Prevalence of Atypical Antipsychotic Drug Use Among Commercially Insured Youths in the United States

Five-year trend of antipsychotic prescription practices in a district Hospital in Ghana: A retrospective study

INTRODUCTION

Antipsychotics are the mainstay treatment for psychotic conditions. Their prescription, however, should come with some caution since the consequences of their side effects can be dire for the patient receiving the prescription. Because of inadequate experts in low-middle-income countries, non-experts are trained through the Mental Health Gap Action Program (MHGAP) to reduce the treatment gap. This retrospective study analyzed the trend of antipsychotic prescriptions in a district hospital where mental health services are delivered by non-experts.

METHODOLOGY

This was a retrospective descriptive study that gathered data between 2015 and 2019 from the electronic database of the hospital. Statistical analysis was conducted using SPSS version 20. We reported the descriptive statistics of our findings in the form of frequencies and percentages.

RESULTS

There was a year-on-year increase in antipsychotic prescriptions over the study period. Starting with 48.1% in 2015 to 56.4% in 2019. The main condition for which antipsychotics were prescribed was psychosis (58.6%), followed by substance use disorder (SUD) (26%). Patients with age ≥ 50 received the most prescription of antipsychotics. Starting from 2015, there was a high percentage of typical antipsychotic prescriptions (90.14%) with atypical antipsychotics being 9.86% and by 2019 atypical antipsychotic prescriptions had shot up to 74.8%. Polypharmacy prescription rate was 8.1% over the study period.

CONCLUSION

Antipsychotics are essential in the treatment of psychosis and other mental health conditions. Prescribers need to know more about these drugs to prescribe them appropriately and to minimize the likelihood of side effects among patients who use these drugs.

Trends in Antipsychotic Medication Use in Young Privately Insured Children

OBJECTIVE

To estimate trends of annual antipsychotic medication use by privately insured young children (aged 2-7 years) in the United States, and to describe the clinical and treatment characteristics of these children.

METHOD

The study population included young children from a nationwide commercial claims database (2007-2017). We estimated annual antipsychotic use by age and sex, defined as the number of children dispensed an antipsychotic per year divided by the number enrolled. We described clinical diagnoses and mental health service use in those with prescription antipsychotic use in 2009 and 2017.

RESULTS

Annual antipsychotic use in young children was 0.27% in 2007, peaked at 0.29% in 2009, and statistically significantly declined to 0.17% by 2017 (linear trend: -0.017% per year, 95% CI: -0.018 to -0.016). Antipsychotic use was higher in boys than in girls. A greater proportion of antipsychotic users received a mental disorder diagnosis in 2017 (89%) than in 2009 (86%, p < .01). The most common clinical diagnoses in antipsychotic users, under a hierarchical classification, were pervasive developmental disorder (2009 = 27%, 2017 = 38%, p < .01), conduct or disruptive behavior disorder (2009 = 15%, 2017 = 21%, p < .01), and attention-deficit/hyperactivity disorder (2009 = 24%, 2017 = 18%, p < .01). Among 2017 antipsychotic users, 32% had 4+ psychotherapy claims, 43% had a psychiatrist visit, and the majority used another psychotropic medication, most commonly a stimulant (boys = 57%, girls = 50%).

CONCLUSION

In privately insured young children, antipsychotic use declined from 2009 to 2017, with shifts toward indications with some supporting evidence. Nevertheless, a majority of use remains off label and for conditions lacking effectiveness and safety data. Improving antipsychotic prescribing in young children remains a challenge.

Gender differences in the use of atypical antipsychotics in early-onset schizophrenia: a nationwide population-based study in Brazil

BACKGROUND

The use of atypical antipsychotics for the treatment of schizophrenia and other mental disorders in populations under 18 years of age is increasing worldwide. Little is known about treatment patterns and the influence of gender differences, which may be a predictor of clinical outcomes. The aim of this study was to investigate gender differences in the use of atypical antipsychotics in patients with early-onset schizophrenia (EOS) assisted by the public health system in Brazil.

METHODS

We conducted a cross-sectional study of outpatients with EOS aged 10 to 17 years who received at least one provision of atypical antipsychotics (clozapine, olanzapine, risperidone, quetiapine or ziprasidone) from a large Brazilian pharmaceutical assistance programme. Data were retrieved from a nationwide administrative database from 2008 to 2017.

RESULTS

Of the 49,943 patients with EOS, 63.5% were males, and the mean age was 13.6 years old. The patients were using risperidone (62.5%), olanzapine (19.6%), quetiapine (12.4%), ziprasidone (3.3%) and clozapine (2.2%). We found gender differences, especially in the 13-17 year age group (65.1% for males vs. 34.9% for females, p < 0.001), in the use of risperidone (72.1% for males vs. 27.9% for females, p < 0.001) and olanzapine (66.5% for males vs. 33.5% for females, p < 0.001). Only in the 13 to 17 years age group were the prescribed doses of olanzapine (p = 0.012) and quetiapine (p = 0.041) slightly higher for males than for females.

CONCLUSIONS

Our findings showed gender differences among patients diagnosed with EOS and who received atypical antipsychotics. More attention should be devoted to gender differences in research and clinical practice.

The Burden of Antipsychotic-Induced Weight Gain and Metabolic Syndrome in Children

Antipsychotic medications are critical to child and adolescent psychiatry, from the stabilization of psychotic disorders like schizophrenia, bipolar disorder, and psychotic depression to behavioral treatment of autism spectrum disorder, tic disorders, and pediatric aggression. While effective, these medications carry serious risk of adverse events-most commonly, weight gain and cardiometabolic abnormalities. Negative metabolic consequences affect up to 60% of patients and present a major obstacle to long-term treatment. Since antipsychotics are often chronically prescribed beginning in childhood, cardiometabolic risk accumulates. An increased susceptibility to antipsychotic-induced weight gain (AIWG) has been repeatedly documented in children, particularly rapid weight gain. Associated cardiometabolic abnormalities include central obesity, insulin resistance, dyslipidemia, and systemic inflammation. Lifestyle interventions and medications such as metformin have been proposed to reduce risk but remain limited in efficacy. Furthermore, antipsychotic medications touted to be weight-neutral in adults can cause substantial weight gain in children. A better understanding of the biological underpinnings of AIWG could inform targeted and potentially more fruitful treatments; however, little is known about the underlying mechanism. As yet, modest genetic studies have nominated a few risk genes that explain only a small percentage of the risk. Recent investigations have begun to explore novel potential mechanisms of AIWG, including a role for gut microbiota and microbial metabolites. This article reviews the problem of AIWG and AP metabolic side effects in pediatric populations, proposed mechanisms underlying this serious side effect, and strategies to mitigate adverse impact. We suggest future directions for research efforts that may advance the field and lead to improved clinical interventions.

Spillover effects of state medicaid antipsychotic prior authorization policies in US commercially insured youth

PURPOSE

To evaluate spillover effects of Medicaid antipsychotic prior authorization (PA) policies among commercially insured youth.

METHODS

Commercially insured youth residing in nine US states that implemented PA exclusively for antipsychotics in 2011 or 2012 were identified using a 10% random sample of enrollees in the IQVIA PharMetrics Plus database spanning 2007 to 2015. Youth were included if they were ≤18 years, met the age criteria of the PA at the time of dispensing, and had at least 1 month of prescription drug coverage from 2007 to 2015. The primary outcome of interest was the monthly prevalence of antipsychotics. We implemented segmented regression of interrupted time series analysis to estimate changes in the monthly prevalence of targeted medications, overall and stratified by age. Trends were compared in the 4-year period before and the 3-year period after implementation of PA policies.

RESULTS

Antipsychotics prescribing significantly decreased 6.74/10 000 (95% CI, -9.04 to -4.44) enrollees per month immediately after PA implementation. However, PA was not associated with significant long-term trend changes (-0.06; 95% CI, -0.16 to 0.03). Antipsychotic prescribing in children <12 years-old significantly decreased 0.14/10 000 (95% CI, -0.21 to -0.07) enrollees per month after PA implementation, while prescribing in adolescents 12 to 18 years-old significantly increased 0.32/10 000 (95% CI, 0.16 to 0.47) enrollees per month.

CONCLUSION

While Medicaid PA polices for antipsychotic oversight did not affect overall prescribing, there were spillover effects in U.S. commercially insured children <12 years-old. This suggests that state-level Medicaid policies intended to improve the quality of care and safe use of antipsychotics can have broad reach.

Nationwide Epidemiologic Study of Atypical Antipsychotic Use Among Pediatric Population with Mental Illness in Korea

Objective: This population-based epidemiologic study aimed to analyze the prevalence and trends of atypical antipsychotic (AAP) use and identify factors associated with AAP prescribing among children and adolescents in Korea. Methods: Using the Health Insurance Review and Assessment Service-Pediatric Patients Sample data between 2010 and 2014, we assessed the prevalence of and secular trends in AAP use; utilization of individual AAP drug based on the type of healthcare services, healthcare institutions, and health security programs; and factors associated with AAP use. Results: The average annual prevalence of AAP use was 417 per 100,000 children and adolescents, which increased by 40% from 2010 to 2014. The major AAP drug of choice has shifted from risperidone (72.70% and 49.29% in 2010 and 2014, respectively) to aripiprazole (11.31% and 34.64% in 2010 and 2014, respectively). Quetiapine was mainly prescribed for inpatients. Therefore, hospitals have 2-3 times higher proportion of quetiapine use than clinics. A prominent difference exists in the prescribing rates and AAP drug of choice based on income level. Patients enrolled in the Medical Aid (MA) program had a higher AAP prescription rate than those enrolled in the National Health Insurance (NHI) program (adjusted odds ratio: 7.78). Moreover, MA recipients were more frequently prescribed with cheaper alternatives, such as risperidone, compared with NHI recipients. Conclusion: AAP has been increasingly used among the pediatric population in Korea. Future studies are needed to identify the causes of this increase and establish evidence on appropriate AAP use. In addition, relevant policies should be developed to ensure that low-income mentally ill children could take advantage of the best available therapy.

Child and adolescent psychiatrists' reported monitoring behaviors for second-generation antipsychotics

OBJECTIVE

The number of children and adolescents (hereafter referred to as "children") who have been prescribed second-generation antipsychotics (SGAs) has increased over the last decade, but little is known about monitoring practices in pediatric patients who are vulnerable to adverse effects. We examined factors associated with psychiatrists' self-reported monitoring of children who were prescribed SGAs.

METHODS

A survey was mailed to a national, randomly selected sample of 1600 child and adolescent psychiatrists from the American Medical Association mailing list. Using logistic regression, we tested whether psychiatrist characteristics, attitudes, and practice characteristics were associated with monitoring (baseline and/or periodic) the following: Patient history, height and weight, blood pressure, waist circumference, lipid and glucose levels, and electrocardiogram.

RESULTS

Among the analytic sample of 308, at least two thirds reported monitoring patient history, height and weight, blood pressure, and fasting plasma lipids and glucose; 23% reported monitoring waist circumference; and 12% reported conducting an electrocardiogram. More than one third stated that they routinely monitored thyroid levels and more than half reported monitoring complete blood count and electrolytes/blood urea nitrogen. Psychiatrists reporting that they were able to measure vital signs on site were more likely to measure height and weight. Those who reported feeling comfortable conducting a physical examination were more likely to measure blood pressure. Those answering that the risk of metabolic syndrome was low were less likely to measure blood pressure and waist circumference. Being board certified and able to measure vital signs on site were associated with more monitoring of glucose and lipid levels. Conversely, years in practice and feeling that patients were nonadherent with blood work were associated with less monitoring of glucose and lipid levels.

CONCLUSIONS

In this sample, inconsistent monitoring patterns of children prescribed SGAs were found. Efforts to communicate guidelines' evidence base and improve office capacity to measure and track adverse effects are needed to increase appropriate adverse effect monitoring in children who have been prescribed SGAs.

Antipsychotic polypharmacy in children and adolescents at discharge from psychiatric hospitalization

STUDY OBJECTIVE

Antipsychotic polypharmacy-the use of more than one antipsychotic concomitantly-has increased in children and adolescents and may be associated with increased adverse effects, nonadherence, and greater costs. Thus, we sought to examine the demographic and clinical characteristics of psychiatrically hospitalized children and adolescents who were prescribed antipsychotic polypharmacy and to identify predictors of this prescribing pattern.

DESIGN

Retrospective medical record review.

SETTING

The inpatient psychiatric unit of a large, acute care, urban children's hospital.

PATIENTS

One thousand four hundred twenty-seven children and adolescents who were consecutively admitted and discharged between September 2010 and May 2011.

MEASUREMENTS AND MAIN RESULTS

At discharge, 840 (58.9%) of the 1427 patients were prescribed one or more antipsychotics, and 99.3% of these received second-generation antipsychotics. Of these 840 patients, 724 (86.2%) were treated with antipsychotic monotherapy, and 116 (13.8%) were treated with antipsychotic polypharmacy. Positive correlations with antipsychotic polypharmacy were observed for placement or custody outside the biological family; a greater number of previous psychiatric admissions; longer hospitalizations; admission for violence/aggression or psychosis; and intellectual disability, psychotic, disruptive behavior, or developmental disorder diagnoses. Negative correlations with antipsychotic polypharmacy included admission for suicidal ideation/attempt or depression, and mood disorder diagnoses. Significant predictors of antipsychotic polypharmacy included admission for violence or aggression (odds ratio [OR] 2.76 [95% confidence interval (CI) 1.36-5.61]), greater number of previous admissions (OR 1.21 [95% CI 1.10-1.33]), and longer hospitalizations (OR 1.08 [95% CI 1.04-1.12]). In addition, diagnoses of intellectual disability (OR 2.62 [95% CI 1.52-4.52]), psychotic disorders (OR 5.60 [95% CI 2.29-13.68]), and developmental disorders (OR 3.18 [95% CI 1.78-5.65]) were predictors of antipsychotic polypharmacy.

CONCLUSION

Certain youth may have a higher likelihood of being prescribed antipsychotic polypharmacy, which should prompt careful consideration of medication treatment options during inpatient hospitalization. Future examinations of the rationale for combining antipsychotics, along with the long-term safety, tolerability, and cost effectiveness of these therapies, in youth are urgently needed.

Adult rats treated with risperidone during development are hyperactive

Risperidone is an antipsychotic drug approved for use in children, but little is known about the long-term effects of early-life risperidone treatment. In animals, prolonged risperidone administration during development increases forebrain dopamine receptor expression immediately upon the cessation of treatment. A series of experiments was performed to ascertain whether early-life risperidone administration altered locomotor activity, a behavior sensitive to dopamine receptor function, in adult rats. One additional behavior modulated by forebrain dopamine function, spatial reversal learning, was also measured during adulthood. In each study, Long-Evans rats received daily subcutaneous injections of vehicle or 1 of 2 doses of risperidone (1.0 and 3.0 mg/kg per day) from postnatal Days 14 to 42. Weight gain during development was slightly yet significantly reduced in risperidone-treated rats. In the first 2 experiments, early-life risperidone administration was associated with increased locomotor activity at 1 week postadministration through approximately 9 months of age, independent of changes in weight gain. In a separate experiment, it was found that the enhancing effect of early-life risperidone on locomotor activity occurred in males and female rats. A final experiment indicated that spatial reversal learning was unaffected in adult rats administered risperidone early in life. These results indicate that locomotor activity during adulthood is permanently modified by early-life risperidone treatment. The findings suggest that chronic antipsychotic drug use in pediatric populations (e.g., treatment for the symptoms of autism) could modify brain development and alter neural set points for specific behaviors during adulthood.

A population-based study of antipsychotic prescription trends in children and adolescents in British Columbia, from 1996 to 2011

OBJECTIVES

To establish prevalence rates of antipsychotic (AP) prescriptions for children 18 years of age or younger in British Columbia (BC) from 1996 to 2011 by age, sex, AP type, and primary diagnosis; and to identify the predominant AP prescribers for children by specialty training.

METHODS

BC Ministry of Health administrative data were used to describe AP prescriptions for youth aged 18 years or younger. Comparisons were made using population prevalence based on sex; age group; AP; International Classification of Diseases, Ninth Revision, diagnosis; and prescriber specialty.

RESULTS

From 1996 to 2011, overall AP (both first and second generation) prescription prevalence rate increased 3.8-fold (1.66 to 6.37 per 1000 population); second-generation AP (SGA) prescriptions increased 18.1-fold (0.33 to 5.98 per 1000 population). The highest increase in all AP prescriptions occurred in males aged 13 to 18 years (3.3 to 14.4 per 1000 population; 4.4-fold), followed by similar increases in males aged 6 to 12 years (2.3 to 8.6 per 1000 population; 3.7-fold) and in females aged 13 to 18 years (2.8 to 10.7 per 1000 population; 3.8-fold). Overall, the 3 most common diagnoses associated with all AP prescriptions were depressive disorders (12.8%), hyperkinetic syndrome of childhood (11.7%), and neurotic disorders (11.1%); however, variation was observed by prescriber specialty training. Among all new AP prescriptions in 2010/11, 38.6%, 34.3%, and 15.6% were provided by psychiatrists, family physicians, and pediatricians, respectively.

CONCLUSIONS

There has been an exponential rise in SGA prescriptions in BC secondary to extensive off-label use, not only by psychiatrists but also by family physicians and pediatricians. Knowledge translation initiatives promoting evidence-based prescribing and monitoring practices related to SGA treatment need to target all 3 prescriber groups and be tailored for age subgroups.

Antipsychotic medication use among children and risk of diabetes mellitus

OBJECTIVE

To assess whether the risk of incident diabetes was increased with the use of second-generation antipsychotics (SGAs) in a large diverse cohort of children.

METHODS

A retrospective study was conducted by using the administrative databases of 3 health plans participating in the Health Maintenance Organization Research Network. Children 5 to 18 years of age who initiated SGA therapy between January 2001 and December 2008 and 2 comparison groups, namely, nonusers of psychotropic drugs and users of antidepressant medications, were identified. Diagnoses from inpatient and outpatient records, pharmacy dispensings, and outpatient laboratory results were used to identify incident cases of diabetes.

RESULTS

The crude incidence rate of diabetes for the SGA-exposed cohort was 3.23 cases per 1000 person-years (95% confidence interval [CI]: 1.67-5.65), compared with 0.76 cases per 1000 person-years (95% CI: 0.49-1.12) among nonusers of psychotropic medications and 1.86 cases per 1000 person-years (95% CI: 1.12-2.90) among antidepressant users. The risk of incident diabetes was significantly increased among SGA users (unadjusted incidence rate ratio: 4.24 [95% CI: 1.95-8.72]) in comparison with nonusers of psychotropic medications but was not significantly increased in comparison with antidepressant medication users (unadjusted incidence rate ratio: 1.74 [95% CI: 0.77-3.78]).

CONCLUSIONS

Although we found a potentially fourfold increased rate of diabetes among children exposed to SGAs, the findings were inconsistent and depended on the comparison group and the outcome definition.

The impact of atypical antipsychotic use on obstructive sleep apnea: a pilot study and literature review

BACKGROUND

Limited evidence links atypical antipsychotics (AAs) use to sleep related respiratory dysfunction and greater severity of obstructive sleep apnea (OSA). The present paper reviews the published evidence and examines the impact of AA use on the presence and severity of OSA among subjects with clinically suspected OSA after adjusting for several confounds.

METHODS

Archives of the University of Iowa Sleep Laboratory from 2005 to 2009 were searched for patients using AAs at the time of diagnostic polysomnogram (PSG). PSG data of the 84 AA users with heterogeneous psychiatric disorders (of these 20 diagnosed only with depression) were subsequently compared to PSG data of two randomly selected, non-AA user groups from the same patient pool: (i) 200 subjects with a depressive disorder as the only psychiatric diagnosis, and (ii) 331 mentally healthy controls. PSG data were analyzed adjusting for known demographic, medical, and psychiatric risk factors for OSA.

RESULTS

Prevalence and severity of OSA did not differ significantly across three groups. Sex, age, body mass index (BMI), and neck circumference (NC) independently predicted OSA. Odds ratio for OSA in the subset of AA users carrying the diagnosis of depression (n=20) compared with subjects without mental illness was 4.53 (p<.05). By contrast, AA users without depression or those with multiple psychiatric diagnoses including depression did not show a statistically significantly elevated OSA risk.

CONCLUSIONS

AA use in subjects with depression appears to increase the risk of OSA after controlling for known predisposing factors.

Multiple psychiatric diagnoses common in privately insured children on atypical antipsychotics

OBJECTIVE

To evaluate the prevalence of atypical antipsychotic use in privately insured children and the diagnoses associated with treatment.

STUDY DESIGN

Claims were used to conduct a retrospective cohort study of children aged 2 through 18 years in the Midwest, covered by private insurance between 2002 and 2005 (n = 172,766). The 1-year prevalence of children receiving atypical antipsychotics was determined along with associated diagnoses.

RESULTS

The 1-year prevalence of atypical antipsychotics ranged from 7.9 per 1000 in 2002 to 9.0 in 2005. The leading diagnoses were disruptive behavior disorders (67%), mood disorders (65%), and anxiety disorders (43%).The authors found that 75% of children on atypical antipsychotics had more than one psychiatric diagnosis.

CONCLUSIONS

Atypical antipsychotic use is primarily seen in children who have multiple psychiatric diagnoses. Studies are needed to assess the long-term safety and effectiveness in such patients with multiple diagnoses.

Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

OBJECTIVE

To review findings from pharmaco-epidemiological studies exploring antipsychotic (AP) drugs prescribing trends.

METHOD

We retrieved original studies that explored AP prescribing trends in general population samples since 2000. For each study, we extracted information on sampling method, period, assessment of AP use and corresponding estimates (incidence rates, prevalence rates, pharmacy sales, prescription data) and diagnostic assessment.

RESULTS

Nearly all studies meeting the inclusion criteria (n = 17) showed an increase in AP prescriptions, mainly because of a dramatic rise in second-generation antipsychotics (SGAP) prescriptions. APs are often prescribed for non-psychotic disorders in adults as well as in children and adolescents.

CONCLUSION

Considering the growing number of persons from the general population exposed to APs, population studies assessing the risk/benefit ratio of SGAP use in disorders other than psychosis are necessary, particularly in children and adolescents.

Paliperidone suppresses the development of the aggressive phenotype in a developmentally sensitive animal model of escalated aggression

RATIONALE

Atypical antipsychotics are commonly prescribed to clinically referred youngsters for treatment of heightened aggressive behavior associated with various psychiatric disorders. Previously, we demonstrated risperidone's anti-aggressive effects using a well-validated animal model of offensive aggression. Paliperidone, the main active metabolite of risperidone, is a potent serotonin-2A and dopamine-2 receptor antagonist with slightly different pharmacodynamic properties compared to risperidone. Given that much of risperidone's therapeutic efficacy is due to its active metabolite, paliperidone may effectively suppress aggression with fewer adverse side effects.

OBJECTIVES

Investigate whether paliperidone administration would reduce heightened aggressive behavior induced by low-dose cocaine exposure in a developmentally sensitive model of offensive aggression.

MATERIALS AND METHODS

Male Syrian hamsters (n = 12/group) were administered an acute dose of paliperidone (0.05, 0.1, 0.2, and 0.3 mg/kg) and then tested for aggressive behavior using the resident-intruder paradigm. To investigate the effects of chronic paliperidone administration, a separate set of animals (n = 12/group) was exposed to repeated paliperidone administration (0.1 mg kg(-1) day(-1)) during different developmental periods and varying lengths of time (1-4 weeks).

RESULTS

Experiment 1 results revealed a dose-dependent decrease in bite and attack behaviors with an effective dose observed at 0.1 mg/kg. In Experiment 2, the maximal reduction in aggressive behavior in response to chronic paliperidone treatment was observed in animals treated during the third week of adolescence, and this reduction occurred without concomitant alterations in non-aggressive behaviors.

CONCLUSIONS

These results support the specific aggression-suppressing properties of paliperidone and the potential use of this compound in the treatment of maladaptive aggression in clinical settings.

Tolerability of oral ziprasidone in children and adolescents with bipolar mania, schizophrenia, or schizoaffective disorder

OBJECTIVE

This study characterizes the tolerability of ziprasidone in children and adolescents with bipolar mania, schizophrenia, or schizoaffective disorder.

METHOD

Sixty-three subjects (aged 10-17 years) entered an open-label study consisting of a 3-week fixed-dose period (Period 1) and a subsequent 24-week flexible-dose period (Period 2). In Period 1, subjects received ziprasidone 80 or 160 mg/d in two divided doses, titrated over 10 days. In Period 2, subjects received flexible doses (20-160 mg/d). Tolerability was evaluated using movement rating scales, laboratory tests, and electrocardiograms. Clinical response was assessed using the Young Mania Rating Scale, the Brief Psychiatric Rating Scale-Anchored Version, and the Clinical Global Impressions-Severity scale.

RESULTS

Adverse events (AEs) occurred mostly during dose titration and in the high-dose (160 mg/d) group. The most common AEs during Period 1 were sedation (32%), somnolence (30%), and nausea (25%) and during Period 2 were sedation (30%), somnolence (30%), and headache (25%). The incidence of movement disorder AEs was 22% and 16% during Periods 1 and 2, respectively. Six percent of study participants discontinued study participation due to AEs during Period 1 and 20% discontinued in Period 2. Thirty-three percent of subjects gained >or=7% of their baseline weight. No Fridericia-corrected QT (QTcF) intervals of >450 ms were observed during Period 1 and only one occurred during Period 2. No QTcF increase >or=60 ms from baseline was observed. Symptom reductions were observed in all patient groups.

CONCLUSIONS

No unexpected tolerability findings were observed in this prospective trial of ziprasidone in children and adolescents with bipolar mania, schizophrenia, or schizoaffective disorder. On the basis of the results, a starting dose of 20 mg/d titrated to between 80 and 160 mg/d over 1-2 weeks appears optimal for most patients.

Antipsychotic-related abnormal involuntary movements and metabolic and endocrine side effects in children and adolescents

There has been a remarkable increase in prescription rates of antipsychotics in children and adolescents in recent years. Their side effects are a neglected area of research in this population, despite its vulnerability. In this cross-sectional study, we compared the presence of side effects in 60 children and adolescents who had taken antipsychotic medication for less than 1 month and 66 who had been receiving treatment with antipsychotics for more than 12 months. Mean age for the total sample was 15.62 years (SD 1.85). Groups did not differ in age, gender, or diagnosis. A total of 21.7% of short-term treatment group patients and 37.9% of longer-term treatment group patients presented mild dyskinetic movements (p = 0.004). Hyperprolactinemia was present in 78.6% and 48.5% in the short-term and longer-term treatment groups, respectively. Body mass index (p < 0.001), cholesterol levels (p < 0.001), and low-density lipoprotein-cholesterol (LDL-C) (p = 0.018) were higher in the longer-term treatment group. The use of these drugs in these populations merits careful scrutiny.

The QT interval and psychotropic medications in children: recommendations for clinicians

The use of psychotropic medications in children has increased significantly in the last few years. There have been several case reports of sudden death in children taking specific psychotropic medications. Fears that these deaths might have been caused by ventricular arrhythmias have been enhanced by reports of electrocardiographic abnormalities, including prolongation of the QTc interval, in patients taking these medications. Several factors including genetic susceptibility, pre-existing cardiac disease, abnormalities of drug clearance and concomitant use of other medications known to affect the QTc interval can increase the susceptibility of the heart to conduction abnormalities. This article discusses the potential of particular psychotropic drugs to prolong the QTc interval in children, and examines other factors that may contribute to conduction abnormalities. We aim to provide clear clinical recommendations for the prescription of these drugs and the monitoring of children taking them.

Patterns and determinants of antipsychotic prescribing in children and adolescents, 2003-2004

OBJECTIVES

This study examined patterns and determinants of antipsychotic prescribing in children and adolescents receiving outpatient care in the United States.

METHODS

Antipsychotic prescribing practices for patients younger than 20 years were examined using the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey. The analysis focused on outpatient visits involving 11 typical and six atypical antipsychotic agents. National visit estimates were used to characterize the nature and extent of antipsychotic prescribing for patients younger than 20 years. Multiple logistic regression analysis was applied to visits involving children and adolescents to examine the need, predisposing, and enabling factors associated with antipsychotic prescribing.

RESULTS

Antipsychotic medications were prescribed in two million outpatient visits annually involving children and adolescents, representing 1% of overall visits by children and adolescents in 2003-2004. Most (99%) of these visits involved prescribing of atypical agents. The most frequently prescribed atypical agents were risperidone, quetiapine, and aripiprazole. The majority of the visits involving antipsychotic medications in children were seen in patients over 9 years, males, and whites. Factors positively associated with antipsychotic prescribing in children and adolescents included age over 9 years, diagnoses (bipolar disorder, psychoses, depression, disruptive behavior, and anxiety), and visits to specialists. Private insurance was negatively associated with antipsychotic prescribing.

CONCLUSIONS

Although the findings were based on cross-sectional analyses of outpatient visit data, the study revealed that atypical antipsychotic medications are being commonly and extensively prescribed to children and adolescents despite the relatively limited scientific evidence to support their pediatric use. Well-designed studies are urgently needed in children and adolescents to address atypical antipsychotic use for a variety of psychiatric disorders.

Safety and Usage of Atypical Antipsychotic Medicines in Children

OBJECTIVE

To study the safety and usage of atypical antipsychotic medicines in post-marketing use in a nationwide paediatric population.

DESIGN

Prospective observational cohort study using prescription event monitoring and record linkage.

POPULATION

New Zealand children aged < or =15 years, who were prescribed atypical antipsychotic medicines between April and July 2003.

OUTCOMES

Usage measures included prescription data for each medication, the diagnosis for which the patient was being treated and main target symptom. Safety outcome measures were all new clinical adverse events between the start of treatment (which could be before April 2003) and 30 November 2004.

RESULTS

The cohort included 420 children aged 2-15 years. Total exposure to atypical antipsychotic medicines was 641.2 patient-years of treatment with most (94%) of the exposure being to risperidone. The most common diagnoses were disruptive disorders. The symptoms most frequently targeted by the atypical antipsychotic were aggression and difficult behaviour. The treatment of sleep disorders as a target symptom was reported in 3% of children. A total of 131 (31%) children experienced an adverse event. The most frequent adverse events reported were weight gain, severe dental caries and somnolence. The incidence of diabetes mellitus was 4 (95% CI 0.5, 15) cases per 1000 patient-years of treatment in this study. Four children prescribed risperidone developed symptoms of depression, giving an incidence of 8 (95% CI 2.0, 21) cases per 1000 patient-years of treatment.

CONCLUSIONS

This study provides a picture of 'real-life' use of atypical antipsychotics in a nationwide cohort of children. Most prescriptions were for risperidone and the most common diagnoses were disruptive disorders. Investigation of the symptoms targeted by these medicines identified unexpected use for the treatment of sleep disorders. Regarding safety, symptoms of depression were identified as a potential new signal for risperidone in the paediatric population. Further research is now required to investigate this.

Epidemiological impact of antidepressant and antipsychotic drugs on the general population

PURPOSE OF REVIEW

To analyse the prevalence of and sex and age distribution associated with antidepressant and antipsychotic drug exposure in the general population and to highlight recent epidemiological findings concerning specific adverse outcomes associated with drug exposure.

RECENT FINDINGS

Epidemiological studies indicate high rates of second-generation antidepressant and antipsychotic drug use in the general population. The use is more prevalent among women than among men, and in older rather than in younger age groups. A new pattern of adverse outcomes has been described in individuals exposed to newer agents, including a possible risk of suicidal acts in adults receiving second-generation antidepressants, the risk of cerebrovascular events in older individuals receiving second-generation antipsychotics and the risk of metabolic disturbances in individuals exposed to specific second-generation antipsychotics.

SUMMARY

The assessment of, and attention to, the development of specific adverse reactions in individuals exposed to second-generation psychotropic drugs may improve treatment outcomes.

Female puberty: clinical implications for the use of prolactin-modulating psychotropics

During puberty, girls may present with psychiatric illness necessitating treatment with psychotropic medications. Pubertal girls are especially vulnerable to medication-associated adverse events. Atypical antipsychotics and antidepressants have the potential to elevate prolactin levels, altering pubertal progression. Selection of prolactin-sparing atypical antipsychotics is recommended, as is treatment with the lowest effective dose of selective serotonin reuptake inhibitors. Monitoring of serum prolactin levels may be necessary.

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