by Joye C. Anestis
Public interest and concern with autism and autism spectrum disorders (ASDs; e.g., Asperger's disorder) has taken off in the past several years. It's always exciting when the media gets involved in a mental health topic and raises awareness about the conditions tackled by clinical psychologists. Even though the media sometimes spreads misinformation about the condition du jour (e.g., recent publicity about a proposed link between vaccines and autism, a link that has been scientifically refuted), the publicity usually benefits the individuals and families struggling with mental disorders, as such attention results in understanding, acceptance, and, importantly, more funding for necessary research. Autism and ASDs are the current condition du jour, with news sources and even entertainment outlets adding it into their storylines (for example, the past season of Grey's Anatomy included a doctor with Asperger's disorder). As those of you reading this with a child or loved one with an autism spectrum disorder know, scientists are still struggling with appropriate treatments for autism and ASDs (a fact of life that I'm sure is overwhelmingly frustrating for caretakers). One common component of treatment is antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs). SSRIs are prescribed for autism and ASDs for a variety of reasons. One primary reason is a supposed similarity between the repetitive behavior displayed in individuals with autism and ASDs and the compulsive behavior seen in obsessive-compulsive disorder (OCD; Hollander et al., 2005; Hollander, Phillips, & Yeh, 2003; McDougle et al., 1995), a disorder for which SSRIs are commonly prescribed. Yet, very little is known about the utility of prescribing these medications to individuals with autism and ASDs. Few studies have been conducted on their efficacy for these conditions, and most of the ones that have been conducted contain flaws which prohibit the drawing of firm conclusions. To begin to fill in this research gap, Bryan King and colleagues conducted the largest, most methodologically sound study of antidepressant use in children for autism and ASDs to date (the article can be found in the June 2009 issue of Archives of General Psychiatry). King et al. (2009) examined the efficacy of citalopram hydrobromide, a commonly used SSRI (Celexa), in reducing repetitive behavior in children with ASDs. Repetitive behavior was chosen as the outcome measure due the aforementioned theoretical link to OCD.
149 children participated in the trial and were randomly assigned to receive citalopram (n = 73) or placebo (n = 76). A liquid form of citalopram was administered based on a detailed dosing schedule, and the placebo matched for smell, taste, and viscosity. Subjects had to be 5 to 17 years old and meet DSM-IV-TR criteria for autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specific (other PDDs were excluded, namely Rett's disorder and childhood disintegrative disorder). These diagnoses were made with the most rigorous assessment instruments available, the Autism Diagnostic Interview Schedule - Revised and the Autism Diagnostic Observation Schedule. Furthermore, subjects had to have at least a moderate illness severity rating on the Clinical Global Impressions scale and at least a moderate score on compulsive behaviors on the Children's Yale-Brown Obsessive Compulsive Scales modified for PDDs. Detailed medication histories were obtained for each subject, and concurrent treatment with psychotropic medications or medications known to intersect with citalopram were not allowed (the only exception to this was some sleep medication). Remarkably, most of the participants (82.6%) completed the 12-week trial.
Contrary to their expectation, the authors found no significant differences between citalopram and the placebo at the end of 12 weeks on any of their outcome measures (there was one small change noted on one subscale of one of the 5 measures, but it was not a clinically significant change). Thus, the medication was no better than placebo in changing repetitive behavior or overall severity of presentation. Furthermore, the medication was associated with multiple side effects as compared to the placebo. For those treated with citalopram, 97.3% reported at least 1 adverse side effect due to the treatment (see the article for a detailed list). This finding is consistent with other studies showing elevated rates of side effects associated with psychotropic medications in this population.
Its unusual for a journal to report null findings (i.e., findings that do not support the hypotheses), but occasionally, studies are conducted in such a rigorous manner that null findings provide important information. In the case of the present study, the lack of effect of citalopram on repetitive behaviors is a novel and important contribution. As SSRIs are increasingly prescribed to help manage the symptoms of autism and ASDs, it necessary to know what effect it might have. The current study suggests that at least citalopram is not an effective medication to deal with repetitive behavior and is likely to cause adverse effects. The study also highlights the need for more rigorous investigations into medications before using them to treat or manage ASDs (and the same could be said for almost every other condition), as well as for alternative treatments for autism and ASDs.
So what do we know about treatments for autism and ASDs? Unfortunately, not a ton. There are currently no empirically supported treatments for these conditions, but hopefully this will change in the near future. If you are looking for treatment resources for your child or someone else, the National Institute of Mental Health offers tips (click here for the link). I would love to hear your thoughts and comments on the current state of autism research or on the article discussed above.