Unanswered questions regarding atypical antipsychotic use in aggressive children and adolescents

Neurobehavioral effects of chronic low-dose risperidone administration in juvenile male rats

Despite substantial increases in the use of antipsychotics to treat various psychiatric conditions in children, there is a lack of literature regarding long-term effects of early treatment. Some studies have indicated that early administration results in differential alterations to neurotransmission systems, but few studies have investigated whether there are long-term behavioral modifications. Therefore, the aim of the current study was to investigate the neurobehavioral effects of low dose risperidone (a commonly prescribed antipsychotic) treatment using juvenile rats. Twenty-four male Sprague-Dawley rats were either subcutaneously implanted with a continuous release risperidone pellet (.04 mg/day) or a placebo pellet. To encompass the peri-adolescent to adolescent timeframe (postnatal day 40-70) thought to be important for brain development, male rats began risperidone treatment at post-natal day 35. Six weeks following commencement of risperidone treatment, all rats were tested on a battery of behavioral assessments including open field, object recognition, Morris Water Maze, and Y-Maze tasks. Risperidone treatment did not affect performance on the open field, object recognition, or Morris Water maze. A significant effect was found on the Y-maze. Although all rats exhibited normal spontaneous alternation, risperidone treated rats demonstrated significantly higher same arm returns, indicative of a working memory deficit. Continued research is needed to determine whether early exposure to risperidone may lead to differences in working memory at longer time-points. These results seem to indicate that early low dose risperidone treatment during the peri-adolescent and adolescent period does not severely impair behavior.

Efficacy of antipsychotics for irritability and aggression in children: a meta-analysis

BACKGROUND

Aggression and irritability in children occur across a range of diagnoses, and are associated with both economic cost and negative psychosocial outcomes. Antipsychotics are frequently prescribed in these cases.

METHODS

A random effects meta-analysis of 14 random controlled trials was conducted. Overall effect sizes for antipsychotics for irritability and aggression were extracted. Subgroup analyses were conducted according to diagnostic indication, specific medication and degree of sedation. Meta-regression examined effects of antipsychotic dose.

RESULTS

Overall, antipsychotics were effective in reducing aggression and irritability (SMD = 0.74, 95% confidence interval [CI] 0.57-0.92, z = 8.4, p < 0.0001). In stratified subgroup analysis, individual antipsychotic agents did not differ in efficacy (χ² = 1.1, df = 3, p = 0.78). However, aripiprazole and risperidone demonstrated significant benefit over placebo. Antipsychotic efficacy did not differ significantly based on diagnostic indication (χ² = 4.2, df = 4, p = 0.39). Meta-regression showed no overall dose effect.

CONCLUSIONS

Clinical data supports the efficacy of risperidone and aripiprazole for aggression and irritability across diagnoses, with insufficient data available for other agents. Available data does not support a difference in efficacy based on underlying diagnosis, choice of agent, or its degree of sedation.

Diagnoses and Antipsychotic Treatment Among Youths in a Public Mental Health System

Background:

The use of antipsychotics, namely newer atypical agents, has increased significantly in children and adolescents. It is important to examine diagnoses associated with antipsychotic treatment in youths.

Objective:

To evaluate trends in psychiatric diagnoses of children and adolescents in a public mental health system who were prescribed antipsychotics.

Methods:

Children and adolescents, up to the age of 19 years, who were prescribed an antipsychotic between January 1998 and December 2001 were identified using the Texas Medicaid Vendor Drug database. Patient identification numbers were then cross-linked to the Client Assignment and Registration database of the Texas Department of Mental Health and Mental Retardation to extract diagnostic data.

Results:

Disruptive behavioral disorders accounted for the highest percentage (35%) of diagnoses associated with children and adolescents receiving antipsychotic treatment and mental healthcare services. Depressive disorders were the second most common diagnosis (18%), and bipolar disorders accounted for roughly 12% of all diagnoses. Approximately 3% of children and adolescents did not have a psychiatric diagnosis. The percentage of youths with comorbid psychiatric diagnoses decreased over time.

Conclusions:

Although disruptive behavioral disorders accounted for a large percentage of antipsychotic use in this population, these findings suggest that antipsychotics are being used to treat other psychiatric diagnoses, for which limited supporting data exist. Future research in children and adolescents should aim to provide needed efficacy and safety data of antipsychotics across the spectrum of neuropsychiatrie disorders.

Neural changes induced by antipsychotic administration in adolescence: A review of studies in laboratory rodents

Adolescence is characterized by major remodelling processes in the brain. Use of antipsychotic drugs (APDs) in adolescents has increased dramatically in the last 20 years; however, our understanding of the neurobiological consequences of APD treatment on the adolescent brain has not kept the same pace and significant concerns have been raised. In this review, we examined currently available preclinical studies of the effects of APDs on the adolescent brain. In animal models of neuropsychiatric disorders, adolescent APD treatment appears to be protective against selected structural, behavioural and neurochemical phenotypes. In "neurodevelopmentally normal" adolescent animals, a range of short- and long-term alterations in behaviour and neurochemistry have been reported. In particular, the adolescent brain appears to be sensitive to long-term locomotor/reward effects of chronic atypical APDs in contrast with the outcomes in adults. Long-lasting changes in dopaminergic, glutamatergic and gamma-amino butyric acid-ergic systems induced by adolescent APD administration have been observed in the nucleus accumbens. A detailed examination of other potential target regions such as striatum, prefrontal cortex and ventral tegmental area is still required. Through identification of specific neural pathways targeted by adolescent APD treatment, future studies will expand the current knowledge on long-term neural outcomes which are of translational value.

Risk factors for weight gain and metabolic syndrome in adolescents with psychiatric disorders: a historical prospective study

OBJECTIVE

Adolescents with mental disorders are at increased risk for being overweight or obese, and subsequently developing metabolic syndrome. However, data regarding risk factors for weight gain during psychiatric hospitalization of adolescents are limited and inconsistent. The aim of this study was to investigate the sociodemographic, clinical, and pharmacological risk factors for weight gain during psychiatric treatment, in order to improve prevention of subsequent metabolic syndrome.

METHODS

We conducted a historical prospective study of 146 adolescent patients (mean age 15.2±1.9 years, 52.7% males), consecutively admitted for day treatment in an adolescent day unit (length of stay 141±76 days). Anthropometric measurements and laboratory analyses of fasting glucose and lipid levels were conducted as part of the routine medical care at admission and discharge. Psychiatric diagnoses, medication histories, and sociodemographic data were obtained from the electronic medical records system.

RESULTS

A significant increase in age- and gender adjusted body mass index (BMI) (i.e., z score) was observed (0.5±1.2 vs. 0.7±1.1 at admission and discharge, respectively, p<0.001). Male subjects were more prone to weight gain than females (odds ratio [OR]=3.5, 95% CI=1.2-10.3) and BMI z score at admission was inversely associated with weight gain (R (2)=0.2, p<0.0001). Surprisingly, age at admission, psychiatric diagnoses, length of stay, and number of medications were not associated with weight gain. Despite weight gain, fasting blood glucose and lipid profile did not change significantly during the study period.

CONCLUSIONS

Hospitalization of adolescents in a psychiatric day unit may be associated with a significant weight gain, especially in male subjects and those with normal weight at admission. Efforts should be aimed to reduce weight gain among youth with psychiatric disorders during treatment, to avoid a subsequent metabolic syndrome.

Methamphetamine psychosis: epidemiology and management

Psychotic symptoms and syndromes are frequently experienced among individuals who use methamphetamine, with recent estimates of up to approximately 40 % of users affected. Although transient in a large proportion of users, acute symptoms can include agitation, violence, and delusions, and may require management in an inpatient psychiatric or other crisis intervention setting. In a subset of individuals, psychosis can recur and persist and may be difficult to distinguish from a primary psychotic disorder such as schizophrenia. Differential diagnosis of primary vs. substance-induced psychotic disorders among methamphetamine users is challenging; nevertheless, with careful assessment of the temporal relationship of symptoms to methamphetamine use, aided by state-of-the art psychodiagnostic assessment instruments and use of objective indicators of recent substance use (i.e., urine toxicology assays), coupled with collateral clinical data gathered from the family or others close to the individual, diagnostic accuracy can be optimized and the individual can be appropriately matched to a plan of treatment. The pharmacological treatment of acute methamphetamine-induced psychosis may include the use of antipsychotic medications as well as benzodiazepines, although symptoms may resolve without pharmacological treatment if the user is able to achieve a period of abstinence from methamphetamine. Importantly, psychosocial treatment for methamphetamine dependence has a strong evidence base and is the optimal first-line treatment approach to reducing rates of psychosis among individuals who use methamphetamines. Prevention of methamphetamine relapse is the most direct means of preventing recurrence of psychotic symptoms and syndromes. Long-term management of individuals presenting with recurrent and persistent psychosis, even in the absence of methamphetamine use, may include both behavioral treatment to prevent resumption of methamphetamine use and pharmacological treatment targeting psychotic symptoms. In addition, treatment of co-occurring psychiatric disorders including depression and anxiety is important as a means of preventing relapse to methamphetamine use, which is often triggered by associated symptoms.

Prescribing trends of antipsychotics in youth receiving income assistance: results from a retrospective population database study

BACKGROUND

Prescribing of antipsychotics (AP) to young people has increased in the last decade internationally. We aimed to characterize AP prescribing in a population of low-income youth in Nova Scotia, Canada.

METHODS

We conducted a population database study of AP prescription claims and health services utilization by young people aged 25 years and younger receiving drug benefits through the publicly funded Pharmacare program between October 1, 2000 to September 30, 2007.

RESULTS

Four percent (1715/43888) of youth receiving Pharmacare benefits filled AP prescriptions. The use of second generation antipsychotics (SGAs) significantly increased (p < 0.0001) in all age groups except 0-5 year olds, whereas first generation antipsychotic use significantly decreased. Pharmacare beneficiaries aged 21-25 years represented 45.2% of AP users. The majority (66%) of youth filling AP prescriptions had 2 or more psychiatric diagnoses. Most youth (76%) filled prescriptions for only one type of AP during the study period. Psychotic disorders were the most common indication for AP use except with risperidone, in which ADHD was the most likely reason for use. Co-prescribing of psychotropics was prevalent with antidepressants and mood stabilizers prescribed in 42% and 27% of AP users, respectively. General practitioners (GPs) prescribed incident APs most often (72%) followed by psychiatrists (16%). The age- and gender-adjusted rate of death was higher in AP users as compared to the age-matched general population of Nova Scotia.

CONCLUSIONS

SGA use increased significantly over seven years in a cohort of 0 to 25 years olds receiving Pharmacare benefits. Off-label use of APs was prevalent with ADHD and other non-psychotic disorders being common reasons for AP use. GPs initiated most AP prescriptions. Co-prescribing of other psychotropics, especially antidepressants and mood stabilizers, was prevalent even in younger age strata. This study raises further questions about AP prescribing in those 25 years of age and under, especially given the range of diagnoses and psychotropic co-prescribing.

Differentiating bipolar disorder-not otherwise specified and severe mood dysregulation

OBJECTIVE

Bipolar disorder-not otherwise specified (BP-NOS) and severe mood dysregulation (SMD) are severe mood disorders that were defined to address questions about the diagnosis of bipolar disorder (BD) in youth. SMD and BP-NOS are distinct phenotypes that differ in clinical presentation and longitudinal course. The purpose of this review is to inform clinicians about the clinical features of the two phenotypes and about the research literature distinguishing them.

METHOD

A literature review was performed on SMD as studied in the National Institute of Mental Health Intramural Research Program and on BP-NOS in youth. For BP-NOS, the phenotype defined in the Course of Bipolar Youth study is the focus, because this has received the most study.

RESULTS

SMD is characterized by impairing, chronic irritability without distinct manic episodes. Most commonly, BP-NOS is characterized by manic, mixed, or hypomanic episodes that are too short to meet the DSM-IV-TR duration criterion. Research provides strong, albeit suggestive, evidence that SMD is not a form of BD; the most convincing evidence are longitudinal data indicating that youth with SMD are not at high risk to develop BD as they age. The BP-NOS phenotype appears to be on a diagnostic continuum with BD types I and II. Subjects with BP-NOS and those with BD type I have similar symptom and family history profiles, and youth with BP-NOS are at high risk to develop BD as they age. Currently, little research guides treatment for either phenotype.

CONCLUSIONS

Pressing research needs include identifying effective treatments for these phenotypes, ascertaining biomarkers that predict conversion from BP-NOS to BD, elucidating associations between SMD and other disorders, and defining the neural circuitry mediating each condition.

Experts' recommendations for treating maladaptive aggression in youth

BACKGROUND

Psychiatric treatment for children and adolescents with clinically significant aggression is common and often involves the use of antipsychotic medications. Increasingly, pediatricians are initiating or managing such treatments despite limited evidence on optimal diagnostic, psychosocial, and medication approaches for pediatric aggression.

AIMS

The objective of this study was to gather clinicians' and researchers' expertise concerning the treatment of maladaptive aggression, using expert consensus survey methods to aid the development of guidelines for pediatricians and psychiatrists on the outpatient treatment of maladaptive aggression in youth (T-MAY).

METHODS

Forty-six experts (psychiatrists, pediatricians, and researchers) with >10 years of clinical and/or research experience in the treatment of pediatric aggression completed a 27-item survey (>400 treatment alternatives) about optimal diagnostic, psychosocial, and medication treatments. Data were analyzed using descriptive statistics and confidence intervals.

RESULTS

Expert consensus methodology clearly differentiated optimal versus nonoptimal treatment strategies for maladaptive aggression. In contrast to current practice trends, results indicated that experts support the use of psychosocial interventions and parent education and training before the use of medication for maladaptive aggression at every stage of medication treatment, from diagnosis to maintenance to medication discontinuation.

CONCLUSION

Overall findings indicate that evidence-informed strategies for outpatient treatment of pediatric maladaptive aggression, guided by systematically derived expert opinions, are attainable. In light of the gap between the research literature and clinical practice, expert consensus opinion supports specific practices for optimal outpatient management in children and adolescents with severe and persistent behavioral difficulties.

Exposure to antipsychotic medications over a 4-year period among children who initiated antipsychotic treatment before their sixth birthday

PURPOSE

This study aims the following: (i) to describe the exposure to antipsychotic medications over a 4-year period experienced by a cohort of children who initiated antipsychotic treatment before their sixth birthday; and (ii) to identify variables associated with the risk of antipsychotic exposure.

METHODS

Children were identified who initiated an index episode of antipsychotic treatment before their sixth birthday in Florida's fee for service Medicaid program. With the use of claims data, the medication utilization of these children was tracked during the year before and the 4 years following the start of their index episodes (pre-index and four post-index periods). Generalized estimating equations were used to identify variables associated with the risk of additional days of antipsychotic exposure.

RESULTS

Five hundred twenty-eight children were included in the cohort. The mean total number of days of exposure was 821.9 (± 431.9), representing 56.3% of all days during the four post-index periods. The mean days of exposure to combinations of antipsychotics and other classes of psychotherapeutic medications were 623.8 ± 447.6 days. Children with primary diagnoses of pervasive developmental disorders and affective disorders were at greater risk of additional days of exposure than children with attention deficit/hyperactivity disorder. Exposure tended to be greater among children with indicators of clinical complexity including the presence of secondary diagnoses and the use of other classes of psychotherapeutic medications in addition to antipsychotics.

CONCLUSIONS

Exposure to antipsychotic mediations was extensive. Although these children may have had complex and severe problems, additional research is urgently needed on the benefits and risks of long-term antipsychotic exposure among very young children.

Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

OBJECTIVE

To review findings from pharmaco-epidemiological studies exploring antipsychotic (AP) drugs prescribing trends.

METHOD

We retrieved original studies that explored AP prescribing trends in general population samples since 2000. For each study, we extracted information on sampling method, period, assessment of AP use and corresponding estimates (incidence rates, prevalence rates, pharmacy sales, prescription data) and diagnostic assessment.

RESULTS

Nearly all studies meeting the inclusion criteria (n = 17) showed an increase in AP prescriptions, mainly because of a dramatic rise in second-generation antipsychotics (SGAP) prescriptions. APs are often prescribed for non-psychotic disorders in adults as well as in children and adolescents.

CONCLUSION

Considering the growing number of persons from the general population exposed to APs, population studies assessing the risk/benefit ratio of SGAP use in disorders other than psychosis are necessary, particularly in children and adolescents.

Health-care costs of pediatric clients developing adverse events during treatment with antipsychotics

OBJECTIVE

To examine the differences over time in health-care costs associated with incident adverse events in children and adolescents treated with antipsychotic agents compared to an untreated control sample.

METHOD

A retrospective cohort design evaluating South Carolina's Medicaid medical and pharmacy claims between January 1996 and December 2005 was employed for 4140 children and adolescents prescribed antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications. The main outcome measures were total health-care costs and emergency, inpatient, and outpatient services use.

RESULTS

Patients with the focal adverse medical conditions incurred significantly higher total care costs (34% higher, on average, over 8–9 years) compared with those without these conditions (F = 710.08; P < 0.0001) or to children not treated with psychotropic medications (F = 2855.54; P < 0.0001). Patients with incident adverse events associated with antipsychotic treatment had significantly higher rates/time under Medicaid coverage of outpatient, emergency, and inpatient services utilization than the control sample patients, controlling for preexisting conditions, receipt of multiple psychotropic medications, and individual risk factor differences for males, adolescents, and non-African Americans.

CONCLUSIONS

The development of adverse medical conditions related to antipsychotic medication use in children and adolescents is significantly associated with higher total costs of health care and to utilization of outpatient, emergency, and inpatient services over time

Hyperprolactinemia-related adverse events associated with antipsychotic treatment in children and adolescents

PURPOSE

To characterize factors related to the development of hyperprolactinemia and the ensuing reproductive/sexual adverse events in children and adolescents treated with antipsychotic and other psychotropic agents, and the additional risk posed for those with comorbid obesity, metabolic, or endocrine disorders.

METHODS

A retrospective cohort design evaluating medical and pharmacy claims from South Carolina's Medicaid program was used to compare incidence rates for sexual/reproductive adverse events in 4140 children and adolescents who were newly prescribed one of six atypical or two conventional antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications, January 1998 to December 2005. Logistic and Cox Proportional Hazards regression and Kaplan-Meier survival analysis were performed.

RESULTS

The treated cohort was not significantly more likely to evince hyperprolactinemia-related disorders than the control sample, but females and adolescents 13 and older were. Incident reproductive/sexual conditions were more likely for females (odds ratio [OR] = 9.52; confidence interval [CI] = 7.63-11.90), adolescents (OR = 3.91; CI = 3.25-4.70), those also taking selective serotonin reuptake inhibitors (SSRIs) (OR = 2.04; CI = 1.56-2.37) or valproic acid derivatives (OR = 1.29; CI = 1.03-1.64), and those with comorbid obesity/weight gain (OR = 1.92; CI = 1.56-2.37), metabolic (OR = 1.41; CI = 1.12-1.78), or endocrine disorders (OR = 2.76; CI = 1.98-3.84).

CONCLUSION

In this treated cohort, female adolescents exposed to SSRIs or valproic acid derivatives and those with comorbid obesity, metabolic, or endocrine disorders while taking antipsychotics were at higher risk of developing hyperprolactinemia and ensuing sexual/reproductive adverse events.

A non-randomized, open study with aripiprazole and ziprasidone for the treatment of aggressive behavior in youth in a community clinic

Forty-six patients (36 male, mean age 11.9 +/- 2.6) with a variety of diagnoses and with significant aggressive behavior were treated in an open, non-randomized fashion with Aripiprazole or Ziprasidone. Patients were diagnosed with the Mini International Neuropsychiatric Interview and the Child/Adolescent Symptom Inventory. The primary outcome measure was the Overt Aggression Scale (OAS). After 2 months, 34 patients were still in treatment. The average improvement of the OAS in these 34 patients was 63%. Clinical Global Impression-Improvement Scale was 2.1 +/- 1.2. Neither at baseline, nor at 2 months, were there any statistically significant differences between the Aripiprazole and Ziprasidone groups. Sedation was the most common side effect.

Olanzapine versus placebo in adolescents with schizophrenia: a 6-week, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To assess olanzapine's efficacy and tolerability in adolescents with schizophrenia.

METHOD

One hundred seven inpatient and outpatient adolescents (olanzapine, n = 72, mean age 16.1 years; placebo, n = 35, mean age 16.3 years) with schizophrenia participated in this randomized (2:1), international, multisite, industry-sponsored trial. All patients met DSM-IV-TR criteria for schizophrenia, and they were treated for up to 6 weeks with flexible doses of olanzapine (2.5-20.0 mg/day) or placebo. Last-observation-carried-forward mean changes from baseline to endpoint on the anchored version of the Brief Psychiatric Rating Scale for Children, Clinical Global Impression Scale-Severity of Illness, and Positive and Negative Syndrome Scale (PANSS) were assessed.

RESULTS

More olanzapine-treated versus placebo-treated patients completed the trial (68.1% versus 42.9%, p =.020). Compared with placebo-treated patients, olanzapine-treated adolescents had significantly greater improvement in Brief Psychiatric Rating Scale for Children total (p =.003), Clinical Global Impressions Scale-Severity of Illness (p =.004), PANSS total (p =.005), and PANSS positive scores (p =.002). Olanzapine-treated patients gained significantly more baseline-to-endpoint weight (4.3 kg versus 0.1 kg, p <.001). Significantly more olanzapine-treated versus placebo-treated patients gained 7% or greater of their body weight at any time during treatment (45.8% versus 14.7%, p =.002). Prolactin and triglyceride mean baseline-to-endpoint changes were significantly higher in olanzapine-treated versus placebo-treated adolescents. The incidence of treatment-emergent significant changes in fasting glucose, cholesterol, or triglycerides did not differ between the groups at endpoint, but significantly more olanzapine-treated patients had high triglycerides at any time during treatment.

CONCLUSIONS

Olanzapine-treated adolescents with schizophrenia experienced significant symptom improvement. Significant increases in weight, triglycerides, uric acid, most liver function tests, and prolactin were observed during olanzapine treatment.Clinical trial registration information-Olanzapine Versus Placebo in the Treatment of Adolescents With Schizophrenia. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00051298.

Neurological adverse events associated with antipsychotic treatment in children and adolescents

A retrospective cohort design using medical and pharmacy claims from one state's Medicaid program compared incidence rates for neurological adverse events associated with antipsychotic use in 4140 youths prescribed antipsychotic medications and an untreated sample of 4500 youths, January 1998 to December 2005. The treated cohort evinced a higher prevalence of involuntary movements, sedation, and seizures. The odds of incident involuntary movements were significantly higher for those taking aripiprazole, risperidone, haloperidol, and multiple antipsychotics. The odds of incident seizures were greater for those taking risperidone, multiple antipsychotics, and serotonin-specific reuptake inhibitors. The odds of incident sedation were greater for those taking ziprasidone, risperidone, quetiapine, multiple antipsychotics, and serotonin-specific reuptake inhibitors. Exposure to risperidone, multiple antipsychotics, and serotonin-specific reuptake inhibitors consistently confers a higher risk of developing a range of neurological adverse events in young patients, especially those with preexisting central nervous system, mental retardation, or cardiovascular disorders.

Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists

OBJECTIVE

The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs).

METHOD

A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia.

RESULTS

Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations.

CONCLUSIONS

Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.

Adverse events in children and adolescents treated with antipsychotic medications

OBJECTIVE

To report the odds of developing adverse events associated with antipsychotic treatment among children and adolescents.

METHOD

A retrospective cohort design evaluating medical and pharmacy claims from one state Medicaid program was used to compare incidence rates for six categories of adverse events of antipsychotic use in 4140 children and adolescents newly prescribed one of six atypical or two conventional antipsychotic medications, January, 1998 to December, 2005 with prevalence rates of these conditions in a random sample of 4500 children not treated with psychotropic medications.

RESULTS

The odds of developing obesity/excessive weight gain, Type II diabetes and dyslipidemia, digestive/urogenital problems, and neurological/sensory symptoms were higher for females and those prescribed multiple antipsychotic medications. The odds of developing cardiovascular conditions were higher for those prescribed multiple antipsychotic medications and haloperidol. The odds of developing somatic conditions were higher for females, children 12 and under, and those prescribed multiple antipsychotics. Those with lengthy exposure to antipsychotics were at higher risk of developing incident neurological/sensory symptoms. Those treated with concomitant antipsychotic agents were at higher risk of developing somatic problems, and digestive/urogenital conditions.

CONCLUSION

Pediatric exposure to antipsychotic polypharmacotherapy confers a higher risk of developing adverse events than monotherapy, especially for females.

Psychopharmacology of aggression in children and adolescents with autism: a critical review of efficacy and tolerability

BACKGROUND

Autism is characterized by a clinical triad of symptoms that affect social, language, and behavioral domains. Aggression and self-injury may be associated symptoms of autism and can result in significant harm to those affected as well as marked distress for their families. The precise nature of the relationship between aggressive or self-injurious behavior (SIB) and autism remains unclear and as a result, these symptoms are treated with a broad range of pharmacological approaches. This review seeks to systematically and critically examine the evidence for the pharmacological management of aggression and SIB in children with autism spectrum disorders.

METHOD

The entire PubMed database was searched for English language biomedical articles on clinical trials with medication in autism spectrum disorders. Studies were selected based on the following inclusion criteria: (1) randomized placebo-controlled trials; (2) a sample population that included children and adolescents; (3) at least one standardized assessment of aggression as a primary outcome measure of the study.

RESULTS

Twenty one trials with 12 medications were identified. Five medications produced significant improvement as compared to placebo, including tianeptine, methylphenidate, risperidone, clonidine, and naltrexone. Only risperidone and methylphenidate demonstrate results that have been replicated across at least two studies.

CONCLUSIONS

Although many medications have been studied under placebo-controlled conditions, few produce significant improvement. Additional placebo-controlled trials are needed to increase the number of therapeutic options available in the treatment of aggression in autism.

Body mass indexes and lipid profiles in hospitalized children and adolescents exposed to atypical antipsychotics

OBJECTIVE

The purpose of this study was to examine body mass indexes (BMI) and lipid profiles of children and adolescents hospitalized for a psychiatric illness and exposed to an atypical antipsychotic.

METHOD

Medical records of children and adolescents (ages of 5-18 years) with an inpatient psychiatric hospitalization between July 1, 2004, and June 30, 2005, were reviewed. Subjects were required to have been treated with at least one atypical antipsychotic during the month prior to admission. Height, weight, and fasting lipid values completed upon admission were collected. Prevalences of overweight (sex-specific BMI for age>or=the 95th percentile) and at risk for overweight (sex-specific BMI for age between the 85th and 94.9th percentiles) were determined and compared to estimates from the 2001-2002 National Health and Nutrition Examination Survey (NHANES) data. The prevalence of abnormal lipid profiles was also evaluated using widely accepted criteria specific for pediatric patients. Exploratory multiple linear regression models were fit to examine relationships of demographic and clinical variables with BMI z-scores and lipid profiles.

RESULTS

Of 95 inpatients (mean age 14 years, 43% female, and 60% white) evaluated, 16% (n=15) were at risk for overweight and 53% (n=50) were overweight. Fifty-one percent (n=48) and 48% (n=46) of the sample had elevated triglycerides (TG) levels and low high-density lipoprotein (HDL) levels, respectively.

CONCLUSION

The prevalence of overweight among hospitalized children and adolescents with exposure to atypical antipsychotics is triple that of national norms. Dyslipidemia was also common in this inpatient sample. Future studies should assess the development of overweight, the factors contributing to it, and related comorbidities in youths with mental illness.

Quetiapine addition in methylphenidate treatment-resistant adolescents with comorbid ADHD, conduct/oppositional-defiant disorder, and aggression: a prospective, open-label study

OBJECTIVE

This study investigated the safety and efficacy of adding the atypical antipsychotic quetiapine to ongoing OROS methylphenidate treatment for adolescents with comorbid ADHD and severe aggression that were incompletely responsive to methylphenidate monotherapy.

METHOD

Participants aged 12-16 years were enrolled in a prospective, open-label trial consisting of 3 weeks of OROS methylphenidate monotherapy titrated to 54 mg/day, followed by 9 weeks of combination treatment with quetiapine and methylphenidate. Twenty-four out of thirty participants failed to meet criteria for significant improvement (Clinical Global Improvement-Severity [CGI-S] and Rating of Aggression Against People and Property [RAAPP] scale scores of 1 or 2 and ADHD-Rating Scale: Investigator Administered and Scored [ADHD-RS-I] score less than 50% of baseline score) with methylphenidate treatment alone and received combined treatment.

RESULTS

Investigator and parent ratings of ADHD symptoms, aggression, and global functioning improved significantly during both methylphenidate monotherapy treatment and during combined methylphenidate-quetiapine treatment. At the conclusion of combined treatment, 42% of the sample met all criteria for clinically significant improvement and 79% showed minimal aggression. Mild and transient sedation was reported by about half the cases. Weight loss (0.9 kg) during methylphenidate treatment was offset by weight gain (1.2 kg) during combination treatment.

CONCLUSION

Quetiapine addition to methylphenidate was effective in reducing ADHD and aggression in individuals who did not respond sufficiently (based on CGI-S, RAAPP, and ADHD-RS-I criteria for significant improvement) to OROS methylphenidate alone at a 54-mg/day dose.

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE

To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking.

METHOD

A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents.

RESULTS

Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment.

CONCLUSIONS

Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.

Risperidone-to-methylphenidate switch reaction in children: three cases

As atypical antipsychotics are increasingly used in the treatment of childhood behavioural disorders either as monotherapy or in combination with other medications, there is a need to know more about their safety, in particular during switching to and from methylphenidate treatment, as antipsychotics and methylphenidate have opposing effects on dopaminergic neurotransmission. This report is about three cases of children who developed severe adverse reactions during switching from risperidone to methylphenidate. The first patient was a 6-year-old boy, diagnosed with attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). He developed severe hyperactivity and agitation on taking methylphenidate after the discontinuation of risperidone treatment. The second patient was a girl of 6, already on risperidone for ADHD and borderline intellectual functioning when referred. She displayed severe hyperactivity, agitation and irritability upon switching to methylphenidate medication. The third patient was a 15-year-old female adolescent with a similar clinical course as the previous patients. In all the cases described here, it is only with the discontinuation of methylphenidate that the adverse reactions resolved and readministration of methylphenidate in two patients did not produce any adverse effect after a drug-free interval. Functional regulation of certain neuroreceptors during risperidone treatment may lead to altered behavioural responses upon switching to methylphenidate. Thus, a drug-free interval is recommended in order to prevent adverse reactions.

Effectiveness and tolerability of aripiprazole in child and adolescent inpatients: a retrospective evaluation

The objective of this study was to evaluate the effectiveness and tolerability of aripiprazole use in child and adolescent psychiatric inpatients. This was a naturalistic, retrospective evaluation of the discharged patients treated with aripiprazole on the child and adolescent unit at the Austin State Hospital. To be included, patients had to be <18 years of age and treated with aripiprazole for at least two consecutive weeks during their hospital stay. We used a chart extracted Clinical Global Impression of Improvement, and a chart extracted Clinical Global Impression of Severity of Illness score to determine their effectiveness. Adverse events and side effects recorded in the physician or nursing notes were collected to establish tolerability. Forty-five patients met the criteria and were included in this analysis. Average clinical global impression of severity of illness scores at baseline and endpoint were 5.04+/-0.91 and 3.33+/-1.24 respectively. This difference was statistically significant (Wilcoxon's signed-rank test: Z=-5.179, P<0.001). Fifty-one percent of the youth had a clinical global impression of severity of illness score that was much improved or very much improved (clinical global impression of improvement score of 1 or 2). Significant reduction in clinical global impression of severity of illness scores suggests a decline in the symptom severity for patients treated with aripiprazole. On the basis of the reported adverse events and side effects, aripiprazole was generally well tolerated. Randomized controlled trials of aripiprazole in childhood mental disorders are warranted.

Neuroleptic Malignant Syndrome From Aripiprazole in an Agitated Pediatric Patient

OBJECTIVE

Neuroleptic malignant syndrome was induced by aripiprazole in a 12 1/2-year-old boy. The patient had a history of reactive airway disease, pervasive developmental disorder, and learning disability.

METHOD

The patient was interviewed and examined, and additional history was taken from the medical records. The Naranjo adverse drug reaction rating scale was applied.

RESULTS

The patient developed neuroleptic malignant syndrome 2 days after starting aripiprazole 10 mg/d. This patient had no history of exposure to dopamine-blocking drugs or selective serotonin reuptake inhibitors or of neurological disorder, movement disorder, or substance use. Aripiprazole discontinuation and supportive treatment led to resolution. The Naranjo scale indicates high probability of neuroleptic malignant syndrome from aripiprazole.

CONCLUSIONS

Aripiprazole can rapidly induce neuroleptic malignant syndrome in adolescents.

Patterns and determinants of antipsychotic prescribing in children and adolescents, 2003-2004

OBJECTIVES

This study examined patterns and determinants of antipsychotic prescribing in children and adolescents receiving outpatient care in the United States.

METHODS

Antipsychotic prescribing practices for patients younger than 20 years were examined using the 2003-2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003-2004 National Hospital Ambulatory Medical Care Survey. The analysis focused on outpatient visits involving 11 typical and six atypical antipsychotic agents. National visit estimates were used to characterize the nature and extent of antipsychotic prescribing for patients younger than 20 years. Multiple logistic regression analysis was applied to visits involving children and adolescents to examine the need, predisposing, and enabling factors associated with antipsychotic prescribing.

RESULTS

Antipsychotic medications were prescribed in two million outpatient visits annually involving children and adolescents, representing 1% of overall visits by children and adolescents in 2003-2004. Most (99%) of these visits involved prescribing of atypical agents. The most frequently prescribed atypical agents were risperidone, quetiapine, and aripiprazole. The majority of the visits involving antipsychotic medications in children were seen in patients over 9 years, males, and whites. Factors positively associated with antipsychotic prescribing in children and adolescents included age over 9 years, diagnoses (bipolar disorder, psychoses, depression, disruptive behavior, and anxiety), and visits to specialists. Private insurance was negatively associated with antipsychotic prescribing.

CONCLUSIONS

Although the findings were based on cross-sectional analyses of outpatient visit data, the study revealed that atypical antipsychotic medications are being commonly and extensively prescribed to children and adolescents despite the relatively limited scientific evidence to support their pediatric use. Well-designed studies are urgently needed in children and adolescents to address atypical antipsychotic use for a variety of psychiatric disorders.

Review of antipsychotics in children and adolescents

The use of antipsychotics in children and adolescents in the clinical setting is increasing. This article reviews 77 clinical trials published in the last 10 years, investigating their efficacy, effectiveness, safety and pharmacokinetic data in paediatric populations. The diagnostic categories in which the antipsychotics are commonly used (schizophrenia, pervasive developmental disorders, Tourette's disorder, mental retardation/subaverage intelligence, mood disorders and disruptive behaviour disorders) were used in order to review the evidence and effectiveness. All randomised, double-blind, placebo-controlled trials from the past decade are also summarised. This review refers to recent relevant practice parameters, guidelines and reviews throughout the text. Consistent with previous reviews, it is concluded that the recent trend of increased use of antipsychotics in children and adolescents is not adequately supported by evidence. Specific suggestions have been provided on how to incorporate the existing evidence base into clinical decision making. The review ends with the authors' opinion on the clinical and research implications for the field and future directions.

Effects of olanzapine on aggressiveness in heroin dependent patients

This study compared the anti-aggressiveness effects of the atypical anti-psychotic olanzapine with that of selective serotonin reuptake inhibitors (SSRI) and benzodiazepines (BZD) among patients with heroin dependence submitted to opioid-agonists substitution treatment. Sixty-seven (67) patients who met the DSM-IV criteria for heroin dependence and showed aggressive personality traits, not affected by comorbid schizophrenia or bipolar disorder, accepted to participate in a 12-week prospective, observational trial. Patients were included into two subgroups in relationship with treatment, for the evaluation of the endpoints at week 12: group 1: substitution treatment in combination with OLA (32 patients); group 2: substitution treatment in combination with fluoxetine/paroxetine and clonazepam (35 patients). Efficacy measures were Buss Durkee Hostility Inventory (BDHI), Symptoms Check List-90 (SCL 90) anger--hostility scores, incidence rates of aggressive incidents and attacks. The rates of patients who remained in treatment at week 12 in group 1, treated with OLA, and group 2, treated with SSRI and BDZ, were not significantly different (17 = 53.1% vs 16 = 45.7%). BDHI total, direct aggressiveness, verbal aggressiveness scores, SCL 90 aggressiveness scores and aggressive incidents rates showed a significantly more consistent decrease from baseline in group 1 than in group 2 subjects, in the patients who completed the treatment (p < 0.001; p < 0.01; p < 0.05; p < 0.01; p < 0.001). Among the completers, 69.3% achieved early full substance abuse remission, while 30.7% achieved partial substance abuse remission, with no significant difference between 1 and 2 treatment subgroups. Although obtained by an observational--open clinical study, with multiple limitations, our findings suggest that OLA may be useful as an adjunctive agent in reducing aggressive/hostile behaviour in heroin addicted individuals during maintenance substitution treatment. Otherwise, atypical anti-psychotic OLA seems to be unable to improve the outcome in terms of addictive behavior and relapse risk in the addicted patients not affected by overt psychotic disorders.