They looked at all of the published trials examining whether antidepressant drugs (mostly SSRIs, like Prozac) were better than placebo in reducing repetetive behaviours in children or adults with an autism spectrum disorder (ASD).
A meta-analysis showed that there was a statistically significant benefit of the drugs overall, but it was marginal, with a small effect size d=0.22, and it was driven mainly by two old, very small studies that found big benefits. One of them only had 12 subjects. By far the largest study, King et al (2009) with 149 people, showed zero effect.
This plot shows all of the studies, with the red line being no benefit of drug vs placebo. The further to the right of the line, the bigger the benefit, but the grey horizontal lines show the uncertainty. As you can see, two small, messy studies found big effects, the others didn't.
Worse yet, although there were 5 published studies, the authors also found that there had been 5 studies that had been completed, but never published. Carrasco, Volkmar and Bloch wrote to the people in charge of those studies and asked for data; only one out of 5 replied. The data showed no benefit.
We don't know what the other 4 unpublished studies found, but the way science works means they probably came out negative. If we assume that they did, then even the small benefit seen in the published studies disappears.
This paper, incidentally, is great example of why trial registration is a great thing. Without mandatory pre-registration on clinicaltrials.gov, no-one would know about the 6 unpublished trials at all. It would have been even better if the researchers had been forced to make public the results, as well as the existence, of the unpublished trials; but it's a lot better than nothing.
Finally, the authors of this paper stress that this doesn't mean antidepressants don't help at all in autism - just that they probably don't help with repetitive behaviors.
Carrasco, M., Volkmar, F., and Bloch, M. (2012). Pharmacologic Treatment of Repetitive Behaviors in Autism Spectrum Disorders: Evidence of Publication Bias Pediatrics, 129 (5) DOI: 10.1542/peds.2011-3285
11 comments:
One of the unpublished completed studies is the Neuropharm-Autism Speaks RCT ("SOFIA"). Looks like those involved refused to share their data.
But the negative results were reported online, more than 3 years ago. Neuropharm has since gone kaput.
SSRI's help against anxiety caused by sensory overstimulation, the root cause of autistic behavioral problems.
Imagine you are a classical music lover and suddenly you find yourself next to a speakersetup of a heavy metal and with the laser show projected on your face and a stampede of people is trying to flatten you.
That's how it feels for most autistics when they are in social situations.Personally i am used to it by now but sometimes it overtakes me nonetheless and my stresshormones fire up causing a rage.
Taking SSRI's in combo with an anti-convulsant sure does help a lot.
Michelle: Oh thanks for the pointing that out.
That was a big study as well... 158 people, if it had been published it would have been the biggest study in the analysis.
Michelle Dawson,
Your comprehensive knowledge of research efforts is hard to beat and unlike too many other researchers you also take an historical perspective in mind.
A living proof of the "special benefits" science and medicine gain from autistic researchers.
(After your conference at the NAS professionnal conference 2012 in Manchester I went and try to read older studies).
Thanks.
Cognitive and behavioral therapies should be the first line of treatment of OCD symptoms for autistic children and the classical excuse is not enough therapists are available to meet the need.
Then,please take into account that the BMJ published a wonderful study (no paywall)offering hope of delivering cognitive therapy through videogames-the authors used the term Computerised cognitive behavioural therapy and called their videogame SPARX. It really seems to be a videogame!
(NB: This videogame congnitive treatment put to the test is about depression cognitive therapy but I can see no reason why a OCD videogame cognitive treatment couldn't be made and tested in the future.)
http://www.bmj.com/content/344/bmj.e2598
I cite:
///(...)187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to a videogame (SPARX )and 93 to treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists.(...)
"SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332)."///
NB: Pr Volkmar and the Yale team of child psychiatry are doing a great job trying to protect autisitic children from Big Pharma and the DSMs 5 proposals in autism- also offering a link between the two dangers.
I am sure videogames can be very good at distracting, so the focus gets diverted from the mental anguish to something else. But i seriously doubt this can have any long-term effect.
CT didn't do much for me, except getting free CFL bulbs from the waiting room ceiling of the hospital.
Whilst not a big fan of the industry, i am of the opinion that medicinal support to suppress negative symptoms is a better way forward then mucking about with costly and sofar unproven longterm 'reprogramming' techniques.
petrossa,
I respect greatly your opinion and the opinions of all people who claim benefit from allopathic drugs.
Many autistic people(and family) claim benefits from gluten free diet (and/or other diets) even when no biological evidence of gluten allergy was founded in their blood sample and biopsy of their intestine.
Idem for Ipad making autisitc children learn and communicate.
I see in those facts good reasons to have studies properly done on those topics.
NB: You are a retired man and you probably do not suffer much from side-effects of the drugs you advocate but I just happen to think that overprescription of big Pharma drugs of dubious proven efficacy to children and pregnant women is a peculiar scandal since the side-effects are severe and brains in the making need to be given a chance not to be mingled with needlessly.
@ivana
If only i'd had had access to those drugs in my puberty i'd now be a very adequate accredited scientist.
Instead i had to selfmedicate which obviously didn't really help much as in those days it was LSD/Crystal Meth which were most readily available.
Imo using CBT and its ilk in this context is not unlike Neurolinguistic programming. Sounds very reasonable and logical but in the end doesn't work.
There is no reason why you couldn't rewire the brain using drugs. In fact it's way more effective if only there would be the right drug.
And particularly in the young, after about 12 years of age.
petrossa,
Many an aspie has done a great carrer as a scientist before any Big Pharma drug and you told us that you had a good carrer as an analyst.Not that bad and very useful to society as well.
And you might still become a great scientist since Gauss did his main math mdiscoveries when he was over 60 if I am not wrong. I am serious on that issue. Since you have a confortable income -unless poor I- you can even start a PhD in neuroscience at any age given your IQ and knowledge in autism and analyst background .
Plus, as the great Dr Norma Wing put it : "When you have known one autistic person, you have known, well, one autistic person " and you may be right in your own case but it do not justify to treat any young autistic person on that anecdoctal basis.
Anecdote for anecdote I already wrote in NS blog comment that my eldest son was considered very hyperactive on his second year at primary school until he was allowed to jump to the third primary school year class with great success on his behaviour in class- until he get bored again a few year later and the same miracle cure worked again.
Not ritalin nor neuroleptics nor anticonvulsivant mind you!
Just a sensible pedagogic measure who worked wonders also academically for him as a secondary benefit.
NB: For many an autisitc person- not everyone of them- earplugs, eyes shades and other "little measures" help a lot to overcome some sensory overstimulations which varies from one person to another.
Anyway, the subject of this NS post is antidepressant treatment of OCD in autistic persons and I learn always a lot reading from you petrossa.
Sorry for rambling offtopic. That's what we do :( On topic: Stimming has nothing to do with OCD so logically treatments for OCD don't work. Doesn't take a genius to see that.
It's more like a nervous tick. When we focus on it it's easy to control. Problem is keeping focus isn't our thing.
petrossa,
You are absolutly right: stimming is not more OCD than a meltdown is a tantrum and nor enough people know that.
Thanks for your explanation.
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