Journal Article Annotations
2021, 3rd Quarter
Annotations by Jeylan Close, MD
September, 2021
The finding:
This study is a comprehensive umbrella review of medications, therapies, and brain stimulation techniques used to treat the most common diagnoses seen by child psychiatrists. Primary outcomes included disease-specific reduction of symptoms and all cause discontinuation. Included in the study were 104 meta-analyses. For ADHD, stimulants had the most evidence, with amphetamines having the largest primary outcome effect sizes; however, methylphenidates had a more favorable safety and tolerability profile. For Autism Spectrum Disorder-related aggression, risperidone and aripiprazole were superior to placebo with similar discontinuation rates as placebo. For depression, fluoxetine was the only antidepressant superior to placebo in decreasing depressive symptoms and to have positive evidence for remission. SNRIs and TCAs had low tolerability and acceptability including increased suicidality compared to placebo with venlafaxine. Interpersonal therapy was the only therapy to show efficacy when compared to placebo for depression. For anxiety disorders and obsessive compulsive disorder, fluoxetine was superior to placebo for efficacy and remission. In head to head comparison, group cognitive behavioral therapy (CBT) was superior to individual CBT for anxiety disorders. For eating disorders, family therapy was the only treatment with evidence meeting inclusion criteria that improved primary outcomes. For post-traumatic stress disorder, CBT was the only intervention with data that met inclusion criteria and was associated with improvement. For schizophrenia spectrum disorders, all antipsychotics except ziprasidone outperformed placebo, with the largest effect sizes for olanzapine and risperidone. For bipolar depression, quetiapine was not more efficacious than placebo, and for mania, aripiprazole was superior to placebo. Of the antipsychotics, lurasidone and aripiprazole were the most tolerable. For enuresis, alarm behavioural therapy had the largest body of evidence.
Strength and weaknesses:
The study’s strengths include its methods of searching multiple databases with a priori terms and inclusion/exclusion criteria, as well as multiple researchers involved in cross-referencing studies. They also used a standardized tool to evaluate the quality of included studies. However, this study was limited to data on interventions that have been examined in meta-analyses, so there may be some high quality randomized controlled trial data that were not represented. Additionally, often there are fewer studies on medications for specific disorders among youth and treatment practices often extrapolated from adult data, so this review may be missing data for treatments that are effective and in use.
Relevance:
This umbrella review broadly summarizes meta-analyses data pertaining to treatments for common disorders in child and adolescent psychiatry. Since children respond to treatments distinctly from adults, it is imperative to be familiar with which treatments are evidenced-based for youth. This study presents both efficacy and tolerability data, which are important to weigh when making treatment choices in practice. As there are limited therapists available compared to the level of need, group therapy could be a possible evidence-based way to improve both access and outcomes. This review also highlights that there is limited data on long-term efficacy or tolerability of interventions, and little evidence on treating youth with treatment resistant conditions.
The finding:
This systemic review and meta-analysis examined prevalence of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) following surgery in children and their parents. Included in the analysis were 16 studies spanning different types of surgery. Their analysis showed that prevalence of PTSD in children post surgery was 16% (N=187, 95% CI 5% to 31%, I2=80%) and prevalence in parents was 23% (N=1444, 95% CI 16% to 31%, I2=91%). By comparison, overall lifetime prevalence of PTSD in the US is approximately 9%, which increases up to 25% in those with an identifiable traumatic experience. The most consistent variable associated with PTSD risk was longer length of inpatient hospitalization; lack of social supports and non-native nationality were also associated with increased rates and severity of PTSD.
Strength and weaknesses:
The study’s strengths include searching multiple databases with a priori terms and inclusion/exclusion criteria applied by multiple researchers cross-referencing studies. Studies included were limited to those specifically examining PTSD or ASD, which may miss many patients who exhibit symptoms of Trauma-and Stressor Related Disorder without specifically meeting criteria for PTSD/ASD. Most of the studies did not examine pre-surgery prevalence of PTSD among their participants or control for a potentially traumatic event that led to need for surgery. There was also inconsistent reporting of potentially confounding variables, such as severity of illness, comorbidities, presence of complications, ethnicity, types of supports for families, or available resources for families. Most of the included studies also did not have long-term follow up to determine the percentage of people who have remission of symptoms.
Relevance:
This study illustrates that surgery can be a traumatic experience for young patients as well as their parents and result in clinically significant trauma-related symptoms. As C-L psychiatrists, it is important to be aware that pediatric surgery can result in rates of PTSD similar to other significantly traumatic experiences, especially in patients with prolonged hospital stays. Additionally, it is important to be cognizant that non-native families and those with fewer resources are at higher risk of PTSD and increased severity of symptoms. Further research is needed to determine if any interventions may decrease rates of PTSD following surgery.
The finding:
The study examined mental health measures in 7-10 year old children in Detroit-area schools, with timepoints of October 2019, May 2020, and August 2020. Of the 64 included children, 71.9% were Black American and 62.5% were female. The children resided in communities where the estimated median household income was approximately $52,000 and were classified as communities of moderate-to-high distress by the Distressed Communities Index. Internalizing and externalizing symptoms were evaluated with the Pediatric Symptom Checklist (PSC) and illness-related fears were evaluated with a modified Fear of Illness and Virus Evaluation (FIVE). In the May 2020 assessment, the authors found that 14% of children had directly witnessed someone sick from COVID-19, and 18.8% knew someone who had died from the pandemic. Black children and children of lower SES had more fears related to social distancing than white children and those of higher resources. Overall fear of illness increased from May to August for participants as a whole. Children of low SES had higher relative levels of internalizing symptoms at baseline, though after the pandemic began their internalizing symptoms decreased to levels similar to the rest of the group. Greater internalizing symptoms at the time of assessment were associated with a higher perceived impact of the pandemic. Externalizing symptoms were unchanged through the duration of the study. Both internalizing and externalizing symptoms were associated with less engagement in protective behaviors. Baseline levels of neither internalizing nor externalizing symptoms were associated with amount of illness related fears.
Strength and weaknesses:
This study used data obtained prior to the start of the COVID-19 pandemic, lending a unique and important longitudinal comparison for participants. Authors used parental educational level as an indicator for SES which, while it has some data for its use as a proxy, is nonetheless imprecise. The baseline assessment was done in-person at school, but follow-up assessments were performed online. There was a higher percentage of Caucasian participants who completed follow-up surveys compared to the baseline group, which may limit findings for Black American youth who have less access to internet resources. That measures were self-reported without clinician evaluation may limit validity. Additionally, the sample size was small and from a small geographic area within the United States. However, children in minority groups are underrepresented in the literature, and the focus on majority Black American youth is a strength of the study.
Relevance:
Minority groups, particularly Black Americans, have been disproportionally negatively affected by the COVID pandemic. In this study of primarily Black American children, by May 2020 almost 1 in 5 children knew someone who had died of COVID-19, indicating a significant level of trauma from the pandemic in this cohort. Children’s fears of illness increased over the course of the pandemic, irrespective of ethnicity, SES, or baseline symptoms pre-pandemic, indicating that all children are at risk of negative mental health affects from COVID-19.