|Year : 2019 | Volume
| Issue : 1 | Page : 26-32
The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study
Bilal Ahmad Bhat1, Arshad Hussain1, Wasim Qadir2, Shabir Ahmad Dar1
1 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pediatrics, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||29-May-2019|
Dr. Bilal Ahmad Bhat
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Psychiatric disorders are now frequently diagnosed in children and adolescents, and psychotropic medications are being used increasingly for the treatment of these disorders. Aims: The aim is to study the frequency and the pattern of prescription of psychotropic drugs in outpatient child and adolescent psychiatric facility. Settings and Design: This was a cross-sectional descriptive study conducted in outpatient child and adolescent psychiatric facility. Materials and Methods: The outpatient department prescription of all patients who were ≤18 years of age, who attended the Outpatient Child and Adolescent Facility of Department of Psychiatry, Government Medical College, Srinagar, over 1½-year period were studied. The following details were recorded – age, gender, diagnosis with comorbidity, and the psychotropic drugs which were prescribed. Results: A total of 624 patients attended the outpatient service during the study period. The mean age was 7.74 years (standard deviation = 3.76). 67.3% were male. Hyperkinetic disorder (27.1%) and mental retardation (26.3%) were the more frequent diagnosis. Comorbidity was present in 28.8%. 60.6% of the patients were prescribed psychotropic medication with 44.9% being prescribed a single psychotropic, 15.1% were prescribed two psychotropics simultaneously, and 0.6% were prescribed three psychotropics simultaneously. Stimulants (17.5%), risperidone (25.2%), and selective serotonin reuptake inhibitors (9.9%) were the commonly prescribed psychotropics. Statistical Analysis: Descriptive analysis was carried out with Statistical Package for the Social Sciences and results were presented as frequencies and percentages. Conclusion: Simulants, antipsychotics, and antidepressants were commonly prescribed psychotropics with stimulants and antidepressants mostly being prescribed for attention-deficit/hyperactivity disorder and depression, while most of the antipsychotics being prescribed for nonpsychotic conditions.
Keywords: Antipsychotics, psychotropic drugs, stimulants
|How to cite this article:|
Bhat BA, Hussain A, Qadir W, Dar SA. The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study. Muller J Med Sci Res 2019;10:26-32
|How to cite this URL:|
Bhat BA, Hussain A, Qadir W, Dar SA. The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study. Muller J Med Sci Res [serial online] 2019 [cited 2020 Jan 19];10:26-32. Available from: http://www.mjmsr.net/text.asp?2019/10/1/26/259247
| Introduction|| |
Although there are many initiatives planned at the international level to guarantee safe and effective pharmacological therapies for children, the lack of information on the safety and efficacy of drugs in childhood still exists., This is true for all drugs including psychotropic medications. Other than stimulants, psychotropic medication use has not been adequately studied in children and their use in children is mostly based on extrapolation of information from the adult studies. The preferences for the use of psychotropic medications over nonpharmacological interventions have grown considerably in child and adolescent mental care.,, The major factors which seem responsible for this preference include severity or type of psychiatric disorder, the need for quick symptom relief, and lack of multidisciplinary care, particularly in the low-resourced countries., The choice of psychotropic medications and patterns of their prescription vary in different settings. In specialized settings for child and adolescent psychiatry, rational prescribing and the use of newer psychotropic agents are favored,,, but in settings without specialized units for children, the pattern of psychotropic prescription remains largely unclear, mainly due to lack of data. For instance in West, where specialized child and adolescent psychiatric services are available, psychosocial management is more preferred, especially for mild-to-moderate conditions.,, In pharmacotherapy, newer agents such as second-generation antipsychotics and fluoxetine are preferred to older ones such as haloperidol and amitriptyline in these settings., A Cochrane review on use of antidepressants in young people agrees that fluoxetine has the best evidence of efficacy in children and should be tried first in childhood and adolescent depression with sertraline and escitalopram tried as the second-line agents. In a systematic review and meta-analysis on the long-term efficacy of immediate release methylphenidate, it was found efficacious for childhood attention deficit hyperactivity disorder for periods longer than 12 weeks. A multinational comparison of antipsychotic drug use in children and adolescents from 2005 to 2012 has found an annual increase in use of antipsychotics. This comparison study further showed the prescription of the second-generation antipsychotics increased in relation to the first-generation antipsychotics. Nonetheless, increase in the rate of off-label use and polypharmacy of psychotropic medications among children and adolescents in these centers has also been reported.,, Although the use of psychotropic medications has been shown to effectively treat mental health problems, there are concerns about the efficacy of polypharmacy and its potential long-term impact on health, particularly among children. There is limited data about the prescription pattern of psychotropic medications in child and adolescent outpatient services in our country. The purpose of our study was to describe the pattern of psychotropic prescription in child and adolescent psychiatry clinic of the Department of Psychiatry, Government Medical College, Srinagar.
| Materials and Methods|| |
This was a cross-sectional study conducted among patients attending the Outpatient Child and Adolescent Psychiatric Facility of Postgraduate Department of Psychiatry, Government Medical College, Srinagar, over a period of 1½ year, from February 2016 to June 2017. Approval for the study was obtained from the institutional ethics committee. Children and adolescents of age 1–18 years whose parent/guardian gave the consent for this study constituted the study population. All the diagnosis were made clinically on the basis of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (↱ICD-10)↱ criteria. The diagnosis was confirmed by the consultant in-charge child psychiatry facility. The diagnosis and types of psychotropic medications prescribed to each child and adolescent on their first visit were documented, in order to find the pattern of prescription from the child and adolescent psychiatric facility. Those patients who were already on some psychotropic medication were excluded from the study. The data about various parameters were entered into Microsoft Excel. Descriptive analysis was carried out with SPSS version 16 (Statistical Package for Social Sciences; IBM Software, Armonk, NY). Chi-square test was used for comparison and P < 0.05 was considered as statistically significant. The information thus generated was presented in tables as frequencies and percentages.
| Results|| |
A total of 624 patients were included in the study. Most of the patients were in 5–10 years age group (n = 267, 43%). The average age of the patients was 7.74 years (standard deviation = 3.76). Males outnumbered females by an approximate ratio of 2:1, with 67.3% (n = 420) males and 32.7% (n = 204) females. 55.1% (n = 344) were from rural background, whereas 44.9% (n = 280) were from urban background [Table 1].
Out of 624 patients, 83.7% (n = 522) received ICD-10 diagnosis, whereas 16.3% (n = 102) did not receive any diagnosis. Hyperkinetic disorder was the most frequent diagnosis occurring in 27.1% (n = 169) of the patients followed by mental retardation (MR) which occurred in 26.3% (n = 164). 9% (n = 56) had pervasive developmental disorder (PDD), anxiety disorders were present in 5.9% (n = 37), depressive episode was found in 5.4% (n = 34), conduct disorders were found in 4% (n = 25), bipolar affective disorder was present in 2.4% (n = 15), schizophrenia in 1.3% (n = 8), dissociative disorders in 1.6% (n = 10), and enuresis in 0.6% (n = 4) [Table 2].
Comorbidity was present in 28.8% (n = 180) as is shown in [Table 3].
Of the 624 patients included in our study, 39.4% (n = 246) were not prescribed any psychotropic medication, whereas 60.6% (n = 378) were treated with some psychotropic medication (Chi-square test = 27.923, P = 0.0001). Out of 444 patients without comorbidity, 224 were treated with psychotropics, whereas out of 180 patients with comorbidity, 154 were treated with psychotropics (Chi-square test = 66.093, P = 0.0001) [Table 4].
44.9% (n = 280) of patients were treated with a single psychotropic agent, 15.1% (n = 94) were treated with two psychotropics simultaneously, and 0.6% (n = 4) were treated with three psychotropics simultaneously. Out of 180 patients with comorbidity, 27 were not on any psychotropic, whereas 63, 86, and 4 patients were, respectively, on one, two, and three psychotropics. Out of 444 patients without co-morbidity, 219 were on no psychotropic, whereas 217 and 8 patients were on one and two psychotropics respectively. Difference between the two groups was statistically significant. (Chi-square test = 2.334, P = 0.0001) [Table 5].
Risperidone was prescribed in 25.2% (n = 157), stimulant (methylphenidate) in 17.5% (n = 109), selective serotonin reuptake inhibitor (SSRI) (fluoxetine) in 9.9% (n = 62), aripiprazole in 7.5% (n = 47), benzodiazepines in 7.5% (n = 47), atomoxetine in 5.3% (n = 33), mood stabilizer (divalproex sodium) in 2.7% (n = 17), and tricyclic antidepressant (imipramine) in 1.9% (n = 12) [Table 6].
| Discussion|| |
Higher number of patients in 5–10 years age group, males outnumbering females and rural predominance in our study are consistent with other hospital-based studies and epidemiological studies from India as well as outside India.,,,,Hyperkinetic disorder was the most frequent diagnosis in our patients. A recent study from the same center found attention-deficit/hyperactivity disorder (ADHD) as the most frequent diagnosis in outpatient child psychiatry. However, this finding is inconsistent with other hospital-based studies from India., Epidemiological studies from India and hospital-based studies from the West have also shown higher frequency of hyperkinetic syndromes.,,, MR was the second most frequent diagnosis in our patients, a pattern consistent with other Indian studies., PDDs, anxiety disorders, conduct disorders, mood disorders, schizophrenia, and enuresis were less frequent disorders in our study which is similar to other studies from India.,,, Low comorbidity in our study is also supported by other Indian studies which have looked into comorbidity.,
The purpose of this study was to look into the pattern of prescription of psychotropics in children and adolescents who attend the outpatient child psychiatry facility. Although there is a lot of literature on pattern of psychotropic prescription in adults, there is very little of it on children, particularly from India. A study by Kaplan et al. in the early 90's showed that the prescription of psychotropic medications in children is modest. There are studies which have documented an increasing trend over time in the prescription of psychotropic medications to children.,, In our study also, a high proportion of children and adolescents were prescribed a psychotropic on their first visit. High rates of psychotropic prescription have been found in some other studies., Overall, the use of psychotropic medication in children and adolescents has increased remarkably in the recent past, and the gap between the rate of prescribing psychotropics in adults and children has narrowed down substantially. Stimulants (methylphenidate), antipsychotics (risperidone and aripiprazole), and SSRI (fluoxetine) as most prescribed class of psychotropics in our study is in accordance with various studies from the West,, but is in contrast to the study from Nigeria which although found atypical antipsychotics being the most prescribed psychotropic, but at the same time, found stimulants and antidepressants not commonly prescribed. The time trends in the prevalence rates of dispensed prescriptions of psychotropics in Denmark over 15 years increased markedly which was most pronounced for the stimulants but was also evident in prescription of antipsychotics and antidepressants. Rapoport, in a recent overview on pediatric psychopharmacology, concluded that the use of new treatments, such as stimulants and SSRIs, in addition of helping otherwise treatment-refractory patients, also contributed to an overacceptance of reductionistic biology.
Methylphenidate and atomoxetine were prescribed in hyperkinetic disorder with Methylphenidate being prescribed more frequently in comparison to atomoxetine. Studies in the West have found a marked increase in use of medication in ADHD since 2005/2006, mostly stimulants and less frequently atomoxetine and other medication for ADHD.,, In view of Garbe et al., rate of prescribing medications to ADHD children has shown a dramatic increase in the past two decades. In the UK primary care, methylphenidate was the most commonly prescribed drug for ADHD in 6–24 year age group during the study period of 20 years making up 89.9% of all prescriptions. Pharmacotherapy, usually stimulants, is one of the most frequent evidence-based interventions in children with ADHD. However, there are concerns with regard to short- and long-term side effects of stimulants. There is a US Food and Drug Administration (FDA) warning for cardiovascular risks of stimulants in ADHD. Other side effects can include insomnia, decreased appetite, headache, dizziness, and mood changes. Although administration of stimulants with drug holidays have not a long-term influence on height, these drugs have raised a controversy with their more sustained and longer use. In addition, controversy regarding long-term benefits of stimulant medications persists, as there is lack of evidence in this regard. A recent review on educational and behavioral outcome in children with ADHD highlighted that the use of stimulants increased without improving medium or long-term outcomes, there was no improvement even in children with the worst preexisting ADHD symptoms and increases in drug use were associated with increase in depression among girls, whether the increased use of medications in ADHD is a desirable compensation of former undertreatment, or it is a reason for concern is not clear.
Among the antipsychotics, atypical agents risperidone and aripiprazole were exclusively prescribed to our patients. Conventional antipsychotics were not prescribed at all. Moreover, >4% of our patients were psychotic, and thus the antipsychotics were prescribed for nonpsychotic conditions, particularly in behavioral dysregulation. A retrospective descriptive analysis of antipsychotic prescriptions among patients aged 1–24 years concluded that antipsychotic use increased from 2006 to 2010 for adolescents and young adults but not for children aged 12 years or younger and the clinical diagnosis patterns are consistent with the management of developmentally limited impulsive and aggressive behaviors rather than psychotic symptoms. The use of antipsychotics mostly for nonpsychotic conditions in children is consistent with other studies., In addition, there is an evidence of steady increase in antipsychotic use in children and adolescents, most of which have been for nonpsychotic indications such as behavioral and emotional problems., Over the recent years from Western countries, there have been reports of increase in the use of atypical antipsychotics.,
Among antidepressants, fluoxetine and imipramine were the antidepressants prescribed with fluoxetine prescribed more frequently than imipramine. Fluoxetine was exclusively used for depression and anxiety disorders, particularly obsessive and compulsive disorder, while imipramine was exclusively used for enuresis. A review on “research on antidepressants in India” found only two studies with imipramine use in children, and these studies have shown it useful in enuresis and behavioral problems such as temper tantrums and obstinacy. A systematic review and meta-analysis of trials of treatment of depression from India concluded that there is a lack of data from India in special populations like children and adolescents. Although studies from the West have also shown fluoxetine being prescribed more frequently in children, they have also found antidepressants being prescribed at much higher rate than our study., This can be explained by higher rates of anxiety and mood disorders in Western outpatient child and adolescent psychiatry., Although risk–benefit balance is less clear for most SSRIs in childhood and adolescent depression, for fluoxetine use, it is favorable. A black box warning was issued by the US FDA in October 2004 indicating an increased risk of suicidal ideation in children and adolescents treated with SSRIs. Consequent to this warning, there was a sudden decline in antidepressant use in children and adolescents within 2 years, but this trend did not persist, and there was a substantial increase in antidepressant use in youth cohorts from five Western countries. Nevertheless, the children and adolescents who are treated with SSRIs should be closely monitored for suicidal ideations, especially during the first few weeks of treatment.
Other psychotropics (benzodiazepines and mood stabilizers) were less frequently prescribed. This is because of lower hospital prevalence for mood and anxiety disorders. Although the studies from the West and other developing countries have also found lower prescription for mood stabilizers, the prescription of benzodiazepines is quite high among patients in these studies.,,,,,
The prevalence of polypharmacy in our study was around 16%. This is in accordance with other studies which have shown higher percentage of patients on polypharmacy.,, Moreover, studies have shown an increasing trend in polypharmacy of psychotropics in children., In our study, children and adolescents with comorbidity were more likely to get a prescription with two or more psychotropics as compared to those without comorbidity. A recent study on polypharmacy of children and adolescents found that the presence of comorbidity was significantly associated with polypharmacy. Studies have consistently shown the presence of psychiatric comorbidity and complex presentation as a risk factor for psychotropic polypharmacy., Fewer avenues for nonpharmacological management of childhood and adolescent psychiatric disorders in our setup and pressure to quickly resolve the symptoms in patients, make nonpharmacological treatment less attractive which further endorse the polypharmacy.
| Conclusion|| |
Very little is known about the prescribing pattern of psychotropic drugs in outpatient child and adolescent psychiatry in India. Our study was an attempt to find such a pattern. Like the studies in the West, our study found stimulants, antidepressants, and antipsychotics being prescribed oftenly in children and adolescents. Stimulants and antidepressants were prescribed for ADHD and depression, while most of the antipsychotics were prescribed for nonpsychotic conditions. Further studies need to be conducted to look for safety of psychotropic drugs in children particularly.
This was an hospital-based descriptive study and thus the results cannot be generalized onto the children and adolescents in the community. Logistical factors such as transportation barrier and availability of services in tertiary care setting may have influenced the presentation and hence prescription pattern in our study. Bias on the part of clinicians can also be due to their preference of pharmacotherapy over psychological interventions. Being a cross-sectional study, trends in prescribing psychotropics over a period of time cannot be discerned. Furthermore, sometimes psychotropics are prescribed later in the course of treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Choonara I. Regulation of drugs for children in Europe. BMJ 2007;335:1221-2.
Rey JM, Omigbodun OO. International dissemination of evidence-based practice, open access and the IACAPAP textbook of child and adolescent mental health. Child Adolesc Psychiatry Ment Health 2015;9:51.
Woods G, Shannon C, Davidson G, Hoy K, Lewis D, Tumelty L, et al.
Psychotropic prescribing patterns among adolescents in Northern Ireland presenting with psychotic symptoms during a 5-year period. Ir J Psychol Med 2016;33:13-20.
Harrison JN, Cluxton-Keller F, Gross D. Antipsychotic medication prescribing trends in children and adolescents. J Pediatr Health Care 2012;26:139-45.
Xiang YT, Weng YZ, Leung CM, Tang WK, Sandor UG. Exploring the clinical and social determinants of prescribing anticholinergic medication for Chinese patients with schizophrenia. Hum Psychopharmacol 2007;22:173-80.
Tunde-Ayinmode MF. Audit of child and adolescent psychiatry in a teaching hospital in Nigeria: Prevalence, pattern and implication for improved services. S Afr J Psychiatry 2010;16:20-6.
Hussain H, Dubicka B, Wilkinson P. Newer generation antidepressants for young people: Real-life evidence needed: Commentary on Cochrane corner. BJPsych Adv 2017;23:75-80.
Maia CR, Cortese S, Caye A, Deakin TK, Polanczyk GV, Polanczyk CA. Long-term efficacy of methylphenidate immediate-release for the treatment of childhood ADHD. J Atten Disord 2017;21:3-13.
Kalverdijk LJ, Bachmann CJ, Aagaard L, Burcu M, Glaeske G, Hoffmann F. A multi-national comparison of antipsychotic drug use in children and adolescents, 2005-2012. Child Adolesc Psychiatry Ment Health 2017;11:55.
Kukreja S, Kalra G, Shah N, Shrivastava A. Polypharmacy in psychiatry: A review. Mens Sana Monogr 2013;11:82-99.
] [Full text]
Comer JS, Olfson M, Mojtabai R. National trends in child and adolescent psychotropic polypharmacy in office-based practice, 1996-2007. J Am Acad Child Adolesc Psychiatry 2010;49:1001-10.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1993.
Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P. Epidemiological study of child & adolescent psychiatric disorders in urban & rural areas of Bangalore, India. Indian J Med Res 2005;122:67-79.
Vogel W, Holford L. Child psychiatry in Johannesburg, South Africa. A descriptive account of cases presenting at two clinics in 1997. Eur Child Adolesc Psychiatry 1999;8:181-8.
Staller JA. Diagnostic profiles in outpatient child psychiatry. Am J Orthopsychiatry 2006;76:98-102.
Bhat BA, Hussain A, Dar MA, Dar SA, Jabeen N, Rasool S. The pattern of psychiatric morbidity in an outpatient child psychiatry clinic: A cross-sectional, descriptive study from a tertiary care hospital in Kashmir, North India. Indian J Psychol Med 2018;40:349-55.
] [Full text]
Malhotra S, Biswas P, Sharan P, Grover S. Characteristics of patients visiting the child & adolescent psychiatric clinic: A 26-year study from North India. J Indian Assoc Child Adolesc Ment Health 2007;3:53-60.
Sidana A, Bhatia MS, Choudhary S. Prevalence and pattern of psychiatric morbidity in children. Indian J Med Sci 1998;52:556-8.
] [Full text]
Nawarathna SC, Subba SH, Guha A. Clinico-epidemiological profile of psychiatric disorders among children in a tertiary care hospital of Southern India. J Clin Diagn Res 2016;10:VC05-8.
Verghese A, Beig A. Psychiatric disturbance in children – An epidemiological study. Indian J Med Res 1974;62:1538-42.
Deivasigamani TR. Psychiatric morbidity in primary school children – An epidemiological study. Indian J Psychiatry 1990;32:235-40.
] [Full text]
Kaplan SL, Simms RM, Busner J. Prescribing practices of outpatient child psychiatrists. J Am Acad Child Adolesc Psychiatry 1994;33:35-44.
Valentine J, Zubrick S, Sly P. National trends in the use of stimulant medication for attention deficit hyperactivity disorder. J Paediatr Child Health 1996;32:223-7.
Gadow KD. An overview of three decades of research in pediatric psychopharmacoepidemiology. J Child Adolesc Psychopharmacol 1997;7:219-36.
Olfson M, Druss BG, Marcus SC. Trends in mental health care among children and adolescents. N
Engl J Med 2015;372:2029-38.
Dosetor DR, Sprague TJ, Nunn KP. A one year audit of psychotropic medication usage in a department of child psychiatry. Bulletin of the Faculty of Child and Adolescent Psychiatry 1995. p.38-48.
Reed E, Vance A, Luk E, Nunn K. Single and combined psychotropic medication use in a child and adolescent mental health service. Aust N
Z J Psychiatry 2004;38:204-11.
Steinhausen HC. Recent international trends in psychotropic medication prescriptions for children and adolescents. Eur Child Adolesc Psychiatry 2015;24:635-40.
Anderson LE, Chen ML, Perrin JM, Van Cleave J. Outpatient visits and medication prescribing for US children with mental health conditions. Pediatrics 2015;136:e1178-85.
Olashore A, Ayugi J, Opondo P. Prescribing pattern of psychotropic medications in child psychiatric practice in a mental referral hospital in Botswana. Pan Afr Med J 2017;26:83.
Staller JA, Wade MJ, Baker M. Current prescribing patterns in outpatient child and adolescent psychiatric practice in central New York. J Child Adolesc Psychopharmacol 2005;15:57-61.
Bakare MO, Igwe MN, Odinka PC, Iteke O. Neuropsychiatric diagnosis and psychotropic medication prescription patterns in a mental hospital-based child and adolescent psychiatric service in Nigeria. J Health Care Poor Underserved 2011;22:751-5.
Steinhausen HC, Bisgaard C. Nationwide time trends in dispensed prescriptions of psychotropic medication for children and adolescents in Denmark. Acta Psychiatr Scand 2014;129:221-31.
Rapoport JL. Pediatric psychopharmacology: Too much or too little? World Psychiatry 2013;12:118-23.
Bachmann CJ, Wijlaars LP, Kalverdijk LJ, Burcu M, Glaeske G, Schuiling-Veninga CC, et al
. Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012. Eur Neuropsychopharmacol 2017;27:484-93.
Dalsgaard S, Nielsen HS, Simonsen M. Five-fold increase in national prevalence rates of attention-deficit/hyperactivity disorder medications for children and adolescents with autism spectrum disorder, attention-deficit/hyperactivity disorder, and other psychiatric disorders: A Danish register-based study. J Child Adolesc Psychopharmacol 2013;23:432-9.
McCarthy S, Wilton L, Murray ML, Hodgkins P, Asherson P, Wong IC. The epidemiology of pharmacologically treated attention deficit hyperactivity disorder (ADHD) in children, adolescents and adults in UK primary care. BMC Pediatr 2012;12:78.
Garbe E, Mikolajczyk RT, Banaschewski T, Petermann U, Petermann F, Kraut AA. Drug treatment patterns of attention-deficit/hyperactivity disorder in children and adolescents in Germany: Results from a large population-based cohort study. J Child Adolesc Psychopharmacol 2012;22:452-8.
Renoux C, Shin JY, Dell'Aniello S, Fergusson E, Suissa S. Prescribing trends of attention-deficit hyperactivity disorder (ADHD) medications in UK primary care, 1995-2015. Br J Clin Pharmacol 2016;82:858-68.
Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011;128:1007-22.
Nissen SE. ADHD drugs and cardiovascular risk. N
Engl J Med 2006;354:1445-8.
Schachter HM, Pham B, King J, Langford S, Moher D. How efficacious and safe is short-acting methylphenidate for the treatment of attention-deficit disorder in children and adolescents? A meta-analysis. CMAJ 2001;165:1475-88.
Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M. Stimulant-related reductions of growth rates in the PATS. J Am Acad Child Adolesc Psychiatry 2006;45:1304-13.
Currie J, Stabile M, Jones L. Do stimulant medications improve educational and behavioral outcomes for children with ADHD? J Health Econ 2014;37:58-69.
Olfson M, King M, Schoenbaum M. Treatment of young people with antipsychotic medications in the United States. JAMA Psychiatry 2015;72:867-74.
Pathak P, West D, Martin BC, Helm ME, Henderson C. Evidence-based use of second-generation antipsychotics in a state Medicaid pediatric population, 2001-2005. Psychiatr Serv 2010;61:123-9.
Zito JM, Derivan AT, Kratochvil CJ, Safer DJ, Fegert JM, Greenhill LL. Off-label psychopharmacologic prescribing for children: History supports close clinical monitoring. Child Adolesc Psychiatry Ment Health 2008;2:24.
Olfson M. Antipsychotic prescriptions for children and adolescents in the UK increased from 1993 to 2005. Evid Based Ment Health 2009;12:30.
Rani FA, Byrne P, Cranswick N, Murray ML, Wong IC. Mortality in children and adolescents prescribed antipsychotic medication: A retrospective cohort study using the UK general practice research database. Drug Saf 2011;34:773-81.
Patten SB, Waheed W, Bresee L. A review of pharmacoepidemiologic studies of antipsychotic use in children and adolescents. Can J Psychiatry 2012;57:717-21.
Bachmann CJ, Lempp T, Glaeske G, Hoffmann F. Antipsychotic prescription in children and adolescents: An analysis of data from a German statutory health insurance company from 2005 to 2012. Deutsches črzteblatt Int 2014;111:25.
Avasthi A, Grover S, Aggarwal M. Research on antidepressants in India. Indian J Psychiatry 2010;52:S341-54.
Sarkar S, Grover S. A systematic review and meta-analysis of trials of treatment of depression from India. Indian J Psychiatry 2014;56:29-38.
] [Full text]
Jane Garland E, Kutcher S, Virani A, Elbe D. Update on the use of SSRIs and SNRIs with children and adolescents in clinical practice. J Can Acad Child Adolesc Psychiatry 2016;25:4-10.
Bachmann CJ, Aagaard L, Burcu M, Glaeske G, Kalverdijk LJ, Petersen I. Trends and patterns of antidepressant use in children and adolescents from five Western countries, 2005-2012. Eur Neuropsychopharmacol 2016;26:411-9.
Fontanella CA, Warner LA, Phillips GS, Bridge JA, Campo JV. Trends in psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002-2008. Psychiatr Serv 2014;65:1332-40.
Olashore AA, Rukewe A. Polypharmacy among children and adolescents with psychiatric disorders in a mental referral hospital in Botswana. BMC Psychiatry 2017;17:174.
Dean AJ, McDermott BM, Marshall RT. Psychotropic medication utilization in a child and adolescent mental health service. J Child Adolesc Psychopharmacol 2006;16:273-85.
McIntyre RS, Jerrell JM. Polypharmacy in children and adolescents treated for major depressive disorder: A claims database study. J Clin Psychiatry 2009;70:240-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]