Citalopram (Celexa), a medication commonly prescribed to children with autism spectrum disorders (ASD), was no more effective than a placebo at reducing repetitive behaviors, according to a multi-site clinical trial guided by lead author Bryan H. King, MD, director of child and adolescent psychiatry at Seattle Children's Hospital and professor and vice chair of psychiatry at the University of Washington School of Medicine.
Because citalopram is also prescribed for patients with obsessive compulsive disorders (OCD), these study results may challenge the widely held premise that repetitive behaviors in children with ASD are similar to repetitive behaviors often found in cases of OCD.
"We're continuing to learn new information about the multiple variables that may cause or contribute to autism spectrum disorders, as well as how to treat them," said King. "Even as our understanding of autism grows, so much still remains a mystery. While our study's findings may be frustrating news for hopeful families and clinicians, each new finding helps us to re-examine and revise treatment plans, refine future studies and build upon what we know as we search for effective treatments and eventually cures for this complex group of disorders."
"When prescribing any medication we must always weigh the possible benefits against possible risks," added King. "Because citalopram showed no more benefit than placebo and it may produce side effects, providers need to carefully examine whether it is appropriately prescribed for repetitive behaviors in children with an ASD."
Citalopram is in a class of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs), which are sometimes prescribed for children with ASD to reduce repetitive behaviors. These behaviors include hand flapping or wringing, repetitive complex body movements like spinning, swaying, or rocking back and forth, repetitive play, and inflexible daily routines.
"Parents of children with autism spectrum disorders face an enormous number of treatment options, not all of which are research-based," said Thomas R. Insel, MD, director of the National Institute of Mental Health (NIMH). "Studies like this help us to better understand which treatments are likely to be beneficial and safe."
Previous research has suggested that some children with ASD may have abnormalities in their serotonin, a brain chemical that, among many other functions, plays an important role in early brain development. Children with OCD may also have abnormal serotonin function, as well as repetitive or inflexible behaviors. OCD is effectively treated with SSRIs, which leads many doctors to prescribe SSRIs to reduce repetitive behaviors in children with ASD. Even though studies have shown mixed results for use in ASD, SSRIs remain among the most frequently prescribed medications for children with ASD.
This six-site, randomized controlled trial included 149 participants, ages 5 to 17 (average age 9.4), who had autism, Asperger disorder, or pervasive developmental disorder-not otherwise specified.
After 12 weeks of treatment, roughly one out of three children in both groups—32.9 percent of those treated with citalopram and 34.2 percent those treated with placebo—showed fewer or less severe repetitive symptoms.
Negative side effects were reported in nearly all children in the study. Symptoms reported significantly more often by the citalopram group than the placebo group included increased energy, impulsiveness, decreased concentration, hyperactivity, diarrhea, insomnia, and dry or itchy skin.
The research was funded by the Studies to Advance Autism Research and Treatment (STAART) network which is jointly funded by: NIMH, the National Institute of Neurological Disorders and Stroke (NINDS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Deafness and Other Communication Disorders, and the National Institute of Environmental Health Sciences, all part of the NIH.
King's research partners participating in the study included: Eric Hollander, MD, Mount Sinai School of Medicine; Linmarie Sikich, MD, University of North Carolina, Chapel Hill; James T. McCracken, MD, University of California Los Angeles; Lawrence Scahill, MSN, PhD, Yale University; Joel D. Bregman, MD, North Shore Long Island Jewish Health System; Craig L. Donnelly, MD, Dartmouth Medical School; Evdokia Anagnostou, MD, Mount Sinai School of Medicine (currently at the University of Toronto); Kimberly Dukes, PhD, DM-STAT, Boston University; Lisa Sullivan, PhD, Boston University; Deborah Hirtz, MD, at NINDS; Ann Wagner, PhD, at NIMH; Louise Ritz, MBA, at NIMH (currently at NINDS); and the STAART Psychopharmacology Network.
- King et al. Lack of Efficacy of Citalopram in Children With Autism Spectrum Disorders and High Levels of Repetitive Behavior: Citalopram Ineffective in Children With Autism. Archives of General Psychiatry, 2009; 66 (6): 583 DOI: 10.1001/archgenpsychiatry.2009.30
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