'Use of antipsychotics in children and adolescents: a picture from the ARITMO population-based European cohort study'

Cardiac safety of antipsychotic medications in pediatric and adolescent population: a systematic review and pathways for future research

Understanding the cardiac risks of antipsychotic use is crucial for clinicians managing psychiatric conditions in children and adolescents. However, the effects on the QT interval in pediatric populations have been poorly investigated. We performed a systematic review to provide clinicians an updated source on the effects of antipsychotic medications on QTc and guide drug's choice. A literature search on the PubMed and Scopus databases was conducted from April 22, 1989, to May 28, 2023, for all studies investigating the effects of antipsychotic medications on the QTc interval in patients aged 0-18 years. A total of 10 articles including 523 patients and 7 different antipsychotic drugs met our search criteria. Among the included articles were three randomized clinical trials, five controlled trials without randomization or prospective comparative cohort trials, and two retrospective cohort studies. Clinical data emerging from these studies were classified according to the Oxford Centre for Evidence-Based Medicine. Risperidone and aripiprazole showed minimal to no significant QTc prolongation, whereas quetiapine, olanzapine, and ziprasidone showed variable effects on QTc. Haloperidol did not demonstrate significant QTc prolongation. In a prospective comparative cohort trial, pimozide exhibited significant QTc prolongation in a cohort with Tourette syndrome.

CONCLUSION

Only 10 studies have carefully addressed the effect of antipsychotic medications on QTc among pediatric patients, underscoring the need for further research. Personalized risk assessment and regular cardiac monitoring should be integrated into clinical management of pediatric and adolescent patients receiving antipsychotics to facilitate early detection of repolarization abnormalities and potential intervention.

WHAT IS KNOWN

• QT interval prolongation is a reported side effect of antipsychotics among adults especially with first-generation antipsychotics and parenteral infusion. • Understanding the effect of antipsychotics on QT is essential for clinical monitoring and avoidance of complications.

WHAT IS NEW

• Risperidone and aripiprazole were the most studied antipsychotics in pediatric patients and showed minimal QT prolongation. • The absence of a standardized protocol for assessing the effects on the QT interval makes comparisons between studies challenging and emphasizes the need for further research.

Antipsychotic prescribing: national findings of children and adolescents attending mental health services in Ireland

Antipsychotic prescribing trends vary internationally, albeit off-label use remains high (i.e., target symptoms). We aim to describe antipsychotic use, target conditions, target symptoms and dosing regimens in children and adolescents in Ireland. We used a sampled cohort from a national audit of children and adolescents attending mental health services with predefined inclusion and exclusion criteria from Jul-2021 to Dec-2021 who were prescribed at least one psychotropic medication and up to and including 17-years of age (n = 3528). Each service provided anonymised data. We described the frequency of antipsychotic medication, medication type, target condition, target symptom and medication doses. We used multivariable logistic regression, adjusted with available co-variates to assess the association of being prescribed an antipsychotic medication. Twelve percentage (n = 437) were prescribed an antipsychotic and 16-17-years (n = 211, 48.3%) was the most common age category. The commonest reason for prescribing an antipsychotic was target symptoms (i.e., off-label use) (n = 329; 75.%) and of these symptoms, agitation (n = 77/329; 25%) and irritability (56/239; 25%) were the most common. Quetiapine (n = 127; 29%) was the most common antipsychotic, followed by risperidone (n = 125; 28.6%), aripiprazole (n = 107; 24.5%), and olanzapine (n = 66; 15.1%). In adjusted analysis, having a psychotic disorder ((adjusted-odds-ratio) aOR: 39.63, CI 95%, 13.40-117.22), bipolar disorder (aOR: 16.96, CI 95%, 3.60-80.00), autism spectrum disorder (aOR: 3.24, CI 95%, 2.45-4.28) or aggression symptoms (aOR: 16.75, CI 95%, 7.22-38.89) was associated with prescribing an antipsychotic medication. This is the first study in children and adolescents that describes the target conditions and target symptoms for antipsychotic use in Ireland. Our results show a high proportion of antipsychotic prescribing based on target symptoms rather than target condition or diagnosis.

Aripiprazole, but Not Olanzapine, Alters the Response to Oxidative Stress in Fao Cells by Reducing the Activation of Mitogen-Activated Protein Kinases (MAPKs) and Promoting Cell Survival

Prolonged use of atypical antipsychotics (AAPs) is commonly associated with increased cardiovascular disease risk. While weight gain and related health issues are generally considered the primary contributors to this risk, direct interference with mitochondrial bioenergetics, particularly in the liver where these drugs are metabolized, is emerging as an additional contributing factor. Here, we compared the effects of two AAPs with disparate metabolic profiles on the response of Fao hepatoma cells to oxidative stress: olanzapine (OLA), which is obesogenic, and aripiprazole (ARI), which is not. Results showed that cells treated with ARI exhibited resistance to H2O2-induced oxidative stress, while OLA treatment had the opposite effect. Despite enhanced survival, ARI-treated cells exhibited higher apoptotic rates than OLA-treated cells when exposed to H2O2. Gene expression analysis of pro- and anti-apoptotic factors revealed that ARI-treated cells had a generally blunted response to H2O2, contrasting with a heightened response in OLA-treated cells. This was further supported by the reduced activation of MAPKs and STAT3 in ARI-treated cells in response to H2O2, whereas OLA pre-treatment enhanced their activation. The loss of stress response in ARI-treated cells was consistent with the observed increase in the mitochondrial production of O2•-, a known desensitizing factor. The physiological relevance of O2•- in ARI-treated cells was demonstrated by the increase in mitophagy flux, likely related to mitochondrial damage. Notably, OLA treatment protected proteasome activity in Fao cells exposed to H2O2, possibly due to the better preservation of stress signaling and mitochondrial function. In conclusion, this study highlights the underlying changes in cell physiology and mitochondrial function by AAPs. ARI de-sensitizes Fao cells to stress signaling, while OLA has the opposite effect. These findings contribute to our understanding of the metabolic risks associated with prolonged AAP use and may inform future therapeutic strategies.

Metabolic Syndrome in people treated with Antipsychotics (RISKMet): A multimethod study protocol investigating genetic, behavioural, and environmental risk factors

INTRODUCTION

The RISKMet project aims to: (1) identify risk factors for metabolic syndrome (MetS) by comparing patients with and without MetS; (2) characterise patients treated with second-generation antipsychotics (SGAs) about MetS diagnosis; (3) study behavioural patterns, including physical activity (PA) and dietary habits, in patients and healthy individuals using a prospective cohort design.

METHOD

The RISKMet project investigates MetS in individuals treated with SGAs, focusing on both adult and paediatric populations. The study utilizes a case-control design to examine potential risk factors for MetS, categorizing participants as MetS+ considered as "Cases" and MetS- considered as "Controls" matched by sex and age. The evaluation of factors such as MetS, lifestyle habits, and environmental influences is conducted at two time points, T0 and T3, after 3 months. Subsequently, the project aims to assess body parameters, including physical examinations, and blood, and stool sample collection, to evaluate metabolic markers and the impact of SGAs. The analysis includes pharmacological treatment data and genetic variability. Behavioural markers related to lifestyle, eating behaviour, PA, and mood are assessed at both T0 and T3 using interviews, accelerometers, and a mobile app. The study aims to improve mental and physical well-being in SGA-treated individuals, establish a biobank for MetS research, build an evidence base for physical health programs, and develop preventive strategies for SGA-related comorbidities.

CONCLUSIONS

This project innovates MetS monitoring in psychiatry by using intensive digital phenotyping, identifying biochemical markers, assessing familial risks, and including genetically similar healthy controls.

STUDY REGISTRATION NUMBER

ISRCTN18419418 at www.isrctn.com.

Psychotropic Medication Prescribing for Children and Adolescents After the Onset of the COVID-19 Pandemic

Importance

Numerous studies have provided evidence for the negative associations of the COVID-19 pandemic with mental health, but data on the use of psychotropic medication in children and adolescents after the onset of the COVID-19 pandemic are lacking.

Objective

To assess the rates and trends of psychotropic medication prescribing before and over the 2 years after the onset of the COVID-19 pandemic in children and adolescents in France.

Design, Setting, and Participants

This cross-sectional study used nationwide interrupted time-series analysis of outpatient drug dispensing data from the IQVIA X-ponent database. All 8 839 143 psychotropic medication prescriptions dispensed to children (6 to 11 years of age) and adolescents (12 to 17 years of age) between January 2016 and May 2022 in France were retrieved and analyzed.

Exposure

Onset of COVID-19 pandemic.

Main outcomes and Measures

Monthly rates of psychotropic medication prescriptions per 1000 children and adolescents were analyzed using a quasi-Poisson regression before and after the pandemic onset (March 2020), and percentage changes in rates and trends were assessed. After the pandemic onset, rate ratios (RRs) were calculated between estimated and expected monthly prescription rates. Analyses were stratified by psychotropic medication class (antipsychotic, anxiolytic, hypnotic and sedative, antidepressant, and psychostimulant) and age group (children, adolescents).

Results

In total, 8 839 143 psychotropic medication prescriptions were analyzed, 5 884 819 [66.6%] for adolescents and 2 954 324 [33.4%] for children. In January 2016, the estimated rate of monthly psychotropic medication prescriptions was 9.9 per 1000 children and adolescents, with the prepandemic rate increasing by 0.4% per month (95% CI, 0.3%-0.4%). In March 2020, the monthly prescription rate dropped by 11.5% (95% CI, -17.7% to -4.9%). During the 2 years following the pandemic onset, the trend changed significantly, and the prescription rate increased by 1.3% per month (95% CI, 1.2%-1.5%), reaching 16.1 per 1000 children and adolescents in May 2022. Monthly rates of psychotropic medication prescriptions exceeded the expected rates by 11% (RR, 1.11 [95% CI, 1.08-1.14]). Increases in prescribing trends were observed for all psychotropic medication classes after the pandemic onset but were substantial for anxiolytics, hypnotics and sedatives, and antidepressants. Prescription rates rose above those expected for all psychotropic medication classes except psychostimulants (RR, 1.12 [95% CI, 1.09-1.15] in adolescents and 1.06 [95% CI, 1.05-1.07] in children for antipsychotics; RR, 1.30 [95% CI, 1.25-1.35] in adolescents and 1.11 [95% CI, 1.09-1.12] in children for anxiolytics; RR, 2.50 [95% CI, 2.23-2.77] in adolescents and 1.40 [95% CI, 1.30-1.50] in children for hypnotics and sedatives; RR, 1.38 [95% CI, 1.29-1.47] in adolescents and 1.23 [95% CI, 1.20-1.25] in children for antidepressants; and RR, 0.97 [95% CI, 0.95-0.98] in adolescents and 1.02 [95% CI, 1.00-1.04] in children for psychostimulants). Changes were more pronounced among adolescents than children.

Conclusions and Relevance

These findings suggest that prescribing of psychotropic medications for children and adolescents in France significantly and persistently increased after the COVID-19 pandemic onset. Future research should identify underlying determinants to improve psychological trajectories in young people.

Antipsychotic-induced weight gain: exploring the role of psychiatrists in managing patients' physical health - challenges, current options and direction for future care

Antipsychotics and severe mental illness (SMI) are associated with weight gain, and obesity increases the risks of cardiometabolic disease and premature death. These present management and liability issues for psychiatrists. Physical healthcare for people with SMI is poor, and this may partly be owing to training limitations and lack of proactiveness by psychiatrists. Ethically and legally, psychiatrists have a duty to avoid unnecessary harm and to maintain an acceptable standard of care. This would apply particularly to patients receiving compulsory treatment for their SMI owing to their vulnerability. Discrepancy between psychiatric and non-psychiatric approaches to pharmacological treatment creates ambiguity, and weight gain could demotivate antipsychotic adherence. This article explores how the Mental Health Act could be used to address these issues, and the ethical considerations, and proposes how long-acting glucagon-like peptide-1 receptor agonists could be introduced into existing psychiatric practice as a treatment option for antipsychotic-induced weight gain and obesity in SMI.

Prevalence and prescribers' knowledge of psychotropic polypharmacy in the Bono, Bono East, and Ahafo Regions, Ghana

The use of psychotropic medications for treating simple and complex psychological and emotional problems is common and relevant among prescribers. This, therefore, come with the tendency to prescribe many medications to a patient on a single visit due to varied reasons. The study, therefore, sought to ascertain the prevalence and prescribers' knowledge of psychotropic polypharmacy. A quantitative, descriptive study was conducted using a simple random approach to select and review the prescription records (both regular and prn basis) of three hundred and nine (309) patients' folders retrospectively within seven (7) mental health units across the study area to ascertain the prevalence of Psychotropic Polypharmacy (PP). Fifty-eight (58) prescribers were selected using probability method (simple random) to respond to the study questionnaire. Psychotropic Polypharmacy was prevalent (66.0 %) in the study area with antipsychotic polypharmacy (74.0 %) being the common form with the co-prescription of chlorpromazine (CPZ) + haloperidol (70.0 %) being frequent. This was more predominant among male patients (78.0 %) than female patients (22.0 %). Prescribers had high (82.8 %) knowledge of Psychotropic Polypharmacy and the majority (68.9 %) disagreed that the practice of Psychotropic Polypharmacy should be promoted. The continuous training of prescribers (i.e. mental health officers) on rational prescriptions would help reduce the prevalence of Psychotropic Polypharmacy.

Effectiveness of lifestyle interventions for improving the physical health of children and adolescents taking antipsychotic medications: protocol for a systematic review and meta-analysis

INTRODUCTION

Children and adolescents are increasingly prescribed antipsychotic medications off-label in the treatment of behavioural disorders. While antipsychotic medications are effective in managing behavioural issues, they carry a significant risk of adverse events that compromise ongoing physical health. Of particular concern is the negative impact antipsychotic medications have on cardiometabolic health. Interventions that aim to modify lifestyle habits have the potential to alleviate the adverse effects of antipsychotic medication by enhancing weight management, increasing physical activity, promoting better nutritional practices, improving dietary habits and promoting healthier sleep patterns and sleep hygiene. However, a comprehensive review has not been performed to ascertain the effectiveness of lifestyle interventions for children and adolescents who are at increased risk of antipsychotic-induced compromises to their physical health.

METHODS AND ANALYSIS

This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases will be searched without any year constraints to identify randomised controlled trials that are published in the English language and report a lifestyle intervention compared with usual care with any physical health outcome measure. Trial registers and results repositories will be scoured to identify additional studies. Two reviewers will independently conduct screening, data extraction and quality assessment and compare the results. Quantitative data will be synthesised, where appropriate, through a random-effects meta-analysis model. Otherwise, data will be reported in a qualitative (narrative) synthesis. Heterogeneity will be quantified using the I2 statistic. The Cochrane Risk of Bias 2 tool will be used for risk of bias assessment. The Grading of Recommendations, Assessment, Development and Evaluation system will be used to evaluate the cumulative body of evidence.

ETHICS AND DISSEMINATION

Ethics approval is not required. The publication plan will target high-impact, peer-reviewed journals that fall under the scope of Psychiatry and Mental Health.

PROSPERO REGISTRATION NUMBER

CRD42022380277.

Psychotropic Medication Use in Children and Adolescents With Type 1 Diabetes

Importance

Children and adolescents with type 1 diabetes (T1D) face elevated risks of psychiatric disorders. Despite their nonnegligible adverse effects, psychotropic medications are a common cost-effective approach to alleviating psychiatric symptoms, but evidence regarding their dispensation to children and adolescents with T1D remains lacking.

Objective

To examine the trends and patterns of psychotropic medication dispensation among children and adolescents with T1D in Sweden between 2006 and 2019.

Design, Setting, and Participants

This cohort study used data from multiple Swedish registers. The main study cohort included children and adolescents residing in Sweden from 2006 to 2019 and was followed up until the earliest of December 31, 2019, 18th birthday, emigration, or death. Data analyses were conducted from November 1, 2022, to April 30, 2023.

Exposures

Type 1 diabetes.

Main Outcomes and Measures

The primary outcomes were trends and patterns of psychotropic medication dispensation (including antipsychotics, antidepressants, anxiolytics, hypnotics, mood stabilizers, and medications for attention-deficit/hyperactivity disorder [ADHD]), psychotropic medication initiation, and history of neurodevelopmental and psychiatric diagnosis. Cumulative incidence curves and Cox proportional hazard models were used to estimate the aggregated incidence and hazard ratios of medication initiation after diabetes onset.

Results

Of 3 723 745 children and adolescents (1 896 199 boys [50.9%]), 13 200 (0.4%; 7242 boys [54.9%]) had T1D (median [IQR] age at diagnosis, 11.1 [7.6-14.7] years). Between 2006 and 2019, psychotropic medication dispensation increased from 0.85% (95% CI, 0.65%-1.10%) to 3.84% (3.11%-4.69%) among children and from 2.72% (95% CI, 2.15%-3.39%) to 13.54% (95% CI, 12.88%-14.23%) among adolescents with T1D, consistently higher than their peers without T1D. The most commonly dispensed medications included hypnotics, ADHD medications, anxiolytics, and selective serotonin reuptake inhibitors, and all exhibited increasing trends. For those with T1D, psychiatric care was the primary prescription source, and up to 50.1% of treatments lasted more than 12 months. In addition, children and adolescents with T1D showed higher cumulative incidence and hazard ratios of medication initiation after diabetes onset than their same-age and same-sex counterparts.

Conclusions and Relevance

This cohort study found an increasing trend in psychotropic medication dispensation among children and adolescents with T1D from 2006 to 2019, persistently higher than those without T1D. These findings call for further in-depth investigations into the benefits and risks of psychotropic medications within this population and highlight the importance of integrating pediatric diabetes care and mental health care for early detection of psychological needs and careful monitoring of medication use.

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

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

Trends in antipsychotic prescribing to children and adolescents in England: cohort study using 2000-19 primary care data

BACKGROUND

The prescription of antipsychotics to children and adolescents has been increasing worldwide. We described up-to-date trends in antipsychotic prescribing and identified likely indications in a contemporary English cohort.

METHODS

We used a large primary care database, the Clinical Practice Research Datalink (CPRD) Aurum database, and we included all children and adolescents aged 3-18 years in the database and registered in England between Jan 1, 2000, and Dec 31, 2019, excluding those whose gender was recorded as indeterminate. Participants were followed up until the earliest of Dec 31, 2019, June 30 of the year they turned 18 years, their death, when they transferred from the primary care practice, or when the practice left the database. Data were not collected on ethnicity. We recorded antipsychotic prescriptions using the date a prescription was issued. As CPRD prescriptions are not linked to indications, we developed an algorithm to ascertain the most likely indication associated with participants' first antipsychotic prescription using clinical codes. We reported prescribing trends as annual period prevalence and the rate of first antipsychotic prescription, and we used joinpoint regression analysis to identify changes in the outcome trend. We stratified prevalence estimates by age group, gender, and Index of Multiple Deprivation quintiles, we reported frequencies of likely indications associated with incident prescriptions, and we explored clinical preference for typical versus atypical antipsychotics within deprivation quintiles.

FINDINGS

Between Jan 1, 2000, and Dec 31, 2019, we included 7 216 791 children and adolescents, of whom 3 480 730 (48·2%) were girls and 3 736 061 (51·8%) were boys, with a mean age at the start of follow-up of 7·3 years (SD 4·9; range 3-18). Median follow-up was 4·1 years (IQR 1·5-8·5). 19 496 (0·3%) individuals received 243 529 antipsychotic prescriptions over follow-up, including 225 710 (92·7%) atypical and 17 819 (7·3%) typical antipsychotic prescriptions. The annual period prevalence of antipsychotic prescriptions rose from 0·057% (95% CI 0·052-0·063%) in 2000 to 0·105% (0·100-0·111%) in 2019. From joinpoint analyses, the period prevalence of all antipsychotic prescriptions increased by an average of 3·3% per year (2·2-4·9%) and the rate of first prescriptions increased by 2·2% per year (1·7-2·7%). The most likely indications of the first identified antipsychotic prescriptions were for autism spectrum disorder (2477 [12·7%]), non-affective psychosis (1669 [8·6%]), anxiety disorders (1466 [7·5%]), ADHD (1391 [7·1%]), depression (1256 [6·4%]), and conduct disorders (1181 [6·1%]).

INTERPRETATION

The observed increase in antipsychotic prescriptions over 20 years results from the accumulation of repeated prescriptions to the same individuals combined with an increase in new prescriptions. These findings highlight the need for continued monitoring of trends in antipsychotic use and, although this was not examined in this paper, the findings highlights the need for better information about long-term antipsychotic safety.

FUNDING

None.

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.

Rates of psychotropic medicine prescribing in paediatric populations in Australian general practice from 2000-2016

General practitioner (GP) prescribing of psychotropic medicines to paediatric patients is increasing across countries, sparking the need for additional research into this field. We examined prescribing rates, GP and patient characteristics and indications associated with prescribing psychotropic medicines to paediatric patients in Australian general practice, using data from the Bettering the Evaluation and Care of Health (BEACH) program. We extracted all encounters with children aged 3 to 17 from 2000 to 2016. Psychotropic medicines were defined as those in the ATC codes N05 (Psycholeptics) and N06 (Psychoanaleptics). Of the 144,397 encounters, GPs prescribed 1829 psychotropic medicines to paediatric patients at an average rate of 1.16 prescriptions per 100 encounters (95% confidence interval 1.09-1.23). We found that the rate of psychotropic medicines prescribed to paediatric patients in Australian general practice increased. Patients who were adolescent, female, socio-economically disadvantaged or from an English-speaking background were significantly more likely to be prescribed a psychotropic medicine. GP practices in remote or regional areas and Australian graduate GPs were more likely to prescribe psychotropic medicines to paediatric patients. Depression, attention deficit hyperactivity disorder, anxiety and autism were the most common psychiatric indications managed with psychotropic medicines. Antidepressants, psychostimulants, benzodiazepines, antipsychotics and other psychotropic medicines were prescribed, signifying a high rate of off-label use. Sertraline was the most common psychotropic medicine prescribed, followed by fluoxetine and methylphenidate. Future studies involving data from other prescribers, e.g. paediatricians and psychiatrists, and studies linking prescribed medicines to their indications may widen our understanding of psychotropic medicine prescribing in Australian paediatric patients.

Emergence of psychiatric adverse events during antipsychotic treatment in AP-naïve children and adolescents

BACKGROUND

Over the last decades, antipsychotic prescriptions in children have increased worldwide. However, adverse events are frequently observed, with some such as psychiatric adverse events remaining poorly documented.

METHOD

The French ETAPE study is a 12-month naturalistic prospective multisite study that included 190 antipsychotic-naïve pediatric patients (mean age = 12 ± 3 years), treated by antipsychotic for psychotic or non-psychotic symptoms. From the ETAPE database, we performed additional analyses focusing on psychiatric adverse events.

RESULTS

Children received mainly second-generation antipsychotic for conditions out of regulatory approval, with risperidone and aripiprazole being the most frequent (respectively 52.5% and 30.83%). Clinicians reported 2447 adverse events, mainly non-psychiatric (n = 2073, 84.72%), including neuromuscular, metabolic, gastroenterological, and (n = 374, 15.28%) psychiatric. 55.88% of psychiatric adverse events were attributable to antipsychotic by the clinician, compared to 89% of non-psychiatric adverse events (p < 0.001). 63.2% (n = 120) of the 190 children and adolescents presented at least one psychiatric adverse event. The most frequent were externalized behaviors such as aggressiveness or agitation (22.7%), mood changes (18.4%) and suicidal ideas or behaviors (11.8%). Half of psychiatric adverse events occurred during the first quarter, 49.46%, compared to 23.79% during the second, 15.77% during the third, and 10.96% during the fourth.

CONCLUSION

This additional analysis from the French ETAPE study emphasizes that psychiatric adverse events might be more frequent than expected in the pediatric population. Also, the potential risk of psychiatric adverse events should be part of the benefit-risk evaluation and sub-sequent follow-up.

Clarity and applicability of adverse drug reaction-related monitoring instructions in clinical practice guidelines for children and adolescents treated with antipsychotic drugs: a review of six clinical practice guidelines

OBJECTIVES

Monitoring instructions related to adverse drug reactions (ADRs) are not always clearly described in clinical practice guidelines (CPGs) and not always easily applicable in daily clinical practice. The aim of this study was to assess the clarity of presentation and the applicability of ADR-related monitoring instructions in CPGs for children and adolescents treated with antipsychotic drugs.

SETTING

Guidelines from different countries were selected, and monitoring instructions for 13 ADR-related parameters were assessed.

PRIMARY AND SECONDARY OUTCOME MEASURES

To assess the clarity and the applicability of the sections concerning monitoring instructions in each CPG, the Appraisal of Guidelines for Research and Evaluation instrument was used. To assess the clarity and the applicability of the monitoring instructions for each ADR-related parameter, the Systematic Information for Monitoring score was used.

RESULTS

Six CPGs were included. Overall, the presentation of the monitoring instructions in the different CPGs was clear; three CPGs scored >75%. All CPGs scored lower on applicability, as, for example, the barriers and facilitators were poorly described. The number of ADR-related parameters included in the CPGs varied between 8 and 13. Why and what to monitor was always described for each parameter. When to start monitoring was also often described (90.2%), but when to stop monitoring was less frequently described (37.4%).

CONCLUSIONS

The CPGs differed on the parameters that needed to be monitored. Overall, the monitoring instructions were clearly presented, but improvement in their applicability is required. By improving the monitoring instructions, CPGs can provide better guidance on monitoring ADRs in daily clinical practice.

Psychotropic Drug Prescription in Children and Adolescents: Approved Medications in European Countries and the United States

Objectives: The decision to prescribe a medication and the choice of which one are often complex, particularly in the field of child and adolescent psychiatry where evidence is scarce. The aim of this review is to provide a synthesis of psychotropic drugs approved in children and adolescents for psychiatric indications in several countries. Methods: All psychopharmacological treatments used in child and adolescent psychiatry, approved by at least one regulatory agency from Switzerland, the United Kingdom, France, the European Union, or the United States, were considered. A comprehensive review of the summaries of product characteristics was performed. Results: A total of 143 psychotropic drugs were included: 47 anxiolytics/hypnotics, 45 antidepressants, 37 antipsychotics, 10 medications for attention-deficit/hyperactivity disorder (ADHD), and 4 mood stabilizers. Only a few of these drugs were approved for use in children or adolescents (38%) at least for a single psychiatric diagnosis in at least one country. The therapeutic class with the lowest rate of approved status was antidepressants (20%), followed by mood stabilizers (25%), anxiolytics/hypnotics (28%), antipsychotics (57%), and medications for ADHD (100%). Important differences in approved diagnoses, ages, and doses were observed between regulatory agencies. Tables presenting drugs for approved diagnoses based on age and regulatory agencies are presented in this article. Drugs classified by regulatory agencies, with complete data on diagnoses, ages, doses, pharmaceutical forms, and particular restrictions, are presented as Supplementary Material. Conclusion: This article provides an overview to prescribers with respect to the approved medications in children and adolescents in selected European countries and the United States.

Comparison of antipsychotic drug use among Dutch Youth before and after implementation of the Youth Act (2010-2019)

OBJECTIVE

The Dutch law on youth care (the Youth Act) was implemented from 2015 onwards. One of the government's aims by implementing this new policy was de-medicalization of youths by separating youth mental healthcare from the rest of the healthcare system. A previous study conducted by our research group showed that prevalence rates of antipsychotic drug prescriptions stabilized among Dutch youth in the period 2005-2015, just before the introduction of the Youth Act. In our study, we aimed to describe antipsychotic drug use among Dutch children aged 0-19 years old before and after implementation of the Youth Act (2010-2019).

METHODS

We analyzed prescription data of 7405 youths aged 0-19 years using antipsychotic drugs between 2010 and 2019, derived from a large Dutch community pharmacy-based prescription database (IADB.nl).

RESULTS

Prevalence rates of antipsychotic drug use per thousand youths decreased significantly in youths aged 7-12 years old in 2019 compared to 2015 (7.9 vs 9.0 p < 0.05). By contrast, prevalence rates increased in adolescent females in 2019 compared to 2015 (11.8 vs 9.5 p < 0.05). Incidence rates increased significantly in adolescent youths in 2019 compared to 2015 (3.9 vs 3.0 p < 0.05), specifically among adolescent girls (4.2 per thousand in 2019 compared to 3.0 per thousand in 2015). Dosages in milligram declined for the most commonly prescribed antipsychotic drugs during the study period. The mean duration of antipsychotic drug use in the study period was 5.7 (95% CI 5.2-6.2) months.

CONCLUSION

Despite the aim of the Youth Act to achieve de-medicalization of youths, no clear reduction was observed in prevalence rates of antipsychotic drugs or treatment duration in all subgroups. Prevalence rates even increased in adolescent females.

Multi-analyte LC-MS/MS quantification of 38 antipsychotics and metabolites in plasma: Method validation & application to routine analyses

The past decades have seen a rise in the prescription of antipsychotic drugs in the European population, despite the risk of extra-pyramidal, metabolic and cardiac side effects. A multi-analyte liquid chromatography - triple quadrupole mass spectrometry method was developed for the quantification of 38 antipsychotic drugs in plasma. Samples were extracted by a straightforward liquid-liquid extraction with methyl-tertiary-butyl-ether and the compounds of interest were chromatographically separated within 6 min. Calibration curves covered the recommended therapeutic range for all compounds, in addition to sub- and supratherapeutic concentrations for most. The method was successfully validated according to the European Medicines Agency guidelines on bioanalytical method validation. Analysis of medico-legal samples confirmed the relatively common use of the second generation antipsychotics quetiapine and olanzapine, as well as the continued presence of the first generation antipsychotic haloperidol.

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.

Antipsychotic Treatment Duration in Children and Adolescents: A Register-Based Nationwide Study

Objective: Despite the increasing use of antipsychotic drugs in children and adolescents in many countries, little is known about the treatment duration in this vulnerable population. The present nationwide study investigated the duration of antipsychotic treatment and factors associated with treatment discontinuation in Finnish children and adolescents. Methods: All subjects aged 1-17 years who had started a second-generation antipsychotic (SGA) drug (risperidone, quetiapine, aripiprazole, or olanzapine) between January 2008 and December 2016 (n = 20,932) were extracted from the Finnish Prescription Registry and followed up until December 31, 2017. Treatment duration was calculated as the time between the initial purchase of medication and treatment discontinuation. Treatment was considered discontinued if the treatment-free gap was more than 270 days. The associations between explanatory factors and treatment discontinuation were analyzed with the Cox proportional hazards models. Results: The mean and median treatment durations were 509 days (95% confidence interval [95% CI]: 500-517 days) and 317 days (95% CI: 306-325 days), respectively. The duration was shorter in girls than in boys (p < 0.001). Of all SGA users, 35.1% used antipsychotics less than 50 days and 16.0% used more than 600 days. Shorter treatment duration was associated with age groups of 7-12 and 13-15 years compared with 1-6 years (hazard ratio [HR]:1.23 [95% CI: 1.11-1.36]; HR: 1.35 [95% CI: 1.21-1.51], respectively) and initiating treatment with quetiapine or olanzapine compared with risperidone (HR: 1.18 [95% CI: 1.12-1.25]; HR: 1.66 [95% CI 1.46-1.88], respectively). Switching of SGA drug during treatment was associated with longer treatment duration (HR: 0.40 [95% CI: 0.38-0.43]). Conclusions: In children and adolescents, the mean treatment duration of SGAs was relatively long given that the majority of SGA use was off-label. Older age and initiating treatment with quetiapine were associated with earlier treatment discontinuation, whereas switching of antipsychotic drug during therapy increased the possibility of longer SGA use.

The Use of Psychotropic Medication in Iranian Children with Developmental Disabilities

The use of psychotropic medication in children is increasing worldwide. Children with developmental disabilities seem to be prescribed these medications at a higher rate compared to their non-disabled peers. Little is known about prescribing in non-Western, middle-income studies. In Iran, the file records of 1133 children, aged 2 to 17 years, assessed as having autism spectrum disorder (ASD) or an intellectual disability (ID) in Tehran City and Province from 2005 to 2019 were collated, and information from parental reports of medications was extracted. Upwards of 80% of children with ASD and 56% of those with ID were prescribed a psychotropic medication with around one quarter in each group taking two or more medications. The rates were higher among male children showing difficult-to-manage behaviors such as hyperactivity, but less so for children of fathers with higher levels of education. The lack of alternative management strategies may be a significant driver for the use of psychotropic medications in Iran and other Low and Middle Income countries, despite their known side effects, and their failure to address the developmental needs of the children. Rather, multi-disciplinary, behavioral, therapeutic, and educational interventions are required, but these are not available widely in Iran, although a start has been made.

Monitoring of Adverse Drug Reaction-Related Parameters in Children and Adolescents Treated With Antipsychotic Drugs in Psychiatric Outpatient Clinics

Aim: To assess the frequency of monitoring of adverse drug reaction (ADR) related parameters in children and adolescents treated with antipsychotic drugs in psychiatric outpatient clinics and the considerations when monitoring was not performed. Methods: This retrospective follow-up study included 100 randomly selected outpatients aged ≤18 years who had a first prescription of an antipsychotic drug recorded in the electronic medical records of psychiatric outpatient clinics between 2014 and 2017. They were followed for up to 3 years. This study assessed the frequency of monitoring for physical parameters (weight, height, body mass index, waist circumference, pulse, blood pressure, and an electrocardiogram) and laboratory parameters (glucose, lipids, and prolactin) before the first prescription of an antipsychotic drug as well as during its use. Monitoring frequencies were stratified by the patient characteristics (sex, age, cardiovascular risk factors, and use of other psychotropic drugs), and by location of antipsychotic drug initiation (psychiatric outpatient clinic or elsewhere). Additionally, this study assessed the considerations mentioned in the medical records for not monitoring ADR-related parameters. Results: Overall, physical parameters were monitored more frequently (weight: 85.9% during the first half-year) than laboratory parameters (glucose and cholesterol: both 23.5%). There were no significant differences in monitoring at least one physical as well as in monitoring at least one laboratory parameter during the baseline period and during the total follow-up of antipsychotic drug treatment between the patient characteristics. In total, 3% of the children and adolescents were never monitored for any physical parameter, and 54% were never monitored for any laboratory parameter. For a minority of the children (14.8%) who were never monitored for laboratory parameters, considerations were recorded in their medical records, including refusal by the child or parents and monitoring performed by the general practitioner or elsewhere. Conclusion: Monitoring frequencies of ADR-related parameters in children and adolescents treated with antipsychotic drugs in psychiatric outpatient clinics varied and especially monitoring of laboratory parameters was infrequent. Considerations why monitoring was not performed were rarely recorded. The optimal method of monitoring and documentation thereof should become clear to optimize the benefit-risk balance of antipsychotic drug treatment for each child.

Analysis of the status of drug treatment in 746 inpatients with early-onset schizophrenia in China: a retrospective study

BACKGROUND

There is limited evidence on the use of antipsychotics in patients with early-onset schizophrenia, which lags significantly behind the studies on adult patients' medication and has a large disparity from actual clinical needs. Hence, this study aims to analyse the status of the drug use and its changes for patients with early-onset schizophrenia in our ward and to provide references on clinical medications for children and adolescents with schizophrenia.

METHODS

The distribution of antipsychotics on the day of discharge and their changes over time were retrospectively analysed in our inpatient department from March 2012 to July 2019. Descriptive statistical methods and χ2 tests were carried out.

RESULTS

A total of 746 inpatients with early-onset schizophrenia were included. Among them, 99.3% of patients were prescribed atypical antipsychotic drugs, with 5.5% of patients prescribed typical antipsychotic drugs. The top five most commonly used antipsychotics were aripiprazole, olanzapine, risperidone, paliperidone and clozapine. Olanzapine and risperidone were used more frequently in men (P < 0.01), whereas aripiprazole was used less frequently (P < 0.01). Olanzapine and paliperidone were used more frequently in patients with adolescent-onset schizophrenia (AOS) (P < 0.05), and risperidone was used more frequently in patients with child-onset schizophrenia (COS) (P < 0.01). Multiple antipsychotics during hospitalization were prescribed in 23.1% of patients. The combination of aripiprazole and olanzapine was the most common in the AOS group, and the combination of risperidone and clozapine was the most common in the COS group. Before and after approval by the competent Chinese authorities, the use of paliperidone and aripiprazole tended to be stable.

CONCLUSION

Atypical antipsychotics have been increasingly valued and used clinically. The consideration of medications for patients with early-onset schizophrenia needs to include factors such as age, sex, and severity of illness, metabolism and cognitive function at baseline.