1. Only one antipsychotic medication should be used at a time. Combinations of antipsychotics should not be tried until monotherapy with different available agents, including conventional antipsychotics, has been used for an extended period of time, for at least six weeks, at therapeutic doses (for each medication), or when single medications at therapeutic levels bring forth unacceptable side effects or increased health risks. There is no evidence-based data to support the use of antipsychotic combinations.
2. Given the patient’s health status, an antipsychotic medication with a better-known effectiveness and a more benign side effect profile should be tried first.
3. Atypical antipsychotic medications with supportive literature should take priority over the ones without published evidence.
4. The CATIE report (2005) stimulates the thinking that perphenazine (and probably other first generation antipsychotics) could be considered alternative treatment options for children and adolescents.
5. Psychiatrists should inform parents or guardians that although antipsychotic medications are extensively used in current psychiatric practice, these medications are not Federal Drug Administration (FDA) approved for use in pediatric populations. Child and adolescent psychiatrists need to appreciate that they carry a higher legal liability for prescribing medications off label.
TABLE Considerations in the Selection of Antipsychotic Medications for Patients with Higher Health Risks lists a number of considerations forusing antipsychotic medications with higher health risks.
1. In patients with overweight/obesity (BMI > 30), the clinician should select medications that are least likely to aggravate the patient’s risks of obesity as well of those of hyperglycemia or diabetes, hypercholesterolemia or hyperlipedemia, or other metabolic syndrome features, sleep apnea, or gall bladder disease.
2. “Counteractive polypharmacy,” the concomitant use of a medication to counteract side effects of another drug, should only be used when the patient responds specifically only to a given drug and that medication brings on undesirable health risks.
TABLE Considerations in the Selection of Antipsychotic Medications for Patients with Higher Health Risks
|1. The patient’s psychiatric condition|
|2. Target symptoms|
|3. Target deficits|
|4. Prior history of antipsychotic use|
|5. The patient’s health history including:|
|(a) Cardiovascular history|
|(b) History of:|
|Overweight or obesity|
|Diabetes and lipidemia history|
|History of endocrinological problems:|
|Menstrual problems, polycystic ovarian disease, gynecomastia|
The clinician needs to try alternative medications prior to exposing the patient to long-term detrimental side effects. It is not a sound practice to use polypharmacy from the very beginning with the goal of preventing a potential antipsychotic side effect (i.e., risperidone plus cabergoline to avoid hyperprolactinemia).
On the other hand, the concomitant use of weight attenuating agents (i.e., amantadine, nizatidine, or sibutramine, and others) has been proposed to decrease the rate of weight gain and other metabolic complications promoted by some atypical antipsychotics.
3. When the patient has gynecomastia, menstrual or other endocrine difficulties, neuroleptics with low prolactin elevation induction risk should be used.
4. If the patient has prior exposure to neuroleptics and subsequently developed undesirable metabolic or neurological side effects, antipsychotics with a lower likelihood of reproducing these complications should be selected.
5. The nature of the comorbidity and possible interactions with concomitant medications will also have a bearing in the antipsychotic selection.
6. When there is no response to atypicals, first generation antipsychotics and other medications should be considered. A number of psychotic children do not respond to atypical antipsychotic medications. If patients do not show benefits in their psychotic symptoms, after a meaningful time and at a high enough dose, the antipsychotic should be discontinued. The caveat is that even though the atypical medication may not be effective against psychotic symptoms, it may have produced beneficial effects in mood, anger control, sleep, or other symptoms. These beneficial effects are frequently not appreciated until the medications are discontinued. Patients who do not respond to atypical antipsychotics may respond to conventional ones. Nonantipsychotic medications and alternative nonpsychopharmacological approaches (psychosocial interventions) should be tried when there is no response to antipsychotic medications.
7. Occasionally, psychotic symptoms do not respond to antipsychotic medications but respond to mood stabilizers, SSRIs, or other medications. In patients whose psychosis is unresponsive to antipsychotics, psychosocial interventions need to be intensified, and techniques of symptom management (blocking of hallucinations, cognitive behavioral therapy, and others) will assist the child and family to handle the symptoms more effectively. PTSD-related psychoses have limited response to antipsychotic medications; psychosocial interventions should be used preferentially instead, or they should be combined with psychotropics.
The above principles are in line with Tandon and Jibsons (2005) guide to major principles of pharmacotherapy for schizophrenia (TABLE Guide to the Major Principles of Pharmacotherapy for Schizophrenia).
TABLE Guide to the Major Principles of Pharmacotherapy for Schizophrenia
|1. Agent Selection. Select antipsychotic agents based on patient factors and physician factors. Input from the child and family is very desirable.|
|2. Initiation of Therapy.|
|(a) Allow adequate duration of antipsychotic therapy (4 to 6 weeks at optimal dose).|
|(b) If no response or inadequate response, change antipsychotic within 8 to 12 weeks. Obviously antipsychotic will need to be changed sooner if problems with tolerability develop.|
|(c) Use continuous antipsychotic treatment (not targeted or intermittent).|
|3. Dose Adjustments and Switching Strategies|
|(a) If patient display cognitive deficits, avoid anticholinergic medications.|
|(b) If patient experiences side effects, consider a dose adjustment or change of agent.|
|(c) If the patient has been on a typical medication consider switching to an atypical. If the patient does not respond to atypicals, some typical antipsychotics may be considered.|
|4. Adjunctive Treatments|
|(a) Adjunctive treatments should be used for the treatment of nonpsychotic associatedsymptoms such as depression or anxiety, particularly if psychotic symptoms have abated.|
|5. Noncompliance, No Response to Therapy|
|(a) Insure patient is taking medication. Check medication levels if pertinent.|
|(b) When there are objective indicators that the child or adolescent is not taking the medications as prescribed, parents will be made aware of this, and they will be expected to increase surveillance over medication intake.|
|(c) If parents cannot insure regular medication intake consider a child’s referral to CPS.|
|(d) If an adolescent does not comply with medications in spite of parents’ best efforts, consider sublingual preparations or depot antipsychotics. All along, psychiatrists and therapists will make efforts to understand the motivational sources that promote a lack of compliance and the depth of patient’s denial.|
|6. These principles should be respected with regard to continuing use.|