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Antipsychotic Treatment Guidelines

These recommendations are excerpted from a report in the February 2003 Journal of the Academy of Child and Adolescent Psychiatry.

• Conduct an initial diagnostic evaluation before using pharmacological treatment.
  
• Assess treatment effects and outcomes. Standardized symptom and behavior rating scales with proven reliability and validity should be used to measure the severity and frequency of target symptoms before treatments are initiated, at regular intervals throughout treatment, during acute episodes, and when treatments are changed or discontinued.
  
• Begin with psychosocial and educational treatment. Structured psychosocial and educational interventions should be the first line of treatment and should be continued even if medications are later initiated to manage aggression.
  
• Use appropriate treatment for primary disorders as a first-line treatment. Aggressive patients who also present with persistent and clinically significant symptoms of hyperactivity, anxiety, depression, or mania should receive at least one adequate trial of a first-line agent for these "primary" disorders.
  
• Use an atypical antipsychotic first rather than a typical antipsychotic to treat aggression.
  
• Use a conservative dosing strategy. Physicians should use a "start low, go slow, taper slow" dosing strategy when using antipsychotic medications to treat aggression in children and adolescents.
  
• Use psychosocial crisis management techniques before medication for acute or emergency treatment of aggression. Physical and mechanical restraints and locked seclusion should be used only when all other approaches have failed.
  
• Avoid frequent use of emergency medications to control behavior. When antipsychotic "stat" or "p.r.n." medications are used several times a day to manage agitation and aggression, physicians and treatment teams should re-evaluate the diagnosis and the adequacy of behavioral and environmental interventions and readjust the treatment plan and medication regimen.
  
• Assess side effects routinely and systematically.
  
• Ensure an adequate trial before changing medications.
  
• Use a different atypical antipsychotic after failure to respond to adequate trial of a first-line atypical. For patients who continue to be dangerous while on a first-line atypical antipsychotic and whose behavior is not due to untreated primary conditions, monotherapy with a different atypical should be considered.
  
• Consider adding a mood stabilizer after partial response to a first-line atypical antipsychotic.
  
• If a patient is not responding to multiple medications, consider tapering one or more medications.
  
• Taper and consider discontinuing antipsychotics in patients who show a remission in aggressive symptoms for six months or longer.
  

Related Article:

State-Funded Health Plan Finds Jump in Antipsychotic Use in Youth

Mark Moran
Psychiatr News 2004 39: 2-42. [Full Text]

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