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Letters to the Editor   |    
Response to Majeske and Kellner
David I. Driver, M.D.; Judith L. Rapoport, M.D.; Nitin Gogtay, M.D.
Am J Psychiatry 2014;171:1000. doi:10.1176/appi.ajp.2014.14050628r
View Author and Article Information

The authors’ disclosures accompany the original article.

From the Child Psychiatry Branch, NIMH, Bethesda, Md.

Copyright © 2014 by the American Psychiatric Association

Accepted June , 2014.

To the Editor: We thank Drs. Majeske and Kellner for their interest in our work and wish to provide clarification on the points raised.

Although it was not listed as a concern, we would like to emphasize that our statement that clozapine was used as a “last resort” was in the context of the psychopharmacological principle of monotherapy. We also intended to draw attention to the fact that although clozapine is considered a third-line medication, clinicians generally shy away from its use, especially in pediatric populations, until it is considered a “last resort” (14).

Regarding the concern that we neglected to consider the use of ECT in this case, Drs. Majeske and Kellner are correct, we did not consider it. The evidence for the use of ECT in children and adolescents with schizophrenia is limited to reports of its use as an adjunct to antipsychotic medication (5), and it is generally recommended that a patient has at least 2–3 adequate trials (adequate dosing and duration) of antipsychotic medication, including a trial of clozapine, before using ECT as an adjunct (5, 6). Given that our patient had not yet had an adequate monotherapy with clozapine, it would have been premature to engage her with adjunctive treatment with ECT.

We agree that it is important to consider all treatment options when managing childhood-onset schizophrenia. Our report is in no way intended to be exhaustive of the available treatments or treatment approaches (monotherapy, switching, combination, augmentation, etc.), but rather to provide a reference for providers using clozapine in children who encounter a fever.

Gogtay  N;  Rapoport  J:  Clozapine use in children and adolescents.  Expert Opin Pharmacother 2008; 9:459–465
[CrossRef] | [PubMed]
 
Vera  I;  Rezende  L;  Molina  V;  Sanz-Fuentenebro  J:  Clozapine as treatment of first choice in first psychotic episodes: What do we know? Actas Esp Psiquiatr 2012; 40:281–289
[PubMed]
 
Driver  DI;  Gogtay  N;  Rapoport  JL:  Childhood onset schizophrenia and early onset schizophrenia spectrum disorders.  Child Adolesc Psychiatr Clin N Am 2013; 22:539–555
[CrossRef] | [PubMed]
 
Driver  DI;  Anvari  AA;  Peroutka  CM;  Kataria  R;  Overman  J;  Lang  D;  Tietcheu  M;  Parker  R;  Baptiste  K;  Rapoport  JL;  Gogtay  N:  Management of clozapine-induced fever in a child.  Am J Psychiatry 2014; 171:398–402
[CrossRef] | [PubMed]
 
Bloch  Y;  Walter  G:  ECT for schizophrenia spectrum disorders, in  Electroconvulsive Therapy in Children and Adolescents . Edited by Neera  G;  Walter  G.  Oxford, United Kingdom,  Oxford Press, 2013, pp 191–216
 
Kranzler  HN;  Kester  HM;  Gerbino-Rosen  G;  Henderson  IN;  Youngerman  J;  Beauzile  G;  Ditkowsky  K;  Kumra  S:  Treatment-refractory schizophrenia in children and adolescents: an update on clozapine and other pharmacologic interventions.  Child Adolesc Psychiatr Clin N Am 2006; 15:135–159
[CrossRef] | [PubMed]
 
References Container
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References

Gogtay  N;  Rapoport  J:  Clozapine use in children and adolescents.  Expert Opin Pharmacother 2008; 9:459–465
[CrossRef] | [PubMed]
 
Vera  I;  Rezende  L;  Molina  V;  Sanz-Fuentenebro  J:  Clozapine as treatment of first choice in first psychotic episodes: What do we know? Actas Esp Psiquiatr 2012; 40:281–289
[PubMed]
 
Driver  DI;  Gogtay  N;  Rapoport  JL:  Childhood onset schizophrenia and early onset schizophrenia spectrum disorders.  Child Adolesc Psychiatr Clin N Am 2013; 22:539–555
[CrossRef] | [PubMed]
 
Driver  DI;  Anvari  AA;  Peroutka  CM;  Kataria  R;  Overman  J;  Lang  D;  Tietcheu  M;  Parker  R;  Baptiste  K;  Rapoport  JL;  Gogtay  N:  Management of clozapine-induced fever in a child.  Am J Psychiatry 2014; 171:398–402
[CrossRef] | [PubMed]
 
Bloch  Y;  Walter  G:  ECT for schizophrenia spectrum disorders, in  Electroconvulsive Therapy in Children and Adolescents . Edited by Neera  G;  Walter  G.  Oxford, United Kingdom,  Oxford Press, 2013, pp 191–216
 
Kranzler  HN;  Kester  HM;  Gerbino-Rosen  G;  Henderson  IN;  Youngerman  J;  Beauzile  G;  Ditkowsky  K;  Kumra  S:  Treatment-refractory schizophrenia in children and adolescents: an update on clozapine and other pharmacologic interventions.  Child Adolesc Psychiatr Clin N Am 2006; 15:135–159
[CrossRef] | [PubMed]
 
References Container
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The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 26.  >
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