Medication Adherence Among Children and Adolescents with Severe Mental Illness: A Systematic Review and Meta-Analysis

Systematic Umbrella Review and Meta-Meta Analysis: Effectiveness of Physical Activity in Improving Depression and Anxiety in Children and Adolescents

OBJECTIVE

Depression and anxiety are prevalent and rising in children and adolescents, prompting interest in exercise as a potential therapeutic intervention. The aim of this systematic umbrella review and meta-meta-analysis was to evaluate the effects of exercise on depression and anxiety symptoms in children and adolescents and identify the most promising exercise-based approaches.

METHOD

This systematic umbrella review was preregistered (PROSPERO ID: CRD42024533558) and followed PRISMA and PRIOR guidelines. A search of 11 databases identified systematic reviews and meta-analyses of randomised controlled trials (RCTs) evaluating the effects of exercise (aerobic, resistance, mind-body exercise) on depression and anxiety symptoms in children and adolescents. Risk of bias was assessed using the AMSTAR-2 tool and certainty of evidence was assessed using GRADE. Meta-analyses were conducted to combine effect sizes, using random effects models. Subgroup analyses were performed to examine participant and intervention characteristics.

RESULTS

Twenty-one systematic reviews (n=375 RCTs, n=38,117 participants aged 5-18 years) were included. Participants had various clinical conditions including depression, psychosocial disorders, obesity, cancer, as well as healthy individuals. The pooled analysis found moderate effect sizes favouring exercise for symptoms of depression (SMD = -0.45 [95% CI, -0.59 to -0.31], I2 = 71.37%, p<0.01, 180 RCTs, n=34,490 participants) and anxiety (SMD = -0.39 [95% CI, -0.61 to -0.17], I2 = 68.1%, p<0.01, n=55 RCTs, n=24,797 participants). Mixed exercise modes and moderate-intensity exercise had the largest effects on depression, while resistance exercise was most effective for symptoms of anxiety. Interventions that were <12 weeks were more effective for depression compared with ≥12-week interventions. Benefits were generally consistent across populations. The certainty of evidence was moderate for depression and low to moderate for anxiety.

CONCLUSION

This meta-meta-analysis finds that exercise reduces depression and anxiety symptoms in children and adolescents. These results suggest that structured exercise programs should be considered as part of comprehensive care approaches.

Psychotropic medication non-adherence and its determinants among people living with mental illnesses in Ethiopia: systematic review and meta-analysis study

BACKGROUND

Over half of patients take medications incorrectly, with non-adherence being a significant challenge in managing mental illnesses and to healthcare systems globally. In mental health, non-adherence to psychotropic medications exacerbates symptoms, increases relapse rates, and contributes to treatment resistance, higher hospitalization rates, and mortality. It also places a financial burden on healthcare systems through preventable hospitalizations and prolonged treatments. Understanding the prevalence and determinants of non-adherence is particularly critical in low-resource settings like Ethiopia, where mental health services are underfunded and sociocultural factors influence treatment behaviors. Therefore, this study aimed to estimate the pooled prevalence and determinants of psychotropic medication non-adherence in Ethiopia.

METHODS

Primary articles were sourced from PubMed (Medline), EMBASE, CINAHL, Web of Science, PsycINFO, Google, and Google Scholar. The review included studies reporting the prevalence and determinants of psychotropic medication non-adherence among individuals with mental illness. Data were extracted using Microsoft Excel and analyzed in STATA 14. A random effects model was applied to estimate the pooled prevalence, and subgroup analyses were performed to explore heterogeneity. Publication bias was assessed using Egger's test and a funnel plot.

RESULTS

Seventeen studies with 7,097 participants were included. The pooled prevalence of psychotropic medication non-adherence was 43.98% (38.15, 49.81). Subgroup analysis revealed regional variations with prevalence rates of 52.85% in Harari, 52.4% in Amhara, 46.39% in Oromia, 39.8% in Addis Ababa, and 27.42% in Tigray. Significant determinants included negative attitudes toward treatment (OR: 3.69; 95% CI: 2.73-4.99), lack of insight (OR: 3.20; 95% CI: 1.71-5.99), medication side effects (OR: 2.84; 95% CI: 2.05-3.93), perceived stigma (OR: 2.41; 95% CI: 1.87-3.10), substance use (OR: 2.36; 95% CI: 2.02-2.74), and poor social support (OR: 2.30; 95% CI: 1.61-3.29).

CONCLUSIONS AND RECOMMENDATIONS

This study found that over four in ten people with mental illness were non-adherent to medications. It is recommended to design intervention strategies that address the factors associated with non-adherence to psychotropic medication.

PROSPERO REGISTRATION

CRD42024563343.

Registered Nurses' Promotion of Children's Participation During Medication Follow-Up in Child and Adolescent Psychiatric Outpatient Care

Children treated with psychotropic medication have regular medication follow-ups with registered nurses (RNs) at the child and adolescent psychiatric outpatient care (CAPOC) unit, where RNs are responsible for ensuring that children can actively participate in their care on their own terms. This study explored how RNs in Swedish CAPOC units promote children's participation in medication follow-ups. Five focus group interviews were conducted with in total 32 RNs, and the data obtained were analyzed by qualitative thematic analysis. Three themes demonstrate how RNs adapt the medication follow-ups to promote children's participation: the first concerns balancing the needs and desires of both the child and the parents; the second involves recognizing each child based on their unique circumstances and interests; and the third theme is about how RNs adjust their communication to ensure that the child is given comprehensible information and has the opportunity to express themself. Our findings highlight how RNs promote children's participation in medication follow-ups and the challenges they encounter in accordance with child-centered care. In this three-way relationship with RNs, the child, and parents, RNs need to balance between the child's perspective and the parents' needs and desires.

Medication adherence and attitudes in adolescent psychiatry: Key influences

Adolescents with mental illnesses often struggle with adhering to prescribed medication regimens. This study investigates how patient perceptions influence medication adherence among adolescents with psychiatric disorders. It also examines the role of patient characteristics and medication-related factors on adherence and attitudes. The Pediatric Medication Adherence Scale (PMAS)- 9 questions and the Pediatric Attitude toward Medication Scale (PAMS)- 18 questions, two reliable self-report scales designed for the adolescent population, were used to assess negative adherence behaviors and patients' perceptions of medication. Statistical analysis examined correlations between adherence, attitudes, and patient characteristics. The scales were administered to 288 adolescents with psychiatric disorders, and a significant correlation was found between concern scores and attitudes toward medication (r = 0.886, p < .05). Patients receiving monotherapy demonstrated lower concern scores and more positive attitudes (p < .05). Experiencing side effects was significantly linked to reduced medication adherence and more negative attitudes toward treatment. Patients with eating disorders demonstrated more negative attitudes, while those using antidepressant-antipsychotic combinations demonstrated more negative attitudes than those using stimulants. This study emphasizes the necessity of addressing critical factors that influence medication adherence and attitudes toward psychiatric medication among adolescents with psychiatric disorders. In particular, it highlights the importance of considering concern perception, managing side effects, and evaluating polypharmacy to optimize pharmacotherapy in this population.

Electronically Monitored Antidepressant Adherence in Adolescents with Anxiety Disorders: A Pilot Study

Background: Antidepressant medication adherence patterns are inconsistent in adolescents with anxiety and related disorders, and the clinical and demographic features predicting adherence are poorly understood. Methods: In an ongoing single-site prospective trial involving adolescents (aged 12-17) with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition anxiety disorders treated with escitalopram, adherence was measured for 12 weeks using electronic monitoring caps. Adherence patterns were examined using qualitative and unsupervised clustering approaches, and predictors of adherence were evaluated using logistic regression, with demographic (age, sex, and race) and clinical variables (e.g., anxiety severity [Pediatric Anxiety Rating Scale], irritability [Affective Reactivity Index], depressive symptoms [Children's Depression Rating Scale]). Results: Among adolescents (N = 33) aged 14.5 ± 1.8 years (64% female), four adherence patterns were identified: persistent adherence, intermittent adherence, early adherence-late nonadherence, and nonadherence. In a logistic model of a 5-day moving average measure of adherence, social anxiety disorder (β = -0.68 ± 0.19, p = 0.002) and separation anxiety disorder (β = -0.61 ± 0.18, p < 0.001) were associated with lower adherence. In contrast, panic disorder, attention-deficit/hyperactivity disorder, generalized anxiety disorder, and depressive symptoms were not associated with adherence. Baseline anxiety severity was linked to lower adherence (β = -0.199 ± 0.05, p < 0.001). Older age also reduced adherence (β = -0.342 ± 0.05, p < 0.001), with each additional year of age increasing time spent nonadherent by 5% (p < 0.001). Being female (β = 0.451 ± 0.17, p = 0.011) and expecting treatment to be efficacious (β = 0.092 ± 0.04, p = 0.011) increased adherence, while greater irritability was associated with nonadherence (β = -0.075 ± 0.03, p = 0.006). Conclusions: Antidepressant adherence is variable, with distinct patterns, and those with social and separation anxiety disorders were less likely to be adherent. Factors such as older age, severe anxiety, and greater irritability predicted lower adherence, while being female and expecting treatment efficacy were associated with better adherence. Interventions that address specific symptoms or enhance treatment expectations may improve adherence.

Challenges and strategies for improving medication adherence among adolescent psychiatric patients: A qualitative study

Despite significant advancements in the development of psychotropic medications, increasing adherence rates remain a challenge in the treatment and management of psychiatric disorders. The purpose of this study is to qualitatively explore the challenges underlying medication adherence and strategies to improve it among adolescents with psychiatric disorders in Malaysia. This qualitative research design presents results from 17 semi-structured interviews with adolescent psychiatric patients, aged 11 to 19 years old, from public hospitals across Peninsular Malaysia. The data collected from interviews were transcribed and processed through thematic analysis using the NVivo 11 software. A total of three main themes concerning medication adherence were identified: (1) challenges; (2) coping strategies and (3) protective factors. In this study, thirteen subthemes emerge as challenges underlying medication adherence experienced by adolescent psychiatric patients. The coping strategies identified in this study fall under three broad subthemes which are problem-focused strategies, emotion-focused strategies and maladaptive strategies. This study also highlights social support and positive medicinal effects as protective factors for non-adherence issues in adolescent psychiatric patients. In conclusion, this study supports the notion that adherence is a multi-factorial phenomenon. This study can inform future development of interventions and targeted health promotion programmes in enhancing adherence.

Adherence Rates and Barriers to Second-Generation Antipsychotic Medication Use in Youth with Bipolar Spectrum Disorders Who Have Overweight/Obesity

Objective: Youth with bipolar spectrum disorders (BSD) are frequently prescribed second-generation antipsychotics (SGAs). Nonadherence to treatment often results in increased mood symptoms and diminished quality of life. We examined SGA adherence rates and adherence barriers among youth who have overweight/obesity and are diagnosed with BSD enrolled in a multisite pragmatic clinical trial. Methods: SGA adherence and adherence barriers at baseline via patient- and caregiver report was assessed. Adherence was defined as taking ≥70% of prescribed SGA doses in the past week. The weighted Kappa statistic was used to measure child-caregiver agreement about adherence rates, barriers, and caregiver assistance. Regression analyses were used to examine associations of caregiver assistance, age, sex, race, insurance status, dosing frequency, and number of concomitant medications with adherence. Barriers to adherence were analyzed separately for youth and their caregivers, using logistic regression to assess associations between informant-reported barriers and informant-reported adherence. Results: Participants included 1485 patients and/or caregivers. At baseline, 88.6% of patients self-reported as adherent; 92.0% of caregivers reported their child was adherent. Concordance between patients and caregivers was moderate (k = 0.42). Approximately, 50% of the sample reported no adherence barriers. Frequently endorsed barriers included forgetting, side effects, being embarrassed to take medications, and preferring to do something else. Concordance between informants regarding adherence barriers was weak (k = 0.05-0.36). Patients and caregivers who did not endorse adherence barriers reported higher adherence than those who endorsed barriers. Male sex and having once daily dosing of medications were associated with lower adherence. Discussion: One-week patient- and caregiver-reported adherence was high in this sample. Half of the sample reported adherence barriers. Most commonly endorsed barriers were forgetting, side effects, being embarrassed, and preferring to do something else. Caregivers and patients have unique perspectives regarding adherence barriers. Understanding and addressing treatment barriers in clinical practice may facilitate adherence.

Development of the medical adherence scale in adolescents using psychotropic medication and evaluation of validity and reliability in Turkish population

PURPOSE

Although treatment non-adherence is relatively high among adolescents, there is a need for standardized measurement tools that measure adherence to treatment in adolescents. This study aimed to develop a new measurement tool to assess the adherence to treatment of adolescents with mental disorders who use psychotropic medication.

METHODS

The data of this methodologically designed study were collected between 01.04.2022 and 01.07.2023 in the Department of Child and Adolescent Psychiatry of a university hospital in the Aegean Region of Turkey. The Medication Adherence Reporting Scale and Adolescent Medical Adherence Scale draft form were used for data collection. The scale items were formed from the themes, sub-themes, and statements in the qualitative study that the researchers had conducted with adolescents with mental disorders and their parents, clinicians' experiences, and systematic reviews and meta-synthesis in the literature. The study sample consisted of 95 adolescents with mental disorders. Exploratory factor analysis was performed with Varimax rotation to determine the factorial construct validity of the scale. Internal consistency analyses were performed in reliability analyses, and Cronbach's alpha coefficient was used.

RESULTS

The mean age of the adolescents was 14.18 years (1.81); 50.5% were male, and 96.8% were attending school. When the mental disorder diagnoses were analyzed, 65.3% of the adolescents were being followed up with Attention Deficit and Hyperactivity Disorder diagnoses, and 58.8% were using stimulants. The 12-item form of the Adolescent Medical Adherence Scale was found to have a three-factor structure with item-total correlation values ranging between 0.26 and 0.66, and these factors were named functionality, responsibility in treatment, and medication adherence. Factor loadings ranged between 0.44 and 0.86, and the items explained 62.98% of the total variance. The internal consistency coefficients of the scale were between 0.69 and 0.83 for the subscales and 0.82 for the total scale.

CONCLUSION

Based on the analysis and results used in this study, the Adolescent Medical Adherence Scale is a valid and reliable new measurement tool.

PRACTICE IMPLICATIONS

This tool can be used in clinical settings to evaluate adolescents' treatment adherence and prognosis. Clinical studies conducted with adolescents can also determine adherence to treatment and affecting factors.

Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

To examine differences in sample characteristics and longitudinal sleep outcomes according to weighted blanket (WB) adherence.

METHODS

Children with attention-deficit/hyperactivity disorder (n = 94), mean age 9.0 (standard deviation 2.2, range 6-14) participated in a 16-week sleep intervention with WBs. Children were classified as WB adherent (use of WB ≥ 4 nights/wk) or nonadherent (use of WB ≤ 3 nights/wk). Changes in objectively measured sleep by actigraphy, parent-reported sleep problems (Children's Sleep Habits Questionnaire) and child-reported Insomnia Severity Index were evaluated according to adherence with mixed effect models. Sex, age, and attention-deficit/hyperactivity disorder subtype were examined as potential moderators.

RESULTS

Children adherent to WBs (48/94) showed an early response in sleep outcomes and an acceptance of the WB after 4 weeks of use as well as a decrease in parent-reported (Children's Sleep Habits Questionnaire) (-5.73, P = .000) and child-reported (Insomnia Severity Index) (-4.29, P = .005) sleep problems after 16 weeks. The improvement in sleep was larger among WB adherent vs nonadherent (between-group difference: Children's Sleep Habits Questionnaire: -2.09, P = .038; Insomnia Severity Index: -2.58, P = .007). Total sleep time was stable for children adherent to WB but decreased for nonadherent (between-group difference: +16.90, P = .019).

CONCLUSIONS

An early response in sleep and acceptance of the WB predicted later adherence to WBs. Improvements in sleep were more likely among WB adherents vs nonadherents. Children with attention-deficit/hyperactivity disorder may thus benefit from using WBs to handle their sleep problems.

CITATION

Lönn M, Svedberg P, Nygren J, Jarbin H, Aili K, Larsson I. Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder. J Clin Sleep Med. 2024;20(9):1455-1466.

Important aspects of experiences from patients and parents related to medications in Child and Adolescents Mental Health Services (CAMHS) - a qualitative study

PURPOSE

Patient-reported experiences are a key source of information on quality in mental health care. Most patient experience surveys are limited to assessments from adults, including those conducted by parents or proxies on behalf of others. The aim of this study was to produce findings to inform development of modules on patient and parent experiences with medication in outpatient CAMHS in Norway, for use in previously validated instruments applied in national surveys.

PATIENTS AND METHODS

We developed survey questions based on a systematic literature review, expert-group consultations, interviews with adolescents and parents, and pretesting of the modules in a pilot study. This study included adolescents aged 12-17 years and parents with experiences from outpatient CAMHS and we present findings from semi-structured interviews.

RESULTS

Adolescents with ADHD emphasized the following aspects as important concerning medication use in CAMHS: positive effects of medication like better function and concentration in school and change of behaviour. They also stressed the importance of side effects such as eating problems, nausea, loss of appetite, insomnia, and changes in thoughts and feelings. In addition, adolescents highlighted the significance of aspects as support in daily routines for taking medications, while parents highlighted needs for a professional follow-up care. Parents emphasized aspects regarding their children's medication included both positive effects and change in behaviour, as well as their identification of negative side effects.

CONCLUSION

Our findings from semi-structured interviews identified important aspects reported by both patients and parents on functions, side effects and follow-up care related to medication. The results indicated that both groups emphasized corresponding aspects of what was important regarding medication. However, when it came to follow-up care, the two groups highlighted distinct aspects, indicating differing priorities or concerns in this area.

Interrupting the Cycle: Association of Parental Stress and Child/Youth Psychotropic Medication Nonadherence

Efficacy of psychotropic medication depends in large part on successful adherence to prescribed regimens. This study investigated child/youth nonadherence in relation to family dynamics and informal support. The participants were 10,225 children and youth prescribed psychotropic medication and receiving services from 50 Ontario mental health agencies, assessed with the interRAI™ Child and Youth Mental Health (ChYMH) and ChYMH-Developmental Disability (ChYMH-DD) tools. Findings suggest a cycle of parental stress and child/youth medication nonadherence possibly leading to or even perpetuated by worsening psychiatric symptoms. Informal supports do not appear to moderate this cycle. While the present data cannot speak to causes of medication nonadherence in children/youth or where the cycle begins, the results are consistent with the extant literature calling for attention to parental wellbeing to support children/youth for optimal therapeutic benefits. Understanding home dynamics related to nonadherence can assist care planning that engages the family to achieve best possible child/youth outcomes.

Enhancing psychiatric rehabilitation outcomes through a multimodal multitask learning model based on BERT and TabNet: An approach for personalized treatment and improved decision-making

Evaluating the rehabilitation status of individuals with serious mental illnesses (SMI) necessitates a comprehensive analysis of multimodal data, including unstructured text records and structured diagnostic data. However, progress in the effective assessment of rehabilitation status remains limited. Our study develops a deep learning model integrating Bidirectional Encoder Representations from Transformers (BERT) and TabNet through a late fusion strategy to enhance rehabilitation prediction, including referral risk, dangerous behaviors, self-awareness, and medication adherence, in patients with SMI. BERT processes unstructured textual data, such as doctor's notes, whereas TabNet manages structured diagnostic information. The model's interpretability function serves to assist healthcare professionals in understanding the model's predictive decisions, improving patient care. Our model exhibited excellent predictive performance for all four tasks, with an accuracy exceeding 0.78 and an area under the curve of 0.70. In addition, a series of tests proved the model's robustness, fairness, and interpretability. This study combines multimodal and multitask learning strategies into a model and applies it to rehabilitation assessment tasks, offering a promising new tool that can be seamlessly integrated with the clinical workflow to support the provision of optimized patient care.

Impact of a national audit on child and adolescent psychiatrists' prescribing practices

BACKGROUND

A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR.

METHOD

The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160).

RESULTS

102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families.

DISCUSSION

Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.

Preliminary Efficacy of a Digital Intervention for Adolescent Depression: Randomized Controlled Trial

BACKGROUND

Adolescent depression is a significant public health concern; however, access to effective mental health care is limited. Digital therapeutics (DTx) can improve access to evidence-based interventions; however, their efficacy in adolescents is sparsely documented.

OBJECTIVE

This study aims to examine the efficacy of a mobile app DTx versus an active control as an adjunct treatment for adolescent depression symptoms.

METHODS

An internet-based open-label randomized control trial was conducted nationwide with a partial crossover design, and 168 adolescents aged 13 to 21 years with symptoms of depression were recruited between November 2020 and September 2021. Participants were randomized (1:1) to the cognitive behavioral therapy-based treatment app (Spark) or to a psychoeducational control app (control), which they would use for a duration of 5 weeks. The primary outcome was a between-group (Spark vs control) difference in the change in depression symptoms from baseline to postintervention, as measured by the Patient Health Questionnaire-8 (PHQ-8) using a linear mixed-effects analysis. The PHQ-8 ranges from 0 to 24, with scores of 5 to 9 indicating mild depression symptoms, scores of 10 to 14 indicating moderate symptoms, scores of 15 to 19 indicating moderately severe symptoms, and scores of 20 to 24 indicating severe symptoms. A minimal clinically important difference (5-point reduction between baseline and postintervention) in the Spark arm and group differences in remission and treatment response rates based on the PHQ-8 at postintervention were also investigated.

RESULTS

A total of 160 participants were randomized, 80 in the Spark arm (mean age 16.89, SD 2.5 y) and 80 in the control arm (mean age 16.79, SD 2.59 y). Data from 121 participants (Spark: n=63; control: n=58) with moderate to severe (PHQ-8≥10) symptoms at baseline were included in the primary analyses following a modified intention-to-treat principle. A linear mixed-effect analysis revealed a nonsignificant difference between the study arms in depression symptom change over the intervention period. The Spark arm met a minimal clinically important difference threshold (mean -5.08, 95% CI -6.72 to -3.42). The remission rate in the Spark arm was significantly higher than that in the control arm (11/63, 17% vs 2/58, 3%; χ21=6.2; P=.01; false discovery rate-adjusted P=.03). The treatment response rates were not significantly different between the study arms (P=.07; false discovery rate-adjusted P=.16). Post hoc analyses including participants with mild to severe (PHQ-8 score ≥5) symptoms at baseline revealed promising evidence that Spark is effective in those with mild to severe symptoms.

CONCLUSIONS

There is initial evidence that a self-guided, cognitive behavioral therapy-based DTx intervention may effectively treat mild to severe depression symptoms in adolescents. DTx may improve access to mental health care for adolescents or serve as an important adjunct to the standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04524598; https://clinicaltrials.gov/study/NCT04524598.

Efficacy of cannabinoids in neurodevelopmental and neuropsychiatric disorders among children and adolescents: a systematic review

A better understanding of the endocannabinoid system and a relaxation in regulatory control of cannabis globally has increased interest in the medicinal use of cannabinoid-based products (CBP). We provide a systematic review of the rationale and current clinical trial evidence for CBP in the treatment of neuropsychiatric and neurodevelopmental disorders in children and adolescents. A systematic search of MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Trials was performed to identify articles published after 1980 about CBP for medical purposes in individuals aged 18 years or younger with selected neuropsychiatric or neurodevelopmental conditions. Risk of bias and quality of evidence was assessed for each article. Of 4466 articles screened, 18 were eligible for inclusion, addressing eight conditions (anxiety disorders (n = 1); autism spectrum disorder (n = 5); foetal alcohol spectrum disorder (n = 1); fragile X syndrome (n = 2); intellectual disability (n = 1); mood disorders (n = 2); post-traumatic stress disorder (n = 3); and Tourette syndrome (n = 3)). Only one randomised controlled trial (RCT) was identified. The remaining seventeen articles included one open-label trial, three uncontrolled before-and-after trials, two case series and 11 case reports, thus the risk of bias was high. Despite growing community and scientific interest, our systematic review identified limited and generally poor-quality evidence for the efficacy of CBP in neuropsychiatric and neurodevelopmental disorders in children and adolescents. Large rigorous RCTs are required to inform clinical care. In the meantime, clinicians must balance patient expectations with the limited evidence available.

Initiation of Aripiprazole Lauroxil Long-Acting Injectable in Adolescents During Hospitalization: A Case Series

Objective: The efficacy and safety of long-acting injectable (LAI) antipsychotics in the pediatric population is not well established due to limited evidence. This case series aims to describe off-label use of aripiprazole lauroxil (AL) LAI in adolescent inpatients, including findings on safety and readmission trends. Methods: This was a retrospective chart review of patients who were initiated on AL LAI while admitted at a county-based adolescent psychiatric unit between March 2021 and March 2023. Data comprised sociodemographic and clinical characteristics, such as psychiatric diagnoses, prior antipsychotic trials, and history of nonadherence. Other observations of interest included tolerability of AL LAI and time to readmission. Results: This analysis identified 12 adolescents who received AL LAI within a 2-year period. The mean age was 16 ± 1 years, and seven (58%) patients were female. There were varying primary psychiatric diagnoses, with the most common being bipolar disorder (25%), schizophrenia (17%), major depressive disorder with psychotic features (17%), and unspecified mood disorder (17%). Eleven (92%) patients had previously trialed at least one antipsychotic, with seven (58%) having exposure to oral aripiprazole before admission. Nonadherence was the driving factor for LAI consideration in all but one patient. AL LAI was well tolerated short term; one patient reported experiencing injection site pain, and one patient discontinued the LAI after discharge due to anxiety. Time to readmission ranged from 15 to 658 days for seven patients who were hospitalized again; two of the readmissions occurred within 1 month. Conclusion: This is the first case series to describe initiation of AL LAI at an inpatient adolescent psychiatric unit. Our study illustrates that AL LAI may hold potential as an acceptably tolerated treatment in adolescents with varying psychiatric diagnoses. Further studies are needed to evaluate long-term safety and effectiveness of AL LAI in youth.

Examining factors that influence medication adherence with children seen at outpatient department in Western China: a cross-sectional survey

We aimed to evaluate the prevalence of medication adherence, assess the association between guardians' mental health and medication adherence for children seen at outpatient department from western China, and identify characteristics associated with nonadherence. We conducted a cross-sectional survey. Participants were recruited by consecutive sampling from the outpatient of the West China Second Hospital from October 2021 to April 2022. The Morisky Medication Adherence Scale (MMAS-8) was used to evaluate patients' medication adherence. A multivariate linear regression model was used to analyze influencing factors. 1206 children with a mean age of 6.02 ± 3.86 years were included. Seventeen percent (208/1206) of patients showed good adherence, 24.7% (298/1206) showed moderate adherence, and 58% (700/1206) showed poor adherence. Thirty-five percent (428/1206) of guardians had anxiety. Factors that influenced medication adherence included anxiety score of guardian (P = 0.030), education level of guardian (P = 0.003), annual household income (P = 0.001), and days the patient is on the medication (P = 0.023). A majority of children seen at outpatient department from West China had low medication adherence, and depression and anxiety among guardians were common. Implementing health education measures will be important for improving medication adherence in future.

Examining Factors Associated With Medication Adherence in Youth With Bipolar Disorder

Objective

To assess medication adherence and factors associated with poor adherence in youth with bipolar disorder (BD) followed from adolescence through young adulthood.

Method

Participants with BD recruited through the Course and Outcome of Bipolar Youth (COBY) study were included in this study if they were prescribed psychotropic medications and had at least 3 follow-up assessments of medication adherence (N= 179, ages 12-36). Medication adherence had been evaluated for a median of 8 years using a questionnaire derived from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For the longitudinal evaluation, adherence was measured as the percentage of follow-up assessments in which the participants did not endorse any of the nonadherence items included in the questionnaire. Concurrent and future predictors of poor adherence were assessed using both univariate and multivariate longitudinal analyses.

Results

Among the participants, 51% reported poor adherence in more than 50% of their follow-up assessments. Younger age, family conflicts, polypharmacy, lower functioning, greater severity of mood symptoms, and comorbid disorders were associated with poor adherence in the univariate analyses. In the multivariate analyses, comorbid ADHD was the single most influential factor associated with concurrent and future poor adherence in all age groups. Participants' most reported reasons for poor adherence were forgetfulness (56%), negative attitudes toward medication treatment (10.5%), and disturbed daily routine (7%).

Conclusions

Poor medication adherence is a significant problem in youth with BD with the most influential factor being the presence of comorbid ADHD. Thus, it is important to identify and appropriately treat comorbid ADHD to improve medication adherence and patients' prognosis. Providers should also recommend tools to enhance consistent medication intake and address patients' concerns and negative beliefs about their illness and treatment.

Parental Factors Associated with Child or Adolescent Medication Adherence: A Systematic Review

Medication adherence, especially among children and adolescents with psychiatric disorders, is often seen as a major treatment challenge. The purpose of this study is to systematically review studies addressing specific aspects of parental factors that are positively or negatively associated with medication adherence among children and adolescents with psychiatric disorders. A systematic literature search of English language publications, from inception through December 2021, was conducted from PubMed, Scopus, and MEDLINE databases. This review has complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. A total of 23 studies (77,188 participants) met inclusion criteria. Nonadherence rates ranged between 8% to 69%. Parents' socioeconomic background, family living status and functioning, parents' perception and attitude towards the importance of medication taking in treating psychiatric disorders, and parents' mental health status are significant parental characteristics associated with medication adherence in children and adolescents with psychiatric disorders. In conclusion, by identifying specific parental characteristics related to the medication adherence of children and adolescents with psychiatric disorders, targeted interventions on parents could be developed to guide parents in improving their child's medication adherence.

Perceptions and Experiences of Adolescents with Mental Disorders and Their Parents about Psychotropic Medications in Turkey: A Qualitative Study

This descriptive phenomenological study aimed to evaluate the perception and experiences of adolescents with mental disorders and their parents about the use of and adherence to psychotropic medications. A total of 12 semi-structured interviews with adolescents between the ages of 12 to 18 who were attending an outpatient psychiatric clinic for children and adolescents and 12 interviews with parents were conducted between October 2021 and January 2022 in Manisa, Turkey. Colaizzi’s phenomenological interpretation method was used for the analysis of the participants’ statements. Our study highlights the main positive effects of psychotropic medication and barriers to medication intake and adherence. Positive effects included symptom management and health improvement. Barriers varied from those directly linked to medication effects (e.g., negative side effects or lack of perceived effect) to personal barriers (e.g., forgetting to take medication or feelings of not being oneself due to medication intake) and societal barriers. In general, the barriers were reflected in concerns related to long-term consequences, such as medication dependence, and in concerns about diminished life prospects. Possible recommendations to improve the use of and adherence to psychotropic medication among adolescents include educating adolescents and parents not only about treatment options but also about mental disorders.

Efficacy, Tolerability, and Acceptance of Long-Lasting Antipsychotics in Children and Adolescents: A Systematic Review

Objectives: While long-lasting antipsychotics (LLA) were specifically developed to address the problem of adherence in patients with chronic psychiatric disorders, their role in pediatric populations is not clear. Methods: To document the efficacy, tolerance, and acceptance of LLAs in children and adolescents, a literature search was conducted using several databases for published studies (PubMed, PsycINFO) from January 1965 to December 2020. Twenty-two studies were identified (16 case reports/series, 3 open label studies, 2 controlled studies, and 1 retrospective analysis of national database). Results: Demographic features were widely heterogeneous across studies (total N = 480, 58% male, mean age = 15.0 ± 1.8). Case reports/series presented positive therapeutic outcomes in noncompliant youths with severe mental illness. Three open-label one-arm studies supported the clinical efficacy of risperidone long-acting injection in patients previously stabilized with oral risperidone. One study showed lower clinical symptoms and higher functioning at 12 months in youths treated for an acute psychotic episode with paliperidone palmitate compared to oral risperidone. The types and rates of side effects of LLA were comparable to those observed for oral antipsychotics. Two studies suggested better metabolic and neurological tolerance of LLA compared to an oral form. Preliminary evidence supported a satisfactory level of treatment satisfaction in patients treated with LLA and their families, while concerns were raised regarding practical administration in outpatient services. However, the average quality of the evidence based on the RoB2 tool was low. Conclusions: The level of evidence was low for the efficacy of LLA in pediatric populations and very low for the tolerance and acceptance. It concerned mostly the effect of risperidone long-acting injection in adolescents with psychotic disorders. Randomized maintenance clinical trials using noninferiority analysis would be more appropriate for further research.

Electroconvulsive therapy efficacy in adolescents with mental illness: A retrospective comparison

BACKGROUND

There is limited evidence on the efficacy of electroconvulsive therapy (ECT) in adolescents with mental illness. The present study reported outcomes of adolescents with mental illness treated with ECT aimed at providing evidence for large-scale feasibility.

OBJECTIVES

The primary objective of this trial was to examine the differences in demographic and clinical data between responders and non-responders. The secondary objective was to determine whether ECT produced differential readmission rates, the burden of oral medication, and social function in responders and non-responders in the long term.

METHODS

Patients aged 14-18 years diagnosed with schizophrenia (SCZ), major depressive disorder (MDD), or bipolar disorder (BD) who received ECT between 2015 and 2020 were included in the study. Demographic and clinical data were compared, and both short-term and long-term outcomes were assessed: response on the Clinical Global Impressions-Improvement scale and readmission at follow-up. The independent-sample t-test was used to compare the continuous variables and the X ² test was used to compare the dichotomous variables with statistical significance at P ≤ 0.05.

RESULTS

Four hundred ten adolescents (aged 14-18 years, 53.90% female) received ECT for SCZ, MDD, and BD. The response rate for SCZ, MDD, and BD were 65.61, 78.57, and 69.95%, respectively. Both SCZ (P = 0.008) and BD (P = 0.008) groups had a significant elder age in responders than in non-responders. Besides that MDD responders had a significantly larger number of ECT sessions than non-responders (P = 0.046), the study failed to find a significant difference in other ECT parameters. A significantly higher proportion of readmission was found in BD non-responders than in responders (P = 0.029), there was no difference in the rate of readmission in other diagnostic groups.

CONCLUSIONS

These data suggested that ECT is an effective treatment for adolescents with severe mental illness, and the rate of readmission was low in the long term. The present study supports that large-scale systematic studies are warranted for further investigation of the response rate of ECT for treating adolescents with mental illness.

Cannabidiol (CBD) as a novel treatment in the early phases of psychosis

The pharmacological interventions available for individuals in the early stages of psychosis are extremely limited. For those at clinical high risk for psychosis, there is no licensed treatment available. For those with first-episode psychosis, all licensed antipsychotic medications act via dopamine D₂ receptors. While treatment with antipsychotics is transformative in some patients, in others, it is ineffective. In addition, these medications can often cause adverse effects which make patients reluctant to take them. This is a particular problem in the early phases of psychosis, when patients are being treated for the first time, as unpleasant experiences may colour their future attitude towards treatment. Recent research has suggested that cannabidiol (CBD), a compound found in the Cannabis sativa plant, may have antipsychotic effects and relatively few adverse effects and could therefore be an ideal treatment for the early phases of psychosis, when minimising adverse effects is a clinical priority. In this review, we consider CBD's potential as a treatment in the clinical high risk and first-episode stages of psychosis. First, we describe the limitations of existing treatments at these two stages. We then describe what is known of CBD's mechanisms of action, effectiveness as a treatment for psychosis, adverse effects and acceptability to patients. We discuss how some of the outstanding issues about the utility of CBD in the early phases of psychosis may be resolved through ongoing clinical trials. Finally, we consider the impact of recreational cannabis use and over-the-counter cannabinoids preparations and discuss the potential therapeutic role of other compounds that modulate the endocannabinoid system in psychosis.

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations

Adherence to antidepressants is crucial for optimal treatment outcomes when treating depressive disorders. However, poor adherence is common among patients prescribed antidepressants. This targeted review summarizes the main factors associated with poor adherence, interventions that promote antidepressant adherence, pharmacological aspects related to antidepressant adherence, and formulates 10 clinical recommendations to optimize antidepressant adherence. Patient-related factors associated with antidepressant non-adherence include younger age, psychiatric and medical comorbidities, cognitive impairment, and substance use disorders. Prescriber behavior-related factors include neglecting medical and family histories, selecting poorly tolerated antidepressants, or complex antidepressant regimens. Multi-disciplinary interventions targeting both patient and prescriber, aimed at improving antidepressant adherence, include psychoeducation and providing the patient with clear behavioral interventions to prevent/minimize poor adherence. Regarding antidepressant choice, agents with individually tailored tolerability profile should be chosen. Ten clinical recommendations include four points focusing on the patient (therapeutic alliance, adequate history taking, measurement of depressive symptoms, and adverse effects improved access to clinical care), three focusing on prescribing practice (psychoeducation, individually tailored antidepressant choice, simplified regimen), two focusing on mental health services (improved access to mental health care, incentivized adherence promotion and monitoring), and one relating to adherence measurement (adherence measurement with scales and/or therapeutic drug monitoring).

Medication Adherence in Pediatric Patients with Bipolar Disorder: A Systematic Review

Objectives: Pediatric bipolar disorder is a severe disabling condition affecting 1%-3% of youth worldwide. Both acute and maintenance treatment with medications are mainstays of treatment. It is well established in adult literature that adherence to medications improves outcomes and many adult studies have examined factors impacting adherence. This systematic review set out to identify the current state of research examining adherence to medications and characteristics influencing adherence in pediatric bipolar disorder. Methods: We performed a systematic literature review in the Medline, PsycINFO, CINAHL, EMBASE, Wiley Clinical Trials, and Cochrane databases. New research regarding characteristics and measurement of adherence to psychotropic medication for bipolar disorder (I, II, or not otherwise specified) in patients ≤18 years old were included for review. Exclusion criteria included no bipolar diagnosis, inclusion of patients >18 years old, no pharmacologic treatment, and lack of adherence measurements. Results: Initial search generated 439 articles after duplicate removal. One hundred thirty-three full-text articles were reviewed, 16 underwent additional review and 6 were selected for final inclusion. The majority of articles were excluded for patients >18 years old. Included articles were extremely heterogeneous for multiple measures, including methodology, determination of adherence, adherence rates, and characteristics influencing adherence. Of medications evaluated, 6/6 studies included mood stabilizers, 4/6 antidepressants, 3/6 antipsychotics, and 2/6 psychostimulants. Three out of six articles included patients <12 years old. Some significant factors affecting adherence included polypharmacy, comorbid psychiatric diagnoses, socioeconomic status, sex, family history and functioning, side effects, race, stability of bipolar diagnosis, and number of follow-up visits attended. Conclusions: Pediatric-specific information on medication adherence in bipolar disorder is very limited. Information on patient characteristics that may influence adherence rates is critical to target interventions to improve adherence. No articles reported on interventions to improve adherence. Given the different psychosocial situations of pediatric patients versus adults, it is likely that targets for improving adherence differ in pediatric patients.

Understanding barriers to prescription retrieval and attitudes toward mental health medications at a university student health services pharmacy

OBJECTIVES

To describe barriers affecting college students' ability to retrieve prescription medications for mental health conditions from a community pharmacy embedded within a student health center on a university campus and then describe beliefs and attitudes toward the use of those medications.

METHODS

We conducted a cross-sectional study of college students who were prescribed a medication(s) for a mental health condition(s) and left the medication(s) unclaimed at the pharmacy for at least 5 days. Eligible participants were identified through routine reminder telephone calls and then provided a link to an online survey via e-mail. The survey collected information on demographics, prescription retrieval barriers, and medication beliefs and attitudes using 2 validated questionnaires. Data were summarized using descriptive statistics and scoring methods specific to the validated questionnaires.

RESULTS

A total of 83 e-mails were distributed with 46 usable responses received (55.4% response rate). Participants were undergraduate students (n = 38, 82.6%) and most frequently prescribed a medication(s) for depression (n = 21, 45.7%) or anxiety (n = 16, 34.8%). Forgetting to pick up their medication was the most commonly cited reason for prescription nonretrieval (n = 32, 69.6%) followed by limited pharmacy hours (n = 21, 45.7%). Participants generally viewed the necessity of their medication(s) as outweighing their concerns about their medication(s), and they generally viewed themselves as medication adherent.

CONCLUSIONS

University students taking medications for mental health conditions identified forgetfulness and limited pharmacy hours as the most common reasons for not retrieving prescriptions. Students generally viewed their medication(s) as necessary and themselves as medication adherent, suggesting that attitudes and beliefs may play a smaller role in medication use behaviors in this population. Future research is needed to develop and evaluate interventions that improve medication adherence in college students, potentially focused on reminder-based interventions.

The Importance of Second-Generation Antipsychotic-Related Weight Gain and Adherence Barriers in Youth with Bipolar Disorders: Patient, Parent, and Provider Perspectives

Objectives: The objective of this research was to understand physician, patient, and parent perspectives on barriers to second-generation antipsychotic (SGA) medication adherence in youth with bipolar spectrum disorders, and attitudes toward treatment of SGA-related weight gain. Methods: Patients diagnosed with bipolar disorder before age 18, parents of children diagnosed before 18, and clinicians with experience prescribing SGAs for these patients completed surveys regarding SGA-related side effects, adherence barriers, and acceptability of weight management strategies. Results: Patients (n = 225), parents (n = 128), and clinicians (n = 54) reported weight gain as the most concerning SGA-related side effect (45.6%, 38.9%, and 70.4%, respectively). Weight gain was also the top adherence barrier for patients (35.9%), but was ranked fourth (41.8%) by parents. Patients (61.5%) were more likely "definitely" willing to co-initiate another medication to manage weight gain upon SGA initiation than parents (20.1%) or clinicians (1.9%). Conversely, parents (54.9%) and clinicians (84.9%) were "definitely" willing to accept/prescribe a second medication aiming to reverse weight gain of ≥10 lbs., and patients (61.1%) were willing to add another medication to reverse any weight gain. Conclusion: SGA-related weight gain impairs medication adherence in young patients with bipolar disorder. Many young patients would start pharmacologic treatment to mitigate SGA-related weight gain at treatment initiation, parents and clinicians are more hesitant. This research informs patient-centered perspectives on SGA adherence barriers and strategies to minimize potential side effects, which may improve adherence in this vulnerable patient population.

Longitudinal course and risk factors associated with psychosis in bipolar youths

OBJECTIVES

To compare the longitudinal clinical course of youths with bipolar disorder (BD) spectrum with lifetime (past, intake, and/or follow-up) psychosis (BDP+) to youths with BD without lifetime psychosis (BDP-). Also, to identify risk factors associated with increased risk of first onset of psychosis during prospective follow-up.

METHOD

Bipolar disorder youths (BDP+ = 137, BDP- = 233), aged 7-17 years old, were followed on average every 7 months for 11.7 years and were evaluated using standardized instruments. Data were analyzed using linear and generalized linear models for the full sample, as well as for youths who developed first period of psychosis (n = 55).

RESULTS

After adjusting for confounders, BDP+ youths with one, and in particular ≥2 lifetime psychotic episodes, had higher rates and more severe mood and anxiety symptoms, higher rates of suicidality, psychiatric hospitalizations, and sexual/physical abuse, and poorer psychosocial functioning than BDP- youths. Even before the first onset of psychosis during follow-up, BDP+ youths showed more psychopathology and had more family history of psychiatric illness than those who never developed psychosis. First-onset psychosis was associated with low socioeconomic status (SES), living with one parent, bipolar disorder type one and type two, comorbid anxiety, history of hospitalizations, and family history of mania and suicidality.

CONCLUSION

BDP+ is associated with poor prognosis and worse clinical picture, even before the onset of psychosis, indicating the need for prompt identification and treatment of these youths. Studies aimed to treat acute symptoms of psychosis, as well as prevent the onset of psychosis, including risk factors amenable to change, are warranted.

Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics

THE PROBLEM

Poor adherence to appropriately prescribed medication is a global challenge for psychiatrists.

PRIOR STUDIES

Measuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients' self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it.

EXPERT OPINION ON FUTURE STUDIES

Future studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with non-adherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.