Prescriptions of antipsychotics for children and teenagers have been increasing year on year globally. In England specifically, more young people are being prescribed antipsychotics for longer periods and more conditions (Radojčić et al., 2023). Despite this continued increase in prescriptions, gaps in the understanding of the long-term effects of antipsychotics use in children and adolescents remain, and challenges in supporting the most acute patients, where antipsychotic trials have not been successful, persist.
In this CYPMHS EveryExpert article, we talk with child and adolescent psychopharmacology specialist Dr Carolina Schneider, CYPMHS Medical Director at Elysium Healthcare and a member of the Psychopharmacology Committee at the Royal College of Psychiatrists. She is the author of two important papers on the use of antipsychotics in children and adolescents. Schneider’s initial study was first published just over a decade ago, in 2014, and reviewed the ongoing clinical challenges of antipsychotics use in children and adolescents for neurodevelopmental, behavioural and psychiatric disorders (Schneider et al., 2014). The second, published in 2015, was a nationwide study conducted in Denmark on clozapine use in childhood and adolescent schizophrenia (EOS), characterising their demographic, clinical and treatment profiles (Schneider et al., 2015). Dr. Schneider continues to be involved in reviewing the use of antipsychotic medication in children and adolescents, in clinical practice and academic groups. We ask Dr. Schneider to look back over the past 10 years and to reflect upon what advances she’s seen in clinical practice and any ongoing challenges.
Carolina, it’s fantastic to talk with you today. Thank you for joining us. It’s been just over 10 years since you published your two papers on antipsychotics use in children and adolescents. What notable changes have you seen in clinical practice during that time?
“Well, in terms of the medication options, olanzapine continues to be the first choice with clinicians within an inpatient setting. There is a pressure, and rightly so, to successfully treat and discharge a young person so they can return to their families or a community setting. Therefore, olanzapine is often chosen because it can produce a positive clinical response that allows discharge to happen. However, there are side effects and some difficulties that can arise after discharge; for example, the patient can experience an increase in weight, which may, in time, mean they stop taking the medication. If this happens, they may experience a deterioration in their mental state and be readmitted to hospital. So, on its own, olanzapine is not a guarantee of success.
“In the case of clozapine, this is still only used in a handful of acute cases despite how successful it can be, because of the associated risk. So, over the past 10 years, this has not really changed. However, one thing that has changed, which is a very, very important change in my opinion, is an increased level of awareness and interest in psychoeducation – learning about and understanding mental health and wellbeing.
“In the past, it would not be uncommon for patients and families to be excluded from decisions around medication, because there was a prevailing opinion that patients would not have the capacity to be involved in medication choice. Typically, the patient would go to the doctor or specialist and follow instructions about what medication to try.
“Now, there is much more explanation around the best option for each patient. We ensure that patients and families understand each option, the pros and cons, any side effects and the wider impact of each course of treatment. We talk about the impact on the brain, and this is tailored to each person, considering their whole story.”
It sounds like psychoeducation is a very important part of co-production (when an individual influences the support and services received). Would you agree?
“Yes, absolutely. It is really important because there is no point in prescribing medication to a patient if they don’t want to take it or don’t have an understanding of why and how it is helping them. They will just stop taking it, and the patient and their family will go through the difficulties again, and the child will put themselves or others at risk. It’s all about working together, and in this way, you can achieve positive outcomes.”
Your earlier research highlighted gaps in the understanding of how pharmacological intervention might interact with cognitive and brain development, and what long-term impacts there were in terms of taking the medication. Has that improved? And are you able to share more with the families so that they can be better informed?
“Yes, 100%. That’s very important because, in terms of antipsychotic medication, we consider the biological impact of the medication, what we are looking for in the brain, and how it works short-term, but also how it can reset the cell in a way.
“I like the word ‘reset’ because this is ultimately what we need the medication to do – help the brain cells to reset. This is the long-term effect we are looking for within the genomic part of the neuron. It is this neuroplasticity, this change in connection of the brain, that would help the young person learn new skills, how to face difficulties and how to stay safe or manage anxiety.
“So, the medication is a tool that helps improve cognitive neuroplasticity, and this is incredibly important when the young person takes part in therapy. The young person is more aroused, more able to learn new things and be stronger emotionally. So that’s what I really try to explain to the patient and the family – medication is not a cure, but a very important tool for a positive outcome.”
Do you find that patients and their families are receptive to that explanation?
“Yes, and positive family involvement is vital to the success of treatment. A young person’s brain goes through so much, especially when there is puberty and all of the biological changes in the brain.
“But with increased neuroplasticity, they are more awake and receptive to new ways of learning. They also have more awareness, and their coping strategies will be more successful. For example, if you have the awareness to realise that you are beginning to feel anxious, such as noticing how your tummy feels, you can then do something about it. If not, things happen, and you don’t realise they have, so you can’t do anything. But if you have awareness, you can verbalise, you can tell someone, and you can do something.”
And is this the same for clozapine?
“In the case of prescribing clozapine, this is given mainly for young people who are psychotic and totally disconnected from reality. Medication can bring them back to reality, in control of themselves and reduce the risk that they usually present to themselves and/or others.
“I would say that I prescribe clozapine to one patient a year on average. They are an acute presentation and fit the known predictors for clozapine. Typically, their journey before they come to us has been very challenging, with input from multiple clinicians, and no treatment has been successful to date. They are very, very high risk and very low functioning.
“In these cases, clozapine can reduce the risk and enable the patient to have a more normal, functioning life. With different medication, a young person may be less psychotic or less depressed, but sometimes, they are still not functioning properly and cannot go to school or cannot go out. Only a partial clinical response has been achieved because their overall functioning has not improved. So, after no clinical response when trying two other antipsychotic medications, clozapine can be considered.”
You said earlier that you have not seen an increase in clozapine use. Is that correct?
“Yes, over the past 10 years, I have not seen an increase in the number of patients who are being prescribed clozapine, and this is down to multiple factors. For example, the potential risk of physical side effects and the complexity of the monitoring that must take place if you do prescribe it, plus the prevalence of new medications that have come to the market.
“But despite this, I believe that clozapine remains a viable option, and because of the rigorous monitoring that takes place (for example, there’s a national database that you need to send the blood test as standardised protocol), the risk is actually low because if there are any negative indicators it can be stopped immediately. Other antipsychotics are not monitored in this way, so sometimes you don’t have a clear view of what is happening.”
References
Schneider, C., Taylor, D., Zalsman, G., Frangou, S., & Kyriakopoulos, M. (2014). Antipsychotics use in children and adolescents: An on-going challenge in clinical practice. Journal of psychopharmacology (Oxford, England), 28(7), 615–623.
Schneider, C., Papachristou, E., Wimberley, T., Gasse, C., Dima, D., MacCabe, J. H., Mortensen, P. B., & Frangou, S. (2015). Clozapine use in childhood and adolescent schizophrenia: A nationwide population-based study. European neuropsychopharmacology: The journal of the European College of Neuropsychopharmacology, 25(6), 857–863.
Radojčić MR, Pierce M, Hope H et al. (2023) Trends in antipsychotic prescribing to children and adolescents in England: cohort study using 2000–19 primary care data. Lancet Psychiatry 10:119–128