Citalopram not effective for repetitive behaviour in autistic spectrum disorders.

ED FROM King BH, Hollander E, Sikich L, et al; STAART Psychopharmacology Network. Lack of effi cacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism. Arch Gen Psychiatry 2009;66:583–90. Correspondence to: Bryan H King, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA; [email protected] Sources of funding: National Institutes of Health. Psychotropic medications, including selective serotonin reuptake inhibitors (SSRIs), are commonly prescribed for children and adolescents with autism spectrum disorders (ASDs) to target associated maladaptive behaviours, comorbid psychiatric conditions or even core symptoms of the disorder.1 Previous small, double blind, placebo controlled randomised clinical trials of fl uvoxamine in adults (n=30) and fl uoxetine in children (n=39) have suggested that these SSRIs are superior to placebo for reducing repetitive behaviours associated with autism.1 However, the majority of the published evidence supporting the use of SSRIs is from open label trials that are subject to publication bias, placebo effects and other shortcomings of uncontrolled trials.1 In addition, although the details have not yet been published, Autism Speaks announced in 2009 that an industry sponsored controlled trial (n=158) demonstrated that fl uoxetine was not superior to placebo for reducing repetitive behaviours in children and adolescents with autistic disorder.2 In this well designed, large, double blind, placebo controlled randomised clinical trial, King and colleagues found that citalopram was not superior to placebo for reduction of repetitive behaviour in children and adolescents with ASDs but was associated with signifi cantly more adverse behavioural effects and medical symptoms. The high placebo response rate of 34%, which has also been found in some other studies involving this population,3 illustrates the importance of double blind, placebo controlled trials. Although the reduction in irritability associated with citalopram relative to placebo (p=0.03) was not clinically meaningful, the children who participated in this study were much less irritable at baseline than those who participated in previous risperidone trials, so the possibility that citalopram is effective for irritability in this population cannot be excluded. Currently, the weight of evidence clearly does not support the use of SSRIs for the treatment of repetitive behaviours in children with ASDs. However, further investigation is necessary to determine whether SSRIs are effective for other target symptoms such as irritability or anxiety in this population.