Antipsychotics in child and adolescent patients with major depressive disorder: A retrospective analysis of prescribing patterns.

Introduction: Depression rates in children/adolescents in the United States have increased in the last 10 years. Fluoxetine and escitalopram are the only 2 antidepressants approved for the treatment of major depression disorder (MDD) in children/adolescents. In adults, some antipsychotics are approved for augmented treatment of MDD. However, there is limited research on antipsychotic augmentation in child/adolescent MDD. Methods: This retrospective chart review evaluated antipsychotic prescribing for MDD in hospitalized patients aged 4 to 17 years to determine the frequency of prescribing antipsychotics for MDD and what factors influence the addition of an antipsychotic. For inclusion, patients were diagnosed with MDD and not on an antidepressant or antipsychotic before admission. Binomial logistic regression was used to analyze variables with prescribed antipsychotics as the dependent variable. Results: There were 6.8% of patients prescribed an antipsychotic. Binomial logistic regression analysis found that increased age (odds ratio [OR] 1.28; 95% CI = 1.045, 1.568; P = .017) and multiple admissions within 1 year (OR 3.277; 95% CI = 2.283, 4.705; P < .001) were associated with the use of antipsychotics in patients with MDD. Posttraumatic stress disorder and disruptive mood dysregulation disorder were also associated with the use of antipsychotics. Discussion: Careful consideration should be taken when using off-label antipsychotics in children due to limited studies on efficacy. Future research is warranted to assess the efficacy and safety of these agents in children and adolescents.

Consumer perception, knowledge, and uses of cannabidiol.

Introduction: The legalization of cannabidiol (CBD) across the United States, in varying degrees, has made CBD easily accessible to consumers for complementary and medical purposes. However, there is a paucity of scientific evidence on the benefits and risks of commercially available CBD. In the literature, 2 studies have gathered consumer perceptions and attitudes on cannabis products, specifically CBD, using survey-based questionnaires. This study aimed to build on the aforementioned studies in obtaining consumer perception and knowledge of CBD products using a national survey-based questionnaire. Methods: Respondents were recruited through an anonymous, nationwide, online survey administered through Qualtrics in the United States from March 28 to April 30, 2021. The survey consisted of demographics, perceived efficacy and safety of CBD, and resources to obtain CBD information. The survey responses were reported using descriptive statistics along with median and interquartile range for the Likert portion. Results: A total of 1158 respondents accessed the survey. The median age was 43 and 50% of respondents were female. The uses for CBD included neurological disorders, pulmonary conditions, gastrointestinal disorders, and chronic pain. The most commonly reported safety concern related to taking CBD was anxiety. Participants agreed that CBD is safe when used responsibly for medical use, and social media was the main source used to obtain information about CBD. Discussion: Respondents who used CBD for a condition thought it was helpful; however, most of the adverse effects were rated as moderate to severe, requiring medical attention from a health care professional, hospital, or emergency room visit.

Comparison of inpatient psychiatric medication management in gender diverse youth with cisgender peers.

Introduction: The primary objective was to determine if gender diverse (GD) youth receive different psychotropic prescribing compared with cisgender (CG) peers with the same diagnosis. Secondary objectives include evaluation of readmission rates and the effect of gender-affirming hormone therapy (GAHT) on psychiatric outcomes in transgender (TG) patients. Methods: A total of 255 GD youth patients were retrospectively matched to CG controls based on age, primary discharge diagnosis, and year of admission. Data collection included psychotropic medications at admission and discharge, baseline demographics, time to readmission, and total number of readmissions within 6 months. Use of GAHT was also documented. Wilcoxon signed rank test was used for continuous and χ2 for nominal data with an a priori α of 0.05. Results: MDD was the primary discharge diagnosis in 74% of patients. GD youth were more likely to present on antidepressants (P = .031) and antipsychotics (P = .007), and to be discharged with antipsychotics (P = .003). They were additionally more likely to be readmitted within 30 days of discharge (P = .032). TG youth on GAHT (13%) had fewer readmissions (P = .046) than those not on GAHT, but there were no differences in psychotropic prescribing. Discussion: Higher antipsychotic and antidepressant prescribing were seen in the GD population despite the same mental health diagnosis. Despite higher prescribing in the GD population, patients presented for readmission within 30 days more frequently, which may represent a need for more rigorous transitions-of-care practices in this population.

Initiation of Antipsychotic Treatment for Amphetamine Induced Psychosis and Its Impact on Length of Stay.

Introduction: A risk of amphetamine use is amphetamine-induced psychosis (AIP). Symptoms of AIP include hallucinations, delusions, and agitation. While AIP may resolve with abstinence from amphetamines, antipsychotics are commonly used despite not being FDA approved. The primary objective of this study was to compare length of stay (LOS) for patients with AIP treated with antipsychotics vs untreated. Secondary aims were to determine antipsychotic prescribed, proportion of patients utilizing as needed doses, time to initiation, and readmissions. Methods: A retrospective chart review conducted at an academic medical center identified adult participants who were diagnosed with AIP, admitted to inpatient psychiatry service, and had a urine drug screen (UDS) positive for amphetamines. Patients were excluded if they were already taking an antipsychotic, had active prescriptions for amphetamine salts, or were in the emergency department for more than 48 hours. Demographics were assessed with descriptive statistics. Length of stay was compared between treatment groups using Kruskal-Wallis. Secondary aims were assessed using chi-square, Mann-Whitney U, and Kruskal-Wallis. Results: Sixty-nine patients were included. Median LOS for patients treated with antipsychotics (n = 35) was longer than untreated patients (n = 34), (5 days vs 2.5 days, P = .001). Type of antipsychotic used and time to initiation of antipsychotic were not found to affect LOS. There was no difference in readmissions rates and positive UDS on readmission between groups. Conclusion: This study found patients with scheduled antipsychotics for AIP had a longer LOS than patients who did not receive scheduled antipsychotics. Future studies are needed to evaluate antipsychotic use in AIP.

Implementation and Outcomes of COVID-19 Vaccinations at a Child and Adolescent Psychiatric Hospital.

Increasing coronavirus disease 2019 (COVID-19) vaccination rates has been identified by the US Centers of Disease Control and Prevention as critical to ending the COVID-19 pandemic.1 On May 10, 2021, the Pfizer-BioNTech COVID-19 vaccine (BNT162b2; Pfizer, Inc, New York, New York, and BioNTech SE, Mainz, Germany) was approved for emergency use authorization by the US Food and Drug Administration for patients 12 years of age or older. Here we report a retrospective study describing the implementation of a COVID-19 vaccination program at our child and adolescent psychiatric hospital. To our knowledge, this is the first report detailing the administration of the COVID-19 vaccination in this setting.

Assessing pharmacy students' knowledge and perceptions of urine drug testing following a pharmacy skills laboratory.

INTRODUCTION: Urine drug tests (UDTs) are commonly used in the healthcare setting to monitor adherence, abuse, and diversion of controlled substances. The goal of our study was to assess the knowledge and perceptions of third-year pharmacy students on UDTs following an educational experience. METHODS: Third-year pharmacy students completed pre- and post-questionnaires following a skills laboratory focused on the use of UDTs in clinical settings. The 34-item questionnaires consisted of three domains: demographics, knowledge regarding UDTs, and personal perceptions of UDTs. A pre-lab teaching podcast was assigned prior to the laboratory session, and two clinical cases were discussed during the live UDT segment. Descriptive statistics were used to assess demographics, and changes in knowledge and perceptions of UDTs were evaluated using chi-square and Mann-Whitney U, respectively, with an a priori alpha of 0.05. RESULTS: One hundred twenty students were included in the analysis. Students in the laboratory were predominately female (n = 72, 60%), Caucasian (n = 84, 70%), and had no prior training with UDTs (n = 104, 86.7%). Student knowledge of UDT interpretation significantly increased from 57% to 71% (four and five correct answers out of seven, respectively). Confidence interpreting UDTs and answering questions related to UDTs also increased significantly. Students felt the laboratory experience was valuable, with 84.2% agreeing or strongly agreeing. CONCLUSIONS: Educational programming focused on UDTs improves student confidence interpreting results and knowledge related to the use of UDTs.

A nationwide survey of pharmacy students' knowledge and perceptions regarding medical cannabis.

OBJECTIVE: The primary objective of this study was to compare knowledge and perceptions of medical cannabis (MC) between pharmacy students who attended schools where MC was legal and illegal. DESIGN: A nationwide anonymous survey regarding MC was distributed to pharmacy students. The survey consisted of the following sections: (1) demographics and personal factors, (2) knowledge assessment of indications and adverse effects of MC, and (3) perceptions assessment. SETTING AND PARTICIPANTS: Equal numbers of pharmacy schools were selected and sent surveys based on geographical regions, private versus public universities, and the state's legal status of MC for first through fourth-year pharmacy students to complete. OUTCOME MEASURES: Student knowledge of MC indications and adverse effects were treated as quizzes. Median percentage correct and whether students passed the quizzes (≥ 70%) were evaluated based on the state's legal status. Students' perceptions were similarly compared. RESULTS: A total of 629 students accessed the survey. Most students who completed the survey attended pharmacy schools where MC was illegal (55%), were female (68%), and had personally tried cannabis (53%). Overall, 91% of students believed that MC should be legalized nationally. A low number of students correctly identify approved indications with 14.8% of students in states with MC legalization scoring greater than 70% compared with 15.9% of students in states without MC legalization (P = 0.748). Similar findings were seen in the side effects quiz with only 6.1% of students in states with legal MC scoring greater than 70% compared with 7.4% of students where MC is illegal (P = 0.569) There were minimal differences in students' perceptions of MC based on the states' legal status. CONCLUSION: Our study continues to highlight that pharmacy students lack knowledge and preparation to counsel and educate on MC. With increasing state legalizations, pharmacy schools need to address this knowledge gap to ensure optimal patient care.

Determination of combination therapy prescribing patterns for the treatment of acute agitation in psychiatric patients: A regression model of patient diagnoses and demographics.

INTRODUCTION: Guidelines for the treatment of acute agitation typically recommend monotherapy with an antipsychotic or a benzodiazepine, but combination therapy is frequently used in practice. We created a regression model to identify which factors lead to the prescribing of combination therapy for acute agitation on a psychiatry unit. METHODS: We collected retrospective data from hospitalized patients in the psychiatry unit. An a priori alpha of 0.05 was used for binary logistic regression models to determine if and how the number of prescribed medications for acute agitation was influenced by: age, sex, race, cardiovascular comorbidities, and psychiatric diagnoses. RESULTS: We identified 1998 encounters from 1200 patients. Patients are significantly more likely to be prescribed combination therapy if they are young, male, and of non-white race or have a diagnosis of central nervous system stimulant use, hallucinogen use, depression, bipolar, cluster B personality, or psychosis. Patients are significantly more likely to be prescribed monotherapy if they have cardiovascular comorbidity or have neurocognitive disorder. DISCUSSION: Several demographic or diagnostic factors predict combination therapy prescribing. Acute agitation guidelines should be reviewed to include more clear instructions on combination therapy use.

Medical Students' Perceptions on the Role of Pharmacists.

BACKGROUND:: Over the last decade, the pharmacists' role in health-care services has evolved and expanded to include more direct patient care and disease management services. OBJECTIVE:: To evaluate medical students' perceptions on pharmacists, their role in health care, and demographic or experiential factors that influenced the medical students' opinions. METHODS:: Medical students, at a Midwest, academic medical center, were solicited to complete a cross-sectional, web-based survey consisting of 3 domains: basic demographics, knowledge of the pharmacy profession, and opinions of pharmacists. RESULTS:: Participants supported pharmacists' role in recommending and monitoring drug therapy. However, participants did not support pharmacists' role in performing physical examinations, health screenings, or managing patients with chronic diseases. The main factors that influenced perceptions of pharmacists were female gender and frequent (weekly or more) interaction with a pharmacist or pharmacy student. Neither year in medical school nor participation in intercollaborative practice significantly influenced perceptions of pharmacists. CONCLUSION:: This survey highlights the need to improve the education medical students receive about pharmacists' contribution to the health-care team and the importance of increasing the interaction between medical students and pharmacists or pharmacy students to enhance interprofessional collaboration.

Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens.

Urine drug testing is frequently used in clinical, employment, educational, and legal settings and misinterpretation of test results can result in significant adverse consequences for the individual who is being tested. Advances in drug testing technology combined with a rise in the number of novel misused substances present challenges to clinicians to appropriately interpret urine drug test results. Authors searched PubMed and Google Scholar to identify published literature written in English between 1946 and 2016, using urine drug test, screen, false-positive, false-negative, abuse, and individual drugs of abuse as key words. Cited references were also used to identify the relevant literature. In this report, we review technical information related to detection methods of urine drug tests that are commonly used and provide an overview of false-positive/false-negative data for commonly misused substances in the following categories: cannabinoids, central nervous system (CNS) depressants, CNS stimulants, hallucinogens, designer drugs, and herbal drugs of abuse. We also present brief discussions of alcohol and tricyclic antidepressants as related to urine drug tests, for completeness. The goal of this review was to provide a useful tool for clinicians when interpreting urine drug test results and making appropriate clinical decisions on the basis of the information presented.

Psychotropic medication use in hospitalized patients with borderline personality disorder.

INTRODUCTION: Use of medications to treat symptoms of borderline personality disorder (BPD) is controversial. The purpose of this study was to describe psychotropic medication use in hospitalized patients with BPD and compare with a control group. METHODS: A retrospective chart review was conducted on hospitalized patients aged 18-65 years having a diagnosis of BPD and compared them with a control group of patients with a diagnosis of major depressive disorder (MDD) without a personality disorder. Patients were excluded from the BPD group if other personality disorders were recorded. Charts were reviewed for demographics and psychotropic medication usage both prior to admission and at discharge. RESULTS: This study included 165 patients (85 in BPD; 80 in MDD). Prior to admission and upon discharge, patients in the BPD group were prescribed significantly more psychotropic medications than patients with MDD (3.21 vs 2.10; P < .001 and 2.87 vs 2.35; P < .05, respectively). Patients in the BPD group were significantly more likely to be prescribed antipsychotics, mood stabilizers, and miscellaneous agents compared with the MDD group. On admission, significantly more BPD patients were prescribed multiple sedative agents (37.6% vs 21.3%; P < .05), but because of the discontinuation of sedative agents, this difference was nonsignificant upon discharge. DISCUSSION: This study found increased medication utilization among patients with BPD. Polypharmacy may increase the risk of side effects, drug interactions, and drug toxicity for BPD patients. Clinicians need to carefully evaluate the efficacy and risk of medications prescribed in patients with BPD.

Pharmacy Students' Knowledge and Attitudes Regarding Medical Marijuana.

OBJECTIVE: To determine pharmacy students' knowledge of and attitudes toward medical marijuana and to determine if pharmacy students need additional education on the topic. METHODS: Pharmacy students were asked to complete a survey on medical marijuana that assessed their knowledge of, medical uses of, adverse effects with, and attitudes toward medical marijuana through 23 Likert-scale questions. RESULTS: Three hundred eleven students completed the survey. Fifty-eight percent of the students felt that medical marijuana should be legalized in all states. However, the majority of students did not feel comfortable answering consumers' questions regarding efficacy, safety, or drug interactions related to the substance. Accurate responses for diseases or conditions for permitted medical marijuana use was low, with only cancer (91%) and glaucoma (57%) identified by more than half the students. CONCLUSION: With an increasing number of states adopting medical marijuana use, pharmacy schools need to evaluate the adequacy of medical marijuana education in their curriculum.

Quality of monitoring for metabolic effects associated with second generation antipsychotics in patients with schizophrenia on public insurance.

Second generation antipsychotics (SGA) are associated with new onset diabetes, dyslipidemia and significant weight gain. Patients with schizophrenia are also at an increase risk of developing metabolic disorders, making routine metabolic monitoring important in patients with schizophrenia. The objective of our study was to identify glucose and lipid monitoring rates in Kansas Medicaid beneficiaries with schizophrenia who received long-term SGA therapy both before and after metabolic concerns of SGA had been introduced in the medical literature and after publication of metabolic monitoring guidelines from professional organizations in 2004. A retrospective cohort study was conducted using health care claims of Kansas Medicaid enrollees (age 18-64 years) with a diagnosis of schizophrenia and receiving long-term SGA. Proportions of these patients receiving annual blood glucose and serum lipid laboratory tests were calculated for two periods: 2002-2003 and 2005-2007. Bivariate and multivariate analyses were conducted to determine associations between demographic characteristics and monitoring outcomes. Among 2204 persons in the 2002 cohort, 23% received annual blood glucose monitoring and 10.1% received lipid monitoring. Among 1646 persons in the 2006 cohort, 75.3% received blood glucose monitoring and 52.5% received lipid monitoring. Our findings showed significant increases in blood glucose and lipid monitoring rates observed across a 4-year period in Kansas Medicaid enrollees with schizophrenia receiving SGA. The large rise in monitoring over time may be due to increase awareness of metabolic concerns by mental health care specialists, whom patients with schizophrenia are likely to receive their care from.

Pharmacy students' knowledge of black box warnings.

OBJECTIVE: To evaluate the progression of pharmacy students' knowledge of black box warnings across 3 years of didactic training, and to determine how they stay current with new warnings. METHODS: A cross-sectional survey instrument was administered to pharmacy students in their first (P1), second (P2), and third (P3) professional years. The survey assessed student awareness of medications possessing a black box warning and familiarity with the warning content for 20 medications (15 with and 5 without warnings). RESULTS: Mean number of correct responses identifying the presence or absence of a black box warning among the 20 medications were 5.8 +/- 3.3, 9.6 +/- 4.0, and 14.8 +/- 2.8 for the P1, P2, and P3 students, respectively. Knowledge of black box warning content was variable. Students were least aware of the warning content for stavudine and enoxaparin. Students were most familiar with the warning content for paroxetine and estrogen. CONCLUSION: Students' awareness and understanding of black box warnings was proportional to their educational progression, but their knowledge level was inconsistent across drug groups.

Urine drug screening: practical guide for clinicians.

Drug testing, commonly used in health care, workplace, and criminal settings, has become widespread during the past decade. Urine drug screens have been the most common method for analysis because of ease of sampling. The simplicity of use and access to rapid results have increased demand for and use of immunoassays; however, these assays are not perfect. False-positive results of immunoassays can lead to serious medical or social consequences if results are not confirmed by secondary analysis, such as gas chromatography-mass spectrometry. The Department of Health and Human Services' guidelines for the workplace require testing for the following 5 substances: amphetamines, cannabinoids, cocaine, opiates, and phencyclidine. This article discusses potential false-positive results and false-negative results that occur with immunoassays of these substances and with alcohol, benzodiazepines, and tricyclic antidepressants. Other pitfalls, such as adulteration, substitution, and dilution of urine samples, are discussed. Pragmatic concepts summarized in this article should minimize the potential risks of misinterpreting urine drug screens.

Relapse rates in patients with schizophrenia receiving aripiprazole in comparison with other atypical antipsychotics.

OBJECTIVE: Aripiprazole is the first of a new generation of antipsychotics that possesses a unique mechanism of action as a partial dopamine agonist. After the release of aripiprazole, case reports appeared conveying an acute psychosis/agitation reaction occurring after the initiation of treatment, most specifically after patients were switched from a previous antipsychotic to aripiprazole. The primary objective of this study was to compare relapse rates among patients with schizophrenia who were switched to aripiprazole with those who switched to a second-generation antipsychotic (SGA) from another antipsychotic. METHOD: The design was a retrospective cohort study based on Kansas Medicaid enrollees with an ICD-9-CM diagnosis code for schizophrenia during calendar year 2002 who switched antipsychotic agents. Six-month psychiatric relapse rates, defined as hospitalization for a psychiatric event, were compared between those subjects who switched to aripiprazole and those who switched to another SGA. Time to relapse was modeled using Cox proportional hazards, adjusting for demographic characteristics, major comorbid conditions, and prior psychiatric-related health care use. RESULTS: Four hundred forty-four aripiprazole and 521 SGA switchers were comparable with respect to gender, race, comorbidities, and health care utilization, though the aripiprazole group was 4.5 years younger. Twenty percent of aripiprazole patients and 19.4% of patients receiving SGAs were hospitalized 6 months after being switched (relative risk = 0.92; 95% CI = 0.67 to 1.26). Mean times to psychiatric hospitalization for the aripiprazole and SGA groups were 65.7 and 73.8 days, respectively (p > .05). Factors associated with hospitalization were prior psychiatric hospitalizations and comorbid depression, substance abuse, and neurotic, personality, and nonpsychotic mental disorders. CONCLUSION: Our study found that rates of relapse and time to relapse with aripiprazole were comparable to other SGAs during a 6-month period. Thus, aripiprazole appears to be an appropriate first-line agent along with the other SGAs.

Medication utilization patterns and methods of suicidality in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a psychiatric disorder characterized by suicidal thoughts/attempts and instability of mood, interpersonal relationships, and self-image. Patients with BPD engage in manipulative acts in apparent attempts to exert control in their interpersonal relationships. This issue of control may also be exhibited in their manner of self-medication. OBJECTIVE: To examine the medication utilization patterns of patients with BPD versus patients without personality disorders in a control group and to compare methods of suicidality between the groups. METHODS: A randomized, retrospective, chart review study was conducted at an academic medical center psychiatric hospital. The study examined the medication utilization patterns and methods of suicidality displayed over a one-year period for 29 patients hospitalized with BPD versus 29 patients in a control group. RESULTS: The number of psychotropic, non-psychotropic, and total drugs on admission and discharge was significantly greater for patients with BPD compared with patients in the control group. There was no significant difference between the 2 groups with respect to overdose and cutting methods of suicidality. The mean number of Axis III discharge diagnoses in the control group upon discharge was significantly less than that in the study group. Approximately 25% of patients with BPD considered overdosage as a means to end their life. CONCLUSIONS: As patients with BPD receive more medications than patients without the disorder and often exhibit suicidal thoughts/attempts, clinicians should closely monitor the use of all medications.