阿摩線上測驗
48.有關13歲以下兒童的憂鬱症治療，下列何者正確？
(A)由於診斷困難，沒有任何一種抗憂鬱劑被核准使用
(B)出現嚴重的焦慮、適應困難或睡眠障礙時，首選是benzodiazepines類藥品
(C)藥品上市前的臨床試驗，對小於13歲的受試者有嚴謹篩選標準，所以用藥相對安全
(D)若使用tricyclic antidepressants治療，宜監測心電圖
統計： A(195), B(1701), C(309), D(3133), E(0) #2039005
詳解 (共 10 筆)
根據2F藥治原文書內容翻譯、整理如下：
(A)只有SSRI的【Fluoxetine】8歲以上可用、【(+)-Escitalopram】12 歲以上可用於憂鬱症。
§另外FDA核准【Sertraline】6歲以上、【Fluvoxamine】8歲以上、【Clomipramine】10歲以上，用於治療強迫症(OCD)，不是核可用於小兒憂鬱症。
(B)SSRI為首選
(D)因為TCA藥物有class 1A抗心率不整活性的存在，因此容易造成心室性心率不整，嚴重可能導致猝死。故，需要監測心電圖。
以上有錯誤歡迎賜教。
補個原文書另外提到的，duloxetine可用來治療大於七歲孩童的generalized anxiety disorder，imipramine可用來治療六歲以上孩童的夜尿症。
❶回5樓，謝謝5樓提醒SSRI的確會造成失眠！但是相較於其他藥如TCA（可能造成猝死），BZD在使用上有較多副作用而有所限制（如下方第❷點）。
⑴SSRI是『相對』較好的選擇。而課本也是寫SSRI對小兒來說是較好的選擇。
⑵根據[Pharmacotherapy:A Pathophysiologic Approach,10e]第68章Major Depressive Disorder如下：
＞在特殊族群中提到（Special Populations）：
＞Pediatric Patients
＞Accumulating evidence indicates that childhood depression occurs quite commonly. Symptoms of depression in the young may vary from accepted diagnostic criteria and include several nonspecific symptoms such as boredom, anxiety, failing adjustment, and sleep disturbance.
Data collected under controlled conditions that support the efficacy of antidepressants in children and adolescents are sparse, and no antidepressant, except fluoxetine and escitalopram, is FDA-approved for the treatment of depression in patients younger than 18 years of age, （B選項）although other antidepressants (eg, sertraline) have been studied in this population.
The use of antidepressants in children and adolescents was complicated when, in March 2004, the FDA issued a black box warning in the product labeling for antidepressant medications warning clinicians and patients of the increased risk for suicidal ideation and behavior when antidepressants are used in this population. However, several retrospective longitudinal reviews of the use of antidepressants in children found no significant increase in the risk of suicide attempts or deaths.Furthermore, adolescents suffering from depression who remain untreated may successfully commit suicide.Further study is needed to resolve this important clinical dilemma.
Several cases of sudden death have been reported in children and adolescents taking antidepressants, such as desipramine. A baseline electrocardiogram (ECG) is recommended before initiating treatment with a TCA in children and adolescents,(D選項) and many clinicians recommend an additional ECG when steady-state plasma concentrations are achieved.
The treatment of depression in children remains challenging, as depression can be difficult to diagnose and treat once identified. Furthermore, differences in efficacy between medication and placebo may be small and nonsignificant in children below the age of 13 years.However, antidepressants (in particular, the SSRIs) remain viable treatment options when prescribed and monitored appropriately.
❷BZD在焦慮症使用上也是作為2線用藥，1線仍為憂鬱症用藥，目前也較少臨床試驗用在小孩身上：
⑴根據[Pharmacotherapy:A Pathophysiologic Approach,10e]第70章Anxiety Disorders: Generalized Anxiety, Panic, and Social Anxiety Disorders如下：
>The management of anxiety in patients with substance abuse, pregnant women, children, elderly patients, and those patients with adherence problems requires special consideration in the choice of anxiolytic. Patients with GAD may misuse alcohol, cannabis, or other substances to manage anxiety. The symptoms of GAD are similar to those of withdrawal, and it is difficult to confirm the diagnosis of GAD until after abstinence is obtained.
There are few controlled clinical trials of drugs in children and adolescents with GAD.(有焦慮症的小孩和青年較少進行臨床試驗) CBT alone or in conjunction with antidepressants can have long-term benefits. Randomized controlled trials of fluvoxamine, fluoxetine, sertraline, duloxetine, and venlafaxine extended-release indicate short-term efficacy; however, irritability and oppotional behavior was reported with clonazepam. No antidepressant is FDA-indicated for GAD in children or adolescents. Increased monitoring for behavioral changes with benzodiazepines and suicide-related adverse effects with antidepressants is necessary if these agents are prescribed.
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