10% of children attending CAMHS prescribed antipsychotic drugs, audit reveals

An audit of prescribing practices at Child and Adolescent Mental Health Services (CAMHS) has revealed 10% of patients are prescribed antipsychotic drugs. 

The findings of the audit - commissioned in the wake of the Maskey Report on South Kerry CAMHS - were published over the weekend (Friday July 28). 

The audit was carried out by an independent team chaired by Dr Colette Halpin and examined prescribing practices across all 75 CAMHS teams nationwide from July to December 2021. 

Within the audit sample of 21,081 children attending CAMHS, 8,191 children were prescribed medication, and of these, 3,528 were randomly selected as a strong representative audit. 

According to the report, evidence of overprescribing was not found, with fewer than 50% of children attending CAMHS being prescribed medicine. 

However, of this cohort, 10.9% of children were prescribed antipsychotic drugs such as aripiprazole, olanzapine, risperidone, and quetiapine. 

The report found the majority of antipsychotic prescriptions (82%) were prescribed off-label based on indication, with only 13.3% of patients prescribed an antipsychotic for a psychotic disorder. 

According to data collected in the audit sample on December 31, 2021, antipsychotics were prescribed to target symptoms (rather than a condition) in 254 cases (73.2%). 

Forty six patients were prescribed antipsychotic drugs to treat psychosis, while 18 patients were treated for depression, tourettes or tics (11 patients), Oppositional Defiant Disorder (9 patients), bipolar disorder (7 patients), and Obsessive Compulsive Disorder (1 patient). 

According to the report, a Cochrane review in 2017 on the use of atypical antipsychotics for disruptive behaviour disorders in children and youths highlighted "the limited evidence base regarding the use of atypical antipsychotics for these conditions, and the need for more trials on the efficacy and safety of these medications". 

The report noted a need for national and international consensus on antipsychotic prescribing to children and adolescents, particularly in instances of off-label prescribing. 

Almost 88% of the antipsychotics prescribed in the audit sample were to children and adolescents aged 12 years and above, with 12% of prescriptions issued to children aged 11 years and below. 

All antipsychotic drugs were reportedly prescribed at low doses, with almost all dosing within recommended levels. 

However, two instances of prescribing above license were noted for Olanzapine and Risperidone. 

Twenty five instances of missing or uncodable data were also noted. 

The Minister of State for Mental Health and Older People, Mary Butler, said the audit "has provided a strong evidentiary basis of reassurance for many families who access CAMHS services, but importantly outlines areas where processes can, and must, be improved". 

Seventy percent of CAMHS patients were found to be on one medication, with 24% on two medications, and 4.6% on three medications.

Of the children prescribed more than one medication, melatonin (a synthetic version of a naturally occurring hormone that is available over the counter in many countries) accounted for 70%. 

The most common disorder reported among the audit sample of medicated children and adolescents was ADHD (56.5%), followed by anxiety disorder (30.3%) and depressive disorder (18.9%). 

The report identified several areas as needing improvement, including in areas such as documentation of consent for medication, baseline assessment and monitoring of patients taking medication, and communication with the GP on initiation and/or changes in medication. 

A number of recommendations were made in the report, including the immediate commissioning of a national software system for patient administration and clinical records. 

The report stated "the requirement for a national IT system for CAMHS is urgent and long overdue". 

The lack of any national IT infrastructure in CAMHS was called "a barrier" to efficient data gathering for the audit and "likely impacted clinical services" due to the extent of time required to complete data collection and input.