Peter Ducharme

Randomized efficacy trial of two psychotherapies for depression in youth with inflammatory bowel disease.

OBJECTIVE Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression. METHOD Youth (51% female and 49% male; age 9-17 years, mean age 14.3 years) with depression and Crohns disease (n = 161) or ulcerative colitis (n = 56) were randomly assigned to a 3-month course of CBT or SNDT. The primary outcome was comparative reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity. RESULTS A total of 178 participants (82%) completed the 3-month intervention. Both psychotherapies resulted in significant reductions in total Childrens Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the 2 treatments was not significant (p = .16). There were large pre-post effect sizes for each treatment (d = 1.31 for CBT and d = 1.30 for SNDT). More than 65% of youth had a complete remission of depression at 3 months, with no difference between CBT and SNDT (67.8% and 63.2%, respectively). Compared to SNDT, CBT was associated with a greater reduction in IBD activity (p = .04) but no greater improvement on the Clinical Global Assessment Scale (p = .06) and health-related quality of life (IMPACT-III scale) (p = .07). CONCLUSION This is the first randomized controlled study to suggest improvements in depression severity, global functioning, quality of life, and disease activity in a physically ill pediatric cohort treated with psychotherapy. Clinical trial registration information-Reducing Depressive Symptoms in Physically Ill Youth; http://clinical trials.gov; NCT00534911.

The overlap of functional abdominal pain in pediatric Crohn's disease.

Background:Children with Crohn’s disease (CD) may report abdominal pain despite clinical remission, suggesting that functional abdominal pain (FAP) may be playing a role. The aim of this study was to explore the presence and impact of FAP in children with CD in remission. Methods:Children, aged 9 to 17 years, with CD were enrolled. Demographic information, the Pediatric Crohn’s Disease Activity Index, and the Children’s Depression Inventory were obtained. Disease remission was defined by physician global assessment, normal laboratories findings, absence of 3 or more stools a day, nocturnal stooling, bloody diarrhea, concurrent steroid therapy, strictures, or disease flare within 6 months. FAP was defined as patients with abdominal pain and CD remission. Rates of depression (Children’s Depression Inventory >9) were compared. Results:Of 307 children, 139 reported abdominal pain. Of this group, 18 of 139 (13%) children met the criteria for FAP. Despite clinical remission, 8 of 18 patients with CD having FAP were classified with active disease by Pediatric Crohn’s Disease Activity Index. These patients had a higher rate of depression than patients with CD in remission with no abdominal pain (55.6% versus 29.9%; P = 0.03), similar to patients with abdominal pain from active CD (55.6% versus 44.8%; P = 0.62). Conclusions:A proportion of children with CD in remission have FAP. These children are at significant risk of depression. Future studies are needed to determine whether depression contributes to functional pain development or if pain itself leads to depression. Especially given that functional pain may exaggerate disease activity, clinicians caring for children with CD and FAP should consider evaluating for depressive disorders before escalating therapy.

Effect of 2 Psychotherapies on Depression and Disease Activity in Pediatric Crohn's Disease

Background:Crohns disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease. Methods:Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Childrens Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohns disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34). Results:Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohns disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohns disease Activity Index (P = 0.03) after CBT. Conclusions:Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.

RAGE-Control: A Game to Build Emotional Strength.

Emotional regulation is an important skill, and some children require extra support to develop that skill. To address this need, we have built an active biofeedback videogame and incorporated the game into a cognitive behavioral therapy. Our approach requires that players simultaneously attend to a demanding task and still maintain emotional control, forcing practice and skill building in both domains concurrently. Early studies have shown that our approach improves emotional control compared with treatment as usual and has led to promising new developments of emotionally aware toys that can reach younger children.

The Effect of Therapy on Medical Utilization in Children With Inflammatory Bowel Disease

alveolar breath samples collected over a 4-hour duration were analyzed for H2 and CH4. Diagnostic positivity was compared using a cut-off level of 20ppm rise above fasting baseline for H2 alone which is consistent with consensus guidelines versus H2 plus twice CH4 which recognizes that CH4 consumes twice the hydrogen. Results: There were 406 lactose tests performed in 93 men and 313 women. There were 178 fructose tests performed in 31 men and 147 women. Conclusion: If H2 alone was measured without additional CH4 analysis, 4% of LM and 14% FM patients would not have been identified using these methods.

The Use of Antiepileptic Drugs (AEDs) for the Treatment of Pediatric Aggression and Mood Disorders.

Aggressive symptomatology presents across multiple psychiatric, developmental, neurological and behavioral disorders, complicating the diagnosis and treatment of the underlying pathology. Anti-Epileptic Drugs (AEDs) have become an appealing alternative in the treatment of aggression, mood lability and impulsivity in adult and pediatric populations, although few controlled trials have explored their efficacy in treating pediatric populations. This review of the literature synthesizes the available data on ten AEDs—valproate, carbamazepine, oxcarbazepine, phenytoin, lamotrigine, topiramate, levetiracetam, zonisamide, gabapentin and tiagabine—in an attempt to assess evidence for the efficacy of AEDs in the treatment of aggression in pediatric populations. Our review revealed modest evidence that some of the AEDs produced improvement in pediatric aggression, but controlled trials in pediatric bipolar disorder have not been promising. Valproate is the best supported AED for aggression and should be considered as a first line of treatment. When monotherapy is insufficient, combining an AED with either lithium or an atypical anti-psychotic can result in better efficacy. Additionally, our review indicates that medications with predominately GABA-ergic mechanisms of action are not effective in treating aggression, and medications which decrease glutaminergic transmission tended to have more cognitive adverse effects. Agents with multiple mechanisms of action may be more effective.