Text version
Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP—or Child and Adolescent Psychiatry—Smart Take, we will examine a crucial understudied area: The risk vs benefit of specific psychotropic medications in treating nonsuicidal self-injury. Eggart and colleagues conducted a systematic review and meta-analysis to try to help raise awareness of this issue and make specific recommendations for future areas of inquiry. This has enormous clinical relevance, as nonsuicidal self-injury in children and adolescents is increasingly common and predicts future nonsuicidal self-injury and suicide attempts. Nonsuicidal self-injury is more common than previously believed; it occurs in about 6.5%–7.5% of adolescents and is significantly more common in girls than boys. These adolescents have an increased risk for hospitalization, and polypharmacy is often the rule rather than the exception.
There remains considerable uncertainty regarding the safety and effectiveness of pharmacotherapies in this population, as well as how to assess the risks and benefits. So, the good news is that according to this review and meta-analysis, SSRIs did not significantly impact the incidence of nonsuicidal self-injury in depressed or anxious adolescents. This finding does not support prior proposed relationships between self-harming behavior and antidepressant drugs in children and adolescents that prompted the FDA black box warnings. There were no significant differences between SSRIs, serotonin–norepinephrine reuptake inhibitors, duloxetine and venlafaxine, and placebo. However, it appeared to be an increased risk for nonsuicidal self-injury in depressed adolescents treated with benzodiazepines and trazodone.
Of particular interest in adolescents with ADHD, atomoxetine and amphetamine were the medications associated with the highest risk for nonsuicidal self-injury. Recognizing that ADHD, with its decreased impulse control, is a risk factor for nonsuicidal self-injury, choosing a medication for adolescents with ADHD and nonsuicidal self-injury takes on greater importance, although it can be challenging. So, methylphenidate compounds appear at this point to be the pharmacotherapy of choice for adolescents with ADHD and nonsuicidal self-injury. I would recommend that if you have an adolescent with ADHD and nonsuicidal self-injury, methylphenidate would be the first-line pharmacotherapy.
The bottom line is that there is limited study in this area. Two very well-done studies greatly influenced this analysis. However, it is still only 2 studies: The TORDIA study by Brent and colleagues on treatment-resistant depression in adolescents, which was published in the American Journal of Psychiatry, and the Findling and colleagues study on the use of escitalopram in adolescent depression, which was published in the Journal of Child and Adolescent Psychopharmacology. Again, both are excellent reports, but controlled studies in children and adolescents are lacking and urgently needed.
Nonetheless, I think this study does provide some highly relevant clinical information regarding nonsuicidal self-injury and its association or lack thereof with different psychotropic medications. Most importantly, it points us toward the next stage of needed controlled research with various medications with different subgroups because specific subgroups may have a higher or lower risk given that the conditions studied—depression, ADHD, anxiety, and psychosis—are heterogeneous.
Abstract
Psychotropic Drugs for the Treatment of Non-Suicidal Self-Injury in Children and Adolescents: A Systematic Review and Meta-Analysis
Vincent Eggart, Sebastian Cordier, Alkomiet Hasan, Elias Wagner
Non-suicidal self-injury (NSSI) in children and adolescents is a frequent phenomenon. NSSI at any time is a significant predictor of future NSSI but also, and more importantly, for suicide attempts. Less evidence is available for the impact, or more specifically, the therapeutic effect of psychotropic drugs on the emergence of NSSI in this population. The phenomenon is clinically highly relevant since adolescent psychiatric inpatients are often affected by NSSI and most of them are treated with psychotropic drugs. While previous reviews on NSSI comprised suicidal self-injury (SSI), this review aims at elucidating the potential impact of psychotropic drugs on the emergence of specifically NSSI in children and adolescents. Systematic searches of articles indexed electronically in PubMed, Embase and PsycInfo were conducted (PROSPERO CRD42020209505). Studies included in the quantitative synthesis were evaluated using the SIGN level of evidence rating. Meta-analyses were performed using RevMan (Version 5.4). 2227 records were identified through database searches. Two additional records were identified manually. In total, seven studies were included in qualitative and four studies in quantitative analyses. In a meta-analysis, selective serotonin reuptake inhibitors (SSRIs) were compared vs. control medication (placebo or serotonin-norepinephrine reuptake inhibitor) and here, no statistically significant difference between the groups could be observed regarding the frequency of NSSI events (Risk Ratio (RR) = 1.07, 95% confidence interval (CI) 0.60-1.91, p = 0.82, I2 = 12%). Evidence regarding the association of SSRI use and NSSI among children and adolescents is sparse and the impact of psychotropic drugs in general on NSSI rates in this population should be addressed in future clinical and observational studies.
Download PDF and other files
Reference
Eggart, V., Cordier, S., Hasan, A., & Wagner, E. (2022). Psychotropic drugs for the treatment of non-suicidal self-injury in children and adolescents: A systematic review and meta-analysis. European Archives of Psychiatry and Clinical Neuroscience.
