Today, we will be discussing the challenges of managing antipsychotic medications in children and adolescents. We will explore various strategies that aim to balance symptom relief with potential side effects, while also guiding towards personalized and safer treatment options. Join us in discovering the art of precision in pediatric mental health care.

Duration:  19 minutes, 25 seconds

Transcript:

JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. This is another special episode from the Child Psychiatry team. I'm Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice. Second edition, 2023, and prescribing psychotropics.

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice, and an avid reader of The Carlat Psychiatry Report. Today we are looking at tapering anti-psychotics, as influenced by Dr. Charmi Patel Rao’s article in our Carlat Child Psychiatry Report October/November/December issue. So, diving in, let's set the stage for today's talk. Dr. Feder, could you give us some context about how antipsychotic meds are being used with kids and teens these days?

JOSH FEDER: Certainly! Here's the scoop: Around 1% of kids between 7 and 12, and about 1.5% of teens aged 13 to 18, are on antipsychotic medications. Some get these medications are for FDA-approved situations like schizophrenia, bipolar disorder, or dealing with irritability linked to autism. But here's the kicker: roughly 65% of the time, these medications are used 'off-label.' Meaning they're given for reasons like tackling aggression, agitation, or other behaviors in ADHD, things that are not officially greenlit. Now, here's the catch – there's not a lot of data about how effective these medications are when used for a long stretch in children and adolescents. But what we do know from studies on humans and animals is that antipsychotics can mess with brain tissue and bring on a bunch of potentially problematic neurological and metabolic side effects. And get this: at high doses, these meds have been linked to higher mortality rates in kids and teens. So, with the inspiration of Dr. Rao's article, today we can dive into how long it's acceptable to use these medications and how to safely dial things down or even stop them altogether.

MARA GOVERMAN: I agree that it's a lot of information to process. When it comes to using antipsychotics in children and adolescents, there are important factors to consider. It's crucial to carefully assess the potential benefits versus the risks, and to evaluate the duration and dosage of these medications. Safety should always be a priority, especially when dealing with developing brains and bodies. The biggest challenge is finding a balance between managing symptoms and minimizing any possible side effects. Dr. Feder what are your thoughts on the issue, and do antipsychotics work in this context?

JOSH FEDER: As Dr. Rao notes, antipsychotics are often used as a quick solution to prevent hospitalization, make it easier for students to experience education, and reduce aggression or self-harm. However, there isn't enough evidence to support their effectiveness in treating severe ADHD or oppositional behavior. Even in situations where the FDA has approved their use, such as in calming irritability in people with autism, it's important to carefully consider whether the patient meets the criteria, such as showing serious aggression, self-harm, or significant mood swings. Sometimes, it may be more beneficial to address other issues, such as sensory problems, or switch to medications with fewer side effects. Although, I want to also note that when antipsychotics are included in a treatment plan for a child or adolescent, it is important to consider the duration of the medication.

MARA GOVERMAN: Yes, that's an important aspect to consider for clinicians. Antipsychotics have gotten the green light from the FDA for a short haul—six months— for kids. But when we look at the longer stretch, there's not a ton of research on how these meds play out in the long run in this population. Now, when we talk antipsychotics, there's a whole list of concerns: think weight gain, diabetes, wonky lipids, feeling super sleepy, heart rhythm consequences like prolonged QT intervals, hormone effects with prolactin, atypical body movements, and even neuroleptic malignant syndrome.

JOSH FEDER: Agreed. To reiterate when these meds are on the table for a child's treatment plan, the duration of how long they're on it? Super important to think through. This brings us again to the question of how to go about the antipsychotic trial. I think Dr. Rao says it best, start with the end in mind. When starting an antipsychotic treatment, it is vital to have a clear understanding of the journey from start to finish. Discuss with the patients and their family about the duration of the treatment and what to expect. It's essential to understand the intensity of the symptoms, the natural progression of the condition, the age of the patient, and other concurrent treatments like therapy.

MARA GOVERMAN: Absolutely! I also want to mention that there is no fixed duration for antipsychotic treatment for non-psychotic cases. Therefore, it is crucial to observe how often and how strongly the specific symptoms appear. Then, work with the patient and their family to determine how much improvement and how long of a good streak would indicate a reduction or cessation of medication. Generally, shorter treatment duration is preferable for most children and adolescents with various conditions. Dr. Feder, do you have anything else to add about the best way to make a trial plan?

JOSH FEDER: We have alluded to it already, but knowing how to taper antipsychotics can be challenging. It's always a good idea to have a chat with the patient and their family during each appointment to discuss how things are going with the treatment. Some things that are some important things to cover are: How have the presenting symptoms improved? Have there been any side effects that are causing concern, like weight gain, elevated cholesterol, feeling sleepy, or involuntary movements? Is the patient taking the medication and following monitoring instructions as directed? Does the patient or their family have any interest in lowering the dose of medication gradually? Checking in on these topics on a regular basis can help make sure that the patient is getting the best possible care and that any issues are taken care of promptly.

MARA GOVERMAN: Yes, navigating the tapering process for antipsychotics can be quite the puzzle. It's a smart move to touch base with the patient and their family every time you meet up to see how the treatment's playing out. You also mentioned how challenging this can be, and sometimes, easing off the meds isn't doable for people dealing with severe psychotic conditions or those who've tried and failed at tapering before. Clinicians should carefully record why you are choosing to use antipsychotics as a course of treatment and watch out for any abnormal metabolic or movement-related side effects.

JOSH FEDER: Stepping back from the meds can be like walking a tightrope, especially for folks facing severe psychotic conditions or those who've had a tough time tapering before. Being thorough in tracking these reasons and side effects ensures the best care for the patient and helps address any issues that arise along the way. I think it is also important to add that it's good practice to review the decision of prescribing antipsychotic medication when you are treating patients who have been taking it under the observation of another provider. If someone has been on these medications for a long time, it's recommended to have a discussion every six months. This will help determine whether continuing the medication is still the right choice based on its effectiveness and any possible side effects. You can initiate this conversation by asking patients and their families about their opinions on the benefits and drawbacks of the medication. If you are dealing with patients who have been taking antipsychotic medications, it is advisable to re-evaluate the decision during your assessment. Moreover, if someone has been taking these medications for an extended period, it is recommended to have a conversation every six months. This will help you decide whether continuing with the medication is still a viable option based on its effectiveness and any side effects that may be present. You can initiate the conversation by asking the patient and their family about the pros and cons of the medication.

MARA GOVERMAN: That is a good point. So, how should providers go about tapering antipsychotics?

JOSH FEDER: As Dr. Rao notes, scaling back on meds doesn't always mean saying goodbye to them altogether. Even making small cuts can sometimes help dodge those pesky side effects, like high cholesterol or sneaky weight gain. Plus, it might lower the chance of odd brain side effects, like tardive dyskinesia. Now, when you and your patient team up to taper off, try these moves:

• Keep it simple when things aren't too tangled up with other conditions or a tumultuous medical

history.

• Hang tight for three to six months of smooth sailing without any new stressors.

• Get your support team ready, possibly leaning on therapy help or school-based services.

• Trim down the dose by around 25% each month.

• Keep the appointments rolling to keep an eye on how those target symptoms are holding up.

MARA GOVERMAN: Additionally, clinicians should take the time to consider changing medications if the first antipsychotic or a certain type of medication is not providing reasonable solutions. It is possible to switch to medications outside of antipsychotics or within the antipsychotic family. If a patient needs to stay on antipsychotics but is experiencing issues, consider shifting to other antipsychotics that might not have as many side effects. This move can also be a good call if previous attempts with antipsychotics have not been successful or if the patient is dealing with severe symptoms such as psychosis or mania after trying other medications.

JOSH FEDER: During our discussion, we discovered that antipsychotic medications can be highly beneficial in saving lives. However, it was emphasized that their usage should be limited to necessary situations, and medical professionals should closely monitor their use through ongoing conversations. This is particularly important to minimize any potential side effects and to discuss the appropriate duration of treatment for each individual case. In summary, while antipsychotics can be valuable in treating certain conditions, we should exercise caution and careful consideration when deciding to use them. For a more compressive take on this topic, please go check out Dr. Rao’s article on our website.

JOSH FEDER: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report, hopefully people will check it out! Subscribers can get printed issues in the mail* and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.

MARA GOVERMAN: And everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.

JOSH FEDER: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding. That helps us to bring you unbiased information that you can trust.

MARA GOVERMAN: As always, thanks for listening and have a great day.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 CreditsTM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.