in a 1:1 fashion. There was no significant difference between groups on the 0- to 24-week change in PDDBI autism composite scores (p = 0.5). There was a significant group by week interaction on the BASC-2 externalizing problem score, with participants randomized to the treatment group demonstrating worsening scores (p = 0.02). There was no statistically significant week by group effect on either adaptive function (p = 0.09) or language (p = 0.6). Omega-3s were relatively well tolerated. Changes in cytokines during the study did not significantly correlate with treatment response.

Conclusions

This study does not support high dose supplementation of omega-3 fatty acids in young children with ASD.

Trial registration

Clinicaltrials.gov NCT01248728. Registered 22 November 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13229-015-0010-7) contains supplementary material, which is available to authorized users.

Update on attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is now the most frequent diagnosis in children seen by Australian general paediatricians. It is a heterogeneous neurodevelopmental disorder and is usually accompanied by one or more co-morbid developmental and/or mental health conditions. In addition to daily symptoms, which often impair quality of life, ADHD can compromise educational and social development for the individual, and impact on families, schools and the broader community. Draft revised National Health and Medical Research Council Guidelines on ADHD were published in November 2009. This comprehensive document discusses the evidence in relation to many aspects of ADHD, which inform the large number of practice recommendations. Although there is an enormous literature on the causes, neurobiology and management of ADHD, there is still much to be learned particularly in relation to early intervention, behavioural therapies and factors influencing long-term outcomes.

Herbal medicines in pediatric neuropsychiatry

An increasing number of studies have evaluated the role of herbal supplements in pediatric disorders, but they have numerous limitations. This review provides an overview of herbal components, regulation of supplements, and importance of product quality assurance. Use of herbal supplements is discussed with reference to factors that influence use in the pediatric population. The remainder of the article discusses the use of St John's wort, melatonin, kava, valerian, eicosapentaenoic acid, and docosahexaenoic acid, focusing on indications, adverse effects, and drug interactions, and providing a limited efficacy review. Herbal supplements used for weight loss are also briefly discussed.

Reduced mania and depression in juvenile bipolar disorder associated with long-chain omega-3 polyunsaturated fatty acid supplementation

Long-chain omega-3 polyunsaturated fatty acid (LCn-3PUFA) supplementation may improve symptoms of depression in children and bipolar disorder (BD) in adults. No studies have examined the effectiveness of LCn-3PUFA supplementation in the treatment of mania and depression in juvenile BD (JBD) when given as an adjunct to standard pharmacological treatment. Eighteen children and adolescents with JBD received supplements containing 360 mg per day eicosapentaenoic acid (EPA) and 1560 mg per day docosahexaenoic acid (DHA) for 6 weeks in an open-label study. Intake and fasting red blood cell (RBC) LCn-3PUFA, mania, depression and global function were assessed before and after supplementation. RBC EPA and DHA were significantly higher following supplementation. Clinician ratings of mania and depression were significantly lower and global functioning significantly higher after supplementation. Parent ratings of internalizing and externalizing behaviours were also significantly lower following supplementation. A larger randomized controlled trial appears warranted in this participant population.

Estimated intakes of meat and fish by children and adolescents in Australia and comparison with recommendations

Long-chain n-3 PUFA are considered important for cardiovascular health and brain development. Meat other than fish contributes significantly to total intakes of long-chain n-3 PUFA in adults; however, there are limited published data examining the intake of individual meat sources in children and adolescents in the Australian population. A review of literature was conducted using PubMed, Agricola and CAB Abstracts using the terms 'intake', 'beef', 'lamb', 'pork', 'poultry', 'fish', 'children' and 'adolescents' and using reference lists in published articles. Studies and surveys were identified that contained published values for intakes of meat or fish. Two national dietary surveys of children and adolescents were conducted in Australia in 1985 and 1995 and two regional surveys were conducted in Western Sydney and Western Australia in 1994 and 2003, respectively. Comprehensive data for the intake of individual meat sources were not reported from the 1995 survey, but estimations of intake were calculated from published values. Reported intakes of meat and fish are generally lower in females than males and tend to increase with age. Weighted mean intakes of red meat (beef plus lamb) across the three most recent studies were 67.3 and 52.2 g/d, respectively, for males and females aged between 7 and 12 years and 87.7 and 54.2 g/d, respectively, for males and females aged 12-18 years. These weighted intakes are within Australian guidelines and are likely to contribute significantly to total long-chain n-3 PUFA intake in children and adolescents in the Australian population.

Long-chain omega-3 polyunsaturated fatty acids in the blood of children and adolescents with juvenile bipolar disorder

Reduced long-chain omega-3 polyunsaturated fatty acids (LCn-3PUFA), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been reported in adult patients suffering from depression and bipolar disorder (BD). LCn-3PUFA status has not previously been examined in children and adolescents with BD compared with healthy controls. Fifteen children and adolescents (9-18 years, M +/- SD = 14.4 +/- 3.48) diagnosed with juvenile bipolar disorder (JBD) and fifteen healthy age and sex-matched controls were assessed for dietary intake and fasting red blood cell (RBC) membrane concentrations of LCn-3PUFA. Fatty acid concentrations were compared between participants diagnosed with JBD and controls after controlling for dietary intake. RBC membrane concentrations of EPA and DHA were not significantly lower in participants diagnosed with JBD compared with healthy controls (M +/- sem EPA = 3.37 +/- 0.26 vs. 3.69 +/- 0.27 microg/mL, P = 0.458; M +/- sem DHA = 22.08 +/- 2.23 vs. 24.61 +/- 2.38 microg/mL, P = 0.528) after controlling for intake. Red blood cell DHA was negatively (r = -0.55; P = 0.044) related to clinician ratings of depression. Although lower RBC concentrations of LCn-3PUFA were explained by lower intakes in the current study, previous evidence has linked reduced LCn-3PUFA to the aetiology of BD. As RBC DHA was also negatively related to symptoms of depression, a randomised placebo-controlled study examining supplementation with LCn-3PUFA as an adjunct to standard pharmacotherapy appears warranted in this patient population.

Complementary medicine for psychiatric disorders in children and adolescents

PURPOSE OF REVIEW

To examine recent empirical studies of herbal and dietary treatments for psychiatric disorders in children and adolescents.

RECENT FINDINGS

Very few quality studies into the use of omega-3 fatty acids, St John's wort, dietary manipulations, kava, gingko and lemon balm in managing psychiatric disorders have been conducted in children and adolescents.

SUMMARY

A number of herbal treatments show promise, but much more empirical research is required to establish their efficacy in the paediatric population.

Complementary and alternative medicine in the treatment of anxiety and depression

PURPOSE OF REVIEW

There is well documented evidence for the increasing widespread use of complementary and alternative medicine in the treatment of physical and psychiatric symptoms and disorders within Western populations. Here we provide a review of the recent literature on evidence for using such interventions in the treatment of anxiety and depression.

RECENT FINDINGS

With regard to herbal treatments, kava is effective in reducing anxiety symptoms and St John's wort in treating mild to moderate depression. The association of kava with hepatotoxicity, however, is a significant concern. Promising data continue to emerge for the use of omega-3 fatty acids in managing depression. Evidence for the use of acupuncture in treating anxiety disorders is becoming stronger, although there is currently minimal empirical evidence for the use of aromatherapy or mindfulness-based meditation.

SUMMARY

The evidence base for the efficacy of the majority of complementary and alternative interventions used to treat anxiety and depression remains poor. Recent systematic reviews all point to a significant lack of methodologically rigorous studies within the field. This lack of evidence does not diminish the popularity of such interventions within the general Western population.