Psychotropic Overprescribing to Youth: Scope of the Problem, Causes, and Possible Solutions

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Background

For more than 20 years, psychotropic medication trends have been steadily increasing, typically without knowledge of either effectiveness or safety in community-treatment intended to control children’s emotions and behaviors. The United States leads the world in high prevalence rates of use. The accessibility and acceptance of a biological psychiatry treatment model have contributed to poorly evidenced treatments becoming common for pediatric mental health services. Most concerning is the fact that the number of children receiving antipsychotics has increased by 50%-200% over the past 20 years, depending on the cohort. Further, most of the antipsychotic use in children targets non-psychotic conditions and have not received FDA-approved labeling, thus, is ‘off-label’ or unapproved. Polypharmacy, i.e. combining classes of psychotropics, despite the lack of robust evidence that benefits outweigh risks, has also sharply increased. As with antipsychotics for behavioral use, there are no pediatric conditions for which polypharmacy is approved.

Unfortunately, parents are seldom aware of the risks associated with these medications and at times are not fully engaged in the decisions to use them. Weight gain, metabolic changes, diabetes, sedation, tremor, somnolence, and restlessness are common side effects of antipsychotic use. The effects of polypharmacy are largely unstudied, and there are significant concerns about drug interactions.

The routes to “too many, too much, too young” psychotropic medication use in children are numerous, yet the routes to reducing them are just being forged. Some government agencies, health organizations, and media outlets have recommended reducing the use of high-risk medications and medication combinations. In addition, some preliminary research suggests that clinicians may be eager to remove or stop medications when appropriate but lack guidance from the field on how to do so. Clinicians also report perceived parental concerns about reducing medications, although some research suggests that parents are interested in deprescribing.

The goals of this Research Topic are to highlight innovative research on the overuse of and potential reduction in psychotropic medications for children, advance research initiatives in this domain, and generate momentum within clinical communities toward safer practices.
There are precedents in pediatrics for efforts to repair or reverse the medicalization of child and adolescent development. For example, recommendations to use fewer antibiotics in pediatrics is now an established practice change. We aim to expand this movement scientifically into child and adolescent psychiatry.

This Research Topic seeks submissions of empirical papers, systematic or scoping reviews, meta-analyses, brief reports, grouped case reports, and editorials. Specifically, we will consider submissions on the following topics:

• Original data demonstrating the scope of overprescribing in various settings and cohorts, which may include trends over time or comparisons across different countries/states
• Analysis of potential reasons and causes for the rise of non-evidence-based use of psychotropic medications in children, including but not limited to: patient or provider perspectives, policy reviews, impacts of pharmaceutical marketing or regulatory practices and policies, societal or cultural shifts
• Potential protective factors that naturally promote safe prescribing practices within certain communities or academic contexts (e.g. models of care)
• Efforts to promote a reduction of “new starts” for polypharmacy or other high-risk medications or medication combinations
• Efforts to intentionally deprescribe (reduce or remove) high-risk medications in children
• Patient, provider, and system-level barriers and facilitators to the reduction of new starts or deprescribing

Keywords: pediatrics, psychiatry, medication risks, overprescribing, deprescribing, medication safety, psychotropic medication, children and adolescents, off-label prescribing

Important note: All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.

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