Youth mental health-related presentations at a quaternary centre: Who comes, What are their needs, and Can we meet their needs.

Background: Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services. Objective: To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources. Methods: We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility. Results: Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month. Conclusions: Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs.

HEARTSMAP-U: Adapting a Psychosocial Self-Screening and Resource Navigation Support Tool for Use by Post-secondary Students.

Background: Mental health challenges are highly prevalent in the post-secondary educational setting. Screening instruments have been shown to improve early detection and intervention. However, these tools often focus on specific diagnosable conditions, are not always designed with students in mind, and lack resource navigational support. Objective: The aim of this study was to describe the adaptation of existing psychosocial assessment (HEARTSMAP) tools into a version that is fit-for-purpose for post-secondary students, called HEARTSMAP-U. Methods: We underwent a three-phase, multi-method tool adaptation process. First, a diverse study team proposed a preliminary version of HEARTSMAP-U and its conceptual framework. Second, we conducted a cross-sectional expert review study with Canadian mental health professionals (N = 28), to evaluate the clinical validity of tool content. Third, we conducted an iterative series of six focus groups with diverse post-secondary students (N = 54), to refine tool content and language, and ensure comprehensibility and relevance to end-users. Results: The adaptation process resulted in the HEARTSMAP-U self-assessment and resource navigational support tool, which evaluates psychosocial challenges across 10 sections. In Phase two, clinician experts expressed that HEARTSMAP-U's content aligned with their own professional experiences working with students. In Phase three, students identified multiple opportunities to improve the tool's end-user relevance by calling for more "common language," such as including examples, definitions, and avoiding technical jargon. Conclusions: The HEARTSMAP-U tool is well-positioned for further studies of its quantitative psychometric properties and clinical utility in the post-secondary educational setting.

Second-Generation Antipsychotic Use in Pediatric Emergency Medicine.

ABSTRACT: In recent years, the number of patients presenting to the emergency department with mental health complaints has been growing, alongside an increase in second-generation antipsychotic (SGAs) prescriptions for a variety of mental health conditions. Children treated with SGAs may have abnormalities, such as rapid weight gain and central adiposity, glucose intolerance, dyslipidemia, and hypertension; they may present to the pediatric emergency department with components of metabolic syndrome or type 2 diabetes, and a subsequent significant risk for cardiovascular complications later in life. Pediatric emergency department providers may serve as a safety net for patients to detect SGA-related metabolic complications, especially among vulnerable populations lacking access to primary care or psychiatric services.

Second-generation antipsychotics in children: Risks and monitoring needs.

Question A 10-year-old male patient presented to my clinic with irritability associated with autism spectrum disorder, and previous therapeutic efforts had not been successful. Treatment with quetiapine has considerably reduced irritability and improved his quality of life; however, the patient's mother has stated that her child's clothes are no longer fitting because his waist size has increased substantially, and that he has gained 5 kg since treatment initiation 8 weeks ago. Should second-generation antipsychotic (SGA) treatment be stopped or continued, and how can these side effects be best mitigated in a family practice setting?Answer Use of SGAs in pediatric patients has increased in recent years, which has brought to light a number of worrisome metabolic side effects that occur in children. Owing to the efficacy of treatment, SGAs must often be continued despite side effects. Even if the drug has been prescribed elsewhere, family physicians should closely monitor these patients following the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children guidelines. When starting an SGA, patients and their families should be educated on the importance of healthy eating and physical activity to preemptively mitigate potential side effects. Recent studies have also shown adjunctive metformin to have a potential role in reducing weight gain.

Antipsychotiques de deuxième génération chez l'enfant: Risques et exigences en matière de surveillance.

Question Un patient de 10 ans est venu en consultation à ma clinique en raison d'une irritabilité associée au trouble du spectre de l'autisme. Les efforts thérapeutiques antérieurs n'avaient pas donné les résultats voulus. Le traitement à la quétiapine a réduit considérablement l'irritabilité et a amélioré la qualité de vie; par contre, sa mère m'a dit que les vêtements de l'enfant ne lui faisaient plus parce que son tour de taille avait considérablement augmenté, et qu'il avait pris 5 kg depuis le début du traitement, 8 semaines auparavant. Faudrait-il cesser le traitement aux antipsychotiques de deuxième génération (ADG) ou le poursuivre? Comment peut-on atténuer les effets secondaires dans un milieu de pratique familiale?Réponse Au cours des dernières années, le recours aux ADG a connu une hausse chez les patients pédiatriques, et cette pratique a fait ressortir un certain nombre d'inquiétants effets secondaires métaboliques chez les enfants. En raison de l'efficacité du traitement, il faut souvent continuer les ADG en dépit des effets secondaires. Par ailleurs, même s'ils ont été prescrits par un autre médecin, les médecins de famille devraient surveiller étroitement ces patients conformément aux lignes directrices de la CAMESA (Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children). Au début d'un traitement aux ADG, les patients et leur famille devraient être informés de l'importance d'une saine alimentation et de l'activité physique pour atténuer les effets secondaires éventuels, à titre préventif. De récentes études ont aussi démontré que la metformine en traitement d'appoint aurait le potentiel de réduire le gain pondéral.

What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review.

BACKGROUND: Many young people who receive psychiatric care in inpatient or residential settings in North America have experienced various forms of emotional trauma. Moreover, these settings can exacerbate trauma sequelae. Common practices, such as seclusion and restraint, put young people at risk of retraumatization, development of comorbid psychopathology, injury, and even death. In response, psychiatric and residential facilities have embraced trauma-informed care (TIC), an organizational change strategy which aligns service delivery with treatment principles and discrete interventions designed to reduce rates of retraumatization through responsive and non-coercive staff-client interactions. After more than two decades, a number of TIC frameworks and approaches have shown favorable results. Largely unexamined, however, are the features that lead to successful implementation of TIC, especially in child and adolescent inpatient psychiatric and residential settings. METHODS: Using methods proposed by Pawson et al. (J Health Serv Res Policy 10:21-34, 2005), we conducted a modified five-stage realist systematic review of peer-reviewed TIC literature. We rigorously searched ten electronic databases for peer reviewed publications appearing between 2000 and 2015 linking terms "trauma-informed" and "child*" or "youth," plus "inpatient" or "residential" plus "psych*" or "mental." After screening 693 unique abstracts, we selected 13 articles which described TIC interventions in youth psychiatric or residential settings. We designed a theoretically-based evaluative framework using the active implementation cycles of the National Implementation Research Network (NIRN) to discern which foci were associated with effective TIC implementation. Excluded were statewide mental health initiatives and TIC implementations in outpatient mental health, child welfare, and education settings. Interventions examined included: Attachment, Self-Regulation, and Competency Framework; Six Core Strategies; Collaborative Problem Solving; Sanctuary Model; Risking Connection; and the Fairy Tale Model. RESULTS: Five factors were instrumental in implementing trauma informed care across a spectrum of initiatives: senior leadership commitment, sufficient staff support, amplifying the voices of patients and families, aligning policy and programming with trauma informed principles, and using data to help motivate change. CONCLUSIONS: Reduction or elimination of coercive measures may be achieved by explicitly targeting specific coercive measures or by implementing broader therapeutic models. Additional research is needed to evaluate the efficacy of both approaches.

Increased Risk of Obesity and Metabolic Dysregulation Following 12 Months of Second-Generation Antipsychotic Treatment in Children: A Prospective Cohort Study.

OBJECTIVE: To determine the risk of developing obesity and related metabolic complications in children following long-term treatment with risperidone or quetiapine. METHODS: This was a 1-year naturalistic longitudinal study conducted between February 2009 and March 2012. A total of 130 children aged 2 to 18 years without prior exposure to second-generation antipsychotics (SGAs) were enrolled at initiation of treatment with either risperidone or quetiapine. Metabolic parameters were measured at baseline and months 6 and 12. Data of 37 participants (20 treated with risperidone and 17 treated with quetiapine) who completed 12-month monitoring were used in the analysis. RESULTS: After 1 year of SGA treatment, mean weight increased significantly by 10.8 kg (95% CI 7.9 kg to 13.7 kg) for risperidone and 9.7 kg (95% CI 6.5 kg to 12.8 kg) for quetiapine. Body mass index z score also increased significantly in both groups (P < 0.001). There was a high incidence of children becoming overweight or obese (6/15 [40.0%] for risperidone-treated and 7/14 [50.0%] for quetiapine-treated). The mean levels of fasting glucose (for risperidone-treated) and ratio of total cholesterol to high-density lipoprotein cholesterol (for quetiapine-treated) increased significantly by 0.23 mmol/L (95% CI 0.03 mmol/L to 0.42 mmol/L) and 0.48 mmol/L (95% CI 0.15 mmol/L to 0.80 mmol/L), respectively. CONCLUSION: Children treated with risperidone or quetiapine are at a significant risk for developing obesity, elevated waist circumference, and dyslipidemia during 12 months of treatment. These data emphasize the importance of regular monitoring for early identification and treatment of metabolic side effects.

Effectiveness of an educational handbook in improving psychiatry resident knowledge of second-generation antipsychotics.

OBJECTIVE: The authors describe a pilot evaluation of an educational handbook designed to increase resident knowledge of second-generation antipsychotic (SGA) use in the pediatric population, with an emphasis on metabolic monitoring. METHODS: An educational handbook focusing on SGA use in children and adolescents was introduced to psychiatry residents undergoing a child psychiatry rotation. Baseline and post-intervention questionnaires were administered to determine whether SGA knowledge increased. RESULTS: Baseline and post-intervention questionnaires were completed by 32 residents. At baseline, most residents (92.9 %) had interacted with an adult patient requiring an SGA and had prescribed SGAs at least five times (70.9 %) in the previous month. Baseline SGA knowledge was limited such that only 5.4 % of participants scored greater than 80 %, and 28.6 % scored below 60 %. Mean total score improved significantly from pre-test (18.4 ± 4.23) to post-test (21.2 ± 3.28, p = 0.001). Stratified analysis suggested a significant improvement of scores (post-test versus pre-test, respectively) in females (21.8 ± 3.11 versus 18.0 ± 4.94, p = 0.003) and junior residents (21.3 ± 3.34 versus 18.1 ± 4.37, p = 0.001). While significant improvements were documented in questions related to Health Canada-approved and other off-label evidence-based indications, and the appropriate physical examination components and laboratory tests to perform at SGA initiation and follow-up, no improvements were documented regarding the distinguishing properties, side effects, and appropriate history-taking prior to SGA initiation. CONCLUSIONS: Implementation of an educational handbook can improve resident knowledge related to SGA use in children over the short-term. However, future research should be directed at the effectiveness of more interactive web-based formats in optimizing learning for male residents and ensuring more comprehensive knowledge uptake. While the introduction of an education handbook is the first step in addressing some of the barriers to metabolic monitoring, prospective longitudinal studies are required to determine whether such an intervention will ultimately improve prescriber adherence over the long-term.

Quetiapine treatment in youth is associated with decreased insulin secretion.

Second-generation antipsychotics (SGAs) are commonly prescribed to youth but are associated with metabolic effects including obesity and diabetes. The mechanisms underlying diabetes development are unclear. The purpose of this study was to compare glucose homeostasis, insulin sensitivity, insulin secretion, and overall ß-cell function in risperidone-treated, quetiapine-treated, and SGA-naive youth with mental illness. We conducted a cross-sectional study in which youth aged 9 to 18 years underwent a 2-hour oral glucose tolerance test. Indices for insulin sensitivity (Matsuda index), insulin secretion (insulinogenic index), and ß-cell function (insulin secretion-sensitivity index-2 [ISSI-2]) were calculated. A total of 18 SGA-naive, 20 risperidone-treated, and 16 quetiapine-treated youth participated. The 3 groups were similar in age, sex, ethnicity, body mass index standardized for age and sex, pubertal status, degree of psychiatric illness, psychiatric diagnoses, and other medications. The median treatment duration was 17 months (range, 3-91 months) for risperidone-treated youth and 10 months (range, 3-44 months) for quetiapine-treated youth. The quetiapine-treated group had lower insulinogenic index (P < 0.01) and lower ISSI-2 (P < 0.01) compared with that in the SGA-naive group. Only the body mass index standardized for age and sex was negatively associated with Matsuda index (ß = -0.540, P < 0.001) in all youth. Quetiapine treatment was negatively associated with insulinogenic index (ß = -0.426, P = 0.007) and ISSI-2 (ß = -0.433, P = 0.008). Quetiapine reduced the insulin expression in isolated mouse islets suggesting a direct ß-cell effect. Our results suggest that quetiapine treatment in youth is associated with impaired ß-cell function, specifically lower insulin secretion. Prospective longitudinal studies are required to understand the progression of ß-cell dysfunction after quetiapine initiation.

Prevalence and patterns of antipsychotic use in youth at the time of admission and discharge from an inpatient psychiatric facility.

The objective of this study was to examine the prevalence and patterns of antipsychotic use in children and adolescents at the time of admission and discharge from a tertiary care inpatient psychiatric facility. This retrospective analysis included all patients 18 years and younger, who were admitted and discharged from a child and adolescent tertiary care inpatient psychiatric facility between May 1, 2008 and December 31, 2009. Data for medications at admission were obtained using a province-wide network that links all pharmacies in British Columbia, Canada to a central set of data systems, whereas data for medications at discharge were obtained using the Department of Pharmacy's (British Columbia Children's Hospital, Vancouver, British Columbia, Canada) inpatient computer database. Apart from antipsychotics, overall drug use included antidepressants, mood stabilizers, benzodiazepines, anticholinergics, stimulants, and sleep medications. Referral and discharge diagnoses were also examined. During the study period, 335 patients were admitted and discharged from the tertiary care inpatient psychiatric facility. Significantly, more patients were prescribed with an antipsychotic at the time of discharge from hospital compared with that of the time when they were admitted to hospital (51.6% vs 30.7%; P < 0.0001). Antidepressants were most often coprescribed with an antipsychotic at admission and discharge (32.0% vs 42.2%, respectively) followed by attention-deficit/hyperactivity disorder medications (22.3% vs 24.9% at admission and discharge, respectively) and anticonvulsants (19.4% vs 19.1% at admission and discharge, respectively). Whether the significant increase in antipsychotic use seen from the time of admission to discharge is solely attributed to clinical worsening or other variables requires further investigation.

A population-based study of antipsychotic prescription trends in children and adolescents in British Columbia, from 1996 to 2011.

OBJECTIVES: To establish prevalence rates of antipsychotic (AP) prescriptions for children 18 years of age or younger in British Columbia (BC) from 1996 to 2011 by age, sex, AP type, and primary diagnosis; and to identify the predominant AP prescribers for children by specialty training. METHODS: BC Ministry of Health administrative data were used to describe AP prescriptions for youth aged 18 years or younger. Comparisons were made using population prevalence based on sex; age group; AP; International Classification of Diseases, Ninth Revision, diagnosis; and prescriber specialty. RESULTS: From 1996 to 2011, overall AP (both first and second generation) prescription prevalence rate increased 3.8-fold (1.66 to 6.37 per 1000 population); second-generation AP (SGA) prescriptions increased 18.1-fold (0.33 to 5.98 per 1000 population). The highest increase in all AP prescriptions occurred in males aged 13 to 18 years (3.3 to 14.4 per 1000 population; 4.4-fold), followed by similar increases in males aged 6 to 12 years (2.3 to 8.6 per 1000 population; 3.7-fold) and in females aged 13 to 18 years (2.8 to 10.7 per 1000 population; 3.8-fold). Overall, the 3 most common diagnoses associated with all AP prescriptions were depressive disorders (12.8%), hyperkinetic syndrome of childhood (11.7%), and neurotic disorders (11.1%); however, variation was observed by prescriber specialty training. Among all new AP prescriptions in 2010/11, 38.6%, 34.3%, and 15.6% were provided by psychiatrists, family physicians, and pediatricians, respectively. CONCLUSIONS: There has been an exponential rise in SGA prescriptions in BC secondary to extensive off-label use, not only by psychiatrists but also by family physicians and pediatricians. Knowledge translation initiatives promoting evidence-based prescribing and monitoring practices related to SGA treatment need to target all 3 prescriber groups and be tailored for age subgroups.

Objectifs : Établir les taux de prévalence des prescriptions d'antipsychotiques (AP) à des enfants et des adolescents de 18 ans et moins en Colombie-Britannique (C.-B.) de 1996 à 2011 selon l'âge, le sexe, le type d'AP, et le diagnostic primaire; et identifier les prescripteurs d'AP prédominants pour les enfants par formation de spécialité. Méthodes : Les données administratives du ministère de la Santé de la C.-B. ont servi à décrire les prescriptions d'AP à des adolescents de 18 ans ou moins. Des comparaisons ont été effectuées au moyen de la prévalence de la population selon le sexe, le groupe d'âge, les AP, la 9e édition de la Classification internationale des maladies, le diagnostic, et la spécialité du prescripteur. Résultats : De 1996 à 2011, le taux global de prévalence des prescriptions d'AP (de la première et de la deuxième génération) a augmenté 3,8 fois (1,66 à 6,37 par 1000 de population); les prescriptions d'AP de deuxième génération (ADG) ont augmenté 18,1 fois (0,33 à 5,98 par 1000 de population). L'augmentation la plus élevée de toutes les prescriptions d'AP a touché les jeunes hommes de 13 à 18 ans (3,3 à 14,4 par 1000 de population; soit 4,4 fois plus), suivie par des augmentations semblables chez les garçons de 6 à 12 ans (2,3 à 8,6 par 1000 de population; soit 3,7 fois plus) et chez les filles de 13 à 18 ans (2,8 à 10,7 par 1000 de population; soit 3,8 fois plus). En général, les 3 diagnostics les plus communs associés à toutes les prescriptions d'AP étaient les troubles dépressifs (12,8 %), l'instabilité de l'enfance (11,7 %), et les troubles névrotiques (11,1 %); toutefois, une variation a été observée dans la formation de spécialité du prescripteur. Parmi toutes les nouvelles prescriptions d'AP en 2010-2011, 38,6 %, 34,3 %, et 15,6 % ont été fournies par des psychiatres, des médecins de famille, et des pédiatres, respectivement. Conclusions : Il y a eu une hausse exponentielle des prescriptions d'ADG en C.-B., consécutive à une vaste utilisation non indiquée sur l'étiquette, non seulement par les psychiatres mais aussi les médecins de famille et les pédiatres. Les initiatives de transmission des connaissances qui prônent des pratiques de prescription et de surveillance fondées sur les données probantes et reliées au traitement par ADG doivent cibler les 3 groupes de prescripteurs et être adaptées aux sous-groupes d'âge.

Health Information Preference among Youth and Caregivers related to Second-Generation Antipsychotic Treatment.

OBJECTIVE: To determine the health information-seeking preferences of youth with mental health challenges and their caregivers, focusing on health literacy needs related to second-generation antipsychotics (SGAs). METHODS: One hundred fifty two youth and 158 caregivers attending outpatient psychiatry clinics at BC Children's Hospital between February 2009 and December 2010 completed a SGA health literacy survey. RESULTS: Youth and caregivers placed emphasis on understanding the benefits and side effects of SGA-treatment, along with strategies to prevent potential side effects. While psychiatrists were viewed as a crucial source of information by both groups, pharmacists were an under-utilized resource by youth. Both youth and caregivers preferred brochures from healthcare providers, websites, and support groups to access health information; however, preferences diverged among other activities. Specifically, youth favoured practical, "hands-on" programs such as cooking and exercise classes, whereas caregivers showed greater interest in didactic presentations and conferences. Sex differences were observed in receptiveness towards certain programs and resources. CONCLUSIONS: The findings from this study support the inclusion of caregivers and youth of both sexes with mental health conditions in the future development of educational resources related to medications such as SGAs. Health literacy strategies need to be multi-faceted, and utilize mixed methods to ensure broad reach and applicability.

Metabolic monitoring training program implementation in the community setting was associated with improved monitoring in second-generation antipsychotic-treated children.

OBJECTIVE: To determine whether implementation of a metabolic monitoring training program (MMTP) in an urban community-based setting improved monitoring in children treated with second-generation antipsychotics (SGAs) and changed prescription rates of SGAs to children. METHOD: The MMTP was implemented in the Vancouver Coastal Health Child and Youth Mental Health Teams (CYMHTs) on January 1, 2009. A retrospective review of paper charts and electronic records for children seen at the CYMHTs from September 1, 2007, to May 1, 2010, was performed to collect the following data: age, sex, foster care, immigrant status, Axis I diagnosis, and medications. In SGA-treated children, anthropometric measurements and blood work completed at baseline and 3, 6, and 12 months were also collected. RESULTS: Among the 1114 children seen pre-MMTP and 1262 children seen post-MMTP implementation, 174 (15.4%) and 81 (6.4%), respectively, were SGA-treated (P < 0.001). Among the SGA-treated children seen at the CYMHTs after MMTP implementation, 38.3% had a copy of the MMTP in their paper chart. Metabolic monitoring increased by up to 40% at baseline (P < 0.01), 20% at 3 (P < 0.01) and 6 months (P < 0.01), and 18% at 12 months after MMTP implementation. CONCLUSIONS: Implementation of an MMTP was associated with significantly improved monitoring rates of anthropometric and blood work parameters at baseline and the 3- and 6-month time points, with a trend for improvement at the 12-month time point, in SGA-treated children cared for in urban community mental health clinics. In addition, a 56% decrease in SGA prescriptions was observed following MMTP implementation in this population.

Waist circumference is a sensitive screening tool for assessment of metabolic syndrome risk in children treated with second-generation antipsychotics.

OBJECTIVE: To compare the prevalence of metabolic syndrome (MetS) and its components in second-generation antipsychotic (SGA)-treated and SGA-naive children; and to explore the utility of clinical markers, such as waist circumference (WC) and body mass index (BMI), as screening tools for MetS. METHODS: Subjects were prospectively recruited from the Psychiatry Emergency Unit at British Columbia Children's Hospital. As part of a quality-assurance project, a metabolic monitoring protocol was implemented, including collection of anthropomorphic and laboratory data. RESULTS: From January 2008 to February 2010, there were 117 SGA-treated and 217 SGA-naive children recruited. The overall prevalence of MetS was 19.0% (16/84; median treatment duration = 14 months) in SGA-treated and 0.8% (1/127) in SGA-naive children (OR 29.7; 95% CI 3.85 to 228.40, P < 0.001), with an increased prevalence of all components except high-density lipoprotein cholesterol (HDL-C), respectively: elevated WC (40.7% and 10.1%; P < 0.001); hypertriglyceridemia (33.7% and 18.8%; P = 0.01); impaired fasting glucose (12.5% and 0.7%; P = 0.005); and elevated blood pressure (41.2% and 16.5%; P < 0.001). SGA treatment was the strongest predictor of MetS (OR 19.2; 95% CI 2.30 to 160.44, P = 0.006) followed by male sex (OR 5.7; 95% CI 1.08 to 30.62, P = 0.04). Presence of abdominal obesity was more sensitive (92.9%) than BMI (68.8%), while fasting glucose of 5.6 mmol/L or more and HDL-C of 1.03 mmol/L or less were most specific (94.1%) in correctly identifying MetS. CONCLUSIONS: SGA treatment confers a significantly increased risk for MetS over the long term. WC measurement is a simple and sensitive screening tool for determining MetS risk in SGA-treated children. These data highlight the dangers of SGA treatment and the importance of standardized metabolic monitoring using sex- and age-adjusted tables in this population.

[Not Available]. / Des recommandations probantes pour surveiller l'innocuité des antipsychotiques de deuxième génération chez les enfants et les adolescents.

BACKGROUND: The use of antipsychotics, especially second-generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use. OBJECTIVE: To synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children, and provide evidence-based recommendations for the monitoring of these side effects. METHODS: A systematic review of controlled clinical trials of SGAs involving children was performed. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. When there was inadequate evidence, recommendations were based on consensus and expert opinion. A multidisciplinary consensus group reviewed all relevant evidence and reached consensus on the recommendations. RESULTS: The present guidelines provide evidence-based recommendations for monitoring SGA safety. The strength of recommendations for specific physical examination manoeuvres and laboratory tests are provided for each SGA medication at specific time points. CONCLUSION: Multiple randomized controlled trials evaluated the efficacy of many of the SGAs in paediatric mental health disorders. These benefits, however, are not without risks - both metabolic and neurological side effects occur in children treated with SGAs. The risk of weight gain, increased body mass index and abnormal lipid levels is greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of the treatment is greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.

Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.

BACKGROUND: The use of antipsychotics, especially second generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use. OBJECTIVE: Our objective was to synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children and make evidence-based recommendations for the monitoring of these side effects. METHODS: We performed a systematic review of controlled clinical trials of SGAs in children. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE system. When there was inadequate evidence to make recommendations, recommendations were based on consensus and expert opinion. A multi-disciplinary consensus group reviewed all relevant evidence and came to consensus on recommendations. RESULTS: Evidence-based recommendations for monitoring SGA safety are provided in the guideline. The strength of recommendations for specific physical examination maneuvers and laboratory tests are provided for each SGA medication at specific time points. CONCLUSION: Multiple randomized controlled trials (RCTs) have established the efficacy of many of the SGAs in pediatric mental health disorders. These benefits however do not come without risk; both metabolic and neurological side effects occur in children treated with these SGAs. The risk of weight gain, increased BMI and abnormal lipids appears greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of treatment appears greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.