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Am J Psychiatry 2012;169:A30-A30. doi:10.1176/appi.ajp.2012.16911issue
 

Clinical Guidance: Mother’s Depression, Not Prenatal Antidepressants, Affects Young Children 

Children of depressed mothers who stop taking antidepressants before pregnancy have IQs and rates of behavioral problems similar to those of children of mothers who take serotonin reuptake inhibitors or venlafaxine, a serotonin-norepinephrine inhibitor, during pregnancy. Nulman et al. (p. 1165) tested children at age 3–6 and report that IQs are lower in these children than in children of nondepressed mothers, and behavioral problems are somewhat more common (figure). However, neither difference is related to prenatal antidepressant dose or duration. The child’s IQ is influenced by the mother’s IQ and child’s sex. Behavioral problems are associated with the severity of the mother’s depression not only during gestation but also during early childhood. The editorial by Steiner (p. 1130) summarizes evidence that untreated depression is a larger threat to offspring than antidepressants, but he recommends medication during pregnancy only if the indication is compelling.

About half of 127 children meeting criteria for psychiatric diagnoses at age 3 received diagnoses again at age 6, and half of those with psychiatric diagnoses at age 6 also had disorders at age 3. Bufferd et al. (CME, p. 1157) recorded increases in depression and attention deficit hyperactivity disorder (ADHD) and a decrease in generalized anxiety disorder between ages 3 and 6. Disorders most likely to remain constant were ADHD, oppositional defiant disorder, and anxiety disorders. The six cases of depression at age 3 were gone at age 6, but several of these children developed anxiety disorders or oppositional defiant disorder. Switches also occurred from anxiety or ADHD to oppositional defiant disorder and from oppositional defiant disorder to ADHD. This continuity of mental disorders in young children, states Luby in an editorial (p. 1127), presents a valuable public health opportunity.

Clinical Guidance: Skin Picking Disorder 

Skin picking consumes hours a day for some individuals, causing disfigurement and interfering with social or work life. Grant et al. (CME, p. 1143) note that skin picking disorder has a prevalence of 1%–5% and can arise at any age, often after the onset of a dermatological condition. Although it has similarities to obsessive-compulsive disorder and body dysmorphic disorder, it is distinguished by a personal or family history of grooming disorders and a lack of preoccupation with appearance. A dermatologist should determine whether the patient has an underlying skin condition and whether medical treatment is needed. Skin picking disorder can be treated with cognitive-behavioral therapy, particularly habit reversal and acceptance-enhanced behavior therapy. Naltrexone and N-acetylcysteine, a glutamatergic agent, have shown promise in case reports. Clinical trials of selective serotonin reuptake inhibitors have had mixed results.

Brain-derived neurotrophic factor (BDNF), which regulates nerve cell growth and function, may provide keys to depression pathology and new antidepressants. Tripp et al. (p. 1194) detected low levels of the primary BDNF receptor in the subgenual anterior cingulate cortex of depressed individuals. The region also had low expression of genes with high and intermediate degrees of BDNF dependency, including several genes affecting γ-aminobutyric acid (GABA), a neurotransmission inhibitor. The review by Kavalali and Monteggia (CME, p. 1150) describes ketamine’s downstream effects on BDNF that account for its rapid antidepressant effect. Antidepressants without ketamine’s side effects might be found in compounds that selectively suppress spontaneous synaptic glutamate release, not release evoked by neuronal activity. Such medications may need to be sex-specific, notes Kerman in an editorial (p. 1137), given the sex-related differences in BDNF abnormalities in brain limbic circuitry.

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