Publications by authors named "Jana Davidson"

23 Publications

  • Page 1 of 1

Second-Generation Antipsychotic Use in Pediatric Emergency Medicine.

Pediatr Emerg Care 2021 Mar;37(3):161-164

Professor, The Pediatric Research in Emergency Therapeutics (PRETx) Program, Division of Pediatric Emergency Medicine, University of British Columbia; BC Children's Hospital Research Institute, Vancouver, BC, Canada.

Abstract: In recent years, the number of patients presenting to the emergency department with mental health complaints has been growing, alongside an increase in second-generation antipsychotic (SGAs) prescriptions for a variety of mental health conditions. Children treated with SGAs may have abnormalities, such as rapid weight gain and central adiposity, glucose intolerance, dyslipidemia, and hypertension; they may present to the pediatric emergency department with components of metabolic syndrome or type 2 diabetes, and a subsequent significant risk for cardiovascular complications later in life. Pediatric emergency department providers may serve as a safety net for patients to detect SGA-related metabolic complications, especially among vulnerable populations lacking access to primary care or psychiatric services.
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http://dx.doi.org/10.1097/PEC.0000000000002387DOI Listing
March 2021

Un temps de réflexion et de renouveau.

J Can Acad Child Adolesc Psychiatry 2020 Nov 1;29(4):216-217. Epub 2020 Nov 1.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595259PMC
November 2020

A Time for Reflection and Renewal.

J Can Acad Child Adolesc Psychiatry 2020 Nov 1;29(4):214-215. Epub 2020 Nov 1.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595260PMC
November 2020

Second-generation antipsychotics in children: Risks and monitoring needs.

Can Fam Physician 2018 09;64(9):660-662

A 10-year-old male patient presented to my clinic with irritability associated with autism spectrum disorder, and previous therapeutic efforts had not been successful. Treatment with quetiapine has considerably reduced irritability and improved his quality of life; however, the patient's mother has stated that her child's clothes are no longer fitting because his waist size has increased substantially, and that he has gained 5 kg since treatment initiation 8 weeks ago. Should second-generation antipsychotic (SGA) treatment be stopped or continued, and how can these side effects be best mitigated in a family practice setting? Use of SGAs in pediatric patients has increased in recent years, which has brought to light a number of worrisome metabolic side effects that occur in children. Owing to the efficacy of treatment, SGAs must often be continued despite side effects. Even if the drug has been prescribed elsewhere, family physicians should closely monitor these patients following the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children guidelines. When starting an SGA, patients and their families should be educated on the importance of healthy eating and physical activity to preemptively mitigate potential side effects. Recent studies have also shown adjunctive metformin to have a potential role in reducing weight gain.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135131PMC
September 2018

What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review.

Int J Ment Health Syst 2017 11;11:36. Epub 2017 May 11.

Child & Adolescent Mental Health & Concurrent Disorders Programs, BC Children's Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada.

Background: Many young people who receive psychiatric care in inpatient or residential settings in North America have experienced various forms of emotional trauma. Moreover, these settings can exacerbate trauma sequelae. Common practices, such as seclusion and restraint, put young people at risk of retraumatization, development of comorbid psychopathology, injury, and even death. In response, psychiatric and residential facilities have embraced trauma-informed care (TIC), an organizational change strategy which aligns service delivery with treatment principles and discrete interventions designed to reduce rates of retraumatization through responsive and non-coercive staff-client interactions. After more than two decades, a number of TIC frameworks and approaches have shown favorable results. Largely unexamined, however, are the features that lead to successful implementation of TIC, especially in child and adolescent inpatient psychiatric and residential settings.

Methods: Using methods proposed by Pawson et al. (J Health Serv Res Policy 10:21-34, 2005), we conducted a modified five-stage realist systematic review of peer-reviewed TIC literature. We rigorously searched ten electronic databases for peer reviewed publications appearing between 2000 and 2015 linking terms "trauma-informed" and "child*" or "youth," plus "inpatient" or "residential" plus "psych*" or "mental." After screening 693 unique abstracts, we selected 13 articles which described TIC interventions in youth psychiatric or residential settings. We designed a theoretically-based evaluative framework using the active implementation cycles of the National Implementation Research Network (NIRN) to discern which foci were associated with effective TIC implementation. Excluded were statewide mental health initiatives and TIC implementations in outpatient mental health, child welfare, and education settings. Interventions examined included: Attachment, Self-Regulation, and Competency Framework; Six Core Strategies; Collaborative Problem Solving; Sanctuary Model; Risking Connection; and the Fairy Tale Model.

Results: Five factors were instrumental in implementing trauma informed care across a spectrum of initiatives: senior leadership commitment, sufficient staff support, amplifying the voices of patients and families, aligning policy and programming with trauma informed principles, and using data to help motivate change.

Conclusions: Reduction or elimination of coercive measures may be achieved by explicitly targeting specific coercive measures or by implementing broader therapeutic models. Additional research is needed to evaluate the efficacy of both approaches.
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http://dx.doi.org/10.1186/s13033-017-0137-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5425975PMC
May 2017

Increased Risk of Obesity and Metabolic Dysregulation Following 12 Months of Second-Generation Antipsychotic Treatment in Children: A Prospective Cohort Study.

Can J Psychiatry 2015 Oct;60(10):441-50

Pediatric Endocrinologist, British Columbia Children's Hospital, Vancouver, British Columbia; Clinical Professor, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Objective: To determine the risk of developing obesity and related metabolic complications in children following long-term treatment with risperidone or quetiapine.

Methods: This was a 1-year naturalistic longitudinal study conducted between February 2009 and March 2012. A total of 130 children aged 2 to 18 years without prior exposure to second-generation antipsychotics (SGAs) were enrolled at initiation of treatment with either risperidone or quetiapine. Metabolic parameters were measured at baseline and months 6 and 12. Data of 37 participants (20 treated with risperidone and 17 treated with quetiapine) who completed 12-month monitoring were used in the analysis.

Results: After 1 year of SGA treatment, mean weight increased significantly by 10.8 kg (95% CI 7.9 kg to 13.7 kg) for risperidone and 9.7 kg (95% CI 6.5 kg to 12.8 kg) for quetiapine. Body mass index z score also increased significantly in both groups (P < 0.001). There was a high incidence of children becoming overweight or obese (6/15 [40.0%] for risperidone-treated and 7/14 [50.0%] for quetiapine-treated). The mean levels of fasting glucose (for risperidone-treated) and ratio of total cholesterol to high-density lipoprotein cholesterol (for quetiapine-treated) increased significantly by 0.23 mmol/L (95% CI 0.03 mmol/L to 0.42 mmol/L) and 0.48 mmol/L (95% CI 0.15 mmol/L to 0.80 mmol/L), respectively.

Conclusion: Children treated with risperidone or quetiapine are at a significant risk for developing obesity, elevated waist circumference, and dyslipidemia during 12 months of treatment. These data emphasize the importance of regular monitoring for early identification and treatment of metabolic side effects.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679120PMC
http://dx.doi.org/10.1177/070674371506001005DOI Listing
October 2015

Effectiveness of an educational handbook in improving psychiatry resident knowledge of second-generation antipsychotics.

Acad Psychiatry 2015 Apr 4;39(2):154-9. Epub 2014 Jul 4.

University of British Columbia, Vancouver, BC, Canada.

Objective: The authors describe a pilot evaluation of an educational handbook designed to increase resident knowledge of second-generation antipsychotic (SGA) use in the pediatric population, with an emphasis on metabolic monitoring.

Methods: An educational handbook focusing on SGA use in children and adolescents was introduced to psychiatry residents undergoing a child psychiatry rotation. Baseline and post-intervention questionnaires were administered to determine whether SGA knowledge increased.

Results: Baseline and post-intervention questionnaires were completed by 32 residents. At baseline, most residents (92.9 %) had interacted with an adult patient requiring an SGA and had prescribed SGAs at least five times (70.9 %) in the previous month. Baseline SGA knowledge was limited such that only 5.4 % of participants scored greater than 80 %, and 28.6 % scored below 60 %. Mean total score improved significantly from pre-test (18.4 ± 4.23) to post-test (21.2 ± 3.28, p = 0.001). Stratified analysis suggested a significant improvement of scores (post-test versus pre-test, respectively) in females (21.8 ± 3.11 versus 18.0 ± 4.94, p = 0.003) and junior residents (21.3 ± 3.34 versus 18.1 ± 4.37, p = 0.001). While significant improvements were documented in questions related to Health Canada-approved and other off-label evidence-based indications, and the appropriate physical examination components and laboratory tests to perform at SGA initiation and follow-up, no improvements were documented regarding the distinguishing properties, side effects, and appropriate history-taking prior to SGA initiation.

Conclusions: Implementation of an educational handbook can improve resident knowledge related to SGA use in children over the short-term. However, future research should be directed at the effectiveness of more interactive web-based formats in optimizing learning for male residents and ensuring more comprehensive knowledge uptake. While the introduction of an education handbook is the first step in addressing some of the barriers to metabolic monitoring, prospective longitudinal studies are required to determine whether such an intervention will ultimately improve prescriber adherence over the long-term.
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http://dx.doi.org/10.1007/s40596-014-0177-9DOI Listing
April 2015

Quetiapine treatment in youth is associated with decreased insulin secretion.

J Clin Psychopharmacol 2014 Jun;34(3):359-64

From the *Department of Pediatrics, Faculty of Medicine, University of British Columbia; †Child & Family Research Institute; Departments of ‡Surgery, and §Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada.

Second-generation antipsychotics (SGAs) are commonly prescribed to youth but are associated with metabolic effects including obesity and diabetes. The mechanisms underlying diabetes development are unclear. The purpose of this study was to compare glucose homeostasis, insulin sensitivity, insulin secretion, and overall β-cell function in risperidone-treated, quetiapine-treated, and SGA-naive youth with mental illness. We conducted a cross-sectional study in which youth aged 9 to 18 years underwent a 2-hour oral glucose tolerance test. Indices for insulin sensitivity (Matsuda index), insulin secretion (insulinogenic index), and β-cell function (insulin secretion-sensitivity index-2 [ISSI-2]) were calculated. A total of 18 SGA-naive, 20 risperidone-treated, and 16 quetiapine-treated youth participated. The 3 groups were similar in age, sex, ethnicity, body mass index standardized for age and sex, pubertal status, degree of psychiatric illness, psychiatric diagnoses, and other medications. The median treatment duration was 17 months (range, 3-91 months) for risperidone-treated youth and 10 months (range, 3-44 months) for quetiapine-treated youth. The quetiapine-treated group had lower insulinogenic index (P < 0.01) and lower ISSI-2 (P < 0.01) compared with that in the SGA-naive group. Only the body mass index standardized for age and sex was negatively associated with Matsuda index (β = -0.540, P < 0.001) in all youth. Quetiapine treatment was negatively associated with insulinogenic index (β = -0.426, P = 0.007) and ISSI-2 (β = -0.433, P = 0.008). Quetiapine reduced the insulin expression in isolated mouse islets suggesting a direct β-cell effect. Our results suggest that quetiapine treatment in youth is associated with impaired β-cell function, specifically lower insulin secretion. Prospective longitudinal studies are required to understand the progression of β-cell dysfunction after quetiapine initiation.
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http://dx.doi.org/10.1097/JCP.0000000000000118DOI Listing
June 2014

Prevalence and patterns of antipsychotic use in youth at the time of admission and discharge from an inpatient psychiatric facility.

J Clin Psychopharmacol 2014 Feb;34(1):17-22

From the *British Columbia Mental Health and Addictions Research Institute; Departments of †Psychiatry, and ‡Anesthesiology, Pharmacology & Therapeutics, University of British Columbia; §Child & Adolescent Mental Health Inpatient Units, and ∥Department of Pharmacy, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.

The objective of this study was to examine the prevalence and patterns of antipsychotic use in children and adolescents at the time of admission and discharge from a tertiary care inpatient psychiatric facility. This retrospective analysis included all patients 18 years and younger, who were admitted and discharged from a child and adolescent tertiary care inpatient psychiatric facility between May 1, 2008 and December 31, 2009. Data for medications at admission were obtained using a province-wide network that links all pharmacies in British Columbia, Canada to a central set of data systems, whereas data for medications at discharge were obtained using the Department of Pharmacy's (British Columbia Children's Hospital, Vancouver, British Columbia, Canada) inpatient computer database. Apart from antipsychotics, overall drug use included antidepressants, mood stabilizers, benzodiazepines, anticholinergics, stimulants, and sleep medications. Referral and discharge diagnoses were also examined. During the study period, 335 patients were admitted and discharged from the tertiary care inpatient psychiatric facility. Significantly, more patients were prescribed with an antipsychotic at the time of discharge from hospital compared with that of the time when they were admitted to hospital (51.6% vs 30.7%; P < 0.0001). Antidepressants were most often coprescribed with an antipsychotic at admission and discharge (32.0% vs 42.2%, respectively) followed by attention-deficit/hyperactivity disorder medications (22.3% vs 24.9% at admission and discharge, respectively) and anticonvulsants (19.4% vs 19.1% at admission and discharge, respectively). Whether the significant increase in antipsychotic use seen from the time of admission to discharge is solely attributed to clinical worsening or other variables requires further investigation.
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http://dx.doi.org/10.1097/JCP.0b013e3182a607ddDOI Listing
February 2014

[Not Available].

Paediatr Child Health 2012 Oct;17(Suppl B):12B-21B

Département de neurosciences cliniques et de pédiatrie, université de Calgary (Alberta);

Background: The use of antipsychotics, especially second-generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use.

Objective: To synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children, and provide evidence-based recommendations for the monitoring of these side effects.

Methods: A systematic review of controlled clinical trials of SGAs involving children was performed. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. When there was inadequate evidence, recommendations were based on consensus and expert opinion. A multidisciplinary consensus group reviewed all relevant evidence and reached consensus on the recommendations.

Results: The present guidelines provide evidence-based recommendations for monitoring SGA safety. The strength of recommendations for specific physical examination manoeuvres and laboratory tests are provided for each SGA medication at specific time points.

Conclusion: Multiple randomized controlled trials evaluated the efficacy of many of the SGAs in paediatric mental health disorders. These benefits, however, are not without risks - both metabolic and neurological side effects occur in children treated with SGAs. The risk of weight gain, increased body mass index and abnormal lipid levels is greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of the treatment is greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486685PMC
October 2012

A population-based study of antipsychotic prescription trends in children and adolescents in British Columbia, from 1996 to 2011.

Can J Psychiatry 2013 Jun;58(6):361-9

University of Toronto, Toronto, Ontario, Canada.

Objectives: To establish prevalence rates of antipsychotic (AP) prescriptions for children 18 years of age or younger in British Columbia (BC) from 1996 to 2011 by age, sex, AP type, and primary diagnosis; and to identify the predominant AP prescribers for children by specialty training.

Methods: BC Ministry of Health administrative data were used to describe AP prescriptions for youth aged 18 years or younger. Comparisons were made using population prevalence based on sex; age group; AP; International Classification of Diseases, Ninth Revision, diagnosis; and prescriber specialty.

Results: From 1996 to 2011, overall AP (both first and second generation) prescription prevalence rate increased 3.8-fold (1.66 to 6.37 per 1000 population); second-generation AP (SGA) prescriptions increased 18.1-fold (0.33 to 5.98 per 1000 population). The highest increase in all AP prescriptions occurred in males aged 13 to 18 years (3.3 to 14.4 per 1000 population; 4.4-fold), followed by similar increases in males aged 6 to 12 years (2.3 to 8.6 per 1000 population; 3.7-fold) and in females aged 13 to 18 years (2.8 to 10.7 per 1000 population; 3.8-fold). Overall, the 3 most common diagnoses associated with all AP prescriptions were depressive disorders (12.8%), hyperkinetic syndrome of childhood (11.7%), and neurotic disorders (11.1%); however, variation was observed by prescriber specialty training. Among all new AP prescriptions in 2010/11, 38.6%, 34.3%, and 15.6% were provided by psychiatrists, family physicians, and pediatricians, respectively.

Conclusions: There has been an exponential rise in SGA prescriptions in BC secondary to extensive off-label use, not only by psychiatrists but also by family physicians and pediatricians. Knowledge translation initiatives promoting evidence-based prescribing and monitoring practices related to SGA treatment need to target all 3 prescriber groups and be tailored for age subgroups.
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http://dx.doi.org/10.1177/070674371305800608DOI Listing
June 2013

Health Information Preference among Youth and Caregivers related to Second-Generation Antipsychotic Treatment.

J Can Acad Child Adolesc Psychiatry 2012 Nov;21(4):302-9

Medical Student, Queen's University, Kingston, Ontario ; Research Assistant, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Objective: To determine the health information-seeking preferences of youth with mental health challenges and their caregivers, focusing on health literacy needs related to second-generation antipsychotics (SGAs).

Methods: One hundred fifty two youth and 158 caregivers attending outpatient psychiatry clinics at BC Children's Hospital between February 2009 and December 2010 completed a SGA health literacy survey.

Results: Youth and caregivers placed emphasis on understanding the benefits and side effects of SGA-treatment, along with strategies to prevent potential side effects. While psychiatrists were viewed as a crucial source of information by both groups, pharmacists were an under-utilized resource by youth. Both youth and caregivers preferred brochures from healthcare providers, websites, and support groups to access health information; however, preferences diverged among other activities. Specifically, youth favoured practical, "hands-on" programs such as cooking and exercise classes, whereas caregivers showed greater interest in didactic presentations and conferences. Sex differences were observed in receptiveness towards certain programs and resources.

Conclusions: The findings from this study support the inclusion of caregivers and youth of both sexes with mental health conditions in the future development of educational resources related to medications such as SGAs. Health literacy strategies need to be multi-faceted, and utilize mixed methods to ensure broad reach and applicability.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490532PMC
November 2012

Evidence-based recommendations for monitoring safety of second-generation antipsychotics in children and youth.

Paediatr Child Health 2011 Nov;16(9):581-9

Department of Clinical Neurosciences and Pediatrics, University of Calgary, Calgary, Alberta;

Background: The use of antipsychotics, especially second-generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use.

Objective: To synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children, and provide evidence-based recommendations for the monitoring of these side effects.

Methods: A systematic review of controlled clinical trials of SGAs involving children was performed. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. When there was inadequate evidence, recommendations were based on consensus and expert opinion. A multidisciplinary consensus group reviewed all relevant evidence and reached consensus on the recommendations.

Results: The present guidelines provide evidence-based recommendations for monitoring SGA safety. The strength of recommendations for specific physical examination manoeuvres and laboratory tests are provided for each SGA medication at specific time points.

Conclusion: Multiple randomized controlled trials evaluated the efficacy of many of the SGAs in paediatric mental health disorders. These benefits, however, are not without risks - both metabolic and neurological side effects occur in children treated with SGAs. The risk of weight gain, increased body mass index and abnormal lipid levels is greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of the treatment is greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223902PMC
November 2011

Metabolic monitoring training program implementation in the community setting was associated with improved monitoring in second-generation antipsychotic-treated children.

Can J Psychiatry 2012 May;57(5):292-9

University of Toronto, Toronto, Ontario.

Objective: To determine whether implementation of a metabolic monitoring training program (MMTP) in an urban community-based setting improved monitoring in children treated with second-generation antipsychotics (SGAs) and changed prescription rates of SGAs to children.

Method: The MMTP was implemented in the Vancouver Coastal Health Child and Youth Mental Health Teams (CYMHTs) on January 1, 2009. A retrospective review of paper charts and electronic records for children seen at the CYMHTs from September 1, 2007, to May 1, 2010, was performed to collect the following data: age, sex, foster care, immigrant status, Axis I diagnosis, and medications. In SGA-treated children, anthropometric measurements and blood work completed at baseline and 3, 6, and 12 months were also collected.

Results: Among the 1114 children seen pre-MMTP and 1262 children seen post-MMTP implementation, 174 (15.4%) and 81 (6.4%), respectively, were SGA-treated (P < 0.001). Among the SGA-treated children seen at the CYMHTs after MMTP implementation, 38.3% had a copy of the MMTP in their paper chart. Metabolic monitoring increased by up to 40% at baseline (P < 0.01), 20% at 3 (P < 0.01) and 6 months (P < 0.01), and 18% at 12 months after MMTP implementation.

Conclusions: Implementation of an MMTP was associated with significantly improved monitoring rates of anthropometric and blood work parameters at baseline and the 3- and 6-month time points, with a trend for improvement at the 12-month time point, in SGA-treated children cared for in urban community mental health clinics. In addition, a 56% decrease in SGA prescriptions was observed following MMTP implementation in this population.
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http://dx.doi.org/10.1177/070674371205700504DOI Listing
May 2012

Waist circumference is a sensitive screening tool for assessment of metabolic syndrome risk in children treated with second-generation antipsychotics.

Can J Psychiatry 2012 Jan;57(1):34-44

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Objective: To compare the prevalence of metabolic syndrome (MetS) and its components in second-generation antipsychotic (SGA)-treated and SGA-naive children; and to explore the utility of clinical markers, such as waist circumference (WC) and body mass index (BMI), as screening tools for MetS.

Methods: Subjects were prospectively recruited from the Psychiatry Emergency Unit at British Columbia Children's Hospital. As part of a quality-assurance project, a metabolic monitoring protocol was implemented, including collection of anthropomorphic and laboratory data.

Results: From January 2008 to February 2010, there were 117 SGA-treated and 217 SGA-naive children recruited. The overall prevalence of MetS was 19.0% (16/84; median treatment duration = 14 months) in SGA-treated and 0.8% (1/127) in SGA-naive children (OR 29.7; 95% CI 3.85 to 228.40, P < 0.001), with an increased prevalence of all components except high-density lipoprotein cholesterol (HDL-C), respectively: elevated WC (40.7% and 10.1%; P < 0.001); hypertriglyceridemia (33.7% and 18.8%; P = 0.01); impaired fasting glucose (12.5% and 0.7%; P = 0.005); and elevated blood pressure (41.2% and 16.5%; P < 0.001). SGA treatment was the strongest predictor of MetS (OR 19.2; 95% CI 2.30 to 160.44, P = 0.006) followed by male sex (OR 5.7; 95% CI 1.08 to 30.62, P = 0.04). Presence of abdominal obesity was more sensitive (92.9%) than BMI (68.8%), while fasting glucose of 5.6 mmol/L or more and HDL-C of 1.03 mmol/L or less were most specific (94.1%) in correctly identifying MetS.

Conclusions: SGA treatment confers a significantly increased risk for MetS over the long term. WC measurement is a simple and sensitive screening tool for determining MetS risk in SGA-treated children. These data highlight the dangers of SGA treatment and the importance of standardized metabolic monitoring using sex- and age-adjusted tables in this population.
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http://dx.doi.org/10.1177/070674371205700107DOI Listing
January 2012

Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth.

J Can Acad Child Adolesc Psychiatry 2011 Aug;20(3):218-33

The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) Guideline Project.

Background: The use of antipsychotics, especially second generation antipsychotics (SGAs), for children with mental health disorders in Canada has increased dramatically over the past five years. These medications have the potential to cause major metabolic and neurological complications with chronic use.

Objective: Our objective was to synthesize the evidence for specific metabolic and neurological side effects associated with the use of SGAs in children and make evidence-based recommendations for the monitoring of these side effects.

Methods: We performed a systematic review of controlled clinical trials of SGAs in children. Recommendations for monitoring SGA safety were made according to a classification scheme based on the GRADE system. When there was inadequate evidence to make recommendations, recommendations were based on consensus and expert opinion. A multi-disciplinary consensus group reviewed all relevant evidence and came to consensus on recommendations.

Results: Evidence-based recommendations for monitoring SGA safety are provided in the guideline. The strength of recommendations for specific physical examination maneuvers and laboratory tests are provided for each SGA medication at specific time points.

Conclusion: Multiple randomized controlled trials (RCTs) have established the efficacy of many of the SGAs in pediatric mental health disorders. These benefits however do not come without risk; both metabolic and neurological side effects occur in children treated with these SGAs. The risk of weight gain, increased BMI and abnormal lipids appears greatest with olanzapine, followed by clozapine and quetiapine. The risk of neurological side effects of treatment appears greatest with risperidone, olanzapine and aripiprazole. Appropriate monitoring procedures for adverse effects will improve the quality of care of children treated with these medications.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143700PMC
August 2011

Barriers and facilitators to implementation of a metabolic monitoring protocol in hospital and community settings for second-generation antipsychotic-treated youth.

J Can Acad Child Adolesc Psychiatry 2011 May;20(2):134-41

Medical Student, University of Toronto, Toronto, Ontario; Research Assistant, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia.

Objective: 1) Assess perceived barriers associated with metabolic monitoring in second-generation antipsychotic (SGA)-treated youth; and 2) Propose a metabolic monitoring protocol (MMP) and implementation strategies.

Method: Online surveys were created for community mental health teams (CMHTs) and BC Children's Hospital (BCCH) with questions designed to evaluate knowledge of physical health care, confidence, communication with primary care, and practical issues.

Results: 26/50 (52%) of CMHT and 44/111 (40%) of BCCH surveys were completed. While both groups agreed that monitoring is their responsibility, 26% of CMHTs and 35% of BCCH professionals agreed that providing information about SGA side-effects would influence medication adherence. CMHTs reported lower overall confidence and more practical issues as monitoring barriers. While higher overall confidence was reported at BCCH, there was still a substantial proportion (23%) of hospital professionals who reported not knowing what parameters to monitor and how frequently. Communication with primary care, including inadequate systems for sharing results and identifying responsibility for acting on abnormal results, appear to be common barriers shared by both settings.

Conclusions: Barriers to metabolic monitoring were more frequently reported by CMHTs who had limited access to nursing staff. We propose hands-on training, educational resources, pre-printed orders, and regular quality assurance evaluation as facilitators to promote MMP uptake.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085673PMC
May 2011

Creating a provincial family council to engage youth and families in child & youth mental health systems.

J Can Acad Child Adolesc Psychiatry 2010 Aug;19(3):169-75

Medical Director and Head, Child & Adolescent Psychiatry, University of British Columbia and BC Mental Health and Addiction Services; Clinical Associate Professor, Psychiatry, University of British Columbia, Vancouver, British Columbia.

Objective: To create a mechanism in British Columbia (BC) for youth and families to directly engage with key provincial committees that develop policy and implement service delivery for child and youth mental health.

Method: In 2009, a plan was initiated to increase the involvement and influence of youth and families in research, policy, practices and programs related to child and youth mental health. This initiative, led by a provincial family advocacy society in partnership with representatives from health services and government, resulted in the establishment of the Provincial Family Council for Child and Youth Mental Health (PFC). Formation of the PFC occurred in two phases: initially, a Working Group co-chaired by a parent and a youth was tasked with developing the Terms of Reference and framework for the PFC; phase two involved ensuring important constituencies/demographics and competencies were represented in the membership of the PFC.

Result: The Provincial Family Council is officially endorsed by the provincial government and is informing key provincial committees in British Columbia.

Conclusion: In BC, the PFC is the vehicle through which youth and families can now work in partnership with "the system" to promote and improve the mental health of BC's children and youth.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938749PMC
August 2010

Engaging children, youth and families - more than a good idea.

J Can Acad Child Adolesc Psychiatry 2010 Aug;19(3):168

Medical Director and Head, Child & Adolescent Psychiatry, University of British Columbia and BC Mental Health and Addiction Services; Clinical Associate Professor, Psychiatry, University of British Columbia, Vancouver, British Columbia.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938748PMC
August 2010

First do no harm: promoting an evidence-based approach to atypical antipsychotic use in children and adolescents.

J Can Acad Child Adolesc Psychiatry 2010 May;19(2):124-37

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

Objectives: To review the evidence for efficacy and metabolic effects of atypical antipsychotics (AAPs), and to propose a metabolic monitoring protocol for AAP use in children and adolescents.

Methods: A PubMed search was performed to obtain all studies related to efficacy, metabolic side-effects, and monitoring in those less than 18 years of age.

Results: There are no approved indications for AAP use in children and adolescents in Canada. Based on US Food and Drug Administration approvals and a review of randomized controlled trials, we identified 7 indications for AAP use that target specific symptoms in youth including schizophrenia, bipolar I disorder, autism, pervasive developmental disorder, disruptive behaviour disorders (including conduct disorder and ADHD), developmental disabilities and Tourette Syndrome. A wide range of metabolic effects including weight gain, increased waist circumference, dysglycemia, dyslipidemia, hypertension, elevated hepatic transaminases and prolactin levels have been reported. We have developed a proposal for metabolic monitoring that includes anthropometric measurements and laboratory testing at baseline and appropriate intervals thereafter.

Conclusion: There is an urgent need for national clinical practice guidelines that provide, not only appropriate treatment algorithms for AAP-use based on evidence, but also address metabolic monitoring and subsequent management of complications in this vulnerable population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2868560PMC
May 2010

Increased prevalence of obesity and glucose intolerance in youth treated with second-generation antipsychotic medications.

Can J Psychiatry 2009 Nov;54(11):743-9

Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: To compare the rates of obesity, impaired fasting glucose (IFG), and type 2 diabetes between second-generation antipsychotic (SGA)-treated and -naive youth.

Methods: A retrospective chart review was conducted for all child and adolescent psychiatry emergency admissions over 2.5 years. Data collected included age, sex, psychiatric diagnosis, medications, height, weight, fasting glucose, and lipid profile. Body mass index (BMI) was standardized for age and sex and converted to a z score. Overweight was defined as a BMI between the 85th and 95th percentile and obese as a BMI at the 95th percentile or greater for age and sex. The 2007 American Diabetes Association criteria for IFG and type 2 diabetes were used.

Results: Among the 432 admissions, 167 (39%) had both height and weight measured, and 145 (34%) had fasting glucose measured. The mean zBMI was higher in the SGA-treated (n = 68), compared with the SGA-naive group (n = 99) (mean difference 0.81; 95% CI 0.46 to 1.16). In the SGA-treated group, 31% were obese and 26% were overweight, compared with 15% and 8%, respectively, in the SGA-naive group (P < 0.01). In the SGA-treated group (n = 65), 21.5% had IFG or type 2 diabetes, compared with 7.5% in the SGA-naive group (n = 80) (P = 0.01).

Conclusions: Youth treated with SGAs have significantly higher rates of obesity and glucose intolerance than SGA-naive youth. These data emphasize the need for consistent metabolic monitoring of youth with psychiatric disorders who are prescribed SGAs.
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http://dx.doi.org/10.1177/070674370905401104DOI Listing
November 2009

A naturalistic study of predictors and risks of atypical antipsychotic use in an attention-deficit/hyperactivity disorder clinic.

J Child Adolesc Psychopharmacol 2009 Oct;19(5):575-82

University of British Columbia , and Provincial ADHD Program, Department of Psychiatry, Children's and Women's Health Centre, Vancouver, British Columbia, Canada.

Objective: This was an exploratory study to examine the use of atypical antipsychotics in an attention-deficit/hyperactivity disorder (ADHD) clinic.

Method: A total of 194 patients was examined to compare those receiving atypical or second-generation antipsychotics (atypicals) from those who were not. A sample of 27 children on atypicals received laboratory investigation for indicators of possible metabolic effects.

Results: In all, 19.1% of the patients in the clinic were receiving atypicals with a mean duration of 313 days; 36 of 37 patients on atypicals had received risperidone, with a mean dose of 0.62 mg. Children receiving atypicals were statistically more likely to have a severe co-morbid disorder, a lower Children's Global Assessment Scale score, a greater total score on the teacher Strengths and Difficulties Questionnaire, and greater difficulty with parent-rated symptoms of being touchy, worried, rages, and explosive outbursts. There were no differences found in measures of functioning, adaptive skills, quality of life, or ADHD symptoms. In the subset of children studied for potential metabolic effects, 68.0% had a waist circumference > or =90(th) percentile that was independent of weight gain, 18.5% had impaired fasting glucose, 12.5% had elevated blood pressure, 11.1% had elevated triglycerides, and 16.7% met full criteria for metabolic syndrome.

Conclusion: Clinical implementation of the efficacy studies of risperidone for disruptive behavior disorders has led to a significant change in practice. Almost 1 in 5 patients are now receiving atypical neuroleptics, typically to treat severe co-morbid disorders and symptoms other than ADHD per se. Despite these children receiving low doses, concomitant stimulants, and low body mass index z-scores, a significant proportion of children demonstrated either one or more components or the full criteria for metabolic syndrome.
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http://dx.doi.org/10.1089/cap.2009.0050DOI Listing
October 2009