Although antidepressants and antipsychotics are commonly prescribed for children and adolescents, their side effects have been largely unexplored in pediatrics. In adults, however, antidepressants have been found to cause lower bone mineral density (BMD) and an increased risk for fractures, while antipsychotics have been associated with weight gain and changes in body composition, leading to metabolic syndrome.

Now, two new studies from NewYork-Presbyterian Hospital/Phyllis and David Komansky Center for Children’s Health at Weill Cornell Medical Center are investigating the effects of these medications on pediatric patients’ bone mass and weight.

Emerging studies suggest that the use of antipsychotics in children also can lead to obesity and increased rates of metabolic disturbances, yet “pediatric studies of mental health are a neglected area of research,” said Marisa Censani, MD, Assistant Professor of Pediatrics in the Division of Pediatric Endocrinology at Weill Cornell Medical College and Assistant Attending Pediatrician at the NYP/Komansky Center.

“Looking at patients over the past two decades, there’s been an increase in prevalence of type 2 diabetes and mental health diagnoses in children, and also an increase in prescription of antipsychotics, so we think more information about the metabolic effects of these medications will be extremely significant for patients’ long-term health outcomes.”

Unintended Effects

Working with John Walkup, MD, Professor of Psychiatry at Weill Cornell Medical College and Director of the Division of Child and Adolescent Psychiatry at NYP/Komansky Center, Dr. Censani is planning a pilot study to follow children aged 5 to 19 years who have been prescribed antipsychotic medications for the management of conditions such as schizophrenia, autism spectrum disorder or pervasive developmental disorder. During the first six months of treatment, study participants will be monitored by a psychiatrist and endocrinologist to measure metrics such as body composition and fasting metabolic parameters.

“One study reported that in the first 11 weeks of treatment, children can gain 10 to 13 pounds on average,” Dr. Censani said. “Our goal is to identify risk factors that predispose children and adolescents to weight gain and obesity comorbidities at the beginning of their treatment, so we can intervene early with individualized treatment plans and be able to provide guidelines for physicians. Right now there is really a dearth of information.”

The study results could inform future intervention trials to focus on the subset of at-risk individuals who have been identified, she said.

Meanwhile, another study, directed by Alexis Feuer, MD, Assistant Professor of Pediatrics in the Division of Pediatric Endocrinology at Weill Cornell Medical College and Assistant Attending Pediatrician at NYP/Komansky Center, has found that selective serotonin reuptake inhibitors (SSRIs) are associated with lower bone mass in adolescents.

Among 62 participants aged 12 to 20 years who reported taking SSRIs, dual-energy x-ray absorptiometry (DXA) scans showed that total femur bone mineral content (BMC) was 8.8% lower and total femur BMD was 6.1% lower than scans of children not taking the medications.

The data were culled from a cross-sectional analysis from the 2005-2010 National Health and Nutrition Examination Study (NHANES) performed by Dr. Feuer and colleagues. The investigators also found that lumbar spine BMC was 7% lower and BMD was 3.2% lower among SSRI users than nonusers, and femoral neck BMC was 5.7% lower and BMD was 5.5% lower.

These results, published in the journal Bone (2015;78:28-33), provide a baseline for future prospective studies, Dr. Feuer said: “We cannot infer any causality because this is a cross-sectional study, but there is an association between SSRI use and lower bone mineral density and content in pediatric patients.” In the NHANES study, Dr. Feuer said, only 1.4% of the 4,303 patients studied reported taking SSRIs—quite a bit lower than the 5% to 7% prevalence rates reported in other published studies.

Dr. Feuer is considering a larger prospective study to study this association further. If the results show that adolescents are indeed losing bone mass, she said, it may be worth monitoring children and adolescents’ BMD through DXA scans.

For now, she said, “These findings should not dissuade somebody from taking the medications if they need them. ... For any child, what we look for to improve bone health is to make sure that they’re eating a well-balanced diet with calcium and vitamin D, that their vitamin D levels are sufficient, and that they have good amounts of exercise and weight-bearing activity, at least 60 minutes a day.”