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Another look at the citalopram trial

Posted Jun 15 2009 5:08pm

A recent study shows that Citalopram doesn’t control repetitive behaviors in people with Autism Spectrum Disorders. The failure of a drug trial usually leads to harsh criticism of the medical establishment from the biomedical community, but I haven’t seen much so far. Instead, Kev has already discussed this and made his opinion crystal clear. (As an aside—anyone who thinks bloggers here are somehow paid by pharmaceutical companies may want to read Kev’s post.)

The bottom line of the study was plain: citalopram doesn’t reduce repetitive behaviors in children with autism. Or, as Kev put it:

 

What the hell did they expect it to do? They expected it to reduce repetitive behaviours.

Seriously.

They put these kids on heavy duty SSRI ’s because they flapped their hands and rocked back and forth. Excuse me for being a little rude here but so fucking what?

There is a good discussion of whether there is value in controlling repetitive behaviors in autistics in the comments to Kev’s post.

I had a different perspective on this—why did they expect citalopram to reduce repetitive behavior? The quoted rationale is that it works for obsessive compulsive disorder. I haven’t seen that many people with OCD, but repetitive behaviors in autism don’t seem all that similar to OCD traits to me.

On the other side of the question, repetitive behaviors are a measurable outcome. This may give some value to repetitive behaviors as a measure of success for autism treatments. This is something often missing from autism treatment trials—a clear, measurable outcome.

That aside, what else can we learn from this trial? The big answer: the placebo effect is alive and well. Consider this from the abstract:

 

There was no significant difference in the rate of positive response on the Clinical Global Impressions, Improvement subscale between the citalopram-treated group (32.9%) and the placebo group (34.2%)

Both the treatment group and the placebo group saw about 30% of the subjects improve. This was for a relatively short, 12 week, trial.

Citalopram has been used off-label for treatment on autistics for some time. I’ll admit that I was not aware of this, even though there are claims that a huge proportion of children with autism are on citalopram. The reason it is used—doctors believe it works.

The study authors expected there to be benefit for some subgroup:

 

“We didn’t expect it to work for everyone, but we were hoping that we’d be able to drill down into the population for whom it was very helpful and begin to identify the predictor of what a positive response would be,” he [Dr. Bryan King] said.

This part speaks well of Dr. King (at least to me). He went into this study with expectations of benefit. When the data said otherwise, he went with the data.

We need good trails of autism treatments. It is very easy for doctors and patients to believe there is benefit.

Does this trial mean that citalopram will be relegated to the dust heap of autism treatments? I somehow doubt it. Here is a quote from Dr. Andrew Zimmerman of the Kennedy Krieger Institute:

 

Zimmerman, the Baltimore autism specialist, said he’s successfully treated younger autistic children, ages 3 to 5, with the drug. He added that he uses smaller doses, which appear to not create as many side effects.

“If you start at a very low dose and build it up slowly, you see improvements in mood and decreases in repetitive behaviors,” he said. “The kids are more attentive.”

No, citalopram is not going away anytime soon.

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