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O'Brien MJ, Pauls AM, Cates AM, Larson PD, Zorn AN. Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior. J Pediatr 2024:114056. [PMID: 38615943 DOI: 10.1016/j.jpeds.2024.114056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period. STUDY DESIGN In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, through December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using non-parametric statistical analysis with odds ratios presented for significant factors. RESULTS Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least one psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall. CONCLUSIONS Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.
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Affiliation(s)
- Matthew J O'Brien
- The University of Iowa, Iowa City, IA, USA; The University of Iowa Stead Family Department of Pediatrics, Iowa City, IA, USA.
| | | | | | - Priya D Larson
- The University of Iowa, Iowa City, IA, USA; The University of Iowa Department of Child and Adolescent Psychiatry, Iowa City, IA, USA
| | - Alithea N Zorn
- The University of Iowa, Iowa City, IA, USA; Center for Public Health Statistics, Iowa City, IA, USA; College of Public Health, Iowa City, IA, USA
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Poweleit EA, Vaughn SE, Desta Z, Dexheimer JW, Strawn JR, Ramsey LB. Machine Learning-Based Prediction of Escitalopram and Sertraline Side Effects With Pharmacokinetic Data in Children and Adolescents. Clin Pharmacol Ther 2024; 115:860-870. [PMID: 38297828 PMCID: PMC11046530 DOI: 10.1002/cpt.3184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024]
Abstract
Selective serotonin reuptake inhibitors (SSRI) are the first-line pharmacologic treatment for anxiety and depressive disorders in children and adolescents. Many patients experience side effects that are difficult to predict, are associated with significant morbidity, and can lead to treatment discontinuation. Variation in SSRI pharmacokinetics could explain differences in treatment outcomes, but this is often overlooked as a contributing factor to SSRI tolerability. This study evaluated data from 288 escitalopram-treated and 255 sertraline-treated patients ≤ 18 years old to develop machine learning models to predict side effects using electronic health record data and Bayesian estimated pharmacokinetic parameters. Trained on a combined cohort of escitalopram- and sertraline-treated patients, a penalized logistic regression model achieved an area under the receiver operating characteristic curve (AUROC) of 0.77 (95% confidence interval (CI): 0.66-0.88), with 0.69 sensitivity (95% CI: 0.54-0.86), and 0.82 specificity (95% CI: 0.72-0.87). Medication exposure, clearance, and time since the last dose increase were among the top features. Individual escitalopram and sertraline models yielded an AUROC of 0.73 (95% CI: 0.65-0.81) and 0.64 (95% CI: 0.55-0.73), respectively. Post hoc analysis showed sertraline-treated patients with activation side effects had slower clearance (P = 0.01), which attenuated after accounting for age (P = 0.055). These findings raise the possibility that a machine learning approach leveraging pharmacokinetic data can predict escitalopram- and sertraline-related side effects. Clinicians may consider differences in medication pharmacokinetics, especially during dose titration and as opposed to relying on dose, when managing side effects. With further validation, application of this model to predict side effects may enhance SSRI precision dosing strategies in youth.
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Affiliation(s)
- Ethan A. Poweleit
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Biomedical Informatics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Research in Patient Services, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel E. Vaughn
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University, School of Medicine, Indianapolis, IN
| | - Judith W. Dexheimer
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey R. Strawn
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Pires PC, Paiva-Santos AC, Veiga F. Liposome-Derived Nanosystems for the Treatment of Behavioral and Neurodegenerative Diseases: The Promise of Niosomes, Transfersomes, and Ethosomes for Increased Brain Drug Bioavailability. Pharmaceuticals (Basel) 2023; 16:1424. [PMID: 37895895 PMCID: PMC10610493 DOI: 10.3390/ph16101424] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 09/29/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Psychiatric and neurodegenerative disorders are amongst the most prevalent and debilitating diseases, but current treatments either have low success rates, greatly due to the low permeability of the blood-brain barrier, and/or are connected to severe side effects. Hence, new strategies are extremely important, and here is where liposome-derived nanosystems come in. Niosomes, transfersomes, and ethosomes are nanometric vesicular structures that allow drug encapsulation, protecting them from degradation, and increasing their solubility, permeability, brain targeting, and bioavailability. This review highlighted the great potential of these nanosystems for the treatment of Alzheimer's disease, Parkinson's disease, schizophrenia, bipolar disorder, anxiety, and depression. Studies regarding the encapsulation of synthetic and natural-derived molecules in these systems, for intravenous, oral, transdermal, or intranasal administration, have led to an increased brain bioavailability when compared to conventional pharmaceutical forms. Moreover, the developed formulations proved to have neuroprotective, anti-inflammatory, and antioxidant effects, including brain neurotransmitter level restoration and brain oxidative status improvement, and improved locomotor activity or enhancement of recognition and working memories in animal models. Hence, albeit being relatively new technologies, niosomes, transfersomes, and ethosomes have already proven to increase the brain bioavailability of psychoactive drugs, leading to increased effectiveness and decreased side effects, showing promise as future therapeutics.
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Affiliation(s)
- Patrícia C. Pires
- Faculty of Pharmacy, Faculty of Pharmacy of the University of Coimbra, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Ana Cláudia Paiva-Santos
- Faculty of Pharmacy, Faculty of Pharmacy of the University of Coimbra, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Francisco Veiga
- Faculty of Pharmacy, Faculty of Pharmacy of the University of Coimbra, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
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Terman SW, Niznik JD, Growdon ME, Gerlach LB, Burke JF. Secular Trends in Central Nervous System-Active Polypharmacy Among Serial Cross-Sections of US Adults, 2009-2020. Drugs Aging 2023; 40:941-951. [PMID: 37695395 PMCID: PMC10629698 DOI: 10.1007/s40266-023-01066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Data comprehensively examining trends in central nervous system (CNS)-active polypharmacy are limited. The objective of this cross-sectional study was to characterize the composition of and trends in CNS-active medication use in US adults. METHODS We included all participants ≥ 18 years old in the National Health and Nutrition Examination Study (NHANES), 2009-2020. The primary outcome was the percent of adults with CNS-active polypharmacy. This was defined as ≥ 3 medications among antidepressants [tricyclic, selective and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs), opioids, antiepileptics, antipsychotics, benzodiazepines, and nonbenzodiazepine receptor agonists ("Z-drugs")]. Secondary outcomes included prevalence of any CNS-active medication and specific medications and classes over time, and their indications. Percentages were weighted according to NHANES's nationally representative sampling frame. log binomial regressions evaluated the relative risk (RR) for each outcome, comparing the last (2017-2020) versus the first (2010-2011) survey cycle. RESULTS We included 34,189 adults (18.8% at least 65 years old) from five serial cross-sections (survey cycles). The prevalence of CNS-active polypharmacy was 2.1% in 2009-2010 and 2.6% in 2017-2020 [RR 1.18, 95% confidence interval (CI) 0.94-1.47]. The prevalence of CNS-active polypharmacy did not significantly change within any specific age group (e.g., age at least 65 years: RR 1.29, CI 0.74-2.24). The prevalence of any CNS-active medication was 21.0% in 2009 and 24.6% in 2017-2020 (RR] 1.12, 95% CI 1.02-1.25). A substantial increase occurred for antiepileptics (5.1-8.3%), specifically among participants aged 65 years and older (8.3-13.7%). This was largely driven by increasing gabapentin prevalence (1.4-3.6% overall; 3.3-7.9% age 65 years and older). Anticholinergic, SSRIs/SNRIs, antiepileptics, and benzodiazepines were elevated in most cycles for participants at least 65 years old compared with participants less than 65 years, and opioid use was increased in several cycles for older participants as well. Alprazolam was the most common benzodiazepine and third most common medication for anxiety/depression. Gabapentin was the most common CNS-active medication (3.6% of all participants in 2017-2020), followed by sertraline, citalopram, and acetaminophen-hydrocodone (each ~2%). The most common categories were antidepressants (13.7% in 2017-2020), followed by opioids (5.1% in 2017-2020). CONCLUSIONS CNS-active medications are increasingly common, particularly gabapentin, and use of any CNS-active medication increased by 12%. Numerous CNS-active classes also increased in older adults throughout the years. Increasing suboptimal medication use highlight the need for further investigation into causes for potentially inappropriate prescribing, particularly for older adults.
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Affiliation(s)
- Samuel W Terman
- Department of Neurology, University of Michigan, Taubman 1st Floor, Reception C, 1500 E Medical Center Dr, SPC 5316, Ann Arbor, MI, 48109, USA.
| | - Joshua D Niznik
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Matthew E Growdon
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James F Burke
- Department of Neurology, The Ohio State University, Columbus, OH, USA
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Walter TJ, Suter RK, Ayad NG. An overview of human single-cell RNA sequencing studies in neurobiological disease. Neurobiol Dis 2023; 184:106201. [PMID: 37321420 PMCID: PMC10470823 DOI: 10.1016/j.nbd.2023.106201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/09/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023] Open
Abstract
Neurobiological disorders are highly prevalent medical conditions that contribute to significant morbidity and mortality. Single-cell RNA sequencing (scRNA-seq) is a technique that measures gene expression in individual cells. In this review, we survey scRNA-seq studies of tissues from patients suffering from neurobiological disease. This includes postmortem human brains and organoids derived from peripheral cells. We highlight a range of conditions, including epilepsy, cognitive disorders, substance use disorders, and mood disorders. These findings provide new insights into neurobiological disease in multiple ways, including discovering novel cell types or subtypes involved in disease, proposing new pathophysiological mechanisms, uncovering novel drug targets, or identifying potential biomarkers. We discuss the quality of these findings and suggest potential future directions and areas open for additional research, including studies of non-cortical brain regions and additional conditions such as anxiety disorders, mood disorders, and sleeping disorders. We argue that additional scRNA-seq of tissues from patients suffering from neurobiological disease could advance our understanding and treatment of these conditions.
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Affiliation(s)
- T Jordan Walter
- Georgetown University, Lombardi Comprehensive Cancer Center, 3970 Reservoir Rd NW, Washington D.C. 20007, USA.
| | - Robert K Suter
- Georgetown University, Lombardi Comprehensive Cancer Center, 3970 Reservoir Rd NW, Washington D.C. 20007, USA
| | - Nagi G Ayad
- Georgetown University, Lombardi Comprehensive Cancer Center, 3970 Reservoir Rd NW, Washington D.C. 20007, USA
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Wu PC, Tsai SJ, Hsu JW, Huang KL, Chen TJ, Chen MH. Risk of periodontitis in adolescents with bipolar disorder: a cohort study of 21,255 subjects. Eur Child Adolesc Psychiatry 2023:10.1007/s00787-023-02259-9. [PMID: 37439794 DOI: 10.1007/s00787-023-02259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/07/2023] [Indexed: 07/14/2023]
Abstract
Although a growing number of studies have investigated the relationship between psychosocial factors and periodontitis, studies investigating the association between bipolar disorder (BD) and periodontitis are lacking. Using the Taiwan National Health Insurance Research Database, 4251 adolescents with BD and 17,004 age- and sex-matched controls were included. They were followed up from enrollment to the end of 2011 or death. Periodontitis was diagnosed during the follow-up. Cox regression analysis indicated that adolescents with BD had a higher risk of periodontitis (hazard ratio [HR]: 2.96, 95% confidence interval [CI] 2.77-3.17) than did controls. Subanalyses stratified by sex revealed a higher risk of periodontitis in male (HR: 2.83, 95% CI 2.56-3.14) and female (HR: 3.01, 95% CI 2.74-3.30) adolescents with BD than their respective controls. The long-term use of mood stabilizers was associated with a higher risk of periodontitis (HR: 1.19, 95% CI 1.06-1.35) in the BD cohort. Our study highlighted an increased risk of periodontitis in adolescents with BD compared with controls during the follow-up. We recommend that more attention should be paid to the prevention of periodontitis in adolescents with BD, especially those who are female or receiving mood stabilizers.
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Affiliation(s)
- Ping-Chung Wu
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Jen Tsai
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Taipei, 11217, Taiwan.
| | - Ju-Wei Hsu
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Taipei, 11217, Taiwan
| | - Kai-Lin Huang
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Taipei, 11217, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Mu-Hong Chen
- Department of Psychiatry, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Department of Psychiatry, Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2, Taipei, 11217, Taiwan.
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Fekete S, Kulpok C, Taurines R, Egberts K, Geissler J, Gerlach M, Malonga Makosi D, König J, Urschitz MS, Toni I, Neubert A, Romanos M. Value of a web-based pediatric drug information system to prevent serious adverse drug reactions in child and adolescent psychiatry. J Neural Transm (Vienna) 2023; 130:53-63. [PMID: 36324035 DOI: 10.1007/s00702-022-02563-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/25/2022] [Indexed: 01/05/2023]
Abstract
Psychotropic drugs are frequently prescribed 'off-label' to children and adolescents and carry the risk of serious adverse drug reactions (sADR). We examined the frequency of sADRs of psychotropic drugs in pediatric inpatients and explored their potential preventability through following the recommendations of a web-based pediatric drug information system (PDIS). The potential socio-economic impacts of using this online system is also addressed. Routine clinical data from all inpatients treated in a child and adolescent psychiatry department between January 2017 and December 2018 were retrospectively examined for the occurrence of sADRs as defined by the European Medicines Agency. The preventability of the sADRs was assessed based on the information of the PDIS. Furthermore, the expected prolongation of the hospital stay due to sADRs was calculated as well as the associated treatment costs. The study was supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. In total, 1036 patients were screened of whom 658 (63.5%) received psychopharmacological treatment. In 53 (8.1%) of these patients 54 sADRs were documented, of which 37 sADRs were identified as potentially preventable through PDIS. Mitigating sADR through PDIS would likely have prevented prolonged hospital stays and conferred considerable savings for health insurance companies. PDIS provides systematic and evidence-based information about pediatric psychopharmacotherapy and helps to prevent prescribing errors. Therefore, PDIS is a useful tool to increase drug therapy safety in child and adolescent psychiatry. Further prospective studies are needed to confirm the results.
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Affiliation(s)
- Stefanie Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany.
| | - Christine Kulpok
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
| | - Regina Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
| | - Karin Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
| | - Julia Geissler
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
| | - Manfred Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
| | - Dorothée Malonga Makosi
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Michael S Urschitz
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Irmgard Toni
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Wuerzburg, Margarete-Höppel-Platz 1, 97080, Würzburg, Germany
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Bilsky S, Blumenthal H, Ramadan B, Lewis S, Leen-Feldner EW. Pediatric Psychotropic Polypharmacy: An Evaluation of the Correlates and Prevalence Across Assessment Cycles in the National Health and Nutrition Examination Survey. J Child Adolesc Psychopharmacol 2022; 32:416-425. [PMID: 36074100 PMCID: PMC9639228 DOI: 10.1089/cap.2022.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Pediatric psychotropic polypharmacy (PPP) is the prescription of more than one medication targeting psychiatric disorders among people younger than 18 years. Recent data suggested that PPP rates may be plateauing. Few studies have evaluated this question in large, nationally recruited samples. Objective: The National Health and Nutrition Examination Survey was used to examine the correlates and prevalence of PPP across assessment cycles. Independent assessments were obtained biannually between 2013 and 2018. Methods: Eleven thousand four hundred thirty-nine participants (4-17 years; Mage = 8.69 years; standard deviation = 5.16) were included in analyses. The Anatomic Therapeutic Chemical coding scheme was employed to classify medications, and participants were characterized as taking psychotropic medication if the medication was associated with a psychiatric diagnosis code. Participants self-reported past month medication use. Logistic regressions were used to examine correlates of pediatric psychotropic monotherapy compared with psychotropic polypharmacy. Results: Across assessments, 1.2% of respondents reported using two or more psychotropic medications. This estimate is lower than has been observed in specialized samples, but higher than other work using national samples. There was a small, significant difference in PPP across assessment cycles, such that rates of PPP were higher at the latter assessments. Correlates of PPP accorded with prior work, including male gender, increasing age, and markers of low socioeconomic status. The most robust predictor was having seen a mental health professional in the past year. Conclusions: This study documents that ∼1% of U.S. participants from a nationally recruited sample endorsed PPP. Findings are situated in the broader literature and the need for additional, prospective data to better characterize those trends in the United States and around the world. Key Takeaway Points It is known that many children and adolescents in the United States take more than one psychotropic medication, although few studies have examined trends in large, nationally recruited datasets. This study adds to this literature by documenting the prevalence of pediatric psychotropic polypharmacy in a large, unselected sample (i.e., 1.2%) and shows that rates were slightly higher at subsequent assessment intervals. Plain Language Summary Many kids take more than one medication for psychological problems. We analyzed data from ∼11,000 children and adolescents from across the United States, evaluated between 2013 and 2018. The number of kids taking multiple medications for psychological problems was different (higher) when measured later in time. Being a boy, being older, living in poverty, and having seen a mental health professional in the past year were associated with taking multiple medications for psychological problems. Implications for Managed Care Pharmacy These findings suggest rates of pediatric psychotropic polypharmacy (PPP) remain high in the United States, and correlate with male gender, poverty, and having recently seen a mental health professional. Relative to White children and adolescents, Black participants were less likely and Hispanic participants more likely to endorse PPP. Policy considerations include fully educating families and practitioners about the benefits as well as potential downsides of PPP and additional intervention options for mental health problems.
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Affiliation(s)
- Sarah Bilsky
- Department of Psychology, University of Mississippi, University Park, Mississippi, USA
| | | | - Banan Ramadan
- Department of Psychology, University of North Texas, Denton, Texas, USA
| | - Sarah Lewis
- Center for Research, Assessment, and Treatment Efficacy (CReATE), Asheville, North Carolina, USA
| | - Ellen W. Leen-Feldner
- Department of Psychological Science, University of Arkansas, Fayetteville, Arkansas, USA
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Pascoe AJ, Haque ZZ, Samandra R, Fehring DJ, Mansouri FA. Dissociable effects of music and white noise on conflict-induced behavioral adjustments. Front Neurosci 2022; 16:858576. [PMID: 36061589 PMCID: PMC9429995 DOI: 10.3389/fnins.2022.858576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Auditory stimuli, encompassing a continually expanding collection of musical genres and sonic hues, present a safe and easily administrable therapeutic option for alleviating cognitive deficits associated with neuropsychological disorders, but their effects on executive control are yet to be completely understood. To better understand how the processing of certain acoustic properties can influence conflict processing, we had a large of cohort of undergraduate students complete the Stroop colour and word test in three different background conditions: classical music, white noise, and silence. Because of pandemic guidelines and the necessity to run the experiment remotely, participants also completed the Wisconsin card sorting test (WCST), so that the reliability and consistency of acquired data could be assessed. We found that white noise, but not classical music increased the response time difference between congruent (low conflict) and incongruent (high conflict) trials (conflict cost), hence impairing performance. Results from the WCST indicated that home-based data collection was reliable, replicating a performance bias reported in our previous laboratory-based experiments. Both the auditory stimuli were played at a similar intensity, thus their dissociable effects may have resulted from differing emotional responses within participants, where white noise, but not music elicited a negative response. Integrated with previous literature, our findings indicate that outside of changes in tempo and valence, classical music does not affect cognitive functions associated with conflict processing, whilst white noise impairs these functions in a manner similar to other stressors, and hence requires further research before its implementation into neuropsychiatric care.
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Affiliation(s)
- Alexander J. Pascoe
- Cognitive Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Zakia Z. Haque
- Cognitive Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Ranshikha Samandra
- Cognitive Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Daniel J. Fehring
- Cognitive Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- ARC Centre of Excellence for Integrative Brain Function, Monash University, Clayton, VIC, Australia
| | - Farshad A. Mansouri
- Cognitive Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
- ARC Centre of Excellence for Integrative Brain Function, Monash University, Clayton, VIC, Australia
- *Correspondence: Farshad A. Mansouri,
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10
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Kantar D, Acun AD, Er H, Afsar E, Yargıcoglu P. Anxiolytic-like effects of extremely low frequency electric field in stressed rats: involvement of 5-HT2C receptors. Int J Radiat Biol 2022; 99:1473-1482. [PMID: 35675556 DOI: 10.1080/09553002.2022.2087929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/03/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Possible modulatory effects of noninvasive brain stimulation have gained interest recently. In our study, the effect of low frequency electric fields (LF-EF) on stress-induced electrophysiological, behavioral changes and the possible involvement of serotonergic 5-HT2C receptors were investigated. MATERIALS AND METHODS A total of eight groups including the control groups were formed by applying LF-EF with or without a 5-HT2C receptor agonist to naïve or acute stress exposed rats to demonstrate the effects of LF-EF. LF-EF administration at 10 kV/m was started 30 min before acute stress application and lasted for 1 h in total. Anxiety levels and social interaction were evaluated using the elevated plus maze test and social interaction test, respectively. Auditory evoked potentials (AEP) were recorded by using ascending loudness paradigms. Loudness dependence AEP (LDAEP) was calculated by using amplitude values to analyze serotonergic transmission. Serotonin and glucocorticoid levels were measured in the frontal cortex and hippocampus. RESULTS It was observed that the applied LF-EF reduced the anxiety behavior, and attenuated the LDAEP responses in stress and/or 5-HT2C receptor agonist applied groups. In parallel, an increase in serotonin levels and a decrease in glucocorticoid levels were observed. However, LF-EF exposure was ineffective in impaired social interaction. CONCLUSIONS Our findings show that 10 kV/m LF-EF administration may modulate the neural network and physiological responses associated with mild acute stress. 5-HT2C receptor dependent functions are thought to play a role in the anxiolytic effect of LF-EF.
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Affiliation(s)
- Deniz Kantar
- Department of Biophysics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Alev Duygu Acun
- Department of Biophysics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Hakan Er
- Department of Medical Imaging Techniques, Vocational School of Health Services, Akdeniz University, Antalya, Turkey
| | - Ebru Afsar
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Istanbul Kültür University, Istanbul, Turkey
| | - Piraye Yargıcoglu
- Department of Biophysics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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11
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Tini E, Smigielski L, Romanos M, Wewetzer C, Karwautz A, Reitzle K, Correll CU, Plener PL, Malzahn U, Heuschmann P, Unterecker S, Scherf-Clavel M, Rock H, Antony G, Briegel W, Fleischhaker C, Banaschewski T, Hellenschmidt T, Imgart H, Kaess M, Kölch M, Renner T, Reuter-Dang SY, Rexroth C, Schulte-Körne G, Theisen F, Fekete S, Taurines R, Gerlach M, Egberts KM, Walitza S. Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Compr Psychiatry 2022; 115:152301. [PMID: 35248877 DOI: 10.1016/j.comppsych.2022.152301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Sertraline is a selective serotonin reuptake inhibitor with specific indications in child and adolescent psychiatry. Notwithstanding its frequent use and clinical benefits, the relationship between pharmacokinetics, pharmacodynamics, efficacy, and tolerability of sertraline across indications, particularly in non-adult patients, is not fully understood. METHOD This naturalistic therapeutic drug monitoring (TDM) study was conducted in a transdiagnostic sample of children and adolescents treated with sertraline (n = 78; mean age, 14.22 ± 2.39; range, 7-18 years) within the prospective multicenter "TDM-VIGIL" project. Associations between dose, serum concentration, and medication-specific therapeutic and side effects based on the Clinical Global Impression scale were examined. Tolerability was measured qualitatively with the 56-item Pediatric Adverse Event Rating Scale. RESULTS A strong linear positive dose-serum concentration relationship (with dose explaining 45% of the variance in concentration) and significant effects of weight and co-medication were found. Neither dose nor serum concentration were associated with side effects. An overall mild-to-moderate tolerability profile of sertraline was observed. In contrast with the transdiagnostic analysis that did not indicate an effect of concentration, when split into depression (MDD) and obsessive-compulsive disorder (OCD) diagnoses, the probability of clinical improvement significantly increased as both dose and concentration increased for OCD, but not for MDD. CONCLUSIONS This TDM-flexible-dose study revealed a significant diagnosis-specific effect between sertraline serum concentration and clinical efficacy for pediatric OCD. While TDM already guides clinical decision-making regarding compliance, dose calibration, and drug-drug interactions, combining TDM with other methods, such as pharmacogenetics, may facilitate a personalized medicine approach in psychiatry.
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12
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Egberts KM, Gerlach M, Correll CU, Plener PL, Malzahn U, Heuschmann P, Unterecker S, Scherf-Clavel M, Rock H, Antony G, Briegel W, Fleischhaker C, Häge A, Hellenschmidt T, Imgart H, Kaess M, Karwautz A, Kölch M, Reitzle K, Renner T, Reuter-Dang SY, Rexroth C, Schulte-Körne G, Theisen FM, Walitza S, Wewetzer C, Fekete S, Taurines R, Romanos M. Serious Adverse Drug Reactions in Children and Adolescents Treated On- and Off-Label with Antidepressants and Antipsychotics in Clinical Practice. Pharmacopsychiatry 2022; 55:255-265. [PMID: 35130562 PMCID: PMC9458344 DOI: 10.1055/a-1716-1856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite the growing evidence base for psychotropic drug treatment in pediatric patients, knowledge about the benefit-risk ratio in clinical practice remains limited. The 'Therapeutic Drug Monitoring (TDM)-VIGIL' study aimed to evaluate serious adverse drug reactions (ADRs) in children and adolescents treated with antidepressants and/or antipsychotics in approved ('on-label'), and off-label use in clinical practice. METHODS Psychiatric pediatric patients aged 6-18 years treated with antidepressants and/or antipsychotics either on-label or off-label were prospectively followed between October 2014 and December 2018 within a multicenter trial. Follow-up included standardized assessments of response, serious ADRs and therapeutic drug monitoring. RESULTS 710 youth (age=14.6±2.2 years, female=66.6%) were observed for 5.5 months on average; 76.3% received antidepressants, 47.5% antipsychotics, and 25.2% both. Altogether, 55.2% of the treatment episodes with antidepressants and 80.7% with antipsychotics were off-label. Serious ADRs occurred in 8.3% (95%CI=6.4-10.6%) of patients, mainly being psychiatric adverse reactions (77.4%), predominantly suicidal ideation and behavior. The risk of serious ADRs was not significantly different between patients using psychotropics off-label and on-label (antidepressants: 8.1% vs. 11.3%, p=0.16; antipsychotics: 8.7% vs 7.5%, p=0.67). Serious ADRs occurred in 16.6% of patients who were suicidal at enrollment versus 5.6% of patients who were not suicidal (relative risk 3.0, 95%CI=1.9-4.9). CONCLUSION Off-label use of antidepressants and antipsychotics in youth was not a risk factor for the occurrence of serious ADRs in a closely monitored clinical setting. Results from large naturalistic trials like ours can contribute to bridging the gap between knowledge from randomized controlled trials and real-world clinical settings.
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Affiliation(s)
- Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Manfred Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Uwe Malzahn
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Heuschmann
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Wuerzburg, Germany
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Hans Rock
- Central Information Office, Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Gisela Antony
- Central Information Office, Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Wolfgang Briegel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Leopoldina Hospital, Schweinfurt, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Alexander Häge
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tobias Hellenschmidt
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Clinic Berlin Neukölln, Berlin, Germany
| | - Harmut Imgart
- Parkland-Clinic, Clinic for Psychosomatics and Psychotherapy, Academic Teaching hospital for the University Gießen, Bad Wildungen, Germany
| | - Michael Kaess
- Clinic for Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.,University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland
| | - Andreas Karwautz
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Michael Kölch
- Department of Child and Adolescent Psychiatry and Psychotherapy, Brandenburg Medical School Brandenburg, Neuruppin, Germany.,Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Center Rostock, Rostock, Germany
| | - Karl Reitzle
- Specialist practice and Medical Care Center for Child and Adolescent Psychiatry Munich, Munich, Germany
| | - Tobias Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Psychiatry and Psychotherapy Tuebingen, Center of Mental Health Tuebingen, Germany
| | - Su-Yin Reuter-Dang
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany.,Specialist practice and Medical Care Center for Child and Adolescent Psychiatry Munich, Munich, Germany
| | - Christian Rexroth
- Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy at the Regensburg District Hospital, Medbo KU, University Hospital, Regensburg, Germany
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-University (LMU) Hospital, Munich, Germany
| | - Frank M Theisen
- Herz-Jesu-Krankenhaus gGmbH, Department of Child and Adolescent Psychiatry and Psychotherapy, Fulda, Germany
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Switzerland
| | - Christoph Wewetzer
- Kliniken der Stadt Köln gGmbH, Clinic for Child and Adolescent Psychiatry Holweide, Children's Hospital Amsterdamer Straße, Cologne, Germany
| | - Stefanie Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Regina Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
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13
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Dagar A, Cherlopalle S, Ahuja V, Senko L, Butler RS, Austerman J, Anand A, Falcone T. Real-world experience of using combinatorial pharmacogenomic test in children and adolescents with depression and anxiety. J Psychiatr Res 2022; 146:83-86. [PMID: 34959162 DOI: 10.1016/j.jpsychires.2021.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/17/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the real-world impact of using a commercially available combinatorial pharmacogenomic (CPGx) test on medication management and clinical outcomes in children and adolescents treated at a tertiary care psychiatry practice. METHODS A retrospective cohort study using our prospectively maintained database of patients undergoing CPGx testing was performed. Only patients with clinical data at the time of ordering CPGx test (pre-baseline), potential medication change visit (baseline) and 8-weeks follow-up (post-baseline) visit were included. Clinical Global Impression (CGI) scores for each visit were calculated. Appropriate statistical analysis, including one-sample t-test, paired t-test and Chi-square test was performed. RESULTS Based on the inclusion criteria, 281 (75.9%) of the 370 patients with CPGx testing were included. Their mean age was 15.8 ± 4.5 years (111 females; 39.5%). The average number of medications significantly increased to 2.4 ± 1.2 on the post-baseline visit [t(280) = 8.34, p < 0.001). Medications were added in 123 (43.7%), replaced in 92 (32.7%) patients and remained unchanged in rest. There was no significant association between medication-related adverse effects and psychotropic medication change group (p = 0.27). The study population showed a significant improvement (p < 0.001) in the CGI severity, efficacy, and global improvement indices. CONCLUSION In our experience of using CPGx test in a large cohort of children and adolescents during routine clinical practice, three-quarter of them underwent medication change. Additionally, we noted an improvement in clinical outcomes without impacting adverse effects. While the role of clinical judgement in medication changes in our cohort is likely, CPGx may supplement clinical decision making. However, the best use and benefit of CPGx in routine clinical practice needs further investigation.
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Affiliation(s)
- Anjali Dagar
- Department of Psychiatry/Epilepsy, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
| | - Suneela Cherlopalle
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Veena Ahuja
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Lillian Senko
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Robert S Butler
- Department of Quantitative Health Sciences, Learner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Austerman
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Amit Anand
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Tatiana Falcone
- Department of Psychiatry/Epilepsy, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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14
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Rajwani K. Should Adolescents be Included in Emerging Psychedelic Research? Canadian Journal of Bioethics 2022. [DOI: 10.7202/1089784ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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15
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Barnes SE, Zera KA, Ivison GT, Buckwalter MS, Engleman EG. Brain profiling in murine colitis and human epilepsy reveals neutrophils and TNFα as mediators of neuronal hyperexcitability. J Neuroinflammation 2021; 18:199. [PMID: 34511110 PMCID: PMC8436533 DOI: 10.1186/s12974-021-02262-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with chronic inflammatory disorders such as inflammatory bowel disease frequently experience neurological complications including epilepsy, depression, attention deficit disorders, migraines, and dementia. However, the mechanistic basis for these associations is unknown. Given that many patients are unresponsive to existing medications or experience debilitating side effects, novel therapeutics that target the underlying pathophysiology of these conditions are urgently needed. METHODS Because intestinal disorders such as inflammatory bowel disease are robustly associated with neurological symptoms, we used three different mouse models of colitis to investigate the impact of peripheral inflammatory disease on the brain. We assessed neuronal hyperexcitability, which is associated with many neurological symptoms, by measuring seizure threshold in healthy and colitic mice. We profiled the neuroinflammatory phenotype of colitic mice and used depletion and neutralization assays to identify the specific mediators responsible for colitis-induced neuronal hyperexcitability. To determine whether our findings in murine models overlapped with a human phenotype, we performed gene expression profiling, pathway analysis, and deconvolution on microarray data from hyperexcitable human brain tissue from patients with epilepsy. RESULTS We observed that murine colitis induces neuroinflammation characterized by increased pro-inflammatory cytokine production, decreased tight junction protein expression, and infiltration of monocytes and neutrophils into the brain. We also observed sustained neuronal hyperexcitability in colitic mice. Colitis-induced neuronal hyperexcitability was ameliorated by neutrophil depletion or TNFα blockade. Gene expression profiling of hyperexcitable brain tissue resected from patients with epilepsy also revealed a remarkably similar pathology to that seen in the brains of colitic mice, including neutrophil infiltration and high TNFα expression. CONCLUSIONS Our results reveal neutrophils and TNFα as central regulators of neuronal hyperexcitability of diverse etiology. Thus, there is a strong rationale for evaluating anti-inflammatory agents, including clinically approved TNFα inhibitors, for the treatment of neurological and psychiatric symptoms present in, and potentially independent of, a diagnosed inflammatory disorder.
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Affiliation(s)
- Sarah E Barnes
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Kristy A Zera
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Geoffrey T Ivison
- Department of Pathology, Stanford University, Stanford, CA, USA
- Department of Infectious Diseases, Stanford University, Stanford, CA, USA
| | | | - Edgar G Engleman
- Department of Pathology, Stanford University, Stanford, CA, USA.
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16
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Malik S. Understanding, Assessing, and Managing the Side Effects of Psychotropic Medications. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210806-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Baker M, Huefner JC, Bellonci C, Hilt R, Carlson GA. Polypharmacy in the Management of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Review and Update. J Child Adolesc Psychopharmacol 2021; 31:148-163. [PMID: 33600217 DOI: 10.1089/cap.2020.0162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: Prescription of multiple medications concurrently for children and adolescents has increased in recent years. Examination of this practice has been undervalued relative to its incidence. This article reviews studies investigating effectiveness of medication combinations for youth with attention-deficit/hyperactivity disorder (ADHD). Methods: A literature search identified studies that combined two or more prescribed medications for the treatment of ADHD. Included studies focused on youth; had study design of randomized controlled trial (RCT), nonrandomized trial, or case review (n > 10); and included an outcome measure of treatment effectiveness. Results: Thirty-nine pertinent studies were identified. All studies combined two medications, with the vast majority including a stimulant (n = 37). The largest group (n = 16) combined stimulant and alpha-agonist, finding greater efficacy than alpha-agonist alone but not stimulant alone in all cases. A few RCTs found benefit from the addition of risperidone or divalproex to stimulant for comorbid aggression. Four studies adding atomoxetine found mixed reports of benefit, including the only small RCT showing no benefit. RCTs with selective serotonin reuptake inhibitors found minimal evidence of benefit for mood or anxiety comorbidities. Conclusion: The best studied combination is stimulant and alpha-agonist; addition of alpha-agonist to stimulant seems effective for residual symptoms of ADHD. Stimulant plus risperidone has the most evidence of efficacy for comorbid aggression or disruptive behavior. Limited support exists for the effectiveness of other medication combinations, including no trials studying three or more medications concurrently. Combinations frequently yielded more side effects, leaving monotherapy preferable if a sufficient treatment response can be achieved.
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Affiliation(s)
- Megan Baker
- Momentum for Health, San Jose, California, USA
| | - Jonathan C Huefner
- Boys Town Child and Family Translational Research Center, Boys Town, Nebraska, USA
| | - Christopher Bellonci
- Judge Baker Children's Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Hilt
- Seattle Children's Hospital, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Gabrielle A Carlson
- Division of Child and Adolescent Psychiatry, Renaissance School of Medicine at Stony Brook, Stony Brook, New York, USA
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Barclay RP, Dillon-Naftolin E, Russell D, Hilt RJ. A Second-Opinion Program for the Care of Youths Prescribed Five or More Psychotropics in Washington State. Psychiatr Serv 2021; 72:362-365. [PMID: 32878541 DOI: 10.1176/appi.ps.202000234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This retrospective study describes a second-opinion review program for the care of children in Washington State who received Medicaid coverage and who were prescribed five or more psychotropic medications, primarily by mental health specialists. In total, 136 second-opinion reviews from 2013 and 169 from 2018 were included in this study. Attention-deficit hyperactivity disorder (ADHD), behavioral difficulties, anxiety, and trauma were prevalent among these children, and participants were commonly prescribed ADHD medications, selective serotonin reuptake inhibitors, and second-generation antipsychotics. The incidence of reviews remained stable over the two periods, but psychosocial treatment increased significantly over this time. This study sheds light on the initiation, maintenance, and identification of polypharmacy psychotropic regimens and highlights psychosocial treatment as an intervention that increases best practice care for at-risk patients.
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Affiliation(s)
- Rebecca P Barclay
- Partnership Access Line, Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle (Barclay); Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dillon-Naftolin, Russell, Hilt). Marvin S. Swartz, M.D., and Steven Starks, M.D., are editors of this column
| | - Erin Dillon-Naftolin
- Partnership Access Line, Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle (Barclay); Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dillon-Naftolin, Russell, Hilt). Marvin S. Swartz, M.D., and Steven Starks, M.D., are editors of this column
| | - Douglas Russell
- Partnership Access Line, Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle (Barclay); Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dillon-Naftolin, Russell, Hilt). Marvin S. Swartz, M.D., and Steven Starks, M.D., are editors of this column
| | - Robert J Hilt
- Partnership Access Line, Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle (Barclay); Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dillon-Naftolin, Russell, Hilt). Marvin S. Swartz, M.D., and Steven Starks, M.D., are editors of this column
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Zito JM, Zhu Y, Safer DJ. Psychotropic Polypharmacy in the US Pediatric Population: A Methodologic Critique and Commentary. Front Psychiatry 2021; 12:644741. [PMID: 34194346 PMCID: PMC8236612 DOI: 10.3389/fpsyt.2021.644741] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/26/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Psychotropic concomitant medication use for the treatment of youth with emotional and behavioral disorders has grown significantly in the U.S. over the past 25 years. The use of pharmacy claims to analyze these trends requires the following: age of the selected population, overlapping days of use, and precision of the outcome itself. This review will also address the gaps in reporting of pediatric psychotropic polypharmacy. Methods: An electronic literature search was undertaken for the period 2000 through 2020 using keywords such as "pediatric," "concomitant," "polypharmacy," "multiple medications," and "concurrent psychotropic"; Relevant references in textbooks were also used. Only English language and U.S. studies were included, resulting in 35 inter-class studies. Results: Studies were organized into seven groups according to data sources and clinical topics: (1) population surveys; (2a) multi-state publicly insured populations; (2b) single/two state studies; (3) privately insured populations; (4) diagnosed populations; (5) foster care populations; (6) special settings. Across 20 years it is apparent that pediatric psychotropic polypharmacy affects substantially more children and adolescents today than had been the case. As many as 300,000 youth now receive 3 or more classes concomitantly. The duration of concomitant use is relatively long, e.g., 69-89% of annual medicated days. Finally, more adverse event reports were associated with 3-class compared with 2-class drug regimens. Discussion: Factors that contribute to the growth of pediatric psychotropic polypharmacy include: (1) predominance of the biological model in psychiatric practice; (2) invalid assumptions on efficacy of combinations, (3) limited professional awareness of metabolic and neurological adverse drug events, and (4) infrequent use of appropriate deprescribing. Conclusion: A review of publications documenting U.S. pediatric psychotropic polypharmacy written over the last 20 years supports the need to standardize the methodologies used. The design of population-based studies should maximize information on the number of youth receiving regimens of 3-, 4-, and 5 or more concomitant classes and the duration of such use. Next, far more post-marketing research is needed to address the effectiveness, safety and tolerability of complex drug regimens prescribed for youngsters.
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Affiliation(s)
- Julie M Zito
- Department of Pharmaceutical Health Services Research, School of Pharmacy, Baltimore, MD, United States.,Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Yue Zhu
- Department of Pharmaceutical Health Services Research, School of Pharmacy, Baltimore, MD, United States.,Department of Epidemiology, School of Public Health, George Washington University, Washington, DC, United States
| | - Daniel J Safer
- Department of Psychiatry, The Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD, United States
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Terman SW, Hill CE, Burke JF. Disability in people with epilepsy: A nationally representative cross-sectional study. Epilepsy Behav 2020; 112:107429. [PMID: 32919202 DOI: 10.1016/j.yebeh.2020.107429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of this study was to explore the prevalence and predictors of limitations causing disability in patients treated for seizures or epilepsy compared with patients without epilepsy. METHODS This was a retrospective cross-sectional study using the National Health and Nutrition Examination Survey (NHANES). We included all participants ≥20 years old for 2013-2018. We classified patients as having epilepsy if they reported taking at least one prescription medication to treat seizures or epilepsy. Physical, mental, and social limitations were determined from interview questions. We report the prevalence of any limitation and total number of limitations for participants without vs. with epilepsy using serial negative binomial regressions and severity of individual limitations according to epilepsy status. RESULTS We included 17,057 participants, of whom 148 (0.8%) had epilepsy. Overall, 80% (95% confidence interval [CI]: 73%-86%) with epilepsy vs. 38% (95% CI: 36%-39%) without epilepsy reported at least 1 limitation (p < 0.01). The mean number of limitations was 7.5 (95% CI: 6.2-8.8) for those with epilepsy vs. 2.4 (95% CI: 2.3-2.6) for those without epilepsy (p < 0.01). Epilepsy was associated with an incidence rate ratio (IRR) of 3.1 (95% CI: 2.6-3.7) in an unadjusted negative binomial regression. After adjusting for demographics and comorbidities, this association was no longer significant (IRR: 1.2, 95% CI: 0.9-1.7). Limitations cited by 40-50% of participants with epilepsy included stooping/kneeling/crouching, standing for long periods of time, and pushing/pulling objects. Limitation severity was consistently higher in patients with epilepsy. CONCLUSIONS Patients with epilepsy had 3.1 times as many physical, mental, or social limitations compared with those without epilepsy, and disability severity was consistently higher. This effect was attenuated after considering baseline variables such as smoking and depression severity. Our work implies the importance of structured mental health screening and self-management programs targeting mood, weight, and lifestyle as potential leverage points towards alleviating epilepsy-related disability.
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Affiliation(s)
- Samuel W Terman
- University of Michigan, Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
| | - Chloe E Hill
- University of Michigan, Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
| | - James F Burke
- University of Michigan, Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
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Terman SW, Aubert CE, Hill CE, Maust DT, Betjemann JP, Boyd CM, Burke JF. Polypharmacy in patients with epilepsy: A nationally representative cross-sectional study. Epilepsy Behav 2020; 111:107261. [PMID: 32629416 PMCID: PMC7869064 DOI: 10.1016/j.yebeh.2020.107261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of the study was to characterize the prevalence of polypharmacy and central nervous system (CNS)-acting medications in patients with epilepsy, and particular types of medications. METHODS This was a retrospective cross-sectional study using data from the nationally representative National Health and Nutrition Examination Survey (NHANES). We included patients who reported taking at least one prescription medication in order to treat seizures or epilepsy during NHANES survey years 2013-2016. We assessed the number and types of drugs and predictors of total number of medications using a negative binomial regression. We then assessed prevalence of polypharmacy (≥5 medications), CNS polypharmacy (≥3 CNS-acting medications) and additional CNS-acting medications, and drugs that lower the seizure threshold (i.e., bupropion and tramadol), and extrapolated prevalence to estimated affected US population. RESULTS The NHANES contained 20,146 participants, of whom 135 reported taking ≥1 antiseizure medication (ASM) for seizures or epilepsy representing 2,399,520 US citizens using NHANES's sampling frame. Patients reported taking a mean 5.3 (95% confidence interval (CI): 4.3-6.3) prescription medications. Adjusting for race, sex, and uninsurance, both age and number of chronic conditions predicted increased number of medications (incident rate ratio (IRR) per decade: 1.16, 95% CI: 1.04-1.28; IRR per chronic condition: 1.19, 95% CI: 1.11-1.27). Polypharmacy was reported by 47% (95% CI: 38%-57%) of patients, CNS polypharmacy by 34% (23%-47%), benzodiazepine use by 21% (14%-30%), opioid use by 16% (11%-24%), benzodiazepine plus opioid use by 6% (3%-14%), and 6% (2%-15%) reported a drug that lowers the seizure threshold. Twelve percent (7%-20%) took an opioid with either a benzodiazepine or gabapentinoid. CONCLUSIONS Polypharmacy is common in patients with epilepsy. Patients taking ASMs frequently reported also taking other CNS-acting medications (i.e., opioids, benzodiazepines, seizure threshold-lowering medications), and medication combinations with black box warnings. Central nervous system polypharmacy poses health risks. Future research is needed to explore drivers of polypharmacy and strategies to help mitigate potentially harmful prescription use in this high-risk population.
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Affiliation(s)
- Samuel W Terman
- University of Michigan Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
| | - Carole E Aubert
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA; Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48109, USA.
| | - Chloe E Hill
- University of Michigan Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
| | - Donovan T Maust
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48109, USA; University of Michigan Department of Psychiatry, Ann Arbor, MI 48109, USA.
| | - John P Betjemann
- University of California San Francisco, Weill Institute for Neurosciences, San Francisco, USA.
| | - Cynthia M Boyd
- Johns Hopkins University, Center on Aging and Health, Baltimore, MD 21205, USA.
| | - James F Burke
- University of Michigan Department of Neurology, Ann Arbor, MI 48109, USA; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI 48109, USA.
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Lin HW, Chang EH, Ko Y, Wang CY, Wang YS, Mafruhah OR, Wu SH, Chen YC, Huang YM. Conceptualization, Development and Psychometric Evaluations of a New Medication-Related Health Literacy Instrument: The Chinese Medication Literacy Measurement. Int J Environ Res Public Health 2020; 17:E6951. [PMID: 32977520 DOI: 10.3390/ijerph17196951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/12/2020] [Accepted: 09/18/2020] [Indexed: 12/26/2022]
Abstract
There is a need for valid and reliable instruments to focus on medication aspects of health literacy and help healthcare professionals address patients’ barriers to medication use. This cross-sectional study describes the conceptualization, development, and psychometric properties of the first Chinese Medication Literacy Measurement (ChMLM) to assess the level of health literacy on medication use. The 17-item ChMLM (ChMLM-17) and its short form, 13-item ChMLM (ChMLM-13), consist of four sections (vocabulary, over-the-counter labels, prescription labels, and advertisements) to cover six domains of medication-related health literacy. Multistage stratified quota sampling was attempted to recruit a representative sample in Taiwan. Receiver operating characteristic curves were used to identify the cut-off point for differentiating high and low medication literacy. Psychometric analyses were performed (n = 1410) to assess the reliability and validity separately on all samples and sociodemographic subgroups. The 17- and 13-item versions both had high construct validity among all patients and patients with low medication literacy. The developed ChMLM-17 and ChMLM-13 is expected to help healthcare providers and researchers to accurately measure medication-related health literacy and improve medication use in the real-world practice.
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Laurent JS, Watts R, Mackey S. Toward Inclusion of Youths With Psychiatric Disorders in Brain-Body Research-Reply. JAMA Pediatr 2020; 174:907-908. [PMID: 32539091 DOI: 10.1001/jamapediatrics.2020.1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jennifer S Laurent
- University of Vermont College of Nursing and Health Sciences, Burlington
| | | | - Scott Mackey
- Larner College of Medicine, Department of Psychiatry, University of Vermont, Burlington
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Abstract
BACKGROUND Detailed research on long-term antidepressant (AD) trends within a single large US Medicaid population of youth has not heretofore been reported. METHODS Administrative claims data for eight annual timepoints across 28 years (1987-2014) were organized for youth (<20 years old) who were continuously enrolled during each study year in a mid-Atlantic state Medicaid program. Total annual AD prevalence and age-, gender-, race-, eligibility group-, and diagnosis-specific prevalence were formed from bivariate analyses; logistic regression assessed the change in use (2007-2014) adjusted for covariates. AD-polypharmacy data were assessed in 2014. RESULTS The major findings are: 1) AD use in state Medicaid enrollees grew 14-fold between 1987 and 2014. Data from 2014 revealed significantly increased odds of youth with SSRI/SNRI dispensings compared to 2007 (AOR=1.15 95% CI 1.11-1.19), representing 78% of total AD users. 2) Recent AD increases were greatest for 15-19-year olds. 3) AD use in girls passed up AD use in boys for the first time in 2014. 4) In 2014, ADs for foster care (12.7%) were 6 times greater than for their income-eligible Medicaid-counterparts. 5) In 2014, a quarter of AD-medicated youth were diagnosed with a behavior disorder. 6) More than 40 percent of AD medicated youth had >=1 other concomitant psychotropic classes for 60 or more days. CONCLUSIONS Second-generation antidepressant use in Medicaid-insured youth has increased despite growing questions that pediatric AD benefits may not outweigh harms. These patterns support the call for publicly funded, independent investigator-conducted post-marketing outcomes research.
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Affiliation(s)
- Julie M Zito
- Department of Psychiatry, University of Maryland, Baltimore, MD, United States.,Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Dinci Pennap
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD, United States.,Center for Drug Evaluation and Research, United States Food and Drug Administration (FDA), Silver Spring, MD, United States
| | - Daniel J Safer
- Johns Hopkins Medical Institutions, Baltimore, MD, United States
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Baiden P, Tadeo SK. Examining the association between bullying victimization and prescription drug misuse among adolescents in the United States. J Affect Disord 2019; 259:317-324. [PMID: 31454592 DOI: 10.1016/j.jad.2019.08.063] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/10/2019] [Accepted: 08/18/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although studies have examined the association between bullying victimization and adolescent substance behaviors, there is a dearth of research investigating the association between bullying victimization and prescription drug misuse. The objective of this study was to examine the cross-sectional association between bullying victimization and prescription drug misuse among adolescents. METHODS Data for this study came from the 2017 Youth Risk Behavior Survey. A sample of 9974 adolescents aged 14-18 years (50.1% female) were analyzed using binary logistic regression with prescription drug misuse as the outcome variable and bullying victimization as the main explanatory variable. RESULTS Of the 9,974 adolescents, 13.1% misused prescription drugs. One in ten adolescents were victims of both school bullying and cyberbullying, 5.1% were victims of only cyberbullying, 9% were victims of only school bullying, and 75.8% experienced neither school bullying nor cyberbullying victimization. In the binary logistic regression model, adolescents who experienced both school bullying and cyberbullying victimization had 1.66 times higher odds of misusing prescription drugs (AOR = 1.66, p < .001, 95% CI = 1.34-2.06) and adolescents who experienced only school bullying victimization had 1.30 times higher odds of misusing prescription drugs (AOR = 1.30, p < .05, 95% CI = 1.02-1.64). Being lesbian, gay, or bisexual; feeling sad or hopeless; cigarette smoking; binge drinking; cannabis use; and illicit drug use were statistically significantly associated with prescription drug misuse. CONCLUSIONS Understanding the association between bullying victimization and prescription drug misuse could contribute to early identification of adolescents who may misuse prescription drugs.
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Affiliation(s)
- Philip Baiden
- School of Social Work, The University of Texas at Arlington, 211 S. Cooper St., Box 19129, Arlington, TX 76019, United States.
| | - Savarra K Tadeo
- School of Social Work, The University of Texas at Arlington, 211 S. Cooper St., Box 19129, Arlington, TX 76019, United States
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Abstract
Background Several studies have examined the risk and health outcomes related to polypharmacy among the elderly. However, information regarding polypharmacy among pediatric patients is lacking. Objective The aim of this study was to investigate the prevalence of polypharmacy and its related factors among the pediatric population of South Korea. Methods We used national claim data from the Health Insurance Review and Assessment Service—Pediatric Patients Sample (HIRA-PPS) in Korea originating from 2012 through 2016. Polypharmacy was defined as a daily average of two or more drugs used yearly. Complex chronic conditions (CCCs) were examined to evaluate concomitant chronic diseases in pediatric patients. Age-specific contraindications and potential drug-drug interactions were assessed according to criteria established by the Korea Institute of Drug Safety & Risk Management (KIDS). Descriptive statistics and logistic regression were conducted to analyze the status of polypharmacy and its associated risk factors in pediatric patients. Results The 5-year prevalence of pediatric polypharmacy in pediatric patients was 3.7%. The prevalence of polypharmacy was much higher in younger pediatric patients: 9.5% for patients between the ages of 1–7 years, 0.9% for ages 6–11 years, and 1.1% for ages 12–19 years. Pediatric patients with CCCs, Medical Aid benefits, or a hospital admission history had a significantly higher prevalence of polypharmacy when compared to their counterparts without those conditions. The most commonly prescribed drugs were respiratory agents (29%) followed by anti-allergic drugs (18.7%), central nervous system agents (15.9%), antibiotics (10.1%), and gastrointestinal drugs (7.7%). There was a positive correlation between the daily average number of inappropriate prescriptions and the degree of polypharmacy, especially in pediatric patients between the ages of 1–7 years. Contraindications and potential drug-drug interactions occurred in 11.0% and 10.1% of patients exposed to polypharmacy, respectively. Conclusions One in ten pediatric patients under the age of 7 years was prescribed two or more concurrent drugs on average per day. Furthermore, pediatric patients exposed to polypharmacy showed an increased risk of inappropriate drug use. The implementation of a medication review system that considers pediatric patient polypharmacy exposure would reduce inappropriate drug use and prevent unwanted adverse outcomes.
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Affiliation(s)
- Soo-Min Jeon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Susan Park
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Sandy Jeong Rhie
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Jin-Won Kwon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
- * E-mail:
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Golchin N, Johnson H, Bakaki PM, Dawson N, Knight EMP, Meropol SB, Liu R, Feinstein JA, Bolen SD, Kleinman LC, Horace A. Outcome measures in pediatric polypharmacy research: a scoping review. Drugs Ther Perspect 2019; 35:447-458. [PMID: 32256042 PMCID: PMC7123381 DOI: 10.1007/s40267-019-00650-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Various methods have been used to interpret the reports of pediatric polypharmacy across the literature. This is the first scoping review that explores outcome measures in pediatric polypharmacy research. OBJECTIVES The aim of our study was to describe outcome measures assessed in pediatric polypharmacy research. METHODS A search of electronic databases was conducted in July 2017, including Ovid Medline, PubMed, Elsevier Embase, Wiley Cochrane Central Register of Controlled Trials (CENTRAL), EBSCO CINAHL, Ovid PsyclNFO, Web of Science Core Collection, ProQuest Dissertations and Thesis A&I. Data were extracted about study characteristics and outcome measures, and also synthesized by harms or benefits mentioned. RESULTS The search strategy initially identified 8169 titles and screened 4398 using the inclusion criteria after de-duplicating. After the primary screening, a total of 363 studies were extracted for the data analysis. Polypharmacy (prevalence) was identified as an outcome in 31.4% of the studies, prognosis-related outcomes in 25.6%, and adverse drug reactions in 16.5%. A total of 265 articles (73.0%) mentioned harms, including adverse drug reactions (26.4%), side effects (24.2%), and drug-drug interactions (20.9%). A total of 83 studies (22.9%) mentioned any benefit, 48.2% of which identified combination for efficacy, 24.1% combination for treatment of complex diseases, and 19.3% combination for treatment augmentation. Thirty-eight studies reported adverse drug reaction as an outcome, where polypharmacy was a predictor, with various designs. CONCLUSIONS Most studies of pediatric polypharmacy evaluate prevalence, prognosis, or adverse drug reaction-related out-comes, and underscore harms related to polypharmacy. Clinicians should carefully weigh benefits and harms when introducing medications to treatment regimens.
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Affiliation(s)
- Negar Golchin
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Hannah Johnson
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Paul M. Bakaki
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Neal Dawson
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, Ohio, USA
| | | | - Sharon B. Meropol
- UH Rainbow Center for Child Health and Policy, University Hospitals and School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rujia Liu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado, Aurora, CO, USA
| | - Shari D. Bolen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
- Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, Ohio, USA
| | - Lawrence C. Kleinman
- UH Rainbow Center for Child Health and Policy, University Hospitals and School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alexis Horace
- Department of Clinical Sciences, University of Louisiana at Monroe College of Pharmacy, Monroe, Louisiana, USA
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Abstract
Creative collaborative approaches are required to meet the demands of managing depression in youth. Primary care providers are well positioned to engage depressed youth and their families, yet often lack the training, access to psychiatric providers, and the reimbursement structure to support their efforts. Child and adolescent psychiatrists are encouraged to support pediatricians in establishing more robust systems to provide screening and effective treatment interventions, particularly for youth at higher risk. Several models of collaborative care are described, in addition to their emerging evidence-base, in an effort to disseminate evolving treatment strategies that can drive implementation of effective collaborative approaches.
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Affiliation(s)
- Ian Kodish
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 4800 Sand Point Way Northeast, O/A 5.154, Seattle, WA 98105, USA
| | - Laura Richardson
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Research Institute, M/S CSB-200, PO Box 5371, Seattle, WA 98105, USA
| | - Abigail Schlesinger
- UPMC Western Psychiatric Hospital, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 11279 Perry Highway, Suite 204, Wexford, PA 15090, USA.
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29
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Lagerberg T, Molero Y, D’Onofrio BM, Fernández de la Cruz L, Lichtenstein P, Mataix-Cols D, Rück C, Hellner C, Chang Z. Antidepressant prescription patterns and CNS polypharmacy with antidepressants among children, adolescents, and young adults: a population-based study in Sweden. Eur Child Adolesc Psychiatry 2019; 28:1137-1145. [PMID: 30659386 PMCID: PMC6675912 DOI: 10.1007/s00787-018-01269-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022]
Abstract
This study examines trends in antidepressant drug dispensations among young people aged 0-24 years in Sweden during the period 2006-2013, as well as prescription patterns and central nervous system (CNS) polypharmacy with antidepressants. Using linkage of Swedish national registers, we identified all Swedish residents aged 0-24 years that collected at least one antidepressant prescription (here defined as antidepressant users) between 1 January 2006 and 31 December 2013 (n = 174,237), and categorized them as children (0-11 years), adolescents (12-17 years), and young adults (18-24 years). Prevalence of antidepressant dispensation rose from 1.4 to 2.1% between 2006 and 2013, with the greatest relative increase in adolescents [by 97.8% in males (from 0.6 to 1.3%) and by 86.3% in females (from 1.1 to 2.1%)]. Most individuals across age categories were prescribed selective serotonin reuptake inhibitors, received their prescriptions from psychiatric specialist care, and had treatment periods of over 12 months. Prevalence of CNS polypharmacy (dispensation of other CNS drug classes in addition to antidepressants) increased across age categories, with an overall increase in prevalence from 52.4% in 2006 to 62.1% in 2013. Children experienced the largest increase in polypharmacy of three or more psychotropic drug classes (4.4-10.1%). Anxiolytics, hypnotics, and sedatives comprised the most common additional CNS drug class among persons who were prescribed antidepressants. These findings show that the dispensation of antidepressants among the young is prevalent and growing in Sweden. The substantial degree of CNS polypharmacy in young patients receiving antidepressants requires careful monitoring and further research into potential benefits and harms.
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Affiliation(s)
- Tyra Lagerberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden.
| | - Y. Molero
- 0000 0004 1937 0626grid.4714.6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden ,0000 0004 1936 8948grid.4991.5Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK ,0000 0004 1937 0626grid.4714.6Department of Clinical Neuroscience, Karolinska Institutet, Solna, 171 65 Stockholm, Sweden
| | - B. M. D’Onofrio
- 0000 0004 1937 0626grid.4714.6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden ,0000 0001 0790 959Xgrid.411377.7Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN USA
| | - L. Fernández de la Cruz
- 0000 0004 1937 0626grid.4714.6Department of Clinical Neuroscience, Karolinska Institutet, Solna, 171 65 Stockholm, Sweden
| | - P. Lichtenstein
- 0000 0004 1937 0626grid.4714.6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - D. Mataix-Cols
- 0000 0004 1937 0626grid.4714.6Department of Clinical Neuroscience, Karolinska Institutet, Solna, 171 65 Stockholm, Sweden ,0000 0001 2326 2191grid.425979.4Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - C. Rück
- 0000 0004 1937 0626grid.4714.6Department of Clinical Neuroscience, Karolinska Institutet, Solna, 171 65 Stockholm, Sweden ,0000 0001 2326 2191grid.425979.4Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - C. Hellner
- 0000 0004 1937 0626grid.4714.6Department of Clinical Neuroscience, Karolinska Institutet, Solna, 171 65 Stockholm, Sweden ,0000 0001 2326 2191grid.425979.4Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Z. Chang
- 0000 0004 1937 0626grid.4714.6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
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30
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Vloet TD, Egberts K, Taurines R, Wewetzer C, Mehler-Wex C, Plener PL, Romanos M, Gerlach M. [Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception]. Z Kinder Jugendpsychiatr Psychother 2018; 47:193-202. [PMID: 30422047 DOI: 10.1024/1422-4917/a000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Polypharmacy of psychotropic drugs in child and adolescent psychiatry in Germany - rather the rule than the exception Abstract. Background: Polypharmacy increases the risk of interactions and enhances the chance of adverse drug reactions (ADRs). Hence, child and adolescent psychiatrists generally try to avoid polypharmacy with psychotropic drugs. However, only little data regarding the frequency of polypharmacy in child and adolescent psychiatry are available. This study analyzes clinical data on polypharmacy and the possible association with a higher risk of ADRs in Germany, with a focus on antidepressants and antipsychotics. Methods: We investigated a total of 940 datasets from descriptive studies on therapeutic drug monitoring (TDM) of pediatric patients treated with different psychotropic drugs. Results: The frequency of polypharmacy ranged up to 45.6 % (escitalopram) and 72.1 % (olanzapine). In 17.4 % of the cases, polypharmacy consisted of four or more psycho-/neuropharmacological substances. No increased incidence of ADRs was reported with polypharmacy of antipsychotics compared to monotherapy. Polypharmacy with sertraline was associated with a higher number of ADRs. Discussion and Conclusion: There is a high prevalence of polypharmacy with psychotropic drugs in child and adolescent psychiatry in Germany. Conclusions concerning individual drugs should be drawn with care since the subsample sizes were relatively small. However, our results do provide an indication of the prevalence of polypharmacy, although the validity of the data is limited. There is an urgent need to analyze data from larger and more homogeneous groups under more controlled conditions.
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Affiliation(s)
- Timo D Vloet
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Karin Egberts
- a geteilte Erstautorenschaft.,1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Regina Taurines
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Christoph Wewetzer
- 2 Abteilung für Kinder- und Jugendpsychiatrie und Psychotherapie, Kliniken der Stadt Köln gGmbH, Köln
| | - Claudia Mehler-Wex
- 3 Privatklinik für Seelische Gesundheit, Jugendliche und junge Erwachsene, HEMERA Klinik, Bad Kissingen
| | - Paul L Plener
- 4 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universitätsklinik Ulm, Ulm
| | - Marcel Romanos
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
| | - Manfred Gerlach
- 1 Zentrum für Psychische Gesundheit (ZEP), Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum Würzburg, Würzburg
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Abstract
PURPOSE OF REVIEW Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use. RECENT FINDINGS Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.
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Affiliation(s)
- Jessie N Rice
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Road, SPC 5766, Ann Arbor, MI, 48109-2700, USA.
| | - Carrie B Gillett
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Road, SPC 5766, Ann Arbor, MI, 48109-2700, USA
| | - Nasuh M Malas
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Road, SPC 5766, Ann Arbor, MI, 48109-2700, USA.,Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
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32
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Qato DM, Alexander GC, Guadamuz JS, Lindau ST. Prescription Medication Use Among Children and Adolescents in the United States. Pediatrics 2018; 142:peds.2018-1042. [PMID: 30150214 DOI: 10.1542/peds.2018-1042] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Information on the use of prescription medications among children and adolescents in the United States is lacking. We estimate the prevalence of prescription medication use, concurrent use, and potential major drug-drug interactions (DDIs) in this population. METHODS We conducted descriptive analyses using nationally representative data for people ≤19 years old from NHANES. Data were derived from a medication log administered by direct observation during in-home interviews. Acute medications were used for ≤30 days. Concurrent use was defined as use of ≥2 prescription medications. Micromedex was used to identify potentially major DDIs. RESULTS During 2013-2014, 19.8% of children and adolescents used at least 1 prescription medication, and 7.1% used acute medications. Concurrent use of prescription medications was 7.5% overall and was highest among boys 6 to 12 years old (12%) and among boys and girls ages 13 to 19 years old (10% for both). Using pooled 2009-2014 data, we found that 8.2% of concurrent users of prescription medications were at risk for a potentially major DDI. The vast majority of interacting regimens involved antidepressants and were more common among adolescent girls than boys (18.1% vs 6.6%; P < .05), driven largely by greater rates of use of acute medications. CONCLUSIONS Many US children and adolescents use prescription medications with nearly 1 in 12 concurrent users of prescription medications potentially at risk for a major DDI. Efforts to prevent adverse drug events in children and adolescents should consider the role of interacting drug combinations, especially among adolescent girls.
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Affiliation(s)
- Dima M Qato
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy and .,Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - G Caleb Alexander
- Department of Epidemiology and.,Center for Drug Safety and Effectiveness, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; and
| | - Jenny S Guadamuz
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy and
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
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33
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Chiara AN, Kashalikar N, Pomfret TC, Lenz K, Faber DM, Goldstein J, Clements KM, Angelini MC, Leto P, Jeffrey PL. An Evaluation of a Multidisciplinary Pediatric Behavioral Health Medication Initiative Workgroup's Interventions on Medication Prescribing in a Population of Medicaid Patients. J Manag Care Spec Pharm 2018; 24:746-751. [PMID: 30058981 PMCID: PMC10398286 DOI: 10.18553/jmcp.2018.24.8.746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In response to concerns surrounding pediatric behavioral health medication prescribing, the Massachusetts Medicaid Pharmacy Program implemented a Pediatric Behavioral Health Medication Initiative (PBHMI), proactively requiring prior authorization for specific behavioral health medications and combination regimens. A multidisciplinary therapeutic class management (TCM) workgroup retrospectively reviews complex cases and conducts prescriber outreach to encourage evidence-based practices in Massachusetts. OBJECTIVE To evaluate recommendation outcomes of telephonic peer-to-peer consultations conducted by the PBHMI TCM workgroup by assessing the percentage of accepted, modified accepted, or rejected recommendations, as well as prescriber satisfaction with consultation. METHODS This retrospective evaluation reviewed PBHMI TCM workgroup cases with completed peer-to-peer consultations from September 1, 2015, to August 28, 2016. The proportion of medication interventions (e.g., medication changes, dose reductions, and elimination of polypharmacy within or across behavioral health medication classes) accepted, modified accepted, or rejected were assessed based on pharmacy claims data and prior authorization resubmission, following a peer-to-peer consultation. The medication class and prescriber type were categorized in relation to the acceptance, modified acceptance, or rejection outcomes. Satisfaction with the TCM workgroup process was evaluated with an anonymous survey offered to prescribers who participated in prescriber outreach. RESULTS A total of 70 cases requiring a peer-to-peer consultation by a TCM workgroup child/adolescent psychiatrist had a completed outreach attempt during the evaluation period. Peer-to-peer consultations resulted in a recommendation acceptance rate of 31.4% (22/70), modified acceptance rate of 44.3% (31/70), and a rejection rate of 24.3% (17/70). Recommendations made during a peer-to-peer consultation were rejected by 30% (12/40) of child/adolescent psychiatrists compared with 16.7% (5/30) of nonchild/adolescent psychiatrists with completed peer-to-peer consultations (P = 0.43). Antipsychotics were most frequently recommended for regimen changes. All recommendations pertaining to a benzodiazepine were accepted by the prescriber. Results of an anonymous prescriber survey assessing satisfaction with the peer-to-peer consultation process exhibited variable responses among individual prescribers. CONCLUSIONS The small sample size in this observational evaluation and lack of a defined control group prevented direct associations between the endpoints and outcomes. Further research is required to determine if prescriber specialty and medication class may be influencing factors on recommendation acceptance. DISCLOSURES No outside funding supported this study. The authors have nothing to disclose. A poster of this project was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2017; March 27-30, 2017; in Denver, CO.
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Affiliation(s)
- Ashley N Chiara
- 1 Clinical Pharmacy Services, University of Massachusetts Medical School, Shrewsbury
| | - Neha Kashalikar
- 1 Clinical Pharmacy Services, University of Massachusetts Medical School, Shrewsbury
| | - Thomas C Pomfret
- 1 Clinical Pharmacy Services, University of Massachusetts Medical School, Shrewsbury
| | | | - Donna M Faber
- 4 Phoenix Veterans Affairs Health Care System, Phoenix, Arizona
| | - Joel Goldstein
- 5 DCF/DMH, Caring Together Initiative, Boston, Massachusetts, and Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, Massachusetts
| | - Karen M Clements
- 6 Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury
| | - Michael C Angelini
- 2 Clinical Pharmacy Services, University of Massachusetts Medical School, Shrewsbury, and MCPHS University, Boston
| | - Patricia Leto
- 1 Clinical Pharmacy Services, University of Massachusetts Medical School, Shrewsbury
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Winters DE, Fukui S, Leibenluft E, Hulvershorn LA. Improvements in Irritability with Open-Label Methylphenidate Treatment in Youth with Comorbid Attention Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder. J Child Adolesc Psychopharmacol 2018; 28:298-305. [PMID: 29708762 PMCID: PMC6016730 DOI: 10.1089/cap.2017.0124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this open-label study was to examine the effects of long-acting methylphenidate (MPH) treatment on irritability and related emotional symptoms associated with disruptive mood dysregulation disorder (DMDD) in youth with comorbid attention-deficit/hyperactivity disorder (ADHD). METHODS The sample included 22 medication-free male and female subjects (ages 9-15) who met criteria for both DMDD and ADHD. Participants underwent a 4-week trial of long-acting MPH treatment (Concerta®), with weekly dosing increases until a therapeutic dose was reached. Repeated measures t-tests were used to compare pre- and posttreatment ratings of primary and secondary measures. The primary outcome was self-report irritability. Secondary outcomes included parent and child ratings of emotional frequency, emotional lability, and negative affect (NA). Multiple regression was used to examine the impact baseline hyperactivity, age, gender, race, socioeconomic status, or comorbid diagnosis had on treatment outcomes. RESULTS Significant improvements (medium to large effect sizes) in child-rated irritability as well as parent and child ratings of emotional lability, NA, and anger were found. As anticipated, ADHD symptoms also improved. While a majority of the sample saw improvement in child-rated irritability (71%), symptoms worsened a small proportion (19%), and an even smaller portion experienced no change (10%). No demographics, psychiatric comorbidities, or severity of ADHD symptoms influenced treatment outcomes. CONCLUSIONS Study findings suggest that MPH treatment significantly improved mood and emotional symptoms associated with DMDD comorbid with ADHD. These findings, coupled with good tolerability in this open-label pilot study supports further research into the use of MPH as a first-line treatment for DMDD. Future work examining MPH treatment of youth with DMDD with and without comorbid ADHD is needed.
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Affiliation(s)
- Drew E. Winters
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Sadaaki Fukui
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Leslie A. Hulvershorn
- Section of Child and Adolescent Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
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35
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Lake JK, Denton D, Lunsky Y, Shui AM, Veenstra-VanderWeele J, Anagnostou E. Medical Conditions and Demographic, Service and Clinical Factors Associated with Atypical Antipsychotic Medication Use Among Children with An Autism Spectrum Disorder. J Autism Dev Disord 2017; 47:1391-402. [PMID: 28210827 DOI: 10.1007/s10803-017-3058-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This study aimed to describe rates of antipsychotic medication use and the association between their use and demographics, clinical variables, and the use of behavioral/education services among children with ASD. For children with ASD ages 2-11 (n = 4749) and those 12-17 (n = 401), 5.4 and 17.7% were prescribed at least one atypical antipsychotic medication respectively. In the multivariable model of young children, older age, use of multiple psychotropic medications, prior ASD diagnosis, non-white Hispanic race/ethnicity, and oppositional defiant problems were associated with antipsychotic use. Among older children, only older age was associated with antipsychotic use. In at least one age group, antipsychotic medication use was also related to behaviour, family and occupational therapy, public insurance, site region, externalizing problems, body mass index, and sleep and gastrointestinal problems.
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Hilt RJ, Barclay RP, Bush J, Stout B, Anderson N, Wignall JR. A Statewide Child Telepsychiatry Consult System Yields Desired Health System Changes and Savings. Telemed J E Health 2015; 21:533-7. [DOI: 10.1089/tmj.2014.0161] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Robert J. Hilt
- Seattle Children's PAL Program, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Rebecca P. Barclay
- Seattle Children's PAL Program, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - James Bush
- Office of Health Care Financing, Wyoming Department of Health, Cheyenne, Wyoming
| | - Brenda Stout
- Office of Health Care Financing, Wyoming Department of Health, Cheyenne, Wyoming
| | | | - Julia R. Wignall
- Seattle Children's PAL Program, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
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Lascar P. ANHPP - Iatrogénie et psychiatrie au travers du dialogue pharmacien-psychiatre. Eur Psychiatry 2014. [DOI: 10.1016/j.eurpsy.2014.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
La réflexion sur la iatrogénie de nos prescriptions médicamenteuses est plus que jamais d’actualité. En psychiatrie, la littérature concernant les effets indésirables des psychotropes de même que la médiatisation de certaines situations conduit à l’accroissement de la vigilance, aussi bien des professionnels de santé que des patients et de leurs familles. La iatrogénie serait effectivement responsable d’environ 330 000 à 490 000 hospitalisations par an, avec un risque particulièrement augmenté chez les sujets âgés. Pourtant près de la moitié des accidents médicamenteux recensés seraient évitables [1]. Plus particulièrement, la iatrogénie des benzodiazépines, consommées par 1 français sur 5, pose un problème majeur de santé publique. Outre leurs effets indésirables neuropsychiatriques, elles favorisent la morbidité, entre autre en augmentant le risque de chute, y compris avec les molécules à demi-vie courte, et notamment chez le sujet âgé [2]. Concernant les antidépresseurs, la survenue d’effets indésirables précoces favorise sensiblement la rupture thérapeutique dans les 12 premières semaines de traitement et récemment, des facteurs génétiques prédicteurs d’effets indésirables dus aux antidépresseurs ont été mis en évidence [3]. Chez l’enfant et l’adolescent, malgré le peu d’études cliniques sur l’usage des psychotropes dans cette population, leur prescription est de plus en plus fréquente, avec de nombreuses interrogations sur leurs effets iatrogènes, principalement métaboliques et endocriniens, et ce d’autant plus lorsqu’ils sont traités avec plusieurs molécules [4]. Dans toutes ces situations qui imposent une évaluation optimale de la balance bénéfice/risque, la collaboration pharmacien-psychiatre à tous les niveaux de prise en charge du patient est un outil essentiel. La méthodologie et la systématisation de cette collaboration doivent être promues.
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Häβler F, Thome J, Reis O. Polypharmacy in the treatment of subjects with intellectual disability. J Neural Transm (Vienna) 2014; 122 Suppl 1:S93-100. [DOI: 10.1007/s00702-014-1219-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/08/2014] [Indexed: 02/02/2023]
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