From melatonin for sleep-onset insomnia to electroconvulsive therapy for severe adolescent mood disorder to steroid-induced psychosis to the risk of stimulant-induced psychosis in youth with ADHD, and MORE! In this two-part episode series, Mara and Dr. Feder will tackle various research topics in the field of child psychiatry. 

Joshua Feder, MD, and Mara Goverman, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

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Published On: 12/6/2021

Duration: 13 minutes, 20 seconds

Referenced Articles: 

“Melatonin for Sleep-Onset Insomnia,” The Carlat Child Psychiatry Report, January/February/March 2021

“Steroid-Induced Psychosis in the ­Pediatric Population,” The Carlat Child Psychiatry Report, May/June/July/August 2021

“ECT in Severe Adolescent Mood ­Disorders,” The Carlat Child Psychiatry Report, April/May/June 2021

Transcript:

Dr. Feder: Hello! I’m Dr. Joshua Feder, the Editor-in-Chief of The Carlat Psychiatry Report, and in this episode, brought to you by The Carlat Child Psychiatry team, Mara and I will tackle various research studies in child psychiatry. These studies focused on research topics ranging from melatonin for sleep-onset insomnia to electroconvulsive therapy for severe adolescent mood disorder to steroid-induced psychosis. 

Which topic do you want to start with, Mara?

Mara: Hmmm. Let’s do the meta-analysis of randomized controlled trials on melatonin for sleep onset insomnia first. 

Sleep-onset insomnia, characterized by difficulty falling asleep and daytime fatigue, is a common problem among youth. 

Dr. Feder: At The Carlat Child Psychiatry Report, we advise caution before using marketed sleep medication in children and adolescents. 

One potentially safer option is melatonin. But is exogenous use of this hormone effective? Is it safe? This meta-analysis looked at the safety and efficacy of melatonin in randomized placebo-controlled studies.

Mara: The authors of the meta-analysis examined 550 studies and found that only seven met their criteria for methodology. In these studies, a total of 387 youth with sleep-onset insomnia were enrolled in placebo-controlled trials. Most subjects were children, with a mean age of 9 years. All studies used immediate-release melatonin tablets at doses of 1–6 mg/day for 1–4 weeks.

Dr. Feder: Melatonin was often effective in very low doses. Sleep onset time, which was selected as the primary outcome for efficacy, generally came over a half hour earlier with use of melatonin compared to placebo. Melatonin increased total sleep time by about 20 minutes.

Mara: Side effects included fatigue, headache, gastrointestinal upset, and depressed mood. Specific percentages of these were not reported; however, symptoms were mild to moderate, with little difference in dropout rates between melatonin and placebo. One patient developed generalized seizures 4 months after using melatonin, and there were mixed reports of both more and fewer seizures in the studies that were not included in the meta-analysis. The authors note possible concerns in long-term use of melatonin, with particular concerns about reproductive function and the course of epilepsy.

Dr. Feder: This study suggests a modest clinical utility for short-term use of melatonin in children and adolescents struggling with sleep-onset insomnia, perhaps starting at 1 mg. Although generally safe, melatonin may lower the seizure threshold and should be used with caution in patients with seizure disorders. 

Mara: As a note, melatonin tends to work better given 90–120 minutes before desired sleep onset.

Moving on to ECT in severe adolescent mood disorders. In adults with severe unipolar depression and bipolar depression, ECT is the gold standard for treatment. In randomized trials of unipolar depression, it has remission rates of 70%–90%. In bipolar depression, response rates are 50%–75%. But how effective is ECT in youth with severe mood disorders?

Dr. Feder: A 2020 retrospective chart study set out to that question. The study consisted of 54 adolescents, mean age 15.8, with treatment-resistant mood disorders (two-thirds unipolar, one-third bipolar), who received ECT at the University of Michigan Medical Center from 1996 to 2010. Treatment resistance was defined as failure to respond to 3 or more mood-stabilizing medications combined with psychotherapy. The patients averaged 4 hospitalizations, 2 suicide attempts, and 7 failed medication trials (4 antidepressants, 3 antipsychotics and mood stabilizers), each of at least 6 weeks duration, with adequate dosage and good compliance.

Mara: The patients received a mean of 13.7 ECT treatments, almost all with bilateral electrode placement. The primary outcome measure was Clinical Global Impressions (CGI) score; response was defined as a CGI score of 2 (much improved), while remission was defined as a score of 1 (very much improved).

Dr. Feder: The response rate at the end of the index ECT treatment was 52.8%, while the remission rate was 15%, both lower than typical findings in adults. While rates increased at 6 and 12 months, this improvement occurred only with observed cases (OC) data, and with dropouts removed. There was minimal improvement at later time points when looking at last observation carried forward (LOCF) data. There was no difference in response or remission rates between unipolar and bipolar patient groups.

Mara: Still, by the end of index treatment, suicidal ideation declined from roughly 80% to 40%; self-injurious behavior declined from about 50% to 18%; and school attendance increased threefold, from 20% to 60%. Side effects were minimal.

Dr. Feder: This study contained a few limitations. These included its relatively small size for a chart review, the use of non-blinded raters, the use of the CGI as the measure of treatment outcome (due to missing depression rating scale data), obtaining data from retrospective chart review, and diagnoses made without the use of standardized instruments.

Mara: While ECT in adolescents appears less effective than in adults, it did produce clinically meaningful changes in these treatment-resistant patients for a year after the index ECT course. Keep it in mind as a possible tool.

Mara: Childhood psychosis is a rare disorder, and accurate diagnosis is crucial. Recently, clinicians at the University of Miami Miller School of Medicine reported a case of steroid-induced psychosis in a pediatric patient.

Dr. Feder: In the case report, a 12-year-old Haitian girl was diagnosed with discoid lupus erythematosus after she presented with fever, fatigue, and anemia. She was started on prednisolone and hydroxychloroquine, and a few days later presented with mutism, drooling, and altered mental status. She was admitted to the PICU, and her symptoms were assumed to be related to her lupus; therefore, she was treated with IV prednisolone.

Mara: After 8 days of admission, the patient remained disoriented, mute, and paranoid.  After a negative organic workup, the psychiatry consultation team recommended tapering the steroid and started her on clonazepam 0.25 mg BID and risperidone 0.5 mg BID (later switched to haloperidol). After 12 days, the patient was much improved—she was more verbal and had no hallucinations. Once the steroid was entirely discontinued, she became completely organized and was discharged on haloperidol 5 mg/day and lorazepam 1 mg twice daily.

Dr. Feder: The authors did a literature review and found 15 other case reports of steroid-induced psychosis in children and adolescents. Asthma was the most common indication for the initiation of steroids. The higher the dose of steroids (>40–80 mg/day), the more chances of psychiatric manifestations.

Mara: Discontinuation of steroids is the gold standard and typically completely diminishes the symptoms within a few days to 1 month. For instances where steroid taper is not possible, a trial of benzodiazepines and antipsychotics was helpful.

This case highlights the need to search for specific causes of psychotic symptoms that can usually be resolved, avoiding unnecessary long-term treatments.

Dr. Feder: These research updates are available for subscribers to read in The Carlat Child Psychiatry Report. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: Go to www.thecarlatreport.com to sign up. You can get a full subscription to any of our four newsletters for $30 off using the coupon code LISTENER.

As always, thanks for listening and have a great day!

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