Journal Article Annotations
2021, 4th Quarter
Annotations by J. Jewel Shim, MD
This is a Cochrane review of effectiveness of different pharmacotherapies for the treatment of trichotillomania (TTM) in children, adolescents, and adults. Twelve studies were included in this review, 10 in adults and 2 in children/adolescents. Pharmacotherapeutic agents included antioxidants, antipsychotics, cell signal transducers, glutamate modulators, opioid antagonists, SSRIs, TCAs. Studies were each from a single center with small numbers of subjects (average n= 29 in adult studies). Most studies were found to have low certainty or very uncertain evidence, except in the case of N-acetylcysteine (NAC), which was judged to have moderate certainty evidence. The authors’ conclusion was that there is insufficient evidence to support the effectiveness of any one agent or class of medications, though there is some evidence to suggest that the most effective treatments among those studied are NAC, clomipramine, and olanzapine.
Strength and weaknesses:
This meta-analysis was limited by the quality of the studies, as well as the small sample sizes in each study. While the data suggest that SSRIs with high serotonergic effects, olanzapine, and NAC may be the most effective for TTM symptoms, the certainty of the evidence is not high.
TTM remains a difficult to treat psychodermatological condition, and it is important to establish the evidence base for the most effective treatments.
This is a systematic review of 9 studies examining whether isotretinoin used in patients with acne were associated with adverse psychological effects. The study authors found inconsistent evidence across these studies as to whether isotretinoin used in patients with acne caused or exacerbated psychological symptoms, was not associated with psychological symptoms, or even improved psychological symptoms. In regard to this latter result, there is some question of whether psychological symptoms improved as a result of the beneficial effects of isotretinoin, leading to an increased sense of well-being and confidence in those who suffer from acne. The authors concluded that isotretinoin could be used with caution with careful monitoring, particularly in patients with a pre-existing psychiatric disorder.
Strengths and weaknesses:
The authors noted that there are no randomized controlled trials examining the association between isotretinoin and psychiatric symptoms, and existing studies generally had small sample sizes.
Isotretinoin, when used in acne patients, has long been associated with exacerbation/onset of psychological symptoms, including depression, anxiety, and suicidal ideation. It is important for the C-L psychiatrist to be aware of the existing evidence in regard to this potential association.