Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : May | Volume : 6 | Issue : 3 | Page : 431 - 436 Full Version

A Descriptive Study of Use of Psychotropic Drugs in Child and Adolescent Psychiatric Illness in an Inpatient Facility


Published: May 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.1954
Fahad Jameel, Ashwin Kamath, Shripathy M. Bhat, Laxminarayana K. Bairy

1. Department of Pharmacology, Kasturba Medical College, Manipal, Manipal University. 2. Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal University. 3. Department of Psychiatry, Kasturba Medical College, Manipal, Manipal University. 4. Department of Pharmacology, Kasturba Medical College, Manipal, Manipal University.

Correspondence Address :
Dr. Ashwin Kamath
Assistant Professor, Department of Pharmacology
Kasturba Medical College, Light house hill road,
Mangalore – 575001, Karnataka, India.
Phone: +919844262808
E-mail: mailmaka@gmail.com

Abstract

Objectives:
To describe the child and adolescent psychiatric disorders in an inpatient setting and their pharmacological management.
Method:
The case record files of all the patients who were ≤ 18 years of age, who were admitted to the psychiatry ward of a tertiary care hospital in southern India over a three year period were studied. The following details were recorded - age, gender, diagnosis and the drugs which were prescribed. The drug classes were delineated as follows – antidepressants, antipsychotics, mood stabilizers, anxiolytics/hypnotics and stimulants/nonstimulants for ADHD.
Results:
A total of 611 patients were admitted during the three year period. 41.6% were females. The mean age was 10.67±5.04 years in males and it was 12.37±4.81 years in females. Neurotic and somatoform disorders were more common in the females (p<0.001), while disorders of psychological development (p=0.023) and behavioural disorders (p<0.001) were more common in males. 44.5% of the cases did not receive any psychotropic medication. The percentage use of the drug classes was as follows – antidepressants- 26%, anxiolytics -18.7%, antipsychotics- 14.7%, mood stabilizers -6.5% and stimulants/ non-stimulants- 2%. Antidepressants and anxiolytics were more commonly prescribed in the females (p<0.001), while stimulants were more commonly prescribed in the males (p=0.001). 2.8% of the cases were discharged on 3 drugs.
Conclusions:
Paediatric admissions due to psychiatric illness were more common in males, although towards adolescence, the percentage of the females increased. The most common diagnoses were behavioural and neurotic disorders, while the most commonly prescribed drugs were antidepressants and anxiolytics. A gender difference was seen in the use of the medications, which correlated with the difference in the disease presentation.

Keywords

Psychotropic drugs, Drug utilization, Children, Adolescents, Inpatients

Introduction
The World Health Report has estimated the worldwide burden of psychiatric morbidity in children and adolescents to be about 20% (1). Psychiatric illness in paediatric age group is a much more serious problem in India because more than 40% of our population is ≤ 18 years of age (2). Studies which have been based on the prescription claims data, the pharmacy dispensing data and on surveys on the general population have shown a trend of increasing psychotropic drug prescription (3),(4). The increase in the medication use has not been accompanied by an increase in the clinical research which evaluates the efficacy of these drugs in the younger population. The clinical experience and the adult psychopharmacology data have added on to the limited information on the psychotropic drug use in children. However, the emergence of data which has questioned the safety of the selective serotonin reuptake inhibitors (SSRIs) in young people have highlighted the need for well conducted research in children and adolescents (5). Also, given the considerable public health relevance of drug safety in children, and the potential effects of psychotropic medications on their physical growth and brain development, it is important to identify valid methods for detecting the possible drug-induced adverse events during an early or prolonged exposure to the drugs (6). Before the issues which are related to excessive psychotropic drug use are addressed, it is essential to determine the actual rates of medication use and the clinical context of their use. Drug utilization studies have thus become essential to identify the Original Article possibly unfounded or hazardous extensions of the indications of medications. Most of the research regarding psychotropic drug use in the paediatric age group has been conducted in the United States or Europe and studies have shown that the patterns of prescribing and drug utilization vary internationally and within regions (7). Very little research has examined the patterns of the psychotropic drug utilization in children in India, especially in the inpatient setting. These children represent some of the most serious emotionally and behaviourally disturbed children who seek treatment and hence their drug utilization is likely to differ from that of the children in the outpatient setting (8). Therefore, this study was undertaken to identify the pattern of the psychiatric illness and the psychotropic drug utilization in children and adolescents who were admitted to the psychiatry ward.

Material and Methods

The medical records of all the inpatients who were ≤ 18 years of age who were admitted with a diagnosis of psychiatric illness (International Statistical Classification of Disease and Related Health Problems, Tenth revision, ICD-10, F00-F99), during the period between 1st January 2006 to 31st December 2008, were retrieved from the medical records section of Kasturba Hospital, Manipal, a tertiary care hospital in southern India. Approval from the institutional ethics committee was obtained prior to start of the study. The following information was obtained from the medical records of each patient: age, gender, diagnoses, whether it was the first admission or readmission and the psychotropic drugs which were prescribed before the admission, during the hospital stay and at the time of discharge. To facilitate the analysis, the psychotropic drugs were classified into 5 broad classes – anti-depressants, antipsychotics, mood stabilizers, anxiolytics/hypnotics and stimulants/ non-stimulants for attention deficit hyperactivity disorder. A patient was considered to be on medication if he had received one or more psychotropic drugs, irrespective of the number of prescriptions and their dose or the patients’ compliance to them. Readmission was considered as a separate medication trial, regardless of the duration between the two hospitalizations. Prescription percentage refers to the percent of the total study population who were prescribed the drugs. The comparisons between the categorical variables were done by using the Chi-square statistic, with the level of significance being set at p < 0.05. The SPSS 14 software package was used for the statistical analysis.

Results

Demographics:
The medical records of 611 paediatric inpatients who were admitted with psychiatric illnesses between 1st January 2006 and 31st December 2008 were studied. Of these, 58.4% (357/611) were males. The mean age was 10.67±5.04 years in males and it was 12.37±4.81 years in females (p<0.001). 48.1% (294/611) of the study sample were aged between 13 to 18 years. The age-wise gender distribution of the patients is shown in (Table/Fig 1). 9.8% (60/611) of the cases constituted readmissions. The median duration of the hospital stay was 5.5 days (range 1-54 days).
Diagnosis:
Based on the ICD-10, the most common primary diagnoses are shown in (Table/Fig 2). The disorders of psychological development (p=0.023) and behavioural disorders (p<0.001) were more common in males, while neurotic and somatoform disorders were more common in females (p<0.001).
Psychotropic Drug Use:
Out of the 611 patients, 16.53% (101/611) were on psychotropic medications before their hospitalization. These included 6.38% who were on antipsychotics, 3.27% who were on antidepressants, 2.13% who were on mood stabilizers, 1.64% who were on anxiolytics/hypnotics and 3.11% who were on drugs for ADHD. 55.5% (339/611) received the psychotropic medication following their hospital admission and the rest were treated with non-psychotropic drugs or psychological therapy. Males accounted for 56.3% (191/339) of the patients who were on the psychotropic medication. 58.3% (148/254) of all the females who were admitted were on psychotropic medication as compared to 53.5% (191/357) of all the males (p=0.24). The patients who stayed in the hospital for longer than 6 days showed higher rates of psychotropic medication use. (Table/Fig 3)(3A-3F) shows the most commonly prescribed drug class and also the most commonly prescribed drugs in each class. There was no significant changeover of the drug classes between the admission and the discharge. Also, there was no significant difference between the prescription rates of a drug class on admission and discharge. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed antidepressants in the study sample – which were given to 20% (122/611) of the patients. Tricyclic antidepressants contributed to 17.6% of all the patients who were discharged on anti-depressants (28/159) and newer antidepressants (venlafaxine, duloxetine, mirtazepine) contributed to 6% (9/159). Anxiolytics and hypnotics were the second most commonly prescribed psychotropic agents (114/611, 18.7%). Clonazepam was the second most commonly used drug (62/611, 10.1%) in the study. Of the 14.7% (90/611) patients who received antipsychotics on hospital discharge, 14.4% (13/90) were on typical anti-psychotics and the rest were on atypical anti-psychotics. Methylphenidate was found to be the only stimulant which was used in 12 of the 74 (16.2%) patients of ADHD who were on psychotropic drugs. Nonstimulant drugs like clonidine (45/74, 60.8%) and atomoxetine (17/74, 30%) were more frequently prescribed for the management of ADHD. The prescription rates of all the drug classes except those for ADHD were significantly higher in older patients who were aged aged 13 to 18 years (p<0.001), while that of stimulants was higher in younger patients who were aged 1 to 12 years (p<0.001). As seen in (Table/Fig 4), anti-depressants and anxiolytics were significantly more commonly prescribed in females, while stimulants were more commonly prescribed in males. This correlated well with the finding that disorders of psychological development (p=0.023) and behavioural disorders (p<0.001) were more common in males, while neurotic and somatoform disorders were more common in females (p<0.001).
Polypharmacy:
34% of all the patients (208/611) were prescribed a single psychotropic drug, 17.8% (109/611) were given 2 drugs and 2.8% (17/611) were given 3 psychotropic drugs at discharge. The use of two drugs during the cross tapering was not considered as polypharmacy. The use of two psychotropic drugs simultaneously was frequently associated with the diagnosis of – neurotic, stress related and somatoform disorders (37.6%, 41/109), mood disorders (29.4%, 32/109), and behavioural and emotional disorders (18.3%, 20/109). Three drugs were co-prescribed for - mood disorders (29.4%, 5/17), schizophrenia, schizotypal and delusional disorders (23.5%, 4/17), and behavioural and emotional disorders (23.5%, 4/17).(Table/Fig 5) shows the incidence of polypharmacy in the 334 patients who were discharged with psychotropic drugs. Anxiolytics/ hypnotics (86/334, 25.7%) and antidepressants (82/334, 22.6%) were most frequently prescribed with other psychotropic drugs. As a group, benzodiazepines were used in 65.9% (83/126) patients who were on ≥2 drugs, SSRIs were used in 49.2% (62/126) patients and atypical anti-psychotics in were used 35.7% (45/126) patients. SSRIs and benzodiazepines were co-prescribed in 42.1% (53/126) of such patients, atypical antipsychotics and benzodiazepines were co-prescribed in 16.7% (21/126) patients and SSRIs were co-prescribed with atypical anti-psychotics in 7.1% (9/126) patients. (Table/Fig 6) shows the most frequently used drugs in polypharmacy. The most frequently used combination in the study was clonazepam with sertraline in 17.5% (22/126) patients who were on ≥2 drugs.

Discussion

This study examined the patterns of psychotropic medication utilization in 611 paediatric inpatients in the psychiatry ward of a tertiary care hospital who were admitted over a period of three years. There was no significant difference in the age presentation of both the genders, a trend which was similar to that which was found in other studies (9),(10). 58.4% of the total admissions comprised of males as compared to a range of 44.3% to 52.5% which was reported in other studies (9),(10). The higher percentage of males who were admitted in our study could be due to the increased social stigma in India and the reluctance of the parents which was associated with the admission of females in the psychiatry ward (11). Neurotic, stress related and somatoform disorders, behavioural and emotional disorders, disorders of psychological development, mental retardation and mood disorders were the most common diagnoses and this pattern was consistent with that of similar studies which were done in India (12). As found by Dean and coworkers, the disorders of psychological development and behavioural disorders were more common in males, while neurotic and somatoform disorders were more common in females (9). More than half (55.5%) of the total sample received one or more psychotropic medication. In similar studies, these values ranged from 49% in residential psychiatry facilities to 71.3% in inpatient units (8),(9). We found that there was no significant change in the number or class of the drugs which were used on hospital admission and discharge. Earlier studies had shown a significant decrease in the use of psychotropic drugs from the time of the hospital admission to the discharge (8),(9). This study confirmed the observation of Dean et al that patients who stayed in the hospital for longer periods had higher rates of psychotropic medication use (9). The prescription rates of all the drug classes were significantly higher in older patients (13 to 18 years), except those of the drugs which were used in ADHD, which has its occurrence at a younger age. The prescription rates of various groups of drugs differed in various studies. In the study which was done by Dean et al, the percentage use of anti-depressants was 56.6%, that of antipsychotics was 32.8%, that of anxiolytics/hypnotics was 13.9%, that of stimulants was 13.9%, and that of mood stabilizers was 3.3% (9). The percentage use of the drug classes in our study was as follows – antidepressants –26%, anxiolytics –18.7%, anti-psychotics –14.7%, mood stabilizers –6.5%, and stimulants/non-stimulants –2%. However, the disease presentation patterns were not similar and hence there was a difference in the drug utilization rates. Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressants. This trend was similar to that which was reported by other studies, both among children and in adults (3),(13). Sertraline was clearly the most popularly prescribed SSRI. Sertraline, and the next commonly prescribed agent, escitalopram, have a more favourable pharmacokinetic profile, including fewer pharmacokinetic drug interactions than other SSRIs (14). This could be the reason for their preference over other antidepressants. Also, the high usage and familiarity with these agents in adult psychiatry may be responsible for their greater use in the paediatric age group. It is important to remember that younger people may show a differential risk of the toxicity outcome while using these agents and this is yet to be determined by systematic studies. Deliberate self harm is a major problem in adolescents (15). In our study, 86.6% of all the patients who received anti-psychotics were on atypical anti-psychotics and risperidone alone accounted for more than half (52.2%) of these cases. The use of atypical antipsychotics for psychotic and nonpsychotic disorders, such as aggression in the youth, is increasing (16). This merits caution because the risk of drug-related side effects, some of which are serious, is greater with antipsychotics than with most other psychotropics which are used in children. Also, of concern is the dearth of evidence to support the current practices which involve the paediatric use of antipsychotics, except for a few short term studies (16), (17). The popularity of the atypical anti-psychotics is mostly due to the lower incidence of the extrapyramidal side effects which are related to them. But the side effects, including extrapyramidal effects, may occur more frequently in younger patients as compared to the adults (18). Currently, there is insufficient evidence regarding the potential, negative, long-term consequences of weight gain and the endocrinological changes which are associated with most of the atypical antipsychotics (17). Larger, detailed studies are needed to confirm these observations. The proactive monitoring of the body weight, fasting blood glucose and the lipid levels is necessary for taking into consideration the developmental norms that incorporate the age- and sex-specific thresholds (19). One of the salient findings in this study was the significantly higher use of anxiolytics/hypnotics as compared to that in the earlier studies. This was the second most commonly prescribed class of drugs (18.7%) in our study, with clonazepam being the second most frequently used drug (10.1%). They were frequently indicated in cases with multiple diagnoses which involved neurotic, stress related and somatoform disorders, mood disorders and behavioural and emotional disorders. Carbamazepine was the most commonly used drug for bipolar disorder in our study, followed by lithium. While lithium is the most studied medication for paediatric bipolar disorder, there are no well controlled large studies which have evaluated the efficacy of anticonvulsants (20). Using an atypical antipsychotic either alone or in addition to another mood stabilizers, has shown its utility in treating manic symptoms, depression in mixed states, and aggression, since children might not respond well to the conventional mood stabilizers alone (21). The use of stimulants was much lower as compared to that in other reports and methylphenidate was the only one which was prescribed. All the prescriptions in our study were written by psychiatrists. The pattern of the stimulant prescription might vary when prescriptions from paediatricians and general practitioners are taken into consideration (10), (22). The reports which showed an increased incidence of growth suppression with chronic stimulant use could also be responsible for the lower prescription rates of these drugs in our study (23).
Polypharmacy:
Nearly 20% of all the patients in our study were started on 2 or more psychotropic drugs simultaneously. The rates of the reported polypharmacy differed among the various settings, with the psychiatric inpatient facilities having higher rates than the outpatient facilities and the paediatric clinics (24). The most frequently prescribed combination in our study, i.e. SSRIs and benzodiazepines, was different from that in other reports. Other studies have reported SSRIs with atypical anti-psychotics or stimulants with clonidine or stimulants with anti-depressants to be the most frequently prescribed combinations (9),(22),(25). As discussed above, this may reflect the differences in the nature of the prescribers, as well as the different clinical profiles of the corresponding patient populations. While polypharmacy alone does not necessarily reflect poor prescribing practices, with the high rates of concomitant pharmacotherapy among the children and adolescents in psychiatric care, additional research on the efficacy and safety of this treatment strategy is necessary (25). Until then, caution must be taken while initiating these psychotropic combinations. Our study has limitations. We did not look for the appropriateness of the psychotropic drugs which were prescribed for the various mental illnesses. Also, the rationality of the drug combinations was not assessed. These would require studying the drug utilization in comparison to the practice guidelines for specific disorders. Our study intended to present the drug utilization data in the child and adolescent inpatients in general. To conclude, the paediatric admissions due to psychiatric illness were more common in males, although towards adolescence, the percentage of the females increased. The most common diagnosis was behavioural and neurotic disorders, while the most commonly prescribed drugs were antidepressants and anxiolytics. A gender difference in the use of the medications was seen, which correlated with the difference in the disease presentation. More than half of the total sample received one or more psychotropic medications. Although appropriate comparisons are scarce, these rates were found to be lower than those which were reported in inpatient and residential psychiatry facilities. About 60% of the patients who received psychotropic medications were on more than one drug. No significant difference in the drug use was seen on admission and discharge. Since all the drugs do not produce equal effects and to the same extent in children and adolescents, well controlled clinical trials are needed to establish their true benefit in this population. The long-term safety and quality of the life outcomes also need to be determined.

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DOI and Others

DOI: JCDR/2012/4041:1954

Financial OR OTHER COMPETING INTERESTS:
None.


Date of Submission: Jul 28, 2011
Date of Peer Review: Jan 08, 2012
Date of Acceptance: Jan 27, 2012
Date of Publishing: May 01, 2012

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