Antipsychotics in Kids: Best Practices Followed Half the Time

Megan Brooks

March 04, 2015

Physicians follow "best practice" guidelines when prescribing antipsychotics to children and adolescents only about half the time, with failure to monitor cholesterol and blood sugar levels their main misstep, new research shows.

The survey also found that antipsychotics are often prescribed for non–US Food and Drug Administration (FDA)–indicated uses but typically only after other types of pharmacologic and nonpharmacologic treatments are tried first.

The survey, published online March 2 in Pediatrics, was conducted by David Rettew, MD, of the University of Vermont, in Burlington, and fellow members of a Vermont state task force that tracks psychiatric medication use in young people.

The study's aim was to examine whether the right youth are being prescribed the right medications at the proper time in their treatment.

"Knee Jerk" Prescribing?

"Part of our concern is that these medicines may be getting pulled out too early in the treatment planning for things like oppositional behavior, ahead of things like behavioral therapy that could be tried first," Dr Rettew said in a statement.

The researchers surveyed prescribers of every antipsychotic medication penned during a 4-month period in 2012 for Medicaid patients younger than 18 years. Risperidone (Risperidal, Janssen Pharmaceuticals, Inc), quetiapine (Seroquel, AstraZeneca Pharmaceuticals LP) and aripiprazole (Abilify, Otsuka Pharmaceuticals Co, Ltd) topped the list.

The survey had a response rate of 80%, yielding 677 surveys submitted by 147 physicians who wrote prescriptions for 647 individual young people. Each prescription prompted a separate survey; thus, prescribers with multiple patients taking antipsychotic medications received a separate survey for each patient. The patients' mean age was 13.2 years, and 70% were male.

Combining patient age, specific medication used, and diagnosis, antipsychotic prescriptions followed indications approved by the FDA in only 27.2% of cases.

The clinical indication for the antipsychotic prescription followed "best practice" guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) in 91.7% of cases. But after combining different criteria, such as age, number of antipsychotic medications, and metabolic monitoring, the overall rate of best practice prescribing was only 50.1%.

The AACAP best practices guidelines advise that children who have not been diagnosed with schizophrenia or other major mental illness but who present with other types of behavioral problems, such as aggression, eating disorders, or oppositional defiant disorder, can be treated with antipsychotics after they fail to respond to other medications or nonpharmacologic therapies.

Who Followed the Guidelines?

Psychiatrists were significantly more likely to follow best practice guidelines than nonpsychiatrists. Antipsychotic medications were typically prescribed only after other pharmacologic and nonpharmacologic treatments were ineffective, although previous treatment with cognitive-behavioral therapy was uncommon (15.5%). Metabolic monitoring that included serial laboratory tests was reported in 57.2% of cases.

Psychiatrists or psychiatric nurse practitioners made up 45.1% of the individual prescribers surveyed (22.2% were child psychiatrists), and they wrote 65.2% of the antipsychotic prescriptions. About half of the prescribers (52.2%) were primary care doctors, including pediatricians (30.6%) and family physicians (16.0%).

A "large" minority (42.4%) of prescriptions were initiated by someone other than the current prescriber, most often (66.2%) by a psychiatrist or psychiatric nurse practitioner, and 31.8% were started in an inpatient or residential facility.

By a wide margin, aggression and mood instability were the top reasons for starting an antipsychotic. Other medications, such as stimulants and antidepressants, were often tried first. In only 5.4% of the cases was an antipsychotic medication used as a first-line pharmacologic treatment.

Overall, these data suggest that antipsychotics are not being used "casually or in a 'knee-jerk' manner for relatively low-level behaviors," the authors write. The results also suggest that when an antipsychotic is prescribed off label or for non-first-line indications, it is given only after other medications and nondrug therapies have failed.

They note potential initiatives that could assist doctors prescribing antipsychotics include use of electronic medical records to remind doctors of the necessary blood work; increased access to evidence-based therapies that can help alleviate anxiety, depression, and oppositional behavior; better training and consultation for doctors who do not initially prescribe the medicine but are responsible for monitoring patients receiving it; and improved access to medical information across centers, so that doctors who prescribe the medications know the history of prior treatment.

The researchers note that in Vermont, use of antipsychotics for pediatric patients is declining. Since 2009, the prescription rate has fallen by 45% for children aged 6 to 12 years, and by 27% for those aged 13 to 17 years.

This research was supported by the Department of Vermont Health Access and the Vermont Child Health Improvement Program. Dr Rettew receives royalties from WW Norton & Company and Psychology Today. The other authors have disclosed no relevant financial relatinships.

Pediatrics. Published online March 2, 2015. Abstract

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