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FLUOXETINE IN ANXIETY DISORDERS
LETTERS TO THE EDITOR
An Academy member replies:
Dr. McDermott referred your letter to me for response because, a little over a year ago, I wrote to him with a very similar suggestion. I had proposed one of two alternatives to help structure the "pooling of anecdotal experiences on a national level." The first suggestion was to have a semistructured format which the Journal could publish and which would have required information to make data presentations somewhat homogeneous (age, weight, type of drug, condition being treated, focus of report, IQ, age of onset of disorder being treated, DSM criteria met). However, the clinician would have the option of using his or her own rating scales and medication administration format and of writing a description of the case(s) and noteworthy results. A designated editor(s) would compile these over the year, and. perhaps a journal supplement (such as the Journal of Chtld Psychology and Psychiatry has) could be published which synthesizes the various results with an appropriate review and editorial caveat. The second suggestion was somewhat more complicated in that it would require a prepublished format for each medication which the clinician would need to follow-like an informal, multisite study. This would appear to be more rigorous, but I also feel it would be more tempting to draw hard and fast conclusions in spite of the fact that medication administration would not have been done under actual controlled conditions. There are all sorts of caveats that would need to be mentioned. However, I, too, felt that this would be an advance over the hearsay mechanism we now have. I had suggested to Dr. McDermott that he send up a trial balloon among the readership to see how many child psychiatrists would be interested in adhering to a consistent format in their treatment regimens and sharing the information so that the information could be synthesized. Perhaps this is that opportunity. Gabrielle A. Carlson, M.D. State University of New York at Stony Brook The Editor comments:
Response from the readership would be most welcome.
J.
McD.
FLUOXETINE IN ANXIETY DISORDERS To the Editor:
As child psychiatrists in an anxiety disorders clinic, we read with interest the "Practice Parameters for the Assessment
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 33:5, JUNE 1994
and Treatment of Anxiety Disorders" published in the September 1993 issue. We noticed that the literature review of pharmacological treatments chose not to mention the use of non-tricyclic antidepressants such as fluoxetine. Although there are no controlled studies of the use of fluoxetine in childhood anxiety disorders (apart from obses.sive-compulsive disorder), anecdotal evidence suggests that it can be efficacious in the treatment of some anxietyrelated problems (Black and Uhde, 1992; Mesaros, 1993). Furthermore, the availability of a liquid preparation permits the use of small, precise doses of the drug in a more palatable form for those children who have difficulty swallowing pills. During the past year, using fluoxetine, we have successfully treated five children aged 5 to 11 (three girls and two boys) with anxiety disorders or anxiety-related problems. All parents were initially reluctant to consider medication, but agreed to try it after other treatments had failed. DSM-III-R diagnoses in the children included separation anxiety disorder (three cases), avoidant disorder (two cases), elective mutism (two cases), overanxious disorder (one case), and trichotillomania (one case). Several children met criteria for more than one diagnosis. Previous treatment had included 4 to 6 months of behavioral or cognitive-behavioral therapy involving the child and parents in all cases. Two mothers had also participated in a psychoeducational group for parents of anxious children. All behavioral interventions were continued after the medication was introduced. All children started fluoxetine at an initial dose of 10 mg/day, which was gradually increased if the child failed to improve. One 8-year-old girl developed intense itching of the scalp at 15 mg/day, which resolved when the dose was reduced to 10 mg/day. One 5-year-old boy reportedly exhibited bizarre behaviors at home (becoming disoriented, staring straight ahead for several minutes) at 20 mg/day. These behaviors resolved promptly when the dose was reduced to 15 mg/day. Both children eventually responded at the lower dose. No other side effects were reported. All parents reported that their children seemed to respond better to previously unsuccessful behavioral interventions after starting the medication. Several parents also reported a decrease in family conflicts which had previously occurred in response to their child's anxious behaviors. All five children reported feeling subjectively less anxious, and three showed decreased scores on the Revised Children's Manifest Anxiety Scale. In summary, within 6 weeks of beginning treatment with fluoxetine, all of the children were less anxious on parental and self-report and had markedly reduced their anxietyrelated behaviors. The only side effects reported were itching of the scalp in one child and bizarre behavior in another. Both problems resolved when the dosage of fluoxetine was
761
LETTERS TO THE EDITOR
reduced. Nausea, agitation, headache, or sleep disturbances were not reported by any child. Controlled studies are clearly needed, but our experience suggests that it may be helpful to consider the use of fluoxetine in some children with refractory anxiety disorders or anxiety-related problems. Katharina Manassis, M.D. Susan Bradley, M.D. Hospital for Sick Children University of Toronto Black B, Uhde TW (1992), Elective mutism as a variant of social phobia. jAm Acad Child Adolesc Psychiatry 31:1090-1094 Mesaros JD (1993), Fluoxetine for primary enuresis (letter). jAm Acad Child Adolesc Psychiatry 32:877-878
BRAIN IMAGING
To the Editor: In a recent letter to the Editor, Amen and Paldi (1993) offer unreviewed research data involving fairly complex machinery and procedures. These authors begin their letter by citing a well-controlled and -reviewed study (Zametkin et aI., 1990), yet in the very same paragraph cite an unreviewed, unsubstantiated set of conclusions as fact (Lubar, 1991). Amen and Paldi offer their research, draw conclusions from the data, which in some cases I believe are incorrect, and finally refer to their letter as "this study." They proceed to suggest that they have demonstrated "decreased prefrontal activity in response to an intellectual stress in children and adolescents who have attention-deficit hyperactivity disorder." I am concerned that you have seen fit to publish this letter. I believe that these authors and others will now cite this letter in your journal as proof of their theories. I am concerned that these authors did not see fit to offer their research for peer review and publication. Letters to the Editor should not be used as a forum to present research data. Sam Goldstein, Ph.D. University of Utah School of Medicine Salt Lake City, UT Amen DG, Paldi JH, Thisted RA (1993), Brain SPECT imaging (letter). jAm Acad Child Adolesc Psychiatry 32:1080-1081 Lubar JF (1991), Discourse on the development of EEG diagnostics and biofeedback for attention deficit-hyperactiviry disorders. Biofeedback SelfReguI16:201-225 Zametkin AJ, Nordah TE, Gross M et al. (1990), Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl j Med 323:1361-1366
762
Dr. Amen replies: Dr. Goldstein's response to our letter to the Editor on brain SPECT imaging and ADHD contains several inaccurate statements. Dr. Goldstein is concerned that we did not see fit to offer our research for peer review, somehow implying that we were trying to get around the proper way to present research. In fact, we did submit this study to the Journal as a research paper, which was not accepted, and the Editor asked us to summarize it as a letter to the Editor. We felt that the readership of this Journal was a very important audience for this work and agreed to do so. In the process of summarizing the article many of the details and case histories had to be omitted. Dr. Goldstein also "believes" that we and others will now cite this letter in the Journal as "proof' of our theories on brain SPECT imaging and ADHD. A "Letter to the Editor" in any journal is hardly proof of a theory. We felt that our research findings would be helpful for other clinicians and researchers. Our work has been presented at national meetings, including the 1993 American Psychiatric Association's Annual Meeting and the 1993 Annual Meeting of Biological Psychiatry Society. In addition, it has been presented at medical schools and psychiatry departments across the country. Dr. Goldstein also said that we cited an "unreviewed, unsubstantiated set of conclusions as fact" (Lubar, 1991) in the first paragraph of the letter. We never said that Lubar's work was fact; we reported what he said in his article. In a later article in a peer-reviewed journal, Lubar presented a study with several other researchers that drew the same conclusion of decreased prefrontal activity in response to intellectual stress in children and adolescents with ADHD (Mann et aI., 1992). This reference was in the original article sent to the Journal. Daniel G. Amen, M.D. Fairfield, CA Lubar JF (1991), Discourse on the development of EEG diagnostics and biofeedback for attention deficit-hyperactivity disorders. Biofeedback SelfReguI16:201-225 Mann CA, Lubar JO, Zimmerman AL et al. (1992), Quantitative analysis of EEG in boys with attention deficit-hyperactivity disorder: controlled study with clinical applications. Pediatr Neurol 8:30-36
The Editor comments: Journal policy states after each Letters to the Editor column that the contents of the letters are the sole responsibility of the authors and do not reflect endorsement by the JournaL The Letters column is a corner of the Journal which encourages opinion, controversy, and preliminary ideas that do not meet the Journal's peer review standards for research articles.
J.
McD.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:5, JUNE 1994
An Academy member replies:
Dr. McDermott referred your letter to me for response because, a little over a year ago, I wrote to him with a very similar suggestion. I had proposed one of two alternatives to help structure the "pooling of anecdotal experiences on a national level." The first suggestion was to have a semistructured format which the Journal could publish and which would have required information to make data presentations somewhat homogeneous (age, weight, type of drug, condition being treated, focus of report, IQ, age of onset of disorder being treated, DSM criteria met). However, the clinician would have the option of using his or her own rating scales and medication administration format and of writing a description of the case(s) and noteworthy results. A designated editor(s) would compile these over the year, and. perhaps a journal supplement (such as the Journal of Chtld Psychology and Psychiatry has) could be published which synthesizes the various results with an appropriate review and editorial caveat. The second suggestion was somewhat more complicated in that it would require a prepublished format for each medication which the clinician would need to follow-like an informal, multisite study. This would appear to be more rigorous, but I also feel it would be more tempting to draw hard and fast conclusions in spite of the fact that medication administration would not have been done under actual controlled conditions. There are all sorts of caveats that would need to be mentioned. However, I, too, felt that this would be an advance over the hearsay mechanism we now have. I had suggested to Dr. McDermott that he send up a trial balloon among the readership to see how many child psychiatrists would be interested in adhering to a consistent format in their treatment regimens and sharing the information so that the information could be synthesized. Perhaps this is that opportunity. Gabrielle A. Carlson, M.D. State University of New York at Stony Brook The Editor comments:
Response from the readership would be most welcome.
J.
McD.
FLUOXETINE IN ANXIETY DISORDERS To the Editor:
As child psychiatrists in an anxiety disorders clinic, we read with interest the "Practice Parameters for the Assessment
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 33:5, JUNE 1994
and Treatment of Anxiety Disorders" published in the September 1993 issue. We noticed that the literature review of pharmacological treatments chose not to mention the use of non-tricyclic antidepressants such as fluoxetine. Although there are no controlled studies of the use of fluoxetine in childhood anxiety disorders (apart from obses.sive-compulsive disorder), anecdotal evidence suggests that it can be efficacious in the treatment of some anxietyrelated problems (Black and Uhde, 1992; Mesaros, 1993). Furthermore, the availability of a liquid preparation permits the use of small, precise doses of the drug in a more palatable form for those children who have difficulty swallowing pills. During the past year, using fluoxetine, we have successfully treated five children aged 5 to 11 (three girls and two boys) with anxiety disorders or anxiety-related problems. All parents were initially reluctant to consider medication, but agreed to try it after other treatments had failed. DSM-III-R diagnoses in the children included separation anxiety disorder (three cases), avoidant disorder (two cases), elective mutism (two cases), overanxious disorder (one case), and trichotillomania (one case). Several children met criteria for more than one diagnosis. Previous treatment had included 4 to 6 months of behavioral or cognitive-behavioral therapy involving the child and parents in all cases. Two mothers had also participated in a psychoeducational group for parents of anxious children. All behavioral interventions were continued after the medication was introduced. All children started fluoxetine at an initial dose of 10 mg/day, which was gradually increased if the child failed to improve. One 8-year-old girl developed intense itching of the scalp at 15 mg/day, which resolved when the dose was reduced to 10 mg/day. One 5-year-old boy reportedly exhibited bizarre behaviors at home (becoming disoriented, staring straight ahead for several minutes) at 20 mg/day. These behaviors resolved promptly when the dose was reduced to 15 mg/day. Both children eventually responded at the lower dose. No other side effects were reported. All parents reported that their children seemed to respond better to previously unsuccessful behavioral interventions after starting the medication. Several parents also reported a decrease in family conflicts which had previously occurred in response to their child's anxious behaviors. All five children reported feeling subjectively less anxious, and three showed decreased scores on the Revised Children's Manifest Anxiety Scale. In summary, within 6 weeks of beginning treatment with fluoxetine, all of the children were less anxious on parental and self-report and had markedly reduced their anxietyrelated behaviors. The only side effects reported were itching of the scalp in one child and bizarre behavior in another. Both problems resolved when the dosage of fluoxetine was
761
LETTERS TO THE EDITOR
reduced. Nausea, agitation, headache, or sleep disturbances were not reported by any child. Controlled studies are clearly needed, but our experience suggests that it may be helpful to consider the use of fluoxetine in some children with refractory anxiety disorders or anxiety-related problems. Katharina Manassis, M.D. Susan Bradley, M.D. Hospital for Sick Children University of Toronto Black B, Uhde TW (1992), Elective mutism as a variant of social phobia. jAm Acad Child Adolesc Psychiatry 31:1090-1094 Mesaros JD (1993), Fluoxetine for primary enuresis (letter). jAm Acad Child Adolesc Psychiatry 32:877-878
BRAIN IMAGING
To the Editor: In a recent letter to the Editor, Amen and Paldi (1993) offer unreviewed research data involving fairly complex machinery and procedures. These authors begin their letter by citing a well-controlled and -reviewed study (Zametkin et aI., 1990), yet in the very same paragraph cite an unreviewed, unsubstantiated set of conclusions as fact (Lubar, 1991). Amen and Paldi offer their research, draw conclusions from the data, which in some cases I believe are incorrect, and finally refer to their letter as "this study." They proceed to suggest that they have demonstrated "decreased prefrontal activity in response to an intellectual stress in children and adolescents who have attention-deficit hyperactivity disorder." I am concerned that you have seen fit to publish this letter. I believe that these authors and others will now cite this letter in your journal as proof of their theories. I am concerned that these authors did not see fit to offer their research for peer review and publication. Letters to the Editor should not be used as a forum to present research data. Sam Goldstein, Ph.D. University of Utah School of Medicine Salt Lake City, UT Amen DG, Paldi JH, Thisted RA (1993), Brain SPECT imaging (letter). jAm Acad Child Adolesc Psychiatry 32:1080-1081 Lubar JF (1991), Discourse on the development of EEG diagnostics and biofeedback for attention deficit-hyperactiviry disorders. Biofeedback SelfReguI16:201-225 Zametkin AJ, Nordah TE, Gross M et al. (1990), Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl j Med 323:1361-1366
762
Dr. Amen replies: Dr. Goldstein's response to our letter to the Editor on brain SPECT imaging and ADHD contains several inaccurate statements. Dr. Goldstein is concerned that we did not see fit to offer our research for peer review, somehow implying that we were trying to get around the proper way to present research. In fact, we did submit this study to the Journal as a research paper, which was not accepted, and the Editor asked us to summarize it as a letter to the Editor. We felt that the readership of this Journal was a very important audience for this work and agreed to do so. In the process of summarizing the article many of the details and case histories had to be omitted. Dr. Goldstein also "believes" that we and others will now cite this letter in the Journal as "proof' of our theories on brain SPECT imaging and ADHD. A "Letter to the Editor" in any journal is hardly proof of a theory. We felt that our research findings would be helpful for other clinicians and researchers. Our work has been presented at national meetings, including the 1993 American Psychiatric Association's Annual Meeting and the 1993 Annual Meeting of Biological Psychiatry Society. In addition, it has been presented at medical schools and psychiatry departments across the country. Dr. Goldstein also said that we cited an "unreviewed, unsubstantiated set of conclusions as fact" (Lubar, 1991) in the first paragraph of the letter. We never said that Lubar's work was fact; we reported what he said in his article. In a later article in a peer-reviewed journal, Lubar presented a study with several other researchers that drew the same conclusion of decreased prefrontal activity in response to intellectual stress in children and adolescents with ADHD (Mann et aI., 1992). This reference was in the original article sent to the Journal. Daniel G. Amen, M.D. Fairfield, CA Lubar JF (1991), Discourse on the development of EEG diagnostics and biofeedback for attention deficit-hyperactivity disorders. Biofeedback SelfReguI16:201-225 Mann CA, Lubar JO, Zimmerman AL et al. (1992), Quantitative analysis of EEG in boys with attention deficit-hyperactivity disorder: controlled study with clinical applications. Pediatr Neurol 8:30-36
The Editor comments: Journal policy states after each Letters to the Editor column that the contents of the letters are the sole responsibility of the authors and do not reflect endorsement by the JournaL The Letters column is a corner of the Journal which encourages opinion, controversy, and preliminary ideas that do not meet the Journal's peer review standards for research articles.
J.
McD.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:5, JUNE 1994