Combination psychotropic regimens in community practice

  • Olfson M
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One of the cross-cutting findings to emerge from the large federally funded clinical treatment trials of the common childhood psychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD), adolescent depression, obsessive-compulsive disorder, and anxiety disorders, is that many children do not achieve remission from available pharmacologic or psychological monotherapies. When faced with patients who do not remit or even respond to standard treatments, physicians commonly venture into therapeutic territory that is uncharted by clinical research. Armed with their clinical experience and judgment, the patient's treatment history and current clinical presentation, and an understanding of the principles of pharmacology, physicians set off in search of a medication regimen that is effective and well tolerated by their patients. In this issue of The Journal of American Academy of Child and Adolescent Psychiatry, Rubin and colleagues provide a valuable portrait of national trends (2004 to 2008) in the use of psychotropic medication combinations to treat children and adolescents in the Medicaid program. They focus primarily on treatment with antipsychotic medications in combination with other psychotropic classes, including stimulants, antidepressants, mood stabilizers, or alpha2-agonists. Given the recent overall increase in treatment of young people with antipsychotic medications and the ongoing review of new national quality measurements in this area, such a careful examination of antipsychotic prescribing practices arrives at an opportune time. We learn from Rubin et al. that these combination regimens are common, typically long in duration, and on the rise. The highest rates of use of antipsychotics with other medication classes occur in children and adolescents with severe mental disorders, such as schizophrenia, bipolar disorder, or autism, who also have comorbid psychiatric disorders. Nevertheless, some of the patient groups with the fastest growth in treatment of these regimens have clinical diagnoses that are further removed from evidence-based targets for antipsychotic medications. Specifically, rapid growth is reported in the rate at which children and adolescents with intellectual disabilities without other mental disorders and those with ADHD without other mental disorders are treated with medication combinations including antipsychotics. Such trends raise the specter that treatments with antipsychotics concurrent with other psychotropic medications are spreading to young people with less complicated conditions who do not have psychotic features. Such trends heighten concerns over tradeoffs between risks and benefits. (PsycINFO Database Record (c) 2015 APA, all rights reserved)

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  • Mark Olfson

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