Hugh F. Johnston

Handbook of depression in children and adolescents

Introduction and General Issues: The Nature and Study of Depression in Children and Adolescents W.M. Reynolds, H.F. Johnston. Phenomenology and Epidemiology of Mood Disorders in Children and Adolescents E.O. Poznanski, H.B. Mokros. Theories and Models of Depression: Dynamic and Interpersonal Theories of Depression J.R. Bemporad. Cognitive and Behavioral Correlates of Childhood Depression: A Developmental Perspective N.J. Kaslow, et al. Approaches to Assessment and Diagnosis: Classification and Diagnostic Criteria of Depression in Children and Adolescents D. Sherak, et al. Evalution of Depression in Children and Adolescents Using Diagnostic Clinical Interviews K. Hodges. Treatment Approaches: Psychological Treatment Approaches for Depression in Children K.D. Stark, et al. Psychological Approaches to the Treatment of Depression in Adolescents P.M. Lewinsohn, et al. Depression in Special Populations: Depression in Infants P.V. Trad. Selected Topics in the Study of Depression in Young People: Maltreatment and Childhood Depression G. Downey, et al. 15 additional articles. Index.

Sertraline treatment of children and adolescents with obsessive-compulsive disorder or depression: pharmacokinetics, tolerability, and efficacy

OBJECTIVE To evaluate the pharmacokinetics, safety, and efficacy of sertraline in children (6 to 12 years old) and adolescents (13 to 17 years old). METHOD Children (n = 29) and adolescents (n = 32) with major depression, obsessive-compulsive disorder (OCD), or both received a single dose of 50 mg of sertraline followed, 1 week later, by 35 days of sertraline treatment as follows: (1) either a starting dose of 25 mg/day titrated to 200 mg/day in 25-mg increments or (2) a starting dose of 50 mg/day titrated to 200 mg/day in 50-mg increments. Sertraline and desmethylsertraline pharmacokinetics were determined approximately weekly, and efficacy measures were assessed before drug administration and at the end of treatment. RESULTS Mean area under the plasma concentration-time curve (AUC), peak plasma concentration (Cmax), and elimination half-life (t1/2) for sertraline and desmethylsertraline were similar to previously reported adult values. No titration-dependent pharmacokinetic or safety differences were seen. While Cmax and AUC0-24 were greater for children versus adolescents, these differences disappeared after parameters were normalized for body weight. Sertraline was well tolerated in both children and adolescents, with adverse experiences similar to those previously reported by adult patients. Efficacy measurements indicated improvement (p < .001) in depression and OCD symptomatology. CONCLUSIONS Sertraline can be safely administered to pediatric patients using the currently recommended adult titration schedule.

The Nature and Study of Depression in Children and Adolescents

Depression is a serious mental health problem in children and adolescents. It has been estimated that nearly 1 of every 6 youngsters admitted to psychiatric hospitals in the United States had an intake diagnosis of a depressive disorder (Silver, 1988). Depression is also one of the most frequently found psychiatric disorders among suicidal children and adolescents [Reynolds and Mazza (Chapter 24)]. Over the past two decades, the study of depression in children and adolescents has become an area of extensive research in the fields of psychiatry, psychology, and related disciplines. The range of research domains, from neuroendocrinology to cognitive deficits, suggests an enormous interest on the part of professionals in the nature, evaluation, and treatment of depression in young people. What is most impressive is that the vast majority of research on depression in children and adolescents has been conducted since the mid-1970s. This delay in our focus on depression in young people may be in part a function of the long-term psychodynamic perspectives of depression as nonexistent in children or normative in adolescents. In particular, the notion or myth of adolescent turmoil overshadowed for many professionals the validity of depression as a form of psychopathology in this age group (Offer & Schonert-Reichl, 1992).

Pemoline Therapy in College Students with Attention Deficit Hyperactivity Disorder: A Retrospective Study

Pemoline, a dopamine agonist, is effective in children with attention deficit hyperactivity disorder (ADHD), but its efficacy in adults is unknown. The authors studied the efficacy and safety of pemoline, using retrospective chart review of treated students with ADHD over a 2-year period. Forty students met diagnostic and treatment criteria; pemoline was associated with much improved or very much improved Clinical Global Impression symptoms scores in 70% of the students during a treatment period of 14 or more days. Severity of illness scores dropped from 4.11 to 3.01 between baseline and subsequent evaluation. Nine evaluable patients had adverse events, most commonly headaches, insomnia, and decreased appetite. Five additional students, who failed to meet the treatment-duration criterion, terminated because of severe initial insomnia. The authors concluded that pemoline is effective and safe in students with ADHD and has a lower abuse potential than methylphenidate and dextroamphetamine, the other two widely used, structurally dissimilar compounds, but controlled studies may be necessary before any final conclusions are reached.

Do subtle neurological impairments predict treatment resistance to clomipramine in children and adolescents with obsessive-compulsive disorder?

ABSTRACT A 10-week double-blind, placebo-controlled design was employed to investigate the effectiveness of clomipramine (CMI) versus placebo in 16 outpatients (ages 10-18 years) with obsessive-compulsive disorder (OCD). While a trend favoring clomipramine was observed, the difference in efficacy between clomipramine (N=8) and placebo (N=8) did not reach statistical significance, partly due to small sample size (N = 6,8). Post-hoc exclusion of two clomipramine-resistant subjects with subtle neurological impairments did, however, yield a statistically significant improvement with drug treatment. Neurological impairments are commonly seen in children with OCD, and may be a risk factor for the disorder during childhood. Speculatively, subtle neurological impairments may also predict resistance to CMI therapy in some patients, and influence the outcome of clinical and research medication trials, depending on differences in neurological inclusion and exclusion criteria.

Pharmacotherapy for Depression in Children and Adolescents

Knowledge in child psychiatry is generated primarily from two sources, systematic research and clinical practice. These two activities create different kinds of knowledge that are collected and communicated in distinct ways. Research-generated knowledge tends to be gathered at academic institutions and is disseminated largely through articles in scientific journals, meeting presentations, and textbooks. Clinical knowledge is amassed through practice and experience and tends to be imparted through “hands-on” training activities. Much of psychiatry in general, and child psychiatry in particular, is taught via an apprenticeship model, largely to facilitate the transfer of clinical knowledge across generations of physicians.

Case Report: High Plasma Level Tricyclic Antidepressant Therapy in Children: A Case Report and Commentary

ABSTRACT It is well known that some adults with major depression fail to respond to tricyclic antidepressants (TCA) at typical doses and plasma levels, but do respond at higher than standard levels. The literature on high-dose TCA treatment and high plasma level treatment in adults is reviewed, along with the more limited literature in children and adolescents. A case is described of a 5-year-old girl with major depression who did not respond to treatment with nortriptyline until the dose was raised to 200 mg daily (7.2 mg/kg, plasma level = 342 ng/ml). She experienced relatively minor side effects at these levels, and showed clinical deterioration when her plasma level was lowered to 188 ng/ml (160 mg/day, 5.8 mg/kg). Her high-dose and plasma level requirement was supported in an ABABA open clinical trial. High-dose, or high plasma level, treatment with tricyclic antidepressants may be a useful therapeutic option for some severely depressed children after more conventional treatments have failed. The general use of high-dose TCA treatment does not seem warranted or safe, but may be valuable for a selected subgroup of patients. Specific treatment guidelines are offered, including criteria for patient selection and monitoring for mild delirium, neurotoxic changes, seizures, electrocardiographic changes, and cardiovascular effects.