Kleptomania Not Inhibited by SSRI

STANFORD, Calif., March 14 -- Despite hopes that selective serotonin reuptake inhibitors can help control chronic kleptomania, a small randomized trial of one agent yielded no more than a placebo response.

During open-label escitalopram (Lexapro) treatment, 79% of the 19 participants had a clinically relevant reduction in stealing, said Lorrin M. Koran, M.D., of Stanford University, and colleagues.

However, the benefit disappeared during the double-blind discontinuation phase when compared with placebo, they reported in the March issue of the Journal of Clinical Psychiatry.

While the results do not support benefit from the SSRI class of antidepressants, the small study cannot rule it out, even for escitalopram in particular, the researchers cautioned.

Previous studies, none of which were double-blind, had mixed results with SSRIs leading some physicians to use it for patients with kleptomania, which has no definitive treatment.

Indeed, 10 of the patients in Dr. Koran's study had previously received an SSRI, 12 had received individual psychotherapy, and three had received group psychotherapy. None of the prior treatments substantially improved their disorder.

The study initially included 24 subjects (17 women) at least 20 years old (mean 49.5) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for kleptomania.

All participants had the disorder for at least a year with at least weekly stealing episodes or at least one appearance before a judge for sentencing (mean 3.6 related arrests). None had organic mental or bipolar disorders, psychoses, substance or alcohol abuse, suicidal risk, or other potentially confounding conditions or psychotropic medication use.

They started on escitalopram at 10 mg/day and increased as necessary to 20 mg/day during the seven week open-label phase. Responders had more than a 50% decrease in self-reported theft episodes per week and a Clinical Global Impressions-Improvement scale score of "much improved" or "very much improved."

The results at week seven were:

• 79% were responders.
• 83% (five of six) of the subjects referred by lawyers or probation officers were responders.
• A significant reduction in mean thefts per week (0.9 1.2 versus 4.0 3.3 at baseline, P<0.0001).
• A significant decrease in kleptomania severity measured by Yale-Brown Obsessive Compulsive Scale scores (7.3 6.9 versus 21.5 4.9 at baseline, P?0.0001).
• A significant reduction in strength of urges to steal (0.9 versus 2.6 P?0.0001).
• A reduction in depression symptoms on the Montgomery-Asberg Depression Rating Scale (4.6 5.2 versus 9.1 8.8 at baseline).

Common adverse events included nausea (29%), insomnia (21%), somnolence (17%), and diarrhea (13%).

The remaining 15 patients went on to participate in a double-blind phase in which they were randomized to continue medication for 17 weeks at their previous dose or to a one-week taper then placebo for 16 weeks.

The groups had similar baseline characteristics as well as depression and obsessive-compulsive scores. Relapse was defined as a return to greater than 50% of baseline weekly theft rate and Clinical Global Impression-Improvement score of "minimally improved" or less.

The double-blind phase results were:

• No significant difference in relapse rate between escitalopram and placebo (43% versus 50% P=0.38).
• No benefit to duration of response with escitalopram versus placebo (relapses at weeks 8, 10, and 18 versus at weeks 10, 22, 23, and 24).
• No difference in outcomes between those referred by lawyers or probation officers and other subjects, and no correlation between relapse and baseline or randomization kleptomania severity.

The initially high response rate "may reflect in part the subjects' high hopes for what we presented as a promising new drug treatment," the researchers wrote.

However, "the similar relapse rates in the escitalopram and placebo groups during the 17-week double-blind discontinuation phase suggest that the open-label response was largely or even wholly a placebo response," they continued.

"Still, the small number of subjects and the high rate of attrition (33% over the course of the study) leave room for other explanations," they added.

They also noted that the use of self-reported stealing rates may have limited the study, though participants were notified that their reports could not be used in any legal proceedings because the researchers had a confidentiality certificate from the U.S. Department of Health and Human Services.

"In view of our results, there remains no pharmacotherapeutic (or psychotherapeutic) treatment of kleptomania with effectiveness demonstrated under controlled conditions," the researchers concluded.

"Clinicians who encounter patients with this disorder could reasonably explore treatment with medications for which the greatest number of positive reports exist (e.g., naltrexone and the SSRIs) and the form of psychotherapy with the greatest number of positive case reports (cognitive-behavioral therapy)," they wrote.