Quality Concerns in Antipsychotic Prescribing for Youth: A Review of Treatment Guidelines

Abstract

Background Antipsychotic prescribing for youth has increased rapidly, is linked with serious health concerns, and lacks clear measures of quality for pediatric care. We reviewed treatment guidelines relevant to 7 quality concepts for appropriate use and management of youth on antipsychotics: 1) use in very young children, 2) multiple concurrent antipsychotics, 3) higher-than-recommended doses, 4) use without a primary indication, 5) access to psychosocial interventions, 6) metabolic screening, and 7) follow-up visits with a prescriber. Methods We searched for clinical practice guidelines meeting the following criteria: developed or endorsed by a national body, published after 2000, and specific treatment recommendations made related to 1 or more of the 7 quality concepts. Sources included electronic databases, the American Academy of Child and Adolescent Psychiatry Web site, and stakeholder and expert advisory committee recommendations. Two raters reviewed the 11 guidelines identified, extracting treatment recommendations, including details that could support measure definitions, and ratings of strength of recommendation and evidence. Results All 7 quality concepts were strongly endorsed by 1 or more guidelines, and 2 or more guidelines assigned their highest strength of recommendation ratings to 6 of the 7 concepts. Two guidelines rated evidence, providing high strength of evidence for 2 quality concepts: psychosocial interventions and metabolic monitoring. Conclusions Guidelines provide support for 7 quality concepts addressing antipsychotic prescribing for youth. However, guideline support is often based on strong clinical consensus rather than a robust evidence base.

Clinical use of second-generation antipsychotics in children

“…In addition, proper facilities and access to equipment for physical evaluation are of importance (46). Despite the already existing guidelines (39)(40)(41)(42), there is still a need to standardize practices concerning antipsychotic medication use in psychiatric health care units treating children. When treating children with medications of long duration that affect both physical and mental development, liaisons should be encouraged between child psychiatry and paediatric medicine and child and adult psychiatry.…”

“…All monitoring recommendations emphasize on the appropriate use of psychosocial interventions and the regular monitoring of metabolic and other adverse effects (41). The guidelines of the American Academy of Child and Adolescent Psychiatry (AACAP), the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA), and the National Institute for Health and Care Excellence (NICE) in the UK include recommendations for monitoring and managing the adverse effects of SGA in children (Table 1) (39,40,42).…”

Use of Pooled State Administrative Data for Mental Health Services Research

“…The significant increase in the use of psychotropic medication among children, including increased use of antipsychotics and multiple concurrent medications, raised quality concerns for both states (Essock et al 2009; Medicaid Medical Directors Learning Network 2010; Kealey et al 2014). NY engaged mental health clinics in a health information technology (HIT) supported (PSYCKES-Medicaid) continuous quality improvement (CQI) initiative to facilitate reduction of psychotropic polypharmacy among children, and PA introduced a prior authorization policy for the use of antipsychotic medications in children.…”

Prolactin-related adverse events and change in prolactin levels in pediatric patients given antipsychotics for schizophrenia and schizophrenia spectrum disorders: A systematic review

“…Between 1999 and 2008 antipsychotic use in Canada for patients aged 18 years or younger increased from 1.9 per 1000 to 7.4 per 1000 [6]. However, while SGAs are considered a safer alternative to FGAs due to the reduced tendency to induce adverse neurological effects, other equally problematic adverse events have been associated with SGAs, especially in the pediatric population [7]. …”