Increasing Use of Antipsychotics in Youth

The era of antipsychotics which began in 1950 with their first use as tranquillizers, and later becoming mainstay treatment of schizophrenia, has been touching new treatment horizons during recent years. Antipsychotics have been the key component of treatment for schizophrenia and many psychiatric disorders including mood, anxiety and bipolar disorders in adults, but these agents are prescribed cautiously with limited indications in children. The developmental changes taking place in the maturing dopamine receptor pathways make the paediatric and adolescent population more vulnerable to the extrapyramidal as well as endocrine and metabolic effects implicated with antipsychotics use [1, 2]. Having equivalent efficacy but superior safety profile, make atypical antipsychotics a preferable choice over the conventional agents and their consequent use in adolescents [3]. Risperidone, Quetiapine, Aripiprazole and chlorpromazine are the noteworthy drugs that fall into the category of some of the few FDA approved antipsychotics that can be used in adolescents. The main indications for the use of antipsychotics in children and adolescents are Schizophrenia, bipolar disorder, severe behavioural problems, agitation, Tourette syndrome, autism-related irritability [4].
Over the past few years, a substantial increase in antipsychotics use has been observed, notably contributed by their off-label and nonpsychotic disorders use [5]. According to a population-based study, the new users of antipsychotics nearly doubled over a period of six years. This very study not only showed a huge increase in percentage (from 6.8% to 95.9%) of new antipsychotic users, but also the 116% increase in the popularity of these agents use in the adolescent patient population [6]. Atypical antipsychotics agents were considered for most of the patients, taking into account the choice of antipsychotics [7]. The observed increase in the trends in use of antipsychotics can be attributed to many aspects. A substantial part of this trend has been contributed by the increase in the co-prescription practice of these agents for many psychiatric disorders [5].
FDA approval of the use of antipsychotics is a breakthrough in the development of effective medication to address the challenging behaviour observed in autism [8]. Antipsychotics are now being the mainstream treatment for autism, intellectual disability and pervasive developmental disorders to alleviate aggression, irritability, tantrums and self-injurious behaviour, associated with these conditions [9]. Also, the distorted expression of psychological issues manifests as higher rates of anxiety and aggression in autistic adolescents than the general population of adolescents. Higher rates of prescribing antipsychotics to autistic adolescents as compared to other psychiatric illnesses might be related to this association [10]. Studies have shown that 16.5% of the patients were prescribed antipsychotics among the PDD patients who got psychotropic medications [11].
One of the factors contributing to increased prescribing trends of antipsychotics might be their popularity in targeting behavioural symptoms of ADHD. ADHD with a prevalence of ranging between 5% and 12%, is the most common neurodevelopmental disorder of paediatric and adolescent population [12]. Antipsychotics are being prescribed in combination not only to treat ADHD independently but have also shown their efficacy in treating the comorbidities commonly associated with ADHD. Despite the conflicting role of antipsychotics in precipitation or exacerbation of tic disorder, antipsychotics are frequently prescribed in ADHD [13].
Antipsychotic agents specifically Risperidone and Aripiprazole have been found effective in improving attention, hyperactivity and cognitive functioning [14]. Although stimulants still remain the first line treatment of ADHD, studies suggest a combined use of stimulants and antipsychotics as an effective treatment of ADHD [14]. Because of the strong association of ADHD with comorbidities like depression, oppositional defiant disorder, mood and conduct disorder in adolescents, antipsychotic agents are being frequently prescribed.
Antipsychotics agents, specifically atypical agents because of their lower incidence of extrapyramidal side effects and comparable efficacy are considered standard therapy for schizophrenia in children in adolescents. FDA approval of Risperidone, Aripiprazole, Quetiapine, Paliperidone, Olanzapine and other antipsychotic medications for schizophrenia has prompted increased use of antipsychotics in youth [15].
Suicide is one of the leading causes of deaths in adolescent and having comorbidities with psychiatric illness puts a patient on the increased risk of suicide and suicidal behaviour. Aggression whether as an independent factor or in association with schizophrenia has strong relation with suicidal behaviour [16]. Atypical antipsychotics have been found effective in addressing suicidal behaviour in schizophrenics [17]. That might be the reason behind their popularity among the adolescent population.
In addition to challenging behaviour, antipsychotics are being prescribed for other psychotic and affective disorders in patients with intellectual disabilities [8]. Also, there has been increased use of antipsychotic agents in adolescents for disruptive behaviour because of their efficacy [18].
Atypical antipsychotics are frequently prescribed as an effective treatment for bipolar disorder in adolescents [19]. In addition to the traditional use of antipsychotics, these agents are getting popularity to address many symptoms of the eating disorder, post-traumatic disorder and obsessive-compulsive disorder in adolescents. The observed increase in the use of antipsychotic medications in adolescents necessitates more studies to be done to evaluate the safety profile and other effects implicated with antipsychotics.

 

Monitoring Editor: Rikinkumar S. Patel MD, MPH

Author: Dr. Hina Saeed MD

Author Affiliation: Baqai Medical University, Karachi (Pakistan )

Correspondence on Email: hinasadeel@gmail.com

References: are available on request

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