Abstract
I
Wagner et al. report on their much-needed investigation into the real-world effects of manualized approaches to the provision of pediatric mental health care. Though their study of an application of guidelines from the Texas Children's Medication Algorithm Project (CMAP) has some limitations, the possibilities for future research and clinical application are truly heartening. The outcomes in medication treatment of children with attention-deficit/hyperactivity disorder (ADHD) aged 5–14 are impressive, including rates of symptom remission about 70%. But perhaps more salient is the durability of the model.
“This study indicates,” the authors write, “that it may be feasible to implement, with a high degree of fidelity, an evidence-informed, best-practice guideline into a clinical service.” Investigations like that of Wagner et al. suggest that research has the potential to affect not only the creation of new treatments but the delivery method and wide-ranging quality of care. As they write, “the encouraging outcomes identified in this analysis also suggest that further examinations of the impact of best-practice guidelines implementation may be useful.”
Elsewhere, Lake et al. take a critical look at the extreme variability in prescribing habits that CMAP is designed to remedy, this time in the population of young people with autism spectrum disorder (ASD) prescribed medication to manage symptoms. After analysis of their diverse sample, the investigators reach a conclusion that likely does not surprise this readership: Polypharmacy in this population is correlated to factors independent of the core clinical syndrome of autism. “The main contributors,” they write, “were history of hurting others, psychiatric comorbidity, parent burden, and therapy service use.”
Lake et al. are careful to note limitations in their study, and that “there are many circumstances where polypharmacy is a necessary and appropriate sign of good psychiatric care.” However, they rightly note, “identification of risk factors for psychotropic polypharmacy could inform the development of alternative interventions that complement or replace pharmacological treatments.”
Finally, Lake et al.'s work should be held close in mind when reading the report of Marrus et al. on the effect of risperidone in the autism population. Their key results are familiar: While this atypical antipsychotic is quite effective at reducing certain aggressive behaviors, it is ineffectual at addressing the core symptoms of the disorder. It follows then, the authors write, that treatment of these symptoms “is likely to require interventions beyond what can be achieved by current FDA-approved pharmacotherapies.”