James C. MacIntyre

Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part I: a review

OBJECTIVES To review the evidence for the safety and efficacy of nonpharmacological and pharmacological treatments for aggression in children and adolescents. METHOD and searches (1990-present) were conducted for double-blind, placebo-controlled studies of atypical antipsychotics for aggression and for literature on the use of other pharmacological agents and psychosocial interventions for aggression. Case reports and adult literature regarding the safety of atypical antipsychotics were used where controlled data for youth were lacking. RESULTS Controlled data on the treatment of aggression in youth is scarce. Psychosocial interventions may be effective alone or in combination with pharmacological treatments. Psychotropic agents (e.g., stimulants, mood stabilizers, beta-blockers) have also been shown to have limited efficacy in reducing aggression. Antipsychotics, particularly the atypical antipsychotics, show substantial efficacy in the treatment of aggression in selected pediatric populations. Atypical antipsychotics are generally associated with fewer extrapyramidal symptoms than are typical antipsychotics. CONCLUSIONS Psychosocial interventions and atypical antipsychotics are promising treatments for aggression in youth. Double-blind studies should examine the safety and efficacy of atypical antipsychotics compared to each other and to medications from other classes, the efficacy of specific medications for different subtypes of aggression, combining various psychotropic medications, optimal dosages, and long-term safety.

Psychotropic Medications Prescribing Patterns for Children and Adolescents in New York's Public Mental Health System

Context: Breakthroughs in the development of effective medications for a number of psychiatric disorders have led to increased use of these compounds in the treatment of children. Objectives: To understand the use of psychotropic medications in the treatment of children, a state-wide study was undertaken based on the data collected in a large planning study. Data and Setting: A stratified random sample of 10 different program types in New York State produced data on children served in different specialty mental health services. Participants: Randomly selected cases were reviewed at a randomly selected sites to generate a sample of 1592 cases on which data were collected on clinical presentation and service use, including psychotropic medication prescriptions. Main Outcome Measures: The Child and Adolescent Needs and Strengths (CANS-MH) tool was used to provide a reliable review of clinical indicators. Results: Psychotropic medication use is common in the childrens public mental health service system in New York. Most children served in high intensity settings receive medication as a part of their treatment. It appears that most prescriptions for stimulants and antidepressants are consistent with either diagnostic or symptom indications. Many children with these indications are not on medications. On the other hand, a large number of children without evidence of psychosis receive antipsychotic medications. Conclusion: The evidence suggests that stimulant and antidepressant are not over-prescribed. However, the use of antipsychotic medications for other indications is a priority for further research.

Regional variation and clinical indicators of antipsychotic use in residential treatment: A four-state comparison

The last decade saw an increase in psychotropic use with pediatric populations. Antipsychotic prescriptions are used frequently in residential treatment settings, with many youth receiving antipsychotics for off-label indications. Residential treatment data from 4 states were examined to determine if regional variation exists in off-label prescription and what clinical factors predict use. The study used clinical and pharmacological data collected via retrospective chart reviews (N = 732). The Child and Adolescent Needs and Strengths Assessment — Mental Health Version was used to measure symptom and risk severity. Of youth receiving antipsychotics, 42.9% had no history of or current psychosis. Statistical analyses resulted in significant regional variation in use across states and yielded attention deficit/impulsivity, physical aggression, elopement, sexually abusive behavior, and criminal behavior as factors associated with antipsychotic prescription in nonpsychotic youth. Antipsychotic prescription is inconsistent across states. Off-label prescription is frequent and likelihood of use increases with behavior problems.

Utilization of private child and adolescent services: Ethical considerations

Any discussion of ethics is inherently a discussion of values and choices. The emergence of for-profit healthcare, especially in the field of mental health and substance abuse treatment for adolescents, has heightened this discussion as it relates to appropriate and necessary care. This paper traces the history of this conflict as it relates to the medical profession and through a case vignette, raises a variety of ethical issues and dilemmas presented by the growth of this rapidly expanding industry.