From Children's Hospital of Philadelphia
By Rick Nauert, Ph.D.
April 8, 2015
A new study finds that prescription antipsychotics convey a significant risk to children’s health.
Researchers from the Children’s Hospital of Philadelphia’s (CHOP) PolicyLab discovered initiating antipsychotics may elevate a child’s risk not only for significant weight gain, but also for Type II diabetes by nearly 50 percent.
Moreover, if a child is also receiving antidepressants, then the risk for Type II diabetes may double.
The study, published in JAMA Pediatrics, is the largest investigation to date on how antipsychotics can increase medical risks among children.
Previous PolicyLab research showed that one in three youth receiving antidepressants in the Medicaid program were receiving an antipsychotic at the same time.
Traditionally, the prescription of antipsychotics have been limited to children with a diagnosis of schizophrenia or bipolar disorder, or to those with significant developmental delays who were displaying aggressive behaviors that were potentially injurious to themselves or others.
However, in recent years, these medications are increasingly being prescribed in the absence of strong supporting safety and efficacy data to treat healthier children and adolescents with disruptive behaviors, such as those who are diagnosed with attention-deficit hyperactivity disorder (ADHD).
Researchers say the new study, which used national Medicaid data on more than 1.3 million youth ages 10 to 18 with a mental health diagnosis, must be interpreted in the context of emerging evidence that Medicaid-enrolled children are far more likely than privately insured children to be prescribed antipsychotic medications.
Overall, over 25 percent of Medicaid-enrolled children receiving prescription medications for behavioral problems were prescribed antipsychotics by 2008, largely for less severe disorders.
“With such vast numbers of children being exposed to these medications, the implications for potential long-lasting harm can be jarring,” said David Rubin, M.D., M.S.C.E., the study’s lead author and co-director of PolicyLab at CHOP.
Nevertheless, Rubin and his co-authors remain cautious in over-reacting to these findings. The baseline risk for diabetes among youth who were not exposed to antipsychotics in the study was only one in 400, rising to one in 260 among those initiating antipsychotics, and at most to one in 200 among those who initiated antipsychotics while they were simultaneously receiving antidepressants.
“Although these findings should certainly give us pause,” Rubin added, “we should not reflexively over-react to them.”
Rubin believes the new findings should facilitate a more thoughtful consideration of the true risks and benefits of prescribing an antipsychotic to a child. That is, use of the powerful medications should be minimized, yet for some children in immediate crisis, the benefit of the antipsychotic for acute management may still outweigh the risk.
The study’s authors recommend that clinicians and families who are making medication decisions periodically revisit the treatment strategy to address challenging behaviors.
For example, when planning to prescribe antipsychotics to a child, professional organizations recommend beginning cautiously with the lowest dose possible, while strictly monitoring for early evidence of weight gain or abnormal lab tests that often predict later onset of diabetes.
Rubin, who is also an attending pediatrician at CHOP, noted, “Once a child is on the antipsychotic drug, a plan should be agreed upon and periodically revisited to see whether or not an evidence-based counseling service, such as trauma-focused cognitive therapy, could address underlying emotional trauma, which is often the root cause for the behavior.
“That same periodic review would also seek to transition the child off the antipsychotic as soon as possible, once these problems are more suitably addressed.”
Ultimately, say Rubin and his co-authors, the prescription of antipsychotics to children and adolescents is likely to continue, reflecting a growing demand to address very challenging behaviors in children.
“At the end of the day, the approach to the individual child who is in crisis is still a case-by-case decision between a family and the treating provider,” said Rubin.
“We can only hope that those decisions are made in full recognition of our findings, and that for some children, alternatives to these powerful medications, such as counseling or other supportive services, will be considered first.”