Psychopharmacological treatment in children: always keeping an eye on adherence and ethics
2013-07-03

Within the last few years, several psychopharmaca, formerly used off-label, received an on-label status for drug treatment in Child and Adolescent Psychiatry (CAP) (e.g., fluoxetine, fluvoxamine, risperidone), but beyond that new options were quite rare (e.g., aripiprazole and melatonin; [1–3]). Also, publications on child and adolescent psychopharmacology in ECAP usually included information on single studies and reviews concerning well-known substances such as haloperidol and other neuroleptics, stimulants, atomoxetine, fluoxetine, and other SSRIs [4]. In 2011, such kind of articles presented 8.5 % (excluding a supplement on an observational trial on a methylphenidate-ER preparation [5]) and in 2012, there appeared 7 % of the ECAP papers on that topic. The content of most of these 2011/2012 publications reflects special aspects of psychopharmacological treatment, where management of adverse effects plays the major role (e.g., [6, 7]) besides quality of life, satisfaction with treatment, and adherence (e.g., [8]). The off-label use of psychopharmaca in children and adolescents is still a matter of debate either with the focus on indication or age or both. Therefore, it is welcome that Dorks et al. [9] inform us about the antidepressant drug use and off-label prescribing in children and adolescents in Germany. They report retrospectively from a large-scale population based cohort study and analyzed cross-sectional data from four German statutory health insurances (comprising about 17 % of the population from all regions in Germany; making up 2,599,685 patients up to 17 years of age). Although the prescription of SSRIs increased slowly from the 2004 to the 2006 cohort, the prescription behavior of physicians seems to reflect good clinical practice, since the use of St. Johns Wort and tricyclic antidepressants decreased. Also, prescribing antidepressants seems to be similar all over Europe, which underlines the process of harmonization in European CAP. However, the authors stated, ‘‘that more than 50 % of children and adolescents received only a single prescription of antidepressants’’. Also, a British Study [10] reported ‘‘more than 50 % discontinued treatment after two months’’. Further, ‘‘around half of all antidepressant prescriptions were off-label with respect to age or indication’’ in the Dorks et al. [9] study, but the off-label use was mostly guided by a specialist and those SSRIs were used which were recommended by clinical guidelines and/or received official on-label qualification later on. The report of Dorks et al. [9] touches another highly important problem in childhood psychopharmacotherapy, namely, how can we improve adherence to guarantee adequate drug treatment? This topic was already reviewed and discussed in ECAP earlier [11]. The author states that ‘‘adherence is the single most modifiable factor associated with treatment outcome ... the best treatment is rendered useless if not adhered to’’. In order to explore this field further, Roedelof et al. [12] investigated the treatment engagement in adolescents with severe psychiatric problems. The authors tried to answer the question how to get the highest profit possible from an evidence-based treatment applied in clinical practice. Using the Treatment Engagement Rating Scale and longitudinal latent class A. Rothenberger (&) Child and Adolescent Psychiatry, University Medical Center Goettingen, von-Siebold-Str. 5, 37075 Goettingen, Germany e-mail: arothen@gwdg.de