Use of Atypical Antipsychotics in Adolescents - Literature review Example

USE OF ATYPICAL ANTIPSYCHOTICS IN ADOLESCENT By Student’s Name Code + Course name Professor’s Name University/College Name City, State Date Background Atypical antipsychotics are been used in the management of various mental disorders conditions in children, adolescents and even adults that include schizophrenia, bipolar disorders and disruptive behavior disorder (Kumar et al. 2013, p. 6; Loy et al. 2012, p. 6). They have been said to be effective over other antipsychotics in treating most psychotic conditions but this assertion has been highly disputed by some researchers claiming that it’s more of a subjective conclusion than an objective finding (Kendall 2011, p. 267). In addition, evidence to support their use in adolescence is limited giving rise to the research question is the use of atypical antipsychotics (AA) appropriate management for adolescent mental health clients? Evidence of AA’s effectiveness in adults has been generalized and extrapolated to adolescents not considering the fact that these two age groups have significant differences in the presentation of psychosis (Kumar et al. 2013, p. 6). Adolescents have prominent negative symptoms of psychosis and a higher predisposition to extrapyramidal side-effect (EPS) compared to adults, a factor that possess a difference in the activity of AA in adolescents (Kumar et al. 2013, p. 6). AA have been touted to have lower drop-outs rates during treatment owing to their preferred side effect profile (Kendall 2011, p. 267). If this finding applies to adolescents as well is a question that begs more research evidence hence the need for this review. The findings from this review shall be significant to healthcare workers tasked with treating and managing mental disorders in adolescents and shall be a source of evidence-based practice (EBP). This audience is responsible for selecting, administering and monitoring treatment using antipsychotics in adolescents among other age groups. Their choice of antipsychotic should be based on evidence from credible, reliable research such as levels I and II evidence (Burns & Grove 2011, p. 25). Since the medical profession relies on evidence in instituting care, this review shall fortify the existing limited evidence on the use of AA in adolescents. Summary of Findings Article One One study from this review’s literature findings was authored by Correll et al. (2009, pp. 1765-1773) and its title read “cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents”. The study was aimed at identifying the cardiometabolic risk factors associated with the use of AA for the first time among children and youth aged four to 19 years. Examples of the cardiometabolic effects under study included unwanted weight gain, glucose and lipid abnormalities, hypertension and obesity. The study was a “nonrandomized second-generation antipsychotic treatment indications, effectiveness and tolerability in youth (SATIETY) cohort study” (Correll et al. 2009, p. 1766). The study was conducted in Queens, New York for a five years period beginning December 2001 to September 2007 (p. 1766). 338 study participants from a tertiary care in- and out-patient clinics were recruited. Patients enrolled had psychotic disorders that included mood spectrum, disruptive/aggressive behavior, schizophrenia and mood disorders (p. 1766). The comparison group consisted of 15 patients that had either rejected participation or were non-adherent to the study specifications. The study treatment intervention consisted of AA such as olanzapine, risperidone, aripiprazole and quetiapine for 12 weeks (p. 1766). The study’s core outcomes were alterations in metabolic and lipid parameters and a gain in weight. The four study interventions resulted in a significant weight gain among the treated study participants compared to the untreated group (p. 1768). Total cholesterol levels were significantly increased with quetiapine and olanzapine while triglyceride levels were significantly increased with risperidone (p. 1768). However, aripiprazole did not exhibit any significant metabolic changes from baseline. Correll et al. (2009, p. 1771) concluded that the four AA if used as first line for the first time in children and youth cause significant weight gain in patients but varied metabolic changes. Article Two The second study was led by Chen et al. (2014, p. 299) and sought to demonstrate the "comparative effectiveness of monotherapy with mood stabilizers versus second generation (atypical) antipsychotics for the treatment of bipolar disorders in children and adolescents”. The study was a five-year retrospective cohort study on children and youth aged between 6-18 years (p. 300). It was done between 2003 -2007, and the interventions were either AA monotherapy or mood stabilizers monotherapy. The bipolar study participants were initiated on either of the two interventions and were followed and monitored for 12 months. The safety and efficacy of the two interventions on pediatric bipolar disorder were then compared. Outcome measures used included early medication discontinuation, psychotic-related hospital admissions and augmentation of treatment. A total of 7423 bipolar adolescents and children were enrolled. 66.60% of the total study participants were started on AA treatment while 33.40% were initiated on mood stabilizers. The results showed that study participants started on AA and mood stabilizers did not exhibit any significant difference in psychiatric hospital admission risks (p. 306). However, study participants on AA exhibited better tolerability to treatment with more participants lasting the treatment period. Compared to AA, participants on mood stabilizers had higher treatment discontinuation rates and were more likely to have their treatment augmented (p. 306). From the study results, Chen et al. (2014, p. 306) concluded that AA, when used as monotherapy, could have better efficacy and safety compared to the use of mood stabilizers monotherapy in managing pediatric bipolar disorder (PBD). Article Three Olfson et al. (2011, p. 1) compared the effectiveness AA on early-onset schizophrenia. The study involved the analysis of Medicaid claims files in the U.S. Study participants were newly-diagnosed schizophrenic or patients with related disorder aged between 6 and 17 years. 805, 382, 260, 173, and 125 patients were started on risperidone, olanzapine, ziprasidone, quetiapine, aripiprazole and ziprasidone respectively as the interventions under study (2011, p. 3). The outcome measure was psychiatric hospital admissions (PHA) and discontinuation of medication across the various AA. "Cox proportional hazard regressions estimated adjusted hazard ratios" of a 180-day medication discontinuation and 180-day PHA for patients on each intervention (2011, p. 3). The results from the study revealed that in youth study participants, medication discontinuation rates during the 180-day period were 70.7%, 73.3%, 73.7%, 74.7% and 76.5% for quetiapine, ziprasidone, olanzapine, risperidone and aripiprazole respectively (2011, p. 5). Olfson et al. (2011, p.5) added that there was lack of significant difference in adjusted time to AA discontinuation among the interventions when compared to the risperidone reference group. While on study intervention, the percentage of youth admitted to the hospital due to psychiatric conditions ranged from 7.19% to 9.89% for aripiprazole and quetiapine respectively. The adjusted hazard ratios for the interventions were not significantly different when compared to the risperidone reference group. The study concluded that that there was a rapid AA medication discontinuation and PHA during treatment of early-onset schizophrenia even though was not any significant differences in the rates of discontinuation and PHA among the interventions. Article Four In another study authored by Golubchik, Sever, & Weizman (2011, p. 216), the effectiveness of an AA – low-dose quetiapine in treating aggression associated with autistic spectrum disorder (ASD) was assessed. The study was an open-label study done for a period of 8 weeks. 11 study participants were enrolled comprising three adolescent girls and eight adolescent boys aged between 13-17 years, diagnosed with ASD and presenting with sleep disturbances and aggressive behavior. The intervention under study was low-dose quetiapine. ASD severity was assessed using the “Global Impression-Severity (CGI-S), while that of sleep disturbances and aggressive behavior were assessed using the “Child Sleep Habits Questionnaire” and the “Overt Aggression Scale” (OAS) respectively (2011, p. 217). The study results show that quetiapine treatment did not result in significant changes in autistic behavior. On the contrary, Quetiapine treatment resulted to a significant reduction in the severity of aggressive behavior as ascertained by the OAS. The study participants showed a significant improvement in sleep disturbances with a positive correlation between abated aggression and improved sleep (2011, p. 218). The intervention was said to have been well-tolerated by the study participants during the study period. The study concluded that the use of a low-dose quetiapine in adolescents suffering from ASD presenting with sleep disturbances and increased aggression can reduce the latter two symptoms when used for a short time. However, low-dose-quetiapine may not be effective in relieving the severity of ASD for such in an 8-week period (2011, p. 219). Discussion AA have been said to be effective in the management of mental disorders in adults after some research on the use of these drugs in adults suggested their effectiveness (Kumar et al. 2013, p. 6). However, adolescence represents a stage where cases of early onset-mental disorders such schizophrenia are higher compared to adults (Crossley et al., 2010, p. 434). Patients experiencing a first episode of psychotic disorders such as schizophrenia are more susceptible to EPS and metabolic complications that have been associated with typical and AA use (Crosssley et al. 2010, p. 434). Correll et al. (2009, p. 1765) noticed the potential metabolic risk associated with the use of AA in adolescents. Adolescence been an age-group where medication associated bodily changes can affect adherence, the findings of this study would be significant to managing adolescents with mental disorders (Yazdi et al. 2008, p. 160). Bodily changes such as weight gain and increased waist circumference may have an impact on the self-esteem of an adolescent, and if the adolescent realizes the changes are associated with antipsychotics medications, risks of discontinuing the treatment are high thus lowering the effectiveness of the treatment and diminishing prospects of faster recovery (Yazdi et al. 2008, p. 163; Correll et al. 2009. p. 1767). Among the four AA, that is olanzapine, quetiapine, risperidone and aripiprazole, the latter exhibited the least weight gain and non-significant metabolic changes (Correl et al. 2009, p.1767). Therefore, aripiprazole may be considered to be the better of the mentioned AA in terms of the likelihood to result in unwanted cardiometabolic changes. Tolerability of medication is paramount to a successful treatment and appropriate management of mental disorders in adolescents. If medications use leads to a high discontinuation rate when initiated, and better medicines with lower discontinuation rates are not available, management of the mental condition may be complicated. Olfson et al. (2011, p. 8) suggested that most AA have high rates of discontinuation when used for the first time in adolescents. Moreover, worsening of symptoms leading to PHA is a common occurrence when using antipsychotic medication in adolescents for the first time. However, this is less common with AA when compared to mood stabilizers as suggested by Chen et al. (2014, p. 306). Chen et al. (2014, p. 307) suggested AA to be better than mood stabilizers in management of bipolar disorders, although the same cannot be said in comparison with typical antipsychotics as Crossley et al. (2010, p. 437) suggested that there is no significant evidence to support superiority in efficacy of AA over typical antipsychotics. Occurrence of weight gain and metabolic changes associated with AA use in adolescents is supported in addition to the aspect that olanzapine could be among the most notorious for these adverse drug reactions (Chen et al. 2014, p. 306). Aripiprazole exhibited the least metabolic and weight changes in Correll et al.'s (2009, p. 1767) and it equally resulted in less PHA than most other AA in Olfson et al.’s (2011, p. 7) study. This shows that aripiprazole could be among the most effective and safer AA for use in adolescents although such an assertion require more research substantiation. Specific AA such as quetiapine can be effective in alleviating aggressiveness in behavior and ameliorate sleep disturbances in adolescents with ASD (Golubchik, Sever & Weizman, 2013, p. 218). Decreased aggression resulted in better sleep with minimal disturbances. This correlation draws some ambiguity in that it is not clear whether quetiapine directly resulted in better sleep, or the improved sleep was as a result of diminished aggressiveness caused by quetiapine. Nevertheless, the study suggested that quetiapine is an AA that is well-tolerated in adolescents although it was not compared to other AAs. This is unlike the other studies that depicted quetiapine and other AAs to be drugs that are not well tolerated by adolescents. Conclusion There continues to be limited evidence to support the use of AA in adolescents. Available research has majored on the use of AA in adults. However, since adolescents have different tolerability to AA compared to adults, more specific research on this age group on the same intervention is warranted to support the assertions that they are effective and safe in adolescents. This review shows AA to have a side effect profile of metabolic changes and weight gain not common with other antipsychotics that have been implicated in medication discontinuation and adherence issues in some participants. The inconsistency of results suggests there is still insufficient or uncorroborated evidence to support the use of AA medicines as the appropriate medication management of mental disorders in adolescents as their side effects seem to overlap with their efficacy. Relative to other drugs used in the management of mental disorders in adolescents, AA need to be compared to them in terms of efficacy and safety to ascertain the most appropriate group of medication for this purpose. 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