Suicidal risk and resilience in juvenile fibromyalgia syndrome: a cross-sectional cohort study

Background To characterize suicidality among youth with juvenile fibromyalgia syndrome (JFMS) receiving treatment from pediatric rheumatologists at a tertiary care center in order to determine the prevalence of suicidality in JFMS and to explore risk factors for persistent suicidal ideation. Methods We performed a cross-sectional cohort study of children 12–17 years old with JFMS seen in a specialty pediatric rheumatology pain clinic from 7/2017–9/2019. All subjects completed patient-reported outcomes measures, complemented by retrospective chart review. Subjects who endorsed item 8 on the Children’s Depression Inventory, 2nd Edition (CDI-2) were categorized as endorsing suicidal ideation. We assessed for differences between the suicidal and non-suicidal patients using Wilcoxon-rank sum test. Logistic regression modeling was performed to identify psychosocial factors associated with suicidality. Results Of the 31 subjects, more than one-quarter endorsed suicidality. Nearly 90% of teens with suicidal ideation were established in outpatient counseling. In bivariate analyses, suicidality was associated with lower resilience and greater depression and anxiety (all p < 0.05). Pain intensity trended towards a statistically significant positive association (OR: 1.16 [0.99–1.37]; p = 0.06). Lower resilience was independently associated with suicidality (OR: 0.90 [95% CI: 0.82–0.98]; p < 0.02). Conclusions Suicidality was prevalent among youth with JFMS and persistent despite concurrent receipt of mental health services. Higher patient-level resilience was independently associated with a reduced odds of suicidality. Future work should examine the role of resilience training on reducing psychological distress and mitigating the risk of suicidality in JFMS.

Suicidality and other severe psychiatric events with duloxetine: Re-analysis of safety data from a placebo-controlled trial for juvenile fibromyalgia

BACKGROUND: In antidepressant trials for pediatric patients with depression or anxiety disorders, the risk of suicidal events and other severe psychiatric adverse events such as aggression and agitation is increased with antidepressants relative to placebo. OBJECTIVE: To examine whether largely mentally healthy adolescents treated for a non-psychiatric condition are also at increased risk of suicidality and other severe psychiatric disorders. METHODS: This is a re-analysis of a placebo-controlled duloxetine trial for juvenile fibromyalgia based on the main journal article and additional data published in the online supplementary material and on ClinicalTrials.gov. Both serious adverse events related to psychiatric disorders and adverse events leading to treatment discontinuation were defined as severe treatment-emergent psychiatric adverse events. RESULTS: We found that a significant portion of adolescents had treatment-emergent suicidal ideation and behaviour as well as other severe psychiatric adverse events with duloxetine, but no such events were recorded on placebo. The incidence of severe treatment-emergent psychiatric adverse events was statistically significantly higher with duloxetine as compared to placebo. CONCLUSIONS: Antidepressants may put adolescents at risk of suicidality and other severe psychiatric disorders even when the treatment indication is not depression or anxiety.

Juvenile fibromyalgia: A call for diagnostic refinement, a case report

BackgroundFibromyalgia is a clinical syndrome consisting of widespread musculoskeletal tenderness and various somatic complaints including nonrestorative sleep, mood disorders such as anxiety or depression, abdominal pain, and/or headaches. There is a great deal of heterogeneity in its expression which leads to difficulty in identifying predisposing factors. A singular review of patients in an academic pediatric pain clinic reveal immune system dysfunction, mood disorders, infection, postural orthostatic tachycardia syndrome, complex regional pain syndrome, and hypermobility are premorbid conditions. It is unclear if these premorbid conditions confer a distinct fibromyalgia clinical phenotype that can provide insight into targeted therapies. Current diagnostic measures for fibromyalgia do not allow for this level of discrimination and are not validated in children.Case Presentation20 children who demonstrated widespread musculoskeletal pain, tenderness to pressure on exam and multiple somatic complaints were diagnosed with fibromyalgia. Average time from start of pain to diagnosis is 2 years. Over half the patients have psychopathology, a third have an immune system dysfunction related to autoimmunity or an infectious exposure, a third with orthostatic intolerance or postural orthostatic tachycardia syndrome, a quarter relating to hypermobility, and a quarter of the cohort with dysmenorrhea were pre or comorbid conditions. Effective therapeutic regimens among patients varied widely from responding to medical monotherapy to multimodal treatment. Trigger point injections worsened pain in one fibromyalgia patient but decreased pain in another. Patients with comorbid autoimmunity report appreciating a difference between a flare in their arthritis as opposed to a flare in their fibromyalgia. Such varying responses within the same clinical syndrome suggest distinct phenotypes within fibromyalgia which is difficult to distinguish using our current diagnostic tools.ConclusionThere is a need for clear diagnostic criteria for both the recognition of juvenile fibromyalgia and tools to distinguish phenotypes within fibromyalgia. Currently, the recognition of clinical symptoms renders it an often-overlooked neuropathic pain condition. This case series suggest there are different phenotypes within fibromyalgia. Some patients respond remarkably to serotonin norepinephrine reuptake inhibitors alone whereas others require multidisciplinary therapy. A diagnostic tool refined to capture these nuances can facilitate targeted treatment recommendations.