Antipsychotic polypharmacy in children and adolescents at discharge from psychiatric hospitalization

Abstract

Study objective: Antipsychotic polypharmacy-the use of more than one antipsychotic concomitantly-has increased in children and adolescents and may be associated with increased adverse effects, nonadherence, and greater costs. Thus, we sought to examine the demographic and clinical characteristics of psychiatrically hospitalized children and adolescents who were prescribed antipsychotic polypharmacy and to identify predictors of this prescribing pattern.

Design: Retrospective medical record review.

Setting: The inpatient psychiatric unit of a large, acute care, urban children's hospital.

Patients: One thousand four hundred twenty-seven children and adolescents who were consecutively admitted and discharged between September 2010 and May 2011.

Measurements and main results: At discharge, 840 (58.9%) of the 1427 patients were prescribed one or more antipsychotics, and 99.3% of these received second-generation antipsychotics. Of these 840 patients, 724 (86.2%) were treated with antipsychotic monotherapy, and 116 (13.8%) were treated with antipsychotic polypharmacy. Positive correlations with antipsychotic polypharmacy were observed for placement or custody outside the biological family; a greater number of previous psychiatric admissions; longer hospitalizations; admission for violence/aggression or psychosis; and intellectual disability, psychotic, disruptive behavior, or developmental disorder diagnoses. Negative correlations with antipsychotic polypharmacy included admission for suicidal ideation/attempt or depression, and mood disorder diagnoses. Significant predictors of antipsychotic polypharmacy included admission for violence or aggression (odds ratio [OR] 2.76 [95% confidence interval (CI) 1.36-5.61]), greater number of previous admissions (OR 1.21 [95% CI 1.10-1.33]), and longer hospitalizations (OR 1.08 [95% CI 1.04-1.12]). In addition, diagnoses of intellectual disability (OR 2.62 [95% CI 1.52-4.52]), psychotic disorders (OR 5.60 [95% CI 2.29-13.68]), and developmental disorders (OR 3.18 [95% CI 1.78-5.65]) were predictors of antipsychotic polypharmacy.

Conclusion: Certain youth may have a higher likelihood of being prescribed antipsychotic polypharmacy, which should prompt careful consideration of medication treatment options during inpatient hospitalization. Future examinations of the rationale for combining antipsychotics, along with the long-term safety, tolerability, and cost effectiveness of these therapies, in youth are urgently needed.

Keywords: antipsychotic; child and adolescent psychiatry; polypharmacy; psychiatric hospitalization.

Figure 1

Predictors of antipsychotic polypharmacy at discharge from inpatient psychiatric hospitalization. The odds ratios for antipsychotic polypharmacy, in association with clinical and demographic factors, were determined by multivariate logistic regression. Horizontal lines represent 95% confidence intervals. *Odds ratios for number of prior admissions and length of stay correspond with a one-unit (e.g., 1 day or 1 hospitalization) increase in the variable; **Truncated (confidence interval 2.29-13.68).