Primum non nocere: balancing the risks and benefits of prescribing psychotropic medications for youth with bipolar disorder

Excess cardiometabolic risk in children and adolescents initiating antipsychotic treatment compared to young adults: results from a nationwide cohort study

Antipsychotic treatment is associated with cardiometabolic risks that may be especially detrimental to children and adolescents. In this Danish population-based cohort study, we included individuals with psychiatric diagnoses who initiated antipsychotics in 2000-2021 at age 6-31 years. We assessed the risk of cardiometabolic adverse events up to 10 years following incident exposure to antipsychotics, compared to age- and sex-matched unexposed individuals with psychiatric diagnoses. Cox regression models were used to calculate hazard ratios (HRs) after adjustment using high-dimensional propensity scores, including age, sex, calendar time, hospital diagnoses, and prescription drug use. HRs were compared between incident exposure in youths (6-17 years) and young adults (18-31 years), and between incident exposure in children (6-11 years) and adolescents (12-17 years). The total cohort consisted of 335,093 individuals, including 36,092 subjects exposed to antipsychotics (children and adolescents: 8,547, mean follow-up: 6.8±3.2 years; young adults: 27,545, mean follow-up: 6.5±3.4 years) and 299,001 age-, sex- and calendar-matched unexposed subjects. The incidence rate of cardiometabolic events was higher for young adults initiating antipsychotics than for children and adolescents (23.2 vs. 14.1 events/1,000 person-years). However, the adjusted excess risk of cardiometabolic events was significantly higher in exposed compared to unexposed children and adolescents (HR=1.87, 95% CI: 1.71-2.05) than in exposed compared to unexposed young adults (HR=1.46, 95% CI: 1.40-1.51) (p<0.001). The excess risk of cardiometabolic events was even higher when antipsychotic treatment was initiated before age 12 years (HR=2.44; 95% CI: 1.99-2.98) than at age 12-17 years (HR=1.69, 95% CI: 1.52-1.87) (p=0.012). Concerning specific cardiometabolic outcomes, there was an effect of age at antipsychotic initiation on the risks of metabolic syndrome (p=0.011) and obesity (p<0.001), that were higher among children and adolescents than young adults. Thus, initiation of antipsychotic treatment before age 18 years is associated with an excess risk of cardiometabolic events compared to age- and sex-matched youths with psychiatric disorders but unexposed to antipsychotics. The excess cardiometabolic risk is significantly higher than that of individuals who start antipsychotic treatment in early adulthood, and significantly higher for treatment onset in childhood compared to adolescence. On the basis of these findings, recommendations are provided about the use of antipsychotics in children and adolescents.

Safety and efficacy of lithium in children and adolescents: A systematic review in bipolar illness

Introduction:

Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium’s safety and efficacy in this population.

Methods:

A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

Results:

30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported.

Conclusions:

Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes.

[Management of bipolar 1 disorder in children and adolescents]

Lifetime prevalence of child and adolescent bipolar 1 disorder (BD1) is nearly 0.1 %. Even though it is not a frequent disorder in young people, there is an increased interest for this disorder at this age, because of the poor outcome, the severe functional impairments and the major risk of suicide. Diagnosis is complex in view of the more frequent comorbidities, the variability with an age-dependant clinical presentation, and the overlap in symptom presentation with other psychiatric disorders (e.g. disruptive disorders in prepubertal the child and schizophrenia in the adolescent). The presentation in adolescents is very similar to that in adults and in prepubertal children chronic persistent irritability and rapid mood oscillation are often at the foreground. For a while, such presentations were considered as BD-not otherwise specified (BD-NOS), which can explain the outburst of the prevalence of bipolar disorder in children in the US. Longitudinal studies that look for the outcome of such emotional dysregulations have not revealed an affiliation with bipolar disorder spectrum, but with depressive disorders in adulthood. The diagnosis of Disruptive Mood Dysregulation Disorder was proposed in the DSM-5 to identify these children and to prevent confusion with bipolar disorder. The goals of the pharmacological and psychosocial treatments are to control or ameliorate the symptoms, to avoid new episodes or recurrences, to improve psychosocial functioning and well-being, and to prevent suicide. In the US, lithium and four atypical antipsychotics have been approved by the FDA for 10 to 13-year-olds (risperidone, olanzapine, aripiprazole and quetiapine). In France, only lithium salts (after the age of 16) and aripiprazole (after the age of 13) are recommended. Psychosocial treatments, such as a familial or individual approach are developing.

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.

Efficacy, long-term safety, and tolerability of ziprasidone in children and adolescents with bipolar disorder

OBJECTIVE

The purpose of this study was to evaluate the short- and long-term efficacy and safety of ziprasidone in children and adolescents with bipolar I disorder.

METHODS

Subjects 10-17 years of age with a manic or mixed episode associated with bipolar I disorder participated in a 4 week, randomized, double-blind, placebo-controlled multicenter trial (RCT) followed by a 26 week open-label extension study (OLE). Subjects were randomized 2:1 to initially receive flexible-dose ziprasidone (40-160 mg/day, based on weight) or placebo. Primary outcome was the change in Young Mania Rating Scale (YMRS) scores from baseline. Safety assessments included weight and body mass index (BMI), adverse events (AEs), vital signs, laboratory measures, electrocardiograms, and movement disorder ratings.

RESULTS

In the RCT, 237 subjects were treated with ziprasidone (n=149; mean age, 13.6 years) or placebo (n=88; mean age, 13.7 years). The estimated least squares mean changes in YMRS total (intent-to-treat population) were -13.83 (ziprasidone) and -8.61 (placebo; p=0.0005) at RCT endpoint. The most common AEs in the ziprasidone group were sedation (32.9%), somnolence (24.8%), headache (22.1%), fatigue (15.4%), and nausea (14.1%). In the OLE, 162 subjects were enrolled, and the median duration of treatment was 98 days. The mean change in YMRS score from the end of the RCT to the end of the OLE (last observation carried forward) was -3.3 (95% confidence interval, -5.0 to -1.6). The most common AEs were sedation (26.5%), somnolence (23.5%), headache (22.2%), and insomnia (13.6%). For both the RCT and the OLE, no clinically significant mean changes in movement disorder scales, BMI z-scores, liver enzymes, or fasting lipids and glucose were observed. One subject on ziprasidone in the RCT and none during the OLE had Fridericia-corrected QT interval (QTcF) ≥ 460 ms.

CONCLUSION

These results demonstrate that ziprasidone is efficacious for treating children and adolescents with bipolar disorder. Ziprasidone was generally well tolerated with a neutral metabolic profile.

CLINICAL TRIALS REGISTRY

NCT00257166 and NCT00265330 at ClinicalTrials.gov.

Prevalence of bipolar disorder diagnoses and psychotropic drug therapy among privately insured children and adolescents

STUDY OBJECTIVES

To estimate the treated prevalence of bipolar disorder in a privately insured population, describe the characteristics of children and adolescents receiving these diagnoses, and describe patterns of their psychotropic drug therapy.

DESIGN

Retrospective, repeated cross-sectional study.

DATA SOURCE

MarketScan Commercial Claims and Encounters inpatient, outpatient, and pharmacy claims databases.

PATIENTS

A total of 22,360 children and adolescents (aged 0-17 yrs) with one inpatient or two or more outpatient claims for any bipolar spectrum disorder between January 1, 2005, and December 31, 2007.

MEASUREMENTS AND MAIN RESULTS

Annual cross-sections were used to estimate the treated prevalence of bipolar disorder diagnoses, patient characteristics, and psychotropic drugs used 30 days after a child's latest recorded bipolar disorder diagnosis within each year. The annual treated prevalence of any bipolar spectrum disorder in this privately insured population was 0.24% in 2005 and 0.26% in 2006 and 2007. Approximately 25% of diagnoses were for children younger than 13 years. Approximately 30% of children had coexisting attention-deficit-hyperactivity disorder during the year. In each year, 35% of patients used no psychotropic drug therapy in the 30-day period after their most recent diagnosis. Twenty-five percent used one psychotropic drug, and 40% used two or more drugs. The most common drug regimens were antipsychotic or mood stabilizer (lithium or anticonvulsant) monotherapy and the combination of mood stabilizers and antipsychotics.

CONCLUSION

Drug therapy patterns suggest that children and adolescents with bipolar diagnoses receive complex treatment regimens, often involving multiple classes of psychotropic drugs. Research on treatment combinations, particularly antipsychotic and mood stabilizer combinations, should be prioritized to better understand the safety and effectiveness of commonly prescribed treatments.

Efficacy and safety of second-generation antipsychotics in children and adolescents with psychotic and bipolar spectrum disorders: comprehensive review of prospective head-to-head and placebo-controlled comparisons

OBJECTIVE

To review data on efficacy and safety of second-generation antipsychotics (SGAs) in children and adolescents with psychotic and bipolar spectrum disorders.

METHODS

Medline/PubMed/Google Scholar search for studies comparing efficacy and/or tolerability: (i) between two or more SGAs; (ii) between SGAs and placebo; and (iii) between at least one SGA and one first-generation antipsychotic (FGA). The review focused on three major side-effect clusters: 1. body weight, body mass index, and cardiometabolic parameters, 2. prolactin levels, and 3. neuromotor side effects.

RESULTS

In total, 34 studies with 2719 children and adolescents were included. Studies lasted between 3 weeks and 12 months, with most studies (79.4%) lasting 3 months or less. Nine studies (n=788) were conducted in patients with schizophrenia, 6 (n=719) in subjects with bipolar disorder, and 19 (n=1212) in a mixed population. Data on efficacy showed that, except for clozapine being superior for refractory schizophrenia, there were no significant differences between SGAs. By contrast, safety assessments showed relevant differences between SGAs. Mean weight gain ranged from 3.8 kg to 16.2 kg in patients treated with olanzapine (n=353), from 0.9 kg to 9.5 kg in subjects receiving clozapine (n=97), from 1.9 kg to 7.2 kg in those on risperidone (n=571), from 2.3 kg to 6.1 kg among patients taking quetiapine (n=133), and from 0 kg to 4.4 kg in those treated with aripiprazole (n=451). Prolactin levels increased the most in subjects on risperidone (mean change ranging from 8.3 ng/mL to 49.6 ng/mL), followed by olanzapine (-1.5 ng/mL to +13.7 ng/mL). Treatment with aripiprazole was associated with decreased prolactin levels, while clozapine and quetiapine were found to be mostly neutral. With respect to neuromotor side effects, SGAs were associated with less parkinsonism and akathisia than FGAs. Most of the studies comparing neuromotor side effects between SGAs found no significant differences.

CONCLUSIONS

SGAs do not behave as a homogeneous group in children and adolescents with psychotic and mood disorders. Except for clozapine, the heterogeneity within the SGA group is mainly due to differences in the rates and severity of adverse events, especially regarding weight gain as a proxy for the risk of cardiometabolic disturbances.

Metabolic and endocrine adverse effects of second-generation antipsychotics in children and adolescents: A systematic review of randomized, placebo controlled trials and guidelines for clinical practice

Second-generation antipsychotics (SGA) are being used more often than ever before in children and adolescents with psychotic and a wide range of non-psychotic disorders. Several SGA have received regulatory approval for some paediatric indications in various countries, but off-label use is still frequent. The aim of this paper was to perform a systematic review and critically evaluate the literature on cardiometabolic and endocrine side-effects of SGA in children and adolescents through a Medline/Pubmed/Google Scholar search of randomized, placebo controlled trials of antipsychotics in children and adolescents (<18 years old) until February 2010. In total, 31 randomized, controlled studies including 3595 paediatric patients were identified. A review of these data confirmed that SGA are associated with relevant cardiometabolic and endocrine side-effects, and that children and adolescents have a high liability to experience antipsychotic induced hyperprolactinaemia, weight gain and associated metabolic disturbances. Only weight change data were sufficiently reported to conduct a formal meta-analysis. In 24 trials of 3048 paediatric patients with varying ages and diagnoses, ziprasidone was associated with the lowest weight gain (-0.04kg, 95% confidence interval [CI]: -0.38 to +0.30), followed by aripiprazole (0.79kg, 95% CI: 0.54 to 1.04], quetiapine (1.43kg, 95% CI: 1.17 to 1.69) and risperidone (1.76kg, 95% CI: 1.27 to 2.25) were intermediate, and olanzapine was associated with weight gain the most (3.45kg, 95% CI: 2.93 to 3.97). Significant weight gain appeared to be more prevalent in patients with autistic disorder who were also younger and likely less exposed to antipsychotics previously. These data clearly suggest that close screening and monitoring of metabolic side effects is warranted and that the least cardiometabolically problematic agents should be used first whenever possible. A good collaboration between child- and adolescent psychiatrists, general practitioners and paediatricians is essential to maximize overall outcomes and to reduce the likelihood of premature cardiovascular morbidity and mortality.