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Dahlén E, Kimland EE. Considerable paediatric drug dispensing - A nationwide study of more than 2 million Swedish children. Acta Paediatr 2024; 113:2147-2154. [PMID: 38822667 DOI: 10.1111/apa.17305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/07/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
AIM The aim of the nationwide study was to describe paediatric drug utilisation in Sweden. METHODS Drug prescriptions dispensed to all children aged 0-17 years in 2019 were analysed using data from the Swedish National Prescribed Drug Register. RESULTS We retrieved data on 2 180 508 unique children. Nearly 4.6 million prescriptions were dispensed to children aged 0-17 years, and 52% of these were to boys. Just under half of the children (47%) were dispensed at least one drug: 48% of girls and 45% of boys (p < 0.01). More than a third (34%) were dispensed three or more different drugs during 2019. The number of dispensed prescriptions per 1000 children was higher in boys than girls up to 12 years of age (p < 0.01), and the opposite trend was observed from 13 years and above, even when we excluded contraceptives (p < 0.01). The most common therapeutic areas were drugs for the respiratory tract (25%), namely antihistamines, antiasthmatics and cough medication. These were followed by psychoanaleptics and melatonin for the nervous system (19%) and dermatologicals (16%), namely cortisone creams and emollients. CONCLUSION Paediatric drug use was common, and a considerable proportion of children were dispensed multiple drugs.
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Affiliation(s)
- Elin Dahlén
- Swedish Medical Products Agency, Uppsala, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
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Cuda S. Special considerations for the child with obesity: An Obesity Medicine Association (OMA) clinical practice statement (CPS) 2024. OBESITY PILLARS 2024; 11:100113. [PMID: 38953014 PMCID: PMC11216014 DOI: 10.1016/j.obpill.2024.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 07/03/2024]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details assessment and management of the child with overweight or obesity. The term "child" is defined as the child between 2 and 12 years of age. Because children are in a continual state of development during this age range, we will specify when our discussion applies to subsets within this age range. For the purposes of this CPS, we will use the following definitions: overweight in the child is a body mass index (BMI) ≥ 85th and <95th percentile, obesity in the child is a BMI ≥95th percentile, and severe obesity is a BMI ≥120% of the 95th percentile. Methods The information and clinical guidance in this OMA Clinical Practice Statement are based on scientific evidence, supported by medical literature, and derived from the clinical perspectives of the authors. Results This OMA Clinical Practice Statement provides an overview of prevalence of disease in this population, reviews precocious puberty in the child with obesity, discusses the current and evolving landscape of the use of anti-obesity medications in children in this age range, discusses the child with obesity and special health care needs, and reviews hypothalamic obesity in the child. Conclusions This OMA Clinical Practice Statement on the child with obesity is an evidence based review of the literature and an overview of current recommendations. This CPS is intended to provide a roadmap to the improvement of the health of children with obesity, especially those with metabolic, physiological, psychological complications and/or special healthcare needs. This CPS addresses treatment recommendations and is designed to help the clinician with clinical decision making.
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Affiliation(s)
- Suzanne Cuda
- Alamo City Healthy Kids and Families, 1919 Oakwell Farms Parkway, Ste 145, San Antonio, TX, 78218, USA
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Hong M. What to Know Before Prescribing Antidepressants to Depressed Youths: A Focus on the Black Box Warning. J Korean Med Sci 2024; 39:e212. [PMID: 39015003 PMCID: PMC11249579 DOI: 10.3346/jkms.2024.39.e212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 06/16/2024] [Indexed: 07/18/2024] Open
Affiliation(s)
- Minha Hong
- Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea.
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Foster AA, Hoffmann JA, Qayyum Z, Porter JJ, Monuteaux M, Hudgins J. Psychotropic Medication Administration in Pediatric Emergency Departments. Pediatrics 2024; 153:e2023063730. [PMID: 38487821 DOI: 10.1542/peds.2023-063730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals. METHODS We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital. RESULTS Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001). CONCLUSIONS Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Zheala Qayyum
- Department of Psychiatry and Behavioral Sciences
- Departments of Psychiatry
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
- Emergency Medicine
- Pediatrics, Harvard Medical School, Boston, Massachusetts
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Gupta N, Gupta M. Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians. CNS Spectr 2024; 29:10-25. [PMID: 37539695 DOI: 10.1017/s1092852923002389] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.
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Affiliation(s)
| | - Mayank Gupta
- Southwood Psychiatric Hospital, Pittsburgh, PA, USA
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Hach I, Bertsch T, Nonell P. The prevalence of off-label use and supratherapeutic blood levels of outpatient psychotropic medication in suicidal adolescents. Front Psychiatry 2024; 14:1240681. [PMID: 38298931 PMCID: PMC10827976 DOI: 10.3389/fpsyt.2023.1240681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Adolescents with mental disorders show an increased risk of suicidal phenomena. Vice versa, suicidality is a serious adverse event of psychotropic drug therapy in adolescents. There are only a few new psychotropic agents approved for this young age group. We evaluated the (pre-pandemic) prevalence of off-label use as well as detailed blood concentrations of outpatient psychotropic medication and sex differences in a clinical population of suicidal adolescents. Methods The urine presence and serum levels of psychotropic substances of adolescents hospitalized due to their acute suicidality but without a known actual suicide attempt (i.e., no acute intoxication or serious self-injuries) were investigated routinely between 01.03.2017 and 31.01.2018. Urine (N = 205) and blood samples (N = 193) were taken at the beginning of closed inpatient admission, i.e., the results of the laboratory analysis reflect outpatient drug intake. The serum levels of psychopharmacological medication and OTC medication were measured. Results Our sample consists of 231 cases (boys: N = 54; girls: N = 177, ratio: 1:3.3), aged 12-17 years (average age: 15,4 years). The most prevalent psychiatric diagnoses were depressive episodes (54%) and adjustment disorders (25%), and girls were more often diagnosed with depressive disorders than boys (boy/girl ratio: 1:9.5, p < 0.0001). More than half of adolescents (56%) used at least one prescribed psychotropic drug at admission (24.8% ≥ two psychotropic drugs). Off-label use of second-generation antipsychotics was significantly more frequent than off-label use of antidepressants (85% vs. 31%, p < 0.01). Adolescents suffering from depressive disorders were significantly more often on-label treated than adolescents with neurotic or stress-related disorders (56% vs. 10%). Female cases with prescribed psychotropic drug use showed significantly more frequent supratherapeutic drug levels than male cases (5% vs. 27%, p < 0.05). Conclusion Female adolescents may have an increased risk of supratherapeutic blood levels, especially when outpatient prescribed psychotropic drugs are off-label used. Measurement of blood levels of outpatient-prescribed psychotropic drugs could be used to enhance the safety and efficacy of the individual psychopharmacological treatment of adolescent suicidal patients. There is an urgent need for more real-world evidence on the effective treatment of adolescents with psychotropic drugs.
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Affiliation(s)
- Isabel Hach
- Department of Education and Science, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Patrick Nonell
- Clinic of Child and Adolescent Psychiatry and Psychotherapy, Klinikum Nürnberg, Paracelsus Medical University Nürnberg, Nürnberg, Germany
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Nickson D, Singmann H, Meyer C, Toro C, Walasek L. Replicability and reproducibility of predictive models for diagnosis of depression among young adults using Electronic Health Records. Diagn Progn Res 2023; 7:25. [PMID: 38049919 PMCID: PMC10696659 DOI: 10.1186/s41512-023-00160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/10/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Recent advances in machine learning combined with the growing availability of digitized health records offer new opportunities for improving early diagnosis of depression. An emerging body of research shows that Electronic Health Records can be used to accurately predict cases of depression on the basis of individual's primary care records. The successes of these studies are undeniable, but there is a growing concern that their results may not be replicable, which could cast doubt on their clinical usefulness. METHODS To address this issue in the present paper, we set out to reproduce and replicate the work by Nichols et al. (2018), who trained predictive models of depression among young adults using Electronic Healthcare Records. Our contribution consists of three parts. First, we attempt to replicate the methodology used by the original authors, acquiring a more up-to-date set of primary health care records to the same specification and reproducing their data processing and analysis. Second, we test models presented in the original paper on our own data, thus providing out-of-sample prediction of the predictive models. Third, we extend past work by considering several novel machine-learning approaches in an attempt to improve the predictive accuracy achieved in the original work. RESULTS In summary, our results demonstrate that the work of Nichols et al. is largely reproducible and replicable. This was the case both for the replication of the original model and the out-of-sample replication applying NRCBM coefficients to our new EHRs data. Although alternative predictive models did not improve model performance over standard logistic regression, our results indicate that stepwise variable selection is not stable even in the case of large data sets. CONCLUSION We discuss the challenges associated with the research on mental health and Electronic Health Records, including the need to produce interpretable and robust models. We demonstrated some potential issues associated with the reliance on EHRs, including changes in the regulations and guidelines (such as the QOF guidelines in the UK) and reliance on visits to GP as a predictor of specific disorders.
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Affiliation(s)
| | - Henrik Singmann
- Department of Experimental Psychology, University College London, London, UK
| | - Caroline Meyer
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Carla Toro
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Lukasz Walasek
- Department of Psychology, University of Warwick, Coventry, UK
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Wang L, Zhou L, Zhu Y, Yan J, Bu N, Fei W, Wu F. Trends in prescription therapy for adolescents with depression in nine major areas of China during 2017-2021. Front Psychiatry 2023; 14:1175002. [PMID: 37953934 PMCID: PMC10639118 DOI: 10.3389/fpsyt.2023.1175002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Abstract
Objective To date, no national-scale drug usage survey for adolescents with depression has been conducted in China, and the purpose of this study was to examine the national trends in prescriptions in Chinese adolescent depression patients from 2017 to 2021. Methods Prescribing data were extracted from the Hospital Prescription Analysis Cooperative Project. The average number of patients per year, the cost of treatment, and the prescription patterns (monotherapy vs. combination therapy) were analyzed, and subgroup analyses were conducted depending on age, sex, and drug class. Results The study included 674,099 patients from 136 hospitals located in nine major areas of China. Of all patients, the proportion of adolescents increased from 1.63% in 2017 to 6.75% in 2021. Visits by adolescent depression patients increased from 1,973 in 2017 to 9,751 in 2021, and the corresponding cost increased from 607,598 Chinese Yuan in 2017 to 2,228,884 Chinese Yuan in 2021. The incidence of adolescent depression among female individuals was far beyond that among male individuals. Combination therapy was more frequent than monotherapy, and the most commonly prescribed drugs were antidepressants, antipsychotics, antiepileptics, and antianxietics. Despite the use of sertraline decreasing from 47.90 to 43.39%, it was the most frequently used drug. Conclusion In summary, the prescriptions and cost of treatment for adolescent depression patients both increased rapidly. The widespread use of those drugs with weak clinical evidence reflects the current state of China, which should arouse our attention. The study can provide references for clinical treatment decisions and a basis for more efficient allocation of healthcare resources by the government.
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Affiliation(s)
- Li Wang
- Department of Pharmacy, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linpo Zhou
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yao Zhu
- Department of Pharmacy, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingjing Yan
- Department of Pharmacy, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Na Bu
- Department of Pharmacy, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weidong Fei
- Department of Pharmacy, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fan Wu
- Department of Pharmacy, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, China
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9
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Antoniou T, McCormack D, Kitchen S, Pajer K, Gardner W, Lunsky Y, Penner M, Tadrous M, Mamdani M, Juurlink DN, Gomes T. Impact of a publicly-funded pharmacare program policy on benzodiazepine dispensing among children and youth: a population-based natural experiment. BMC Pediatr 2023; 23:519. [PMID: 37858122 PMCID: PMC10585894 DOI: 10.1186/s12887-023-04331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND In January 2018, the Government of Ontario, Canada, initiated a universal pharmacare program (OHIP+) for all individuals aged 24 years and younger. In April 2019, the program was amended to cover only children and youth without private insurance. Because benzodiazepines are commonly prescribed to children and youth despite their potential hazards, we examined whether changes in publicly-funded drug coverage influenced benzodiazepine dispensing trends in this demographic. METHODS We conducted a population-based natural experiment study of benzodiazepine dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the impact of OHIP + and its subsequent modification on these trends. RESULTS The implementation of OHIP + was associated with an immediate increase in the monthly rate of benzodiazepine dispensing of 12.9 individuals per 100,000 population (95% confidence interval [CI]; 7.5 to 18.3 per 100,000). Benzodiazepine dispensing rates rose from 214.2 to 241.5 per 100,000 from December 2017 to March 2019, a 12.8% (95% CI 9.6-16.0%) increase. In stratified analyses, increases were most pronounced among females, children and youth living in the lowest income neighbourhoods and individuals aged 20 to 24. The April 2019 modification to OHIP + was not associated with changes in monthly benzodiazepine dispensing trends (0.39 individuals per 100,000; 95% CI -1.3 to 2.1 per 100,000). However, rates remained elevated relative to the period preceding OHIP + implementation. CONCLUSIONS Implementation of a publicly-funded pharmacare program resulted in more children and youth being prescribed benzodiazepines.
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Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada.
| | | | | | - Kathleen Pajer
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - William Gardner
- ICES, Toronto, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Yona Lunsky
- ICES, Toronto, ON, Canada
- Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Melanie Penner
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto Ontario, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Unity Health, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (Mamdani), University of Toronto, Toronto, ON, Canada
| | - David N Juurlink
- ICES, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (Mamdani), University of Toronto, Toronto, ON, Canada
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Isomura K, Wang X, Chang Z, Hellner C, Hasselström J, Ekheden I, Jayaram-Lindström N, Lichtenstein P, D'Onofrio BM, Mataix-Cols D, Sidorchuk A. Factors associated with long-term benzodiazepine and Z-drug use across the lifespan and 5-year temporal trajectories among incident users: a Swedish nationwide register-based study. Eur J Clin Pharmacol 2023; 79:1091-1105. [PMID: 37294340 PMCID: PMC10361867 DOI: 10.1007/s00228-023-03515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE Despite being discouraged by guidelines, long-term use of benzodiazepines and related Z-drugs (BZDR) remains frequent in the real-world. An improved understanding of factors associated with the transition from new to long-term BZDR use and of temporal BZDR use trajectories is needed. We aimed to assess the proportion of long-term BZDR use (> 6 months) in incident BZDR-recipients across the lifespan; identify 5-year BZDR use trajectories; and explore individual characteristics (demographic, socioeconomic and clinical) and prescribing-related factors (pharmacological properties of the initial BZDR, prescriber's healthcare level, and concurrent dispensing of other medications) associated with long-term BZDR use and distinct trajectories. METHODS Our nationwide register-based cohort included all BZDR-recipients in Sweden with first dispensation in 2007-2013. Trajectories of BZDR use days per year were built using group-based trajectory modelling. Cox regression and multinomial logistic regression were fitted to assess the predictors of long-term BZDR use and trajectories' membership. RESULTS In 930,465 incident BZDR-recipients, long-term use increased with age (20.7%, 41.0%, and 57.4% in 0-17, 18-64, and ≥ 65-year-olds, respectively). Four BZDR use trajectories emerged, labelled 'discontinued', 'decreasing', 'slow decreasing' and 'maintained'. The proportion of the 'discontinued' trajectory members was the largest in all ages, but reduced from 75.0% in the youths to 39.3% in the elderly, whereas the 'maintained' increased with age from 4.6% to 36.7%. Prescribing-related factors, in particular multiple BZDRs at initiation and concurrent dispensing of other medications, were associated with increased risks of long-term (vs short-term) BZDR use and developing other trajectories (vs 'discontinued') in all age groups. CONCLUSIONS The findings highlight the importance of raising awareness and providing support to prescribers to make evidence-based decisions on initiating and monitoring BZDR treatment across the lifespan.
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Affiliation(s)
- Kayoko Isomura
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Xinchen Wang
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Clara Hellner
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Jan Hasselström
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Isabella Ekheden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nitya Jayaram-Lindström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Brian M D'Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, USA
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Anna Sidorchuk
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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11
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Pesiou S, Barcelo R, Fradera M, Torres F, Pontes C. Utilisation of drugs for the treatment of psychiatric diseases in the pediatric population: focus on off-label use. Front Pharmacol 2023; 14:1157135. [PMID: 37397481 PMCID: PMC10312111 DOI: 10.3389/fphar.2023.1157135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Psychotropics are increasingly used in pediatrics, often as off-label medicines. The guarantees of safety and efficacy are not always granted in clinical practice compared to adult authorised indications. A retrospective observational study was done to estimate the prevalence of psychotropic use in pediatric subjects of Catalonia (Spain). Anonymised data on dispensation of psychotropics to pediatric patients, demography and other related data were obtained by the local healthcare management for the period 2008-2017. Estimation of off-label use was done through description of drug dispensations with no authorised use related to age range. The prevalence of psychotropics was 40.8-64.2 per 1,000 pediatric inhabitants. Hydroxyzine-only represented two-thirds of dispensations, and when removed, the prevalence dropped to 26.4-32.2 per 1,000 pediatric inhabitants. Adolescents and boys were more likely to receive a psychotropic. Psychostimulants had the highest exposure rate, mainly due to methylphenidate. Off-label use was observed in 12% of subjects, corresponding to 4.6% of all dispensed psychotropics with boys being more exposed. The proportion of off-label use vs. labelled use was higher in younger populations. Aripiprazole had the highest off-label frequency. Our data support the frequent reality of off-label use in pediatrics, despite the potential underestimation related to the selected off-label definition. There is an urgent need to systematically ascertain effectiveness and any potential adverse events in the off-label pediatric setting, and to generate valuable information for risk-benefit assessment in these populations where extrapolation from adults is not reliable.
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Affiliation(s)
- Stella Pesiou
- European Medicines Agency, Amsterdam, Netherlands
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Edifici M Campus de la UAB, Bellaterra, Spain
| | - Rafel Barcelo
- Departament of Pediatrics, Gynecology and Obstetrics, and Preventive Medicine, Universitat Autònoma de Barcelona, Edifici M Campus de la UAB, Bellaterra, Spain
| | - Marc Fradera
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Edifici M Campus de la UAB, Bellaterra, Spain
- Unitat Mixta de Neurociència Traslacional I3PT-INc-UAB, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Sabadell, Spain
| | - Ferran Torres
- Departament of Pediatrics, Gynecology and Obstetrics, and Preventive Medicine, Universitat Autònoma de Barcelona, Edifici M Campus de la UAB, Bellaterra, Spain
| | - Caridad Pontes
- European Medicines Agency, Amsterdam, Netherlands
- Department of Medicines, Area of Healthcare Services, Catalan Health Service, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3), Institut d’Investigacio Biomedica de Bellvitge (IDIBELL), Barcelona, Spain
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12
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Van Norman GA. Off-Label Use vs Off-Label Marketing of Drugs: Part 1: Off-Label Use-Patient Harms and Prescriber Responsibilities. JACC Basic Transl Sci 2023; 8:224-233. [PMID: 36908673 PMCID: PMC9998554 DOI: 10.1016/j.jacbts.2022.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 03/02/2023]
Abstract
Once medical drugs and devices are approved for marketing by the FDA they can legally be used for purposes and in ways other than the ones for which they have been tested and approved. However, it is illegal for manufacturers to advertise or promote such unapproved uses of the drugs and devices. Part 1 of this review focuses on off-label use of FDA-approved therapies. Part 2 addresses illegal off-label marketing of drugs and devices. While off-label use can be beneficial to patients, unless carefully undertaken off label use may undermine the important safety mission of the FDA, can expose patients to elevated risks without proven benefits (or possibly no benefit), and can reduce motivation of companies to study the safety and risks of off-label use of therapies. These problems are further amplified when off-label use occurs among very vulnerable patient populations such as the elderly, patients with mental health disorders, pregnant women and pediatric patients. This review considers ethical issues in off-label use, as well as important steps for physicians considering an off-label prescription of a drug or device.
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Affiliation(s)
- Gail A Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
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13
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Muacevic A, Adler JR, Madabushi J. Off-Label Cyproheptadine in Children and Adolescents: Psychiatric Comorbidities, Interacting Variables, Safety, and Risks of Hepatotoxicity. Cureus 2023; 15:e33745. [PMID: 36788882 PMCID: PMC9922522 DOI: 10.7759/cureus.33745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/15/2023] Open
Abstract
Cyproheptadine is a widely prescribed first-generation antihistamine, and due to its unique chemical structure, it has a popular off-label choice for a range of clinical conditions. Its efficacy is widely debated in the literature, but there are reports of hepatotoxicity as a rare adverse effect. Its benefits in migraine prophylaxis and appetite stimulation also underscore a highly overlapping clinical pathway that requires additional assessment and evaluation. The evidence suggests a baseline metabolic profile before initiation and assessment for co-occurring mental health conditions may improve overall response with evidence-based mental health interventions.
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14
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The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121878. [PMID: 36553324 PMCID: PMC9777172 DOI: 10.3390/children9121878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.
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15
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Fekete S, Güntzel T, Egberts K, Geissler J, Neubert A, Gerlach M, Romanos M, Taurines R. Serious Adverse Drug Reactions to Antipsychotics in Minors with Multiple Disabilities: Preventability and Potential Cost Savings by Therapeutic Drug Monitoring. PHARMACOPSYCHIATRY 2022; 56:32-39. [PMID: 36332618 PMCID: PMC9811527 DOI: 10.1055/a-1963-7631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Children and adolescents with multiple disabilities and mental disorders (CAMD) are frequently treated with antipsychotic drugs. However, CAMD are particularly susceptible to serious adverse drug reactions (sADRs). This retrospective study examined the frequency of sADRs to antipsychotics in CAMD. Further, the potential preventability of these sADRs through therapeutic drug monitoring (TDM) and the potential socio-economic benefits of TDM were explored. METHODS Routine clinical data of all patients treated at a specialized psychiatric clinic for CAMD between January 2017 and December 2018 were retrospectively examined. Data on the occurrence of sADRs (definition according to the European Medicines Agency), their causality with antipsychotics, as well as their preventability (Schumock criteria) were extracted from patient files. The prolongation of the hospital stay due to sADRs was calculated, and the cost savings were estimated if TDM had been applied. The data were based on a subsample of the KiDSafe project, supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. RESULTS One hundred two CAMD who were administered at least one antipsychotic drug during inpatient treatment were identified. Of these patients, 22 (21.6%) sADRs with a possible causal relationship with the antipsychotic treatment were documented. Eleven sADRs (50%) could potentially have been prevented through TDM. Mitigating sADRs through TDM likely would have prevented prolonged hospital stays and thus conferred considerable savings for health insurance companies. DISCUSSION The routine implementation of TDM is urgently recommended for antipsychotic treatment in CAMD to increase drug therapy safety.
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Affiliation(s)
- Stefanie Fekete
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,Correspondence Dr. Stefanie
Fekete University hospital of
WürzburgDepartment of Child and Adolescent
Psychiatry, Psychosomatics and Psychotherapy, Margarete-Höppel-Platz
197080
WurzburgGermany
| | - Tim Güntzel
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Karin Egberts
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Julia Geissler
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, University Hospital
Erlangen, Erlangen, Germany
| | - Manfred Gerlach
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring,Competence network for Therapeutic Drug Monitoring in child and
adolescent psychiatry
| | - Marcel Romanos
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group ‘Child and Adolescent
Psychopharmacology’,AGNP-Work group Therapeutic Drug Monitoring
| | - Regina Taurines
- Department Child and Adolescent Psychiatry, Psychosomatic and
Psychotherapy, Center of Mental Health, University Hospital Wuerzburg,
Wuerzburg, Germany,AGNP-Work group Therapeutic Drug Monitoring
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16
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Rolling J, Rabot J, Schroder CM. Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It? Nat Sci Sleep 2022; 14:1927-1944. [PMID: 36325278 PMCID: PMC9621019 DOI: 10.2147/nss.s340944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/18/2022] [Indexed: 01/24/2023] Open
Abstract
Sleep is a vital physiological function that is impaired in ranges from 10% in the typically developing pediatric population to over 80% in populations of children with neurodevelopmental disorders and/or psychiatric comorbidities. Pediatric insomnia disorder is an increasing public health concern given its negative impact on synaptic plasticity involved in learning and memory consolidation but also on mood regulation, hormonal development and growth, and its significant impact on quality of life of the child, the adolescent and the family. While first-line treatment of pediatric insomnia should include parental education on sleep as well as sleep hygiene measures and behavioural treatment approaches, pharmacological interventions may be necessary if these strategies fail. Melatonin treatment has been increasingly used off-label in pediatric insomnia, given its benign safety profile. This article aims to identify the possible role of melatonin treatment for pediatric insomnia, considering its physiological role in sleep regulation and the differential effects of immediate release (IR) versus prolonged release (PR) melatonin. For the physician dealing with pediatric insomnia, it is particularly important to be able to distinguish treatment rationales implying different dosages and times of treatment intake. Finally, we discuss the benefit-risk ratio for melatonin treatment in different pediatric populations, ranging from the general pediatric population to children with different types of neurodevelopmental disorders, such as autism spectrum disorder or ADHD.
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Affiliation(s)
- Julie Rolling
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, Strasbourg, France
- CNRS UPR3212- Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, Strasbourg, France
| | - Juliette Rabot
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, Strasbourg, France
- CNRS UPR3212- Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, Strasbourg, France
- Expert Centre for High-Functioning Autism, Fondation FondaMental, Strasbourg, France
- Autism Resources Centre 67 for Children and Adolescents, Strasbourg, France
| | - Carmen M Schroder
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, Strasbourg, France
- CNRS UPR3212- Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, Strasbourg, France
- Expert Centre for High-Functioning Autism, Fondation FondaMental, Strasbourg, France
- Autism Resources Centre 67 for Children and Adolescents, Strasbourg, France
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17
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Schaffer AL, Bruno C, Buckley NA, Cairns R, Litchfield M, Paget S, Zoega H, Nassar N, Pearson S. Prescribed medicine use and extent of off-label use according to age in a nationwide sample of Australian children. Paediatr Perinat Epidemiol 2022; 36:726-737. [PMID: 35172017 PMCID: PMC9540111 DOI: 10.1111/ppe.12870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/16/2022] [Accepted: 01/25/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Medicine prescribing for children is impacted by a lack of paediatric-specific dosing, efficacy and safety data for many medicines. OBJECTIVES To estimate the prevalence of medicine use among children and the rate of 'off-label' prescribing according to age at dispensing. METHODS We used population-wide primarily outpatient dispensing claims data for 15% of Australian children (0-17 years), 2013-2017 (n = 840,190). We estimated prescribed medicine use and 'off-label' medicine use according to the child's age (<1 year, 1-5 years, 6-11 years, 12-17 years) defined as medicines without age-appropriate dose recommendations in regulator-approved product information. Within off-label medicines, we also identified medicines with and without age-specific dose recommendations in a national prescribing guide, the Australian Medicines Handbook Children's Dosing Companion (AMH CDC). RESULTS The overall dispensing rate was 2.0 dispensings per child per year. The medicines with the highest average yearly prevalence were systemic antibiotics (435.3 per 1000 children), greatest in children 1-5 years (546.9 per 1000). Other common medicine classes were systemic corticosteroids (92.7 per 1000), respiratory medicines (91.2 per 1000), acid-suppressing medicines in children <1 year (47.2 per 1000), antidepressants in children 12-17 years (40.3 per 1000) and psychostimulants in children 6-11 years (27.0 per 1000). We identified 12.2% of dispensings as off-label based on age, but 66.3% of these had age-specific dosing recommendations in the AMH CDC. Among children <1 year, off-label dispensings were commonly acid-suppressing medicines (35.5%) and topical hydrocortisone (33.1%); in children 6-11 years, off-label prescribing of clonidine (16.0%) and risperidone (13.1%) was common. Off-label dispensings were more likely to be prescribed by a specialist (21.7%) than on-label dispensings (7.5%). CONCLUSIONS Prescribed medicine use is common in children, with off-label dispensings for medicines without paediatric-specific dosing guidelines concentrated in classes such as acid-suppressing medicines and psychotropics. Our findings highlight a need for better evidence to support best-practice prescribing.
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Affiliation(s)
- Andrea L. Schaffer
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Claudia Bruno
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Nicholas A. Buckley
- Biomedical Informatics and Digital HealthThe University of SydneySydneyNew South WalesAustralia,NSW Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNew South WalesAustralia
| | - Rose Cairns
- NSW Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNew South WalesAustralia,Faculty of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Melisa Litchfield
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Simon Paget
- The Children’s Hospital at Westmead Clinical SchoolThe University of SydneySydneyNew South WalesAustralia
| | - Helga Zoega
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,Centre of Public Health SciencesFaculty of MedicineUniversity of IcelandReykjavikIceland
| | - Natasha Nassar
- The Children’s Hospital at Westmead Clinical SchoolThe University of SydneySydneyNew South WalesAustralia,Menzies Centre for Health PolicyThe University of SydneySydneyNew South WalesAustralia
| | - Sallie‐Anne Pearson
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,Menzies Centre for Health PolicyThe University of SydneySydneyNew South WalesAustralia
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18
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Off-label use of drugs in pediatrics: a scoping review. Eur J Pediatr 2022; 181:3259-3269. [PMID: 35831681 DOI: 10.1007/s00431-022-04515-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/03/2022]
Abstract
To explore the current state of research on off-label drug use in children and identify the existing research gaps in this topic. Six literature databases were searched to identify studies focusing exclusively on off-label drug use in children (aged < 18 years) published in Chinese or English between 2016 and 2021. We also searched clinicaltrials.gov for pediatric clinical trials conducted in the same period and compared the numbers of studies on off-label use and clinical trials for the most commonly reported drugs and drug types. Our search revealed 568 studies on off-label drug use. Almost half of the studies (n = 240) were cross-sectional. A total of 212 specific drugs or drug types were addressed in 361 studies, the most frequent being antipsychotic agents (n = 12), dexmedetomidine (n = 10), and rituximab (n = 8). Antipsychotic agents were also the most common type of drug examined in clinical trials in children. We identified a total of 435 different types of off-label use, the top three being unapproved indication (n = 157), population (n = 96), or age (n = 36). Only about one-third of the studies reported collecting informed consent (n = 195) or having ethics committee approval (n = 166). Conclusions: Off-label use of antipsychotics in children is widely reported in the literature. We suggest pediatric researchers to consider the number of studies on off-label use and existing clinical trials on different drugs when selecting target drugs for new studies and systematic reviews. What is Known: • There exist a large number of studies on off-label drug use in children. What is New: • This is the first scoping review of studies on off-label drug use in children. • Off-label use of antipsychotic agents is widely reported.
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19
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Lopez-Morinigo JD, Leucht S, Arango C. Pharmacological Treatment of Early-Onset Schizophrenia: A Critical Review, Evidence-Based Clinical Guidance and Unmet Needs. PHARMACOPSYCHIATRY 2022; 55:233-245. [PMID: 35777418 PMCID: PMC9458343 DOI: 10.1055/a-1854-0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Early-onset schizophrenia (EOS) – onset before age 18 – is linked
with great disease burden and disability. Decision-making for EOS
pharmacological treatment may be challenging due to conflicting information from
evidence and guidelines and unidentified care needs may remain unmet. We searched for systematic reviews, meta-analyses and umbrella reviews of EOS
pharmacological treatment published in PubMed over the past 10 years and
selected five clinical guidelines from Europe, North-America and Australia.
Based on predefined outcomes, we critically compared the evidence supporting
EOS-approved drugs in Europe and/or North-America with guidelines
recommendations. We also evaluated the coverage of these outcomes to identify
unmet needs. One systematic review, nine meta-analyses and two umbrella reviews (k=203
trials, N=81,289 participants, including duplicated samples across
selected articles) were retrieved. Evidence supported the efficacy of
aripiprazole, clozapine, haloperidol, lurasidone, molindone, olanzapine,
quetiapine, risperidone and paliperidone in EOS, all of which obtained approval
for EOS either in Europe and/or in North-America. Cognition, functioning
and quality of life, suicidal behaviour and mortality and services utilisation
and cost-effectiveness were poorly covered/uncovered. Among the antipsychotics approved for EOS, aripiprazole, lurasidone, molindone,
risperidone, paliperidone and quetiapine emerged as efficacious and comparably
safe options. Olanzapine is known for a high risk of weight gain and haloperidol
for extrapyramidal side-effects. Treatment-resistant patients should be offered
clozapine. Future long-term trials looking at cognition, functioning, quality of
life, suicidal behaviour, mortality, services utilisation and cost-effectiveness
are warranted. Closer multi-agency collaboration may bridge the gap between
evidence, guidelines and approved drugs.
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Affiliation(s)
- Javier-David Lopez-Morinigo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaninger Straße 22, Munich, Germany
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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20
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Taliaz D, Serretti A. Investigation of Psychoactive Medications: Challenges and a Practical and Scalable New Path. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2022; 22:CNSNDDT-EPUB-124837. [PMID: 35762546 DOI: 10.2174/1871527321666220628103843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/17/2022] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
In the last two decades the validity of clinical trials in psychiatry has been subject to discussion. The most accepted clinical study method in the medical area, randomized controlled trial (RCT), faces significant problems when applied to the psychiatric world. One of the causes for this scenario is the strict participant inclusion and exclusion criteria that may not represent the real world. The inconsistency of the different endpoint parameters that are used in the field is another cause. We think that psychiatric RCTs' challenges, together with the underlying complexity of psychiatry, lead to a problematic clinical practice. Today, psychoactive drugs are routinely tested not in an official clinical trial setting. Off-label psychoactive drugs are commonly prescribed, and other substances, such as herbal remedies, are also regularly consumed. Learning from those real-life experiments can teach us useful lessons. Real-world data (RWD) includes information about heterogeneous patient populations, and it can be measured with standardized parameters. Collecting RWD can also address the need for systematically documenting and sharing case reports' outcomes. We suggest using digital tools to capture objective and continuous behavioral data from patients passively. New conclusions will be constantly drawn, possibly allowing more personalized treatment outcomes. The relevant next-generation decision support tools are already available.
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Affiliation(s)
- Dekel Taliaz
- 2 Prof. Yehezkel Kaufmann Street, Textile Center (15th Floor), Tel Aviv 6801294, Israel
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Italy
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21
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Lai AG, Chang WH. There is no health without mental health: Challenges ignored and lessons learned. Clin Transl Med 2022; 12:e897. [PMID: 35638534 PMCID: PMC9152988 DOI: 10.1002/ctm2.897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alvina G Lai
- Institute of Health Informatics, University College London, London, UK
| | - Wai Hoong Chang
- Institute of Health Informatics, University College London, London, UK
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22
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Florida Medicaid Children's Receipt of First-Line Psychosocial Care Prior to Antipsychotic Initiation. Acad Pediatr 2022; 22:S100-S107. [PMID: 35339236 DOI: 10.1016/j.acap.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/05/2021] [Accepted: 11/21/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVE First-line, nonpharmacological therapy is recommended for many pediatric mental health (MH) conditions prior to initiating antipsychotic prescription therapies. Many children do not receive these recommended services, despite the known association between antipsychotic medications and metabolic dysfunction. The main objective of this study was to quantify the association among children's MH diagnosis categories, sociodemographic characteristics and receipt of first-line psychosocial care among children in Florida Medicaid METHODS: Florida Medicaid enrollment, healthcare and pharmacy claims were used for this multivariate analysis. Children were assigned to condition clusters wherein related diagnoses were grouped into clinically relevant categories. A total of 7704 children were included in the final analysis. RESULTS Twenty-four percent of children in Florida Medicaid do not receive first-line, nonpharmacological psychosocial care. Age was significantly associated with not receiving psychosocial services, with older children less likely to receive. Non-Hispanic White children as well as those living in rural areas had lower odds of receiving behavioral intervention prior to initiating antipsychotics. Children with mood-disorders, behavior problems, anxiety and stress related disorders were more likely to receive first-line psychosocial care. CONCLUSIONS This study provides an important understanding of the variability in receipt of first-line psychosocial care before antipsychotic medication initiation among children in Medicaid based on sociodemographic and MH health characteristics. These analyses can be used to develop quality improvement initiatives targeted toward children that are most vulnerable for not receiving recommended care.
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23
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Egberts K, Fekete S, Häge A, Hiemke C, Scherf-Clavel M, Taurines R, Unterecker S, Gerlach M, Romanos M. [Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2022; 50:133-152. [PMID: 35274573 DOI: 10.1024/1422-4917/a000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice Abstract. Despite the improved evidence base, many uncertainties remain in child and adolescent psychiatric pharmacotherapy about the efficacy and tolerability of drugs, which are often prescribed off-label or in combination therapy in this age group. Because medium- to long-term use is unavoidable in many cases, clinicians should minimize adverse drug reactions as far as possible and tailor an effective dosage to the individual characteristics of the patient. Not only are children and adolescents particularly vulnerable to certain adverse drug effects, they are also exposed to iatrogenic risks from dosing or application errors, which can lead to under- or overdosing with correspondingly negative effects on the success of the therapy. In addition to determining a strict indication, it is therefore essential to establish precise dosage and systematic monitoring of the safety of the psychopharmacotherapy. This article introduces therapeutic drug monitoring as a useful clinical tool and describes how its correct application in practice can improve the efficacy as well as the safety and tolerability of psychotropic therapy in children and adolescents for the immediate benefit of patients. Keywords: Psychopharmacotherapy, adverse drug reactions, pharmacovigilance, therapeutic drug monitoring, quality assurance.
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Affiliation(s)
- Karin Egberts
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefanie Fekete
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V
| | - Alexander Häge
- Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Christoph Hiemke
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Maike Scherf-Clavel
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Regina Taurines
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Stefan Unterecker
- Speziallabor für Therapeutisches Drug Monitoring, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V
| | - Manfred Gerlach
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Therapeutisches Drug-Monitoring" der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) e. V.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
| | - Marcel Romanos
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Zentrum für Psychische Gesundheit, Universitätsklinikum Würzburg.,Arbeitsgruppe "Kinder- und jugendpsychiatrische Pharmakologie" der AGNP e. V.,Kompetenznetz Therapeutisches Drug Monitoring in der Kinder- und Jugendpsychiatrie g. e. V
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Smogur M, Onesanu A, Plessen KJ, Eap CB, Ansermot N. Psychotropic Drug Prescription in Children and Adolescents: Approved Medications in European Countries and the United States. J Child Adolesc Psychopharmacol 2022; 32:80-88. [PMID: 35138922 DOI: 10.1089/cap.2021.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives: The decision to prescribe a medication and the choice of which one are often complex, particularly in the field of child and adolescent psychiatry where evidence is scarce. The aim of this review is to provide a synthesis of psychotropic drugs approved in children and adolescents for psychiatric indications in several countries. Methods: All psychopharmacological treatments used in child and adolescent psychiatry, approved by at least one regulatory agency from Switzerland, the United Kingdom, France, the European Union, or the United States, were considered. A comprehensive review of the summaries of product characteristics was performed. Results: A total of 143 psychotropic drugs were included: 47 anxiolytics/hypnotics, 45 antidepressants, 37 antipsychotics, 10 medications for attention-deficit/hyperactivity disorder (ADHD), and 4 mood stabilizers. Only a few of these drugs were approved for use in children or adolescents (38%) at least for a single psychiatric diagnosis in at least one country. The therapeutic class with the lowest rate of approved status was antidepressants (20%), followed by mood stabilizers (25%), anxiolytics/hypnotics (28%), antipsychotics (57%), and medications for ADHD (100%). Important differences in approved diagnoses, ages, and doses were observed between regulatory agencies. Tables presenting drugs for approved diagnoses based on age and regulatory agencies are presented in this article. Drugs classified by regulatory agencies, with complete data on diagnoses, ages, doses, pharmaceutical forms, and particular restrictions, are presented as Supplementary Material. Conclusion: This article provides an overview to prescribers with respect to the approved medications in children and adolescents in selected European countries and the United States.
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Affiliation(s)
- Michal Smogur
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - Alice Onesanu
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - Kerstin Jessica Plessen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland.,Centre for Research and Innovation in Clinical Pharmaceutical Sciences, University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva and Lausanne, Switzerland
| | - Nicolas Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
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25
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Egberts KM, Gerlach M, Correll CU, Plener PL, Malzahn U, Heuschmann P, Unterecker S, Scherf-Clavel M, Rock H, Antony G, Briegel W, Fleischhaker C, Häge A, Hellenschmidt T, Imgart H, Kaess M, Karwautz A, Kölch M, Reitzle K, Renner T, Reuter-Dang SY, Rexroth C, Schulte-Körne G, Theisen FM, Walitza S, Wewetzer C, Fekete S, Taurines R, Romanos M. Serious Adverse Drug Reactions in Children and Adolescents Treated On- and Off-Label with Antidepressants and Antipsychotics in Clinical Practice. PHARMACOPSYCHIATRY 2022; 55:255-265. [PMID: 35130562 PMCID: PMC9458344 DOI: 10.1055/a-1716-1856] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite the growing evidence base for psychotropic drug treatment in pediatric patients, knowledge about the benefit-risk ratio in clinical practice remains limited. The 'Therapeutic Drug Monitoring (TDM)-VIGIL' study aimed to evaluate serious adverse drug reactions (ADRs) in children and adolescents treated with antidepressants and/or antipsychotics in approved ('on-label'), and off-label use in clinical practice. METHODS Psychiatric pediatric patients aged 6-18 years treated with antidepressants and/or antipsychotics either on-label or off-label were prospectively followed between October 2014 and December 2018 within a multicenter trial. Follow-up included standardized assessments of response, serious ADRs and therapeutic drug monitoring. RESULTS 710 youth (age=14.6±2.2 years, female=66.6%) were observed for 5.5 months on average; 76.3% received antidepressants, 47.5% antipsychotics, and 25.2% both. Altogether, 55.2% of the treatment episodes with antidepressants and 80.7% with antipsychotics were off-label. Serious ADRs occurred in 8.3% (95%CI=6.4-10.6%) of patients, mainly being psychiatric adverse reactions (77.4%), predominantly suicidal ideation and behavior. The risk of serious ADRs was not significantly different between patients using psychotropics off-label and on-label (antidepressants: 8.1% vs. 11.3%, p=0.16; antipsychotics: 8.7% vs 7.5%, p=0.67). Serious ADRs occurred in 16.6% of patients who were suicidal at enrollment versus 5.6% of patients who were not suicidal (relative risk 3.0, 95%CI=1.9-4.9). CONCLUSION Off-label use of antidepressants and antipsychotics in youth was not a risk factor for the occurrence of serious ADRs in a closely monitored clinical setting. Results from large naturalistic trials like ours can contribute to bridging the gap between knowledge from randomized controlled trials and real-world clinical settings.
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Affiliation(s)
- Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Manfred Gerlach
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, Ulm, Germany.,Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Uwe Malzahn
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Heuschmann
- Clinical Trial Center Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Wuerzburg, Germany
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Hans Rock
- Central Information Office, Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Gisela Antony
- Central Information Office, Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Wolfgang Briegel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Leopoldina Hospital, Schweinfurt, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Alexander Häge
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tobias Hellenschmidt
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Clinic Berlin Neukölln, Berlin, Germany
| | - Harmut Imgart
- Parkland-Clinic, Clinic for Psychosomatics and Psychotherapy, Academic Teaching hospital for the University Gießen, Bad Wildungen, Germany
| | - Michael Kaess
- Clinic for Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.,University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland
| | - Andreas Karwautz
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Michael Kölch
- Department of Child and Adolescent Psychiatry and Psychotherapy, Brandenburg Medical School Brandenburg, Neuruppin, Germany.,Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics, and Psychotherapy, University Medical Center Rostock, Rostock, Germany
| | - Karl Reitzle
- Specialist practice and Medical Care Center for Child and Adolescent Psychiatry Munich, Munich, Germany
| | - Tobias Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Psychiatry and Psychotherapy Tuebingen, Center of Mental Health Tuebingen, Germany
| | - Su-Yin Reuter-Dang
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany.,Specialist practice and Medical Care Center for Child and Adolescent Psychiatry Munich, Munich, Germany
| | - Christian Rexroth
- Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy at the Regensburg District Hospital, Medbo KU, University Hospital, Regensburg, Germany
| | - Gerd Schulte-Körne
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Ludwig-Maximilians-University (LMU) Hospital, Munich, Germany
| | - Frank M Theisen
- Herz-Jesu-Krankenhaus gGmbH, Department of Child and Adolescent Psychiatry and Psychotherapy, Fulda, Germany
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Switzerland
| | - Christoph Wewetzer
- Kliniken der Stadt Köln gGmbH, Clinic for Child and Adolescent Psychiatry Holweide, Children's Hospital Amsterdamer Straße, Cologne, Germany
| | - Stefanie Fekete
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Regina Taurines
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Wuerzburg, Wuerzburg, Germany
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Abstract
Melatonin is a hormonal product of the pineal gland, a fact that is often forgotten. Instead it is promoted as a dietary supplement that will overcome insomnia, as an antioxidant and as a prescription only drug in most countries outside the United States of America and Canada. The aim of this review is to step back and highlight what we know about melatonin following its discovery 60 years ago. What is the role of endogenous melatonin; what does melatonin do to sleep, body temperature, circadian rhythms, the cardiovascular system, reproductive system, endocrine system and metabolism when administered to healthy subjects? When used as a drug/dietary supplement, what safety studies have been conducted? Can we really say melatonin is safe when it has not been systematically studied and many studies show interactions with a wide range of physiological processes? Finally the results of studies investigating the efficacy of melatonin as a drug to alleviate insomnia are critically evaluated. In summary, melatonin is an endogenous pineal gland hormone with specific physiological functions in animals and humans, with its primary role in humans to maintain synchrony of sleep with the day/night cycle. When administered as a drug it affects a wide range of physiological systems and has clinically important drug interactions. With respect to efficacy for treating sleep disorders, melatonin can advance the time of sleep onset but the effect is modest and variable. In children with neurodevelopmental disabilities melatonin appears to have the greatest impact on sleep onset but little effect on sleep efficiency.
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Affiliation(s)
- David J Kennaway
- Robinson Research Institute and Adelaide School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Patterns and Predictors of Off-Label Drug Prescribing in Psychiatric Practice: A Qualitative Study. PHARMACY 2021; 9:pharmacy9040203. [PMID: 34941635 PMCID: PMC8703660 DOI: 10.3390/pharmacy9040203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Off-label drug prescribing (OLDP) must be based on strong scientific evidence to make sure that patients get the optimum therapeutic outcomes. Adherence to the prerequisites is determined by the physicians’ attitude and knowledge. In this context, the present study was conducted with the goal of investigating psychiatrists’ perceptions of the use of OLDP in their clinical practice. A total of 14 psychiatrists were interviewed using a semi-structured interview guide. Thematic content analysis was performed. Data saturation was achieved at the 12th interview. Six major themes and fifteen subthemes emerged from qualitative interviews. Among the major themes were knowledge and concepts about the off-label drugs, attitude and current practice of prescribing off-label drugs, and rationale of prescribing and suggestions for reducing the use of off-label drugs. Almost all of the respondents interviewed provided detailed comments concerning the OLDP concept, depicted an optimistic approach and deemed that OLDP is quite common in psychiatry. Off-label usage of benzodiazepines such as clonazepam, diazepam and lorazepam in mania, depression, and obsessive–compulsive disorder were commonly reported. It was observed that the majority of the respondents did not inform the patients before prescribing off-label drugs. The present findings revealed that respondents had awareness; however, they depicted diverse attitudes towards prescribing off-label drugs. Further education and sensitization in regions with impoverished knowledge would certainly assist in preventing the risks associated with the use of OLDP.
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28
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Suk JW, Soltis-Vaughan B, Mahato K, Hwang S. Practical and Ethical Issues in Pediatric Psychopharmacology: Introductory Considerations. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210913-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zhu M, Ferrara M, Tan W, Shang X, Syed S, Zhang L, Qin Q, Hu X, Rohrbaugh R, Srihari VH, Liu Z. Drug-naïve first-episode schizophrenia spectrum disorders: Pharmacological treatment practices in inpatient units in Hunan Province, China. Early Interv Psychiatry 2021; 15:1010-1018. [PMID: 32924286 PMCID: PMC8359180 DOI: 10.1111/eip.13046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/08/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022]
Abstract
AIM This study describes antipsychotic prescription patterns for drug-naïve inpatients diagnosed with first-episode schizophrenia-spectrum (FES) disorders and factors associated with practices deviating from China's current guidelines. METHODS All inpatients aged 7 to 45 years experiencing a first episode of schizophrenia-spectrum disorder with a duration of untreated illness of less than 18 months and admitted between 1 August 2016 and 1 August 2017 to one of eight psychiatric hospitals in Hunan were included. Demographics, clinical characteristics and prescriptions at discharge were collected from electronic medical records. Logistic regression and random forest methods were used to model relationships between demographic and clinical factors and deviations from China's guidelines. RESULTS Of the 602 inpatients included in the study, 598 (99.3%) were prescribed antipsychotics, and no patients were discharged on long-acting injectable antipsychotics. Polypharmacy (more than one antipsychotic prescribed) was present in 121 (20.2%) participants. Clozapine was prescribed to 45 (7.5%) patients. Adults receiving polypharmacy were more likely to be prescribed high-dose antipsychotics than those receiving a single antipsychotic. Minors under 13 years of age were more likely to receive polypharmacy and unapproved antipsychotics than those older than 13 years. CONCLUSIONS Our findings suggest that most of the inpatients were prescribed a single antipsychotic at discharge, consistent with China's guidelines. Minors with FES and patients discharged on polypharmacy and clozapine may require more intense monitoring and management. With the current implementation of China's National Mental Health Working Plan, these results will assist decision-makers in allocating resources and conducting reforms to facilitate best practice treatment for FES.
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Affiliation(s)
- Mengran Zhu
- Department of PsychiatrySecond Xiangya Hospital of Central South UniversityChangshaChina
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Program for Specialized Treatment Early in Psychosis (STEP)Connecticut Mental Health CenterNew HavenConnecticutUSA
| | - Maria Ferrara
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Program for Specialized Treatment Early in Psychosis (STEP)Connecticut Mental Health CenterNew HavenConnecticutUSA
| | - Wenjian Tan
- Department of PsychiatrySecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Xingbo Shang
- Yale Systems Biology Institute and Department of Biomedical EngineeringYale UniversityNew HavenConnecticutUSA
| | - Sumaiyah Syed
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Program for Specialized Treatment Early in Psychosis (STEP)Connecticut Mental Health CenterNew HavenConnecticutUSA
| | - Li Zhang
- Department of PsychiatrySecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Qilin Qin
- Department of NeurosurgerySecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Xinran Hu
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
| | - Robert Rohrbaugh
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
| | - Vinod H. Srihari
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Program for Specialized Treatment Early in Psychosis (STEP)Connecticut Mental Health CenterNew HavenConnecticutUSA
| | - Zhening Liu
- Department of PsychiatrySecond Xiangya Hospital of Central South UniversityChangshaChina
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30
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Solmi M, Fornaro M, Ostinelli EG, Zangani C, Croatto G, Monaco F, Krinitski D, Fusar‐Poli P, Correll CU. Safety of 80 antidepressants, antipsychotics, anti-attention-deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: a large scale systematic meta-review of 78 adverse effects. World Psychiatry 2020; 19:214-232. [PMID: 32394557 PMCID: PMC7215080 DOI: 10.1002/wps.20765] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Mental disorders frequently begin in childhood or adolescence. Psychotropic medications have various indications for the treatment of mental dis-orders in this age group and are used not infrequently off-label. However, the adverse effects of these medications require special attention during developmentally sensitive periods of life. For this meta-review, we systematically searched network meta-analyses and meta-analyses of randomized controlled trials (RCTs), individual RCTs, and cohort studies reporting on 78 a priori selected adverse events across 19 categories of 80 psychotropic medications - including antidepressants, antipsychotics, anti-attention-deficit/hyperactivity disorder (ADHD) medications and mood stabilizers - in children and adolescents with mental disorders. We included data from nine network meta-analyses, 39 meta-analyses, 90 individual RCTs, and eight cohort studies, including 337,686 children and adolescents. Data on ≥20% of the 78 adverse events were available for six antidepressants (sertraline, escitalopram, paroxetine, fluoxetine, venlafaxine and vilazodone), eight antipsychotics (risperidone, quetiapine, aripiprazole, lurasidone, paliperidone, ziprasidone, olanzapine and asenapine), three anti-ADHD medications (methylphenidate, atomoxetine and guanfacine), and two mood stabilizers (valproate and lithium). Among these medications with data on ≥20% of the 78 adverse events, a safer profile emerged for escitalopram and fluoxetine among antidepressants, lurasidone for antipsychotics, methylphenidate among anti-ADHD medications, and lithium among mood stabilizers. The available literature raised most concerns about the safety of venlafaxine, olanzapine, atomoxetine, guanfacine and valproate. Nausea/vomiting and discontinuation due to adverse event were most frequently associated with antidepressants; sedation, extrapyramidal side effects, and weight gain with antipsychotics; anorexia and insomnia with anti-ADHD medications; sedation and weight gain with mood stabilizers. The results of this comprehensive and updated quantitative systematic meta-review of top-tier evidence regarding the safety of antidepressants, antipsychotics, anti-ADHD medications and mood stabilizers in children and adolescents can inform clinical practice, research and treatment guidelines.
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Affiliation(s)
- Marco Solmi
- Neurosciences DepartmentUniversity of PaduaPaduaItaly,Padua Neuroscience CenterUniversity of PaduaPaduaItaly,Early Psychosis: Interventions and Clinical‐detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | | | - Edoardo G. Ostinelli
- Oxford Health NHS Foundation TrustWarneford Hospital, and Department of Psychiatry, University of OxfordOxfordUK,Department of Health SciencesUniversity of MilanMilanItaly
| | | | | | | | | | - Paolo Fusar‐Poli
- Early Psychosis: Interventions and Clinical‐detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,OASIS ServiceSouth London & Maudsley NHS Foundation TrustLondonUK,Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly,National Institute for Health Research, Maudsley Biomedical Research CentreSouth London & Maudsley NHS Foundation TrustLondonUK
| | - Christoph U. Correll
- Department of Psychiatry, Zucker Hillside HospitalNorthwell HealthGlen OaksNew YorkNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Center for Psychiatric NeuroscienceFeinstein Institute for Medical ResearchManhassetNYUSA,Department of Child and Adolescent PsychiatryCharité Universitätsmedizin BerlinBerlinGermany
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31
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Procaccini DE, Lobner K, Anton B, Kudchadkar SR. Melatonin Use in Hospitalized Children for Non-Anesthetic Indications: A Systematic Review. Pharmacotherapy 2020; 40:692-703. [PMID: 32342515 DOI: 10.1002/phar.2408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Melatonin, a potent free radical scavenger, plays an important role in homeostasis of cell and organ physiology. The increased demand and synthesis from the pineal gland during times of oxidative stress suggests a potential benefit of melatonin supplementation during hospitalization for acute illness. Yet, the paucity of clinical studies for non-anesthetic-associated indications in pediatric populations hampers the safe, effective, and consistent use of melatonin. The objective of this study was to systematically review published studies of melatonin use for non-sedative and non-analgesic indications in hospitalized pediatric patients. We conducted a search of PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Scopus databases for articles on the use of melatonin for pediatric patients in a hospital setting. Thirteen eligible studies, all in neonates, were identified. Data elements extracted included study design, number of study subjects, indication for melatonin therapy, and melatonin regimen (formulation, dosage, and duration). Because study methodologies were very heterogeneous, a quantitative synthesis of the published findings was not possible. The identified studies were therefore categorized by the indication of melatonin (adjuvant-antioxidant or anti-inflammatory therapy) in the following specific disease states: (i) acute infections, (ii) respiratory distress syndrome, (iii) neurologic injury, and (iv) jaundice. The current data suggest that melatonin is safe for use in hospitalized neonates. Melatonin may be beneficial for reducing inflammatory markers in neonatal patients with disease states and clinical sequelae that are associated with increased inflammation and oxidative stress. Melatonin, in conjunction with phototherapy, is not superior to use of vitamin D with phototherapy for treatment of neonatal jaundice. However, studies in other pediatric populations are needed given widespread use across clinical inpatient settings.
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Affiliation(s)
- David E Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Katie Lobner
- Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Blair Anton
- Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sapna R Kudchadkar
- Departments of Anesthesiology & Critical Care Medicine, Pediatrics, and Physical Medicine & Rehabilitation, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Hughes KL, Roberts G. Who is prescribing psychotropic medications in a public developmental-behavioural clinical service and how often? J Paediatr Child Health 2020; 56:532-536. [PMID: 31721351 DOI: 10.1111/jpc.14676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/15/2019] [Accepted: 10/14/2019] [Indexed: 11/29/2022]
Abstract
AIM Psychotropic prescribing by paediatricians is increasingly common, and there is considerable variation in care provided. The aims of this study were to examine current rates of psychotropic prescribing in the developmental-behavioural outpatient clinics at the Royal Children's Hospital's Centre for Community Child Health, and to compare rates between paediatric consultants and advanced trainees. METHODS Data were extracted for appointment encounters from electronic medical records across 12 months in 2017. Patient demographics, provider and medication order data were analysed using Excel and STATA to calculate logistic regression, standard deviation, percentages and means. RESULTS From 5069 encounters, there were 847 (16.7%) that included psychotropic prescribing. Advanced trainees prescribed psychotropic medications in only 4.4% of their encounters compared with consultants who prescribed these medications in 23% of encounters (P < 0.001). Stimulants were the most commonly prescribed psychotropic medication (62%), either alone (86.3%) or in combination (13.7%). CONCLUSIONS Psychotropic prescribing rates were lower than expected. Advanced trainees may need more experience in psychotropic prescribing.
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Affiliation(s)
- Katherine L Hughes
- Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gehan Roberts
- Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia.,Population Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Horace A, Golchin N, Knight EMP, Dawson NV, Ma X, Feinstein JA, Johnson HK, Kleinman L, Bakaki PM. A Scoping Review of Medications Studied in Pediatric Polypharmacy Research. Paediatr Drugs 2020; 22:85-94. [PMID: 31823339 PMCID: PMC6984990 DOI: 10.1007/s40272-019-00372-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to describe medications most commonly studied in pediatric polypharmacy research by pharmacologic classes and disease using a scoping review methodology. METHODS A search of electronic databases was conducted in July 2019 that included Ovid Medline, PubMed, Elsevier Embase, and EBSCO CINAHL. Primary observational studies were selected if they evaluated polypharmacy as an aim, outcome, predictor, or covariate in children 0-21 years of age. Studies not differentiating between adults and children or those not written in English were excluded. Study characteristics, pharmacologic categories, medication classes, and medications were extracted from the included studies. RESULTS The search identified 8790 titles and after de-duplicating and full-text screening, 414 studies were extracted for the primary data. Regarding global pharmacologic categories, central nervous system (CNS) agents were most studied (n = 185, 44.9%). The most reported pharmacologic category was the anticonvulsants (n = 250, 60.4%), with valproic acid (n = 129), carbamazepine (n = 123), phenobarbital (n = 87), and phenytoin (n = 83) being the medications most commonly studied. In studies that reported medication classes (n = 105), serotonin reuptake inhibitors (n = 32, 30.5%), CNS stimulants (n = 30, 28.6%), and mood stabilizers (n = 27, 25.7%) were the most studied medication classes. CONCLUSION While characterizing the literature on pediatric polypharmacy in terms of the types of medication studied, we further identified substantive gaps within this literature outside of epilepsy and psychiatric disorders. Medications frequently identified in use of polypharmacy for treatment of epilepsy and psychiatric disorders reveal opportunities for enhanced medication management in pediatric patients.
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Affiliation(s)
- Alexis Horace
- College of Pharmacy, University of Louisiana at Monroe College of Pharmacy, Monroe, LA, USA,Corresponding Author , Phone: 318-342-6601
| | - Negar Golchin
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | | | - Neal V. Dawson
- Center for Health Care Research and Policy, MetroHealth, Cleveland, OH, USA,Department of Medicine, MetroHealth Medical Center, Cleveland, OH, USA
| | - Xuan Ma
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - James A. Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hannah K. Johnson
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Lawrence Kleinman
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Paul M. Bakaki
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
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Off-Label Medications in Pediatrics. Indian J Pediatr 2019; 86:1149. [PMID: 31327145 DOI: 10.1007/s12098-019-03029-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
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Ali MM, Teich J, Lynch S, Mutter R. Utilization of Mental Health Services by Preschool-Aged Children with Private Insurance Coverage. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 45:731-740. [PMID: 29476292 DOI: 10.1007/s10488-018-0858-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There is increasing recognition that some preschool-aged children suffer from mental health conditions, but little is known about the treatment they receive. Using the 2014 MarketScan Commercial Claims and Encounters database (N = 1,987,759) the study finds that only a small proportion of preschool-aged children receive any behavioral interventions, including psychotherapy, in conjunction with having a filled psychiatric prescription. Nearly all of the preschool-aged children who had psychotropic prescriptions filled had no other claims for treatment, and among those children who had prescriptions for psychotropic medication filled, the vast majority did not have a mental health diagnosis on a claim.
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Affiliation(s)
- Mir M Ali
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD, 20852, USA.
| | - Judith Teich
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD, 20852, USA
| | - Sean Lynch
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD, 20852, USA
| | - Ryan Mutter
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD, 20852, USA
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The evidence-based choice for antipsychotics in children and adolescents should be guaranteed. Eur J Clin Pharmacol 2019; 75:769-776. [PMID: 30729258 DOI: 10.1007/s00228-019-02641-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/28/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Drug use in the pediatric population still often features off-label prescriptions, particularly for psychotropic drugs. We reviewed the registration status, scientific evidence, and recommendations from the guidelines for antipsychotics used for psychiatric disorders in children. METHODS Antipsychotic drugs marketed in Italy, the United Kingdom (UK) and United States (US) were identified with the ATC Classification System. The licensing status and Summary of Product Characteristics (SPC) were taken from the national formularies. We analyzed reviews and guidelines on antipsychotics use in children and adolescents in the MEDLINE, EMBASE, and PsycINFO databases. RESULTS Out of 67 drugs, 19 were marketed with a pediatric license in at least one country: three in all the selected countries, and only paliperidone with the same indications. Haloperidol was the only antipsychotic authorized for autism in Italy and the UK, and as well as risperidone and aripiprazole in the US. Aripiprazole and paliperidone were licensed in all three countries for schizophrenia. Aripiprazole was licensed for bipolar disorders in all three countries. Haloperidol was licensed for Tourette syndrome in Italy and the UK, and pimozide and aripiprazole in the US. We retrieved 21 pertinent reviews and 13 guidelines for the management of neuropsychiatric disorders in pediatrics. There was a complete overlap between the authorized therapeutic indications and the available scientific evidence for autism in the US, for conduct disorders and bipolar disorders in the UK, and for Tourette syndrome and tics in the UK and Italy. CONCLUSIONS These results highlight the different regulatory processes that deny to many children and adolescents the most appropriate and rational antipsychotic therapy.
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Use of Psychotropic Drugs among Children and Adolescents with Autism Spectrum Disorders in Denmark: A Nationwide Drug Utilization Study. J Clin Med 2018; 7:jcm7100339. [PMID: 30308952 PMCID: PMC6211111 DOI: 10.3390/jcm7100339] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 12/22/2022] Open
Abstract
Children with autism spectrum disorder (ASD) have a considerable use of psychotropics. Leveraging nationwide registry data, we aimed to describe the use of psychotropics among children and adolescents with ASD in Denmark. Use of melatonin and attention-deficit/hyperactivity disorder (ADHD) medication increased from 2010 to 2017, while there were limited changes in use of antidepressants and antipsychotics. Thirty percent of the identified children used psychotropics in 2017 most commonly ADHD medication (17%) and melatonin (13%). Methylphenidate, sertraline and risperidone were most often prescribed. Most children filled more than one prescription and, across drug classes, at least 38% received treatment two years after treatment initiation. Use of psychotropics followed psychiatric comorbidities. Comorbidities did not affect age at treatment initiation. Use of psychotropics varied according to age and sex with limited use in the youngest children. In summary, psychotropic drug use has increased in children with ASD mainly due to an increase in the use of ADHD medication and melatonin. In accordance with previous studies, use seems to follow comorbidities. The long treatment duration underlines the need to investigate long-term effects of psychotropic drug use in children with ASD.
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Off-label antidepressant prescription in pediatric outpatients based on China Food and Drug Administration and Food and Drug Administration regulations: a Chinese retrospective study. Int Clin Psychopharmacol 2018; 33:172-179. [PMID: 29505485 DOI: 10.1097/yic.0000000000000216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The objective of this study was to evaluate the prevalence and relative risk of off-label prescription of antidepressants in Chinese pediatric outpatients according to China Food and Drug Administration (C-FDA) and USFDA regulations. Medical records of 18 459 pediatric outpatients were identified between 2013 and 2015. Patient characteristics, prevalence of off-label antidepressant prescriptions, and relative risk factors associated with off-label prescribing were analyzed. The results indicate that patients aged from 12 to 17 years account for 88.1% of antidepressant prescriptions, with the most commonly prescribed being sertraline (41.4%). In total, 90.0 and 84.1% of antidepressant prescriptions were off-labeled according to C-FDA and USFDA, respectively, and off-label indications was the most frequent type in this study. Depression was the most common indication for antidepressant treatment, followed by bipolar disorder and schizophrenia. Patients aged 12-17 years diagnosed with bipolar affective disorder have a high risk of off-label antidepressant prescription according to C-FDA regulations. Patients diagnosed with obsessive-compulsive disorder have a low risk of off-label antidepressant prescription according to both regulations. Therefore, future studies are recommended to collect evidence to safeguard appropriate prescribing of off-label antidepressants among pediatric patients.
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Zhu X, Hu J, Sun B, Deng S, Wen Y, Chen W, Qiu C, Shang D, Zhang M. Comparison of Unlicensed and Off-Label Use of Antipsychotics Prescribed to Child and Adolescent Psychiatric Outpatients for Treatment of Mental and Behavioral Disorders with Different Guidelines: The China Food and Drug Administration Versus the FDA. J Child Adolesc Psychopharmacol 2018; 28:216-224. [PMID: 29336603 DOI: 10.1089/cap.2017.0079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study aims to compare the prevalence of unlicensed and off-label use of antipsychotics among child and adolescent psychiatric outpatients with guidelines proposed by the China Food and Drug Administration (CFDA) and the U.S. Food and Drug Administration (FDA), and to identify factors associated with inconsistencies between the two regulations. METHODS A retrospective analysis of 29,326 drug prescriptions for child and adolescent outpatients from the Affiliated Brain Hospital of Guangzhou Medical University was conducted. Antipsychotics were classified as "unlicensed" or "off-label use" according to the latest pediatric license information registered by the CFDA and the FDA or the package inserts of antipsychotics authorized by the CFDA or the FDA for the treatment of pediatric mental and behavioral disorders, respectively. Binary logistic regression analysis was performed to assess factors associated with inconsistencies between the two regulations. RESULTS The total unlicensed use, according to the CFDA analysis, was higher than that found in the FDA analysis (74.14% vs. 22.04%, p < 0.001). However, the total off-label use, according to the FDA analysis, was higher than that found in the CFDA analysis (46.53% vs. 15.77%, p < 0.001). Antipsychotic drug classes, age group, number of diagnoses, and diagnosis of schizophrenia and schizotypal and delusional disorders were associated with inconsistent unlicensed use. Antipsychotic drug classes, age group, number of prescribed psychotropic drugs, gender, diagnosis of schizophrenia and schizotypal and delusional disorders, diagnosis of mood [affective] disorders, diagnosis of mental retardation, and diagnosis of psychological development disorders were associated with inconsistent off-label use. CONCLUSIONS The difference in prevalence of total unlicensed and off-label use of antipsychotics between the two regulations was statistically significant. This inconsistency could be partly attributed to differences in pediatric license information and package inserts of antipsychotics. The results indicate a need for further clinical pediatric studies and better harmonization between agencies regarding antipsychotic used in pediatrics.
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Affiliation(s)
- Xiuqing Zhu
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Jinqing Hu
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Bin Sun
- 2 Neuropsychiatric Research Institute, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Shuhua Deng
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Yuguan Wen
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Weijia Chen
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Chang Qiu
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Dewei Shang
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
| | - Ming Zhang
- 1 Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital) , Guangzhou, China
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Kornø KT, Aagaard L. Off-Label Prescribing of Antipsychotics in a Danish Child and Adolescent Mental Health Center: A Register-Based Study. J Res Pharm Pract 2018; 7:205-209. [PMID: 30622989 PMCID: PMC6298142 DOI: 10.4103/jrpp.jrpp_18_42] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective We analyzed prescribing patterns of antipsychotics for children and adolescent affiliated with a Danish Child and Adolescent Mental Health Center) with respect to age, sex, medicine, diagnoses, off-label status, and time. Methods We included all patients below 19 years of age prescribed antipsychotics during 2007-2008 and as of November 1, 2014. Prescription data included all antipsychotic prescriptions and prescriptions of concomitant psychotropic medications. We defined an antipsychotic user as a patient receiving at least one prescription during the study period, irrespective of any previous history of antipsychotic use. We defined off-label prescribing as prescriptions outside the licensed age group and approved indication. Findings We analyzed 404 antipsychotic prescriptions that were located for 150 patients. The patients were between 7 and 18 years of age. Two-thirds of the prescriptions were for girls and two-thirds of prescriptions for olanzapine and quetiapine. Totally, 92% of all prescribed antipsychotics were used off-label. For typical antipsychotics, this share was 96% and for atypical antipsychotics 90%. As of November 1, 2014, the total share of off-label antipsychotic prescriptions was 96%, and 63% of these were for medications prescribed outside the approved age group, and 26% for nonlicensed indication(s). Conclusion This study demonstrated a high level of off-label prescribing over time with respect to age and indication. The prescribing patterns underpin the need for further economic incentives for pharmaceutical companies to register pediatric indications, particular for off-patent products.
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Affiliation(s)
- Kristine Tøfting Kornø
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lise Aagaard
- Havemann Law Firm, Frederiksberggade, Copenhagen, Denmark
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Off-label prescription of psychiatric drugs by non-psychiatrist physicians in three general hospitals in Germany. Ann Gen Psychiatry 2018; 17:7. [PMID: 29449869 PMCID: PMC5806239 DOI: 10.1186/s12991-018-0176-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/23/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Off-label prescribing of psychoactive drugs is a common practice in psychiatry. Here, we sought to investigate the frequency of off-label prescribing in a population of hospitalized patients with a somatic illness who were also suffering from a psychiatric pathology. METHODS Using a prospective, observational design, we collected data from 982 hospitalized patients with a somatic illness for whom a psychiatric consultation was requested because of the presence of additional psychiatric symptoms. Data were collected at three hospitals in Germany. Demographic and clinical data, including the previous psychoactive medications and an assessment of the suitability of the previous medications, were recorded and analyzed. RESULTS Data on the previous psychiatric medications were available for 972 patients. In 16.6% of patients, at least one psychoactive drug had been prescribed off-label, 20.2% had received on-label medication, and 63.2% had not received any psychiatric medication. Among all patients receiving psychiatric medication, 45.1% had received off-label medication. The logistic regression analysis showed a significant influence of age on the likelihood of receiving off-label medication (p = 0.018). Benzodiazepines were the most frequent off-label prescription (25.8% of off-label prescriptions), followed by atypical antipsychotics (18.2%) and low-potency antipsychotics (17.2%). Notably, 57.1% of off-label prescriptions were judged to be 'not indicated' by experienced psychiatrists. CONCLUSIONS Our data show a high frequency of the off-label prescription of psychoactive drugs by physicians treating patients with somatic illnesses in general hospitals. Because more than half of these cases were judged to be "not indicated", these prescriptions indicate a potential risk to patients. Furthermore, the classes of drugs that were most frequently prescribed off-label, benzodiazepines and antipsychotics, both show a substantial risk profile, particularly for elderly patients.
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Pagsberg AK, Jeppesen P, Klauber DG, Jensen KG, Rudå D, Stentebjerg-Olesen M, Jantzen P, Rasmussen S, Saldeen EAS, Lauritsen MBG, Bilenberg N, Stenstrøm AD, Nyvang L, Madsen S, Werge TM, Lange T, Gluud C, Skoog M, Winkel P, Jepsen JRM, Fagerlund B, Correll CU, Fink-Jensen A. Quetiapine extended release versus aripiprazole in children and adolescents with first-episode psychosis: the multicentre, double-blind, randomised tolerability and efficacy of antipsychotics (TEA) trial. Lancet Psychiatry 2017; 4:605-618. [PMID: 28599949 DOI: 10.1016/s2215-0366(17)30166-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/24/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Head-to-head trials to guide antipsychotic treatment choices for paediatric psychosis are urgently needed because extrapolations from adult studies might not be implementable. In this superiority trial with two-sided significance testing, we aimed to compare the efficacy and safety of quetiapine-extended release (quetiapine-ER) versus aripiprazole in children and adolescents with first-episode psychosis, to determine whether differences between the two treatments were sufficient to guide clinicians in their choice of one drug over the other. METHODS In this multicentre, double-blind, randomised trial in seven Danish university clinics, we recruited children and adolescents aged 12-17 years with a diagnosis of ICD-10 schizophrenia-spectrum disorder, delusional disorder, or affective-spectrum psychotic disorder, and psychotic symptoms scoring at least 4 on at least one of the following Positive and Negative Syndrome Scale (PANSS) items: P1 (delusions), P2 (conceptual disorganisation), P3 (hallucinations), P5 (grandiosity), P6 (suspiciousness/persecution), and G9 (unusual thought content), and a total PANSS score greater than 60. Patients were randomly assigned (1:1) to 12 weeks of treatment with target doses of 600 mg/day of quetiapine-ER (starting from 50 mg/day) or 20 mg/day of aripiprazole (starting from 2·5 mg/day). The assigned drug was titrated over five levels, with 2 days at each dose, and the final dose achieved on day 9. Randomisation was done using a computer-generated concealed sequence with a block size of 8, and stratified by baseline PANSS positive score (≤20 points or >20 points) and age (12-14 years or 15-17 years). Study drugs were administered in identical capsules, and interventions, assessments, and data analysis were done masked. The primary outcome was PANSS positive score. Key adverse outcomes were bodyweight, homoeostatic model of insulin resistance (HOMA-IR), akathisia, and sedation. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01119014. FINDINGS Between June 10, 2010, and Jan 29, 2014, 231 participants were assessed for elegibility, of whom 113 were randomly assigned to quetiapine-ER (n=55) or aripiprazole (n=58). PANSS positive score did not differ between groups after 12 weeks (adjusted mean change -5·05 [5·46] for quetiapine-ER, -6·21 [5·42] for aripiprazole; p=0·98), but decreased over time in both groups (p<0·0001). Weight gain was more rapid with quetiapine-ER (p=0·0008), with an adjusted mean weight group difference at week 12 of 3·33 kg (SD 7·23; effect size 0·64; p<0·0001). The HOMA-IR group difference at week 12 favoured aripiprazole (adjusted mean log-transformed group difference 0·259 [SD 0·906]; effect size 0·35; p=0·0060). Akathisia was more common with aripiprazole at week 2 (observed in 34 [60%] of 57 patients; estimated 63·5%) than with quetiapine-ER (15 [30%] of 50; estimated 31·3%; p=0·0021), but not at other timepoints. Sedation proportions did not change significantly over time with either intervention (observed at weeks 2, 4, and 12, respectively, for quetiapine-ER in 43 [83%] of 52, 40 [83%] of 48, and 34 [72%] of 47 patients and for aripiprazole in 49 [89%] of 55, 52 [96%] of 54, and 44 [92%] of 48 patients), and the overall estimated probability combining all timepoints was significantly higher for aripiprazole (97·1%) than for quetiapine-ER (89·2%; p=0·012). In addition to sedation and akathisia, the most common adverse events were tremor (42 [79%] patients in the quetiapine-ER group vs 52 [91%] patients in the aripiprazole group), increased duration of sleep (47 [92%] vs 39 [71%]), orthostatic dizziness (42 [78%] vs 46 [81%]), depression (43 [80%] vs 44 [77%]), tension/inner unrest (37 [69%] vs 50 [88%]), failing memory (41 [76%] vs 44 [77%]), and weight gain (46 [87%] vs 38 [68%]). INTERPRETATION This first head-to-head comparison of quetiapine-ER versus aripiprazole in early-onset psychosis showed no significant group differences in severity of psychopathology after 12 weeks of treatment. Quetiapine-ER was associated with more metabolic adverse events and aripiprazole with more initial akathisia and, unexpectedly, more sedation. The limited antipsychotic efficacy and high level of adverse events were noticeable. This trial provides novel information for the treatment of early-onset psychosis and highlights the importance of adverse event profiles when choosing among antipsychotics for children and adolescents who often require chronic treatment. FUNDING The National Research Council for Health and Disease Foundation for Health Promotion, AP Møller Foundation, Rosalie Petersens Foundation, Stevn and Rindom Foundation, Foundation for the Promotion of Medical Science, The Capital Region Psychiatric Research Foundation, Tryg Foundation, Region of Southern Denmark Research Foundation, Danish Psychiatric Research Educational Fund, Psychiatry Foundation, Foundation of 17-12-1981, Psychiatric Research Foundation Region Zealand, Capital Region Strategic Research Foundation, Knud og Dagny Andresens Foundation, Psychiatric Research Foundation of 1967, The Capital Region Research Foundation, Dr Sofus Carl Emil Friis and Hustru Olga Friis Scholarship, Tømrerhandler Johannes Fogs Foundation, Brdr Hartmanns Foundation DKK, Aase and Ejnar Danielsens Foundation, Jacob Madsen and wife Olga Madsens Foundation, CC Klestrup and wife Scholarship, Lundbeck Foundation Scholarship, and Tømrermester Jørgen Holm and wife Elisas Scholarship.
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Affiliation(s)
- Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Pia Jeppesen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Dea Gowers Klauber
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Karsten Gjessing Jensen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Rudå
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Stentebjerg-Olesen
- Psychiatric Centre Copenhagen, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark & Laboratory of Neuropsychiatry, Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Peter Jantzen
- Psychiatric Centre Sct Hans, Mental Health Services, Capital Region of Denmark, Roskilde, Denmark & Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Simone Rasmussen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Maj-Britt Glenn Lauritsen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Bilenberg
- Child and Adolescent Psychiatry Research Unit, Region of Southern Denmark, Odense, Denmark & Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Anne Dorte Stenstrøm
- Child and Adolescent Psychiatry Research Unit, Region of Southern Denmark, Odense, Denmark & Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Louise Nyvang
- Mental Health Centre for Child and Adolescent Psychiatry, Region Zealand, Roskilde, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sarah Madsen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas M Werge
- Institute for Biological Psychiatry, Psychiatric Centre Sct Hans, Mental Health Services, Capital Region of Denmark, Roskilde, Denmark & Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark; Center for Statistical Science, Peking University, Beijing, China
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria Skoog
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Richardt M Jepsen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Center for Neuropsychiatric Schizophrenia Research and Lundbeck Foundation Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research, Psychiatric Centre Glostrup, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Fagerlund
- Center for Neuropsychiatric Schizophrenia Research and Lundbeck Foundation Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research, Psychiatric Centre Glostrup, Capital Region of Denmark, Glostrup, Denmark & Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christoph U Correll
- Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark & Laboratory of Neuropsychiatry, Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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