Diagnoses and Antipsychotic Treatment Among Youths in a Public Mental Health System

System struggles and substitutes: A qualitative study of general practitioner and psychiatrist experiences of prescribing antipsychotics to children and adolescents

There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians' experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers' experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.

Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis

OBJECTIVE

Although irritability and aggression are relevant treatment targets in autism spectrum disorders (ASDs) and intellectual disability (ID) that may prompt antipsychotic use, antipsychotic prescribing patterns in such youth have not been systematically reviewed.

METHOD

We systematically searched PubMed/MEDLINE/PsycInfo until March 2015 for studies reporting data on the frequency of youth diagnosed with ASDs and/or ID among antipsychotic-treated youth, as well as antipsychotic use in youth with ASD/ID, conducting a meta-analysis and meta-regression analysis of potential moderators, including publication year, study time point, country, setting, sample size, age, sex, and race/ethnicity.

RESULTS

A total of 39 studies were meta-analyzed (n = 365,449, age = 11.4 ± 6.2 years, males = 70.0% ± 10.0%). Among 27 studies (n = 273,139, age = 11.9 ± 8.0 years, males = 67.0% ± 12.9%) reporting on antipsychotic-treated youth, 9.5% (95% CI = 7.8%-11.5%) were diagnosed with ASD/ID. In 20 studies (n = 209,756) reporting data separately for ASD, 7.9% (95% CI = 6.2%-9.9%) had an ASD diagnosis. In 5 longitudinal studies, the proportion of antipsychotic-treated youth with ASD did not change significantly from 1996 to 2011 (6.7% to 5.8%, odds ratio = 0.9, 95% CI = 0.8-1.0, p =.17). However, later study time point moderated greater ASD/ID proportions (β = 0.12, p < .00001). In 13 studies (n = 96,688, age = 9.8 ± 1.2 years, males = 78.6% ± 2.0%) reporting on antipsychotic use in ASD samples, 17.5% (95% CI = 13.7%-22.1%) received antipsychotics. Again, later study time point moderated higher antipsychotic use among patients with ASD (β = 0.10, p = .004).

CONCLUSION

Almost 1 in 10 antipsychotic-treated youth were diagnosed with ASD and/or ID, and 1 in 6 youth with ASD received antipsychotics. Both proportions increased in later years; however, clinical reasons and outcomes of antipsychotic use in ASD/ID require further study.

Antipsychotic use in children and adolescents: a 1-year follow-up study

OBJECTIVE

The objective of this study was to analyze the initial treatment with antipsychotics (APs) and its changes during the first year of treatment in patients visited in specialized child and adolescent psychiatry departments.

METHODS

Participants were 265 patients, aged 4 to 17 years, who attended consecutively at 4 different centers and were naive of AP or quasi-naive (less than 30 days since the beginning of AP treatment). Type of AP, dosage, and concomitant medication were registered at baseline, 1, 3, 6, and 12 months after beginning the treatment with AP.

RESULTS

At baseline, the patients' mean age was 14.4 (2.9) years, and 145 (54.7%) patients were males. Antipsychotics were more prescribed in the following: schizophrenia spectrum disorders (30.2%), disruptive behavior disorders (DBDs) (18.9%), bipolar disorders (14.3%), depressive disorders (12.8%), and eating disorders (11.7%). A total of 93.2% of the patients were on an off-label indication of AP. Risperidone was the AP most prescribed in all the assessments, but differences were observed in the type of AP according to diagnosis. Thus, risperidone was significantly most prescribed in patients with DBD and olanzapine was most prescribed in patients with eating disorders. Olanzapine and quetiapine were the second-generation APs (SGAs) most prescribed after risperidone, and haloperidol was the most prescribed first-generation AP. Up to 8.3% of patients during the follow-up were on AP polypharmacy. Almost 16% patients had a change in its AP treatment during the follow-up, and the main switch was from one SGA to another.

CONCLUSIONS

Second-generation APs were the APs most prescribed in our sample and approximately 93% of the patients used AP off-label. Risperidone was the most common AP used above all in patients with DBD, whereas olanzapine was most prescribed in patients with eating disorders. Antipsychotic polypharmacy and switch rates were low during the follow-up.

Trends, correlates, and disease patterns of antipsychotic use among children and adolescents in Taiwan

PURPOSE

We used Taiwan's population-based National Health Insurance database to investigate the trends, correlates, and disease patterns of antipsychotic use among children and adolescents.

METHODS

The National Health Research Institutes provided a database of 1,000,000 random subjects for study. We chose subjects who were aged 18 years or younger during 1997-2005. In this sample, subjects who were given at least one antipsychotic prescription, including first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs), were identified. Trends, prevalence, and associated factors of antipsychotic use were determined. The proportion of antipsychotic use for psychiatric and medical disorders was also analyzed.

RESULTS

The 1-year prevalence of SGA use increased from 0.00 % in 1997 to 0.09 % in 2005, whereas the 1-year prevalence of FGA use ranged from 2.24 to 3.43 % during this same period, with no significant change. Age and male gender were associated with higher SGA use. Among SGA users, the greatest proportion suffered from psychiatric disorders, including tics, hyperkinetic syndrome of childhood, schizophrenia, affective disorders, and autism. Among FGA users, a larger proportion was for medical conditions, including diseases of the digestive and respiratory systems.

CONCLUSION

The prevalence of pediatric SGA use increased greatly from 1997 to 2005. Among pediatric subjects using antipsychotics, SGAs were mostly used for psychiatric disorders, whereas FGAs were mostly prescribed for medical conditions. Future research will focus on indication, dosage, frequency, duration, adverse effects, and off-label use of antipsychotics in the pediatric population.

Pharmacoepidemiology of antipsychotic use in youth with ADHD: trends and clinical implications

Although concern has been raised about antipsychotic prescribing to youth with attention-deficit/hyperactivity disorder (ADHD), the available database is limited to individual studies. Therefore, in order to provide a synthesis of prevalence and time trends, we conducted a systematic review and pooled analysis of pharmaco-epidemiologic data on antipsychotic use in ADHD youth. Of 1806 hits, 21 studies (N) were retained that reported analyzable data for three separate populations: 1) antipsychotic-treated youth (N = 15, n = 341,586); 2) ADHD youth (N = 9, n = 6,192,368), and 3) general population youth (N = 5, n = 14,284,916). Altogether, 30.5 ± 18.5% of antipsychotic-treated youth had ADHD. In longitudinal studies, this percentage increased over time (1998-2007) from 21.7 ± 7.1% to 27.7 ± 7.7%, ratio = 1.3 ± 0.4. Furthermore, 11.5 ± 17.5% of ADHD youth received antipsychotics. In longitudinal studies, this percentage also increased (1998-2006) from 5.5 ± 2.6% to 11.4 ± 6.7%, ratio = 2.1 ± 0.6. Finally, 0.12 ± 0.07% of youth in the general population were diagnosed with ADHD and received antipsychotics. Again, in longitudinal studies, this percentage increased over time (1993-2007): 0.13 ± 0.09% to 0.44 ± 0.49%, ratio = 3.1 ± 2.2. Taken together, these data indicate that antipsychotics are used by a clinically relevant and increasing number of youth with ADHD. Reasons for and risk/benefit ratios of this practice with little evidence base require further investigation.

Prescribing trends of antipsychotics in youth receiving income assistance: results from a retrospective population database study

BACKGROUND

Prescribing of antipsychotics (AP) to young people has increased in the last decade internationally. We aimed to characterize AP prescribing in a population of low-income youth in Nova Scotia, Canada.

METHODS

We conducted a population database study of AP prescription claims and health services utilization by young people aged 25 years and younger receiving drug benefits through the publicly funded Pharmacare program between October 1, 2000 to September 30, 2007.

RESULTS

Four percent (1715/43888) of youth receiving Pharmacare benefits filled AP prescriptions. The use of second generation antipsychotics (SGAs) significantly increased (p < 0.0001) in all age groups except 0-5 year olds, whereas first generation antipsychotic use significantly decreased. Pharmacare beneficiaries aged 21-25 years represented 45.2% of AP users. The majority (66%) of youth filling AP prescriptions had 2 or more psychiatric diagnoses. Most youth (76%) filled prescriptions for only one type of AP during the study period. Psychotic disorders were the most common indication for AP use except with risperidone, in which ADHD was the most likely reason for use. Co-prescribing of psychotropics was prevalent with antidepressants and mood stabilizers prescribed in 42% and 27% of AP users, respectively. General practitioners (GPs) prescribed incident APs most often (72%) followed by psychiatrists (16%). The age- and gender-adjusted rate of death was higher in AP users as compared to the age-matched general population of Nova Scotia.

CONCLUSIONS

SGA use increased significantly over seven years in a cohort of 0 to 25 years olds receiving Pharmacare benefits. Off-label use of APs was prevalent with ADHD and other non-psychotic disorders being common reasons for AP use. GPs initiated most AP prescriptions. Co-prescribing of other psychotropics, especially antidepressants and mood stabilizers, was prevalent even in younger age strata. This study raises further questions about AP prescribing in those 25 years of age and under, especially given the range of diagnoses and psychotropic co-prescribing.

Evidence review and clinical guidance for the use of ziprasidone in Canada

While indicated for schizophrenia and acute mania, ziprasidone's evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success.

Clinical characteristics of children receiving antipsychotic medication

This study explored the demographic and diagnostic features of children who were currently receiving antipsychotics compared to children who were receiving other psychotropics in a cohort of children with and without elevated symptoms of mania (ESM). Participants were recruited from 10 child outpatient mental health clinics associated with four universities. Guardians with children between 6-12 years who presented for new clinical evaluations completed the Parent General Behavior Inventory-10 Item Mania Scale (PGBI-10M). All children who scored ≥12 on the PGBI-10M and a select demographically matched comparison group of patients who scored ≤11 were invited to participate. Children were divided into two groups: those receiving at least one antipsychotic medication and those receiving other psychotropic medications. The groups were compared on demographics, diagnoses, psychiatric symptoms, functioning, and past hospitalizations. Of the 707 children enrolled in the Longitudinal Assessment of Manic Symptoms (LAMS) study, 443 (63%) were prescribed psychotropic medication at baseline: 157 (35%) were receiving an antipsychotic and 286 (65%) were prescribed other agents. Multivariate results indicated that being prescribed antipsychotics was related to being white, previous hospitalization, having a psychotic or bipolar 1 disorder and the site where the child was receiving services (p<0.001). In this sample, it is relatively common for a child to be prescribed an antipsychotic medication. However, the only diagnoses associated with a greater likelihood of being treated with an antipsychotic were psychotic disorders or unmodified DSM-IV bipolar 1 disorder.

Exposure to antipsychotic medications over a 4-year period among children who initiated antipsychotic treatment before their sixth birthday

PURPOSE

This study aims the following: (i) to describe the exposure to antipsychotic medications over a 4-year period experienced by a cohort of children who initiated antipsychotic treatment before their sixth birthday; and (ii) to identify variables associated with the risk of antipsychotic exposure.

METHODS

Children were identified who initiated an index episode of antipsychotic treatment before their sixth birthday in Florida's fee for service Medicaid program. With the use of claims data, the medication utilization of these children was tracked during the year before and the 4 years following the start of their index episodes (pre-index and four post-index periods). Generalized estimating equations were used to identify variables associated with the risk of additional days of antipsychotic exposure.

RESULTS

Five hundred twenty-eight children were included in the cohort. The mean total number of days of exposure was 821.9 (± 431.9), representing 56.3% of all days during the four post-index periods. The mean days of exposure to combinations of antipsychotics and other classes of psychotherapeutic medications were 623.8 ± 447.6 days. Children with primary diagnoses of pervasive developmental disorders and affective disorders were at greater risk of additional days of exposure than children with attention deficit/hyperactivity disorder. Exposure tended to be greater among children with indicators of clinical complexity including the presence of secondary diagnoses and the use of other classes of psychotherapeutic medications in addition to antipsychotics.

CONCLUSIONS

Exposure to antipsychotic mediations was extensive. Although these children may have had complex and severe problems, additional research is urgently needed on the benefits and risks of long-term antipsychotic exposure among very young children.

Early diagnoses and psychotherapeutic medication treatment experiences of a cohort of children under 6 years old who received antipsychotic treatment in Florida's Medicaid program

OBJECTIVE

To describe the diagnostic characteristics and psychotherapeutic medication experiences of a cohort of children who received antipsychotic treatment before their sixth birthday.

METHODS

Children enrolled in Florida's Medicaid program were identified as having initiated an index episode of antipsychotic treatment before their sixth birthday. The characteristics of these children were compared to nonrecipients who were less than 6 years old on January 1, 2004. An index episode is described as the filling of at least two consecutive antipsychotic prescriptions with a gap no greater than 15 days between the last day supplied of the first prescription and the fill date of the second prescription. We describe the diagnoses and psychotherapeutic medication experiences of these children during the 365 days before the start of their index episodes (preindex periods) and during the 365 days immediately after the start of their index episodes (index periods).

RESULTS

Five hundred twenty-eight recipients were identified. Recipients were more likely than nonrecipients to be male, to be older, and to have a supplemental security income enrollment status. Recipients were exposed to psychotherapeutic medications at very early ages. Four hundred thirty-nine (83%) had already been treated with some psychotherapeutic medication during their preindex periods. Of these children, 303 (69%) filled at least one prescription for an antipsychotic medication. Index antipsychotic episodes were often lengthy. Mean ± standard deviation and median episode lengths were 266.9 ± 286.8 and 174 days, respectively. During the index periods half of the children were found to have attention-deficit/hyperactivity disorder and 18% had disruptive behavior disorders. Treatment during these periods included other classes of psychotherapeutic medications for 73% of children. Nearly 30% (29.6%) received two or more classes of medications in addition to antipsychotics.

CONCLUSIONS

We found a large group of very young children who were persistently treated with antipsychotic medications. This early and extensive exposure is a cause for concern.

Multiple psychiatric diagnoses common in privately insured children on atypical antipsychotics

OBJECTIVE

To evaluate the prevalence of atypical antipsychotic use in privately insured children and the diagnoses associated with treatment.

STUDY DESIGN

Claims were used to conduct a retrospective cohort study of children aged 2 through 18 years in the Midwest, covered by private insurance between 2002 and 2005 (n = 172,766). The 1-year prevalence of children receiving atypical antipsychotics was determined along with associated diagnoses.

RESULTS

The 1-year prevalence of atypical antipsychotics ranged from 7.9 per 1000 in 2002 to 9.0 in 2005. The leading diagnoses were disruptive behavior disorders (67%), mood disorders (65%), and anxiety disorders (43%).The authors found that 75% of children on atypical antipsychotics had more than one psychiatric diagnosis.

CONCLUSIONS

Atypical antipsychotic use is primarily seen in children who have multiple psychiatric diagnoses. Studies are needed to assess the long-term safety and effectiveness in such patients with multiple diagnoses.

Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies

OBJECTIVE

To review findings from pharmaco-epidemiological studies exploring antipsychotic (AP) drugs prescribing trends.

METHOD

We retrieved original studies that explored AP prescribing trends in general population samples since 2000. For each study, we extracted information on sampling method, period, assessment of AP use and corresponding estimates (incidence rates, prevalence rates, pharmacy sales, prescription data) and diagnostic assessment.

RESULTS

Nearly all studies meeting the inclusion criteria (n = 17) showed an increase in AP prescriptions, mainly because of a dramatic rise in second-generation antipsychotics (SGAP) prescriptions. APs are often prescribed for non-psychotic disorders in adults as well as in children and adolescents.

CONCLUSION

Considering the growing number of persons from the general population exposed to APs, population studies assessing the risk/benefit ratio of SGAP use in disorders other than psychosis are necessary, particularly in children and adolescents.

One-year incidence rates of tardive dyskinesia in children and adolescents treated with second-generation antipsychotics: a systematic review

OBJECTIVE

The aim of this study was to assess the 1-year risk of second-generation antipsychotics (SGAs) for tardive dyskinesia (TD) in children and adolescents with assumed minimal past exposure to first-generation antipsychotics.

METHOD

We performed a systematic review and exploratory meta-analysis of long-term studies with SGAs, lasting at least 11 months and reporting on new cases of TD in patients less than 18 years old.

RESULTS

In 10 studies, 783 youth (mean age: 9.74 years, 79.2% prepubertal, 81.6% male, 78.4% white) received risperidone (n = 737, mean dose: 1.58 mg/day), quetiapine (n = 27, mean dose: 378.7 mg/day), or olanzapine (n = 19, mean dose: 10.4 mg/day) for a weighted mean of 329.6 days. Diagnoses included disruptive behavior disorders (n = 688, 87.9%), bipolar disorder (n = 52, 6.6%), schizophrenia/schizoaffective disorder (n = 26, 3.3%) and autism spectrum disorders (n = 17, 2.2%). Eight studies were open-label trials, two were retrospective chart reviews, and none included a comparator. Overall, three new cases of TD emerged during long-term treatment with SGAs of up to 3 years, resulting in crude and annualized TD rates of 0.38% (95% confidence interval, CI, 0.079-1.11) and 0.42% (95% CI, 0.087-1.24). The crude and annualized TD rates for risperidone (n = 737) were 0.27% (95% CI, 0.033-0.97) and 0.30% (95% CI, 0.037-1.10), respectively. In the two cases with information, TD resolved within weeks after antipsychotic discontinuation.

CONCLUSIONS

Results across 10 studies suggest relatively low 1-year TD rates in pediatric patients treated with SGAs. However, the available data base is limited by the small sample size of studies with SGAs other than risperidone and by the use of relatively low doses, which may have obscured a potentially greater risk for TD in children and adolescents treated with higher total SGA doses and for longer durations. Large, long-term studies of various SGAs, using state-of-the art methodology, are needed before firm conclusions can be reached about the risk of TD in pediatric patients treated long-term with SGAs.

Safety and Usage of Atypical Antipsychotic Medicines in Children

OBJECTIVE

To study the safety and usage of atypical antipsychotic medicines in post-marketing use in a nationwide paediatric population.

DESIGN

Prospective observational cohort study using prescription event monitoring and record linkage.

POPULATION

New Zealand children aged < or =15 years, who were prescribed atypical antipsychotic medicines between April and July 2003.

OUTCOMES

Usage measures included prescription data for each medication, the diagnosis for which the patient was being treated and main target symptom. Safety outcome measures were all new clinical adverse events between the start of treatment (which could be before April 2003) and 30 November 2004.

RESULTS

The cohort included 420 children aged 2-15 years. Total exposure to atypical antipsychotic medicines was 641.2 patient-years of treatment with most (94%) of the exposure being to risperidone. The most common diagnoses were disruptive disorders. The symptoms most frequently targeted by the atypical antipsychotic were aggression and difficult behaviour. The treatment of sleep disorders as a target symptom was reported in 3% of children. A total of 131 (31%) children experienced an adverse event. The most frequent adverse events reported were weight gain, severe dental caries and somnolence. The incidence of diabetes mellitus was 4 (95% CI 0.5, 15) cases per 1000 patient-years of treatment in this study. Four children prescribed risperidone developed symptoms of depression, giving an incidence of 8 (95% CI 2.0, 21) cases per 1000 patient-years of treatment.

CONCLUSIONS

This study provides a picture of 'real-life' use of atypical antipsychotics in a nationwide cohort of children. Most prescriptions were for risperidone and the most common diagnoses were disruptive disorders. Investigation of the symptoms targeted by these medicines identified unexpected use for the treatment of sleep disorders. Regarding safety, symptoms of depression were identified as a potential new signal for risperidone in the paediatric population. Further research is now required to investigate this.