Trends in Atypical Antipsychotics Prescribed to Children Six Years of Age or Less on Medicaid in Kentucky

Early-life risperidone alters locomotor responses to apomorphine and quinpirole in adulthood

An escalating trend of antipsychotic drug use in children with ADHD, disruptive behavior disorder, or mood disorders has raised concerns about the impact of these drugs on brain development. Since antipsychotics chiefly target dopamine receptors, it is important to assay the function of these receptors after early-life antipsychotic administration. Using rats as a model, we examined the effects of early-life risperidone, the most prescribed antipsychotic drug in children, on locomotor responses to the dopamine D1/D2 receptor agonist, apomorphine, and the D2/D3 receptor agonist, quinpirole. Female and male Long-Evans rats received daily subcutaneous injections of risperidone (1.0 and 3.0 mg/kg) or vehicle from postnatal day 14-42. Locomotor responses to one of three doses (0.03, 0.1, and 0.3 mg/kg) of apomorphine or quinpirole were tested once a week for four weeks beginning on postnatal day 76 and 147 for each respective drug. The locomotor activity elicited by the two lower doses of apomorphine was significantly greater in adult rats, especially females, administered risperidone early in life. Adult rats administered risperidone early in life also showed more locomotor activity after the low dose of quinpirole. Overall, female rats were more sensitive to the locomotor effects of each agonist. In a separate group of rats administered risperidone early in life, autoradiography of forebrain D2 receptors at postnatal day 62 revealed a modest increase in D2 receptor density in the medial caudate. These results provide evidence that early-life risperidone administration can produce long-lasting changes in dopamine receptor function and density.

Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy

OBJECTIVE

This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children.

METHODS

State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use.

RESULTS

In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period.

CONCLUSIONS

Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.

'Pediatric Bipolar Disorder' rates are still lower than claimed: a re-examination of eight epidemiological surveys used by an updated meta-analysis

Background

‘Pediatric bipolar disorder’ (PBD) is a controversial diagnosis with varying rates of clinical diagnosis. A highly cited meta-analysis (Van Meter et al. 2011) of a dozen epidemiological surveys suggested a global community prevalence of PBD of 1.8%. This was updated to 3.9% with eight additional surveys (Van Meter et al. 2019a). In terms of the Cochrane Handbook for Systematic Reviews of Interventions, the heterogenous community surveys were arguably unsuitable for statistical meta-analysis and warranted a narrative analysis. A narrative analysis (Parry et al. 2018) of the original 12 surveys concluded rates of PBD were substantially lower than 1.8% and led to a nine-article debate on the validity, arguable overdiagnosis and iatrogenic aspects of the PBD diagnosis (e.g. Carlson and Dubicka Child Adolesc Mental Health 21:86–87, 2019). This article extends the narrative analysis to include the eight newer community surveys.

Methods

A narrative analysis of the methodologies and the prevalence rates reported by the epidemiological surveys.

Results

Across all twenty surveys there was significant variation in methodologies and reported prevalence rates. Of the eight newer surveys, five (two Brazilian, one English, one Turkish, one United States) provided information of pre-adolescent prevalence rates of bipolar spectrum disorder. These pre-adolescent rates were zero or close to zero. Rates of adolescent hypomania and mania were higher, but follow-up data in two studies suggested hypomania might sometimes achieve prolonged remission or not lead to adult bipolar disorder.

Limitations

Methods in the original surveys vary and criteria used for various bipolar diagnoses were not always fully described. This limitation applies to a narrative analysis but also to a statistical meta-analysis.

Conclusion

Bipolar disorder is very rare in childhood and rare in adolescence. PBD as a diagnostic construct fails to correlate with adult bipolar disorder and the term should be abandoned. Hypomanic syndromes in adolescence may not always progress to adult bipolar disorder. Early diagnosis of bipolar disorder is important, but over-diagnosis risks adverse iatrogenic consequences.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid

BACKGROUND

The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits.

METHODS

A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration.

RESULTS

High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate.

CONCLUSIONS

Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Trends Over Time in Antipsychotic Initiation at a Large Children's Health Care System

Objectives: Antipsychotic prescribing in children and adolescents increased sharply beginning in the 1990s, but recent reports among Medicaid enrollees suggest declining trends. However, few studies have included both commercially and publicly insured patients or focused on trends in new antipsychotic medications in children without documented psychotic disorders or other indicated conditions. The objective of the study was to report trends in new antipsychotic prescribing for pediatric patients (age 3-17 years) in a large children's health care system. Methods: Data were abstracted from electronic medical records (January 1, 2013 to December 31, 2017). New antipsychotic medication orders were defined as antipsychotic orders for patients without an order in the 180 days prior. Patients were excluded if the order was initiated in an emergency department or inpatient setting; they were diagnosed with psychotic disorder, mania, autism spectrum disorder, or intellectual disability; or the order was for prochlorperazine. The crude rate of new antipsychotic prescribing is reported quarterly with Poisson 95% confidence intervals in the total sample and by demographic subgroups (child vs. adolescent, female vs. male, public vs. private insurance, and white vs. nonwhite). Results: Antipsychotic orders decreased from 54.9 prescriptions per 10,000 person months in the first quarter of 2013 to 34.1 per 10,000 person months in the last quarter of 2017. Rates of antipsychotic prescribing were significantly higher for adolescents compared with children, patients who were commercially insured compared with Medicaid insured, and at most time points for white compared with non-white patients. However, prescribing rates did not differ significantly based on gender. Conclusions: Antipsychotic prescribing declined for both commercially and Medicaid-insured children in a pediatric hospital-based system, although white and commercially insured patients were more likely to be prescribed antipsychotics. More attention may be needed for reducing potentially avoidable prescribing of antipsychotics in previously understudied subgroups, such as commercially insured patients. Clinical Trial Registration Number: NCT03448575.

Editorial: Beyond the Prior Authorization: Multimodal Efforts to Reduce Antipsychotic Medication Prescribing in Foster Care Youth

When it comes to efforts to reduce the overprescribing of psychiatric medications, the first thing that comes to mind for many clinicians is burdensome prior authorizations or generic letters from insurance companies telling you things you already know. Most psychiatrists and primary care clinicians are well aware of the potential risks associated with drugs such as antipsychotic medications, and many wonder if these intrusions into the doctor-patient relationship go beyond saving money and actually contribute to improved care.

The geography of a controversial diagnosis: A bibliographic analysis of published academic perspectives on 'paediatric bipolar disorder'

BACKGROUND

The hypothesis that bipolar disorder presents before puberty with atypical mania has proved to be controversial. Published academic perspectives on the validity of Paediatric Bipolar Disorder (PBD) appear to vary between the United States and the rest of the world.

METHODS

We examined the perspectives of articles citing four seminal articles. The citing articles were grouped as either supportive or non-supportive of the PBD hypothesis, and the perspectives of the articles by US authors were compared with those by non-US authors.

RESULTS

There were 787 citing articles commenting on PBD, mostly published in US-based journals. Most authors were affiliated with several US institutions. Among the 624 articles with US authorship, the majority (83%) supported PBD. Of the 163 articles by non-US authors, most (60%) supported the traditional view that bipolar disorders are rare before mid-adolescence. Published academic perspectives in favour of the PBD hypothesis are mostly concentrated in several US institutions.

CONCLUSION

There is majority support for PBD among citing articles from the United States, whereas the traditional perspective predominates in articles from most other countries.

Debate: Pediatric bipolar disorder - divided by a common language?

The paediatric bipolar disorder (pBD) debate is seen as a prototypical transatlantic controversy. But this is a Eurocentric view that ignores just how big a country the United States is - it contains multitudes, to paraphrase Walt Whitman writing in the aftermath of the Civil War. Indeed, such are the multitudes that a child can receive a diagnosis of bipolar in one State, but not in a neighbouring one. It was the force of this intra-American division that swept over the Atlantic. As this has been the case for many other goods imported from the United States, the European high-brow response was that pBD was just a New World fad. This response was evidently wrong. Of course, there are young children who have full-blown manic and depressive episodes and who need treatment. And the bitter truth was (and continues to be in parts of the United Kingdom) that often such children are dismissed as having 'character pathology' and their families accused of all sorts of inadequacies. Clearly, here was an important problem hidden under layers of Old-World crustiness.

The effects of amphetamine on working memory and locomotor activity in adult rats administered risperidone early in life

Antipsychotic drugs are used to manage symptoms of pediatric psychiatric disorders despite the relative absence of research regarding the long-term effects of these drugs on brain development. Using rats as a model, research has demonstrated that administration of the antipsychotic drug, risperidone, during early postnatal development elevates locomotor activity and sensitivity to the locomotor effects of amphetamine during adulthood. Because risperidone targets neurotransmitter receptors and forebrain regions associated with working memory, the present study determined whether early-life risperidone altered working memory during adulthood and its sensitivity to amphetamine-induced impairment. Female and male rats received subcutaneous (sc) injections of risperidone daily on postnatal days 14-42. Early-life risperidone increased spontaneous locomotor activity and amphetamine-induced hyperactivity during adulthood, although the effects were significantly greater in females. Working memory was tested in an operant-based, delayed non-matching-to-sample task. Early-life risperidone did not affect the percentage of correct choices observed during sessions with 0-8 second delays but impaired performance during sessions with 0-24 second delays. In a subsequent set of tests using 0-24 second delays, amphetamine (0.75 and 1.25 mg/kg, sc) significantly reduced the percentage of correct choices at most delays, but risperidone did not exacerbate this effect. These data suggest that early-life risperidone leads to modest deficits in working memory during adulthood, but does not alter the perturbation of working memory by amphetamine.

Psychotropic Polypharmacy Among Children and Youth Receiving Medicaid, 2012-2015

BACKGROUND

The rates of mental health diagnoses in children have increased. Children in poverty have the highest rates. The use of psychotropic medication for children has been increasing, which is concerning because of the unknown long-term effects and the increased burden on the health care system. The state of Kentucky ranks among the highest in the United States for children with mental health problems, children living in poverty, and children receiving psychotropic medication.

OBJECTIVE

To examine recent trends and determinants of interclass psychotropic polypharmacy (PP) use for children and youth receiving Medicaid to inform intervention development.

METHODS

A retrospective cohort study was conducted using 2012-2015 Kentucky Medicaid claims for children aged 0-17 years, with continuous enrollment for ≥ 90 days with at least 1 behavioral health diagnosis (N = 237,393). Interclass PP was defined as the presence of at least 2 psychotropic medication prescription fills for at least 2 different classes of medication that, if taken as directed, would be used concurrently for at least 90 consecutive days (allowing for a single 15-day lag). The outcome variables were the presence of any interclass PP and the number of months a child received interclass PP. We conducted a descriptive analysis and developed 2 separate generalized linear regression models to test for associations between individual characteristics of children treated with psychotropic medication for ≥ 90 days (n = 75,639) and each outcome of interest.

RESULTS

For the sample of children with at least 90 days of psychotropic medication treatment, 38% had at least 3 covered months of PP over the 4 years studied. Children in foster care received alpha agonists (116 vs. 69 per 1,000 children) or antidepressants (225 vs. 176 per 1,000) at a higher rate than other children receiving Medicaid but received stimulants at a lower rate (403 vs. 638 per 1,000). The primary 2-drug class combinations were stimulants with either alpha agonists or antidepressants. Children in foster care (OR = 1.7, 95% CI = 1.58, 1.84, P < 0.001), with a bipolar disorder (OR = 2.24, 95% CI = 2.10, 2.38, P < 0.001), mood disorder not otherwise specified (OR = 1.11, 95% CI = 1.04, 1.17, P < 0.001), or autism spectrum disorders (OR = 1.17, 95% CI = 1.08, 1.26, P < 0.001) had increased the odds of ever receiving PP. Black children had lower odds (OR = 0.72, 95% CI = 0.67, 0.77, P < 0.001) of ever receiving PP. Children aged 6-11 years (beta = 3.08, 95% CI = 2.87, 3.29) and 12-17 years (beta = 1.61, 95% CI = 1.38, 1.83) had more covered months with PP compared with those aged 0-5 years. Black children had fewer covered months of PP compared with white children (beta = -1.36, 95% CI = -1.61, -1.11]. Children in foster care (beta = 1.83, 95% CI = 1.53, 2.13) had more covered months with PP. Children residing in nonurban areas had fewer months with PP (beta = -0.4, 95% CI = -0.54, -0.26) compared with those residing in urban areas, as did those children with depression (beta = -3.32, 95% CI = -3.55, -3.1), impulse control disorder (beta = -2.07, 95% CI = -2.28, -1.85), and conduct disorder (beta = -1.34, 95% CI = -1.64, -1.05). Children with bipolar disorder (beta = 3.62, 95% CI = 3.38, 3.86) and autism (beta = 2.04, 95% CI = 1.75, 2.33) had more covered months with PP. As comorbidity increased, the duration of PP treatment increased (beta = 2.49, 95% CI = 2.36, 2.62).

CONCLUSIONS

The rates of PP are concerning, especially for children in foster care and children aged 6-11 years. Efforts to safeguard medication use are needed, as well as future exploration of racial differences in PP.

DISCLOSURES

This project was supported by the Kentucky Cabinet for Health and Family Services, Department for Medicaid; Norton Healthcare; and the School of Medicine, Department of Pediatrics; School of Public Health and Information Sciences; and Kent School of Social Work at the University of Louisville. Kentucky Medicaid approved the use of the data and granted permission to publish but played no role in the interpretation of data. Lui is employed by Kentucky Medicaid. The other authors report no potential conflicts of interest. An earlier version of this study was presented at the Pediatric Academic Societies' Annual Meeting in Baltimore, MD, on April 30-May 3, 2016. A poster presentation was given at the Society for Developmental and Behavioral Pediatrics in Cleveland, OH, on October 14-16, 2017.

Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people

BACKGROUND

Irritability is one of the most common reasons for referral to child and adolescent mental health services and is the main characteristic of the new diagnosis of disruptive mood dysregulation disorder (DMDD). However, the recognition and management of irritability presents a major challenge in clinical practice and may be partly responsible for the dramatic increase in antipsychotic prescribing in recent years.

METHODS

In this review, we provide up-to-date information on the definition and mechanisms underlying irritability, and its assessment in clinical practice. We aim to discuss the latest research on DMDD, and the presence of severe irritability in the context of other disorders, as well as to recommend a treatment algorithm.

RESULTS

Severe irritability is associated with aberrant reward processing and bias toward threatening stimuli. Several measures are available to easily assess irritability. The recent diagnosis of DMDD captures children whose main problem is severe irritability and differ from those with bipolar disorder in longitudinal outcomes, family history, and behavioral and neural correlates. Treatment of irritability might depend on the context it appears. Indirect evidence suggests that parent management training (PMT) and cognitive behavioral therapy (CBT) are the most supported psychological treatments for irritability.

CONCLUSIONS

Irritability, recognized as a mood problem rather than a purely behavioral manifestation, is a common condition for young people. Practitioners should not ignore irritability as it is associated with substantial morbidity and impairment. Although there are no trials with irritability as main outcome, clinicians can apply several existing pharmacological and psychological interventions for its treatment. Also, new promising approaches relying on pathophysiological findings, such as exposure-based cognitive behavioral therapy techniques and interpretation bias training (IBT), are being currently investigated.

Psychotropic medication in children and adolescents in the United States in the year 2004 vs 2014

BACKGROUND

There is a global perception that psychotropic utilization in children and adolescents is increasing in the US.

METHODS

We present prevalent estimates for all psychotropics prescribed in the US (using commercial claims from Medicare and Medicaid) to children and adolescents in 2004 (total population N = 6,808,453) and in 2014 (total population N = 11,082.260). Further we evaluated if there has been a statistically significant change in prevalence during this time period. Analyses were stratified for the 6 major drug classes, all individuals' psychotropics (87 drugs), age and sex.

RESULTS

The prevalence of psychotropic drug prescription was 8.55% in 2004 and 9.00% in 2014 (age stratified in 2004 and 2014 toddlers: 3.08 and 2.63%, children: 8.74 and 8.73%, adolescents: 10.89% and 12.11). The prevalence for each drug class in 2004 and 2014 was: stimulants/other ADHD drugs 5.0 and 5.8%; antidepressants 2.8 and 2.7%; anxiolytic-hypnotic-sedative 2.2 and 2.3%; mood stabilizers 0.1 and 0.1%; antipsychotics 1.3 and 1.1%; and for drugs treating drug dependence 0.02 and 0.02%.

CONCLUSIONS

The perception that psychotropic utilization in children and adolescents is increasing in the US, derived from the 2 to 3 fold increase seen from the mid 80's to the mid 90's is not valid anymore. There has been a slowdown in the increase of prescribing psychotropics. In the last 10 years, in toddlers there was a decrease in the prescription; in children there was no change; and in adolescents there was a slight increase. The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall. Graphical abstract In the last 10 years there has been a slowdown in the increase of prescribing psychotropics. In toddlers there was a decrease in the prescription (3.08 and 2.63%); in children (8.74 and 8.73%) there was no change; and in adolescents there was a slight increase (10.89% and 12.11). The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall.

Antipsychotics in Dutch Youth: Prevalence, Dosages, and Duration of Use from 2005 to 2015

Objectives: The use of antipsychotic drugs by youth is associated with serious side effects, especially when prescribed in higher dosages and for a longer period. Despite this, little is known about recent trends in the dosages and duration of use of antipsychotic drugs in children and adolescents. The aim of this study was to describe trends in prevalence, incidence, dosages, duration of use, and preceding psychotropic medication in Dutch youth who had been prescribed antipsychotic drugs from 2005 to 2015. Methods: We analyzed 84,828 antipsychotic prescriptions of youths aged 0-19 years between 2005 and 2015, derived from a large Dutch community pharmacy-based prescription database (IADB.nl). Results: Since a peak of 9.8 users per 1000 youths in 2009, prevalence rates stabilized. Dosages in milligram per kilogram declined for the most frequently prescribed antipsychotic drugs during the study period. The median duration of use was 6.0 (95% CI 5.4-6.6) months. Boys used antipsychotic drugs significantly longer than girls, with a median of 6.9 (95% CI 6.1-7.7) versus 4.6 (95% CI 3.9-5.3) months (p < 0.01). Of the youths prescribed antipsychotics, 12.4% used them for at least 48 months. The majority of youths had used other psychotropic agents in the year before the start of an antipsychotic drug (62.4% in 2005 and 64.7% in 2015). Conclusions: Despite a stabilization of usage rates and decline in dosages and duration of use, one in eight youths still used antipsychotic drugs for 4 years or longer. A substantial share of youths may, therefore, be at high risk for serious side effects.

Nationwide Epidemiologic Study of Atypical Antipsychotic Use Among Pediatric Population with Mental Illness in Korea

Objective: This population-based epidemiologic study aimed to analyze the prevalence and trends of atypical antipsychotic (AAP) use and identify factors associated with AAP prescribing among children and adolescents in Korea. Methods: Using the Health Insurance Review and Assessment Service-Pediatric Patients Sample data between 2010 and 2014, we assessed the prevalence of and secular trends in AAP use; utilization of individual AAP drug based on the type of healthcare services, healthcare institutions, and health security programs; and factors associated with AAP use. Results: The average annual prevalence of AAP use was 417 per 100,000 children and adolescents, which increased by 40% from 2010 to 2014. The major AAP drug of choice has shifted from risperidone (72.70% and 49.29% in 2010 and 2014, respectively) to aripiprazole (11.31% and 34.64% in 2010 and 2014, respectively). Quetiapine was mainly prescribed for inpatients. Therefore, hospitals have 2-3 times higher proportion of quetiapine use than clinics. A prominent difference exists in the prescribing rates and AAP drug of choice based on income level. Patients enrolled in the Medical Aid (MA) program had a higher AAP prescription rate than those enrolled in the National Health Insurance (NHI) program (adjusted odds ratio: 7.78). Moreover, MA recipients were more frequently prescribed with cheaper alternatives, such as risperidone, compared with NHI recipients. Conclusion: AAP has been increasingly used among the pediatric population in Korea. Future studies are needed to identify the causes of this increase and establish evidence on appropriate AAP use. In addition, relevant policies should be developed to ensure that low-income mentally ill children could take advantage of the best available therapy.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Early-life risperidone enhances locomotor responses to amphetamine during adulthood

Antipsychotic drug prescriptions for pediatric populations have increased over the past 20 years, particularly the use of atypical antipsychotic drugs such as risperidone. Most antipsychotic drugs target forebrain dopamine systems, and early-life antipsychotic drug exposure could conceivably reset forebrain neurotransmitter function in a permanent manner that persists into adulthood. This study determined whether chronic risperidone administration during development modified locomotor responses to the dopamine/norepinephrine agonist, D-amphetamine, in adult rats. Thirty-five male Long-Evans rats received an injection of one of four doses of risperidone (vehicle, .3, 1.0, 3.0mg/kg) each day from postnatal day 14 through 42. Locomotor activity was measured for 1h on postnatal days 46 and 47, and then for 24h once a week over the next two weeks. Beginning on postnatal day 75, rats received one of four doses of amphetamine (saline, .3, 1.0, 3.0mg/kg) once a week for four weeks. Locomotor activity was measured for 27h after amphetamine injection. Rats administered risperidone early in life demonstrated increased activity during the 1 and 24h test sessions conducted prior to postnatal day 75. Taking into account baseline group differences, these same rats exhibited significantly more locomotor activity in response to the moderate dose of amphetamine relative to controls. These results suggest that early-life treatment with atypical antipsychotic drugs, like risperidone, permanently alters forebrain catecholamine function and increases sensitivity to drugs that target such function.

Second generation antipsychotics in 'real-life' paediatric patients. Adverse drug reactions and clinical outcomes of drug switch

OBJECTIVE

Gap in knowledge on benefit/risk ratio of second generation antipsychotics (SGA) in the paediatric population represents a challenge for the scientific community. This study aims to analyse all suspected adverse drug reactions (ADRs) to SGA observed during the study period; compare the safety profiles of risperidone and aripiprazole; evaluate the effect of switching from risperidone to aripiprazole or to a first generation antipsychotic (FGA).

METHODS

Prospective analysis of spontaneously reported ADRs concerning 184 paediatric outpatients between 2012 and 2014.; clinical outcomes of drug switch were evaluated.

RESULTS

Out of the 184 patients, 130 experienced at least one ADR; ADRs were usually not serious and more frequently associated with aripiprazole. Switching to aripiprazole was associated with better results than switching to FGAs in the Clinical Global Impression scale- Efficacy (CGI-E) scores (p = 0.018), Disturbed behaviour checklist-parents (DBC-P) self-absorption subscale (p = 0.010); only a trend for difference between changing to aripiprazole vs FGAs in the DBC-P total score (p = 0.054) and social relating subscale (p = 0.053) was observed.

CONCLUSIONS

SGAs safety data were consistent with the ones already known; however, there is still a need to improve the knowledge in pharmacovigilance field among clinicians. Switching to aripiprazole may be a valid alternative to risperidone.

Trends in Antipsychotic Prescribing in Medicaid-Eligible Youth

OBJECTIVE

To examine trends in the use of antipsychotic medication in Medicaid-eligible youth from 2008 to 2013 and the factors associated with this use.

METHOD

Youth aged 0 to 17 years with at least one claim indicating antipsychotic medication use were identified from the network of a behavioral health managed care organization (BHMCO). Demographic and clinical variables were derived from state eligibility data and service claims data from the BHMCO. Overall and specific prevalence rates of antipsychotic drug use were calculated over the course of 6 years (2008-2013). The probability of antipsychotic use during 2013 was further explored with logistic regression that included demographic and diagnostic groups.

RESULTS

The overall trend in prevalence for antipsychotics for youth decreased from 49.52 per 1,000 members in 2008 to 30.54 in 2013 (p < .0001). Although rates decreased for all age groups, the rate per 1,000 members in 2013 for the youngest children was 3.79, versus 39.23 for 6- to 12-year-olds and 64.33 for 13- to 17-year-olds. Controlling for demographic and clinical variables, children 0 to 5 years old were 79% less likely to be prescribed antipsychotic medications compared to the oldest youth, 13 to 17 years of age (p < .0001). Rates were higher for males versus females regardless of age (odds ratio [95% CI] =1.48 [1.36-1.62], p < .0001). Children with a diagnosis of attention-deficit/hyperactivity disorder were less likely to be prescribed antipsychotics compared to those with diagnoses of autism spectrum disorder, bipolar disorder, psychoses, and depression.

CONCLUSION

Prevalence rates decreased significantly over time for all socio-demographic groups. The largest decrease was observed for the youngest children, ages 0 to 5 years, with a rate in 2013 under half the rate for 2008. Clinical, policy, and managed care implications are discussed.

Patterns of Antipsychotic Prescribing by Physicians to Young Children

OBJECTIVE

Antipsychotic use among young children has grown rapidly despite a lack of approval by the U.S. Food and Drug Administration (FDA) for broad use in this age group. Characteristics of physicians who prescribed antipsychotics to young children were identified, and prescribing patterns involving young children and adults were compared.

METHODS

Physician-level prescribing data from IMS Health's Xponent database were linked with American Medical Association Masterfile data and analyzed. The sample included all U.S. psychiatrists and a random sample of 5% of family medicine physicians who wrote at least ten antipsychotic prescriptions per year from 2008 to 2011 (N=31,713). Logistic and hierarchical binomial regression models were estimated to examine physician prescribing for children ages zero to nine, and the types and numbers of ingredients used for children versus adults ages 20 to 64 were compared.

RESULTS

Among antipsychotic prescribers, 42.2% had written at least one antipsychotic prescription for young children. Such prescribing was more likely among physicians age ≤39 versus ≥60 (odds ratio [OR]=1.70) and physicians in rural versus nonrural areas (OR=1.11) and was less likely among males (OR=.93) and graduates of a top-25 versus a lower-ranked U.S. medical school (OR=.87). Among physicians who prescribed antipsychotics to young children and adults, 75.0% of prescriptions for children and 35.7% of those for adults were for drugs with an FDA-approved indication for that age. Fewer antipsychotic agents were prescribed for young children (median=2) versus adults (median=7).

CONCLUSIONS

Prescribing antipsychotics for young children was relatively common, but prescribing patterns differed between young children and adults.