Current pharmacotherapy options for conduct disorders in adolescents and children

Umbrella Review: Association Between Antipsychotic Drugs and Metabolic Syndrome Hallmarks in Children and Adolescents

OBJECTIVE

To summarize the available evidence on metabolic parameters indicating metabolic adverse effects and risk of metabolic syndrome in children and adolescents treated with antipsychotics, following a pre-specified protocol (PROSPERO ID 252336).

METHOD

We searched PubMed, Embase and PsycINFO until May 14, 2021, to identify systematic reviews (SR), meta-analyses (MA) and network meta-analyses (NMA) examining symptoms associated to metabolic syndrome in patients <18 years of age who required treatment with oral antipsychotic drugs. Evidence from quantitative analyses for all outcomes related to anthropometric, glyco-metabolic, and blood pressure parameters (measured from baseline to intervention-end and/or follow-up, in subjects exposed to antipsychotics and placebo) was reported on the basis of their metrics (median difference [medianD], mean difference [MD], standardized mean difference [SMD], odds ratio [OR], risk ratio ([RR]). A qualitative synthesis was also made. A formal quality assessment of the included studies was carried out by using the AMSTAR 2. We also provided a hierarchical stratification of the evidence from meta-analyses based on the class of evidence.

RESULTS

A total of 23 articles (13 MA, 4 NMA and 6 SR) were included for review. As compared with placebo, an increase in triglyceride levels was associated with olanzapine (medianD [95% CI]: 37 [12.27, 61.74] mg/dL; MD [95% CI]: 38.57 [21.44, 55.77] mg/dL) and quetiapine (medianD [95% CI]: 21.58 [95% CI]: 4.27, 38.31 mg/dL; MD [95% CI]: 34.87 [20.08, 49.67] mg/dL; SMD [95% CI]: 0.37 [0.06, 0.068]), whereas decreased triglyceride levels were found for lurasidone. Increased total cholesterol level was associated with asenapine (medianD [95% CI]: 9.1 [1.73, 16.44] mg/dL), quetiapine (medianD [95% CI]: 15.60 [7.30, 24.05] mg/dL; olanzapine (MD [95% CI] from 3.67 [1.43, 5.92] mg/dL to 20.47 [13.97, 26.94] mg/dL]; and lurasidone (medianD [95% CI]: 8.94 [1.27, 16.90] mg/dL). Change in glucose levels did not differ among antipsychotics or placebo. Lurasidone, molindone, and ziprasidone were the best tolerated in terms of weight gain. According to the AMSTAR 2 scoring system, 13 (56.5%) reviews were rated as very low quality. According to classes of evidence, most MA were level 4, especially because of their limited total sample size.

CONCLUSION

By collating meta-analyses assessing biochemical markers of metabolic syndrome in antipsychotic-treated children, we conclude that olanzapine should not be the antipsychotic of choice in patients at risk for hypertriglyceridemia or hypercholesterolemia. Aripiprazole and lurasidone appear to be better tolerated in terms of metabolic adverse events. Insufficient meta-analytic data are available to provide a precise risk estimate of metabolic syndrome, and, overall, the quality of evidence is low.

STUDY REGISTRATION INFORMATION

Association between the use of antipsychotic drugs and alterations of the parameters defining the Metabolic Syndrome (MetS) in children and adolescents: an umbrella review; https://www.crd.york.ac.uk/prospero/; CRD42021252336.

Treatment of childhood disruptive behavior disorders and callous-unemotional traits: a systematic review and two multilevel meta-analyses

BACKGROUND

Children with callous-unemotional (CU) traits are at high lifetime risk of antisocial behavior. It is unknown if treatments for disruptive behavior disorders are as effective for children with CU traits (DBD+CU) as those without (DBD-only), nor if treatments directly reduce CU traits. Separate multilevel meta-analyses were conducted to compare treatment effects on DBD symptoms for DBD+CU versus DBD-only children and evaluate direct treatment-related reductions in CU traits, as well as to examine moderating factors for both questions.

METHODS

We systematically searched PsycINFO, PubMed, Cochran Library (Trials), EMBASE, MEDLINE, APA PsycNet, Scopus, and Web of Science. Eligible studies were randomized controlled trials, controlled trials, and uncontrolled studies evaluating child-focused, parenting-focused, pharmacological, family-focused, or multimodal treatments.

RESULTS

Sixty studies with 9,405 participants were included (Mage  = 10.04, SDage  = 3.89 years, 25.09% female, 44.10% racial/ethnic minority). First, treatment was associated with similar reductions in DBD symptoms for DBD+CU (SMD = 1.08, 95% CI = 0.45, 1.72) and DBD-only (SMD = 1.01, 95% CI = 0.38, 1.64). However, DBD+CU started (SMD = 1.18, 95% CI = 0.57, 1.80) and ended (SMD = 0.73, p < .001; 95% CI = 0.43, 1.04) treatment with more DBD symptoms. Second, although there was no overall direct effect of treatment on CU traits (SMD = .09, 95% CI = -0.02, 0.20), there were moderating factors. Significant treatment-related reductions in CU traits were found for studies testing parenting-focused components (SMD = 0.21, 95% CI = 0.06, 0.35), using parent-reported measures (SMD = 0.16, 95% CI = 0.04, 0.28), rated as higher quality (SMD = 0.26, 95% CI = 0.13, 0.39), conducted outside the United States (SMD = 0.19, 95% CI = 0.05, 0.32), and with less than half the sample from a racial/ethnic minority group (SMD = 0.15, 95% CI = 0.002, 0.30).

CONCLUSIONS

DBD+CU children improve with treatment, but their greater DBD symptom severity requires specialized treatment modules that could be implemented alongside parenting programs. Conclusions are tempered by heterogeneity across studies and scant evidence from randomized controlled trials.

COVID-19 and Youth Psychopathological Distress in Umbria, Central Italy: A 2-Year Observational Study in a Real-World Setting

INTRODUCTION

Adolescents and young adults represent a vulnerable population in the context of the Coronavirus disease 2019 (COVID-19) pandemic. The present retrospective study aims to investigate the pandemic's psychological impact on adolescents and young adults by analyzing data from an outpatient mental health service dedicated to youths in Umbria, central Italy.

MATERIALS AND METHODS

The clinical charts of subjects aged 14-24 who first accessed the service in the timeframe between March 1st, 2019, and February 28th, 2021, were reviewed. Subjects were divided into two subgroups according to the period of time when they accessed the service (pre-COVID-19 vs. during- COVID-19 outbreak). Bivariate analyses were performed using the Chi-square test and the Welch's t-test. A secondary analysis was performed considering only subjects suffering from psychiatric disorders. Furthermore, data concerning individuals who were already followed by the service before the pandemic were analyzed by the McNemar's test and the t-paired test to assess changes in treatment features.

RESULTS

The number of new accesses during the pandemic period remained stable. After the emergency onset, youths accessing the service showed a higher prevalence of anxiety disorders (p = 0.022). During the COVID-19 period, services were more frequently delivered by using a digital mental health approach (p = 0.001). Psychopharmacological treatment was more frequently prescribed among subjects that were referred to the service after the pandemic onset (p = 0.033). As for substance use, a highly significant reduction in opioid use was observed (p = 0.003). Family therapy was delivered less frequently in the during-COVID-19 subgroup, especially in the subpopulation of subjects suffering from psychiatric disorders (p = 0.013). When considering subjects referred to the service in the pre-COVID-19 period, the number of interventions provided to this population increased after the pandemic outbreak (p = 0.038).

CONCLUSION

In the context of the COVID-19-related public health crisis, youths represent an at-risk population for which pathways to care should be reinforced, and targeted interventions, including psychosocial treatments, should be implemented.

Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents

Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology. Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as "aggression," "aggressive behavio(u)r," "maladaptive aggression," "juvenile," and "developmental trajectory." These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019. Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed. Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.