Search

Knowledge about the diagnosis of autoimmune encephalitis (AE) is rapidly expanding. In the last 15 years, multiple new antibodies have been described. Anti-N-methyl-D-aspartate receptor (NMDAR)–antibody-mediated encephalitis, in particular, has been found to be common among teenagers and young adults1 and accounts for up to 86% of AE in patients aged 18 years present with behavioral, psychiatric, and/or memory issues ∼75% of the time. In the pediatric population of those aged

The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery.This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS.We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (rTotal postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology.Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.

Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments.We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children's Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool.Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022.Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.

Despite growing recognition of how curriculum modules can benefit child and adolescent psychiatry (CAP) training, there are few standardized teaching resources for pediatric consultation-liaison psychiatry (PCLP). A Special Interest Group (SIG) of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee (PICC) conducted a needs assessment to establish interest in, and availability of, a library of online, self-paced learning modules specific to PCLP.An email needs assessment survey was distributed to the PICC listserv in the fall of 2019 with four core areas of inquiry: (1) clinical service description, (2) teaching barriers, (3) interest in curriculum resources, and (4) interest in evaluation resources.Respondents were representative of typical academic PCLP programs. The response rate was 28% (n = 39). Programs endorsed barriers to teaching including high service obligations and limited protected teaching time. All respondents indicated that they would utilize high-quality, online learning modules. Psychiatric complications of medical illness, catatonia, and delirium were identified as priority topics in the care of pediatric patients with comorbid medical conditions.There are currently no published educational studies regarding the training needs for PCLP programs, even among tertiary care academic facilities. This training needs assessment is the first step in establishing a national PCLP training curriculum. New paradigms to develop standardized curriculum resources for PCLP are needed.

OBJECTIVES Pediatric behavioral health admissions to children’s hospitals for disposition planning are steadily increasing. These children may exhibit violent behaviors, which can escalate to application of physical limb restraints for safety. Using quality improvement methodology, we sought to decrease physical restraint use on children admitted to our children’s hospital for behavioral health conditions from a baseline mean of 2.6% of behavioral health patient days to METHODS We included all children ≥3 years of age admitted to our hospital medicine service with a primary behavioral health diagnosis from July 1, 2016, to February 1, 2020. A multidisciplinary team, formed in July 2018, tested interventions based on key drivers targeted toward our aim. The primary outcome measure was the percent of behavioral health patient days on which physical restraints were ordered. The balancing measure was the percent of patient days with a staff injury event. Statistical process control charts were used to view and analyze data. RESULTS Our cohort included 3962 consecutive behavioral health patient encounters, encompassing a total of 9758 patient days. A 2-year baseline revealed physical restraint orders placed on 2.6% of behavioral health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries. CONCLUSIONS Team-based quality improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to our children’s hospital. These results indicate that physical restraint use can be safely reduced in children’s hospitals.

Transitional age youth with a history of mood disorders, such as major depressive disorder, are uniquely vulnerable to clinical destabilization and relapse in the context of life transition. Moving from a structured adolescence to a more independent and potentially more demanding young adult life can result in worsening symptoms and barriers to effective help-seeking. Transitional age youth newly diagnosed are exposed to their first course of treatment of a potentially chronic condition. This article describes the challenges inherent in navigating this life transition, and also offers strategies to promote a successful "launch" into adulthood.

OBJECTIVES ICU delirium is a predictor of greater morbidity and higher mortality in the pediatric population. The diagnostic obstacles and validity of delirium monitoring among neonates and young infants have yet to be fully delineated. We sought to validate the Preschool Confusion Assessment Method for the ICU in neonates and young infants and determine delirium prevalence in this young population. DESIGN Prospective cohort study to validate the Preschool Confusion Assessment Method for the ICU for the assessment of ICU delirium in neonates and young infants compared with the reference standard, Child and Adolescent Psychiatry. SETTING Tertiary medical center PICU, including medical, surgical, and cardiac patients. PARTICIPANTS Infants less than 6 months old admitted to the PICU regardless of admission diagnosis. MEASUREMENTS AND MAIN RESULTS We enrolled 49 patients with a median age of 1.8 months (interquartile range, 0.7-4.1 mo), 82% requiring mechanical ventilation. Enrolled patients were assessed for delirium in blinded-fashion by the research team using the Preschool Confusion Assessment Method for the ICU and independently assessed by the psychiatry reference rater using Diagnostic and Statistical Manual of Mental Disorders-5 criteria. A total of 189 paired assessments were completed, and the Preschool Confusion Assessment Method for the ICU performed with a sensitivity of 95% (95% CI, 89-100%), specificity of 81% (68-90%), "negative and positive predictive values" of 97% (94-100%) and 69% (55-79%), respectively, compared with the reference rater. Delirium prevalence was 47%, with higher rates of 61% observed among neonates (< 1 mo old) and 39% among infants 1-6 months old. CONCLUSIONS The Preschool Confusion Assessment Method for the ICU is a valid screening tool for delirium monitoring in infants less than 6 months old. Delirium screening was feasible in this population despite evolving neurocognition and arousal architecture. ICU delirium was prevalent among infants. The consequence of acute brain dysfunction during crucial neurocognitive development remains unclear. Future studies are necessary to determine the long-term impact of ICU delirium and strategies to reduce associated harm in critically ill infants.

To assess the prevalence of psychiatric disorders and associated therapies in children during their heart transplantation admission.All pediatric heart transplant recipients (1999-2016) were included from a linked administrative and clinical registry database. Psychiatric disorders and associated therapies were identified using International Classification of Diseases or billing codes during the transplant admission. Data were analyzed using standard descriptive statistics. Multivariable logistic regression assessed factors independently associated with psychiatric disorders or therapies.A total of 3073 pediatric heart transplant recipients were included. Psychiatric disorders were present in 434 (14.1%) patients during the heart transplant admission, with adjustment disorders being the most common. Antidepressant therapy was prescribed to 212 patients (6.9%) and selective serotonin reuptake inhibitors were most commonly used. Psychiatric diagnoses (8.4% vs 18.1%; P .001) and the use of antidepressants (4.5% vs 8.9%; P .001) increased over time (era 1, 1999-2009 vs era 2, 2010-2016). Psychiatric disorders were present in 39.8% of patients ≥8 years of age requiring ventricular assist device support at heart transplantation. The need for ventricular assist device support was independently associated with psychiatric diagnoses (aOR, 1.57; 95% CI, 1.18-2.1; P = .002) and antidepressant therapy (aOR, 2.11; 95% CI. 1.43-3.12; P .001).Psychiatric disorders are common in pediatric heart transplant recipients, especially among those bridged with ventricular assist device support. Psychiatric diagnoses and the use of antidepressants has increased over time, likely representing improved recognition of psychiatric comorbidities in this vulnerable population. Access to psychiatric services represents an important component of the multidisciplinary team caring for pediatric heart transplant recipients.

Background Learners developing competency-based skills, attitudes, and knowledge through the achievement of defined milestones is a core feature of competency-based medical education. In 2017, a special interest study group of the American Academy of Child and Adolescent Psychiatry convened a panel of specialists to describe pediatric consultation-liaison psychiatry (CLP) best educational practices during child and adolescent psychiatry fellowship. Objective The objective of this project was to develop a national consensus on pediatric CLP competencies to help guide training in this specialty. Methods An expert working group developed a list of candidate competences based on previously established educational outcomes for CLP (formerly Psychosomatic Medicine), child and adolescent psychiatry, and general psychiatry. A survey was distributed to members of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee to determine child and adolescent psychiatry fellowship educational needs on pediatric CLP services and generate consensus regarding pediatric CLP competencies. Results Most survey respondents were supportive of the need for a national consensus on core competencies for pediatric CLP. Consensus from a panel of experts in the field of pediatric CLP generated a list of proposed core competencies that track the Accreditation Council for Graduate Medical Education's six core competencies. Conclusions Consistent learning outcomes provide the foundation for further development of tools to support training in pediatric CLP. There is a need to develop further tools including outcome assessment instruments and self-directed learning materials that can be used to support lifelong learning.

Transitioning to college presents many challenges to students who are physically and emotionally healthy; students with mental illness have additional potential risks impacting success. Understanding the university mental health system and the university campus resources is critical. Students may need one or more medical leave(s) to mitigate the impact of illness with eventual success in part dependent upon effective consultation and collaboration. Medical leaves should be requested when the student has mental health concerns contributing to inability to function safely or effectively as a student. The mental health condition may negatively impact student welfare and academic engagement even if grades are acceptable. This case describes a student with significant mental illness requiring two medical leaves of absence from college, demonstrating the development of a safety net including residential housing, disability services, academic support, and the university Students of Concern team while maintaining a role for the home psychiatrist. The chapter identifies challenges of transitional age youth living independent of family and discusses the implications of Title II regulations. The case demonstrates successful use of medical leave in a young adult with mental illness who was able to make incremental developmental changes leading to completion of his education.

Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence.Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU.Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled.An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis.The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.

IMPORTANCE: Children and youths who are prescribed antipsychotic medications have multiple, potentially fatal, dose-related cardiovascular, metabolic, and other adverse events, but whether or not these medications are associated with an increased risk of death is unknown. OBJECTIVE: To compare the risk of unexpected death among children and youths who are beginning treatment with antipsychotic or control medications. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted from 1999 through 2014 and included Medicaid enrollees aged 5 to 24 years in Tennessee who had no diagnosis of severe somatic illness, schizophrenia or related psychoses, or Tourette syndrome or chronic tic disorder. Data analysis was performed from January 1, 2017, to August 15, 2018. EXPOSURES: Current, new antipsychotic medication use at doses higher than 50 mg (higher-dose group) or 50 mg or lower chlorpromazine equivalents (lower-dose group) as well as control medications (ie, attention-deficit/hyperactivity disorder medications, antidepressants, or mood stabilizers) (control group). MAIN OUTCOMES AND MEASURES: Deaths during study follow-up while out of hospital or within 7 days after hospital admission, classified as either deaths due to injury or suicide or unexpected deaths. Secondary outcomes were unexpected deaths not due to overdose and death due to cardiovascular or metabolic causes. RESULTS: This study included 189 361 children and youths in the control group (mean [SD] age, 12.0 [5.1] years; 43.4% female), 28 377 in the lower-dose group (mean [SD] age, 11.7 [4.4] years; 32.3% female), and 30 120 in the higher-dose group (mean [SD] age, 14.5 [4.8] years; 39.2% female). The unadjusted incidence of death in the higher-dose group was 146.2 per 100 000 person-years (40 deaths per 27 354 person-years), which was significantly greater than that in the control group (54.5 per 100 000 population; 67 deaths per 123 005 person-years) (P

PURPOSE: To assess the safety of psychotropic medication use in children and adolescents, it is critical to be able to identify suicidal behaviors from medical claims data and distinguish them from other injuries. The purpose of this study was to develop an algorithm using administrative claims data to identify medically treated suicidal behavior in a cohort of children and adolescents. METHODS: The cohort included 80 183 youth (6-18 years) enrolled in Tennessee's Medicaid program from 1995-2006 who were prescribed antidepressants. Potential episodes of suicidal behavior were identified using external cause-of-injury codes (E-codes) and ICD-9-CM codes corresponding to the potential mechanisms of or injuries resulting from suicidal behavior. For each identified episode, medical records were reviewed to determine if the injury was self-inflicted and if intent to die was explicitly stated or could be inferred. RESULTS: Medical records were reviewed for 2676 episodes of potential self-harm identified through claims data. Among 1162 episodes that were classified as suicidal behavior, 1117 (96%) had a claim for suicide and self-inflicted injury, poisoning by drugs, or both. The positive predictive value of code groups to predict suicidal behavior ranged from 0-88% and improved when there was a concomitant hospitalization but with the limitation of excluding some episodes of confirmed suicidal behavior. CONCLUSIONS: Nearly all episodes of confirmed suicidal behavior in this cohort of youth included an ICD-9-CM code for suicide or poisoning by drugs. An algorithm combining these ICD-9-CM codes and hospital stay greatly improved the positive predictive value for identifying medically treated suicidal behavior. Copyright © 2013 John Wiley & Sons, Ltd. Language: en

To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements.A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center.A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009.None.Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria.A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0).The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

OBJECTIVES: Recent data showing possible increased risk for suicidal behavior among children and adolescents treated with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) antidepressants have created significant concern among patients, families, and providers, including concerns about the risk of individual antidepressants. This study was designed to compare the risk for medically treated suicide attempts among new users of sertraline, paroxetine, citalopram, escitalopram, and venlafaxine to risk for new users of fluoxetine. METHODS: A retrospective cohort study included 36 842 children aged 6 to 18 years enrolled in Tennessee Medicaid between 1995 and 2006 who were new users of 1 of the antidepressant medications of interest (defined as filling no prescriptions for antidepressants in the preceding 365 days). Medically treated suicide attempts were identified from Medicaid files and vital records and confirmed with medical record review. RESULTS: Four hundred nineteen cohort members had a medically treated suicide attempt with explicit or inferred attempt to die confirmed through medical record review, including 4 who completed suicide. The rate of confirmed suicide attempts for the study drugs ranged from 24.0 per 1000 person-years to 29.1 per 1000 person-years. The adjusted rate of suicide attempts did not differ significantly among current users of SSRI and SNRI antidepressants compared with current users of fluoxetine. Users of multiple antidepressants concomitantly had increased risk for suicide attempt. CONCLUSIONS: In this population-based study of children recently initiating an antidepressant, there was no evidence that risk of suicide attempts differed for commonly prescribed SSRI and SNRI antidepressants.

A 13-year-old boy with a 4-year history of bipolar disorder and concomitant obsessive-compulsive disorder required four hospitalizations and two partial hospitalizations due to inadequate responses to combinations of neuroleptics and traditional treatments for bipolar disorder. The use of clozapine in combination with lithium and clomipramine facilitated successful discharge from the hospital and return to a structured school setting. Significant adverse affects from interactions between valproic acid and clozapine necessitated discontinuation of valproic acid.

OBJECTIVE: To identify circumstances and characteristics of suicidal behavior among early (aged 10–14 years) and late (aged 15–18 years) adolescents from a cohort of youth who were prescribed antidepressant medication. METHODS: In-depth reviews of all available medical records were performed for 250 randomly chosen confirmed episodes of suicidal behavior identified as part of a large retrospective cohort study of antidepressant users and suicidal behavior. Study data were obtained from Tennessee Medicaid records and death certificates from January 1, 1995, to December 31, 2006. Medical records and autopsy reports for cases identified from electronic data were adjudicated by 2 investigators blinded to exposure status and classified by using a validated scale. RESULTS: Of the 250 cases reviewed, 65.6% were female and 26.4% were aged 10 to 14 years. Medication ingestion was the most frequent method of suicidal behavior for both early and late adolescents; however, early adolescents were significantly more likely to use hanging as a method of suicide. Nearly one-half of the adolescents had previously attempted suicide. Early adolescents were significantly more likely to have a history of sexual abuse and significantly less likely to have a history of substance abuse. Early adolescents were also significantly more likely than older adolescents to have a history of a psychotic disorder and to report hallucinations before the suicide attempt. CONCLUSION: Suicidal behavior among early and late adolescents prescribed antidepressant medication differed in terms of methods used, previous psychiatric history, and proximal symptoms.

Objective To report the first use of electroconvulsive therapy (ECT) in a patient with a cochlear implant (CI). Study design Clinical Capsule Report. Setting University hospital. Patient : A 17-year-old boy who underwent Nucleus 22 cochlear implantation in 1995 presented with delirious mania in 2009. Aggressive pharmacologic management was ineffective, and ECT was recommended due to the potentially lethal nature of his psychiatric illness. Interventions After careful consideration by a multidisciplinary team, unilateral ECT on the side opposite the CI without removal of the device was recommended. Electroconvulsive therapy was performed on hospital Days 20 and 21. Integrity testing of the CI was performed on hospital Day 38. Main outcome measures Subjective and objective assessment of cochlear implant functioning and response to ECT. Results Electroconvulsive therapy was well tolerated and contributed to alleviation of presenting symptoms. The patient used his CI without subjective degradation of performance. Integrity testing of the CI after ECT confirmed proper functioning of the device. Conclusion This is the first report of ECT in a patient with CI. Unilateral ECT was performed contralateral to the CI without subjective or objective decline in performance. This Clinical Report motivates further study regarding the use of ECT in CI patients.

The increased prescribing of antipsychotics for children and youth has heightened concerns that this practice increases the risk of type 2 diabetes mellitus.To compare the risk of type 2 diabetes in children and youth 6 to 24 years of age for recent initiators of antipsychotic drugs vs propensity score-matched controls who had recently initiated another psychotropic medication.Retrospective cohort study of the Tennessee Medicaid program with 28 858 recent initiators of antipsychotic drugs and 14 429 matched controls. The cohort excluded patients who previously received a diagnosis of diabetes, schizophrenia, or some other condition for which antipsychotics are the only generally recognized therapy.Newly diagnosed diabetes during follow-up, as identified from diagnoses and diabetes medication prescriptions.Users of antipsychotics had a 3-fold increased risk for type 2 diabetes (HR = 3.03 [95% CI = 1.73-5.32]), which was apparent within the first year of follow-up (HR = 2.49 [95% CI = 1.27-4.88]). The risk increased with cumulative dose during follow-up, with HRs of 2.13 (95% CI = 1.06-4.27), 3.42 (95% CI = 1.88-6.24), and 5.43 (95% CI = 2.34-12.61) for respective cumulative doses (gram equivalents of chlorpromazine) of more than 5 g, 5 to 99 g, and 100 g or more (P.04). The risk remained elevated for up to 1 year following discontinuation of antipsychotic use (HR = 2.57 [95% CI = 1.34-4.91]). When the cohort was restricted to children 6 to 17 years of age, antipsychotic users had more than a 3-fold increased risk of type 2 diabetes (HR = 3.14 [95% CI = 1.50-6.56]), and the risk increased significantly with increasing cumulative dose (P.03). The risk was increased for use restricted to atypical antipsychotics (HR = 2.89 [95% CI = 1.64-5.10]) or to risperidone (HR = 2.20 [95% CI = 1.14-4.26]).Children and youth prescribed antipsychotics had an increased risk of type 2 diabetes that increased with cumulative dose.

To evaluate the effect of UK and US warnings placed in response to reports of suicidal thinking in pediatric patients receiving selective serotonin reuptake inhibitor and selective norepinephrine reuptake inhibitor antidepressants on antidepressant prescribing for children and adolescents.Interrupted time-series analysis of antidepressant prescriptions.Tennessee's Medicaid program, January 1, 2002, through September 30, 2005.A mean of 405,000 children and adolescents aged 2 to 17 years qualified each month. Main Exposure Piecewise linear regression models were used to estimate the cumulative effect of the warnings, which were considered the exposure of interest.Monthly proportions of study children and adolescents who were new users of antidepressants, had discontinuity in antidepressant use, or were users of other psychotropic drugs.During the 2 years preceding the UK warning, there was no trend in the monthly proportions of new antidepressant users, with 23 new users per 10 000 persons per month. This proportion subsequently decreased 33% (95% confidence interval, 23% to 41%; P.001) by 21 months following the UK warning. The reduction was most pronounced for the nonfluoxetine selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors, where initiations decreased 54% (95% confidence interval, 46% to 62%; P.001). In contrast, new users of fluoxetine increased 60% (95% confidence interval, 9% to 135%; P = .02). There was no increase in discontinuations of antidepressants, and there was no evidence of substitution of other psychotropic drugs.The regulatory warnings led to decreased use of antidepressants in children and adolescents, but the clinical and public health consequences of this change are unknown.