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.

Cardiac and metabolic safety profile of antipsychotics in youths: A WHO safety database analysis

A significant heterogeneity prevails in antipsychotics (APs) safety monitoring recommendations. Youths are deemed more vulnerable to cardiometabolic side effects. We aimed to assess age-dependent reporting of cardiac and metabolic disorders in youths, relying on the WHO safety database (VigiBase®). VigiBase® was queried for all reports of cardiac, glucose, lipid and nutritional disorders involving APs. Patients <18 years were classified as pediatric population. Disproportionality analyses relied on the Information Component (IC): the positivity of the lower end of its 95 % confidence interval was required to suspect a signal. We yielded 4,672 pediatric reports. In disproportionality analysis, nutritional disorders were leading in youths (IC 3.9 [3.9-4.0]). Among healthcare professionals' reports, stronger signals were detected in youths than in adults. Children had the greatest signal with nutritional disorders (IC 4.7 [4.6-4.8]). In adolescents, aripiprazole was ascribed to non-alcoholic steatohepatitis (NASH). Our findings, based on real-world data, support the hypothesis of a greater propensity for nutritional disorders in youths, despite limitations of pharmacovigilance studies. We suggest specific safety profiles, such as aripiprazole and NASH. Pending more answers from population-based studies, a careful anamnesis should seek for risk factors before AP initiation. A cautious monitoring is warranted to allow earlier identification of side effects.

Metabolic monitoring of pediatric patients prescribed second-generation antipsychotic medication

INTRODUCTION

The prevalence of psychotropic medication prescription use in youth has increased over the past several years. Despite recommendations and practice parameters established by the American Diabetes Association-American Psychiatric Association (ADA-APA) outlining metabolic monitoring of patients prescribed second-generation antipsychotic (SGA) medication, monitoring adherence for the pediatric patient population remains inadequate.

AIMS

This project aimed to improve metabolic monitoring of pediatric patients prescribed SGAs and discharge recommendations for follow-up monitoring within a small, child, and adolescent psychiatric hospital.

METHODS

This project compared metabolic monitoring adherence rates pre and postimplementation of a metabolic monitoring organizational policy developed to provide procedural guidance, using ADA-APA guidelines. Participants included prescribing clinicians (physicians and psychiatric nurse practitioners).

RESULTS

Phase 1 chart reviews found no records of fasting blood glucose, fasting lipid profile or waist circumference. Following project implementation, chart review found that fasting blood glucose and fasting lipid profile was recorded in 21 (72.4%) of the charts, and waist circumference was recorded in 18 (62.1%) of the charts for patients prescribed SGA medication. For patients discharged on an SGA, written recommendations for follow-up metabolic monitoring improved from 13% to 70% (<0.001).

CONCLUSIONS

Implementing an organizational metabolic monitoring policy and protocol can improve clinician adherence to ADA-APA guidelines for recording in-patient monitoring of metabolic parameters and discharge recommendations for pediatric patients prescribed SGA medication.

Common Issues for General Practitioners in the Medical Management of Child and Adolescent Psychiatric Care

With a limited number of child and adolescent psychiatrists available to see youth patients, many common psychiatric problems in youth are managed by other providers. Clinical pearls from experts in child and adolescent psychiatry can help general practitioners with this management. Some common issues are discussed here for which practical guidance is offered, ranging from approaches to assessment and how to start and titrate medications for the treatment of attention deficit hyperactivity disorder, depression, and sleep problems.

Association Between Abnormal Metabolic Parameters and Receiving Subsequent Interventions in Children and Adolescents Initiating Second-Generation Antipsychotics

Objectives: This study aimed to examine the association between abnormal readings of metabolic parameters detected during second-generation antipsychotic (SGA) treatment and the likelihood of receiving subsequent adverse drug event interventions. Methods: This was a nested case-control study conducted on patients 1-17 years of age with at least two prescriptions of SGAs between January 2010 and January 2019 using TriNetX EMR data. Following an incident density sampling procedure, patients who received the SGA metabolic adverse event intervention (mAEI) (case) were matched with three nonrecipients (controls). The abnormal readings of metabolic parameters within 30 days before the initiation of mAIEs were further identified. These metabolic parameters include body mass index (BMI) and laboratory parameters such as cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, blood glucose, HbA1c, thyroid hormones, liver enzymes, and prolactin. The association of abnormal metabolic parameters with subsequent mAEIs was assessed using a conditional logistic regression model, after adjusting for demographic and other clinical risk factors. Results: One thousand eight hundred eighty-four children and adolescents met the inclusion criteria and were prescribed SGA mAEIs. The most common types of mAEIs prescribed were weight management pharmacotherapy (40.6%), switching from a high or medium metabolic risk profile SGA to a low-risk one (30.9%), nonpharmacological treatment (25.4%), and switching from SGA polytherapy to monotherapy (11.7%). The conditional logistic regression analysis on matched mAEI recipients and nonrecipients showed that patients with an abnormal BMI had 43% higher odds of receiving mAEI (odds ratio [95% confidence interval]: 1.43 [1.13-1.79]). However, the presence of an abnormal laboratory reading was not associated with the initiation of mAEIs. Conclusions: The prescribing of mAEIs were associated with the presence of obesity, but not with abnormal readings of other metabolic parameters, suggesting that additional data are needed to clarify the long-term implication of SGA metabolic adverse events other than weight gain and to inform the appropriate timing for interventions.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Meta-Analysis of Antipsychotic-Induced Hypo- and Hyperprolactinemia in Children and Adolescents

Objective: Antipsychotic-related prolactin changes may expose children and adolescents to severe adverse reactions (ARs) related to pubertal development and growth. We therefore aimed to assess the effects of antipsychotics on prolactin levels and associated somatic ARs in children and adolescents. Methods: We systematically searched PubMed and CENTRAL for placebo-controlled randomized trials of antipsychotics in children and adolescents aged ≤18 years, reporting prolactin levels and related ARs. We conducted a random-effect meta-analysis and assessed risk of bias version 2 (ROB2). Results: Thirty-two randomized controlled trials with an average trial duration of 6 weeks, covering 4643 participants with an average age of 13 years and a male majority of 65.3%. Risk of bias across domains was low or unclear. The following antipsychotic compounds: aripiprazole (n = 810), asenapine (n = 506), lurasidone (n = 314), olanzapine (n = 179), paliperidone (n = 149), quetiapine (n = 381), risperidone (n = 609), and ziprasidone (n = 16) were compared with placebo (n = 1658). Compared with placebo, statistically significant higher prolactin increase occurred with risperidone (mean difference [MD] = 28.24 ng/mL), paliperidone (20.98 ng/mL), and olanzapine (11.34 ng/mL). Aripiprazole significantly decreased prolactin (MD = -4.91 ng/mL), whereas quetiapine, lurasidone, and asenapine were not associated with significantly different prolactin levels than placebo. Our results on ziprasidone are based on a single study, making it insufficient to draw strong conclusions. On average, 20.8% of patients treated with antipsychotic developed levels of prolactin that were too high (hyperprolactinemia), whereas only 1.03% of patients reported prolactin-related ARs. Data were highly limited for long-term effects. Conclusions: In children and adolescents, risperidone, paliperidone, and olanzapine are associated with significant prolactin increase, whereas aripiprazole is associated with significant decrease. Despite the significant changes in prolactin level, few ARs were reported. Study protocol on PROSPERO: CRD42018116451.

How to Mitigate Risk of Premature Cardiovascular Disease Among Children and Adolescents with Mental Health Conditions

Purpose of Review

The goal of this article is to characterize the myriad of ways that children with mental health conditions can be at risk for premature cardiovascular disease (CVD) and various modalities to ameliorate this risk in childhood in order to improve the life course of these children.

Review Findings

Child and adolescent mental health conditions are a common yet underrecognized risk factor for premature CVD. The American Heart Association has recently included psychiatric conditions as a CVD risk factor (CVDRF) and the evidence linking childhood adversity to cardiometabolic disease. There are bidirectional and additive effects from the intrinsic emotional dysregulation and inflammatory changes from the mental health condition, the associations with risky health behaviors, and in some cases, metabolic side effects from pharmacotherapy. These pathways can be potentiated by toxic stress, a physiologic response to stressors from childhood adversity. Toxic stress is also associated with development of mental health conditions with epigenetic effects that can result in transgenerational inheritance of cardiometabolic risk. Exposure to toxic stress and mental health conditions in isolation sometimes compounded by pharmacotherapies used in treatment increase the risk of cardiometabolic diseases in childhood. The multiple pathways, which adversely influence cardiometabolic outcomes, encourage clinicians to consider strategies to mitigate these factors and justify the importance of early screening and treatment for CVDRFs.

Summary

Mental health, health behaviors, and environmental factors co-occur and intersect in complex pathways that can increase CVD risk over the lifespan. Early detection and response can mitigate the risks associated with premature development of CVD.

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.

Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial

OBJECTIVE

To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths.

METHOD

A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations.

RESULTS

The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments.

CONCLUSION

Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths.

CLINICAL TRIAL REGISTRATION INFORMATION

Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.

Metabolic events associated with the use of antipsychotics in children, adolescents and young adults: a multinational sequence symmetry study

It is known that younger patients treated with antipsychotics are at increased risk of metabolic events; however, it is unknown how this risk varies according to ethnicity, the class of antipsychotic and the specific product used, and by age group. We conducted a multinational sequence symmetry study in Asian populations (Hong Kong, Japan, Korea, Taiwan and Thailand) and non-Asian populations (Australia and Denmark) to evaluate the metabolic events associated with antipsychotics in both Asian and non-Asian populations, for typical and atypical antipsychotics, and by the subgroups of children and adolescents, and young adults. Patients aged 6-30 years newly initiating oral antipsychotic drugs were included. We defined a composite outcome for metabolic events which included dyslipidemia, hypertension and hyperglycemia. We calculated the sequence ratio (SR) by dividing the number of people for whom a medicine for one of the outcome events was initiated within a 12-month period after antipsychotic initiation by the number before antipsychotic initiation. This study included 346,904 antipsychotic initiators across seven countries. Antipsychotic use was associated with an increased risk of composite metabolic events with a pooled adjusted SR (ASR) of 1.22 (95% CI 1.00-1.50). Pooled ASRs were similar between Asian (ASR, 1.22; 95% CI 0.88-1.70) and non-Asian populations (ASR, 1.22; 95% CI 1.04-1.43). The pooled ASR for typical and atypical antipsychotics was 0.98 (95% CI 0.85-1.12) and 1.24 (95% CI 0.97-1.59), respectively. No difference was observed in the relative effect in children and adolescents compared to young adults. The risk of metabolic events associated with antipsychotics use was similar in magnitude in Asian and non-Asian populations despite the marked difference in drug utilization patterns.

Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing

It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.

Weight gain and metabolic screening in young people with early psychosis on long acting injectable antipsychotic medication (aripiprazole vs paliperidone)

AIM

Long-acting injectable (LAI)antipsychotics are often used in psychosis to assist with medication compliance and relapse prevention, although the weight gain and metabolic effects in young people are yet to be examined. This study examined the long-term effects of aripiprazole and paliperidone in LAI formulation on weight gain and metabolic parameters in young people with early episode psychosis.

METHODS

Weight gain and other metabolic effects of aripiprazole and paliperidone in LAI formulation were examined in 59 young people with early episode psychosis over a 12-month period. Changes in outcome measurements were examined at baseline and 3 monthly intervals.

RESULTS

The results showed that both aripiprazole and paliperidone were associated with time-dependent increases in weight. At 12 months, weight increased by an average of 7% (6 kg) with both aripiprazole and paliperidone relative to the baseline, and the percentage of overweight or obese people increased from 33% to 60%. There was no advantage of aripiprazole compared to paliperidone with regards to weight change, although aripiprazole was associated with lower triglycerides and prolactin levels.

CONCLUSIONS

Both LAI medications were associated with substantial weight increases over time. These results build on emerging evidence showing that aripiprazole is not weight neutral in young people. Our recommendation is that weight-management programs should be offered from the start of medication initiation.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention

Feeling irritable is a common experience, both in health and disease. In the context of psychiatric illnesses, it is a transdiagnostic phenomenon that features across all ages, and often causes significant distress and impairment. In mood disorders, irritability is near ubiquitous and plays a central role in diagnosis and yet, despite its prevalence, it remains poorly understood. A neurobiological model of irritability posits that, in children and adolescents, it is consequent upon deficits in reward and threat processing, involving regions such as the amygdala and frontal cortices. In comparison, in adults with mood disorders, the few studies that have been conducted implicate the amygdala, orbitofrontal cortices, and hypothalamus; however, the patterns of activity in these areas are at variance with the findings in youth. These age-related differences seem to extend to the neurochemistry of irritability, with links between increased monoamine transmission and irritability evident in adults, but aberrant levels of, and responses to, dopamine in youth. Presently, there are no specific treatments that have significant efficacy in reducing irritability in mood disorders. However, treatments that hold some potential and warrant further exploration include agents that act on serotonergic and dopaminergic systems, especially as irritability may serve as a prognostic indicator for overall clinical responsiveness to specific medications. Therefore, for understanding and treatment of irritability to advance meaningfully, it is imperative that an accurate definition and means of measuring irritability are developed. To achieve this, it is necessary that the subjective experience of irritability, both in health and illness, is better understood. These insights will inform an accurate, comprehensive, and valid interrogation of the qualities of irritability in health and illness, and allow not only a clinical appreciation of the phenomenon, but also a deeper understanding of its important role within the development and manifestation of mood disorders.

The Burden of Antipsychotic-Induced Weight Gain and Metabolic Syndrome in Children

Antipsychotic medications are critical to child and adolescent psychiatry, from the stabilization of psychotic disorders like schizophrenia, bipolar disorder, and psychotic depression to behavioral treatment of autism spectrum disorder, tic disorders, and pediatric aggression. While effective, these medications carry serious risk of adverse events-most commonly, weight gain and cardiometabolic abnormalities. Negative metabolic consequences affect up to 60% of patients and present a major obstacle to long-term treatment. Since antipsychotics are often chronically prescribed beginning in childhood, cardiometabolic risk accumulates. An increased susceptibility to antipsychotic-induced weight gain (AIWG) has been repeatedly documented in children, particularly rapid weight gain. Associated cardiometabolic abnormalities include central obesity, insulin resistance, dyslipidemia, and systemic inflammation. Lifestyle interventions and medications such as metformin have been proposed to reduce risk but remain limited in efficacy. Furthermore, antipsychotic medications touted to be weight-neutral in adults can cause substantial weight gain in children. A better understanding of the biological underpinnings of AIWG could inform targeted and potentially more fruitful treatments; however, little is known about the underlying mechanism. As yet, modest genetic studies have nominated a few risk genes that explain only a small percentage of the risk. Recent investigations have begun to explore novel potential mechanisms of AIWG, including a role for gut microbiota and microbial metabolites. This article reviews the problem of AIWG and AP metabolic side effects in pediatric populations, proposed mechanisms underlying this serious side effect, and strategies to mitigate adverse impact. We suggest future directions for research efforts that may advance the field and lead to improved clinical interventions.

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

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

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

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

Monitoring of metabolic adverse events of second-generation antipsychotics in a naive paediatric population followed in mental health outpatient and inpatient clinical settings: MEMAS prospective study protocol

INTRODUCTION

Second-generation antipsychotics (SGAs) are widely used in the paediatric population. It is currently established that SGAs may induce metabolic adverse events (AEs) such as weight gain, perturbation of blood lipids or glucose with risk of potential cardiovascular morbidity and mortality. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in children (CAMESA) has published recommendations for monitoring the metabolic AEs of SGAs. Factors that may be associated with the onset of SGA's metabolic AEs and long-term consequences are less studied in the literature. The objectives of our research are to evaluate some factors that can influence the development of the SGA's metabolic AEs and to study clinical adherence to CAMESA guidelines.

METHODS AND ANALYSIS

The Monitoring des Effets Métaboliques des Antipsychotiques de Seconde Génération study is a multicenter, prospective, longitudinal observational study with repeated measures of metabolic monitoring over 24 months. Two recruiting centres have been selected for patients under 18 years of age, previously naive of antipsychotics, starting an SGA or who have started an SGA for less than 4 weeks regardless of the diagnosis that motivated the prescription. Assessments are performed for anthropometric measures, blood pressure, blood tests at baseline and 1, 2, 3, 6, 9, 12 and 24 months of follow-up.

ETHICS AND DISSEMINATION

The study protocol was approved by the CHU Sainte-Justine's Research Ethics Board (MP-21-2016-1201) in 2016 and obtained institutional suitability for the 'Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal' Research Center in May 2018. For all participants, written consent will be obtained from parents/caregivers as well as the participant's assent in order to enable their participation in this research project. The results of this research will be published.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (number NCT04395326).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of risk factors and metabolic monitoring practices in patients on antipsychotic drugs in South India

The objectives of this study were to identify the risk factors for metabolic syndrome in patients on antipsychotics and to compare the frequency of metabolic monitoring with evidence-based guidelines. We conducted a retrospective cohort study in a tertiary care health institution of South India. The study included patients with schizophrenia, bipolar disorder, and schizoaffective disorders prescribed with antipsychotic drugs. Data was collected from the medical records department. American Diabetic Association/American Psychiatric Association (ADA/APA) guidelines were used as a reference standard to assess the monitoring for metabolic parameters. Diagnosis of metabolic syndrome was done according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) guidelines. Risk factors for metabolic syndrome and frequency of metabolic monitoring were analyzed. A total of 668 patients were included for clinical audit. About 16.5 % of the patients were diagnosed with metabolic syndrome. Age >50 years (Odds Ratio (OR) 2.00; p value <0.001) and duration of antipsychotic treatment>5 years (OR 1.55; p value< 0.05) were recognized as the independent risk factors for metabolic syndrome using multiple logistic regression. Blood pressure (BP) and fasting blood sugar (FBS) levels were documented in 99.7 % and 47 % of cases at baseline respectively, however, subsequent annual data on BP and FBS monitoring was reduced to 72.7 % and 46 % respectively. Weight was documented in 60 % of the cases at baseline, whereas the subsequent data on four times the annual assessment of weight was reduced to 9.8 %. The extent of documentation of metabolic monitoring parameters was inadequate.

Current pharmacotherapy for tic disorders

Introduction: Though many unanswered questions about the pathophysiology of Tourette Syndrome remain, several pharmacotherapies for tics have been studied, with varying results in terms of efficacy and the strength of evidence.Areas covered: This literature review encompasses pharmacotherapies for tics. The pharmacotherapies discussed in this review include: alpha agonists, antipsychotics, topiramate, botulinum toxin, and dopamine depleters.Expert opinion: Once the presence of tics is confirmed and psychoeducation and support are provided to patients and caregivers, one must examine the degree of tic-related impairment and the presence of psychiatric comorbidities. These factors influence treatment decisions as the presence of comorbidity and related impairment may shift the treatment target. When selecting a medication for tics, the presence of ADHD (the most frequent comorbidity) strengthens the case for choosing an alpha agonist. The case for antipsychotic medications is strongest when tic-related impairment is severe and/or the tics are refractory to more conservative measures. All medications require drug safety monitoring procedures and reevaluation over time.

Multidisciplinary treatment plan for challenging behaviors in neurodevelopmental disorders

Among symptoms that patients with neurodevelopmental disorders can exhibit, challenging behaviors (CBs) are some of the more complex to face, both for caregivers and the patients themselves. They are more frequent in individuals with severe autism spectrum disorders and intellectual disability, and during the transition period from late childhood to young adulthood. Here, we offer an overview of the therapeutic approaches proven worthy in managing CB. Topics include nonpharmacologic treatments (such as behavioral and family interventions), drug prescriptions, and specific intensive care for life-threatening situations, including inpatient stay in specialized neurobehavioral units. Then, we focus on rare, complex, and resistant clinical presentations, mainly based on the authors' clinical experience. We propose a multimodal intervention framework for these complex presentations, embracing developmental and dimensional approaches. A case presentation illustrates the proposed framework, with the aim of serving readers and health practitioners that are facing such cases.

Safety and Tolerability of Antipsychotic Drugs in Pediatric Patients: Data From a 1-Year Naturalistic Study

Background: Antipsychotic drugs (APs) are increasingly used to treat a variety of psychiatric disorders in children and adolescents. However, their safety and tolerability profiles, when used in a developmental age context, show different characteristics from the ones observed in adult patients. Treatment with APs in pediatric patients is often long-term. However, the tolerability data regarding these patients mostly derive from short-term studies. Methods: Starting from April 2017, for a 1-year period, patients between 4 and 18 years of age followed by five units of developmental age neuropsychiatry, who initiated a treatment with at least an AP (ATC class N05A) were included into the study. Patient-related data have been collected at baseline and regularly thereafter, as allowed by the clinical routine. Changes to continuous variables over time have been analyzed using a linear mixed model in subsamples of our population treated with risperidone or aripiprazole. Results: During the observation period, 158 patients were initially enrolled, but only 116 completed 12 months of therapy with an AP. Risperidone was the most used AP (n = 52) followed by aripiprazole (n = 44) and olanzapine (n = 7). For both the aripiprazole and risperidone groups, the mean body mass index (BMI) (P < 0.001 for both groups) and heart rate (P = 0.026 for aripiprazole group and P < 0.001 for the risperidone one) values significantly increased over time. The mean prolactin concentration value significantly increased over time only in the risperidone group (P = 0.04). Eighty-six patients experienced at least one adverse drug reaction (ADR), accounting for a total of 238 specific reactions, with the most frequent being weight gain (n = 34), increased serum prolactin levels (n = 21), hyperphagia (n = 20), and hypercholesterolemia (n = 14). Among these, only 24 ADRs were classifiable as serious. Conclusions: The results of this study confirm that risperidone and aripiprazole are relatively well-tolerated therapeutic options for the treatment of a variety of psychiatric disorders in pediatric patients. However, in findings such as statistically significant increments of BMI and heart rate mean values, the variations over time in prolactin levels observed with risperidone and the differences between the two drugs remark the necessity of systematic monitoring.

Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders

OBJECTIVE

To make recommendations on the assessment and management of tics in people with Tourette syndrome and chronic tic disorders.

METHODS

A multidisciplinary panel consisting of 9 physicians, 2 psychologists, and 2 patient representatives developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.

RESULTS

Forty-six recommendations were made regarding the assessment and management of tics in individuals with Tourette syndrome and chronic tic disorders. These include counseling recommendations on the natural history of tic disorders, psychoeducation for teachers and peers, assessment for comorbid disorders, and periodic reassessment of the need for ongoing therapy. Treatment options should be individualized, and the choice should be the result of a collaborative decision among patient, caregiver, and clinician, during which the benefits and harms of individual treatments as well as the presence of comorbid disorders are considered. Treatment options include watchful waiting, the Comprehensive Behavioral Intervention for Tics, and medication; recommendations are provided on how to offer and monitor these therapies. Recommendations on the assessment for and use of deep brain stimulation in adults with severe, treatment-refractory tics are provided as well as suggestions for future research.

The Pharmacoepidemiology of Psychotropic Medication Use in Canadian Children from 2012 to 2016

Objective: The goal of this study was to characterize the frequency and trends of psychotropic drug prescribing in Canadian children from 2010 to 2016 and to compare these results with a previous study conducted between 2005 and 2009. Methods: Using a national physician panel survey database from IQVIA Canada, aggregated frequencies of written prescriptions and therapeutic indications for antipsychotics, attention-deficit/hyperactivity disorder (ADHD) medications (psychostimulants and nonstimulants), and antidepressants were analyzed in children. Changes in frequency of written prescriptions and therapeutic indications are presented using descriptive statistics. Results: Written prescriptions for antipsychotics decreased by 10% from 2010 to 2016, in contrast to a 114% increase in written prescriptions for antipsychotics observed between 2005 and 2009. Written prescriptions for psychostimulants and antidepressants rose by 35% and 27%, respectively, between 2012 and 2016, comparable with previous results. The most common reasons for recommending an antipsychotic were ADHD and conduct disorder, although there appears to be a downward trend for ADHD compared with other conditions. In contrast, the share of written prescriptions for antipsychotics for autism increased 34% over the study period. Within the second-generation antipsychotics, written prescriptions for aripiprazole increased. An increase in the use of guanfacine extended release for ADHD was also observed. Conclusion: Several factors may be involved in stabilization and small decrease in antipsychotic use in recent years, including physician and patient awareness of adverse effects related to antipsychotic use, knowledge implementation strategies advocating short-term and judicious use of antipsychotics in children, and the approval of guanfacine extended release for use in Canada for ADHD in 2013.

Risk Factors for Unhealthy Weight Gain and Obesity among Children with Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a developmental disorder characterized by social and communication deficits and repetitive behaviors. Children with ASD are also at a higher risk for developing overweight or obesity than children with typical development (TD). Childhood obesity has been associated with adverse health outcomes, including insulin resistance, diabetes, heart disease, and certain cancers. Importantly some key factors that play a mediating role in these higher rates of obesity include lifestyle factors and biological influences, as well as secondary comorbidities and medications. This review summarizes current knowledge about behavioral and lifestyle factors that could contribute to unhealthy weight gain in children with ASD, as well as the current state of knowledge of emerging risk factors such as the possible influence of sleep problems, the gut microbiome, endocrine influences and maternal metabolic disorders. We also discuss some of the clinical implications of these risk factors and areas for future research.

Adherence to Antipsychotic Adverse Effect Monitoring Among a Referred Sample of Children with Intellectual Disabilities

OBJECTIVES

Despite frequent use of antipsychotic medications to target severe behavioral problems among children with intellectual disabilities (ID), there is little information as to the extent to which adverse effect monitoring is in place for this population. The aim of this pilot study was to determine the extent to which monitoring for adverse effects was documented in health records of a cohort of children with ID who had been prescribed antipsychotic medication.

METHODS

Data were available on all children referred to a mental health clinic at a children's hospital in Canada who had ID and behavioral difficulties with intake appointments between September 1, 2016 and November 30, 2017. Charts of all those on antipsychotic medications were reviewed for a 12-week period to determine the extent to which adverse effect monitoring was documented using the parameters stipulated by the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA), including laboratory, anthropometric, and neurological measures.

RESULTS

The database was composed of 47 patients of whom 25 were on antipsychotics (56% boys; mean age 13 [SD 3] years). The most commonly used antipsychotic was risperidone (48%). The extent of adherence to the guidelines was (1) 96% for weight, height, and body mass index; (2) 84% for extrapyramidal symptom screening; (3) 80% for blood pressure; (4) 64% for abdominal girth and liver enzymes; (5) 60% for fasting plasma glucose; and (6) 56% for fasting lipids. Only 20% had all core recommended parameters documented.

CONCLUSIONS

There were significant gaps in adverse effect monitoring in this cohort. Examination of variation in larger samples from multiple clinical services are required to determine the extent of this quality care gap. Several barriers to adherence are proposed with suggested solutions.

Atypical Antipsychotics for Irritability in Pediatric Autism: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Irritability is common in pediatric autism spectrum disorder (ASD) patients. This can have major implications in child development, receptivity to behavioral therapy, as well as child and caregiver well-being. A systematic review and network meta-analysis were conducted to assess the efficacy and safety of atypical antipsychotics in treating irritability in these patients.

METHODS

Studies were identified from Medline, Embase, and PsycINFO from inception to March 2018. The clinical trials database was reviewed. Studies were included if they were a double-blind, randomized controlled trial utilizing the Aberrant Behavior Checklist Irritability (ABC-I) to measure the efficacy of atypical antipsychotic monotherapy. Data extraction was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analyses for network meta-analysis guidelines. The main outcome was the reduction in irritability score using the ABC-I subscale from baseline.

RESULTS

Eight trials comparing four interventions-risperidone, aripiprazole, lurasidone, and placebo in 878 patients, were included. Both risperidone and aripiprazole had significantly reduced ABC-I scores than placebo. Estimates of mean differences (95% credible intervals) were risperidone, -6.89 (-11.14, -2.54); aripiprazole, -6.62 (-10.88, -2.22); and lurasidone, -1.61 (-9.50, 6.23). Both risperidone and aripiprazole had similar safety. There were only eight studies included in the analysis, however, sample sizes were not small. Variance in reporting of adverse effects limited the quality of safety analysis.

CONCLUSION

Risperidone and aripiprazole were the two best drugs, with comparable efficacy and safety in pediatric ASD patients. These two medications could be beneficial in improving irritability in these patients.

Current pharmacotherapy options for conduct disorders in adolescents and children

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

ADHD in children and youth: Part 3-Assessment and treatment with comorbid ASD, ID, or prematurity

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD,2) Establish a standard for ADHD care, and3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 3, which focuses on associated autism spectrum disorder, intellectual disability, and prematurity, include the challenges of diagnostic assessment, common presentations, the role of genetics, and treatment, including the benefits of physical activity. Recommendations are based on current guidelines, evidence from the literature, and expert consensus.

Hormonal Risk Factors for Osteoporosis: Different Profile Among Antipsychotics

Objectives: Osteoporosis is a major risk factor for fracture and treatment is mainly preventive. Patients with severe psychiatric condition and treated with antipsychotics are at risk for vitamin D deficiency and iatrogenic hyperprolactinemia, two serious risk factors of osteoporosis. We aim to determine whether all antipsychotics are similar regarding the risk of osteoporosis in young patients. Methods: From January 2009 to March 2015, we determined the vitamin D blood level (VDBL) among 484 inpatients and from January 2012 to March 2015, we determined the prolactin blood level (PBL) among 205 inpatients. We systematically recorded well-documented risk factors (e.g., age, gender, ethnic origin, body mass index, or season) and suspected risk factors (e.g., disease type or antipsychotic treatment). Results: Up to 89% of the inpatients had a VDBL under the recommended threshold. Up to 60% of the inpatients had hyperprolactinemia. The multivariate model found a significant effect on VDBL for seasonality (higher VDBL in summer), ethnicity (lower VDBL in Black individuals), and treatment exposure. The multivariate model found a significant effect on PBL for gender and treatment exposure. In both models, aripiprazole had a safer profile compared with other antipsychotics. Conclusion: Because adolescence is a period of bone construction and a critical window of opportunity for maximizing bone mass, we recommend vitamin D supplementation in young patients with severe mental condition. It could be interesting to reconsider to regularly monitor PBL among youth patients treated with antipsychotic, with the exception of aripiprazole.

Glucose and Prolactin Monitoring in Children and Adolescents Initiating Antipsychotic Therapy

OBJECTIVE

We aimed to evaluate glucose and prolactin monitoring in children and adolescents initiating antipsychotic therapy using a nationwide claims database.

METHODS

A retrospective 15-month cohort study was conducted using the National Database of Health Insurance Claim Information and Specified Medical Checkups in Japan. Patients aged ≤18 years, who were newly prescribed antipsychotics between April 2014 and March 2015, were followed up for 450 days. Outcomes were the use of glucose and prolactin testing through 15 months after drug initiation (index date) with consideration of persistence with antipsychotic therapy. The incidence proportion of patients monitored was assessed within the following four time windows: baseline (between 30 days before the index date and the index date), at 1-3 months (between 1 and 90 days after the index date), at 4-9 months (between 91 and 270 days after the index date), and at 10-15 months (between 271 and 450 days after the index date).

RESULTS

Of 43,608 new users in 6620 medical institutions, the percentage of persistent antipsychotic users was 46.4% at 90 days, 29.7% at 270 days, and 23.8% at 450 days after the index date. The proportion of patients who received monitoring within the baseline period was 13.5% (95% confidence interval [CI], 13.2-13.8) for glucose and 0.6% (95% CI, 0.5-0.6) for prolactin, respectively. The proportion of patients who received glucose monitoring at all time windows decreased to 0.9%. The proportion of patients who received prolactin monitoring by the second time window decreased to 0.1%.

CONCLUSIONS

Our study shows that monitoring for glucose and prolactin is infrequent in children and adolescents initiating antipsychotic therapy. Strategies for physicians, patients, and guardians are needed to overcome the barriers in glucose and prolactin monitoring.

Monitoring and Treating Metabolic Abnormalities in Patients with Early Psychosis Initiated on Antipsychotic Medications

Antipsychotic medications carry an established lifetime risk of metabolic syndrome. This retrospective chart review evaluated feasibility of a metabolic monitoring clinical decision support tool (CDST) for weight, lipid, blood glucose, and blood pressure management of 163 clients in an early psychosis outpatient clinic over 2 years. Each parameter had at least 98 (60.1%) clients with a recorded value, the most being documented for weight with 112 (68.7%) clients. CDST adherence ranged from at least 54.3-100% for non-pharmacologic interventions (e.g. clinic counseling, referral to health program or primary care) and at least 33.3-100% for pharmacologic interventions (e.g. metformin). Though no baseline cardiometabolic abnormalities were identified, dyslipidemia and obesity were later found in 37 (22.7%) and 35 (21.5%) clients, respectively. Only 14 (8.6%) clients were prescribed medications for cardiometabolic abnormalities by psychiatrists in the clinic. Increasing focus on physical health is needed to better this population's long-term prognosis.

Second-Generation Antipsychotics in Adolescent Psychiatric Patients: Metabolic Effects and Impact of an Early Weight Change to Predict Longer Term Weight Gain

OBJECTIVES

To examine the metabolic profile of adolescents at baseline and to determine the potential predictive power of a 1-month weight gain (WG) on weight changes during longer term second-generation antipsychotic (SGA) treatment.

METHODS

A retrospective chart review study, including patients between 13 and 18 years of age and treated with SGA, was conducted. Available data at baseline, 1, 3, and 12 months of treatment were recorded.

RESULTS

Four hundred fifty-six patients were included, with a median age of 15 years. Ten percent of the patients were obese (>95th percentile) and abdominal obesity (>90th percentile) was observed in 12% of patients. In a subgroup of 42 patients with both baseline, 1, and 3-month weight data available, WG >4.5% after 1 month was found to be the best predictor (sensitivity: 100; specificity: 66; area under the curve: 83) for a WG >15% after 3 months. After adjusting for potential confounders, a threshold of WG >4% was found as being the best predictor.

CONCLUSIONS

A worrisome prevalence of metabolic disorders was observed in an adolescent psychiatric cohort. In such patients, a WG >4% during the first month of treatment should raise concerns about weight controlling strategies. Further research is needed to confirm the present results and to determine the impact of a 1-month WG on a 1-year weight change.

Understanding the impact of diet and nutrition on symptoms of Tourette syndrome: A scoping review

Anecdotal reports frequently suggest some dietary involvement in the maintenance of tics in children with Tourette syndrome (TS). This scoping review aimed to (1) understand the possible influence of diet as a trigger of tics and (2) map out the existing studies documenting dietary interventions in children with TS. Current evidence suggests no single diet to benefit individuals with TS. However, reports from parents of children with TS suggest that certain allergens in food may exacerbate tic-related symptoms. For example, an increase in tics has been related to the consumption of caffeine and refined sugar. Moreover, oligoantigenic diets and sugar-free diets have been identified as significantly reducing tics. More research is urgently needed to develop more accurate guidance for parents and children with TS, as many have reported using dietary and nutritional supplements, despite the lack of evidence detailing any benefits, side effects and recommended doses.

Tourette syndrome and other chronic tic disorders: an update on clinical management

INTRODUCTION

The management of Tourette syndrome (TS) and other chronic tic disorders occurs in multiple stages and begins with comprehensive assessment and complex psychoeducation. Behavioral and pharmacological interventions (second stage) are needed when tics cause physical or psychosocial impairment. Deep brain stimulation surgery or experimental therapies represent the third stage. Areas covered: Discussed are recent advances in assessment and therapy of chronic tic disorders, encompassing the three stages of intervention, with the addition of experimental, non-invasive brain stimulation strategies. A PubMed search was performed using as keywords: 'tic disorders', 'Tourette syndrome', 'assessment', 'rating scales', 'behavioral treatment', 'pharmacological treatment', 'deep brain stimulation', 'transcranial magnetic (or current) stimulation', and 'transcranial current stimulation'. More than 300 peer-reviewed articles were evaluated. The studies discussed have been selected on the basis of novelty and impact. Expert commentary: Comprehensive assessment of tic disorders and psychoeducation are crucial to a correct active management approach. Behavioral treatments represent first line of active interventions, with increasing potential offered by telehealth. Antipsychotics and alpha agonists remain first line pharmacological interventions for tics, although VMAT-2 inhibitors appear promising. Deep brain stimulation is a potential option for medically refractory, severely disabled patients with tics, but age and target selection require further investigation.

Long-Term Metabolic Effects in French-Canadian Children and Adolescents Treated with Second-Generation Antipsychotics in Monotherapy or Polytherapy: A 24-Month Descriptive Retrospective Study

OBJECTIVE

To compare weight and glucose changes of long-term second-generation antipsychotic (SGA) monotherapy versus polytherapy (switching or combining SGAs) in children and adolescents.

METHODS

This is a 24-month retrospective study conducted between November 2005 and June 2013. From 147 antipsychotic-naive patients selected (mean age, 12.8 years; 95% confidence interval [CI], 9.8-15.9), 116 (78.9%) received SGA monotherapy and 31 (21.1%) SGA polytherapy for up to 24 months. Height, weight, and fasting glucose (FG) were measured at baseline and 1, 3, 6, 12, and 24 months. Linear mixed-model analysis was used to compare weight, body mass index z score (BMI z score), and glucose changes between the 2 SGA treatment groups, with the repeated factor being the time relative to baseline at 1, 3, 6, 12, and 24 months.

RESULTS

Overall, after 24 months of SGA treatment, mean weight increased significantly by 12.8 kg (95% CI, 10.4-15.0), BMI z score by 0.44 (95% CI, 0.21-0.68), and FG levels by 0.29 mmol/L (95% CI, 0.11-0.47). Incidence of overweight/obesity was 22.6%, BMI z score increase over 0.5 was 9.4%, impaired fasting glucose was 9.4%, and type 2 diabetes mellitus was 3.1%. Regarding metabolic effects, no significant difference was found between the subjects taking a single SGA and those exposed to an SGA polytherapy.

CONCLUSION

Our study confirms the significant increase of metabolic complications during 24 months of SGA treatment without excluding or confirming a difference between the 2 groups of treatment (mono vs. poly).

Feasibility and Relevance of Antipsychotic Safety Monitoring in Children With Tourette Syndrome: A Prospective Longitudinal Study

PURPOSE/BACKGROUND

Antipsychotics are efficacious for tics and are increasingly prescribed to children with behavioral disorders. Antipsychotics have important adverse effects, and systematic monitoring of drug safety is infrequently performed. The objectives of this study were to determine the feasibility of antipsychotic safety monitoring in children with Tourette Syndrome using a defined protocol and to evaluate the risk of adverse effects with chronic use.

METHODS/PROCEDURES

A prospective longitudinal study of children prescribed antipsychotics was performed. Children were monitored for extrapyramidal, metabolic, and hormonal adverse effects using the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotic Medications guidelines. This included the measurement of height, weight, waist circumference, the Extrapyramidal Symptom Rating Scale, and laboratory tests of lipids, glucose, insulin, and prolactin at prespecified time points.

FINDINGS/RESULTS

Fifty-seven children who started on risperidone or aripiprazole were monitored for a mean of 10 months 3 days. Significant increases in body mass index (BMI) and waist circumference percentiles occurred with time. There was a significant time by drug interaction, with children on aripiprazole having smaller changes in BMI initially, followed by a faster rate of increase than with risperidone. There was a significant difference between Extrapyramidal Symptom Rating Scale scores on versus before starting antipsychotics and significant increases in insulin and prolactin. Change from a healthy to overweight or obese BMI percentile occurred in 26%. Extrapyramidal symptoms occurred in 35%. Medication was discontinued because of metabolic effects in 19%, and extrapyramidal symptoms in 7%.

IMPLICATIONS/CONCLUSIONS

Monitoring of antipsychotic safety in children is feasible and recommended to inform treatment decisions.

Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth

OBJECTIVE

Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders.

METHODS

A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts.

RESULTS

Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain.

CONCLUSIONS

Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended.

The predictive value of ABCB1, ABCG2, CYP3A4/5 and CYP2D6 polymorphisms for risperidone and aripiprazole plasma concentrations and the occurrence of adverse drug reactions

We investigated in ninety Caucasian pediatric patients the impact of the main polymorphisms occurring in CYP3A, CYP2D6, ABCB1 and ABCG2 genes on second-generation antipsychotics plasma concentrations, and their association with the occurrence of adverse drug reactions. Patients with the CA/AA ABCG2 genotype had a statistically significant lower risperidone plasma concentration/dose ratio (Ct/ds) (P-value: 0.007) and an higher estimated marginal probability of developing metabolism and nutrition disorders as compared to the ABCG2 c.421 non-CA/AA genotypes (P-value: 0.008). Multivariate analysis revealed that the ABCG2 c.421 CA/AA genotype was found associated to a higher hazard (P-value: 0.004) of developing adverse drug reactions classified as metabolism and nutrition disorders. The ABCB1 2677TT/3435TT genotype had a statistically significant lower aripiprazole Ct/ds if compared with patients with others ABCB1 genotypes (P-value: 0.026). Information obtained on ABCB1 and ABCG2 gene variants may result useful to tailor treatments with these drugs in Caucasian pediatric patients.