Use Of Second-generation Antipsychotics Research Articles

Factors associated with discontinuation in the drug and placebo groups of trials of second generation antipsychotics for acute schizophrenia: A meta-regression analysis: Discontinuation in antipsychotic trials

This study investigated factors associated with discontinuation in double-blind, randomized, placebo-controlled trials (DBRPCTs) of second-generation antipsychotics (SGAs) for acute schizophrenia, with a view to establishing what factors were associated with all-cause discontinuation. 77 eligible studies (96 comparisons; n = 22,678) were included in this study. Thirty-one factors potentially affecting all-cause discontinuation, related to the participants, study design, and drugs, were included in a meta-regression analysis that examined the factors associated with discontinuation rates in treatment and placebo groups and/or the treatment–placebo group difference in discontinuation. Smaller improvements in Positive and Negative Syndrome Scale total scores from baseline to endpoint were associated with higher discontinuation rates in both the treatment and placebo groups, and smaller response rates in the treatment group were associated with higher discontinuation rates in the treatment group. These factors were also associated with the treatment–placebo group difference in discontinuation. Although the risk of weight gain from SGA use was not associated with discontinuation rates in either the treatment or placebo groups, SGAs with a risk of weight gain were associated with a larger treatment–placebo group difference in discontinuation, although the reason is unknown. Factors associated with discontinuation rates in both treatment and placebo groups did not influence the treatment–placebo group difference in discontinuation. The efficacy and the risk of weight gain of SGAs seemed to influence treatment–placebo group difference in discontinuation in DBRPCTs of SGAs for acute schizophrenia.

The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second-generation antipsychotics.

Metabolic syndrome is a well-documented adverse effect of second-generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates. A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs. Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart. Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.

Second-generation antipsychotics and the risk of chronic kidney disease: a population-based case-control study

ObjectivesTo examine the association between use of second-generation antipsychotics (SGA) and the risk of chronic kidney disease (CKD).DesignPopulation-based case-control study.SettingRoutinely collected laboratory, prescription and diagnostic information on all inhabitants with...

Metabolic Syndrome in Child and Adolescent Psychiatry

In adults, metabolic syndrome (MetS) is defined as a constellation of at least 3 of 5 cardiometabolic risk factors: central obesity, hyperglycemia, elevated blood pressure, elevated triglycerides, and decreased high-density lipoprotein cholesterol. In pediatric populations, MetS remains a controversial topic due to lack of clear consensus regarding the definition, clinical utility, and lack of standardized guidelines. Despite these controversies, pediatric MetS is receiving increasing clinical and research attention due to the growing obesity epidemic and a substantial increase in the use of second-generation antipsychotics in recent years. Clinicians should be familiar with prevention, early identification, and management of obesity and metabolic derangements while working with youth with psychiatric disorders. [ Psychiatr Ann . 2020;50(8):326–333.]

Sexually transmitted infections among adolescents with conduct disorder: a nationwide longitudinal study.

Studies have demonstrated that conduct disorder is related to risky sexual behaviors, the dominant risk factor for contracting a sexually transmitted infection (STI). However, the association between conduct disorder and STIs remains unclear. Using the Taiwan National Health Insurance Research Database, 5733 adolescents with conduct disorder and 22,932 age- and sex-matched controls without conduct disorder were enrolled from 2001 to 2009 and were subject to follow-up until the end of 2011. Participants who contracted any STI during the follow-up period were identified. Cox regression analysis was performed to examine the likelihood of subsequently contracting an STI for patients and controls. Patients with conduct disorder were more likely than controls to develop any STI (HR 3.95, 95% CI 2.97-5.26) after adjusting for demographic data, psychiatric comorbidities, and use of medications. Long-term use of second-generation antipsychotics (SGAs) was related to a reduced risk (HR 0.36, 95% CI 0.14-0.91) of developing an STI among patients with conduct disorder. Adolescents with conduct disorder had an increased risk of developing any STI later in life compared with those without conduct disorder. Long-term use of SGAs was associated with a lower risk of subsequent STI.

Trends in prescriptions of lithium and other medications for patients with bipolar disorder in office-based practices in the United States: 1996–2015

BackgroundStudies have shown that rates of lithium use for bipolar disorder in the United States declined through the 1990s as other mood stabilizing anticonvulsants and second-generation antipsychotics (SGAs) became more popular. We examined trends of medications for bipolar disorder from 1996 to 2015. MethodsTwenty years of data from the National Ambulatory Medical Care Survey (NAMCS) were used. Weighted percentages of reported use of lithium, anticonvulsants, SGAs and antidepressants were calculated over two-year intervals. Logistic regression was used to examine factors related to polytherapy. ResultsReported use of lithium declined from 38.1% (95%CI: 29.8% - 46.3%) in 1996–97 to 14.3% (95%CI: 10.6% - 18.1%) in 2006–07 and has remained stable since. During this time, reports of SGAs more than doubled. SGAs and/or anticonvulsants were reported in 75.4% (95%CI: 69.5% - 81.3%) of visits with bipolar diagnoses in 2014–15. Polytherapy increased by approximately 3% every two years and in 2014–15 occurred in over 30% of visits. Antidepressants were reported in 40–50% of visits, but their reported use without other mood stabilizers decreased from 18.2% (95%CI: 11.7% - 24.8%) in 1998–99 to 7.5% (95%CI: 4.2% - 10.9%) in 2014–15. LimitationsThe sample had limited power to study the effect of individual medications or the potential for differing effects in certain sub-groups of patients. ConclusionsThis study further documents the declining use of lithium for bipolar disorder, and corresponding increase in use of anticonvulsants and SGAs, despite the fact that lithium is typically recommended as a first line therapy for bipolar disorder.

Markedly increased prevalence of migraine headaches in adolescents with bipolar disorder.

There is substantial evidence of increased prevalence of migraines, and negative psychiatric correlates of migraines, in adults with bipolar disorder (BD). Given the paucity of data on this topic in youth, we investigated the prevalence and correlates of migraine in a large sample of adolescents with BD. The study included 165 adolescents with BD-I, -II, or -not otherwise specified (NOS), diagnosed via the KSADS-PL semi-structured interview, and 89 healthy controls (HCs). Non-migraine headache and migraine headache was evaluated using the validated ID-Migraine 3-item screener. Although the prevalence of non-migraine headaches did not differ between adolescents with BD (24.2%) and HCs (32.6%; P=.15), migraine was significantly more prevalent among adolescents with BD (38.2%) compared to HCs (3.4%; adjusted odds ratio 14.76, 95% confidence interval 4.39-49.57; P<.001). Within BD, migraine was associated with female sex, BD-II/-NOS subtype, less severe worst past functioning, higher past depression severity, higher self-reported affective lability, higher body mass index, and less use of lithium and second-generation antipsychotics. Migraine is much more prevalent among adolescents with BD compared to HCs; the magnitude of this association exceeds what has been reported in adult samples. Correlates of migraine in youth BD are similar to those found for adults, including the link with the depressive polarity of BD. Future prospective studies are warranted to evaluate temporal associations between migraine and mood symptoms, and to evaluate neurobiological and cardiovascular underpinnings of these associations.

Second Generation Antipsychotics Monotherapy as Maintenance Treatment for Bipolar Disorder: a Systematic Review of Long-Term Studies.

Atypical or so called second generation antipsychotics (SGA) are playing a role of increasing importance in treatment of bipolar disorder (BD). This study is aimed towards a systematic review of their efficacy when used as monotherapy in order to prevent relapses in the long term treatment. Publications about this subject were identified after a thorough bibliographic research in Medline, The Cochrane Library and Web of Science, employing the PICO method for the creation of a database search strategy and carrying out a critical read and analysis of the found evidence. 14 studies were found which informed about the results of randomized and controlled clinical trials (RCT) about the efficacy of these SGA in monotherapy for BD, when it comes to prevention of relapse, in adult patients diagnosed with either type I or II BD, with a minimum follow-up time of 6months. Evidence of the use of SGAs for maintenance treatment in BD is limited. Amongst all antipsychotics assessed only aripiprazole, olanzapine, lurasidone, risperidone and quetiapine have been found to be competent for their use in monotherapy, according to RCT.

New antipsychotic drugs for the treatment of agitation and psychosis in Alzheimer's disease: focus on brexpiprazole and pimavanserin.

Behavioral and psychological symptoms of dementia are symptoms of disturbed perception, mood, behavior, and thought content that occurred frequently. These symptoms, which include apathy, depression, anxiety, psychosis, agitation, and aggression, can serve as predictors of and early clinical diagnostic markers for Alzheimer’s disease (AD) and are common precipitants of institutional care. Agitation and psychosis are associated with accelerated disease progression and increased tau phosphorylation in patients with AD. Current guidelines recommend the use of second-generation antipsychotics for the treatment of agitation and psychosis in AD, but only after first-line non-pharmacological interventions and for no longer than 12 weeks because long-term use of these drugs is associated with an increased risk of mortality and an increased frequency of cerebrovascular events. Therefore, new antipsychotic drugs with improved efficacy and safety are needed as an alternative to current antipsychotic drugs. In this report, we discuss some of the most relevant advances in the field of agitation and psychosis in AD and focus on the recent positive clinical evidence observed with two new antipsychotics drugs: brexpiprazole and pimavanserin. Brexpiprazole is a receptor partial agonist (D2, D3, 5-HT1A), receptor antagonist (5-HT2A/B, α1B/α2C) according to the neuroscience-based nomenclature. Two recent phase III clinical trials have shown that brexpiprazole 2 mg/day is effective for the treatment of agitation in patients with AD and has an improved tolerability and safety profile compared with currently available second-generation antipsychotics. Pimavanserin is a receptor antagonist (5-HT2A, 5-HT2C) that has been given market authorization for psychosis occurring in Parkinson’s disease. Recent phase II studies suggest that this drug is effective in AD patients with more severe psychosis, although further long-term studies are needed to better define the efficacy and long-term safety profile of pimavanserin for the treatment of psychosis in AD.

Antipsychotics Increasingly Prescribed for Bipolar Disorder

Antipsychotics Increasingly Prescribed for Bipolar Disorder

Circulating IGFBP-2 levels reveal atherogenic metabolic risk in schizophrenic patients using atypical antipsychotics

Objectives Second generation antipsychotics (SGAs) induce weight gain and dyslipidemia, albeit with important intervariability. Insulin-like growth factor binding protein (IGFBP)-2 is proposed as a circulating biomarker negatively associated with waist circumference and hypertriglyceridemia. Thus, we tested whether metabolic alterations developed upon the use of SGAs are associated with plasma IGFBP-2 levels. Methods A cross-sectional study was performed in 87 men newly diagnosed with schizophrenia and administered for approximately 20 months with olanzapine or risperidone as their first antipsychotic treatment. Plasma IGFBP-2 concentration, anthropometric data, as well as glucose and lipid profiles were determined at the end of the treatments. Results IGFBP-2 levels were similar between patients using olanzapine or risperidone and were negatively correlated with waist circumference, insulin sensitivity, and plasma triglycerides (TG). A higher proportion of men with a hypertriglyceridemic (hyperTG) waist phenotype was found in patients with IGFBP-2 levels lower than 220 ng/mL (43% for olanzapine and 13% for risperidone) compared to those with IGFBP-2 above this threshold (10% and 0%, respectively). Conclusions IGFBP-2 may have a role in altering metabolic risk in schizophrenic patients using SGAs. Longitudinal studies are required to evaluate whether IGFBP-2 can predict the development of a hyperTG waist phenotype in this population.

S90. A SYSTEMATIC REVIEW AND META-ANALYSIS OF PHARMACOLOGICAL INTERVENTIONS FOR REDUCTION OF WEIGHT GAIN IN PEOPLE WITH SCHIZOPHRENIA: 2019 UPDATE

BackgroundWeight gain and obesity are common problems encountered by patients with schizophrenia. This is partially attributable to use of second-generation antipsychotics that are associated with weight gain and other metabolic disturbances. The significance of this prevalence and its impact on premature mortality and morbidity requires better consensus on its management. The objective of this review is to determine the effects of adjunctive pharmacological interventions aimed at reducing weight gain in schizophrenia.MethodsWe searched the Cochrane Schizophrenia Group’s Trials Register which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. Inclusion criteria consisted of all randomized controlled trials examining any adjunctive pharmacological intervention for weight loss in patients with schizophrenia or schizophrenia-like illnesses. The primary outcome of each study had to be body weight or a weight related measure. We reliably selected, quality assessed, and extracted data from studies. As endpoint and change data was combined in the analysis, mean differences (MD) of the change from baseline were calculated using Review Manager 5.3.ResultsSixty-one randomized controlled trials met inclusion criteria for this review (pooled n = 3328). Metformin is effective in bringing about modest weight loss (Weight: MD -3.40 kg, 95% CI -4.63 to -2.16; participants = 731; studies = 12; BMI: MD -1.39, 95% CI -1.94 to -0.85; participants = 879; studies = 13). Heterogeneity was reduced by dividing populations into first episode psychosis (FEP) and chronic populations, where FEP patients appeared to benefit most from early metformin intervention (Weight: MD -5.18 kg, 95% CI -6.22 to -4.14; BMI: MD -1.87 kg/m2, 95% CI -2.19 to -1.56; participants = 214; studies = 3) as compared to chronic patients (Weight: MD -2.22 kg, 95% CI -3.07 to -1.37; participants = 517; studies = 9; BMI: MD -1.18 kg/m2, 95% CI -1.89 to -0.48; participants = 665; studies = 10). However, ethnicity could be a confounder for the apparent effect of illness stage, as all first episode metformin intervention studies were conducted in patients with Chinese ethnicity. Metformin as a treatment for weight gain may be associated with additional adaptive changes in fasting insulin levels and insulin resistance. The frequency of adverse effects did not differ between metformin and placebo groups. Moreover, glucagon-like peptide agonists (GLP-1RAs), such as liraglutide and exenatide, were also effective in reducing weight (Weight: MD -3.95 kg, 95% CI -7.08 to -0.83; participants = 165; studies = 3; BMI -1.26 kg/m2, 95% CI -2.21 to -0.30; participants = 165; studies = 3; waist circumference: MD -3.25, 95% CI -5.93 to -0.57; participants = 165, studies = 3). The frequency of adverse effects did not differ between GLP-1RA and placebo groups. Topiramate 200 mg was also effective for weight reduction (Weight: MD=-6.61 kg, 95% CI -9.62 to -3.61; BMI: MD=-2.72, 95% CI -3.25 to -2.20; participants = 181, studies = 3).DiscussionThis review highlights the promise of pharmacological interventions for decreasing weight gain associated with antipsychotic use. Of the drugs studied, metformin has the most evidence and was most effective in bringing about modest weight loss. Topiramate and GLP-1RA also have accumulating evidence supporting efficacy in reducing weight. Interpretation for other agents is limited by the small number of studies, sample size, and short study duration. Future studies that are adequately powered, with longer treatment duration, will be needed in evaluating the efficacy and safety of interventions for managing weight gain further.

The 12-year trend report of antipsychotic usage in a nationwide claims database derived from four million people in Japan

The current study aimed to describe the use of antipsychotics to clarify the gap between clinical guidelines and health care practice in Japan. We used data from the JMDC Claims Database (JMDC Inc., Tokyo, Japan), a nationwide claims database, from 2005 to 2016. Antipsychotics were defined as drugs coded as N05A with the Anatomical Therapeutic and Chemical (ATC) codes. We described the annual changes in proportions based on the number of patients prescribed any antipsychotics. From the database of 4,081,102 people, the data of 12,382 patients was extracted by applying the following exclusion criteria: no use of antipsychotics, missing the prescription date or dose, inpatients, prescribed antipsychotics only for use as needed, prescribed only injectable antipsychotics except for long-acting injections (LAIs), without schizophrenia as the primary disease, not exceeding 75 mg/day chlorpromazine equivalent, and less than 18 years old. The use of second-generation antipsychotics (SGA) has been expanding, while the use of first-generation antipsychotics has been decreasing. Aripiprazole accounted for the highest proportion of prescribed antipsychotics (31.9%) in 2016. Even though clozapine is categorized as a SGA, it accounted for a paltry 0.2%. The proportion of prescribed antipsychotics accounted for by LAIs was less than 5%. Although the use of antipsychotics for schizophrenia in Japan mostly corresponds to various clinical guidelines, limited use of clozapine and LAIs was identified. Further research focusing on the factors affecting the prescription of these underused antipsychotics may help advance the pharmacological therapy of schizophrenia.

Metabolic Adverse Effects of Off-Label Use of Second-Generation Antipsychotics in the Adult Population: A Systematic Review and Meta-Analysis

Second generation antipsychotics (SGAs) are approved by the US Food and Drug Administration for treatment of schizophrenia, bipolar disorder, and refractory depression. Since the 1990’s, antipsychotic prescription has more than doubled, with off-label use disproportionately contributing. SGAs used “on-label’ have significant metabolic adverse effects (MAEs). Currently, there is no literature systematically investigating the MAEs of ‘off-label’ use to guide clinical decision-making practices.

Development of two different pharmacogenomics detection methods for second-generation antipsychotic drugs quetiapine and aripiprazole

Abstract Objective: Second-generation antipsychotics are widely used in mental illness, but the treatment effects and side effects are affected by single nucleotide polymorphisms (SNPs) of related genes. Quetiapine and aripiprazole are two frequently used second-generation antipsychotic drugs. The aim of this study was to develop two different SNP detection methods for four SNP alleles associated with the pharmacokinetics of quetiapine and aripiprazole, based on high-resolution melting (HRM) and multicolor melting curve assay (MMCA) respectively. Methods: Whole genome DNA samples were obtained from 240 healthy people (107 females and 133 males) without genetic diseases. HRM methods were established using four kinds of specific primers and a saturated fluorescent dye. Each SNP allele with their own primers was detected in a single reaction. In the MMCA method, a multiplex polymerase chain reaction with 4 different-colored fluorescent probes was established to detect four SNP alleles in a single reaction. All experimental protocols were approved by the Ethics Committee of the Shanghai Children's Medical Center, China (SCMC-201015) on November 22, 2010. Results: Two detection methods for the pharmacogenomics of quetiapine and aripiprazole, based on HRM and MMCA respectively, were established in this study. The single-target HRM method can be completed in 96 minutes, whereas the quadruplex MMCA method takes 133 minutes. It was found that the results of HRM and MMCA for the four SNP alleles had 100% coincidence with Sanger sequencing in the 240 samples. Conclusion: This study developed two methods for the detection of four pharmacogenomic SNP alleles that correlated with quetiapine and aripiprazole. Both methods are rapid, cost-saving, highly accurate and potentially facilitate rational use of second-generation antipsychotics for clinical medication.

Revisiting Tardive Dyskinesia: Focusing on the Basics of Identification and Treatment.

The use of second-generation antipsychotics has not eliminated tardive dyskinesia (TD), and the prevalence of the disorder is higher than commonly realized. The involuntary movements of TD can decrease patients' quality of life, cause embarrassment, and lead to social withdrawal. Clinicians must evaluate patients taking DRBAs for TD risk factors and regularly screen them for TD using a rating scale. Familiarity with tools and diagnostic criteria will enable clinicians to conduct a differential diagnosis. Once a diagnosis is made, medications approved by the US Food and Drug Administration can be used to treat the condition. These medications are effective, but clinicians should be aware of key differences. A baseline assessment and regular follow-up evaluations will allow the clinician to monitor the patient's progress and make adjustments to meet treatment goals.​.

A Case of Comorbid PTSD and Posttraumatic OCD Treated with Sertraline-Aripiprazole Augmentation

Several studies report on traumatic history in Obsessive Compulsive Disorder (OCD) and comorbidity between Posttraumatic Stress Disorder (PTSD) and OCD. First-line pharmacological treatments for both OCD and PTSD are primarily based on antidepressants, including Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Noradrenaline Reuptake Inhibitors (SNRI) such as Venlafaxine for PTSD. Second-Generation Antipsychotic (SGA) augmentation has shown good outcomes for nonresponsive OCD cases. However, evidence on the use of SGA in PTSD is more limited. In the present paper, we report on comorbid OCD-PTSD successfully treated with aripiprazole augmentation of sertraline. Shared psychopathological and pharmacological aspects of the disorders are discussed.

A study on haloperidol and risperidone induced metabolic derangements in patients with newly diagnosed schizophrenia

Background: The occurrence of metabolic abnormalities in schizophrenic patients has been increased with the rampant use of second-generation antipsychotics. The aim and objective of this study is to compare the metabolic derangements induced by a typical antipsychotic: haloperidol and an atypical antipsychotic, risperidone in patients with newly diagnosed schizophrenia in a tertiary care hospital.Methods: Out of 60 newly diagnosed schizophrenic patients, 30 patients received tablet haloperidol and the remaining 30 patients received tablet risperidone orally. The anthropometric measurements like height, weight, waist circumference was measured and blood investigations like fasting blood glucose level and fasting lipid profile were taken at baseline and at the end of 3 and 6 months of drug therapy. The metabolic derangements induced by the two antipsychotics were compared and analyzed at end of 3rd and 6th month using SPSS software version 16.Results: At the end of 6th month statistically significant differences (p&lt;0.05) were observed in weight, waist circumference, fasting blood sugar, fasting triglyceride and high-density lipoprotein level between the haloperidol and risperidone group on following the International Diabetic Federation (IDF) criteria of metabolic syndrome. Risperidone caused metabolic abnormalities in 13.3%, 4 patients whereas none of the patients in haloperidol group developed metabolic syndrome.Conclusions: Hence it is concluded that the atypical antipsychotic risperidone has been associated with an increased risk of causing metabolic abnormalities than the typical antipsychotic haloperidol. Regular and periodic monitoring of the anthropometric and metabolic parameters in schizophrenic patients on antipsychotics especially the atypical antipsychotics is mandatory to prevent further complications.

Metabolic Monitoring Rates of Youth Treated with Second-Generation Antipsychotics in Usual Care: Results of a Large US National Commercial Health Plan.

Objectives: To examine metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. Methods: In this retrospective study, data were collected from a large national commercial health plan for the period covering January 1, 2016 to December 31, 2017. Commercially insured children and adolescents, aged 8-19 years with ≥2 SGA prescription claims during the CY, were identified for the CY2016 and CY2017 cohorts. The primary outcome of interest was the percentage of subjects with any glucose or lipid metabolism parameter monitoring. Other calculated metabolic testing rates included glucose, hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), other cholesterol (including triglycerides), and combined glucose and lipid metabolism testing (≥1 test for blood glucose or HbA1c and ≥1 test for LDL-C or other cholesterol). Results: In CY2016 and CY2017, 1502 and 1239 subjects, respectively, were identified for this study. The most common psychiatric diagnoses in CY2016 and CY2017 were major depressive disorder (57.1%, 56.5%, respectively), anxiety disorders (42.9%, 47.5%), attention-deficit/hyperactivity disorder (41.6%, 45.8%), and bipolar disorder (24.1%, 25.9%). The rate of any metabolic testing was 53.5% in CY2016 and 51.3% in CY2017. Glucose testing (50.3%, 46.9%, respectively) was most common in both CYs, followed by LDL-C testing (31.2%, 28.5%). Rates of combined glucose and lipid metabolism testing were 30.7% in CY2016 and 26.9% in CY2017. Conclusions: Given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. There is a critical need for understanding barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring.

Earlier Diagnosis of Tardive Dyskinesia.

Because the symptoms of tardive dyskinesia (TD) have an insidious onset and fluctuating nature, and the risk of TD associated with second-generation antipsychotic (SGA) treatment has been underestimated, it has been challenging for clinicians to make an early and accurate TD diagnosis. More patients are at risk of developing this potentially permanent, disabling condition than ever before because of the widespread use of SGAs; therefore, prevention of TD, if possible, is of utmost importance. Clinicians must use reliable screening tools and diagnostic criteria to assess patients for TD, rule out other abnormal movement conditions, and make an accurate TD diagnosis.