Antipsychotic Prescribing and Safety Monitoring Practices in Children and Youth: A Population-Based Study in Alberta, Canada

Trends and off-label utilization of antipsychotics in children and adolescents from 2016 to 2021 in China: a real-world study

BACKGROUND

Global antipsychotic usage, including off-label prescriptions, has increased in recent decades. However, trends in China, particularly for children and adolescents, remain unclear. This study explored these trends from 2016 to 2021 and identified factors associated with off-label prescriptions.

METHODS

In this retrospective study, we analyzed on-label and off-label prescriptions based on drug information approved by the China National Medical Products Administration. To identify factors associated with off-label prescriptions, we conducted multivariate logistic regression analysis.

RESULTS

Our study included 48,258 antipsychotic prescriptions, 52.4% (25,295) of which were prescriptions for males. Of these, 61.7% (29,813) were off-label. Over time, the number of antipsychotics and the percentage of off-label prescriptions for children and adolescents overall increased from 2016 to 2021. The use of atypical antipsychotics increased, whereas that of typical antipsychotics decreased. For off-label usage, all of the factors in our study were associated with off-label usage, including age, sex, year, region, department, reimbursement, antipsychotic type, drug expense, number of polypharmacy and diagnoses. Additionally, tiapride (15.8%) and aripiprazole (18.6%) were the most common typical and atypical antipsychotics, respectively. For pediatric diseases, common diagnoses included mood or affective disorders (31.7%) and behavioral and emotional disorders, with onset usually occurring in childhood and adolescence (29.1%). Furthermore, a depressive state was the most common diagnosis for which antipsychotic polypharmacy was used for treatment.

CONCLUSION

In this retrospective study, off-label antipsychotic prescriptions were common, with trends generally increasing among children and adolescents from 2016 to 2021. However, there is a lack of evidence supporting off-label usage, thus emphasizing the need for studies on the efficacy and safety of these treatments.

Impact of the COVID-19 pandemic on antidepressant and antipsychotic use among children and adolescents: a population-based study

Background

The COVID-19 pandemic was associated with increases in the prevalence of depression, anxiety and behavioural problems among children and youth. Less well understood is the influence of the pandemic on antidepressant and antipsychotic use among children. This is important, as it is possible that antidepressants and antipsychotics were used as a "stop-gap" measure to treat mental health symptoms when in-person access to outpatient care and school-based supportive services was disrupted. Furthermore, antipsychotics and antidepressants have been associated with harm in children and youth. We examined trends in dispensing of these medications two years following the pandemic among children 18 years of age and under in Ontario, Canada.

Methods

We conducted a population-based time-series study of antidepressant and antipsychotic medication dispensing to children and adolescents ≤18 years old between September 1, 2014, and March 31, 2022. We measured monthly population-adjusted rates of antidepressant and antipsychotics obtained from the IQVIA Geographic Prescription Monitor (GPM) database. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of antidepressants and antipsychotics occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected use of these drugs.

Results

Overall, we found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. Specifically, we observed an immediate step decrease in antidepressant dispensing associated with a structural break in April 2020 (-55.8 units per 1,000 individuals; 95% confidence intervals [CI] CI: -117.4 to 5.8), followed by an increased monthly trend in the rate of antidepressant dispensing of 13.0 units per 1,000 individuals (95% CI: 10.2-15.9). Antidepressant dispensing was consistently greater than predicted from September 2020 onward. Antipsychotic dispensing increased immediately following a June 2020 structural break (26.4 units per 1,000 individuals; 95% CI: 15.8-36.9) and did not change appreciably thereafter. Antipsychotic dispensing was higher than predicted at all time points from June 2020 onward.

Conclusion

We found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. These increases were sustained through nearly two years of observation and are especially concerning in light of the potential for harm with the long-term use of antipsychotics in children. Further research is required to understand the clinical implications of these findings.

Adherence to antipsychotic laboratory monitoring guidelines in children and youth: a population-based study

Background

In 2011, the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) published guidelines for the metabolic monitoring of antipsychotic-treated children and youth. Population-based studies examining adherence to these guidelines are needed to ensure the safe use of antipsychotics in children and youth.

Methods

We conducted a population-based study of all Ontario residents aged 0 to 24 who were newly dispensed an antipsychotic between April 1, 2018, and March 31, 2019. We estimated prevalence ratios (PRs) and 95% confidence intervals (CI) associating sociodemographic characteristics with the receipt of baseline and follow-up (3- and 6-month) laboratory testing using log-Poisson regression models.

Results

Overall, 6,505 of 27,718 (23.5%) children and youth newly dispensed an antipsychotic received at least one guideline-recommended baseline test. Monitoring was more prevalent among individuals aged 10 to 14 years (PR 1.20; 95% CI 1.04 to 1.38), 15 to 19 years (PR 1.60; 95% CI 1.41 to 1.82), and 20 to 24 years (PR 1.71; 95% CI 1.50 to 1.94) compared to children under the age of 10. Baseline monitoring was associated with mental health-related hospitalizations or emergency department visits in the year preceding therapy (PR 1.76; 95% CI 1.65 to 1.87), a prior diagnosis of schizophrenia (PR 1.20; 95% CI 1.14 to 1.26) or diabetes (PR 1.35; 95% CI 1.19 to 1.54), benzodiazepine use (PR 1.13; 95% CI 1.04 to 1.24), and receipt of a prescription from a child and adolescent psychiatrist or developmental pediatrician versus a family physician (PR 1.41; 95% CI 1.34 to 1.48). Conversely, monitoring was less frequent in individuals co-prescribed stimulants (PR 0.83; 95% CI 0.75 to 0.91). The prevalence of any 3- and 6-month follow-up monitoring among children and youth receiving continuous antipsychotic therapy at these time points was 13.0% (1,179 of 9,080) and 11.4% (597 of 5,261), respectively. Correlates of follow-up testing were similar to those of baseline monitoring.

Conclusion

Most children initiating antipsychotic therapy do not receive guideline-recommended metabolic laboratory monitoring. Further research is needed to understand reasons for poor guideline adherence and the role of clinician training and collaborative service models in promoting best monitoring practices.

Weight Gain During Antipsychotic Treatment in Children, Adolescents, and Adults: A Disproportionality Analysis in the Global Pharmacovigilance Database, Vigibase®

INTRODUCTION

While antipsychotic-induced weight gain has been widely described in adults, it has yet to be better characterized in children and adolescents.

OBJECTIVE

The aim of this study was to assess antipsychotic-induced weight-gain reporting in children and adolescents as compared to adults, and according to the type of antipsychotic.

METHODS

The study is an observational, case-non-case study using individual case safety reports from the WHO global pharmacovigilance database VigiBase^® from 1 January 2000 to 2 June 2021. Disproportionality in antipsychotic-related weight-gain reporting in children and adolescents compared to adults was evaluated based on reporting odds ratios (RORs) with corresponding 95% confidence intervals (CIs) through multivariate logistic regression modeling. Analysis was adjusted for sex, region of reporting, year of notification, reporter qualification, concomitant use of antidepressants, and use of more than one antipsychotic.

RESULTS

Among 282,224 antipsychotic-related spontaneous reports included in this analysis, we identified 16,881 (6.0%) weight-gain cases. Disproportionality in weight-gain reporting was found in children (adjusted ROR (aROR) 3.6; 95% CI 3.3-3.8) and in adolescents (aROR 2.3; 95% CI 2.2-2.4) compared to adults. Use of risperidone was associated with the highest increase in weight-gain reporting in children (aROR 4.9; 95% CI 3.9-6.1) and adolescents (aROR 3.6; 95% CI 3.1-4.1).

CONCLUSIONS

Compared to adults, weight-gain reporting with antipsychotics was disproportionally higher in the pediatric population, especially in children under 12 years of age. Considering the impact of weight gain on global morbidity and mortality, physicians should closely monitor weight gain in young patients, especially children on risperidone.

Polypharmacy in children and adolescents initiating antipsychotic drug in 2008-2016: a nationwide register study

OBJECTIVE

The use of antipsychotics in children and adolescents has increased rapidly. Little is known about psychotropic polypharmacy in children and adolescent initiating an antipsychotic drug. Thus, we investigated the frequency and predictors of polypharmacy during the first year of antipsychotic use in Finnish children and adolescents.

METHODS

Between 2008 and 2016, 14 848 individuals aged 1-17 years initiating risperidone, quetiapine, aripiprazole, or olanzapine treatment were identified from Finnish Prescription Registry. Data on psychotropic drug prescriptions prior to and during antipsychotic treatment were collected. Associations between predictors and polypharmacy were analyzed with regression models.

RESULTS

During the study period polypharmacy occurred in 44.9% of the new antipsychotic users, being more frequent in girls (55.5%) than in boys (44.5%, p < 0.001). The two most frequent concomitant psychotropic drug classes were antidepressants (66.2%) and psychostimulants/atomoxetine (30.8%). Adolescents aged 13-15 and 16-17 years, and girls showed an increased risk of polypharmacy during antipsychotic treatment (OR 2.37 [95% CI 1.91-2.92], OR 2.39 [95% CI 1.92-2.98], and OR 1.64 [95% CI 1.51-1.78], respectively). The use of psychostimulants/atomoxetine or antidepressants prior to initiation of antipsychotic treatment was strongly associated with polypharmacy during antipsychotic treatment (OR 8.39 [95% CI 7.49-9.41], OR 3.02 [95% CI 2.75-3.31]).

CONCLUSIONS

Polypharmacy was common in children and adolescents initiating antipsychotic treatment. Prior use of psychostimulants/atomoxetine and antidepressants increased the risk of polypharmacy. The use of antipsychotics was mainly off-label, thus, the risks of concomitant use of antipsychotics with other psychotropic drugs should be carefully weighed.

Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012-2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms "disruptive behaviour disorder", "oppositional defiant disorder", "conduct disorder" and their variants, along with "antipsychotic", "atypical antipsychotic" and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

In search of measures to improve the detection of increased cardiometabolic risk in children using second-generation antipsychotic medications

PURPOSE

Second-generation antipsychotic medications (SGAs) are widely used in child psychiatry. SGA-induced metabolic disturbances are common in children, but monitoring practices need systematisation. The study's aims were to test an SGA-monitoring protocol, examine the distributions of metabolic measurements compared to reference values in child psychiatry patients, and determine whether using a homeostasis model for the assessment of insulin resistance (HOMA-IR) and triglyceride/high-density lipoprotein (TG/HDL) ratio could improve the detection of increased cardiometabolic risk.

MATERIALS AND METHODS

A systematic monitoring protocol was implemented. Weight and height, blood pressure, fasting glucose, insulin, HDL, and TG were measured at baseline and four times during follow-up. HOMA-IR, TG/HDL ratio and zBMI were calculated. Age-, gender- and BMI-specific percentile curves for HOMA-IR were used to define elevated cardiometabolic risk.

RESULTS

The study patients (n = 55, mean age 9.9 years) were followed for a median of 9 months. A disadvantageous, statistically significant shift, often appearing within the reference range, was seen in zBMI, TG, HDL, glucose, insulin, HOMA-IR, and TG/HDL ratio. The increase in HOMA-IR appeared earlier than individual laboratory values and was more evident than the TG/HDL ratio increase. An HOMA-IR cut point of 1.98 resulted in a sensitivity and specificity of 83%. Compared to a previous study performed in the same location, the monitoring rates of metabolic parameters improved.

CONCLUSION

The monitoring protocol implementation improved the monitoring of metabolic parameters in child psychiatric patients using SGAs. Using HOMA-IR as part of systematic SGA monitoring could help detect metabolic adverse effects.

The FTO rs9939609 Variant Is Associated with Cardiometabolic Disease Risk and Dietary Energy Intakes in Children with Mental Health Disorders

Background

Second-generation antipsychotics (SGAs) are used to treat children for mental health disorders but in some children they cause cardiometabolic complications including weight gain and type 2 diabetes. Genetic variants can place a child at risk of developing these metabolic complications. The fat mass and obesity-associated (FTO) rs9939609 A allele has been associated with obesity and dietary energy intakes in healthy children but its relation to metabolic complications in SGA-treated children is not known.

Objectives

This study investigated the association of the FTO rs9939609 variant and SGA treatment with cardiometabolic complications and dietary intakes in children with mental health disorders.

Methods

A cross-sectional population of children (≤18 y; n = 506) with mental health disorders that were SGA-treated (n = 197) and SGA-naïve (n = 309) were recruited through the Department of Psychiatry at BC Children's Hospital. Dietary intakes were estimated using 3-d food records in a subset of children (n = 73).

Results

Genotype frequencies were not different between SGA-treated (TT genotype 42.6%, TA genotype 38.6%, AA genotype 18.8%) and SGA-naïve (TT 41.1%, TA 39.5%, AA 19.4%) children. Children with the A allele had lower BMI z-sores compared with the TT genotype (0.84 ± 1.19 compared with 1.19 ± 1.36; P = 0.005, adjusted for ethnicity). We observed an interaction between FTO genotype and SGA status on fasting glucose (P = 0.036). SGA-naïve children with the A allele had higher fasting glucose than those with the TT genotype (4.96 ± 0.35 compared with 4.81 ± 0.35 mmol/L; P = 0.001), in adjusted models (age, sex, ethnicity, and BMI z-score). This was not observed in SGA-treated children. Children with the A allele had higher daily total energy intakes compared with the TT genotype (1994 ± 619 compared with 1814 ± 484 kcal/d; P = 0.048), in adjusted models (age, sex, ethnicity, and BMI z-score); no effect of SGA-treatment was observed.

Conclusions

Our findings suggest the A allele of the FTO rs9939609 variant is associated with higher BMI in children with mental health disorders, but only in those not treated with SGAs.

Monitoring of metabolic side-effects in children and adolescents prescribed antipsychotic medication: A systematic review

OBJECTIVES

Prescribing antipsychotic medications to children and adolescents with severe mental and developmental disorders is common; however, there is a lack of consensus on appropriate metabolic monitoring for this population. This review systematically evaluates studies examining metabolic monitoring of children and adolescents prescribed antipsychotic medication to understand the clinical practice of metabolic monitoring and identify opportunities to improve the safety of antipsychotic prescribing in this population.

METHODS

A systematic search for original research on metabolic monitoring in children and adolescents prescribed antipsychotics was conducted in six databases (PubMed, EMBASE, PsycINFO, The Cochrane Library [Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CENTRAL], Cochrane Methodology Register and Web of Science [Science and Social Science Citation Index]) from inception to February 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for quality and findings summarised using narrative synthesis.

RESULTS

Fifteen papers were identified. Studies agreed on the need for metabolic monitoring; however, there was a gap between guideline-recommended practice and clinical practice. Variable rates of baseline and subsequent monitoring were reported for both physical and biochemical parameters, with particularly low rates for monitoring requiring venesection. Younger age was also associated with lower monitoring rates. Implementation of quality improvement activities (new guidelines, staff education and checklists) improved monitoring rates although the measurement of biochemical parameters still occurred in only a minority of children.

CONCLUSION

Despite widespread awareness and concern regarding metabolic side-effects, monitoring occurred inconsistently and infrequently, particularly for biochemical parameters requiring venesection. Monitoring of anthropometric measures (weight, body mass index and waist circumference) with escalation to more laboratory testing where metabolic concerns are identified may improve monitoring. Minimising iatrogenic harm, through reduced antipsychotic prescription where possible, is a clinical priority in this population.

Long-Term Metabolic Monitoring of Youths Treated with Second-Generation Antipsychotics 5 Years after Publication of the CAMESA Guidelines Are We Making Progress? Surveillance Métabolique à Long Terme des Jeunes Traités par Antipsychotiques de Deuxième Génération, Cinq ans Après la publication des Lignes Directrices Camesa: Faisons-Nous des Progrès?

OBJECTIVE

The potential metabolic adverse effects of second-generation antipsychotics (SGA) need to be monitored. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics (CAMESA) offers guidelines for this purpose. We aimed to evaluate the long-term rates of youths receiving monitoring in mental health clinics and document the factors that may influence them.

METHOD

The charts of 180 patients (13.3 ± 3.1 years, 54.4% males) receiving SGA treatment for the first time between January 2016 and June 2018 were reviewed. Monitoring was divided into baseline and 1- to 6-month and 9- to 24-month periods. Population under study was stratified into children (4 to 12 years) and adolescents (13 to 18 years). Sociodemographic characteristics, psychiatric diagnosis and comorbidities, prescribed SGAs and comedications, anthropometric measures (AM), blood pressure (BP), blood tests (BT), electrocardiogram, and the psychiatrist's years of practice were collected. Cross tables were used to present the monitoring rates. Categories were compared by covariate analysis. Rates of patients monitored across categories were compared using Fisher exact test.

RESULTS

Monitoring rates for AM, BT, and BP were 55%, 47.8%, and 46.7% at baseline; 50%, 41.7%, and 45.2% at 1 to 6 months; and 47.2%, 41.5%, and 40.6% at 9 to 24 months, respectively. Higher monitoring rates were significantly associated with adolescent status (baseline, 1 to 6 months), a diagnosis of psychotic and/or affective disorder (baseline, 1 to 6 months, 9 to 24 months), having ≤1 psychiatric comorbidities (1 to 6 months), high SGA dose (baseline, 1 to 6 months), and clinician's experience (baseline, 9 to 24 months). Significantly lower monitoring rates were associated with the psychostimulant/atomoxetine comedication (baseline, 1 to 6 months, 9 to 24 months).

CONCLUSION

Five years after publication of the CAMESA guidelines, metabolic monitoring is conducted for less than half of patients. In our sample, age, diagnostic category, psychiatric comorbidities, SGA dose, clinician's experience, and comedications influenced the monitoring rates. Major progress still needs to be made before reaching a satisfactory level of monitoring.

Gender differences in the use of atypical antipsychotics in early-onset schizophrenia: a nationwide population-based study in Brazil

BACKGROUND

The use of atypical antipsychotics for the treatment of schizophrenia and other mental disorders in populations under 18 years of age is increasing worldwide. Little is known about treatment patterns and the influence of gender differences, which may be a predictor of clinical outcomes. The aim of this study was to investigate gender differences in the use of atypical antipsychotics in patients with early-onset schizophrenia (EOS) assisted by the public health system in Brazil.

METHODS

We conducted a cross-sectional study of outpatients with EOS aged 10 to 17 years who received at least one provision of atypical antipsychotics (clozapine, olanzapine, risperidone, quetiapine or ziprasidone) from a large Brazilian pharmaceutical assistance programme. Data were retrieved from a nationwide administrative database from 2008 to 2017.

RESULTS

Of the 49,943 patients with EOS, 63.5% were males, and the mean age was 13.6 years old. The patients were using risperidone (62.5%), olanzapine (19.6%), quetiapine (12.4%), ziprasidone (3.3%) and clozapine (2.2%). We found gender differences, especially in the 13-17 year age group (65.1% for males vs. 34.9% for females, p < 0.001), in the use of risperidone (72.1% for males vs. 27.9% for females, p < 0.001) and olanzapine (66.5% for males vs. 33.5% for females, p < 0.001). Only in the 13 to 17 years age group were the prescribed doses of olanzapine (p = 0.012) and quetiapine (p = 0.041) slightly higher for males than for females.

CONCLUSIONS

Our findings showed gender differences among patients diagnosed with EOS and who received atypical antipsychotics. More attention should be devoted to gender differences in research and clinical practice.

Second-Generation Antipsychotic Use in Pediatric Emergency Medicine

ABSTRACT

In recent years, the number of patients presenting to the emergency department with mental health complaints has been growing, alongside an increase in second-generation antipsychotic (SGAs) prescriptions for a variety of mental health conditions. Children treated with SGAs may have abnormalities, such as rapid weight gain and central adiposity, glucose intolerance, dyslipidemia, and hypertension; they may present to the pediatric emergency department with components of metabolic syndrome or type 2 diabetes, and a subsequent significant risk for cardiovascular complications later in life. Pediatric emergency department providers may serve as a safety net for patients to detect SGA-related metabolic complications, especially among vulnerable populations lacking access to primary care or psychiatric services.

Aripiprazole in Children and Adolescents

Objective: To review the use of aripiprazole in children and adolescents. Methods: Medline and Embase databases were systematically searched using the keywords aripiprazole and child or adolescent over the period from 2000 to 2019. The initial screen yielded 163 publications, from which 99 studies were reviewed. Results: Aripiprazole is one of the most widely prescribed atypical antipsychotics. Like others, its use in children and adolescents is becoming commonplace and occurs in off-label indications. Aripiprazole has proven efficacy for several indications in children and adolescents, including schizophrenia, bipolar disorder, Tourette's syndrome, and behavioral impairments associated with autism and intellectual disability. Adverse effects are more important in children and adolescents than adults, particularly weight gain, drowsiness, extrapyramidal effects, and metabolic effects, even though the latter may appear less important than with other atypical antipsychotics. Severe adverse effects often occur in multiple-prescription settings. At present, postprescription monitoring is very poor. Conclusion: Aripiprazole has proven efficacy for several indications in children and adolescents. However, its use requires clinical and paraclinical monitoring to assess the occurrence of adverse events that may challenge the benefit/risk ratio. In addition, off-label prescriptions should be limited, as they appear to account for a significant proportion of aripiprazole use worldwide.

Impact of Antipsychotic Guidelines on Laboratory Monitoring in Children with Neurodevelopmental Disorders

Objectives: The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) guidelines provide monitoring recommendations for children who are treated with second-generation antipsychotics (SGAs). The objective of this study was to determine the impact of the CAMESA guidelines on SGA monitoring in children with neurodevelopmental disorders. Methods: A retrospective chart review compared laboratory monitoring in children treated with SGAs who were referred to a tertiary psychopharmacology clinic before (2008-2011) and after (2013-2016) CAMESA publication. Chi-squared tests were used to detect changes in SGA use and monitoring between the two time periods. Results: A total of 345 charts were reviewed (n = 136 pre-CAMESA, n = 209 post-CAMESA). The proportion of children taking an SGA increased significantly (35% vs. 49%; p = 0.02) as did the duration of SGA treatment before tertiary assessment (18.6 months vs. 27.2 months; p = 0.03). SGA monitoring data were missing in 40% of charts pre-CAMESA and in 31% of charts post-CAMESA. The proportion of patients with any available laboratory monitoring did not change between the time periods (35% pre-CAMESA vs. 39% post-CAMESA; p = 0.56). Similarly, the proportion of patients with full laboratory monitoring was not significantly different between time periods (15% pre-CAMESA vs. 25% post-CAMESA; p = 0.23). Conclusions: SGA monitoring rates did not significantly improve after CAMESA guideline publication. To maximize benefit and mitigate risks of these medications, there is a need to identify barriers to SGA monitoring.

Use of Antipsychotics: The Experiences, Views, and Monitoring Practices of Child and Adolescent Psychiatrists in Turkey

Objectives: The aim of this study is to evaluate the antipsychotics prescribed by child psychiatrists and their applications on the follow-up of these drugs. Methods: The universe of this research included consultant physicians and child psychiatry residents working in the field. A questionnaire has been created that assesses the use of antipsychotics and follow-up processes of physicians. The survey involved 19 questions. Contents of the survey were sociodemographic data, short-term and long-term follow-up of antipsychotic drugs, side-effect intervention strategies, and diagnoses of the most commonly preferred antipsychotic medications. The survey was delivered via e-mail and sent as a message to the child and adolescent psychiatrists in Turkey. Results: One hundred sixty-one physicians working in the field of child and adolescent psychiatry participated in the study. Aripiprazole (32.2%), risperidone (30.4%), and quetiapine (14.9%) were three most commonly prescribed antipsychotics. Disruptive behavior-related disorders (28.9%), behavior problems related to autism spectrum disorder (20.7%), behavior problems related to intellectual disability (14.5%), and attention-deficit/hyperactivity disorder (12.4%) were the most common diagnoses requiring antipsychotics medications. Before starting antipsychotic treatment, the most commonly evaluated parameters were body mass index (BMI) (47.2%), waist circumference (10.5%), blood pressure (28.5%), lipid profile (37%), and blood glucose level (41.6%). When the evaluations made at least in a year after starting antipsychotic drug therapy were examined, 80.2% of physicians reported blood glucose, 79.6% lipid profile, 65.7% BMI, 59.1% blood pressure, and 26.6% waist circumference measurement almost always done. Conclusions: The results showed that the adherence to recommendations in guidelines for the screening of antipsychotic-related side effects was low. This study suggests that interventions should be made about antipsychotic monitoring training to physicians.

Guideline Adherence of Monitoring Antipsychotic Use for Nonpsychotic Indications in Children and Adolescents: A Patient Record Review

BACKGROUND

Antipsychotics are frequently prescribed to children and adolescents for nonpsychotic indications. Guidelines recommend regularly assessing treatment response and adverse effects and the ongoing need for their use. We aimed to assess adherence to recommendations of available guidelines regarding monitoring antipsychotic use and to test the influence of children's age, sex, intelligence quotient, and diagnosis on adherence.

METHODS

We reviewed 426 medical records from 26 centers within 3 large Dutch child and adolescent psychiatry organizations, excluding children with schizophrenia, psychosis, mania, or an intelligence quotient below 70. We investigated whether there was regular assessment of treatment response, adverse events (physical and laboratory), and at least annual discussion of the need of continued use.

RESULTS

On average, treatment response was assessed in 69.3% of the recommended treatment periods, height in 25.6%, weight in 30.6%, blood pressure in 20.6%, evaluation of adverse events in 19.4%, and cardiometabolic measures in 13.7%; discontinuation and/or continued need was discussed at least annually in 36.2%. Extrapyramidal and prolactin-related adverse effects, waist circumference, glucose, and lipids were rarely investigated. Higher age was associated with lower rates of assessment of treatment response. Most antipsychotics were prescribed long-term. In those children with sufficient documentation of the course of treatment, 57.7% was still using an antipsychotic 3 years after initiation.

CONCLUSIONS

Our findings indicate insufficient adherence to guideline recommendations for monitoring antipsychotic use in children and adolescents, as well as long duration of use in the majority of children. Especially, older children are at higher risk of receiving suboptimal care.

Advocacy for better metabolic monitoring after antipsychotic initiation: based on data from a French health insurance database

Background: Nearly 3% of the population is treated by antipsychotic. The aim of this study was to assess the conformity of monitoring with guidelines to prevent Metabolic Syndrome. Research design and method: The analysis was conducted using SNIIRAM data (2013 to 2017) on a cohort of patients who received at least eight antipsychotic dispensings in the first year. Glucose and lipid testings were recorded according to refunds at initiation [between -3 and 0.5 months], 3 months [between 2 and 4 months], and 12 months [between 11 and 13 months] after, and assuming optimal testing during hospitalization (exclusive of psychiatric unit). Descriptive and comparative analysis, «chi-squared test or Student's t-test», were performed as well as multivariate analysis with logistic regression. Results: 18 760 patients were selected, 14 421 were still alive and monitored at the end of the follow up. In the recommended period, only 2.89% of patients had three complete testings and 50.6% one or two complete testings Non-optimal testing was more likely to occur in children and adults (vs elderly), in patients with less than 3 prescribers, and with universal medical coverage. Conclusion: Monitoring remains dramatically insufficient. New actions involving patients, practitioners, and authorities are warranted.

Treatment-related weight gain and metabolic complications in children with mental health disorders: potential role for lifestyle interventions

Over 1 million Canadian children are estimated to have a mental health disorder, which are commonly treated with medications, such as second-generation antipsychotics (SGAs). Estimates suggest that SGA prescriptions to children are increasing in Canada. Although these medications are important and lifesaving components of psychiatric treatment, they are not without side effects. For some children, SGA treatment is associated with adverse metabolic complications including rapid weight gain, dyslipidemia, elevated blood pressure, and risk for type 2 diabetes. It is not clear why these complications develop, but it is assumed that SGAs stimulate appetite and food intake, and reduce resting energy expenditure leading to weight gain and that the metabolic complications occur secondary to the weight gain. Understanding the mechanisms underlying these complications is key to being able to identify children at risk and prevent and optimize treatment. In this narrative review, we provide an overview of the literature pertaining to the weight gain and metabolic complications in children treated with SGAs, highlighting the scope of the problem and the current limited research on how diet and physical activity can be used to prevent or lessen the severity of the metabolic complications and improve the long-term health trajectories of SGA-treated children. Novelty: Children are increasingly being treated with second-generation antipsychotics for mental health disorders. Dietary and physical activity assessments are not commonly considered in clinical settings. Randomized controlled trials of lifestyle interventions are needed to determine the effectiveness of mitigating the cardiometabolic complications in second-generation antipsychotic-treated children.

Current follow-up practices often fail to detect metabolic and neurological adverse reactions in children treated with second-generation antipsychotics

AIM

This study examined the use and adverse reactions of second-generation antipsychotics (SGAs), alone or combined with other psychotropic medication, to identify areas for standardising prescribing and monitoring practices.

METHODS

We conducted a retrospective study at Tampere University Hospital, Finland, involving 128 patients (81% boys) who were under 13 years old at SGA initiation and had SGA treatment between October 2013 and October 2014.

RESULTS

The median age at baseline was 9.4 years. Weight gain was reported as an adverse reaction in 33%, but an increase in standardised body mass index, adjusted for age and sex (BMI z-score), was detected in 75% of patients with sufficient data. The statistically significant median changes during the study were an increase of 0.46 in BMI z-score, a reduction of 0.25 mmol/L in fasting plasma high-density lipoprotein and an increase of 0.28 mmol/L in triglyceride values. The weight gain was most apparent in patients treated with just an SGA or SGA plus melatonin. Patients treated with an SGA plus medication for attention deficit hyperactivity disorder were less likely to gain weight.

CONCLUSION

SGA-induced metabolic disturbances remained partly unrecognised in children under 13 years of age and more systematic monitoring is needed.

Pharmacoepidemiological research for the development and evaluation of drugs in pediatrics

New regulations have come into force in Europe and the US establishing the pediatric development as an integral part of the early development of medicinal products. Parallel to the advances in pediatric clinical research, it became obvious that all available sources and research tools to gather valuable information for the safe and efficacious prescription of medicines in children should be used. Real-life, pharmacoepidemiological studies provide information that contribute to the better knowledge of drug utilization, effects and safety in the pediatric population and thereby, a better prescribing in children. In this paper, we suggest some possible applications, provide examples of impact of pharmacoepidemiological and pharmacovigilance studies and expose future perspectives in pediatric pharmacoepidemiology.

Current pharmacotherapy options for conduct disorders in adolescents and children

INTRODUCTION

Conduct disorder (CD) is a common mental health disorder of childhood and adolescence. CD's complexity, with its heterogenous clinical manifestations and overlapping comorbidities makes the application of evidence-based management approaches challenging. This article aims to combine a systematic review of the available literature, with a consensus opinion from both child and adolescent psychiatrists and developmental pediatricians on the clinical and pharmacological management of children and adolescents with conduct disorder (CD).

AREAS COVERED

The authors review the CD population and provide a systematic review and meta-analysis of the effectiveness and safety of pharmacotherapies using preferred reporting items for systematic review and meta-analysis (PRISMA) and strength of evidence recommendation taxonomy (SORT) guidelines. The authors then provide an expert clinical opinion for the use of different pharmacotherapies to address aggressive and disruptive behavior in children.

EXPERT OPINION

Atypical antipsychotics (e.g. risperidone) demonstrate evidence for efficacy in CD. Other pharmacotherapies (e.g. mood stabilizers, anticonvulsants, psychostimulants and selective norepinephrine reuptake inhibitors) have a low level of evidence for CD alone, however, can sometimes be effective in managing the symptoms of CD when other psychiatric disorders are also present.

Risperidone medication errors in children: an analysis of French poison centres data

OBJECTIVES

To describe clinical consequences of risperidone medication errors in children of less than 13 years and to estimate a clinically relevant toxic dose.

METHODS

All cases of risperidone medication errors managed by French Poison Centres from 2001 to 2012 were analyzed. Inclusion criteria were a delay of at least 2 hours between ingestion and request to the FPC in asymptomatic children, an ingested dose above two-fold the maximal daily dose for children above 5 years or any symptomatic patient at the time of first contact.

RESULTS

One hundred and sixty cases met our criteria. Median age was 8 years (range 0.9-12) and 28.1% were aged 5 years or less. Causes of the error were an incorrect dose in treated children (84.2%) or a dose given to a wrong child (15.8%). The median ingested dose was 0.1 mg/kg or 3.3-fold the maximum recommended dose. Overall, 59 children had no symptoms, 95 experienced minor symptoms and six moderate symptoms. Somnolence/sedation was the most common (73.3%). Of the 17 children who developed extrapyramidal disorders, all had minor or moderate symptoms and only five required a symptomatic treatment.

CONCLUSIONS

Risperidone medication errors in children cause minimal effects. Somnolence and mild to moderate extrapyramidal reactions were the main features of toxicity, and significant cardiac or other neurological features were not observed. No case with severe toxicity was noted. At home surveillance can be proposed for children exposed to a dose ≤0.15 mg/kg.