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Children cured of Cushing syndrome still need mental health screening

Primary care physicians caring for children who have been successfully treated for Cushing syndrome should continue screening for mental illness, according to data published in Pediatrics.

In an NIH study, the researchers found what they called the first documented evidence of suicide ideation in a subgroup of children and adolescents in remission of Cushing syndrome.

“[Cushing syndrome] affects children in many ways that are different than adults and is associated with residual impairment in quality of life even after remission of hypercortisolemia,” Margaret F. Keil, PhD, CRNP, of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, at the NIH, and colleagues wrote. “Also, studies in adult patients report improvement in cognitive function after remission of [Cushing syndrome], while children may experience cognitive decrement. Although the observations of parents of children with [Cushing syndrome] support personality changes, significant psychopathology has not been described.”

The researchers reviewed case histories of all 149 children and adolescents who were treated for Cushing syndrome as part of an NIH clinical trial between 2003 and 2014. The children underwent transsphenoidal surgery and were defined as cured by postsurgery serum cortisol or adrenocortical insufficiency, for which they received glucocorticoid replacement.

According to the researchers, nine children (6%) developed significant affective pathology, with symptoms including anger-rage outbursts, suicidal ideation, irritability, anxiety and depression, following successful treatment of Cushing syndrome. One child, who had a history of anxiety during active Cushing syndrome, committed suicide 60 months following surgery, after recently discontinuing antidepressant medication. Seven of the patients experienced symptoms within 7 months of surgery. These patients were on glucocorticoid replacement, and demonstrated recovery of hypothalamic pituitary adrenal axis and biochemical evidence of remission at 1-year follow-up. The remaining two patients began experiencing symptoms 48 months or later following surgery.

“Clinicians caring for children with [Cushing syndrome] should provide anticipatory guidance that after surgery mood and behavior may not normalize for months or years,” Keil and colleagues wrote. “It is imperative for clinicians to carefully review the psychosocial history, including a family history of mental illness and suicidal ideation, since patients may not spontaneously mention neuropsychiatric symptoms.” – by Jason Laday