Psychological side effects of MTX treatment in juvenile idiopathic arthritis: a pilot study

To document the psychological side effects of methotrexate (MTX) treatment in children with juvenile idiopathic arthritis (JIA) and to explore the usefulness of psychological therapy to ameliorate these side effects.

The patients included in this study consisted of 29 patients with JIA using MTX. Of these, ten were referred to a pediatric psychologist because of MTX side effects, and had behavioural therapy to cope with these side effects with a strong behavioural component (anticipatory nausea, anxiety). The behavioural therapy was adapted to age and used systemic desensitization (distraction in a positive atmosphere) or cognitive behavioural therapy (relaxation and overruling negative thoughts by positive ones). The parents of the 29 children were interviewed about MTX treatment and the side effects their child had developed. Parents of children referred to the psychologist were also interviewed for their impression of the results of the behavioural therapy.

Prior to the behavioural therapy, nine out of 10 children reported MTX related nausea. Six of these ten were nauseous even before the administration and developed anticipatory nausea. Nine out of ten patients also showed some sign of distress in anticipation of MTX treatment, either orally of via injections. The behavioural therapy they had fully abolished side effects in five children and decreased the severity of nausea and distress in two children. Of the remaining nineteen children, not referred to the pediatric psychologist, 11 reported nausea after MTX treatment and four of these developed anticipatory nausea. In addition, eight of these 18 developed behavioural distress in anticipation of the treatment.

This study showed that children with JIA who receive MTX treatment frequently develop psychological side effects, such as anticipatory nausea and behavioural distress in anticipation of treatment. This is true for patients selected for reported MTX side effects, as well as for randomly chosen JIA patients using MTX. As MTX is still the first choice in the treatment of severe JIA, more attention should be given to the treatment and prevention of side effects. Psychological intervention can be of help, but further studies are needed on the nature of the side effects, as well as on the prerequisites and efficacy of behavioural therapy.