Antipsychotics in clinical practice: guidelines for safe and effective use

Survey of atypical antipsychotic prescribing by Canadian child psychiatrists and developmental pediatricians for patients aged under 18 years

OBJECTIVE

To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada.

METHOD

We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics Section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used.

RESULTS

Ninety-four percent of the child psychiatrists (95% CI, 90% to 97%) and 89% of the developmental pediatricians (95% CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed.

CONCLUSIONS

Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group.

Benefit coverage of novel antipsychotics in Medicaid programs and the Veterans Health Administration

When risperidone, olanzapine, and quetiapine were introduced, concerns were raised regarding the extent to which drug benefit policies might constrain their use. A national survey of eligible Medicaid programs (N = 47; 100%) and Veterans Health Administration facilities (N = 141; 94%) in 1998 found that within Medicaid, open formularies were common, preauthorization requirements were rare, and few barriers existed, whereas VHA facilities reported relatively more constraints in terms of formulary restrictions and preauthorization requirements. Although drug benefit policies have the potential to exert a major influence over prescribing practices, it is unlikely that these policies significantly restricted access to these antipsychotics.