Maladaptive aggression accompanies different forms of psychopathology Affective disorders (depression, bipolar disorders), PPD, mental retardation, psychosis, PTSD, ADHD, and others can produce maladaptive aggression. The Treatment Recommendations for the use of Antipsychotics for Aggressive Youth (TRAAY) developed by the Center for the Advancement of Children’s Mental Heath and the New York State Office of Mental Health, offers specific guidelines for the use of antipsychotic medications in patients with violent and destructive behaviors. The recommendations were developed from a review of actual prescribing practices, consensus derived from focus groups, consensus of clinical and research experts, and a review of the current pertinent literature. Although, the recommendations have specific relevance for the use of atypical antipsychotics in aggressive behaviors, the principles delineated have broader applicability for the general use of atypical antipsychotic medications. Fourteen recommendations were issued.
The child psychiatrist needs to know that even though he or she attends to the above principles, there is a growing public apprehension over the overuse of these medications in children; especially, there is increasing criticism over the use of antipsychotic medications for behavioral control. Furthermore, there is a growing concern about the serious health risks that antipsychotic medications pose to the safety of children when they are combined with physical interventions; for example, restraint/hold, four-point restraint, or seclusion. These interventions are progressively perceived as coercive and traumatic. Consumers favor benzodiazepines and atypical antipsychotics over restraint or seclusion. In the experts’ opinion, even in psychiatric emergency settings, injectables [intramuscular injections (IM)], are only needed in 10% of the cases. It is likely that consumers’ perceptions are more favorable with the parental antipsychotics olanzapine, and particular with ziprasidone that produces tranquilization without neuroleptization.
Meta-analytic studies showed rather conclusively that ADHD treatment with stimulants and related compounds reduces aggression significantly. The antiaggressive effects are more pronounced in overt aggression that tends to be more impulsive and affectively charged. There is abundant evidence that treatment of childhood onset psychosis, PDD, and mental retardation with antipsychotics results in reduction of overt aggression. Divalproex reduces overt aggression in bipolar offspring and also decreases the affectively charged PTSD-related aggression.
Patel, Crismon, et al. (2005) highlighted that there is no empirical support for the extensive used of atypical antipsychotics for the treatment of aggressive behavior in children and adolescents. Risperidone is the only atypical that has persuasive evidence for efficacy against aggressive behavior across different psychiatric conditions in children and adolescent; however, the supporting data come mostly from short-term studies There are recent long-term studies that support chronic risperidone use in developmentally impaired populations. Although, the use of atypicals for aggressive behavior is off-label, the evidence from randomized control studies represents an evidence-based treatment approach. Underutilization of nonpsychopharmacological treatments and other psychosocial approaches is a major concern. Psychotherapeutic approaches for treatment of aggression of children and adolescents show significant efficacy, and parent management techniques (PMT), and multisystemic therapy (MST), have shown efficacy in the treatment of aggressive youth. In spite of this, the effect size of psychopharmacological treatment is greater than the psychosocial intervention(s) one(s).
There is also a growing concern regarding the psychiatric hospital and residential treatment programs’ physical restraining practices, which are responsible for most of the untimely deaths while the patients are in custody. Children account for up to 26% of the reported deaths in psychiatric facilities.
TABLE Treatment Recommendations for the Use of Antipsychotics in Aggressive Youth (TRAAY)
|1. Conduct a comprehensive psychiatric evaluation before starting pharmacological treatment.|
|2. Determine target symptoms and treatment outcomes.|
|3. Start treatment with psychosocial and educational interventions.|
|4. Use appropriate treatments for primary disorders:|
|• For aggressive youth with verifiable history of ADHD, consider stimulants before antipsychotics;|
|• For aggressive youth with current depressive or anxious symptoms consider SSRI or dual mechanism antidepressants before using antipsychotics;|
|• For aggressive youth with mania or verifiable history of bipolar disorders consider mood stabilizers before using antipsychotics;|
|• For aggressive youth with psychotic symptoms, consider antipsychotic medications at appropriated doses before targeting the treatment of aggression.|
|5. Consider atypical antipsychotic first rather than conventional antipsychotics.|
|6. Use a conservative dosing strategy: “Start slow, go slow, taper slow strategy.”|
|7. Use psychosocial crisis management interventions before medications for acute or emergency treatment of aggression.|
|8. Avoid frequent use of Stat or P.R.N. medications to control behavior.|
|9. Assess side effects routinely and systematically|
|10. Ensure an adequate trial (enough dose and appropriate length of treatment) before changing medications.|
|11. Use a different atypical after a failure to respond to an adequate trial of the initial first-line atypical.|
|12. Consider adding a mood stabilizer after a partial response to an initial first-line atypical.|
|13. If the patient does not respond to multiple medications consider tapering one or more medications.|
|Candidates for discontinuation:|
|• Medications with the highest potential for side effects;|
|• Medications with the highest potential for drug interactions;|
|• Medications or combinations of medications whose side effects may be misinterpreted as treatable symptoms;|
|• Medications with limited empirical evidence to support their efficacy (use);|
|• Optimal tapering and discontinuation are completed in small increments over 2- to 4-week period.|
|14. Consider discontinuing medications in patients who show remission of aggressive symptoms for six months or longer.|
|To the above recommendations we add:|
|15. Atypical medications with supportive empirical evidence should be used before others lacking that literature support.|
|16. Atypical antipsychotics with the safest side effect profile should be used before considering others with more serious side effects.|
|17. Psychiatrists need to be aware of provider’s medication formulary and family’s financial resources when considering the best psychopharmacological alternatives for each patient.|
|18. The CATIE results, suggest the first generation antipsychotics, like perphenazine, may be considered as an effective and a cost effective alternative.|