Antipsychotic Prescribing Patterns in Pediatric Patients with Major Depressive Disorder

The prevalence of major depressive disorder (MDD) in children and adolescents in the United States has increased over the past 10 years. Although MDD is one of the most common psychiatric disorders of childhood and adolescence, due to symptom variation from adult criteria, clinicians often fail to recognize and treated it.¹

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The only 2 antidepressants approved for treatment of MDD in the pediatric population are fluoxetine (≥7 years old) and escitalopram (≥12 years old). Recommendations and research on the use of antipsychotics in children and adolescents with MDD are limited. However, physicians still use antipsychotics in children and adolescents in clinical practice. Evidence for antipsychotic use in pediatric population is needed for prescribers to provide the best possible care.²

A team of pharmacists from the University of Kansas Health System examined the frequency of antipsychotic prescribing in child/adolescent patients and associated factors. Study results were published in the February 2024 issue of The Mental Health Clinician from the American Association of Psychiatric Pharmacists.²

The study was a retrospective chart review of 600 child and adolescent patients admitted to a psychiatric hospital at the University of Kansas Medical Center. Patients were 4 to 17 years old with a diagnosis of MDD and were not taking an antipsychotic or antidepressant prior to admission.²

Findings from this retrospective review highlight several factors associated with prescribing antipsychotics in the inpatient setting to children or adolescents with MDD. Adolescent patients of older age were more often prescribed antipsychotics. This is likely due to clinician comfortability with prescribing medications approved for adults in. Multiple admissions within a year were associated with increased antipsychotic prescribing because it indicated disease progression and need for alternative treatment. Patients with comorbid diagnoses of post-traumatic stress disorder and disruptive mood dysregulation disorder were also more commonly prescribed antipsychotics.²

Quetiapine and aripiprazole were the most prescribed antipsychotics in this study. Quetiapine is FDA approved for bipolar mania monotherapy in adolescents (10 to 17 years) and schizophrenia in adolescents (13 to 17 years).³ Aripiprazole is FDA approved for schizophrenia in adolescents, for bipolar mania in pediatric patients as monotherapy or adjunct to lithium or valproate, for irritability associated with autistic disorder in pediatric patients, and for Tourette syndrome.⁴

These findings emphasize the importance of further research on effective and safe alternative treatments for MDD in children and adolescents, specifically in patients who are refractory to nonpharmacologic treatment and/or standard of care antidepressants.

In adults, some antipsychotics are approved as adjunctive treatment for MDD, but the major concerns in children are potential metabolic adverse effects and risk of extrapyramidal symptoms. The study authors state that clinicians must use careful thought and planning when prescribing antipsychotics to children and adolescents with MDD, given the insufficient evidence for efficacy and safety due to long-term adverse effects.

References

1. Mullen S. Major depressive disorder in children and adolescents. Ment Health Clin. 2018;8(6):275-283. Published 2018 Nov 1. doi:10.9740/mhc.2018.11.275

2. Dauchot D, Rettey S, Melton BL, Moeller KE. Antipsychotics in child and adolescent patients with major depressive disorder: a retrospective analysis of prescribing patterns. Ment Health Clin [internet]. 2024;14(1):10-16. DOI: 10.9740/mhc.2024.02.010.

3. Quetiapine [package insert]. AstraZeneca Pharmaceuticals; 2009.

4. Aripiprazole [package insert]. Otsuka Pharmaceutical Co; 2014.