"Real world" atypical antipsychotic prescribing practices in public child and adolescent inpatient settings

Prevalence and Factors Affecting the Use of Antipsychotics and Antipsychotic Polypharmacy in a Child and Adolescent Psychiatry Inpatient Service

Objective: We aimed to examine the antipsychotics used by patients hospitalized in the child and youth inpatient service providing tertiary care to investigate whether there is a difference between admission and discharge, polypharmacy, which antipsychotics are used, and which psychotropics are used concomitant with antipsychotics. Methods: Research data were collected retrospectively from all children and adolescents hospitalized in a child and adolescent psychiatry inpatient service in a university hospital in a 4-year period (2015-2019). The sociodemographic and clinical characteristics of the patients, the antipsychotics they used at admission and discharge, the other psychotropics concomitantly used with antipsychotics, and the side effects associated with antipsychotics during hospitalization were collected from the files of the 363 patients. Results: Patients on antipsychotics increased 12.1% from hospitalization to discharge. Antipsychotic polypharmacy increased from 16.2% at admission to 30.7% at discharge. Logistic regression analysis was performed to investigate the factors affecting antipsychotic and antipsychotic polypharmacy. Self-harm, aggression/violence, and extended hospitalization were factors associated with increased antipsychotic use. Psychotic symptoms, psychotic disorder, and extended hospitalization were factors associated with an increase in antipsychotic polypharmacy. Conclusions: Understanding the factors that may cause antipsychotic use and polypharmacy in inpatient services in children and adolescents may prevent unnecessary drug use and long-term side effects that may occur due to these drugs.

A Critical Review of the Psychomotor Agitation Treatment in Youth

(1) Background: To systematically review evidence on the safety and efficacy of psychopharmacological treatments available for psychomotor agitation (PA) in children and adolescents. (2) Methods: Studies assessing the safety and efficacy of psychopharmacological treatments for acute PA in children and adolescents that were published between January 1984 and June 2022 on PubMed were systematically reviewed. We included: (i) papers that presented a combination of the search terms specified in the "Search strategy" sub-paragraph; (ii) manuscripts in English; (iii) original papers; (iv) prospective or retrospective/observational studies and experimental or quasi-experimental reports. The exclusion criteria were: (i) review papers; (ii) non-original studies including editorials and book reviews; (iii) studies not specifically designed and focused on the selected topic. (3) Results: We selected 42 papers: 11 case series (11/42, 26.19%), 8 chart reviews (8/42, 19.05%), 8 case reports (8/42, 19.05%), 6 double-blind placebo-controlled randomized studies (6/42, 14.29%), 4 double-blind controlled randomized studies (4/42, 9.52%), 4 open-label trials (4/42, 9.52%) and 1 case control (1/42, 2.38%). (4) Conclusions: The drugs most frequently used to treat agitation in children and adolescents were ziprasidone, risperidone, aripiprazole, olanzapine and valproic acid. Further studies are needed to evaluate the efficacy/safety ratio, considering the limited number of observations in this field.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

Psychopharmacology of Treating Explosive Behavior

Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.

Tackling myths of common prescribing patterns in schizophrenia amongst Egyptian psychiatrists

Background

There is limited data related to how psychiatrists actually choose amongst different medications, especially in Egypt. Our aim was to survey a sample of psychiatrists regarding common patterns of antipsychotic prescribing practices and review how these vary from the evidence-based. We conducted a qualitative, cross-sectional survey of 124 psychiatrists of different grades from hospitals across Cairo, Egypt. Questions were asked to elicit attitudes towards common antipsychotic prescribing practices and the use of treatment guidelines in schizophrenia.

Results

A total 77.4% participants said they would prescribe atypical antipsychotics as first-line treatment if cost were not an issue, 42.7% said they commonly add anticholinergics from the start with antipsychotics, 50% said they would maintain patients on anticholinergics for as long as they were receiving antipsychotics, 93.5% said they commonly or in some situations combine typical depot antipsychotics with oral atypical antipsychotics, 88.7% said they commonly or in some situations use antipsychotics in small doses for sedation, and 55.6% sometimes add a mood stabilizer to enhance the effect of antipsychotic drugs. Using logistic regression, physician grade significantly predicted whether participants commonly add anticholinergic medication from the start with antipsychotics (p = 0.001). Age and gender significantly predicted whether participants sometimes add a mood stabilizer to enhance the effect of antipsychotics (p < 0.05).

Conclusions

We demonstrated that several antipsychotic prescribing practices were not evidence-based, yet appeared to be prevalent in a large proportion of participants. A number of demographic and psychiatrist-related factors predicted certain prescribing patterns.

Concomitant Use of Psychotropic Medication With Stimulants for the Treatment of ADHD in Children and Adolescents: A Retrospective Insurance Claims Study in the United States

Objective: To evaluate annual concomitant psychotropic medication use among stimulant-treated children/adolescents with ADHD. Method: Children/adolescents with ≥1 primary ADHD diagnosis who had received ≥30 days of stimulant medication were identified from insurance claims for each calendar year (2011-2014). Use of 15 psychotropic medications concomitantly with stimulants was evaluated and their prevalence in each year was calculated overall and by medication category for children (6-12 years) and adolescents (13-17 years). Results: Each year 133,354 to 157,303 children and 95,632 to 111,280 adolescents were included. Annual period prevalence of any concomitant psychotropic medication use was 22.9% to 25.0% for children and 25.2% to 28.2% for adolescents. The most common medication categories included selective serotonin reuptake inhibitors (children: 6.8%-7.9%; adolescents: 12.7%-14.9%), atypical antipsychotics (4.2%-5.4%; 5.3%-6.3%), and guanfacine extended release (5.1%-7.0%; 2.3%-3.6%). Conclusion: Around a quarter of children/adolescents with ADHD were prescribed psychotropic medication concomitant to stimulant treatment, although only 2 of the 15 medication classes studied were Food and Drug Administration (FDA)-approved for adjunctive use.

Variation of the prevalence of pediatric polypharmacy: A scoping review

PURPOSE

To examine the range of prevalence of pediatric polypharmacy in literature through a scoping review, focusing on factors that contribute to its heterogeneity in order to improve the design and reporting of quality improvement, pharmacovigilance, and research studies.

METHODS

We searched Ovid Medline, PubMed, EMBASE, CINAHL, Ovid PsycINFO, Cochrane CENTRAL, and Web of Science Core Collection databases for studies with concepts of children and polypharmacy, along with a hand search of the bibliographies of six reviews and 30 included studies. We extracted information regarding study design, disease conditions, and prevalence of polypharmacy.

RESULTS

Two hundred eighty-four studies reported prevalence of polypharmacy. They were more likely to be conducted in North America (37.7%), published after 2010 (44.4%), cross-sectional (67.3%), in outpatient settings (59.5%). Prevalence ranged from 0.9% to 98.4%, median 39.7% (interquartile range [IQR] 22.0%-54.0%). Studies from Asia reported the highest median prevalence of 45.4% (IQR 27.3%-61.0%) while studies from North America reported the lowest median prevalence of 30.4% (IQR 14.7%-50.2%). Prevalence decreased over time: median 45.6% before 2001, 38.1% during 2001 to 2010, and 34% during 2011 to 2017. Studies involving children under 12 years had a higher median prevalence (46.9%) than adolescent studies (33.7%). Inpatient setting studies had a higher median prevalence (50.3%) than studies in outpatient settings (38.8%). Community level samples, higher number and duration of medications defining polypharmacy, and psychotropic medications were associated with lower prevalence.

CONCLUSIONS

The prevalence of pediatric polypharmacy is high and variable. Studies reporting pediatric polypharmacy should account for context, design, polypharmacy definition, and medications evaluated.

Defining pediatric polypharmacy: A scoping review

OBJECTIVES

Lack of consensus regarding the semantics and definitions of pediatric polypharmacy challenges researchers and clinicians alike. We conducted a scoping review to describe definitions and terminology of pediatric polypharmacy.

METHODS

Medline, PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the Web of Science Core Collection databases were searched for English language articles with the concepts of "polypharmacy" and "children". Data were extracted about study characteristics, polypharmacy terms and definitions from qualifying studies, and were synthesized by disease conditions.

RESULTS

Out of 4,398 titles, we included 363 studies: 324 (89%) provided numeric definitions, 131 (36%) specified duration of polypharmacy, and 162 (45%) explicitly defined it. Over 81% (n = 295) of the studies defined polypharmacy as two or more medications or therapeutic classes. The most common comprehensive definitions of pediatric polypharmacy included: two or more concurrent medications for ≥1 day (n = 41), two or more concurrent medications for ≥31 days (n = 15), and two or more sequential medications over one year (n = 12). Commonly used terms included polypharmacy, polytherapy, combination pharmacotherapy, average number, and concomitant medications. The term polypharmacy was more common in psychiatry literature while epilepsy literature favored the term polytherapy.

CONCLUSIONS

Two or more concurrent medications, without duration, for ≥1 day, ≥31 days, or sequentially for one year were the most common definitions of pediatric polypharmacy. We recommend that pediatric polypharmacy studies specify the number of medications or therapeutic classes, if they are concurrent or sequential, and the duration of medications. We propose defining pediatric polypharmacy as "the prescription or consumption of two or more distinct medications for at least one day". The term "polypharmacy" should be included among key words and definitions in manuscripts.

Long-Acting Injectable Atypical Antipsychotic Use in Adolescents: An Observational Study

OBJECTIVES

Although second generation long-acting injectable antipsychotics (SG-LAIAs) have been approved and are widely used in adults, there is limited evidence for the use of long-acting formulations in children and adolescents. Thus, we systematically describe the off-label use of SG-LAIAs in clinical practice in adolescent inpatients.

METHODS

All individuals admitted to our Children and Adolescent Inpatient Psychiatry Unit receiving treatment with SG-LAIAs between January 2013 and June 2016 were reviewed. A retrospective analysis of medical records was conducted. Clinical diagnoses were established using DSM-5 criteria.

RESULTS

Thirty individuals (53.3% female) out of a total of 1,148 admitted patients (2.6%) were identified. The mean age was 16.3 (SD = 1.3; range: 12.5-17.9).The main diagnoses were psychosis (70%) and disruptive behavior disorders (DBDs) (30%), although comorbidity was frequent (96.6%), especially drug use (55.2%, mostly cannabis). SG-LAIAs used were aripiprazole (40%), risperidone (36.7%), and paliperidone palmitate (23.3%), and the main reasons were a history of low compliance (90%) and/or poor insight (73.3%). A mean improvement of 31.7 (SD = 8.7) between admission and discharge was registered in the Children's Global Assessment Scale (CGAS); no differences were observed between different SG-LAIAs. Although they were generally well tolerated, 23.3% of patients reported mild short-term side effects, which were more frequent with risperidone than with aripiprazole (p = .014).

CONCLUSIONS

Our clinical experience suggests that SG-LAIAs may be a safe treatment option during adolescence in inpatients with psychotic disorders, as well as with DBD. No differences were found in CGAS improvement scores between the three SGA-LAIAs used, although patients on risperidone reported more side effects than those on aripiprazole. Further research is needed so as to evaluate safety and effectiveness of SG-LAIAs in this population.

Psychotropic Drug Prescription in Adolescents: A Retrospective Study in a Swiss Psychiatric University Hospital

OBJECTIVES

This retrospective study aims to evaluate off-label prescriptions and administrations of psychotropic medications in adolescents in a university psychiatric hospital in Switzerland.

METHODS

Data were collected during the entire stays from the electronic database for 76 inpatients in 2008 and 76 inpatients in 2014. Data collected included gender, age, psychiatric diagnosis, duration of hospitalization, and psychotropic drug prescriptions and administrations.

RESULTS

A total of 224 psychotropic drugs (mean 2.9 drugs/patient) were prescribed in 2008 and 268 (mean 3.5 drugs/patient) in 2014. Due to the prescriptions of some drugs as required, only 76% of the prescriptions were actually administered in 2008 (mean 2.3 drugs/patient) and 55% in 2014 (mean 1.9 drugs/patient). Antipsychotics were the most frequently prescribed drugs in 2008 (74% of patients) and 2014 (86% of patients). Anxiolytics were also highly prescribed in 2008 (54% of patients) and 2014 (66% of patients), as well as antidepressants in 2008 (30% of patients), but less in 2014 (13% of patients). Overall, 69% of prescriptions were found to be off label in 2008 and 68% in 2014, according to age, diagnosis, dose, or formulation as approved by Swissmedic. The medication classes with the highest rate of off-label prescriptions were antidepressants (100% for both years), antipsychotics (94% in 2008 and 92% in 2014), and hypnotics (67% in 2008 and 100% in 2014). For both study periods, at least one off-label psychotropic drug prescription and administration was recorded in 96% and 79% of the patients, respectively.

CONCLUSION

The high rate of off-label psychotropic drug use strengthens the need for clinical trials to better evaluate the efficacy and safety of these treatments in adolescents.

Diagnoses and Antipsychotic Treatment Among Youths in a Public Mental Health System

Background:

The use of antipsychotics, namely newer atypical agents, has increased significantly in children and adolescents. It is important to examine diagnoses associated with antipsychotic treatment in youths.

Objective:

To evaluate trends in psychiatric diagnoses of children and adolescents in a public mental health system who were prescribed antipsychotics.

Methods:

Children and adolescents, up to the age of 19 years, who were prescribed an antipsychotic between January 1998 and December 2001 were identified using the Texas Medicaid Vendor Drug database. Patient identification numbers were then cross-linked to the Client Assignment and Registration database of the Texas Department of Mental Health and Mental Retardation to extract diagnostic data.

Results:

Disruptive behavioral disorders accounted for the highest percentage (35%) of diagnoses associated with children and adolescents receiving antipsychotic treatment and mental healthcare services. Depressive disorders were the second most common diagnosis (18%), and bipolar disorders accounted for roughly 12% of all diagnoses. Approximately 3% of children and adolescents did not have a psychiatric diagnosis. The percentage of youths with comorbid psychiatric diagnoses decreased over time.

Conclusions:

Although disruptive behavioral disorders accounted for a large percentage of antipsychotic use in this population, these findings suggest that antipsychotics are being used to treat other psychiatric diagnoses, for which limited supporting data exist. Future research in children and adolescents should aim to provide needed efficacy and safety data of antipsychotics across the spectrum of neuropsychiatrie disorders.

Psychotropic prescribing patterns among adolescents in Northern Ireland presenting with psychotic symptoms during a 5-year period

OBJECTIVE

To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period.

METHODS

The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications.

RESULTS

A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%).

CONCLUSIONS

This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.

Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment

BACKGROUND

Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities.

OBJECTIVE

The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making.

METHODS

Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory.

RESULTS

MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making.

CONCLUSION

This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.

Predictors of polypharmacy and off-label prescribing of psychotropic medications: a national survey of child and adolescent psychiatrists

We employed a national survey of child psychiatrists to examine typical prescribing practices for children with anxiety, depression, and disruptive behavior disorders. We examined the extent to which polypharmacy and off-label prescribing occur in routine practice and the degree to which child characteristics, child psychiatrist characteristics, and medication availability may influence these prescribing practices. We found that child psychiatrists most often prescribed medications that were on-label according to U.S. Food and Drug Administration (FDA) guidelines, and that they were progressively less likely to choose medications with partial approval (i.e., medications having pediatric approval but not for the patient's age or problem type), and then medications with no pediatric approval. We also found that prescribing multiple concomitant medications was the norm. We employed best subsets regression to determine the best theoretically relevant predictors to explain polypharmacy and off-label prescribing and found that the best fitting model only included number of child diagnoses. These findings suggest that comorbidity is an important issue in the pharmacotherapy of children with mental health disorders and one that must be addressed in future clinical trials.

Trends in psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002-2008

OBJECTIVE

This study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income).

METHODS

Serial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes).

RESULTS

Both types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]=1.12, 99% confidence interval [CI]=1.10-1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09-1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07-1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants.

CONCLUSIONS

Polypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states

OBJECTIVE

The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children.

METHODS

Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents.

RESULTS

The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years.

CONCLUSIONS

Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

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.

Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment

Antipsychotic polypharmacy (APP), which is common in adults with psychotic disorders, is of unproven efficacy and raises safety concerns. Although youth are increasingly prescribed antipsychotics, little is known about APP in this population. We performed a systematic PubMed search (last update 26 January 2013) of studies reporting the prevalence of APP in antipsychotic-treated youth. Summary statistics and statistical tests were calculated at the study level and not weighted by sample size. Fifteen studies (n = 58 041, range 68-23 183) reported on APP in youth [mean age = 13.4 ± 1.7 yr, 67.1 ± 10.2% male, 77.9 ± 27.4% treated with second-generation antipsychotics (SGAs)]. Data collected in these studies covered 1993-2008. The most common diagnoses were attention-deficit hyperactivity disorder (ADHD; 39.9 ± 23.5%) and conduct disorder/oppositional defiant disorder (CD/ODD; 33.6 ± 24.8). In studies including predominantly children (mean age = <13 yr, N = 5), the most common diagnosis were ADHD (50.6 ± 25.4%) and CD/ODD (39.5 ± 27.5%); while in studies with predominantly adolescents (mean age = ⩾13 yr, N = 7) the most common diagnoses were schizophrenia-spectrum disorders (28.6 ± 23.8%), anxiety disorders (26.9 ± 14.9%) and bipolar-spectrum disorders (26.6 ± 7.0%), followed closely by CD/ODD (25.8 ± 17.7). The prevalence of APP among antipsychotic-treated youth was 9.6 ± 7.2% (5.9 ± 4.5% in child studies, 12.0 ± 7.9% in adolescent studies, p = 0.15). Higher prevalence of APP was correlated with a bipolar disorder or schizophrenia diagnosis (p = 0.019) and APP involving SGA+SGA combinations (p = 0.0027). No correlation was found with APP definition [⩾1 d (N = 10) vs. >30-⩾90 d (N = 5), p = 0.88]. Despite lacking safety and efficacy data, APP in youth is not uncommon, even in samples predominantly consisting of non-psychotic patients. The duration, clinical motivations and effectiveness of this practice require further study.

Period prevalence of concomitant psychotropic medication usage among children and adolescents with attention-deficit/hyperactivity disorder during 2009

OBJECTIVE

Stimulants are recommended as a first-line treatment for attention- deficit/hyperactivity disorder (ADHD); however, a subset of the patient population augments their stimulant treatment with other medications. The objective of this study was to estimate the 1 year period prevalence of concomitant psychotropic medication use among children and adolescents with ADHD during 2009.

METHODS

Patients 6-17 years of age with one or more primary ADHD diagnoses between July 1, 2008 and December 31, 2009 and one or more stimulant prescription fills during 2009 were identified from a large United States commercial claims database. Concomitant psychotropic medication use, defined as 30 days of continuous medication supply overlap between the augmenting agent and stimulant, was evaluated for 14 distinct psychotropic medication categories (6 with a United States Food and Drug Administration (FDA) approved indication for ADHD, 8 without an indication for ADHD). The 1 year period prevalence of concomitant psychotropic medication use (both overall and within each medication category) was calculated and compared between patients with and without psychiatric or neurologic comorbidities. Children (6-12 years) and adolescents (13-17 years) were evaluated separately.

RESULTS

A total of 71,201 children and 49,959 adolescents met the inclusion criteria. The 1 year period prevalence of concomitant psychotropic medication use among children and adolescents was 20.3% and 23.4%, with 5.7% and 6.7% augmenting with two or more medication categories, respectively. The most common concomitant medication categories were selective serotonin reuptake inhibitors (SSRIs) (children: 6.2%; adolescents: 11.4%), atypical antipsychotics (5.8%; 6.8%) and clonidine immediate release (5.4%; 2.9%). Children and adolescents with psychiatric or neurologic comorbidities had higher rates of augmentation than did those without comorbidities (all p<0.001).

CONCLUSIONS

This epidemiologic study found that the prevalence of concomitant psychotropic medication use in children and adolescents ranged from 12.6% for noncomorbid ADHD to 41.7% for comorbid ADHD, in 2009. Future research is warranted to evaluate the rationale for, and clinical benefit of, concomitant psychotropic medication usage in patients with ADHD.

Prevalence and patterns of antipsychotic use in youth at the time of admission and discharge from an inpatient psychiatric facility

The objective of this study was to examine the prevalence and patterns of antipsychotic use in children and adolescents at the time of admission and discharge from a tertiary care inpatient psychiatric facility. This retrospective analysis included all patients 18 years and younger, who were admitted and discharged from a child and adolescent tertiary care inpatient psychiatric facility between May 1, 2008 and December 31, 2009. Data for medications at admission were obtained using a province-wide network that links all pharmacies in British Columbia, Canada to a central set of data systems, whereas data for medications at discharge were obtained using the Department of Pharmacy's (British Columbia Children's Hospital, Vancouver, British Columbia, Canada) inpatient computer database. Apart from antipsychotics, overall drug use included antidepressants, mood stabilizers, benzodiazepines, anticholinergics, stimulants, and sleep medications. Referral and discharge diagnoses were also examined. During the study period, 335 patients were admitted and discharged from the tertiary care inpatient psychiatric facility. Significantly, more patients were prescribed with an antipsychotic at the time of discharge from hospital compared with that of the time when they were admitted to hospital (51.6% vs 30.7%; P < 0.0001). Antidepressants were most often coprescribed with an antipsychotic at admission and discharge (32.0% vs 42.2%, respectively) followed by attention-deficit/hyperactivity disorder medications (22.3% vs 24.9% at admission and discharge, respectively) and anticonvulsants (19.4% vs 19.1% at admission and discharge, respectively). Whether the significant increase in antipsychotic use seen from the time of admission to discharge is solely attributed to clinical worsening or other variables requires further investigation.

Use of clozapine in a state child and adolescent psychiatric hospital

We assessed the predictors of clozapine initiation among youth 18 years and younger within a state psychiatric hospital. Administrative data (n = 358) were evaluated of inpatients from a long-term state child and adolescent psychiatric hospital. We investigated 25 background and clinical patient characteristics to determine which factors predicted clozapine initiation following the first 21 days of hospital admission. A Cox proportional model was used to evaluate factors that independently predicted the hazard rate of clozapine initiation. Emergency medication administration during the first 3 weeks of admission, which was more common among the clozapine (84.9 %) than control (61.7 %) patients (p < 0.001), was associated with a significantly increased probability of clozapine initiation (Hazard Ratio = 1.9, 95 % Confidence Interval = 1.2-3.1). Use of a mood stabilizer during the first 3 weeks of the inpatient was non-significantly related to an increased probability of clozapine initiation (Hazard Ratio = 1.7, 95 % Confidence Interval = 1.0-2.9). In this setting, emergency medication use predicts clozapine initiation suggesting that it may be used to treat patients with aggressive behavior.

Prescribing trends of antipsychotics in youth receiving income assistance: results from a retrospective population database study

BACKGROUND

Prescribing of antipsychotics (AP) to young people has increased in the last decade internationally. We aimed to characterize AP prescribing in a population of low-income youth in Nova Scotia, Canada.

METHODS

We conducted a population database study of AP prescription claims and health services utilization by young people aged 25 years and younger receiving drug benefits through the publicly funded Pharmacare program between October 1, 2000 to September 30, 2007.

RESULTS

Four percent (1715/43888) of youth receiving Pharmacare benefits filled AP prescriptions. The use of second generation antipsychotics (SGAs) significantly increased (p < 0.0001) in all age groups except 0-5 year olds, whereas first generation antipsychotic use significantly decreased. Pharmacare beneficiaries aged 21-25 years represented 45.2% of AP users. The majority (66%) of youth filling AP prescriptions had 2 or more psychiatric diagnoses. Most youth (76%) filled prescriptions for only one type of AP during the study period. Psychotic disorders were the most common indication for AP use except with risperidone, in which ADHD was the most likely reason for use. Co-prescribing of psychotropics was prevalent with antidepressants and mood stabilizers prescribed in 42% and 27% of AP users, respectively. General practitioners (GPs) prescribed incident APs most often (72%) followed by psychiatrists (16%). The age- and gender-adjusted rate of death was higher in AP users as compared to the age-matched general population of Nova Scotia.

CONCLUSIONS

SGA use increased significantly over seven years in a cohort of 0 to 25 years olds receiving Pharmacare benefits. Off-label use of APs was prevalent with ADHD and other non-psychotic disorders being common reasons for AP use. GPs initiated most AP prescriptions. Co-prescribing of other psychotropics, especially antidepressants and mood stabilizers, was prevalent even in younger age strata. This study raises further questions about AP prescribing in those 25 years of age and under, especially given the range of diagnoses and psychotropic co-prescribing.

759C/T Variants of the Serotonin (5-HT2C) Receptor Gene and Weight Gain in Children and Adolescents in Long-Term Risperidone Treatment

BACKGROUND

Great inter-individual variability exists in the susceptibility to gain weight during antipsychotic treatment. Thus, we examined whether the -759C/T variants in the promoter region of the 5HT2C receptor gene were differentially associated with weight gain in children and adolescents in long-term risperidone treatment.

METHODS

Medically healthy 7 to 17 year-olds, treated with risperidone for ≥ six months, were enrolled. Anthropometric measurements, laboratory tests, and treatment history were obtained upon enrollment and from medical records. The effect of the genotype on the trajectory of age-sex-adjusted weight and body mass index (BMI) z scores before and after the onset of risperidone treatment was investigated.

RESULTS

In 124 subjects (90% males, mean age: 11.8 years) treated with risperidone for a mean of 2.8 years, weight and BMI z scores significantly increased after starting risperidone. This change was similar across the two genotype groups as were changes in several cardiometabolic variables.

CONCLUSION

In contrast to other reports, the T allele failed to confer protection against excessive weight gain or cardiometabolic abnormalities in this group of children and adolescents chronically treated with risperidone.

Evidence review and clinical guidance for the use of ziprasidone in Canada

While indicated for schizophrenia and acute mania, ziprasidone's evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success.

Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management

OBJECTIVE

To develop guidelines for management and treatment of maladaptive aggression in the areas of family engagement, assessment and diagnosis, and initial management, appropriate for use by primary care clinicians and mental health providers. Maladaptive aggression in youth is increasingly treated with psychotropic medications, particularly second-generation antipsychotic agents. Multiple treatment modalities are available, but guidance for clinicians' assessment and treatment strategies has been inadequately developed. To address this need, the Center for Education and Research on Mental Health Therapeutics and the REACH Institute convened a steering group of national experts to develop evidence-based treatment recommendations for maladaptive aggression in youth.

METHODS

Evidence was assembled and evaluated in a multistep process that included a systematic review of published literature; a survey of experts on recommended treatment practices; a consensus conference that brought together clinical experts along with researchers, policy makers, and family advocates; and subsequent review and discussion by the steering committee of successive drafts of the recommendations. The Center for Education and Research on Mental Health Therapeutics Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines reflect a synthesis of the available evidence, based on this multistep process.

RESULTS

The current article describes 9 recommendations for family engagement, assessment, and diagnosis as key prerequisites for treatment selection and initiation.

CONCLUSIONS

Recognizing the family and social context in which aggressive symptoms arise, and understanding the underlying psychiatric conditions that may be associated with aggression, are essential to treatment planning.

Outpatient treatment of children and adolescents with antipsychotic drugs in Croatia

BACKGROUND

A large increase in the use of atypical antipsychotics (AAPs) in the Western developed countries has been reported. Patterns of antipsychotic therapy and the extent of use of AAPs for youth outside of the developed world are lacking.

AIMS

To evaluate patterns of antipsychotic treatment of pediatric outpatients in Croatia, including the rate of AAP use.

MATERIAL AND METHODS

Retrospective analysis of outpatient visits to child psychiatrists by persons aged 18 and younger that included prescription of antipsychotics. Antipsychotic treatment data were identified by frequency, medication class, subclass and drug entity and were analyzed in relation to age group, gender and psychiatric diagnosis.

RESULTS

Overall, 1.3% (106/7953) of pediatric outpatients received antipsychotic therapy during the study period. Antipsychotic treatment was significantly more common in boys and in adolescents. AAPs (80.1%) were significantly more often prescribed than typical antipsychotics (19.9%) (t = 7.76; P < 0.01). In all diagnostic categories (behavior disorders, pervasive developmental disorders and mental retardation, psychotic disorders, mood and tic disorders), the treatment with AAPs was more frequent than typical antipsychotics (χ(2) = 9.92, df = 4, P < 0.05). AAPs were used as monotherapy in 62.2% of outpatients. Off-label prescribing was found in 52.9% of young patients who had received AAPs.

CONCLUSIONS

AAPs comprise most of the antipsychotic medications prescribed to pediatric outpatients in Croatia in all diagnostic categories, reflecting trends in other countries. Unfortunately, such practice occurs in the absence of supporting data about long-term safety and in spite of the lack of evidence regarding their efficacy in some indications.

Pharmacologic management of acutely agitated pediatric patients

Acute agitation is a state of behavioral dyscontrol that requires intervention. Medications available in rapid delivery formats are frequently administered to treat acute agitation, either as a chemical restraint or on a voluntary basis. Prior to initiating treatment, the etiology of agitation must be evaluated. In choosing a medication, general pharmacologic principles should be followed. Medication should be selected based on the underlying cause in conjunction with weighing the risks, benefits, and side effects of medications. There are three classes of medications administered to children and adolescents to treat agitation: antihistamines, benzodiazepines, and antipsychotics. The most concerning short-term side effects of antipsychotics are their adverse neurologic effects, neuroleptic malignant syndrome, and prolonged corrected QT interval. Compared with typical antipsychotics, atypical antipsychotics have a more favorable short-term side effect profile.

Safety and efficacy of long-acting injectable risperidone in daily practice: an open-label, noninterventional, prospective study in schizophrenia and related disorders

This postauthorization safety study evaluated the long-term safety, tolerability, and efficacy of risperidone long-acting injectable (RLAI) in routine clinical practice. In this 6-month, multicenter, European, naturalistic study, patients were included if, during routine clinical practice, long-term antipsychotic therapy with RLAI was deemed necessary by the treating physician. Efficacy measures included Clinical Global Impression-Severity and Global Assessment of Functioning. Safety was evaluated by recording treatment-emergent adverse events (AE). RLAI was initiated in 5134 patients (aged 14-94 years); predominantly male (58.6%) with paranoid schizophrenia (69.8%). RLAI initial doses were 25 mg every 2 weeks (37.0% patients), 37.5 mg (18.0%), and 50 mg (44.4%). Treatment was completed by 4314 patients (84.0%). RLAI was discontinued on account of loss to follow-up (n=346; 6.7%), insufficient response (n=116; 2.3%), and AEs (n=106; 2.1%). Clinical Global Impression-Severity significantly improved from baseline to endpoint (P<0.001). Patient functioning on the Global Assessment of Functioning scale also significantly improved from baseline to endpoint (45.4 + or - 16.0 vs. 62.4 + or - 17.7, respectively, P<0.001). Treatment-emergent AEs were recorded by 1018 (20%) of patients. AEs occurring in > or = 5% of patients were akathisia, extrapyramidal disorders, depression, psychotic disorder, anxiety, and weight gain. Serious AEs were reported by 384 (8%) patients. This study confirms good safety, tolerability, and efficacy with RLAI in routine clinical practice.

Psychotropic Medication Changes, Polypharmacy, and the Risk of Early Readmission in Suicidal Adolescent Inpatients

Background:

Adolescents with acute suicidal ideation and attempts are frequently treated with psychotropic medications in psychiatric hospitals. However, little is known about whether pharmacologic interventions used to stabilize suicidal adolescents within inpatient settings are effective in reducing early readmission.

Objective:

To examine whether psychotropic medication changes and polypharmacy are associated with 30-day readmission rates for suicidal adolescents.

Methods:

We conducted a retrospective cohort study of 318 Medicaid-enrolled adolescents admitted for suicidal behaviors to 3 major inpatient psychiatric hospitals in Maryland. Comprehensive data on patient demographics, clinical factors, service history, and inpatient treatment practices were collected from hospital medical records. Medications prescribed prior to admission and during the hospital stay were matched and compared with regard to drug, dosage, and frequency of administration to identify the different types of medication changes. Multivariate Cox proportional hazard analysis was used to examine the association of medication changes and polypharmacy with readmission.

Results:

At least one medication change was made in 78% of suicidal adolescent inpatients, typically the addition of an antidepressant, mood stabilizer, or antipsychotic. At discharge, nearly one quarter (23%) of youths were prescribed 3 or more medications from different drug classes. Controlling for demographic and clinical factors, the addition of an antidepressant was associated with an 85% lower risk of readmission (HR 0.15; 95% CI 0.03 to 0.68). However, the use of 3 or more medications from different drug classes was associated with a 2.6 times higher risk of readmission (95% CI 1.03 to 6.52).

Conclusions:

In this sample of suicidal adolescents, antidepressant treatment was associated with a lower risk of readmission and polypharmacy was associated with a higher risk of readmission. Study findings highlight the need for quality improvement efforts that optimize pharmacologic treatment and physician decision making.

Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists

OBJECTIVE

The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs).

METHOD

A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia.

RESULTS

Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations.

CONCLUSIONS

Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.

Initiation and change of psychotropic medication regimens among adolescents in inpatient care

OBJECTIVE

The purpose of this study was to compare clinical and service utilization profiles of adolescents admitted to inpatient treatment with and without a psychotropic medication regimen, and estimate correlates of medication use separately for the two groups.

METHOD

Comprehensive data on clinical characteristics and service utilization of 517 adolescents enrolled in Medicaid who were admitted to three inpatient hospitals (one for-profit and two nonprofit) in a mid-Atlantic state were used. Medication correlates were examined with bivariate statistics (chi-square and t-test) and multivariate logistic regressions.

RESULTS

Psychotropic medication was prescribed for the majority (90.5%) of adolescents at discharge. During their inpatient stay, 76.3% of the youths who were not on medication at admission (n = 190) initiated medication use, and 45% admitted with prior medication (n = 327) had a medication change. Adolescents admitted with and without medication differed on all sociodemographic and clinical characteristics except age, suicidality, and hospital. Controlling on demographic, clinical, and service history characteristics, hospital setting was the only correlate significantly associated with both initiation and change.

CONCLUSIONS

Institutional factors may be more important than clinical factors in appraising medication patterns in inpatient settings. Interventions to ensure the development and implementation of medication management guidelines may need to be tailored to the climate and culture of the provider organization as well as directly to individual practitioners, parents or adolescents themselves.

Body mass indexes and lipid profiles in hospitalized children and adolescents exposed to atypical antipsychotics

OBJECTIVE

The purpose of this study was to examine body mass indexes (BMI) and lipid profiles of children and adolescents hospitalized for a psychiatric illness and exposed to an atypical antipsychotic.

METHOD

Medical records of children and adolescents (ages of 5-18 years) with an inpatient psychiatric hospitalization between July 1, 2004, and June 30, 2005, were reviewed. Subjects were required to have been treated with at least one atypical antipsychotic during the month prior to admission. Height, weight, and fasting lipid values completed upon admission were collected. Prevalences of overweight (sex-specific BMI for age>or=the 95th percentile) and at risk for overweight (sex-specific BMI for age between the 85th and 94.9th percentiles) were determined and compared to estimates from the 2001-2002 National Health and Nutrition Examination Survey (NHANES) data. The prevalence of abnormal lipid profiles was also evaluated using widely accepted criteria specific for pediatric patients. Exploratory multiple linear regression models were fit to examine relationships of demographic and clinical variables with BMI z-scores and lipid profiles.

RESULTS

Of 95 inpatients (mean age 14 years, 43% female, and 60% white) evaluated, 16% (n=15) were at risk for overweight and 53% (n=50) were overweight. Fifty-one percent (n=48) and 48% (n=46) of the sample had elevated triglycerides (TG) levels and low high-density lipoprotein (HDL) levels, respectively.

CONCLUSION

The prevalence of overweight among hospitalized children and adolescents with exposure to atypical antipsychotics is triple that of national norms. Dyslipidemia was also common in this inpatient sample. Future studies should assess the development of overweight, the factors contributing to it, and related comorbidities in youths with mental illness.

Observed clinical and health services outcomes in pediatric inpatients treated with atypical antipsychotics: 1999-2003

OBJECTIVE

The aim of this study was to compare clinical and health services outcomes in pediatric inpatients prescribed an atypical antipsychotic (AA) to those not prescribed an AA at discharge.

METHODS

Descriptive statistics, analysis of variance (ANOVA), and, where necessary, analysis of covariance (ANCOVA) were used to compare differences between and within an inpatient group prescribed risperidone, olanzapine, or quetiapine (n=1,131) with an inpatient group not prescribed an antipsychotic at discharge (n=1,741).

RESULTS

The AA treatment group showed greater psychiatric symptom difficulty at admission as measured by the Brief Psychiatric Rating Scale for Children (Mean BPRS-C) than the group not prescribed AAs (40.3 [n=433] vs. 35.2 [n=452], respectively, p<0.001). AA-treated inpatients also had a higher number of mental health outpatient visits during the 6 months prior to admission. Patients receiving AAs (n=1,050) had significantly longer adjusted length of stay (LOS) than those not receiving antipsychotics (n=1,664): 26.4 days versus 22.4 days, respectively (p<0.04).

CONCLUSIONS

The findings suggested pediatric inpatients presenting with greater psychiatric symptom difficulty at hospital admission were more likely to be prescribed an AA. Choice of AA may influence certain clinical and health services outcomes. Additional prospective controlled studies evaluating AA efficacy and safety, including head-to-head comparisons, in pediatric inpatients are warranted.

Consensus report on impulsive aggression as a symptom across diagnostic categories in child psychiatry: implications for medication studies

OBJECTIVE

To determine whether impulsive aggression (IA) is a meaningful clinical construct and to ascertain whether it is sufficiently similar across diagnostic categories, such that parallel studies across disorders might constitute appropriate evidence for pursuing indications. If so, how should IA be assessed, pharmacological studies designed, and ethical issues addressed?

METHOD

Experts from key stakeholder communities, including academic clinicians, researchers, practicing clinicians, U.S. Food and Drug Administration, National Institute of Mental Health, industry sponsors, and patient and family advocates, met for a 2-day consensus conference on November 4 and 5, 2004. After evaluating summary presentations on current research evidence, participants were assigned to three workgroups, examined core issues, and generated consensus guidelines in their areas. Workgroup recommendations were discussed by the whole group to reach consensus, and then further iterated and condensed into this report postconference by the authors.

RESULTS

Conference participants agreed that IA is a substantial public health and clinical concern, constitutes a key therapeutic target across multiple disorders, and can be measured with sufficient precision that pharmacological studies are warranted. Additional areas of consensus concerned types of measures, optimal study designs, and ethical imperatives.

CONCLUSION

Derived from scientific evidence and clinical experience, these consensus-driven recommendations can guide the design of future studies.

A naturalistic evaluation of intramuscular ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents

OBJECTIVE

The aim of this study was to compare the efficacy and safety of intramuscular ziprasidone versus intramuscular (i.m.) olanzapine in treating aggression in youth.

METHODS

A retrospective chart review of 100 hospitalized patients less than 18 years of age treated with either i.m. ziprasidone or i.m. olanzapine for agitation or aggression was conducted. Comparisons were performed using statistical analysis of data collected from medical records.

RESULTS

Baseline demographics were similar in the i.m. olanzapine and ziprasidone treatment groups regarding age and ethnicity; however, gender differences did reach statistical significance (p < 0.001). Dosing between children and adolescents significantly differed in the olanzapine group, whereas dosing was comparable in the ziprasidone group. No significant differences between the olanzapine and ziprasidone treatment groups were noted regarding length of stay, efficacy of the study medications, number of restraints, and duration of restraints. Ziprasidone subjects received significantly more doses of emergency medication during their hospital stay and significantly more doses of ziprasidone were administered with concomitant lorazepam or antihistamines.

CONCLUSIONS

The results suggest i.m. ziprasidone and intramuscular olanzapine may be equally effective in treating aggression in youth. These agents may also be similar with regard to safety because no clinically significant adverse events were reported for either treatment group. The possibility of poor documentation of adverse events and side effects prevents formulating definitive conclusions regarding safety from this study.

Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment

BACKGROUND

Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue.

APPROACH

The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined.

FINDINGS

The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy.

RECOMMENDATIONS

Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.

Survey of Atypical Antipsychotic Medication Use by Child and Adolescent Psychiatrists

BACKGROUND

  Atypical antipsychotics could be replacing traditional antipsychotics in the treatment of childhood disorders.

METHOD

  A postal survey was conducted of Child Psychiatrists in a region of the United Kingdom to evaluate their use of atypical antipsychotics for psychotic and non-psychotic conditions.

RESULTS

  97% of respondents reported prescribing atypical antipsychotics and at least 65% did so for non-psychotic indications although several concerns were raised. Differences in prescribing and monitoring practices between Community and Specialist services were noted.

CONCLUSIONS

  Atypical antipsychotics appear to play a significant role in current child psychiatry practice. Further discussions and research needs to occur about their use and guidelines produced.

Medical decision making: a selective review for child psychiatrists and psychologists

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.

Unanswered questions regarding atypical antipsychotic use in aggressive children and adolescents

The aim of this paper was to discuss the arguments for and against the use of atypical antipsychotics in children and adolescents with aggression, and provide recommendations for future research. A MEDLINE search (1985-2004) was performed to identify key literature. Search terms included, but were not limited to, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, children, and adolescents. The search was limited to English-language literature and randomized controlled trials. The use of atypical antipsychotics in children and adolescents has increased significantly over the past few years. Atypical antipsychotics are associated with a more favorable side-effect profile, and growing evidence supports their efficacy for aggression in this population. However, the long-term effects of these agents are unknown. No head-to-head evidence exists to suggest whether pharmacological or nonpharmacological treatments are superior for managing aggression associated with childhood and adolescent psychiatric and behavioral conditions. Future research of atypical antipsychotics in children and adolescents needs to evaluate not only the efficacy but also the effectiveness. Examination of treatment mediators and moderators may help to optimize treatment regimens and improve patient outcomes. Finally, effective interventions require the development and implementation of evidence-based treatment strategies using a multidisciplinary approach.

Intramuscular ziprasidone for acute agitation in adolescents

Several neuropsychiatric disorders in children and adolescents often present with aggressive behavior. In fact, aggression is one of the most common reasons for psychiatric admission for inpatient hospitalization. Psychotropic medication can be helpful in reducing the need for more restrictive interventions, such as seclusion or restraint. The use of "as needed " (PRN) medications has been reported to decrease seclusion and restraint in a university-affiliated hospital setting. In our study, we report the cases of 3 youngsters whose escalating aggression responded to intramuscular ziprasidone with an immediate calming effect and good clinical outcome.

Clinical effectiveness of new generation antipsychotics in adolescent patients

In addition to management of symptoms of disease, pharmacological interventions in adolescents with psychotic disorders must be clinically effective to provide the best possible outcome in terms of well-being, functioning, and disease burden. Six outcome domains should be considered: symptoms of disease, tolerability, everyday functioning, subjective well-being, family/career burden, and treatment adherence. To date, few studies have compared the clinical effectiveness of the different new generation antipsychotics in adolescents. However, clear differences exist between available agents, particularly in terms of tolerability profile. This review will focus on the particular issues that clinicians need to consider in order to maximise the clinical effectiveness of the new generation antipsychotics in adolescent patients with psychosis. For example, adolescents are not only more susceptible to the side effects of antipsychotic medication than adults, but they are also more likely to be sensitive to the negative impact of side effects on appearance, body image, and self-esteem. Data available in children and adolescents will be reviewed, and the practical implications for patient management will be highlighted. The importance of dosing the new generation antipsychotics appropriately will also be discussed.

Atypical antipsychotic use in a state hospital inpatient adolescent population

Atypical antipsychotics are now the most commonly prescribed antipsychotics in young patients. These drugs are increasingly being used because of better tolerance and safety as seen in the adult populations. Youth with more severe psychopathology who are treated in the inpatient setting have been overlooked in much of the published research, and the extent of use and rationale in this population is unknown. This naturalistic retrospective study examined a population of adolescents in an inpatient state hospital setting with regard to their use of atypical antipsychotics. All patients who received an inpatient prescription for atypical antipsychotics between January 1, 1997 and June 1, 2000 and were ages 18 or younger at the time of medication initiation were included in the study. Twenty-three percent (88/380) of patients received an atypical antipsychotic: 68% (60/88) risperidone, 27% (24/88) olanzapine, and 5% (4/88) quetiapine. Psychotic disorders were considered as the primary diagnosis in only 17% of patients treated with atypical antipsychotics, and no particular diagnosis was predictive of monotherapy with an atypical antipsychotic. In the adolescent populations, atypical antipsychotics are being used for a wide variety of diagnoses and are commonly used adjunctively (more than 80%) with many concomitant psychotropic medications. More research is needed to develop useful and specific practice guidelines in children and adolescents for these commonly used medications.

Quality of life in persons with schizophrenia in out-patient treatment with first- or second-generation antipsychotics

OBJECTIVE

Effects of first in comparison with second-generation antipsychotics on the subjective quality of life (QoL) of patients with schizophrenia under routine treatment conditions were examined.

METHOD

In a prospective naturalistic trial the QoL, social, clinical, and treatment-related characteristics and type of antipsychotic medication of 307 patients with schizophrenia (ICD-10 F 20) were assessed five times with 6-month intervals over 2.5 years. Longitudinal and cross-sectional effects of antipsychotic medication were assessed by hierarchical regression models. Selection bias was controlled by propensity scores.

RESULTS

While positive effects of first-generation antipsychotics on subjective QoL in comparison with no antipsychotic treatment were found, second-generation antipsychotics caused no better QoL than first-generation antipsychotics.

CONCLUSION

The hypothesis that second-generation in comparison with first-generation antipsychotics have a better effect on the improvement of subjective QoL of people with schizophrenia in routine out-patient treatment was not supported.

New developments in the pharmacotherapy of schizophrenia

This review summarizes current key research strategies and the most prominently pursued new potential treatments for schizophrenia. First, new routes of administration for second generation antipsychotics are presented. These include rapidly dissolving tablets, drops and sirups as well as new intramuscular formulations. Newly available short acting and long acting (depot) antipsychotics complement oral antipsychotics so that the full spectrum of routes of administration is now available for second generation antipsychotics. Next to antipsychotic polypharmacy, in which two or more antipsychotics are combined, pharmacological add-on treatments, mainly with benzodiazepines, antidepressants and mood stabilizers enjoy increasing popularity. Most of this practice is driven by personal preferences, clinical experience and marketing rather than evidence based medicine. New pharmacological mechanisms currently utilized in advanced states of development include partial dopamine D2-receptor agonism, supplementation with glutamatergic agents, estrogen and omega-3-fatty acids. While the concept of partial D1-agonism has already led to the successful launch of a new antipsychotic, aripiprazole, the other attempts to improve therapeutic response in schizophrenia patients have so far provided equivocal results. It is argued that they may be helpful for certain subgroups or specific symptoms of schizophrenia patients. In conclusion, many exciting new pharmacological leads are currently pursued and this will very likely augment the options for treating patients with schizophrenia.

Psychopharmacologic strategies for the treatment of aggression in juveniles

Maladaptive aggression in youth is one of the most common and troublesome reasons for referrals to child psychiatrists. It has a complex relationship with psychopathology. There are several syndromes, which are primary disturbances of clustered maladaptive aggression, most notably oppositional defiant disorder and conduct disorder. However, problems with aggression also appear in a wide range of other disturbances, such as bipolar disorder, posttraumatic stress disorder, and mood disorders. Additionally, aggression is normative, serves an adaptive purpose and can be situationally induced. These complexities need to be carefully addressed before targeting maladaptive aggression psychopharmacologically. We summarize the literature on the psychopharmacology of maladaptive aggression in youth, focusing on disorders without cognitive impairment. We delineate the subtypes of aggression which are most likely to respond to medication (reactive-affective-defensive-impulsive in their acute and chronic form) and conclude with a discussion of specific medication strategies which are supported by controlled clinical trials and clinical experience.

Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II

OBJECTIVE

To develop treatment recommendations for the use of antipsychotic medications for children and adolescents with serious psychiatric disorders and externalizing behavior problems.

METHOD

Using a combination of evidence- and consensus-based methodologies, recommendations were developed in six phases as informed by three primary sources of information: (1) current scientific evidence (published and unpublished), (2) the expressed needs for treatment-relevant information and guidance specified by clinicians in a series of focus groups, and (3) consensus of clinical and research experts derived from a formal survey and a consensus workshop.

RESULTS

Fourteen treatment recommendations on the use of atypical antipsychotics for aggression in youth with comorbid psychiatric conditions were developed. Each recommendation corresponds to one of the phases of care (evaluation, treatment, stabilization, and maintenance) and includes a brief clinical rationale that draws upon the available scientific evidence and consensus expert opinion derived from survey data and a consensus workshop.

CONCLUSION

Until additional research from controlled trials becomes available, these evidence- and consensus-based treatment recommendations may be a useful approach to guide the use of antipsychotics in youth with aggression.