Early Study of N-Acetylcysteine to Treat Deliberate Self-Harm in Adolescents
| Status: | Completed |
|---|---|
| Conditions: | Psychiatric |
| Therapuetic Areas: | Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 13 - 21 |
| Updated: | 12/9/2018 |
| Start Date: | March 2011 |
| End Date: | May 2015 |
N-Acetylcysteine in the Treatment of Deliberate Self-Harm in Adolescents: An Open Label Pilot Study
Deliberate Self-Harm (DSH) among adolescents is a serious behavioral problem associated with
significant injury, impaired functioning, reduced quality of life, and high rates of
psychiatric hospitalizations. While DSH has not been shown to have a direct link to suicide
attempts themselves, there is a clear link between individuals who engage in DSH and overall
rates of suicide. There is currently no medication treatment approved by the FDA for the
treatment of DSH.
The goal of this study is to evaluate the efficacy and safety of the dietary supplement
N-Acetylcysteine in adolescents aged 13-21 with deliberate self-harm behaviors. There will be
an additional neuroimaging component to expand knowledge regarding the neural correlates of
this treatment in the study population. We hypothesize that N-Acetylcysteine will reduce the
severity of deliberate self harm behaviors because this supplement has been helpful in
treating disorders that share some similar traits with DSH. We will be using this medication
in 40 young people who deliberately harm themselves and we will assess the severity of their
behaviors while being treated with this dietary supplement. We also will collect neuroimaging
data on the study participants at baseline and after the treatment with N-Acetylcysteine and
compare it to 40 age-matched healthy peer neuroimaging data. The purpose of including this
healthy group is to expand knowledge about neural correlates of the study population prior to
treatment.
significant injury, impaired functioning, reduced quality of life, and high rates of
psychiatric hospitalizations. While DSH has not been shown to have a direct link to suicide
attempts themselves, there is a clear link between individuals who engage in DSH and overall
rates of suicide. There is currently no medication treatment approved by the FDA for the
treatment of DSH.
The goal of this study is to evaluate the efficacy and safety of the dietary supplement
N-Acetylcysteine in adolescents aged 13-21 with deliberate self-harm behaviors. There will be
an additional neuroimaging component to expand knowledge regarding the neural correlates of
this treatment in the study population. We hypothesize that N-Acetylcysteine will reduce the
severity of deliberate self harm behaviors because this supplement has been helpful in
treating disorders that share some similar traits with DSH. We will be using this medication
in 40 young people who deliberately harm themselves and we will assess the severity of their
behaviors while being treated with this dietary supplement. We also will collect neuroimaging
data on the study participants at baseline and after the treatment with N-Acetylcysteine and
compare it to 40 age-matched healthy peer neuroimaging data. The purpose of including this
healthy group is to expand knowledge about neural correlates of the study population prior to
treatment.
Deliberate Self-Harm (DSH) among adolescents is a serious behavioral problem associated with
significant morbidity and mortality, impaired functioning, reduced quality of life, and high
rates of psychiatric hospitalizations. Rates of DSH among high-school adolescents range
between 14% and 21%, highlighting the need for effective behavioral and pharmacological
interventions . Because DSH has been closely linked to Borderline Personality Disorder (BPD),
treatments that have been used successfully for BPD such as Dialectical Behavior Therapy
(DBT) have been used to treat adolescents with DSH. While DSH has not been shown to have a
direct link to suicide attempts themselves, there is a clear link between individuals who
engage in DSH and overall rates of suicide. In addition to these high rates of DSH in
adolescents, research is continuing to show that similar to adult patients; adolescent DSH is
related to high levels of impulsivity.
Considerable advances in the understanding of the neurobiology of risk and reward and
impulsivity have improved the general understanding of the neuropathology of a behavior such
as DSH. Our previous neuroimaging research of DSH in BPD found that frontal white matter
integrity was significantly impaired in these individuals. One conceptualization of DSH is
that it represents an imbalance between a strong desire for the reward of DSH (i.e. an
overactive ventral tegmental area [VTA]) and an inability to inhibit the drive (i.e. impaired
inferior frontal cortex). If the frontal cortex is impaired due to inadequate white matter
integrity as our earlier study demonstrated, then reducing the drive for DSH may be the most
beneficial target for treatment. Glutamate is known to activate dopamine neurons in the VTA.
Because such activation can increase dopamine release in mesocorticolimbic targets, this
glutamate-dopamine interaction in the VTA may underlie the chronic reward-seeking that
underlies DSH. In fact, dysregulated prefrontal cortex-nucleus accumbens synaptic glutamate
transmission appears to underlie the unmanageable motivation to engage in DSH.
Because interactions of glutamate with the dopaminergic system within the VTA mediate reward,
N-acetyl cysteine (NAC), a glutamate modulating agent, should attenuate the rewarding
properties of DSH by interfering with DSH-induced stimulation of the mesolimbic dopaminergic
pathway. NAC increases the activity of cysteine-glutamate antiporters in the nucleus
accumbens and abolishes reward-seeking behavior. Behaviorally, NAC administration should lead
to diminished urges to engage in DSH. Increased extracellular glutamate by NAC may correct
the underlying pathophysiology and symptoms of this compulsive drive to self-injure. NAC has
been extensively studied in a variety of medical problems (e.g., cocaine dependence,
acetaminophen overdose, AIDS, gambling), and its lack of significant side effects may present
a marked advantage over pharmacological agents.
There is a need to develop effective treatment options that are well tolerated, widely
available, and do not have prohibitive costs. NAC is an amino acid, available in health food
stores, cheaper than the cost of most insurance co-payments, and is easily tolerated. If
effective, NAC could be a treatment option available to people throughout the country that do
not currently have insurance but are suffering from DSH.
The population to be studied for this trial is 40 men and women, ages 13-21, who engage in
deliberate self-harm behaviors at least twice a month. We will also add a sample of 40
matched healthy adolescents to serve as a comparison group for the baseline neuroimaging
measures. Study participants will be recruited from outpatient mental health clinics and from
the community through advertisements.
The study consists of two components: treatment with N-acetyl cysteine and brain imaging.
Participants will be invited to participate in either or both, depending on the distinct
eligibility criteria of the two components (see below.)
Treatment component:
The treatment component of the study consists of eight weeks of open label N-Acetylcysteine
(NAC). All eligible study subjects will be treated with 600mg of NAC twice a day for 2 weeks,
then the dose will be increased to 1200mg twice a day for two weeks, and to 1800mg twice a
day for 4 weeks. weeks. Subjects will be seen every two weeks during the 8-week study.
Efficacy and safety assessments will be performed at each visit.
Imaging component: A brain imaging session will take place before and after the treatment
with NAC. For individuals that either chose not to compete the treatment component or who did
not meet entry criteria, they will only have the baseline scan.
The healthy group will only participate in assessment and neuroimaging, not in the treatment
or the second scan.
All participants will undergo a comprehensive clinical assessment which will include the
following interviews/rating scales/tests:
1. KSADS interview (adolescents and parents) or SCID (adult participants)
2. Child Depression Rating Scale-Revised (CDRS-R)
3. Columbia Suicide Severity Rating Scale (CSSRS) (patients only)
4. Inventory of Statements About Self-Harm (ISAS) (patients only)
5. The Deliberate Self Harm Inventory (DSHI) (patients only)
6. Deliberate Self Harm Questionnaire (DSHQ) (patients only)
7. Beck Depression Inventory-II (BDI-11)
8. Wechsler Abbreviated Scale of Intelligence (WASI)
9. Edinburgh Handedness inventory
10. Iowa Gambling Task (IGT)
11. NIH Toolbox
12. Tanner Questionnaire
13. Eating Questionnaire (EDEQ)
14. Personality Assessment Inventory (PAI)
15. Symptom Check-List-90-R (SCL-90)
16. Barrett Impulsivity Scale (BIS)
17. Difficulties in Emotion Regulation Scale (DERS)
18. Satisfaction with Life Questionnaire
19. Toronto Alexithymia scale
20. Rejection Sensitivity Questionnaire - Adolescent (RSQ-A)
All participants will be invited to undergo an MRI session that includes a structural scan, a
resting state fMRI scan, an emotion task fMRI scan, diffusion tensor imaging, and magnetic
resonance spectroscopy in the anterior cingulate cortex.
Every two weeks the following assessments will be utilized to assess the efficacy of current
treatment on NAC participants:
1. Inventory of Statements About Self-Injury Since Last Visit version (ISAS - SLV)
2. Self-Injury Assessment Scale (SIAS)
3. Deliberate Self Harm Inventory Clinical Change Version (DSHI - CCV)
4. Columbia Suicide Severity Rating Scale Since Last Visit version (CSSRS - SLV)
At the end of the 8 week administration of NAC participants will complete:
1. Inventory of Statements About Self-Injury Since Last Visit version (ISAS - SLV)
2. Self-Injury Assessment Scale (SIAS)
3. Deliberate Self Harm Inventory Clinical Change Version (DSHI - CCV)
4. Columbia Suicide Severity Rating Scale Since Last Visit version (CSSRS - SLV)
5. Barrett Impulsivity Scale (BIS)
6. SCL-90
7. DERS
8. Satisfaction with Life Questionnaire
9. BDI-II
10. Iowa Gambling Task (IGT)
11. The same MRI protocol as described above.
significant morbidity and mortality, impaired functioning, reduced quality of life, and high
rates of psychiatric hospitalizations. Rates of DSH among high-school adolescents range
between 14% and 21%, highlighting the need for effective behavioral and pharmacological
interventions . Because DSH has been closely linked to Borderline Personality Disorder (BPD),
treatments that have been used successfully for BPD such as Dialectical Behavior Therapy
(DBT) have been used to treat adolescents with DSH. While DSH has not been shown to have a
direct link to suicide attempts themselves, there is a clear link between individuals who
engage in DSH and overall rates of suicide. In addition to these high rates of DSH in
adolescents, research is continuing to show that similar to adult patients; adolescent DSH is
related to high levels of impulsivity.
Considerable advances in the understanding of the neurobiology of risk and reward and
impulsivity have improved the general understanding of the neuropathology of a behavior such
as DSH. Our previous neuroimaging research of DSH in BPD found that frontal white matter
integrity was significantly impaired in these individuals. One conceptualization of DSH is
that it represents an imbalance between a strong desire for the reward of DSH (i.e. an
overactive ventral tegmental area [VTA]) and an inability to inhibit the drive (i.e. impaired
inferior frontal cortex). If the frontal cortex is impaired due to inadequate white matter
integrity as our earlier study demonstrated, then reducing the drive for DSH may be the most
beneficial target for treatment. Glutamate is known to activate dopamine neurons in the VTA.
Because such activation can increase dopamine release in mesocorticolimbic targets, this
glutamate-dopamine interaction in the VTA may underlie the chronic reward-seeking that
underlies DSH. In fact, dysregulated prefrontal cortex-nucleus accumbens synaptic glutamate
transmission appears to underlie the unmanageable motivation to engage in DSH.
Because interactions of glutamate with the dopaminergic system within the VTA mediate reward,
N-acetyl cysteine (NAC), a glutamate modulating agent, should attenuate the rewarding
properties of DSH by interfering with DSH-induced stimulation of the mesolimbic dopaminergic
pathway. NAC increases the activity of cysteine-glutamate antiporters in the nucleus
accumbens and abolishes reward-seeking behavior. Behaviorally, NAC administration should lead
to diminished urges to engage in DSH. Increased extracellular glutamate by NAC may correct
the underlying pathophysiology and symptoms of this compulsive drive to self-injure. NAC has
been extensively studied in a variety of medical problems (e.g., cocaine dependence,
acetaminophen overdose, AIDS, gambling), and its lack of significant side effects may present
a marked advantage over pharmacological agents.
There is a need to develop effective treatment options that are well tolerated, widely
available, and do not have prohibitive costs. NAC is an amino acid, available in health food
stores, cheaper than the cost of most insurance co-payments, and is easily tolerated. If
effective, NAC could be a treatment option available to people throughout the country that do
not currently have insurance but are suffering from DSH.
The population to be studied for this trial is 40 men and women, ages 13-21, who engage in
deliberate self-harm behaviors at least twice a month. We will also add a sample of 40
matched healthy adolescents to serve as a comparison group for the baseline neuroimaging
measures. Study participants will be recruited from outpatient mental health clinics and from
the community through advertisements.
The study consists of two components: treatment with N-acetyl cysteine and brain imaging.
Participants will be invited to participate in either or both, depending on the distinct
eligibility criteria of the two components (see below.)
Treatment component:
The treatment component of the study consists of eight weeks of open label N-Acetylcysteine
(NAC). All eligible study subjects will be treated with 600mg of NAC twice a day for 2 weeks,
then the dose will be increased to 1200mg twice a day for two weeks, and to 1800mg twice a
day for 4 weeks. weeks. Subjects will be seen every two weeks during the 8-week study.
Efficacy and safety assessments will be performed at each visit.
Imaging component: A brain imaging session will take place before and after the treatment
with NAC. For individuals that either chose not to compete the treatment component or who did
not meet entry criteria, they will only have the baseline scan.
The healthy group will only participate in assessment and neuroimaging, not in the treatment
or the second scan.
All participants will undergo a comprehensive clinical assessment which will include the
following interviews/rating scales/tests:
1. KSADS interview (adolescents and parents) or SCID (adult participants)
2. Child Depression Rating Scale-Revised (CDRS-R)
3. Columbia Suicide Severity Rating Scale (CSSRS) (patients only)
4. Inventory of Statements About Self-Harm (ISAS) (patients only)
5. The Deliberate Self Harm Inventory (DSHI) (patients only)
6. Deliberate Self Harm Questionnaire (DSHQ) (patients only)
7. Beck Depression Inventory-II (BDI-11)
8. Wechsler Abbreviated Scale of Intelligence (WASI)
9. Edinburgh Handedness inventory
10. Iowa Gambling Task (IGT)
11. NIH Toolbox
12. Tanner Questionnaire
13. Eating Questionnaire (EDEQ)
14. Personality Assessment Inventory (PAI)
15. Symptom Check-List-90-R (SCL-90)
16. Barrett Impulsivity Scale (BIS)
17. Difficulties in Emotion Regulation Scale (DERS)
18. Satisfaction with Life Questionnaire
19. Toronto Alexithymia scale
20. Rejection Sensitivity Questionnaire - Adolescent (RSQ-A)
All participants will be invited to undergo an MRI session that includes a structural scan, a
resting state fMRI scan, an emotion task fMRI scan, diffusion tensor imaging, and magnetic
resonance spectroscopy in the anterior cingulate cortex.
Every two weeks the following assessments will be utilized to assess the efficacy of current
treatment on NAC participants:
1. Inventory of Statements About Self-Injury Since Last Visit version (ISAS - SLV)
2. Self-Injury Assessment Scale (SIAS)
3. Deliberate Self Harm Inventory Clinical Change Version (DSHI - CCV)
4. Columbia Suicide Severity Rating Scale Since Last Visit version (CSSRS - SLV)
At the end of the 8 week administration of NAC participants will complete:
1. Inventory of Statements About Self-Injury Since Last Visit version (ISAS - SLV)
2. Self-Injury Assessment Scale (SIAS)
3. Deliberate Self Harm Inventory Clinical Change Version (DSHI - CCV)
4. Columbia Suicide Severity Rating Scale Since Last Visit version (CSSRS - SLV)
5. Barrett Impulsivity Scale (BIS)
6. SCL-90
7. DERS
8. Satisfaction with Life Questionnaire
9. BDI-II
10. Iowa Gambling Task (IGT)
11. The same MRI protocol as described above.
Inclusion Criteria:
All participants:
1. Participants must be aged 13 years to 21 years with the ability to provide consent or
guardian consent and assent.
2. They must be available to come to the University of Minnesota for study visits.
All DSH participants:
1) Must have engaged in DSH at least 4 times, with most recent episode in past three
months.
Controls
1. Have no history of deliberate self-harm
2. Have no current or past psychiatric diagnoses
Exclusion Criteria:
1. Those who are pregnant, breastfeeding, or who have a positive urine drug screen will
not be included.
2. Individuals with unstable medical illnesses, a history of seizures or heart attack, or
arrhythmia not be included.
3. Participants will not have a history of Bipolar type I or II, dementia, schizophrenia
or any other psychotic disorder.
4. Patients with active suicidal intent will not be included.
5. If DSH participants are currently taking medications, the doses of these must be
stable 1 month prior to study onset.
For Receiving NAC:
1. Participants may not be taking the following medications concurrently, due to the
possibility of medication interactions: activated charcoal, ampicillin, carbamazepine,
cephaloridine, cloxacillin, methicillin, nitroglycerin, oxacillin, penicillin G,
quinacillin.
2. Participants cannot have a history of allergic reaction to NAC.
For MRI Scanning:
1. Participants may not have any metal in their body that would be unsafe in an MRI
scanner.
2. Participants with claustrophobia will not be included.
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