American Academy of Child & Adolescent Psychiatry (AACAP): Psychopharmacology Update Institute

NEW YORK – An electrocadiogram* probably isn’t necessary for most youngsters starting a medication for attention-deficit/hyperactivity disorder.

Some easy screening questions should be enough to identify any children who have cardiovascular risks that a stimulant could exacerbate, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"I am going to suggest that we end this neurosis" about cardiovascular risks during ADHD treatment. "The questions to ask before starting a kid out on any psychotropic medication are the same you would ask any child who is getting a sports physical," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles.

The biggest fear is sudden cardiovascular death – an event usually associated with sport. "I don’t think a month goes by that I don’t hear about a soccer player, cheerleader, or basketball player who has had a sudden death. It’s tragic, but it happens. The bottom line is that there is a three times greater risk of sudden death associated with sports than with being on a stimulant."

In light of this statistic, he said: "There would be more sense in doing an EKG on every high school athlete, but no one is calling for that."

The key questions that should be in every ADHD assessment focus on family and personal history:

• Have you ever fainted while exercising?

• Is there a family history of sudden cardiac death?

• Is there any cardiac abnormality or a heart murmur?

If the answer to any of these is "yes," the patient should see a pediatric cardiologist before starting a stimulant medication. Otherwise, Dr. McGough said, "The benefit of an EKG is really not worth the cost."

The American Heart Association raised concerns about cardiac death and ADHD medications in 2008, when it recommended that every child have an EKG read by a pediatric cardiologist before beginning stimulant medication. However, the group noted, although the test was preferred, it should not be mandatory (Circ. 2008;117:2407-23).

A 2009 postmortem case-control study seemed to bolster the recommendation (Am. J. Psychiatry 2009;166:992-1001).

The authors examined amphetamine exposure among 1,128 children aged 7-19 years, half of whom had a sudden unexplained death and half of whom died in motor vehicle accidents. Ten of those in the sudden death group had amphetamine exposure compared to two in the accident group – a significant difference. The authors concluded that amphetamines could increase the risk of sudden death.

Despite this study, the Food and Drug Administration decided not to require cardiac testing for every ADHD start, Dr. McGough said. More recent studies suggest that the risk is very small or absent.

"There are about a half dozen papers on this now," including one published recently and two large retrospective cohort studies published last year.

The current study examined the risk of cardiovascular events in a database of 171,126 youngsters aged 6-21 years. There were three new cardiac symptoms and less than one cardiac event per 1 million days of current stimulant use. Compared to the reference group, the adjusted odds ratio of cardiac events during current use was 1.18, and with past use, 0.93 (J. Am. Acad. Child Adolesc. Psychiatry 2012;51:147-56).

Last November, the New England Journal of Medicine published a cohort study of 1.2 million children and young adults, 373,667 of whom were currently using ADHD medications. There were 81 serious cardiovascular events, a rate of 3 per 100,000 person-years (N. Engl. J. Med. 2011;365:1896-904).

Another study appeared in Pediatrics. The cohort consisted of 241,417 ADHD medication users. No significant associations were found with sudden death, ventricular arrhythmia, or all-cause mortality. None of the strokes identified during exposed time to ADHD agents were validated (Pediatrics 2011;127:1102-10).

"I think it’s time we put an end to this brouhaha," Dr. McGough said.

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi, Shire Pharmaceuticals, and Supernus Pharmaceuticals. He also is a consultant for Alexa Pharmaceuticals and MedImmune.

* Correction 2/27/2012: The technology mentioned in this sentence previously was misidentified.

NEW YORK – An electrocadiogram* probably isn’t necessary for most youngsters starting a medication for attention-deficit/hyperactivity disorder.

Some easy screening questions should be enough to identify any children who have cardiovascular risks that a stimulant could exacerbate, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"I am going to suggest that we end this neurosis" about cardiovascular risks during ADHD treatment. "The questions to ask before starting a kid out on any psychotropic medication are the same you would ask any child who is getting a sports physical," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles.

The biggest fear is sudden cardiovascular death – an event usually associated with sport. "I don’t think a month goes by that I don’t hear about a soccer player, cheerleader, or basketball player who has had a sudden death. It’s tragic, but it happens. The bottom line is that there is a three times greater risk of sudden death associated with sports than with being on a stimulant."

In light of this statistic, he said: "There would be more sense in doing an EKG on every high school athlete, but no one is calling for that."

The key questions that should be in every ADHD assessment focus on family and personal history:

• Have you ever fainted while exercising?

• Is there a family history of sudden cardiac death?

• Is there any cardiac abnormality or a heart murmur?

If the answer to any of these is "yes," the patient should see a pediatric cardiologist before starting a stimulant medication. Otherwise, Dr. McGough said, "The benefit of an EKG is really not worth the cost."

The American Heart Association raised concerns about cardiac death and ADHD medications in 2008, when it recommended that every child have an EKG read by a pediatric cardiologist before beginning stimulant medication. However, the group noted, although the test was preferred, it should not be mandatory (Circ. 2008;117:2407-23).

A 2009 postmortem case-control study seemed to bolster the recommendation (Am. J. Psychiatry 2009;166:992-1001).

The authors examined amphetamine exposure among 1,128 children aged 7-19 years, half of whom had a sudden unexplained death and half of whom died in motor vehicle accidents. Ten of those in the sudden death group had amphetamine exposure compared to two in the accident group – a significant difference. The authors concluded that amphetamines could increase the risk of sudden death.

Despite this study, the Food and Drug Administration decided not to require cardiac testing for every ADHD start, Dr. McGough said. More recent studies suggest that the risk is very small or absent.

"There are about a half dozen papers on this now," including one published recently and two large retrospective cohort studies published last year.

The current study examined the risk of cardiovascular events in a database of 171,126 youngsters aged 6-21 years. There were three new cardiac symptoms and less than one cardiac event per 1 million days of current stimulant use. Compared to the reference group, the adjusted odds ratio of cardiac events during current use was 1.18, and with past use, 0.93 (J. Am. Acad. Child Adolesc. Psychiatry 2012;51:147-56).

Last November, the New England Journal of Medicine published a cohort study of 1.2 million children and young adults, 373,667 of whom were currently using ADHD medications. There were 81 serious cardiovascular events, a rate of 3 per 100,000 person-years (N. Engl. J. Med. 2011;365:1896-904).

Another study appeared in Pediatrics. The cohort consisted of 241,417 ADHD medication users. No significant associations were found with sudden death, ventricular arrhythmia, or all-cause mortality. None of the strokes identified during exposed time to ADHD agents were validated (Pediatrics 2011;127:1102-10).

"I think it’s time we put an end to this brouhaha," Dr. McGough said.

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi, Shire Pharmaceuticals, and Supernus Pharmaceuticals. He also is a consultant for Alexa Pharmaceuticals and MedImmune.

* Correction 2/27/2012: The technology mentioned in this sentence previously was misidentified.

NEW YORK – An electrocadiogram* probably isn’t necessary for most youngsters starting a medication for attention-deficit/hyperactivity disorder.

Some easy screening questions should be enough to identify any children who have cardiovascular risks that a stimulant could exacerbate, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"I am going to suggest that we end this neurosis" about cardiovascular risks during ADHD treatment. "The questions to ask before starting a kid out on any psychotropic medication are the same you would ask any child who is getting a sports physical," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles.

The biggest fear is sudden cardiovascular death – an event usually associated with sport. "I don’t think a month goes by that I don’t hear about a soccer player, cheerleader, or basketball player who has had a sudden death. It’s tragic, but it happens. The bottom line is that there is a three times greater risk of sudden death associated with sports than with being on a stimulant."

In light of this statistic, he said: "There would be more sense in doing an EKG on every high school athlete, but no one is calling for that."

The key questions that should be in every ADHD assessment focus on family and personal history:

• Have you ever fainted while exercising?

• Is there a family history of sudden cardiac death?

• Is there any cardiac abnormality or a heart murmur?

If the answer to any of these is "yes," the patient should see a pediatric cardiologist before starting a stimulant medication. Otherwise, Dr. McGough said, "The benefit of an EKG is really not worth the cost."

The American Heart Association raised concerns about cardiac death and ADHD medications in 2008, when it recommended that every child have an EKG read by a pediatric cardiologist before beginning stimulant medication. However, the group noted, although the test was preferred, it should not be mandatory (Circ. 2008;117:2407-23).

A 2009 postmortem case-control study seemed to bolster the recommendation (Am. J. Psychiatry 2009;166:992-1001).

The authors examined amphetamine exposure among 1,128 children aged 7-19 years, half of whom had a sudden unexplained death and half of whom died in motor vehicle accidents. Ten of those in the sudden death group had amphetamine exposure compared to two in the accident group – a significant difference. The authors concluded that amphetamines could increase the risk of sudden death.

Despite this study, the Food and Drug Administration decided not to require cardiac testing for every ADHD start, Dr. McGough said. More recent studies suggest that the risk is very small or absent.

"There are about a half dozen papers on this now," including one published recently and two large retrospective cohort studies published last year.

The current study examined the risk of cardiovascular events in a database of 171,126 youngsters aged 6-21 years. There were three new cardiac symptoms and less than one cardiac event per 1 million days of current stimulant use. Compared to the reference group, the adjusted odds ratio of cardiac events during current use was 1.18, and with past use, 0.93 (J. Am. Acad. Child Adolesc. Psychiatry 2012;51:147-56).

Last November, the New England Journal of Medicine published a cohort study of 1.2 million children and young adults, 373,667 of whom were currently using ADHD medications. There were 81 serious cardiovascular events, a rate of 3 per 100,000 person-years (N. Engl. J. Med. 2011;365:1896-904).

Another study appeared in Pediatrics. The cohort consisted of 241,417 ADHD medication users. No significant associations were found with sudden death, ventricular arrhythmia, or all-cause mortality. None of the strokes identified during exposed time to ADHD agents were validated (Pediatrics 2011;127:1102-10).

"I think it’s time we put an end to this brouhaha," Dr. McGough said.

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi, Shire Pharmaceuticals, and Supernus Pharmaceuticals. He also is a consultant for Alexa Pharmaceuticals and MedImmune.

* Correction 2/27/2012: The technology mentioned in this sentence previously was misidentified.

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.