SSRIs Don’t Help in Childhood Autism?

Seven trials, 606 children, and no convincing benefit

STUDY: Trinari E et al, Clinical Medicine Insights

STUDY TYPE: Systematic review and meta-analysis

FUNDING: Independent

Background

SSRIs treat OCD, but not all kinds of compulsivity. They failed in anorexia and trichotillomania, and this analysis questions their use for compulsivity in autism.

The Study

• Seven placebo-controlled randomized controlled trials, 606 children with autism spectrum disorder.
• SSRIs studied included fluoxetine, citalopram, sertraline, and fluvoxamine.
• Treatment duration ranged from 12 to 26 weeks.
• Outcomes included repetitive behaviors, anxiety, obsessive-compulsive symptoms, disruptive behaviors, and global functioning.

Results

Across every outcome, SSRIs failed to outperform placebo.

Global functioning showed no difference: 32% of children responded to SSRIs versus 32% on placebo (risk ratio 0.99). The certainty here was moderate, making it the most reliable finding in the review.

Obsessive-compulsive symptoms showed little to no change on the CYBOCS-PDD scale (mean difference: 0.10 points; minimum important difference: 2 points). Evidence certainty was low.

Restricted repetitive behaviors and anxiety symptoms were both rated very low certainty, meaning the data can’t reliably answer the question either way.

No studies measured depression.

Side Effects

SSRIs produced a small increase in adverse events: 77 per 100 children versus 74 per 100 on placebo. Common problems included gastrointestinal upset, activation, sleep disturbance, and irritability. Four cases of suicidal ideation were reported across all arms.

Limitations

Small data set, high drop out rates, considerable heterogeneity in doses, ages, and specific SSRI.

Practice Implications

1. Statistics from clinical studies are a better than pharmacodynamic theories (eg, “dopamine is energizing” or “serotonin is anxiolytic”) or linguistic analogies (“antidepressants help bipolar depression” or “meds for OCD reduce compulsivity”).
2. Learn more about the controversial leucovorin (folinic acid) in autism.