A cross-sectional observational study of healthcare professional views of factors affecting teenage adherence with antipsychotic medication

Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012-2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms "disruptive behaviour disorder", "oppositional defiant disorder", "conduct disorder" and their variants, along with "antipsychotic", "atypical antipsychotic" and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

Information for children and young people about reporting suspected adverse drug reactions

BACKGROUND

When children and young people (CYP) report their own suspected adverse drug reactions (ADRs), different patterns of drugs and symptoms are noted. A new guide to reporting suspected ADRs using the Medicines and Healthcare Products Regulatory Agency (MHRA) Yellow Card scheme was developed by CYP, paediatric clinical pharmacology, Yellow Card Centres and the MHRA.

METHODS

An anonymous quality improvement project to assess the guide for CYP was undertaken (September 2020-February 2021).

RESULTS

The survey was completed by 234 CYP age 13-18 years. Within respondents, 68/226 (30.1%) were using medicines, 209/225 (92.9%) had used medicines previously, and 211/225 (93.8%) had heard of side effects. 79/225 (35.1%) believed they had experienced a side effect, with some requiring hospitalisation. Only 8/221 (3.6%) respondents were aware of the MHRA Yellow Card scheme.Overall, 182/196 (92.9%) of CYP both understood the guide and felt more knowledgeable about how to report suspected side effects. CYP comfortable to report their own suspected ADR increased from 179/222 (80.6%) before reading guide, to 189/196 (96.4%) after reading the new CYP guide. In addition, 156/196 (79.6%) believed they would report a side effect from a medicine used in future. Over 360 free-text comments were also received, providing comments about what was good about the new guide and areas for improvement that could be made.

CONCLUSION

The new guide for CYP to inform them about how to report a suspected ADR to the MHRA was well received and increased the knowledge, and confidence to report, in those who responded.

Clinicians' views of treatment types for first episode psychosis delivered in a randomised controlled trial (MAPS)

BACKGROUND

Clinicians' treatment beliefs could affect the feasibility of delivering different treatments in a randomised controlled trial (RCT). In MAPS (Managing Adolescent first Episode Psychosis: a feasibility Study), adolescents with first episode psychosis (FEP) were randomly allocated to receive either antipsychotic medication (AP), psychological intervention (cognitive behavioural therapy [CBT] and family intervention [FI]), or both. We conducted a nested qualitative study to investigate clinicians' views of these treatments.

METHODS

Purposive sampling identified seventeen clinicians from CAMHS and Early Intervention services with prescribing responsibilities for 14-18 year olds at three participating MAPS sites. Individual participants were interviewed to examine their views of treatments in the MAPS trial. Interview transcripts were analysed using inductive Thematic Analysis.

FINDINGS

Clinicians viewed the decision to refer adolescents to the MAPS trial as requiring careful clinical judgement. Assessment complexity and diagnostic uncertainty had to be balanced against the urgency for treatment to reduce risk and distress. Underlying influences including duty of care and treatment beliefs underpinned decisions. Clinicians consistently valued AP as the primary treatment for FEP, with CBT and/or FI seen as helpful secondary treatment options. Nevertheless, the potential harms of prescribing AP, or not, to such a young population were highlighted as being of concern in treatment decision-making, and fostered reluctance to refer into a RCT.

INTERPRETATION

The design and delivery of RCTs involving young people experiencing FEP should consider the views of responsible clinicians, recognising that perceived treatment urgency, limitations in diagnostic precision, and existing treatment beliefs may influence trial processes.

FUNDING

NIHR HTA programme (project number 15/31/04).

An Investigation of Cardiovascular Risks in a Group of Children and Adolescents Who Use Atypical Antipsychotics

This study was conducted to identify the metabolic parameters and body measurements associated with cardiovascular risks in a group of children and adolescents who as part of inpatient treatment received atypical antipsychotics at a psychiatric hospital in Turkey. Body mass indexes (BMIs), waist circumferences (WCs), diastolic blood pressures (DBPs), systolic blood pressures (SBPs) and heart rates (HRs) of the patients were evaluated during hospitalization and at discharge. A statistically significant difference was found among the mean BMIs, WCs, DBPs and HRs of the patients at the stages of their hospitalization and discharge (p < 0.05). On the basis of the study findings, it is recommended that mental health nurses evaluate these risk factors in children and adolescents and provide education on this subject to the patients and their families.

Psychotropic induced sexual dysfunction for people with a dual diagnosis

Purpose

– The purpose of this paper is: first, to consider the reported problems in sexual function caused by psychotropic medication. Second, the complex undertaking of completing an assessment of sexual functioning. Third, the role of the pharmaceutical industry is explored. Finally, implications for future research and practice are suggested.

Design/methodology/approach

– As a commentary this paper draws on the available literature to synthesise what is already known about the relationship between psychoactive substances and sexual functioning.

Findings

– The limited literature and lack of research attention given to psychotropic induced sexual dysfunction limits our collective understanding of how many people are affected and in what way.

Research limitations/implications

– A greater focus on psychotropic induced sexual dysfunction is needed for people with a dual diagnosis. There has been an over reliance on single case studies and self-reporting. Large scale epidemiological investigation would help understand the extent and nature of the problem more fully. The demographic shift particularly in relation to an ageing population should be considered as psychotropic substances effect individuals in different ways as they grow older.

Practical implications

– There is scope for workers to engage more fully in a conversation with clients about their experience of using psychotropic substances and how this has impacted their sexual functioning. The literature suggests that clients want to talk about this issue but staff are unwilling or unable to discuss the topic.

Originality/value

– To the authors’ knowledge this is the first paper that draws on the available literature to explore the known and likely implications of psychotropic induced sexual dysfunction for this client group.