Prescription of psychiatric medications and polypharmacy in the LAMS cohort

Advances in the management of bipolar disorder in children and adolescents: an update on the literature

INTRODUCTION

Early diagnosis and treatment concerning bipolar disorder (BD) are related to a better functioning over the long-term period. Although pharmacotherapy is indicated for approximately all youths with BD, nearly one-third of patients do not receive adequate medications for their condition.

AREAS COVERED

The authors discuss the available scientific evidence from the current literature about the management of BD in both children and adolescents, giving particular focus to the efficacy and tolerability of the available pharmacological agents. Studies were identified searching MEDLINE and retrieved from reference listings of relevant articles and through consultation with experts in the field.

EXPERT OPINION

Many D2-blockers, approved by the Food and Drug Administration (FDA) based on their antimanic properties in youths, are related to both short- and long-term side effects. Lurasidone was found to be effective for the treatment of acute juvenile bipolar depression, while lithium for the treatment and recurrence prevention of manic/mixed episodes. The most common anticonvulsants were found to be most useful as adjunctive antimanic agents in non-responders to first-line monotherapies. No data was found to support the use of antidepressants in juvenile BD.

Fourteen-year trends in the prescribing patterns of pediatric bipolar patients discharged from two public mental hospitals in Taiwan

INTRODUCTION

The management of pediatric bipolar disorder (PBD) requires pharmacotherapy to control acute symptoms, reduce relapse, prevent suicide, and improve psychosocial functioning. The purpose of this study was to investigate prescribing patterns among PBD patients discharged from two public mental hospitals in Taiwan, from 2006 to 2019.

METHODS

PBD patients discharged from the two study hospitals, from 1 January 2006 to 31 December 2019 (n = 420), were included in the analysis. Prescribed drugs at discharge, including mood stabilizers (i.e., lithium, valproate, carbamazepine, and lamotrigine), antipsychotics (i.e., second- and first-generation antipsychotics, SGAs and FGAs), and antidepressants, were explored. Complex polypharmacy was defined as the use of 3 or more agents among the prescribed drugs. Time trends of each prescribing pattern were analyzed using the Cochran-Armitage Trend test.

RESULTS

The most commonly prescribed psychotropic agents were SGAs (76.0%), followed by valproate (65.7%) and FGAs (24.8%). The prescription rates of SGAs, antidepressants, antidepressant plus antipsychotic, and antidepressant without mood stabilizer significantly increased over time, whereas the prescription rates of mood stabilizers, lithium, and FGAs significantly decreased.

DISCUSSIONS

Prescribing patterns changed greatly for PBD patients over time. However, much more evidence supporting the effectiveness of psychotropic agents in PBD patients is required.

A brief motivational intervention for enhancing medication adherence for adolescents with bipolar disorder: A pilot randomized trial

BACKGROUND

Youth with bipolar disorder (BP) exhibit poor medication adherence, contributing to affective recurrence. Brief Motivational Interventions (BMIs) improve adherence among adolescents with chronic conditions.

METHODS

In an open pilot series, we developed a 3-session BMI for BP adolescents targeting medication adherence and conducted a pilot randomized trial comparing Standard Care (SC) versus SC+BMI. Participants include 43 adolescents with BP prescribed psychotropic medications. We assessed medication adherence objectively via bluetooth-enabled electronic pillbox (MedTracker). A blinded evaluator assessed mood symptoms at intake, 3- and 6-months.

RESULTS

The BMI was well-received. Average objective medication adherence increased with time in SC+BMI, but decreased in SC-Alone (p < 0.0001). Adolescents' baseline self-rated expectation of improvement with treatment moderated the effect of treatment on improvement in adherence over time (p = 0.003). Across groups, poor adherence predicted increased likelihood of depression and hypo/mania symptoms in the subsequent two weeks; medication adherence mediated the effect of the BMI on the likelihood of depressive symptoms (p = 0.007).

LIMITATIONS

Electronic pillbox use (across groups) may enhance adherence, resulting in overestimates compared with naturalistic conditions. This pilot randomized trial may have been underpowered to detect some group differences.

CONCLUSIONS

A BMI offers promise as a disseminable adjunctive intervention for improving medication adherence for adolescents with BP. Future studies with larger samples can establish efficacy. NCT03203720.

Progress in diagnosis and treatment of bipolar disorder among children and adolescents: an international perspective

Bipolar disorder (BPD) is a potentially lifelong condition characterised by extreme changes in mood that may begin in childhood and cause substantial impairment. Over the past decades, BPD has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in children and adolescents. This report addresses these controversies by reviewing the extant evidence base, providing clinicians with a summary of the literature on diagnosis, phenomenology and treatment of paediatric BPD. The debate regarding diagnosing children with BPD based on severe irritability and aggression is mostly resolved. The current data support utilising the diagnostic criteria based on episodic changes of mood polarity. Therefore, longitudinal course of illness should be explored in detail when diagnosing BPD. Given high rates of genetic predisposition for BPD, assessment of youth should focus on obtaining accurate family history of this condition. Additionally, there has been a substantial increase in randomised placebo-controlled clinical trials evaluating pharmacological agents for mood stabilisation in children and adolescents, which we summarise in this review. Despite significant progress being made in the field of paediatric BPD, more research is needed in the areas of phenomenology, pathophysiology, course and treatment of this condition in youth.

Early-Onset Bipolar Disorder: Characteristics and Outcomes in the Clinic

OBJECTIVE

To assess patient characteristics and clinician-rated outcomes for children diagnosed with early-onset bipolar disorder in comparison to a depressive disorders cohort from a single clinic site. To assess predictors of bipolar treatment response.

METHODS

Medical records from 714 consecutive pediatric patients evaluated and treated at an academic tertiary child and adolescent psychiatry clinic between 2006 and 2012 were reviewed. Charts of bipolar children (n = 49) and children with depressive disorders (n = 58) meeting study inclusion/exclusion criteria were compared on variables assessing clinical characteristics, treatments, and outcomes. Outcomes were assessed by using pre- and post-Clinical Global Impressions (CGI)-Severity and Children's Global Assessment Scale (CGAS) scores, and a CGI-Improvement score ≤2 at final visit determined responder status. Bipolar outcome predictors were assessed by using multiple linear regression.

RESULTS

Clinic prevalence rates were 6.9% for early-onset bipolar disorder and 1.5% for very early-onset bipolar disorder. High rates of comorbid diagnoses, symptom severity, parental stress, and child high-risk behaviors were found in both groups. The bipolar cohort had higher rates of aggression and higher lifetime systems of care utilization. The final CGI and CGAS outcomes for unipolar depression patients differed statistically significantly from those for the bipolar cohort, reflecting better clinical status and more improvement at outcome for the depression patients. Both parent-reported Child Behavior Checklist total T-score at clinic admission and the number of lifetime systems-of-care for the child were significantly and inversely associated with improvement for the bipolar cohort.

CONCLUSIONS

Early-onset bipolar disorder is a complex and heterogeneous psychiatric disorder. Evidence-based treatment should emphasize psychopharmacology with adjunctive family and individual psychotherapy. Strategies to improve engagement in treatment may be especially important. Given high rates of high-risk behaviors in these youth, regular mental health follow-up to assess safety is important. Additional evidence-based treatments for pediatric bipolar disorder are needed.

Longitudinal course and characteristics of cyclothymic disorder in youth

OBJECTIVES

Epidemiological studies suggest that cyclothymic disorder is the most prevalent subtype of bipolar disorder (BD). However, it is rarely diagnosed, especially in youth. This may be because it can be difficult to ascertain whether a youth meets diagnostic criteria. Clearer, easy-to-apply criteria could reduce misdiagnosis. The objective oftable this study was to determine whether proposed research diagnostic criteria for cyclothymic disorder (RDCyc), based on DSM-5 criteria, could be quantified and validated in youth.

METHODS

Participants from the Longitudinal Assessment of Manic Symptoms (LAMS) study were recruited based on symptoms of mania and followed prospectively. RDCyc criteria were: 1) At least one core symptom each of mania and depression; 2) one additional symptom of mania and of depression; 3) persistence over two consecutive six-month periods, and 4) impairment. Exclusionary criteria were having a [hypo]manic or depressive episode. Outcomes at the two-year follow-up were compared between RDCyc youth and other diagnostic groups (BD I/II, BD NOS/non-RDCyc cyclothymic disorder, disruptive behavior disorders [DBD], depression).

RESULTS

Thirty-seven youth met RDCyc criteria. There were no consistent differences between the RDCyc youth and youth with other BD subtypes (ps=0.001-0.960, with all-but-one p value >0.02). RDCyc youth had higher depression (p<0.0005) and mania scores (p=0.001), lower functioning (p=0.012), and higher suicide risk than DBD youth (p=0.001). They had higher mania scores than depressed youth (p.018).

LIMITATIONS

The majority of youth in the sample were recruited due to elevated symptoms of mania, which may limit the generalizability of the results. Youth were followed for two years, which may not be long enough to determine whether or not they will eventually develop a manic or depressive episode.

CONCLUSIONS

Applying RDCyc criteria identified youth who were similar to others with BD and were more impaired than those with DBD. Using these criteria could reduce misdiagnosis and increase our understanding of this prevalent, but largely ignored, diagnosis.

Off-Label Prescription of Psychopharmacological Drugs in Child and Adolescent Psychiatry

This study aimed to describe the frequency of off-label prescriptions of psychopharmacological drugs in a child and adolescent psychiatric setting. A cross-sectional study was conducted on November 1, 2014, including all inpatients and outpatients at the Mental Health Centre for Child and Adolescent Psychiatry, Capital Region of Denmark, aged 0 to 17 years receiving medical treatment with antidepressants, antipsychotic agents, benzodiazepines, melatonin and/or attention deficit hyperactivity disorder (ADHD) medication. We included a total of 5555 prescriptions representing 2932 patients. The main findings were that 32.3% of all prescriptions were off-label, and 41.6% of subjects received at least 1 off-label prescription. The most frequent off-label category was low age, 72.2%, meaning that the drug was not approved for the age group of the patient. The off-label rates for each drug class were as follows: melatonin, 100%; antipsychotic agents, 95.6%; benzodiazepines, 72.5%; antidepressants, 51.1%; and ADHD medication, 2.7%. Prescription of 2 or more psychopharmacological drugs per patient was common (31.5%). The group of subjects with 4 or more prescriptions (n = 36) was characterized by a higher frequency of inpatients, older age, and a different distribution of diagnoses. This study found a frequent use of off-label prescriptions when treating children and adolescents with psychopharmacological drugs other than ADHD medication. In addition, prescription of more than 1 psychotropic drug is common. These findings support the need for extending the evidence base for psychopharmacologic treatment in children and adolescents.

Disruptive Mood Dysregulation Disorder in a Community Mental Health Clinic: Prevalence, Comorbidity and Correlates

OBJECTIVE

The revision of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) added a new diagnosis of disruptive mood dysregulation disorder (DMDD) to depressive disorders. This study examines the prevalence, comorbidity, and correlates of the new disorder, with a particular focus on its overlap with oppositional defiant disorder (ODD), with which DMDD shares core symptoms.

METHODS

Data were obtained from 597 youth 6-18 years of age who participated in a systematic assessment of symptoms offered to all intakes at a community mental health center (sample accrued from July 2003 to March 2008). Assessment included diagnostic, symptomatic, and functional measures. DMDD was diagnosed using a post-hoc definition from item-level ratings on the Schedule for Affective Disorders and Schizophrenia for School-Age Children that closely matches the DSM-5 definition. Caregivers rated youth on the Child Behavior Checklist.

RESULTS

Approximately 31% of youth met the operational definition of DMDD, and 40% had Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnoses of ODD. Youth with DMDD almost always had ODD (odds ratio [OR] = 53.84) and displayed higher rates of comorbidity with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder than youth without DMDD. Caregivers of youth with DMDD reported more symptoms of aggressive behavior, rule-breaking, social problems, anxiety/depression, attention problems, and thought problems than all other youth without DMDD. Compared with youth with ODD, youth with DMDD were not significantly different in terms of categorical or dimensional approaches to comorbidity and impairment.

CONCLUSIONS

The new diagnosis of DMDD might be common in community mental health clinics. Youth with DMDD displayed more severe symptoms and poorer functioning than youth without DMDD. However, DMDD almost entirely overlaps with ODD and youth with DMDD were not significantly different than youth with ODD. These findings raise concerns about the potentially confusing effects of using DMDD in clinical settings, particularly given that DSM-5 groups DMDD with depressive disorders, but ODD remains a disruptive behavior disorder, potentially changing the decision-making framework that clinicians use to select treatments.

Child, parent, and service predictors of psychotropic polypharmacy among adolescents and young adults with an autism spectrum disorder

OBJECTIVE

This study examined the child, parent, and service factors associated with polypharmacy in adolescents and young adults with autism spectrum disorders (ASD).

METHODS

As part of an online survey examining health service utilization patterns among individuals with ASD, parents provided demographic and clinical information pertaining to their child. This included information on current medication use, as well as information on clinical services received, clinical history, and parent well-being. Analyses examined the bivariate association between individual child, parent, and service variables and polypharmacy. Variables significantly associated with polypharmacy were included in a multiple variable logistic regression.

RESULTS

Of the 363 participants sampled, ∼25% were receiving two or more psychotropic drugs concurrently. The patient's psychiatric comorbidity, history of hurting others, therapy use, and parent burden were predictors of polypharmacy.

CONCLUSIONS

Adolescents and young adults with ASD are a highly medicated population with multiple factors associated with psychotropic polypharmacy. Although there may be circumstances in which polypharmacy is necessary, a richer understanding of what predicts polypharmacy may lead to targeted interventions to better support these individuals and their families. Findings also highlight the need to support families of children with ASD prescribed multiple psychotropic medications.

Adapting the posterior probability of diagnosis index to enhance evidence-based screening: an application to ADHD in primary care

This study adapts the Posterior Probability of Diagnosis (PPOD) Index for use with screening data. The original PPOD Index, designed for use in the context of comprehensive diagnostic assessments, is overconfident when applied to screening data. To correct for this overconfidence, we describe a simple method for adjusting the PPOD Index to improve its calibration when used for screening. Specifically, we compare the adjusted PPOD Index to the original index and naïve Bayes probability estimates on two dimensions of accuracy, discrimination and calibration, using a clinical sample of children and adolescents (N = 321) whose caregivers completed the Vanderbilt Assessment Scale to screen for attention-deficit/hyperactivity disorder and who subsequently completed a comprehensive diagnostic assessment. Results indicated that the adjusted PPOD Index, original PPOD Index, and naïve Bayes probability estimates are comparable using traditional measures of accuracy (sensitivity, specificity, and area under the curve), but the adjusted PPOD Index showed superior calibration. We discuss the importance of calibration for screening and diagnostic support tools when applied to individual patients.