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Iffland M, Livingstone N, Jorgensen M, Hazell P, Gillies D. Pharmacological intervention for irritability, aggression, and self-injury in autism spectrum disorder (ASD). Cochrane Database Syst Rev 2023; 10:CD011769. [PMID: 37811711 PMCID: PMC10561353 DOI: 10.1002/14651858.cd011769.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self-injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). OBJECTIVES To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self-injury in ASD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. SELECTION CRITERIA We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait-list control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self-injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. MAIN RESULTS We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short-term follow-up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) -0.90, 95% confidence interval (CI) -1.25 to -0.55, 12 studies, 973 participants; moderate-certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD -0.44, 95% CI -0.89 to 0.01; 1 study, 77 participants; very low-certainty evidence). Atypical antipsychotics may also reduce self-injury (SMD -1.43, 95% CI -2.24 to -0.61; 1 study, 30 participants; low-certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low-certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low-certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short-term follow-up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD -0.18, 95% CI -0.37 to -0.00; 8 studies; 466 participants; very low-certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self -injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low- and very low-certainty evidence). Attention-deficit hyperactivity disorder (ADHD)-related medications versus placebo At short-term follow-up, ADHD-related medications may reduce irritability slightly (SMD -0.20, 95% CI -0.40 to -0.01; 10 studies, 400 participants; low-certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD-related medications have an effect on self-injury (SMD -0.62, 95% CI -1.63 to 0.39; 1 study, 16 participants; very low-certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low-certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low-certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short-term follow-up, there was no clear evidence that antidepressants have an effect on irritability (SMD -0.06, 95% CI -0.30 to 0.18; 3 studies, 267 participants; low-certainty evidence). No data for aggression or self-injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low-certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low-certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low-certainty evidence), nor between groups in musculoskeletal AEs (very low-certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. AUTHORS' CONCLUSIONS Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD-related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self-injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self-injury between ADHD-related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self-injury, although the evidence is uncertain. No data were reported (or could be used) for self-injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD-related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD-related medications. The other drug classes had minimal or no associated AEs.
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Affiliation(s)
- Michelle Iffland
- Senior Practitioner Branch, NDIS Quality and Safeguards Commission, Penrith, Australia
| | - Nuala Livingstone
- Cochrane Evidence Production and Methods Directorate , Cochrane, London, UK
| | - Mikaela Jorgensen
- Senior Practitioner Branch, NDIS Quality and Safeguards Commission, Penrith, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Donna Gillies
- Senior Practitioner Branch, NDIS Quality and Safeguards Commission, Penrith, Australia
- Sydney, Australia
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Jack RH, Joseph RM, Hollis C, Hippisley-Cox J, Butler D, Waldram D, Coupland C. Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data. BMJ Ment Health 2023; 26:e300855. [PMID: 37914411 PMCID: PMC10649373 DOI: 10.1136/bmjment-2023-300855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND There is an increasing demand for mental health services for young people, which may vary across the year. OBJECTIVE To determine whether there are seasonal patterns in primary care antidepressant prescribing and mental health issues in adolescents and young adults. METHODS This cohort study used anonymised electronic health records from general practices in England contributing to QResearch. It included 5 081 263 males and females aged 14-18 (adolescents), 19-23 and 24-28 years between 2006 and 2019. The incidence rates per 1000 person-years and the incidence rate ratios (IRRs) were calculated for the first records of a selective serotonin reuptake inhibitor (SSRI) prescription, depression, anxiety and self-harm. The IRRs were adjusted for year, region, deprivation, ethnic group and number of working days. FINDINGS There was an increase in SSRI prescribing, depression and anxiety incidence in male and female adolescents in the autumn months (September-November) that was not seen in older age groups. The IRRs for SSRI prescribing for adolescents peaked in November (females: 1.75, 95% CI 1.67 to 1.83, p<0.001; males: 1.72, 95% CI 1.61 to 1.84, p<0.001, vs in January) and for depression (females: 1.29, 95% CI 1.25 to 1.33, p<0.001; males: 1.29, 95% CI 1.23 to 1.35, p<0.001). Anxiety peaked in November for females aged 14-18 years (1.17, 95% CI 1.13 to 1.22, p<0.001) and in September for males (1.19, 95% CI 1.12 to 1.27, p<0.001). CONCLUSIONS There were higher rates of antidepressant prescribing and consultations for depression and anxiety at the start of the school year among adolescents. CLINICAL IMPLICATIONS Support around mental health issues from general practitioners and others should be focused during autumn.
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Affiliation(s)
- Ruth H Jack
- Centre for Academic Primary Care, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rebecca M Joseph
- Centre for Academic Primary Care, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Chris Hollis
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Debbie Butler
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dave Waldram
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol Coupland
- Centre for Academic Primary Care, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
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Hedna K, Jonson M, Sigström R, Åberg M, Wilhelmson K, Waern M. Healthcare visits for mental disorders and use of psychotropic medications before and after self-harm in a cohort aged 75. Aging Ment Health 2023; 27:2052-2060. [PMID: 36803189 DOI: 10.1080/13607863.2023.2179974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVES Non-fatal self-harm (SH) is a major risk factor for late-life suicide. A better knowledge of the clinical management of older adults who self-harm is needed to establish where improvements could be made for the implementation of effective suicide prevention interventions. We therefore assessed contacts with primary and specialised care for mental disorders and psychotropic drug use during the year before and after a late-life non-fatal SH episode. METHOD Longitudinal population-based study in adults aged ≥75 years with SH episode between 2007 and 2015 retrieved from the regional database VEGA. Healthcare contacts for mental disorders and psychotropic use were assessed during the year before and after the index SH episode. RESULTS There were 659 older adults who self-harmed. During the year before SH, 33.7% had primary care contacts with a mental disorder, 27.8% had such contacts in specialised care. Use of specialised care increased sharply after the SH, reaching a maximum of 68.9%, but this figure dropped to 19.5% by the end of the year. Use of antidepressants increased from 41% before to 60% after the SH episode. Use of hypnotics was extensive before and after SH (60%). Psychotherapy was rare in both primary and specialised care. CONCLUSION The use of specialised care for mental disorders and antidepressant prescribing increased after SH. The drop in long-term healthcare visits should be further explored to align primary and specialised healthcare to the needs of older adults who self-harmed. The psychosocial support of older adults with common mental disorders needs to be strengthened.
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Affiliation(s)
- Khedidja Hedna
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Statistikkonsulterna AB, Gothenburg, Sweden
| | - Mattias Jonson
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Affective Clinic, Gothenburg, Sweden
| | - Robert Sigström
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Cognition and Old Age Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Åberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Regionhälsan, Gothenburg, Sweden
| | - Katarina Wilhelmson
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Margda Waern
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Clinic, Gothenburg, Sweden
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Ng VWS, Gao L, Chan EW, Lee HME, Hayes JF, Osborn DPJ, Rainer TH, Man KKC, Wong ICK. Association between the pharmacological treatment of bipolar disorder and risk of traumatic injuries: a self-controlled case series study. Psychol Med 2023; 53:5185-5193. [PMID: 35866370 DOI: 10.1017/s0033291722002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with bipolar disorder (BPD) are prone to engage in risk-taking behaviours and self-harm, contributing to higher risk of traumatic injuries requiring medical attention at the emergency room (ER).We hypothesize that pharmacological treatment of BPD could reduce the risk of traumatic injuries by alleviating symptoms but evidence remains unclear. This study aimed to examine the association between pharmacological treatment and the risk of ER admissions due to traumatic injuries. METHODS Individuals with BPD who received mood stabilizers and/or antipsychotics were identified using a population-based electronic healthcare records database in Hong Kong (2001-2019). A self-controlled case series design was applied to control for time-invariant confounders. RESULTS A total of 5040 out of 14 021 adults with BPD who received pharmacological treatment and had incident ER admissions due to traumatic injuries from 2001 to 2019 were included. An increased risk of traumatic injuries was found 30 days before treatment [incidence rate ratio (IRR) 4.44 (3.71-5.31), p < 0.0001]. After treatment initiation, the risk remained increased with a smaller magnitude, before returning to baseline [IRR 0.97 (0.88-1.06), p = 0.50] during maintenance treatment. The direct comparison of the risk during treatment to that before and after treatment showed a significant decrease. After treatment cessation, the risk was increased [IRR 1.34 (1.09-1.66), p = 0.006]. CONCLUSIONS This study supports the hypothesis that pharmacological treatment of BPD was associated with a lower risk of ER admissions due to traumatic injuries but an increased risk after treatment cessation. Close monitoring of symptoms relapse is recommended to clinicians and patients if treatment cessation is warranted.
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Affiliation(s)
- Vanessa W S Ng
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Le Gao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
| | - Ho Ming Edwin Lee
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Joseph F Hayes
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - David P J Osborn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London NW10PE, UK
| | - Timothy H Rainer
- Emergency Medicine Unit, The University of Hong Kong, Hong Kong, China
| | - Kenneth K C Man
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK
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Guinovart M, Coronas R, Caixàs A. Psychopathological disorders in Prader-Willi syndrome. ACTA ACUST UNITED AC 2019; 66:579-587. [PMID: 31006652 DOI: 10.1016/j.endinu.2019.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/27/2019] [Accepted: 03/02/2019] [Indexed: 01/07/2023]
Abstract
Prader-Willi syndrome is a genetic disorder caused by chromosomal changes in segment 15q11-q13 including cognitive, mental, and behavioral symptoms, as well as a specific physical phenotype. Both the most common psychopathological changes (intellectual disability, obsessions, impulsivity, autism spectrum disorders, self-injuries) and the main psychiatric comorbidities (affective disorders, psychosis, obsessive-compulsive disorder, autism spectrum disorder) are characterized by a great heterogeneity, which warrants the need for better identification of their frequency and clinical signs. In addition to its effects on body compositionand hypotony, growth hormone has been shown to be useful for regulating patient behavior, and psychoactive drugs are also an option. Other alternatives have shown promising results in experimental trials. Adequate understanding of the psychopathology associated to Prader-Willi syndrome would allow for improving clinical approach, symptom identification, detection of comorbidities, and administration of more effective treatments, leading to better clinical outcomes.
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Affiliation(s)
- Martí Guinovart
- Servicio de Salud Mental, Hospital Universitari Parc Taulí, Universidad Autónoma de Barcelona, Sabadell (Barcelona), España
| | - Ramón Coronas
- Servicio de Salud Mental, Hospital Universitari Parc Taulí, Universidad Autónoma de Barcelona, Sabadell (Barcelona), España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, España
| | - Assumpta Caixàs
- Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí, Universidad Autónoma de Barcelona, Sabadell (Barcelona), España.
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Affiliation(s)
- Lukas Propper
- From the IWK Health Centre, Department of Psychiatry and Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
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Hamm B, Khokhar N, Jimenez XF. Refractory Self-Injurious Behavior in Severe Intellectual Disability Responsive to Topiramate: A Case Report. Psychosomatics 2017; 58:209-212. [PMID: 28189287 DOI: 10.1016/j.psym.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Brandon Hamm
- Department of Psychiatry, A. Cleveland Clinic, Cleveland, OH.
| | - Naveed Khokhar
- Department of Psychiatry, A. Cleveland Clinic, Cleveland, OH
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Togawa M, Saito Y, Maegaki Y, Ohno K. [Treatment of self-injurious behaviors in Lesch-Nyhan syndrome with S-adenosylmethionine]. No To Hattatsu 2017; 49:25-27. [PMID: 30011150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
An 11-year-old boy with Lesch-Nyhan syndrome (LNS) had persistently injured himself by biting his lips and buccal mucosa since infancy. Risperidone was only partially effective in suppressing this behavior. Oral administration of S-adenosylmethionine (SAMe), involving increasing the dose from 400 mg to 1 g, resulted in the amelioration of self-injurious behavior and anxiety as well as marked improvement in his self-esteem, performance at school, and friendships. No adverse effects were noted. SAMe may have a favorable effect on symptoms of LNS by activating monoaminergic pathways and/or increasing the adenosine pool in the salvage pathway of guanosine monophosphate synthesis. Defects in these pathways have been essentially implicated in the neurological pathophysiology of LNS.
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Rus CP. [A girl with self-harm treated with N-acetylcysteine (NAC)]. Tijdschr Psychiatr 2017; 59:181-184. [PMID: 28350146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Deliberate and recurrent self-harm could be regarded as addictive behaviour that can be treated with medication. In addiction, the dopaminergic mesolimbic reward system is activated. Pain caused by cutting stimulates the reward system through the opioid system. Glutamatergic neurotransmission follows the same pathway and plays a role in addiction as well. In this case-study a 17-year-old girl was successfully treated with N-acetylcysteine (nac) in order to reduce the frequency of self-cutting. In addition, in this case nac reduced the symptoms of attention deficit/hyperactivity disorder and depression. nac modulates the glutamatergic neurotransmission. This article provides possible explanations for the effect of nac in this case.
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Elchaar GM, Maisch NM, Augusto LMG, Wehring HJ. Pediatrics Efficacy and Safety of Naltrexone Use in Pediatric Patients with Autistic Disorder. Ann Pharmacother 2016; 40:1086-95. [PMID: 16735648 DOI: 10.1345/aph.1g499] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To review the efficacy and safety of naltrexone in pediatric patients with autistic disorder (AD). Data Sources: Using the terms pediatric, child, naltrexone, autism, and autistic disorder, a literature search was performed using MEDLINE (1966–May 18, 2006) and the International Pharmaceutical Abstracts (1971–May 18, 2006) database. The references of these articles were scanned for additional relevant literature. Study Selection and Data Extraction: All articles describing or evaluating the efficacy and/or safety of naltrexone in pediatric patients with AD were included in this review. Three case reports, 8 case series, and 14 clinical studies were identified as pertinent. Data Synthesis: Naltrexone has been used most commonly at doses ranging from 0.5 to 2 mg/kg/day and found to be predominantly effective in decreasing self-injurious behavior. Naltrexone may also attenuate hyperactivity, agitation, irritability, temper tantrums, social withdrawal, and stereotyped behaviors. Patients may also exhibit improved attention and eye contact. Transient sedation was the most commonly reported adverse event. Small sample size, short duration, and inconsistent evaluative methods characterize the available research. Conclusions: A child affected by AD may benefit from a trial of naltrexone therapy, particularly if the child exhibits self-injurious behavior and other attempted therapies have failed. Serious adverse effects have not been reported in short-term studies.
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Affiliation(s)
- Gladys M Elchaar
- Department of Clinical Pharmacy Practice, College of Pharmacy and Allied Health Professions, St. John's University, Queens, NY 11439, USA
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Saunders KE, Smith KA. Interventions to prevent self-harm: what does the evidence say? Evid Based Ment Health 2016; 19:69-72. [PMID: 27436413 PMCID: PMC10699448 DOI: 10.1136/eb-2016-102420] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 06/26/2016] [Accepted: 06/27/2016] [Indexed: 11/03/2022]
Abstract
Self-harm is a major public health concern and a risk factor for future suicide. It predominantly occurs in young people with around 65% of self-harm occurring before the age of 35. Self-harm causes distress to families and is associated with poorer educational outcomes as well as increased health and social care costs. Repetition is common with a quarter of individuals presenting to hospital with a further episode of self-harm within a year. We review the evidence from randomised controlled trials of treatments for self-harm, focusing on pharmacological and psychological approaches. We then contrast this with the current observational evidence and reflect on the challenges and limitations of randomised controlled trials for the treatment of self-harm.
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Affiliation(s)
- Kate E Saunders
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK;
| | - Katharine A Smith
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK;
- NIHR Oxford Cognitive Health Clinical Research Facility, Warneford Hospital, Oxford, UK
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13
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Selles RR, McGuire JF, Small BJ, Storch EA. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry 2016; 41:29-37. [PMID: 27143352 DOI: 10.1016/j.genhosppsych.2016.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 04/06/2016] [Accepted: 04/08/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE While individual trials suggest benefit of interventions for excoriation (skin-picking) disorder (ExD), limited systematic evaluation of treatments, or their collective benefit, exists. METHODS The present study examined the current state of treatments for ExD in a systematic review and meta-analysis and explored potential treatment moderators. Twelve trials were identified for review, including five with a control condition. Of these, nine were eligible to be included in the meta-analysis (three with a control). RESULTS A fixed-effects meta-analysis found a large overall treatment effect size (g=1.13), comprised of large effects for behavioral treatments (g=1.19), lamotrigine (g=0.98) and selective serotonin reuptake inhibitors (g=1.09). Clinician-rated measures did not significantly differ from self-rated measures; however, larger effects were observed on self-rated measures of severity, as compared to impairment [Q(1)=4.63, P=.03]. Treatment type, trial length and trial methodological quality were not significant moderators. For controlled trials, the comparative efficacy of treatments for ExD was in the moderate range (g=0.47). CONCLUSION Findings suggest that treatment for ExD has benefit; however, the meta-analysis did not provide strong evidence to support any specific treatment or to suggest its unique clinical benefit over control conditions. Overall, there is a lack of study on treatments for ExD and additional randomized controlled trials with inclusion of multiple informants in assessment is needed.
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Affiliation(s)
- Robert R Selles
- Department of Psychology, University of South Florida, Tampa, FL.
| | - Joseph F McGuire
- Semel Institute of Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA
| | - Brent J Small
- School of Aging Studies, University of South Florida, Tampa, FL
| | - Eric A Storch
- Department of Psychology, University of South Florida, Tampa, FL; Department of Pediatrics, University of South Florida, St. Petersburg, FL; Department of Health Policy and Management, University of South Florida, Tampa, FL; Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL; Rogers Behavioral Health - Tampa Bay, Tampa, FL; All Children's Hospital - Johns Hopkins Medicine, St. Petersburg, FL
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Redden SA, Leppink EW, Grant JE. Body focused repetitive behavior disorders: Significance of family history. Compr Psychiatry 2016; 66:187-92. [PMID: 26995252 DOI: 10.1016/j.comppsych.2016.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/07/2016] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The significance of family history in body-focused repetitive behavior disorders (BFRBs) (i.e. trichotillomania and skin picking) has received scant research attention. We sought to understand the clinical and cognitive impact of having a first-degree relative with a BFRB or a substance use disorder (SUD). METHODS 265 participants with BFRBs undertook clinical and neurocognitive evaluations. Those with a first-degree relative with a BFRB or an SUD were compared to those without on a number of clinical and cognitive measures. RESULTS 77 (29.1%) participants had a first-degree family member with a BFRB and 59 (22.2%) had a first-degree family member with an SUD. In terms of clinical severity, the amount of time spent picking or pulling per day in the past week was higher among those with a first-degree relative with an SUD. There were a higher rate of ADHD and higher HAM-D scores among those with a positive family history of an SUD. There were no significant cognitive differences based on family history. CONCLUSIONS These results indicate that among those with BFRBs, having a first-degree family member with an SUD may be associated with a unique clinical and cognitive presentation. Whether family history also is associated with differential response to treatments awaits further research.
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Affiliation(s)
- Sarah A Redden
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Eric W Leppink
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Jon E Grant
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.
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Downs J, Hotopf M, Ford T, Simonoff E, Jackson RG, Shetty H, Stewart R, Hayes RD. Clinical predictors of antipsychotic use in children and adolescents with autism spectrum disorders: a historical open cohort study using electronic health records. Eur Child Adolesc Psychiatry 2016; 25:649-58. [PMID: 26472118 PMCID: PMC4889626 DOI: 10.1007/s00787-015-0780-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 09/28/2015] [Indexed: 02/01/2023]
Abstract
Children with autism spectrum disorders (ASD) are more likely to receive antipsychotics than any other psychopharmacological medication, yet the psychiatric disorders and symptoms associated with treatment are unclear. We aimed to determine the predictors of antipsychotic use in children with ASD receiving psychiatric care. The sample consisted of 3482 children aged 3-17 with an ICD-10 diagnosis of ASD referred to mental health services between 2008 and 2013. Antipsychotic use outcome, comorbid diagnoses, and other clinical covariates, including challenging behaviours were extracted from anonymised patient records. Of the 3482 children (79 % male) with ASD, 348 (10 %) received antipsychotic medication. The fully adjusted model indicated that comorbid diagnoses including hyperkinetic (OR 1.44, 95 %CI 1.01-2.06), psychotic (5.71, 3.3-10.6), depressive (2.36, 1.37-4.09), obsessive-compulsive (2.31, 1.16-4.61) and tic disorders (2.76, 1.09-6.95) were associated with antipsychotic use. In addition, clinician-rated levels of aggression, self-injurious behaviours, reduced adaptive function, and overall parental concern for their child's presenting symptoms were significant risk factors for later antipsychotic use. In ASD, a number of comorbid psychiatric disorders are independent predictors for antipsychotic treatment, even after adjustment for familial, socio-demographic and individual factors. As current trial evidence excludes children with comorbidity, more pragmatic randomised controlled trials with long-term drug monitoring are needed.
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Affiliation(s)
- Johnny Downs
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK.
| | - Matthew Hotopf
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
| | - Tamsin Ford
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
- University of Exeter Medical School, Exeter, UK
| | - Emily Simonoff
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
| | - Richard G Jackson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Hitesh Shetty
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Richard D Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, Box 63, SE5 8AF, London, UK
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Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. WITHDRAWN: Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database Syst Rev 2015; 2015:CD001764. [PMID: 26436718 PMCID: PMC10759787 DOI: 10.1002/14651858.cd001764.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This review has been withdrawn because the topic has been split into three separate reviews, one on psychosocial interventions for self‐harm in adults; another on interventions for self‐harm in children and adolescents; and a third on pharmacological interventions for self‐harm in adults. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Keith Hawton
- Warneford HospitalCentre for Suicide Research, University Department of PsychiatryOxfordUKOX3 7JX
| | - Ellen Townsend
- University of NottinghamSelf‐Harm Research Group, School of PsychologyUniversity ParkNottinghamUKNG7 2RD
| | - Ella Arensman
- University College CorkNational Suicide Research Foundation and Department of Epidemiology and Public HealthCorkIreland
| | - David Gunnell
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PR
| | - Philip Hazell
- Sydney Medical SchoolDiscipline of PsychiatryG03 ‐ Thomas Walker HospitalHospital RdConcord WestNew South WalesAustralia2138
| | - Allan House
- University of LeedsLeeds Institute of Health SciencesCharles Thackrah Building101 Clarendon RoadLeedsUKLS2 9LJ
| | - Kees van Heeringen
- Ghent UniversityUnit for Suicide Research, Department of Psychiatry and Medical PsychologyGhentBelgium9000
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17
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George NM, Whitaker J, Vieira G, Geronimo JT, Bellinger DA, Fletcher CA, Garner JP. Antioxidant Therapies for Ulcerative Dermatitis: A Potential Model for Skin Picking Disorder. PLoS One 2015; 10:e0132092. [PMID: 26167859 PMCID: PMC4500395 DOI: 10.1371/journal.pone.0132092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/10/2015] [Indexed: 01/04/2023] Open
Abstract
Skin Picking Disorder affects 4% of the general population, with serious quality of life impacts, and potentially life threatening complications. Standard psychoactive medications do not help most patients. Similarly, Mouse Ulcerative Dermatitis (skin lesions caused by excessive abnormal grooming behavior) is very common in widely used inbred strains of mice, and represents a serious animal welfare issue and cause of mortality. Treatment options for Ulcerative Dermatitis are largely palliative and ineffective. We have proposed mouse Ulcerative Dermatitis as a model for human Skin Picking Disorder based on similar epidemiology, behavior, and its comorbidity and mechanistic overlap with hair pulling (trichotillomania). We predicted that mouse Ulcerative Dermatitis would be treated by N-Acetylcysteine, as this compound is highly effective in treating both Skin Picking Disorder and Trichotillomania. Furthermore, we hypothesized that N-Acetylcysteine’s mode of action is as a precursor to the production of the endogenous antioxidant glutathione in the brain, and therefore intranasal glutathione would also treat Ulcerative Dermatitis. Accordingly, we show in a heterogenous prospective trial, the significant reduction in Ulcerative Dermatitis lesion severity in mice receiving either N-acetylcysteine (oral administration) or glutathione (intranasal). The majority of mice treated with N-acetylcysteine improved slowly throughout the course of the study. Roughly half of the mice treated with glutathione showed complete resolution of lesion within 2-4 weeks, while the remainder did not respond. These findings are the first to show that the use of N-acetylcysteine and Glutathione can be curative for mouse Ulcerative Dermatitis. These findings lend additional support for mouse Ulcerative Dermatitis as a model of Skin Picking Disorder and also support oxidative stress and glutathione synthesis as the mechanism of action for these compounds. As N-Acetylcysteine is poorly tolerated by many patients, intranasal glutathione warrants further study as potential therapy in Skin Picking, trichotillomania and other body-focused repetitive behavior disorders.
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Affiliation(s)
- Nneka M. George
- Department of Pathology and Laboratory Medicine, Division of Laboratory Animal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Julia Whitaker
- Department of Pathology and Laboratory Medicine, Division of Laboratory Animal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Giovana Vieira
- Department of Animal Sciences, Purdue University, West Lafayette, Indiana, United States of America
| | - Jerome T. Geronimo
- Department of Comparative Medicine, Stanford University, Stanford, California, United States of America
| | - Dwight A. Bellinger
- Department of Pathology and Laboratory Medicine, Division of Laboratory Animal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Craig A. Fletcher
- Department of Pathology and Laboratory Medicine, Division of Laboratory Animal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joseph P. Garner
- Department of Comparative Medicine, Stanford University, Stanford, California, United States of America
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, United States of America
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Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K. Pharmacological interventions for self-harm in adults. Cochrane Database Syst Rev 2015; 2015:CD011777. [PMID: 26147958 PMCID: PMC8637297 DOI: 10.1002/14651858.cd011777] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. OBJECTIVES To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. SEARCH METHODS For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. SELECTION CRITERIA We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. MAIN RESULTS We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. AUTHORS' CONCLUSIONS Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.
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Affiliation(s)
- Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK, OX3 7JX
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Roy A, Roy M, Deb S, Unwin G, Roy A. Are opioid antagonists effective in attenuating the core symptoms of autism spectrum conditions in children: a systematic review. J Intellect Disabil Res 2015; 59:293-306. [PMID: 24589346 DOI: 10.1111/jir.12122] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND ASC (autism spectrum conditions) may result from a failure of striatal beta endorphins to diminish with maturation. Many symptoms of ASC resemble behaviours induced in animals or humans by opiate administration, including decreased socialisation, diminished crying, repetitive stereotypies, insensitivity to pain and motor hyperactivity. Naltrexone, an opioid antagonist, has been used in the management of children with ASC and can produce a clinically significant reduction in the serious and life-threatening behaviour of self-injury for individuals who have not been responsive to any other type of treatment and is important for this reason. It was therefore appropriate to reconsider the available evidence and a systematic review was undertaken. METHODS Four electronic databases were searched for relevant journal articles. In addition, cross-referencing of pertinent reviews and a hand search for articles in major international intellectual disability (ID) journals between the years 2010 and 2012 was carried out to ensure that all relevant articles were identified. We also searched databases for unpublished clinical trials to overcome publication bias. Each database was searched up to present (February 2013) with no restrictions on the date of publication. The search terms consisted of broad expressions used to describe ID and autistic spectrum disorder as well as terms relating to opioid antagonists and specific drugs. All studies identified by the electronic database search and hand search were examined on the basis of title alone for relevance and duplication. The abstracts of the remaining papers were then scrutinised against the inclusion criteria. Where abstracts failed to provide adequate information, the full texts for these papers were obtained. All the full texts were then evaluated against the inclusion proforma. Two reviewers carried out all the stages of the process independently. The reviewers met to discuss their selections and where disagreements arose, these were settled by discussion with a member of the study group. Data from each study meeting the inclusion criteria were extracted on a pre-piloted data extraction form. The quality of each study was further assessed using the Jadad scale, a tool developed to assess the quality of randomised controlled trials. RESULTS 155 children participated in 10 studies; 27 received placebo. Of the 128 that received naltrexone 98 (77%) showed statistically significant improvement in symptoms of irritability and hyperactivity. Side effects were mild and the drug was generally well tolerated. CONCLUSIONS Naltrexone may improve hyperactivity and restlessness in children with autism but there was not sufficient evidence that it had an impact on core features of autism in majority of the participants. It is likely that a subgroup of children with autism and abnormal endorphin levels may respond to naltrexone and identifying the characteristics of these children must become a priority.
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Affiliation(s)
- A Roy
- Manchester Medical School, Manchester, UK
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20
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Roy A, Roy M, Deb S, Unwin G, Roy A. Are opioid antagonists effective in reducing self-injury in adults with intellectual disability? A systematic review. J Intellect Disabil Res 2015; 59:55-67. [PMID: 24397316 DOI: 10.1111/jir.12111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND Self-injury in people with intellectual disability (ID) may be due to variety of factors both environmental and biological. As the drive in UK is to manage people with ID and problem behaviours in the community, it is important to critically examine all treatment options available. As abnormalities in the endogenous opioid system may be a factor in some people with ID, we undertook a systematic review to evaluate the evidence for the effectiveness of opioid antagonists. METHODS Four electronic databases were searched for relevant journal articles. In addition, cross-referencing of pertinent reviews and a hand search for articles in major international ID journals between the years 2010 and 2012 was carried out to ensure that all relevant articles were identified. We also searched databases for unpublished clinical trials to overcome publication bias. Each database was searched up to present (February 2013) with no restrictions on the date of publication. The search terms consisted of broad expressions used to describe ID and autistic spectrum disorder as well as terms relating to opioid antagonists and specific drugs. All studies identified by the electronic database search and hand search were examined on the basis of title alone for relevance and duplication. The abstracts of the remaining papers were then scrutinised against the inclusion criteria. Where abstracts failed to provide adequate information, the full texts for these papers were obtained. All the full texts were then evaluated against the inclusion proforma. Two reviewers carried out all the stages of the process independently. The reviewers met to discuss their selections and where disagreements arose, these were settled by discussion with a member of the study group. Data from each study meeting the inclusion criteria was extracted on a pre-piloted data extraction form. The quality of each study was further assessed using the Jadad scale, a tool developed to assess the quality of randomised controlled trials. RESULTS Out of 10 randomised control trials eight reported a reduction in the frequency of self-injurious behaviour. This meant that 62 participants out of 124 (50%) showed an improvement of which 61 were statistically significant. Forty-nine participants had autism. Eleven (9%) had minor side-effects. The improvement was more marked in people with severe and profound ID and was not affected by the coexistence of autism. CONCLUSIONS This review suggests that some people respond to opioid antagonists with a reduction in self-injury but the trials do not predict who they may be. Future research may identify this sub-group when opioid antagonists may prove to be a useful addition in the pharmacotherapy of self-injury.
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Affiliation(s)
- A Roy
- Manchester Medical School, Manchester, UK
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Abstract
The aim of this report is to present a case of a patient with bilateral lacrimal gland abscesses in the course of dacryoadenitis. A 45-year-old female patient with a long history of cocaine abuse presented with bilateral bacterial dacryoadenitis and upper lid inflammation with purulent discharge from a palpebral wound of the right upper lid. The diagnosis was confirmed with microbiology culture and an orbital CT scan, which revealed lacrimal gland abscesses. The patient admitted to vigorous eye scratching, which we believe was the mechanism responsible for the process. The infection resolved on targeted antibiotic therapy. This is the first reported case of bilateral infectious dacryoadenitis produced in a self-inflicted mechanism in a cocaine addict.
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Affiliation(s)
- Marta Latasiewicz
- Department of Ophthalmology, Hospital Clinic de Barcelona , Barcelona , Spain
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Deb S, Farmah BK, Arshad E, Deb T, Roy M, Unwin GL. The effectiveness of aripiprazole in the management of problem behaviour in people with intellectual disabilities, developmental disabilities and/or autistic spectrum disorder--a systematic review. Res Dev Disabil 2014; 35:711-725. [PMID: 24405794 DOI: 10.1016/j.ridd.2013.12.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 12/10/2013] [Indexed: 06/03/2023]
Abstract
The management of problem behaviours (PB) in individuals with intellectual disabilities (ID), developmental disabilities (DD) and/or autistic spectrum disorders (ASD) can be challenging. Antipsychotic medications are commonly prescribed where other strategies have failed. A systematic review (SR) was conducted to establish the research evidence for the efficacy of aripiprazole in the management of PB in adults and children with ID, DD and/or ASD. Although included studies supported the efficacy of aripiprazole for this indication, the overall quality of studies was poor. Of the 20 studies included in this systematic review there were only two randomised controlled trials (RCTs) on children with ASD and/or ID/DD, both of which were conducted by the pharmaceutical company that manufactures aripiprazole, and it is not clear whether a number of same participants were included in both RCTs. One of the RCTs was extended into an open label long term follow up, which showed that aripiprazole's efficacy lasted over 52 weeks and the adverse effects were tolerable. Four studies were open label prospective studies, 11 were retrospective case reports which included four single case reports, and two were prospective case series. Most studies reported adverse effects from aripiprazole in the form of weight gain, increased appetite, sedation, tiredness, drooling and tremor. However, aripiprazole improved serum prolactin level in some participants and overall did not show any adverse effect on QTc interval. There is a need for more carefully designed RCTs into the use of aripiprazole in the management of PB in people with ID/DD and/or ASD, which should be carried out independent of pharmaceutical companies.
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Affiliation(s)
| | | | | | | | - Meera Roy
- Birmingham Community Healthcare NHS Trust, UK.
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Norelli LJ, Smith HS, Sher L, Blackwood TA. Buprenorphine in the treatment of non-suicidal self-injury: a case series and discussion of the literature. Int J Adolesc Med Health 2014; 25:323-30. [PMID: 23995832 DOI: 10.1515/ijamh-2013-0069] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 12/01/2012] [Indexed: 11/15/2022]
Abstract
A global public health problem, non-suicidal self-injury (NSSI) is highly prevalent in both males and females, and tends to first occur in adolescence. NSSI is correlated with a history of childhood trauma, and with a variety of developmental and psychiatric disorders. NSSI is associated with increased risk of morbidity and premature death from suicide, accidents, and natural causes. Current treatment approaches are inadequate for a substantial number of people. Converging evidence for opioid system dysregulation in individuals with NSSI make this a promising area of investigation for more effective treatments. The pharmacological profile of buprenorphine, a potent μ-opioid partial agonist and κ-opioid antagonist, suggests that it may be beneficial. In this paper, we describe the successful treatment of severe NSSI with buprenorphine in six individuals, followed by discussion and further recommendations.
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Ward F, Tharian P, Roy M, Deb S, Unwin GL. Efficacy of beta blockers in the management of problem behaviours in people with intellectual disabilities: a systematic review. Res Dev Disabil 2013; 34:4293-4303. [PMID: 24171827 DOI: 10.1016/j.ridd.2013.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 08/15/2013] [Indexed: 06/02/2023]
Abstract
Both medication and non-medication based strategies are used in the management of problem behaviours in individuals with intellectual disabilities. Beta-adrenoceptor blocking medications are one group of drugs used for this purpose. However, despite its regular use, the evidence for the efficacy of these drugs for in this context is lacking. A systematic review was conducted to establish the research evidence for the efficacy of beta blockers in problem behaviours in adults and children with intellectual disabilities. Although the research identified supported the efficacy of beta blockers for this indication the overall quality of studies identified was poor and no randomised controlled trials were identified. There is a need for more robust research into the use of beta blockers for people with intellectual disabilities who show problem behaviours.
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Affiliation(s)
- Frances Ward
- Southern Health NHS Foundation Trust, United Kingdom.
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25
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Wong JW, Koo JYM. Psychopharmacological therapies in dermatology. Dermatol Online J 2013; 19:18169. [PMID: 24011270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 06/02/2023] Open
Abstract
When patients with psychodermatologic disorders present in clinic, the dermatologist can refer them to psychiatrists or other mental health care professionals. However, it is often the case that these patients will refuse a psychiatric referral because they either do not believe they have a disorder of psychiatric nature or they feel there is societal stigma associated with psychiatric illness. Therefore, it is essential for dermatologists to understand the common classifications for psychodermatological cases and to know how to optimally treat these patients with pharmacotherapy. The intent of this article is to help guide physicians in understanding the classifications of psychodermatological cases and in managing these conditions with pharmacotherapies. In this article, two classifications for psychodermatological cases are presented, followed by a discussion of medical therapies used to treat the main categories of psychopathologies that are more frequently encountered in dermatology. These include depression, anxiety, delusions, and obsessive-compulsive disorder.
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Affiliation(s)
- Jillian W Wong
- UCSF Psoriasis and Skin Treatment Center, San Fancisco, CA 94118, USA.
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Abstract
BACKGROUND Self-injurious behaviour among people with intellectual disability is relatively common and often persistent. Self-injurious behaviour continues to present a challenge to clinicians. It remains poorly understood and difficult to ameliorate despite advances in neurobiology and psychological therapies. There is a strong need for a better evidence base in prescribing and monitoring of drugs in this population, especially since none of the drugs are actually licensed for self-injurious behaviour. OBJECTIVES To determine clinical effectiveness of pharmacological interventions in management of self-injurious behaviour in adults with intellectual disability. SEARCH METHODS We searched the following databases on 19 February 2012: CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Science and Humanities, ZETOC and WorldCat. We also searched ClinicalTrials.gov, ICTRP and the reference lists of included trials. SELECTION CRITERIA We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour (SIB) in adults with intellectual disability. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias for each trial using a data extraction form. We present a narrative summary of the results is presented. We did not consider meta-analysis was appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures. MAIN RESULTS We found five double-blind placebo-controlled trials that met our inclusion criteria. These trials assessed effectiveness and safety of drugs in a total of 50 people with intellectual disability demonstrating SIB. Four trials compared the effects of naltrexone versus placebo and one trial compared clomipramine versus placebo.One of the naltrexone versus placebo trials reported that naltrexone had clinically significant effects (≥ 33% reduction) on the daily rates of three of the four participants' most severe form of SIB and modest to substantial reductions in SIB for all participants; however, this study did not report on statistical significance. Another trial reported that naltrexone attenuated SIB in all four participants, with 25 mg and 50 mg doses producing a statistically significant decrease in SIB (P value < 0.05). Another trial (eight people) indicated that naltrexone administration was associated with significantly fewer days of high frequency self injury and significantly more days with low frequency self injury. Naltrexone had different effects depending on the form and location of self injury. Another trial with only 26 participants found that neither single-dose (100 mg) nor long-term (50 and 150 mg) naltrexone treatment had any therapeutic effect on SIB.Comparison of clomipramine versus placebo found no statistically significant benefit for any outcome measure, which included SIB rate and intensity, stereotypy and adverse events. However, it showed clinically significant improvement in the rate and intensity of SIB and stereotypy.There were very few noteworthy adverse events to report in any of the four trials in which these were reported.All trials were at high risk of bias, apart from one trial (Lewis 1996), which was probably at low risk of bias. The short period of follow-up was a significant drawback in the design of all five trials, as it did not allow long-term assessment of behaviour over time.We were unable to examine the efficacy of antidepressants other than clomipramine, antipsychotics, mood stabilisers or beta-blockers as we did not identify any relevant placebo-controlled trials. AUTHORS' CONCLUSIONS There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating SIB. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.
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Affiliation(s)
- Fareez Rana
- Psychiatry of Intellectual Disability, Southern Health NHS Foundation Trust, Oxford, UK.
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Tribó MJ, Rozas-Muñoz EA, Gallardo F, Casanova N, Ros-Montalban S, Bulbena A, Pujol R. Zonisamide for the treatment of self-inflicted dermatoses related to impulse control disorders. Arch Dermatol 2012; 148:762-764. [PMID: 22710467 DOI: 10.1001/archdermatol.2011.3620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Mehl-Madrona L, Leung B, Kennedy C, Paul S, Kaplan BJ. Micronutrients versus standard medication management in autism: a naturalistic case-control study. J Child Adolesc Psychopharmacol 2010; 20:95-103. [PMID: 20415604 PMCID: PMC2875953 DOI: 10.1089/cap.2009.0011] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Autism spectrum disorder (ASD) is often accompanied by self-injurious behavior (SIB), aggression, and tantrums, symptoms that have reportedly improved with micronutrient (vitamins and minerals) treatment. The current study took advantage of naturally occurring differences in parental preferences for treatment approaches. The micronutrient group asked for treatment without pharmaceuticals (n = 44, aged 2-28 years at entry [M = 8.39 +/- 5.58]). Their records were matched with those of 44 similar children whose families requested conventional treatment (medication group). Both groups improved on both the Childhood Autism Rating Scale and the Childhood Psychiatric Rating Scale (all p values <0.0001). Both groups also exhibited significant decreases in total Aberrant Behavior Checklist scores, but the micronutrient group's improvement was significantly greater (p < 0.0001). SIB Intensity was lower in the micronutrient group at the end of the study (p = 0.005), and improvement on the Clinical Global Impressions scale was greater for the micronutrient group (p = 0.0029). It is difficult to determine whether the observed changes were exerted through improvement in mood disorder or through an independent effect on autistic disorder. There were some advantages to treatment with micronutrients-lower activity level, less social withdrawal, less anger, better spontaneity with the examiner, less irritability, lower intensity SIB, markedly fewer adverse events, and less weight gain. Advantages of medication management were insurance coverage, fewer pills, and less frequent dosing.
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Affiliation(s)
- Lewis Mehl-Madrona
- Department of Psychology, Argosy University, Honolulu, Hawaii, and Department of Family Medicine, University of Hawaii School of Medicine, Honolulu, Hawaii
| | - Brenda Leung
- Department of Community Health Sciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
| | - Carla Kennedy
- Department of Anthropology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarah Paul
- School of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Bonnie J. Kaplan
- Departments of Pediatrics, and Community Health Sciences, University of Calgary Faculty of Medicine, Calgary, Alberta, Canada
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Abstract
Self-injurious behaviors (SIB) in patients who have developmental disabilities is a complex disorder, and its underlying etiologies are poorly understood. SIB is a significant factor in hospitalizations, decisions to use psychotropic medications, and institutional placement for people who have developmental disabilities. Because this group often manifests oral SIB, the dentist may be the first professional called upon to evaluate a patient. Dental therapy focuses on symptomatic treatment to minimize tissue damage caused by SIB, but addressing the underlying impetus for the behavior is essential for successful treatment. Determining definitive therapeutic interventions is difficult because of the mixed bio behavioral etiologies for SIB. This complication necessitates a team approach that includes medical and behavioral specialists.
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Affiliation(s)
- Maureen Romer
- Arizona School of Dentistry and Oral Health, A.T. Still University, 5855 E. Still Circle, Mesa, AZ 85206, USA.
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Fontenot MB, Musso MW, McFatter RM, Anderson GM. Dose-finding study of fluoxetine and venlafaxine for the treatment of self-injurious and stereotypic behavior in rhesus macaques (Macaca mulatta). J Am Assoc Lab Anim Sci 2009; 48:176-184. [PMID: 19383215 PMCID: PMC2679666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 05/08/2008] [Accepted: 07/21/2008] [Indexed: 05/27/2023]
Abstract
The short-term effects on rates and durations of self-injurious behavior and self-directed stereotypies associated with various doses of fluoxetine (FLX) and venlafaxine (VEN) were examined in rhesus macaques. Adult male macaques (Macaca mulatta; n = 17; age, 7 to 15 y) with at least 1 episode of severe SIB within the past 5 y were randomized to treatment with FLX (n = 6), VEN (n = 6), or placebo (PLC, n = 5), administered by voluntary consumption of medication provided in fruit-flavored tablets. After 4-wk baseline and 4-wk placebo lead-in phases, doses were increased monthly for 4 mo (FLX: 0.5, 2.0, 4.0, and 8.0 mg/kg; VEN: 2.0, 4.0, 8.0, and 16.0 mg/kg). Animals in the PLC condition received similar nonmedicated fruit-flavored tablets. Focal behavioral observations, plasma drug levels, and neurochemical data were obtained. Results indicated that rates and percentage time spent self-biting declined at all doses of FLX, with the greatest effect seen at 2.0 mg/kg. For VEN, percentage time spent self-biting was significantly lower only at the 4.0 mg/kg dose. Treatment-induced reductions in platelet serotonin and cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5HIAA) concentrations were substantially greater in the FLX-treated condition than in the VEN-treated condition. Plasma FLX and norfluoxetine levels increased with FLX dose; plasma levels of VEN were low and not dose-related. Fluoxetine at a dose of 2.0 mg/kg daily was most efficacious in reducing SIB, and the observed reductions in platelet serotonin and CSF 5HIAA levels indicated substantial bioeffect at this dose. Treatment with VEN was marked by noncompliance, low bioeffect, and low efficacy.
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Affiliation(s)
- M Babette Fontenot
- Division of Behavioral Sciences, New Iberia Research Center, University of Louisiana at Lafayette, Lafayette, Louisiana, USA.
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Watson SL, McCoy JG, Fontenot MB, Hanbury DB, Ward CP. L-tryptophan and correlates of self-injurious behavior in small-eared bushbabies (Otolemur garnettii). J Am Assoc Lab Anim Sci 2009; 48:185-191. [PMID: 19383216 PMCID: PMC2679665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 06/30/2008] [Accepted: 09/17/2008] [Indexed: 05/27/2023]
Abstract
Self-injurious behavior (SIB) among captive primates is a recurring problem for those who manage such facilities. Its prevalence highlights the need for research evaluating the effectiveness of potential treatment approaches. In the present study, 4 wk of dietary supplementation with L-tryptophan (100 mg daily) was evaluated for the treatment of self-inflicted wounds in 22 small-eared bushbabies, a prosimian primate, with a history of SIB. The treatment significantly reduced stereotypy and was associated with a reduction in wound area and severity. In terms of physiologic measures, preexisting high levels of cortisol were reduced in bushbabies with SIB, whereas serotonin concentrations were increased after 4 wk of treatment. Results indicate that L-tryptophan as a dietary supplement may be a viable adjunct to standard husbandry procedures for animals exhibiting maladaptive behaviors such as stereotypy and SIB.
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Affiliation(s)
- Sheree L Watson
- University of Southern Mississippi, Department of Psychology, Hattiesburg, Mississippi, USA.
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Abstract
Self-injuring behavior (SIB) is a life-threatening behavior exhibited by many species, including humans, and has no known cause and no agreed upon treatment. The role of the stress axis in the maintenance of this mysterious behavior was examined in subjects with life-long SIB. Over a 6-year period, 40 hr of direct observations of behavior and the environment were recorded on palmtop computers while 36 residential subjects (28 target and 8 control subjects) conducted their daily activities. Blood samples were collected in morning and evening for all subjects and within minutes after a self-injuring act in 28 target subjects who exhibited SIB to determine levels of ACTH and B-endorphin (BE). Self-injuring events in the patient group were significantly sequentially dependent (i.e., the only predictor of a self-injuring act was an antecedent self-injuring act). Higher morning levels of BE relative to ACTH predicted [r(df=27) = .57, p < .001] the sequentially dependent pattern of SIB. This effect was validated in a subgroup retested several months later [r(df=22) = .60, p < .001]. A subgroup of seven subjects exhibiting sequentially dependent patterns were administered an opiate blocker (naltrexone) in a double-blind, crossover design with an additional 14 hr/week of observation for 7 weeks. Naltrexone challenge interrupted the sequential pattern (improved behavior) in subjects with elevated BE immediately following SIB (r = .85, p < .01). The pattern of results supported the conclusion that the stress axis played a significant role in the maintenance of complex episodes of self-injury.
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Affiliation(s)
- Curt A Sandman
- Department of Psychiatry and Human Behavior, University of California, 2501 Harbor Blvd, Costa Mesa, Irvine, CA 92626, USA.
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Abstract
A double-blind, placebo-controlled clinical trial was conducted to determine the efficacy of clomipramine hydrochloride in cats with psychogenic alopecia. Twenty-five cats were randomly assigned to receive clomipramine hydrochloride (0.5 mg/kg orally q 24 hours) or placebo for 56 days. Eleven cats in each group completed the trial. The results of this study showed that clomipramine hydrochloride failed to demonstrate significant changes in the number of grooming bouts, hair regrowth, and the area of alopecia in cats with psychogenic alopecia when compared to a placebo. It was uncertain whether these results reflected a lack of drug efficacy, insufficient treatment duration, or an insufficient number of cases enrolled.
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Affiliation(s)
- Petra A Mertens
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota 55108, USA
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Hergüner S, Mukaddes NM. Risperidone-induced double incontinence. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:1085-6. [PMID: 18387724 DOI: 10.1016/j.pnpbp.2008.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 02/18/2008] [Accepted: 02/18/2008] [Indexed: 11/28/2022]
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Sharma H. Psychogenic excoriation responding to fluoxetine: a case report. J Indian Med Assoc 2008; 106:245-262. [PMID: 18828345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Compulsive skin picking, 'acne excoriee', neurotic (psychogenic) excoriation, dermatotillomania, occurring in 2% dermatology patients mostly in women, is a result of excessive scratching, picking, gouging or squeezing of the skin using teeth, tweezers, nail files, pins and knives, etc. The lesions are usually found on face and also on upper limbs and upper back, areas patients can easily reach. They may occur in absence or in response to skin pathology or sensation of itching. A young female patient attended OPD with the complaints of multiple excoriated lesions over the face, arms and forearms. The diagnosis was psychogenic excoriation which is an uncommon psychodermatological condition. She was treated with fluoxetine and behaviour therapy. The patient recovered fully with above treatment at the end of 3 months. Psychogenic excoriation is an uncommon psychodermatological condition which responds well to selective serotonin reuptake inhibitors and behaviour therapy (habit reversal training).
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Affiliation(s)
- Himanshu Sharma
- Department of Psychiatry, PS Medical College and SK Hospital, Karamsad 388325
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Sohanpal SK, Deb S, Thomas C, Soni R, Lenôtre L, Unwin G. The effectiveness of antidepressant medication in the management of behaviour problems in adults with intellectual disabilities: a systematic review. J Intellect Disabil Res 2007; 51:750-65. [PMID: 17803494 DOI: 10.1111/j.1365-2788.2006.00935.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND A comprehensive systematic review was performed to establish the current evidence base regarding the effectiveness of antidepressant medication for the management of behaviour problems in adults with intellectual disabilities. METHOD An electronic search of PsycInfo, Embase, Medline and Cinahl databases was conducted spanning the time period 1990 to October 2005 for primary trials. This was supplemented by hand searching and cross-referencing of relevant reviews. Strict scientific methodology requirements were formulated that the studies had to meet in order to merit inclusion in this review. RESULTS One crossover randomized controlled trial in a small cohort, seven prospective uncontrolled trials and two retrospective studies were yielded in the search. Of these, one explored the effectiveness of the tricyclic antidepressant--clomipramine, and nine considered various selective serotonin reuptake inhibitors (SSRIs). CONCLUSION Evidence based primarily on a small number of either prospective or retrospective case studies that included a small number of participants and often used non-validated outcome measures for a short period of follow-up, suggests that antidepressants, particularly SSRIs, show improvement of aggression and self-injurious behaviour on average in less than 50% of cases and the rest show either no improvement or deterioration. The effect is most pronounced in the presence of an underlying anxiety or an associated diagnosis of obsessive-compulsive disorder. Most studies have highlighted the concern regarding adverse effects.
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Affiliation(s)
- S K Sohanpal
- Department of Psychiatry, Division of Neuroscience, University of Birmingham, Birmingham, UK
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Affiliation(s)
- Craig A Erickson
- Department of Psychiatry, Indiana University School of Medicine, and the Christian Sarkine Autism Treatment Center, James Whitcomb Riley Hospital for Children, Indianapolis 46202-4800, USA
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Abstract
Pathological skin picking is characterized by dysfunctional, repetitive and excessive manipulation of the skin resulting in noticeable tissue damage. This study sought to assess the effectiveness of escitalopram in treating pathological skin picking. Twenty-nine individuals with pathological skin picking were enrolled in an 18-week, open-label trial of escitalopram. Study measures assessing skin picking severity and impact, anxiety, depression, and quality of life were given at baseline and weeks 2, 4, 6, 10, 14, and 18. The mean maximally tolerated dose was 25.0 mg (standard deviation=8.4). For the 19 study completers, pre-post-treatment analyses revealed significant improvements (P<0.05) on measures of skin picking severity and impact, quality of life, and self-rated anxiety and depression. Completer as well as intent-to-treat analyses indicated that approximately half of the sample satisfied full medication response criteria and one-quarter were partial medication responders. Correlational analyses indicated that changes in depression, anxiety, and quality of life co-occurred with reductions in skin picking severity but not impact. A high percentage of variance in severity, however, remained unexplained. These results suggest that escitalopram can be an effective agent in reducing pathological skin picking. The lack of medication response in a subset of our sample suggests the possibility of pathological skin picking subtypes.
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Affiliation(s)
- Nancy J Keuthen
- Massachusetts General Hospital/Harvard Medical School, 185 Cambridge Street, Boston, MA 02114, USA.
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Basu D, Barnwal PK. Omega-3 fatty acid for recurrent self-harm: unanswered questions. Br J Psychiatry 2007; 191:264; author reply 264. [PMID: 17766772 DOI: 10.1192/bjp.191.3.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Low cholesterol has been reliably demonstrated in people who self-harm. AIMS To determine whether people who self-harm also have low levels of essential fatty acids (EFAs) and to examine associations between the EFAs and serotonergic function. METHOD Depression, impulsivity and suicidal intent were measured in patients with self-harm (n=40) and matched controls, together with plasma lipids and EFAs. Platelet serotonergic studies were carried out in a subgroup (n=27). RESULTS Patients with self-harm had significantly more pathology on all psychometric measures, lower mean total cholesterol levels (4.18 (s.d.=0.93) v. 4.87 (s.d.=0.83) mmol/l, P=0.003) and lower mean total EFA levels (89. 5 (15.6) v.103.7 (17.1) microg/ml, P=0.0001) than controls after adjustment for confounding variables. Total n-3 and n-6 EFA levels were also significantly lower. Impulsivity and depression scores were significantly inversely correlated with both n-6 EFAs and n-3 EFAs, but were not associated with total or low-density lipoprotein cholesterol levels. Platelet serotonergic measures did not differ between groups, and were not related to psychobiological measures. CONCLUSIONS Lower plasma EFA levels combined with low cholesterol concentrations were associated with self-harm as well as impulsivity and affect. This was not related to platelet serotonergic measures.
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Affiliation(s)
- Malcolm R Garland
- Department of Adult Psychiatry, Galway University Hospital and the Clinical Sciences Institute, National University of Ireland, Ireland.
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Sasso DA, Kalanithi PSA, Trueblood KV, Pittenger C, Kelmendi B, Wayslink S, Malison RT, Krystal JH, Coric V. Beneficial effects of the glutamate-modulating agent riluzole on disordered eating and pathological skin-picking behaviors. J Clin Psychopharmacol 2006; 26:685-7. [PMID: 17110840 DOI: 10.1097/01.jcp.0000245567.29531.d6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Blake BL, Muehlmann AM, Egami K, Breese GR, Devine DP, Jinnah HA. Nifedipine suppresses self-injurious behaviors in animals. Dev Neurosci 2006; 29:241-50. [PMID: 17047321 PMCID: PMC2951318 DOI: 10.1159/000096414] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 04/12/2006] [Indexed: 11/19/2022] Open
Abstract
Self-injurious behavior is a common problem in many developmental disorders. The neurobiology of this behavior is not well understood, but the differing behavioral manifestations and associations with different disorders suggest that the underlying biological mechanisms are heterogeneous. The behavioral and biological heterogeneity is also evident in several animal models, where different manifestations can be provoked under different experimental conditions. Identifying commonalities among the different mechanisms is likely to be helpful in the design of treatments useful for the broadest populations of patients. The current studies reveal that nifedipine suppresses self-injurious behavior in 4 unrelated animal models: acute administration of high doses of +/-BayK 8644 or methamphetamine in mice, dopamine agonist treatment in rats with lesions of dopamine pathways during early development and repeated administration of pemoline in rats. The effect of nifedipine does not appear to be due to nonspecific mechanisms, such as sedation, since other classes of behaviors are unaffected or exaggerated. These results suggest that nifedipine may target a common biological mechanism in the expression of self-injurious behavior, and they suggest it should be considered in the treatment of self-injury in humans.
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MESH Headings
- 3-Pyridinecarboxylic acid, 1,4-dihydro-2,6-dimethyl-5-nitro-4-(2-(trifluoromethyl)phenyl)-, Methyl ester
- Animals
- Behavior, Animal/drug effects
- Calcium Channel Agonists
- Calcium Channel Blockers/pharmacology
- Central Nervous System Stimulants
- Disease Models, Animal
- Female
- Male
- Methamphetamine
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Nifedipine/pharmacology
- Oxidopamine
- Pemoline
- Pregnancy
- Rats
- Rats, Long-Evans
- Rats, Sprague-Dawley
- Self-Injurious Behavior/chemically induced
- Self-Injurious Behavior/drug therapy
- Sympatholytics
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Affiliation(s)
- Bonita L Blake
- Department of Psychiatry, University of North Carolina, Chapel Hill, USA
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Reinblatt SP, Abanilla PK, Jummani R, Coffey B. Loxapine treatment in an autistic child with aggressive behavior: therapeutic challenges. J Child Adolesc Psychopharmacol 2006; 16:639-43. [PMID: 17069553 DOI: 10.1089/cap.2006.16.639] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Valicenti-McDermott MR, Demb H. Clinical effects and adverse reactions of off-label use of aripiprazole in children and adolescents with developmental disabilities. J Child Adolesc Psychopharmacol 2006; 16:549-60. [PMID: 17069544 DOI: 10.1089/cap.2006.16.549] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [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 on the clinical efficacy and side effects of aripiprazole in treating behavioral symptoms of children with a developmental disability (DDs). DESIGN/METHODS A retrospective chart review of the first 32 children treated with aripiprazole at an urban clinic for children with DD was conducted. RESULTS Ages ranged from 5 to 19 years; 9 (28%) were female. Twenty four had diagnoses within the autistic spectrum and 18 had mental retardation (MR). Other disorders included: attention-deficit/hyperactivity disorder/disruptive behavior disorders (n = 13), mood disorders (n = 7), reactive attachment (n = 2), and sleep disorders (n = 2). Target symptoms included aggression, hyperactivity, impulsivity and, self-injurious behaviors. Twenty eight of the children were switched from another antipsychotic. The mean daily aripiprazole starting dose was 7.1 +/- 0.32 mg (0.17 mg/kg/day) and the mean daily maintenance dose was 10.55 +/- 6.9 mg (0.27 mg/kg/day). Aripiprazole had been used for a period between 6 and 15 months. Improvement in target symptoms was found in 56%. When treating a child with MR, the concomitant presence of an autistic spectrum diagnosis predicted a worse outcome. Side effects were reported in 16 (50%), with the most frequent being sleepiness (n = 6). Mean body mass index (BMI) rose from 22.5 to 24.1 (p = 0.003) over the follow up period, with changes in the BMI z scores. These changes were more pronounced in children younger than 12 years. CONCLUSIONS These results with aripiprazole in this difficult-to-treat population suggest that this medication warrants controlled studies of its effectiveness and safety.
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Affiliation(s)
- Maria R Valicenti-McDermott
- Children's Evaluation and Rehabilitation Center, R.F. Kennedy Center of Excellence in Developmental Disabilities, Albert Einstein College of Medicine, Bronx, New York, USA.
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Troost PW, Althaus M, Lahuis BE, Buitelaar JK, Minderaa RB, Hoekstra PJ. Neuropsychological effects of risperidone in children with pervasive developmental disorders: a blinded discontinuation study. J Child Adolesc Psychopharmacol 2006; 16:561-73. [PMID: 17069545 DOI: 10.1089/cap.2006.16.561] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Little is known about the neuropsychological effects of risperidone in children with pervasive developmental disorders. METHOD Twenty-four children (aged 5-17 years) with pervasive developmental disorders and co-morbid disruptive behavior who responded favorably to open-label treatment with risperidone as part of a previously described controlled discontinuation study completed two different computerized attention tasks at baseline, weeks 4, 8, and 24 of open-label treatment, and, at 8 weeks after random assignment to either placebo or risperidone. The primary efficacy measures were response latencies to visually presented stimuli requiring two different types of attention-controlled processing, i.e., focused and divided attention. RESULTS About half of the clinical responders did not produce valid performance measures. These could be shown to be of younger mental age and less adaptive as measured by the Vineland Behavior Scales. For the valid task performers divided attention (serial search in working memory) was shown to regress in the placebo group (n = 7), while in the risperidone group (n = 7) there was further improvement. No such group difference was found for focused attention. CONCLUSIONS The study suggests a beneficial effect of risperidone after several months of treatment, enhancing divided attention in children with pervasive developmental disorders.
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Affiliation(s)
- Pieter W Troost
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, The Netherlands.
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Glick N. Dramatic reduction in self-injury in Lesch-Nyhan disease following S-adenosylmethionine administration. J Inherit Metab Dis 2006; 29:687. [PMID: 16906475 DOI: 10.1007/s10545-006-0229-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Revised: 06/30/2006] [Accepted: 07/03/2006] [Indexed: 10/24/2022]
Abstract
A man with Lesch-Nyhan disease (LND; OMIM 300322) experienced significantly reduced self-injury and improved comfort while receiving S-adenosylmethionine.
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Affiliation(s)
- Norris Glick
- Department of Medical Services, Central Wisconsin Center, Madison, Wisconsin, USA.
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Abstract
Repetitive and stereotypic behavioral disturbances in patients with dementia are common; however, little is known regarding successful treatments. The authors describe six cases of elderly cognitively impaired patients exhibiting repetitive and stereotypic behaviors who were treated successfully with buspirone. The cases demonstrate that buspirone may be an effective and safe treatment for patients with dementia who demonstrate repetitive and stereotypic behavior disorders.
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Affiliation(s)
- Badalin Helvink
- Department of Psychiatric Medicine, University of Virginia, Charlottesville, USA
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