Prescription Pattern of Antidepressants for Children and Adolescents in Korea Based on Nationwide Data

Temporal trends of antidepressant utilization patterns in children and adolescents in Hong Kong: A 14-year population-based study with joinpoint regression analysis

BACKGROUND

There is limited research on real-world antidepressant utilization patterns in children and adolescents, particularly in non-western countries. We aimed to examine temporal trends of antidepressant prescribing practice among Chinese children and adolescents in Hong Kong over 14-year period.

METHODS

This population-based study identified 9566 patients aged 5-17 years who had redeemed at least one antidepressant prescription within 2005-2018, using data from health-record database of Hong Kong public healthcare services. We calculated annual prescription rates (per 1000 persons) for any antidepressant, antidepressant drug classes, and individual antidepressants. Joinpoint-regression analyses were performed to assess temporal antidepressant prescription trends, quantified by average annual-percent-change (AAPC), with 95 % confidence-intervals (CIs).

RESULTS

Overall antidepressant prescription rate significantly increased over time (AAPC: 7.30 [95 % CI: 6.70-7.90]), from 3.883 in 2005 to 9.916 in 2018. The use of selective-serotonin-reuptake-inhibitors (SSRIs), serotonin-norepinephrine-reuptake-inhibitors (SNRIs), and other antidepressants significantly increased over 14 years, while tricyclic-antidepressants remained stable. SSRI represented the most commonly-prescribed drug class. Fluoxetine and sertraline constituted the two most frequently-prescribed individual antidepressants, while desvenlafaxine (AAPC: 55.68 [30.74-85.39]) and bupropion (AAPC: 35.28 [23.68-47.98]) exhibited the sharpest increase in prescription rates over the study period.

LIMITATIONS

Medication adherence could not be assessed and actual drug use may be overestimated.

CONCLUSIONS

Our results affirm a significant rising trend of antidepressant prescriptions among Chinese children and adolescents over time. All antidepressant drug-classes, except TCA, demonstrated significantly increased use, with SSRI being the most frequently-prescribed drug class. Future investigation should clarify indications, hence off-label use, of antidepressant initiation in this vulnerable population.

Trends in Prescribing Antipsychotics for Children and Adolescents in Japan: A Descriptive Epidemiological Study Using a Large-Scale Pharmacy Dataset

Little is known about antipsychotic prescription patterns among children and adolescents in Japan, particularly in outpatient settings. We investigated the prevalence and trends of antipsychotic prescription for outpatients aged ≤ 17 years receiving a first antipsychotic prescription from 2006 to 2012 based on a large-scale dispensation dataset. Measurements included age, sex, department of diagnosis and treatment, type of prescription (monotherapy or polytherapy), antipsychotic dosage, and concomitant psychotropic drugs. Of the 10,511 patients, 65.1% were aged 13-17 years, and 52.9% were males. Second-generation antipsychotic monotherapy prescriptions increased from 53.8% in 2006 to 78.3% in 2012. Risperidone was the most frequently prescribed antipsychotic, followed by aripiprazole and olanzapine. Approximately 25.0% of patients were prescribed an initial dose less than recommended. Second-generation antipsychotic monotherapy is currently the most frequent prescription pattern among outpatients aged ≤ 17 years receiving an initial antipsychotic prescription.

Multi-omics reveal microbial determinants impacting the treatment outcome of antidepressants in major depressive disorder

BACKGROUND

There is a growing body of evidence suggesting that disturbance of the gut-brain axis may be one of the potential causes of major depressive disorder (MDD). However, the effects of antidepressants on the gut microbiota, and the role of gut microbiota in influencing antidepressant efficacy are still not fully understood.

RESULTS

To address this knowledge gap, a multi-omics study was undertaken involving 110 MDD patients treated with escitalopram (ESC) for a period of 12 weeks. This study was conducted within a cohort and compared to a reference group of 166 healthy individuals. It was found that ESC ameliorated abnormal blood metabolism by upregulating MDD-depleted amino acids and downregulating MDD-enriched fatty acids. On the other hand, the use of ESC showed a relatively weak inhibitory effect on the gut microbiota, leading to a reduction in microbial richness and functions. Machine learning-based multi-omics integrative analysis revealed that gut microbiota contributed to the changes in plasma metabolites and was associated with several amino acids such as tryptophan and its gut microbiota-derived metabolite, indole-3-propionic acid (I3PA). Notably, a significant correlation was observed between the baseline microbial richness and clinical remission at week 12. Compared to non-remitters, individuals who achieved remission had a higher baseline microbial richness, a lower dysbiosis score, and a more complex and well-organized community structure and bacterial networks within their microbiota. These findings indicate a more resilient microbiota community in remitters. Furthermore, we also demonstrated that it was not the composition of the gut microbiota itself, but rather the presence of sporulation genes at baseline that could predict the likelihood of clinical remission following ESC treatment. The predictive model based on these genes revealed an area under the curve (AUC) performance metric of 0.71.

CONCLUSION

This study provides valuable insights into the role of the gut microbiota in the mechanism of ESC treatment efficacy for patients with MDD. The findings represent a significant advancement in understanding the intricate relationship among antidepressants, gut microbiota, and the blood metabolome. Additionally, this study offers a microbiota-centered perspective that can potentially improve antidepressant efficacy in clinical practice. By shedding light on the interplay between these factors, this research contributes to our broader understanding of the complex mechanisms underlying the treatment of MDD and opens new avenues for optimizing therapeutic approaches. Video Abstract.

Hospitalization and emergency department visits associated with potentially inappropriate medication in older adults: self-controlled case series analysis

Introduction

Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories.

Methods

We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected..

Results

Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications.

Discussion

Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.

Acute and long-lasting effects of adolescent fluoxetine exposure on feeding behavior in Sprague-Dawley rats

The antidepressant medication fluoxetine (FLX) is frequently prescribed for the management of mood-related illnesses in the adolescent population-yet its long-term neurobehavioral consequences are not understood. To investigate how juvenile FLX exposure influences feeding behavior in adulthood, we conducted two experiments. In Experiment 1, adolescent male and female Sprague-Dawley rats were administered with 20 mg/kg/day FLX (postnatal day [PND] 35-49) and exposed to a binge access paradigm in adulthood (PND72+) to evaluate potential alterations for sweetened-fat preference. No long-term FLX-induced differences in preference for sweetened fat versus chow, nor total caloric intake, were noted; however, females displayed higher preference for sweetened fat compared to males. In Experiment 2, PND35 male rats received FLX (PND35-49) and were exposed to chronic variable stress (CVS) in adulthood (PND74-88). During treatment, FLX decreased body weight and intake (meal size), but not total meal number. Also, no differences in meal pattern parameters were observed after FLX completion. Likewise, no differences in meal pattern parameters to a palatable diet (45% fat, 17% sucrose) presented from PND74 to PND88, even after CVS, were observed. Our findings indicate that juvenile FLX reduces body weight gain acutely via reduced meal size intake; however, no long-term changes in ad libitum feeding behavior or binge access to a palatable stimulus are evident.

Effect of early-life stress or fluoxetine exposure on later-life conditioned taste aversion learning in Sprague-Dawley rats

In rodents, early-life exposure to environmental stress or antidepressant medication treatment has been shown to induce similar long-term consequences on memory- and depression-related behavior in adulthood. To expand on this line of work, we evaluated how juvenile exposure to chronic variable stress (CVS) or the selective serotonin reuptake inhibitor fluoxetine (FLX) influences conditioned taste aversion (CTA) learning in adulthood. To do this, in Experiment 1, we examined how adolescent CVS alone (postnatal day [PND] 35-48), or with prenatal stress (PNS) history (PNS + CVS), influenced the acquisition and extinction of CTA in adult male Sprague Dawley rats. Specifically, at PND70+ (adulthood), rats were presented with 0.15 % saccharin followed by an intraperitoneal (i.p.) injection of lithium chloride (LiCl) to induce visceral malaise. A total of four saccharin (conditioned stimulus) and LiCl (unconditioned stimulus) pairings occurred across the CTA acquisition phase. Next, saccharin was presented without aversive consequences, and intake was measured across consecutive days of the extinction phase. No differences in body weight gain across the experimental days, rate of CTA acquisition, or extinction of CTA, were observed among the experimental groups (control, n = 7; CVS, n = 12; PNS + CVS, n = 9). In Experiment 2, we evaluated if early-life FLX exposure alters CTA learning in adulthood. Specifically, adolescent stress naïve male and female rats received FLX (0 or 20 mg/kg/i.p) once daily for 15 consecutive days (PND35-49). During antidepressant exposure, FLX decreased body weight gain in both male (n = 7) and female rats (n = 7), when compared to respective controls (male control, n = 8; female control, n = 8). However, juvenile FLX exposure decreased body weight-gain in adult male, but not female, rats. Lastly, adolescent FLX history had no effect on CTA acquisition or extinction in adulthood (PND70), in neither male nor female rats. Together, the data indicate that juvenile FLX exposure results in a long-term decrease of body weight-gain in a male-specific manner. Yet, independent of sex, neither early-life stress nor FLX exposure alters CTA learning in adulthood.

Prescribing behavior of antidepressants for depressive disorders: A systematic review

Objective

Guidelines for the prescription of antidepressants for Depressive Disorders (DD) have been in place for a long time. However, there is a lack of systematic information on the prescribing behavior of antidepressants in evidence-based clinical practice in psychopharmacotherapy of depressive disorders. This may suggest a lack of implementation of clinical guidelines by clinicians. Existing literature mainly focuses on specific issues or medications. To provide general information on the prescribing behavior of antidepressants for depressive disorders, a systematic review of available studies since 2013 was conducted.

Methods and materials

To ensure a structured and systematic approach for the literature search and subsequent review process, the PRISMA guidelines for systematic reviews were followed. Major medical and health and psychological databases were used for the literature search. These included Ebsco Host, OVID, PubMed, Science Direct, Scopus, and Web of Science. The online application "Covidence" was employed to manage the titles collected and the full articles retrieved from the initial literature search. Upon finalizing the list of selected studies, data extraction was then conducted using a build-in function of the Covidence platform with the required information pre-set on a template for data extraction. The extracted information was tabulated and summarized in a table.

Results

Forty-one studies were identified after an extensive search of the literature following the PRISMA guidelines. Of these, 37 quantitative studies providing useful information were systematically reviewed and information extracted. There was a high level of heterogeneity among these studies with different foci or characteristics. Most studies were conducted in or utilized data obtained from hospital and primary healthcare settings. SSRIs were the most commonly prescribed type of antidepressant in the past decade, particularly among younger patients. Among these studies, antidepressants were mainly prescribed by psychiatrists with some by other physicians and general practitioners. This might reflect differences in legislation regarding professional requirements for prescribers or clinical practices.

Conclusions

A few themes that would be considered important in terms of the effect of prescription behavior on depression, specifically children/adolescents, special target populations, and off-label prescription. The results highlighted the need for more studies on a community-based approach and the role of GPs in the treatment of DD.

Effects of escitalopram therapy on resting-state functional connectivity of subsystems of the default mode network in unmedicated patients with major depressive disorder

Antidepressants are often the first-line medications prescribed for patients with major depressive disorder (MDD). Given the critical role of the default mode network (DMN) in the physiopathology of MDD, the current study aimed to investigate the effects of antidepressants on the resting-state functional connectivity (rsFC) within and between the DMN subsystems. We collected resting-state functional magnetic resonance imaging (rs-fMRI) data from 36 unmedicated MDD patients at baseline and after escitalopram treatment for 12 weeks. The rs-fMRI data were also collected from 61 matched healthy controls at the time point with the same interval. Then, we decomposed the DMN into three subsystems based on a template from previous studies and computed the rsFC within and between the three subsystems. Finally, repeated measures analysis of covariance was conducted to identify the main effect of group and time and their interaction effect. We found that the significantly reduced within-subsystem rsFC in the DMN core subsystem in patients with MDD at baseline was increased after escitalopram treatment and became comparable with that in the healthy controls, whereas the reduced within-subsystem rsFC persisted in the DMN dorsal medial prefrontal cortex (dMPFC) and medial temporal subsystems in patients with MDD following escitalopram treatment. In addition, the reduced between-subsystem rsFC between the core and dMPFC subsystem showed a similar trend of change after treatment in patients with MDD. Moreover, our main results were confirmed using the DMN regions from another brain atlas. In the current study, we found different effects of escitalopram on the rsFC of the DMN subsystems. These findings deepened our understanding of the neuronal basis of antidepressants' effect on brain function in patients with MDD. The trial name: appropriate technology study of MDD diagnosis and treatment based on objective indicators and measurement. URL: http://www.chictr.org.cn/showproj.aspx?proj=21377 . Registration number: ChiCTR-OOC-17012566.

Educational and health outcomes of children and adolescents receiving antidepressant medication: Scotland-wide retrospective record linkage cohort study of 766 237 schoolchildren

Background

Childhood depression is relatively common, under-researched and can impact social and cognitive function and self-esteem.

Methods

Record linkage of routinely collected Scotland-wide administrative databases covering prescriptions [prescribing information system (PIS)], hospitalizations (Scottish Morbidity Records 01 and 04), maternity records (Scottish Morbidity Records 02), deaths (National Records of Scotland), annual pupil census, school absences/exclusions, special educational needs (Scottish Exchange of Educational Data; ScotXed), examinations (Scottish Qualifications Authority) and (un)employment (ScotXed) provided data on 766 237 children attending Scottish schools between 2009 and 2013 inclusively. We compared educational and health outcomes of children receiving antidepressant medication with their peers, adjusting for confounders (socio-demographic, maternity and comorbidity) and explored effect modifiers and mediators.

Results

Compared with peers, children receiving antidepressants were more likely to be absent [adjusted incidence rate ratio (IRR) 1.90, 95% confidence interval (CI) 1.85–1.95] or excluded (adjusted IRR 1.48, 95% CI 1.29–1.69) from school, have special educational needs [adjusted odds ratio (OR) 1.77, 95% CI 1.65–1.90], have the lowest level of academic attainment (adjusted OR 3.00, 95% CI 2.51–3.58) and be unemployed after leaving school (adjusted OR 1.88, 95% CI 1.71–2.08). They had increased hospitalization [adjusted hazard ratio (HR) 2.07, 95% CI 1.98–2.18] and mortality (adjusted HR 2.73, 95% CI 1.73–4.29) over 5 years’ follow-up. Higher absenteeism partially explained poorer attainment and unemployment. Treatment with antidepressants was less common among boys than girls (0.5% vs 1.0%) but the associations with special educational need and unemployment were stronger in boys.

Conclusions

Children receiving antidepressants fare worse than their peers across a wide range of education and health outcomes. Interventions to reduce absenteeism or mitigate its effects should be investigated.

Comparison of risk of cardiovascular disease related adverse events between selective serotonin reuptake inhibitor users and serotonin norepinephrine reuptake inhibitor users in Korean adult patients with depression: retrospective cohort study

Serotonin norepinephrine reuptake inhibitor (SNRI) has been increasingly administered, but the associated cardiovascular disease (CVD) related adverse events risk is not clearly understood. So, we conducted a cohort study to identified CVD-related adverse events risk of SNRI comparing to selective serotonin reuptake inhibitor (SSRI). We used Korea Health Insurance Review and Assessment data. During the period from April 2009 to March 2011, patients who were prescribed SSRI or SNRI for depression, who were followed up till March 2018, were the subjects. Hemorrhagic stroke, ischemic stroke, and myocardial infarction were selected as the outcomes. High-dimensional propensity scores were used to adjust the unmeasured confounders. the cox proportional hazard model was used for the statistical analysis. A total of 1,016,136 patients diagnosed with depression over the age of 20 were screened and there were 64,739 SSRI users and 3,711 SNRI users in the group of patients. The adjusted hazard ratio did not differ between the two groups, but the subgroup analysis according to comorbidities showed a high risk of hemorrhagic stroke in SNRI users with hypertension or diabetes mellitus.

Non-pharmacological and pharmacological approaches for psychiatric disorders: Re-appraisal and insights from zebrafish models

Acute and chronic stressors are common triggers of human mental illnesses. Experimental animal models and their cross-species translation to humans are critical for understanding of the pathogenesis of stress-related psychiatric disorders. Mounting evidence suggests that both pharmacological and non-pharmacological approaches can be efficient in treating these disorders. Here, we analyze human, rodent and zebrafish (Danio rerio) data to compare the impact of non-pharmacological and pharmacological therapies of stress-related psychopathologies. Emphasizing the likely synergism and interplay between pharmacological and environmental factors in mitigating daily stress both clinically and in experimental models, we argue that environmental enrichment emerges as a promising complementary therapy for stress-induced disorders across taxa. We also call for a broader use of novel model organisms, such as zebrafish, to study such treatments and their potential interplay.

Psychotropic Medication Prescription Rates and Trends for New Zealand Children and Adolescents 2008-2016

Objectives: The prescription of psychotropic medication used to treat psychiatric disorders has increased worldwide over the past two decades and has been discussed widely in the literature; however, limited data have been available for New Zealand. The current article aimed to address this knowledge gap. Methods: Prescription data obtained from The Pharmaceutical Management Agency of New Zealand (PHARMAC) were analyzed to obtain prescription dispensing rates and trends for antidepressants, antipsychotics, anxiolytics, sedatives and hypnotics, and stimulants/attention-deficit/hyperactivity disorder medications for youth aged 0-17 years in New Zealand during 2008-2016, including a gender and ethnicity breakdown for 2016 to provide a "snapshot" of prescription demographics. These data sets contained all individual prescriptions dispensed in New Zealand during this time period, alongside a unique encrypted National Health Index number to distinguish individuals and demographic data. Results: In 2016, 2.36% of New Zealand youth, totaling 26,175 individuals, were prescribed at least one psychotropic medication, an increase of 65.03% from 2008. Rate of prescription for youth in 2016 and percentage increase since 2008 for each medication class were as follows: antidepressants: 1.07%, 78.33% increase; antipsychotics: 0.37%, 105.60% increase; anxiolytics: 0.15%, 50% increase; and sedatives and hypnotics: 0.22%, 37.50% increase. Stimulants were prescribed to 1.06% of the population, a 41.33% increase since 2011. In 2016 the number of prescriptions was split roughly equally between males and females, with more males receiving stimulant prescriptions and more females receiving antidepressant prescriptions. Stimulants were the medication most likely to be prescribed to Māori, Pacific, and Middle Eastern/Latin American/African groups, with antidepressants most likely for European and Asian groups. Māori tended to be prescribed medications at rates lower than the general population. Conclusions: Overall, prescription rates and the increase in prescription of psychotropic medication to children and adolescents in New Zealand fall within the mid range compared to other Western countries worldwide.

Management of Depression in Adolescents in Japan

Objectives: In Japan, there are currently no approved antidepressant treatments for pediatric patients with depression. This study aimed to estimate the prevalence of depression among adolescents under medical care in Japan, the pharmacological treatments used, and the perceived unmet needs among the medical specialties treating depression in the pediatric population. Methods: The study was conducted in November 2014 as an internet survey among physicians in clinical practice. It included a sample of 731 physicians with the potential to treat adolescent patients with depression and 161 physicians who had treated at least one adolescent with depression with pharmacotherapy in the previous 12 months. Of the sample of 161 treating physicians, 60 were internal medicine specialists, 73 were psychiatrists, and 28 were certified specialists from the Japanese Society of Child and Adolescent Psychiatry, Japanese Society of Psychosomatic Medicine Pediatrics, or Japanese Society of Pediatric Psychiatry and Neurology. The participants completed questionnaires concerning their patient population with depression, drug-treated population, and drugs prescribed. Results: Estimates of prevalence data indicated that there were ∼550,000 adolescent patients with depression in Japan (10% of the patient population with depression) under medical care of different medical specialties; ∼64% of these patients were receiving pharmacotherapy. Pharmacotherapy for adolescents with depression was prescribed mainly by psychiatrists (62% of prescriptions for these patients). The most common first-choice agent was sertraline (23% of respondents) followed by anxiolytics (17%) and fluvoxamine (13%), while antipsychotics were the preferred choice for 7%. Conclusion: The study indicates a high prevalence of depression among adolescents in Japan. These patients are seen by different medical specialties; the use of pharmacotherapy is relatively common and comprises various drug classes, including antidepressants, anxiolytics, and antipsychotics. This study shows that there is a medical need for approved treatments for adolescents with depression in Japan.

Characteristics of patients attending the child and adolescent psychiatric outpatient clinic in Erbil city

BACKGROUND

The Erbil psychiatric hospital is the major governmental psychiatric facility in the governorate of Erbil, the capital of the Kurdistan region in Iraq, providing services for the diagnosis, treatment and follow-up of patients from the city and its surrounding areas. The child and adolescent outpatient clinic in the hospital is for patients younger than 18 years. The objectives of this study were to explore the sociodemographic, pregnancy and birth characteristics, as well as the clinical profiles, of patients who presented to the child and adolescent psychiatric outpatient clinic to statistically estimate the frequency of various psychiatric disorders among the attendees and to test hypotheses of the association of these psychiatric disorders with sociodemographic and birth and pregnancy characteristics as reported by many previous studies but with inconsistent results.

METHODS

A descriptive consecutive cross-sectional study was conducted from October 2017 to February 2018 in the Child and Adolescent Psychiatric Outpatient Clinic in Erbil province of Iraq's Kurdistan region. The diagnostic criteria of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) were implemented. Chi-square tests were used to test the hypothesized associations.

RESULTS

Of a total of 207 patients, 142 were males and 65 were females, and most lived in low socioeconomic status. Most of the patients' fathers were school educated, and most mothers were illiterate. Consanguinity was found in 41% of the parents, 26.6% of the patients were born by caesarean section(C/S), 62.8% were nurtured exclusively by breastfeeding in their first six months after birth, 42.5% of them visited faith healers before consulting a psychiatrist, 43% had neurodevelopmental disorders, 26.6% had intellectual disabilities with behavioral and emotional comorbidities and 30.4% had other mental/behavioral disorders.

CONCLUSION

This study revealed that the child and adolescent psychiatric disorders in Erbil city are versatile and that many factors are significantly associated with them. Cultural concepts are still influential in the region in a way that can interfere with children's well-being, a situation that calls for more concern and attention.