Prevalence and Factors Affecting the Use of Antipsychotics and Antipsychotic Polypharmacy in a Child and Adolescent Psychiatry Inpatient Service

Abstract

Objective:

We aimed to examine the antipsychotics used by patients hospitalized in the child and youth inpatient service providing tertiary care to investigate whether there is a difference between admission and discharge, polypharmacy, which antipsychotics are used, and which psychotropics are used concomitant with antipsychotics.

Methods:

Research data were collected retrospectively from all children and adolescents hospitalized in a child and adolescent psychiatry inpatient service in a university hospital in a 4-year period (2015–2019). The sociodemographic and clinical characteristics of the patients, the antipsychotics they used at admission and discharge, the other psychotropics concomitantly used with antipsychotics, and the side effects associated with antipsychotics during hospitalization were collected from the files of the 363 patients.

Results:

Patients on antipsychotics increased 12.1% from hospitalization to discharge. Antipsychotic polypharmacy increased from 16.2% at admission to 30.7% at discharge. Logistic regression analysis was performed to investigate the factors affecting antipsychotic and antipsychotic polypharmacy. Self-harm, aggression/violence, and extended hospitalization were factors associated with increased antipsychotic use. Psychotic symptoms, psychotic disorder, and extended hospitalization were factors associated with an increase in antipsychotic polypharmacy.

Conclusions:

Understanding the factors that may cause antipsychotic use and polypharmacy in inpatient services in children and adolescents may prevent unnecessary drug use and long-term side effects that may occur due to these drugs.

Introduction

There has been an increase in the use of psychotropics in children and adolescents in recent years (Gómez-Lumbreras et al., 2021; Hartz et al., 2016). A class of psychotropics used in children and adolescents is antipsychotics. There is an increase in the use of antipsychotics in children and adolescents worldwide (Hálfdánarson et al., 2017; Kaguelidou et al., 2020; Varimo et al., 2020). This increase in the use of antipsychotics may have different reasons, such as the use of psychotropic drugs in children has become more acceptable, the knowledge and awareness of antipsychotics have increased, and the need for rapid and accessible treatment (Harrison et al., 2012).

Antipsychotics are divided into first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs). Extrapyramidal side effects of SGAs are less likely (Schneider et al., 2014), and they are preferred over FGAs in most countries. Especially in the United States, SGAs are almost the only type of antipsychotics used among children and adolescents (2012: 98.3%) (Kalverdijk et al., 2017). For most antipsychotics approved by the U.S. Food and Drug Administration (FDA) for children and adolescents, the indications are limited to the treatment of schizophrenia and bipolar mania. In addition, risperidone and aripiprazole are FDA-approved for autism spectrum disorder (ASD)-related irritability, and Pimozide and aripiprazole are in children with Tourette's syndrome (Findling et al., 2012; Pillay et al., 2017).

Apart from these diagnoses, antipsychotics could also be used for irritability, aggressive behaviors (van Schalkwyk et al., 2017), impulsivity, disruptive behaviors, conduct disorders (Yektaş and Tufan, 2018), and aggressive behaviors with attention-deficit/hyperactivity disorder (ADHD) (Saylor and Amann, 2016).

There is an increase in hospitalization rates due to mental health conditions in children and adolescents. The most common causes of hospitalization are anxiety disorders, mood disorders, ADHD, alcohol, and other substance use disorders, suicide, and self-harm (Torio et al., 2015).

A study from Croatia found that hospitalized adolescents were more frequently prescribed psychiatric medication than outpatients (Kaštelan et al., 2019). In a study investigating the use of antipsychotics during hospitalization and discharge in Canada, more patients were on antipsychotics at discharge than were at admission (Procyshyn et al., 2014). Another study investigating antipsychotic polypharmacy (use of two or more antipsychotics) at the time of discharge from a pediatric hospital in the United States determined that 13.8% of patients treated with antipsychotics had antipsychotic polypharmacy (Saldaña et al., 2014). Other psychotropics were also used together with antipsychotics. Antidepressants, mood stabilizers, and psychostimulants are most commonly used with antipsychotics (Toteja et al., 2014). In one of the studies conducted in Turkey, 91.6% of children and adolescents received antipsychotic treatment in an inpatient service (Özbaran et al., 2016). In another study in Turkey, this rate was 84.9% (Şentürk Pilan et al., 2017).

Data on the use of antipsychotics in inpatient services providing tertiary care are insufficient. In this study, we aimed to examine the antipsychotics used by patients hospitalized in the child and youth inpatient service providing tertiary care to investigate whether there is a difference between admission and discharge, polypharmacy, which antipsychotics are used, and which psychotropics are used concomitant with antipsychotics in Turkey.

Methods

Permission for the study was obtained from the Pamukkale University Medical Ethics Committee (17.03.2020/06).

Research data were collected retrospectively from all children and adolescents hospitalized in Pamukkale University Hospital child and adolescent psychiatry inpatient service between 01.01.2015 and 31.12.2019. This is a 7-bed unit inside a 100-bed hospital located in Denizli, Turkey. The service has a catchment area covering Denizli and surrounding towns, covering more than a million people. In addition to psychopharmacological treatment, additional methods such as psychotherapeutic methods, occupational therapy, family therapy, and sports are also used in the service. In the service, four child and adolescent psychiatrists organize treatments. At the decision stage of the treatments, two child and adolescent psychiatrists start the treatment with a joint decision, and the treatments are evaluated by four specialists weekly.

Information about gender, age, diagnosis, duration of hospitalization and reasons for hospitalization, antipsychotics used at admission and discharge, number of antipsychotics they used, other psychotropic drugs they used together with antipsychotic medications, and side effects during hospitalization due to antipsychotic drug use were collected from the files of the patients. Diagnoses were made per DSM classification.

Statistical analyses

All statistical analyses were performed using SPSS 25.0 (IBM SPSS Statistics 25 software; IBM Corp., Armonk, NY). Continuous variables were defined by the mean ± standard deviation and median (interquartile range Q1–Q3: 25th–75th percentiles), and categorical variables were defined by number and percent. Logistic regression analysis was used to determine the risk factors for antipsychotic and antipsychotic polypharmacy. First, univariate analyzes were established with the factors included in the research, and then multivariate models were established with factors found to be statistically significant due to univariate analyses. Models predicting antipsychotic polypharmacy were examined as two or more antipsychotics versus none and one antipsychotic combined. Statistical significance was defined as p ≤ 0.05. Patients were grouped into outcomes based on their medication use at discharge. In cases with more than one hospitalization, only data from the last hospitalization was used.

Results

The number of all patients hospitalized was 363. Most of them were females (65.6%). The mean age was 14.2 ± 2.6 years old, and most of the patients were between 14 and 18 years old. The median length of stay of the patients was 15 days (range = 7–25 days), and most patients had a single hospitalization and were on only one psychotropic at admission as well as at discharge (Table 1).

Table 1.

Characteristics of All Admissions

Number of patients	N = 363
Gender
Male	34.4% (n = 125)
Female	65.6% (n = 238)
Age (years)	14.2 ± 2.6
5–9	6.9% (n = 25)
10–14	36.6% (n = 133)
14–18	56.5% (n = 205)
Length of stay (days): median (IQR Q1–Q3)	15 (7–25)
Number of psychotropics at admission: median (IQR Q1–Q3)	1 (0–1)
Number of psychotropics at discharge: median (IQR Q1–Q3)	1 (1–2)

IQR, interquartile range.

Reasons for hospitalization were aggression/violence (n = 109, 30.0%), self-harm (n = 95, 26.2%), suicidality (n = 132, 36.4%), severe obsession (n = 8, 2.2%), psychotic symptoms (n = 56, 15.4%), impulsivity (n = 20, 5.5%), eating problems (n = 16, 4.4%), and differential diagnosis (n = 19, 5.2%).

Diagnosis of patients were psychotic disorders (n = 49, 13.5%), bipolar disorders (n = 23, 6.3%), depressive disorders (n = 148, 40.7%), anxiety disorders (n = 38, 10.5%), ADHD (n = 117, 32.2%), disruptive, impulse-control, and conduct disorders (n = 80, 22.0%), obsessive-compulsive and related disorders (n = 24, 6%), trauma- and stressor-related disorders (n = 18, 4.9%), eating disorders (n = 17, 4.7%), intellectual disabilities (n = 25, 6.9%), ASD (n = 20, 5.5%), dissociative disorders (n = 4, 1.1%), somatic symptom and related disorders (n = 15, 4.1%), and tic disorders (n = 5, 1.4%). Two-hundred ten patients (57.9%) had two or more diagnoses at discharge. Of these, 136 patients had two diagnoses (37.5%), 55 patients had three diagnoses (15.2%), 15 patients had four diagnoses (4.1%), and 4 patients had five diagnoses (1.1%).

While 278 of 363 patients were on antipsychotics at admission, this number increased to 322 at discharge. While 7 patients who were on antipsychotics at admission were not at discharge, 52 patients who were not on antipsychotics at admission were at discharge. The antipsychotics used by the patients and their doses are shown in Table 2.

Table 2.

The Antipsychotics Used and Their Respective Doses for Patients upon Admission and Discharge

	Antipsychotic users at admission (n = 278)	Antipsychotic users at discharge (n = 322)	Doses of antipsychotics at admission: median (IQR Q1–Q3) mg	Doses of antipsychotics at discharge: median (IQR Q1–Q3) mg
FGAs
Haloperidol	4 (1.4%)	7 (2.2%)	1.7 (1.4–1.9)	1.5 (1.2–6.0)
Zuclopenthixol	3 (1.0%)	7 (2.2%)	9.0^a	15.0 (9.0–18.0)
Chlorpromazine	1 (0.3%)	1 (0.3%)	25.0	25.0
SGAs
Quetiapine	32 (11.5%)	53 (16.4%)	50 (25.0–100.0)	100.0 (25.0–300.0)
Risperidone	124 (44.6%)	144 (44.6%)	2.0 (1.0–2.5)	2.0 (1.0–3.0)
Aripiprazole	106 (38.1%)	157 (48.6%)	5.0 (3.5–10.0)	5.0 (5.0–10.0)
Olanzapine	42 (15.1%)	45 (13.9%)	10.0 (5.0–15.0)	15.0 (8.8–20.0)
Paliperidone	3 (1.0%)	3 (0.9%)	6.0^a	6.0^a
Amisulpride	3 (1.0%)	11 (3.4%)	200.0^a	400.0 (400.0–400.0)
Sulpride	1 (0.3%)	1 (0.3%)	100.0	100.0
Clozapine	0	4 (1.2%)	0.0	250.0 (200.0–375.0)
Injection
Risperidone	1 (0.3%)	9 (2.8%)	25.0	25.0
Zuclopenthixol	0	1 (0.3%)	0.0	200.0
Polypharmacy	45 (16.2%)	99 (30.7%)	–	–

Since the number of subjects is insufficient to calculate the IQR, the values for Q1 and Q3 are not shown. Only median values are given.

FGAs, first-generation antipsychotics; IQR, interquartile range; SGAs, second-generation antipsychotics.

The number of antipsychotics used at admission and discharge is shown in Table 3. The number of patients on antipsychotic was 322 at discharge. The number of patients were on two or more antipsychotics increased from 45 to 99. Of 322 patients, 223 were on one antipsychotic, 83 were on two antipsychotics, and 16 were on three antipsychotics.

Table 3.

The Number of Antipsychotics Used at Admission and Discharge

Number of antipsychotics	Antipsychotic users at admission (n = 278)	Antipsychotic users at discharge (n = 322)
1	233 (83.8%)	223 (69.0%)
2	38 (13.7%)	83 (25.7%)
3	6 (2.1%)	16 (5.0%)
4	1 (0.4%)	0 (0.0)

The most common side effects related to antipsychotics are shown in Table 4. Side effects associated with antipsychotics occurred in 67 patients during hospitalization. Apart from these, neuroleptic malignant syndrome occurred in one patient on olanzapine and haloperidol, frequent urination in one patient due to risperidone, epistaxis in one patient and oculogyric crisis in one patient due to zuclopenthixol, and tremor in one patient due to aripiprazole. The antipsychotics in 27 (40.3%) patients were discontinued due to side effects related to the antipsychotic. In comparison, the treatment was continued in 40 (59.7%) patients after the side effects were controlled.

Table 4.

The Most Common Side Effects Related to Antipsychotics During Hospitalization

Antipsychotic (n, discharge)	Hyperprolactinemia	Dystonia	Akathisia	Neuroleptic malignant syndrome	Hypersalivation
Risperidone (144)	15.2% (n = 22)	17.4% (n = 25)	0.7% (n = 1)
Olanzapine (45)	4.4% (n = 2)	11.1% (n = 5)	4.4% (n = 2)	2.2% (n = 1)
Aripiprazole (157)		0.6% (n = 1)	1.2% (n = 2)		0.6% (n = 1)
Clozapine (4)					50% (n = 2)
Amisulpride (11)					27.3% (n = 3)
Haloperidol (7)		28.6% (n = 2)		14.3% (n = 1)
Zuclopenthixol (7)		85.7% (n = 6)			14.3% (n = 1)
Total (322)	7.4% (n = 24)	12.1% (n = 39)	1.5% (n = 5)	0.6% (n = 2)	2.2% (n = 7)

The psychotropics used concomitant with antipsychotics at admission and discharge are shown in Table 5. The most common psychotropics used concomitantly were antidepressants at admission as well as at discharge (57.9%). ADHD medication (14.7% to 35.3%), mood stabilizers (9.3% to 16.7%), and anticholinergics (4.7% to 10.8%) increased by approximately two times or more at discharge from admission. Benzodiazepines (15.8% to 14.2%) and lithium (1.8% to 1.5%) at discharge were similar to admission.

Table 5.

The Psychotropics Used Concomitant with Antipsychotics at Admission and Discharge

	Antipsychotic users at admission (n = 278)	Antipsychotic users at discharge (n = 322)
Antidepressants	n = 129 (46.4%)	n = 187 (57.9%)
ADHD medication (methylphenidate + atomoxetine)	n = 41 (28 + 13) (14.7%)	n = 114 (74 + 40) (35.3%)
Benzodiazepines	n = 44 (15.8%)	n = 46 (14.2%)
Mood stabilizers	n = 26 (9.3%)	n = 54 (16.7%)
Anticholinergics	n = 13 (4.7%)	n = 35 (10.8%)
Lithium	n = 5 (1.8%)	n = 5 (1.5%)

ADHD, attention-deficit/hyperactivity disorder.

Logistic regression analysis was performed to investigate the factors (length of hospitalization, the number of hospitalizations, reasons for hospitalizations, and diagnosis) affecting the use of antipsychotic and antipsychotic polypharmacy (Table 6). The first step was to perform univariate analyses. Afterward, we performed multivariate analyses with the variables found to be significant in univariate analyses.

Table 6.

The Factors Affecting the Use of Antipsychotic and Antipsychotic Polypharmacy

	Antipsychotic users at discharge		Two or more antipsychotic users at discharge
	p	OR (95% CI)	P	OR (95% CI)
Univariate models
Length of hosp.	0.005^*	1.047 (1.014–1.082)	0.000^*	1.05 (1.034–1.067)
Number of hosp.	0.268	1.416 (0.766–2.618)	0.000^*	1.868 (1.345–2.596)
Hosp. reasons
Aggression/violence	0.033^*	2.653 (1.08–6.518)	0.063	1.591 (0.976–2.595)
Self-harm	0.02^*	3.53 (1.222–10.2)	0.575	1.16 (0.691–1.946)
Suicidality	0.613	0.841 (0.429–1.646)	0.028^*	0.568 (0.342–0.942)
Severe obsession	0.999	205139665.522 (0–0)^a	0.16	2.737 (0.671–11.162)
Eating problems	0.54	1.899 (0.244–14.776)	0.088	0.169 (0.022–1.3)
Psychotic symptoms	0.071	3.814 (0.893–16.287)	0.000^*	3.324 (1.848–5.979)
Impulsivity	0.561	0.685 (0.192–2.449)	0.024^*	2.854 (1.15–7.084)
Diagnosis
Somatic symptom and related disorders	0.267	0.476 (0.128–1.764)	0.102	0.182 (0.024–1.404)
ASD	0.998	213264008.522 (0–0)^a	0.007^*	3.542 (1.42–8.831)
Intellectual disabilities	0.27	3.13 (0.412–23.788)	0.006^*	3.174 (1.395–7.221)
Eating disorders	0.497	2.033 (0.262–15.751)	0.723	0.813 (0.259–2.555)
Trauma- and stressor-related disorders	0.131	0.408 (0.127–1.305)	0.133	0.32 (0.072–1.416)
Obsessive-compulsive and related disorders	0.665	1.389 (0.314–6.139)	0.249	1.66 (0.702–3.926)
Disruptive, impulse-control, and conduct disorders	0.061	2.769 (0.955–8.029)	0.535	1.189 (0.688–2.052)
ADHD	0.167	1.73 (0.795–3.764)	0.137	0.677 (0.405–1.133)
Anxiety disorders	0.325	0.623 (0.243–1.598)	0.807	1.097 (0.522–2.306)
Depressive disorders	0.261	1.491 (0.742–2.996)	0.078	0.648 (0.399–1.051)
Bipolar disorder	0.312	2.85 (0.374–21.738)	0.027^*	2.625 (1.118–6.162)
Psychotic disorder	0.061	6.807 (0.913–50.727)	0.000^*	5.606 (2.975–10.566)
Multiple Model 1
Length of hosp.	0.009^*	1.043 (1.01–1.076)	–	–
Aggression/violence	0.023^*	2.885 (1.157–7.195)	–	–
Self-harm	0.02^*	3.579 (1.22–10.497)	–	–
Multiple Model 2
Length of hosp.	–	–	0.000^*	1.046 (1.027–1.065)
Number of hosp.	–	–	0.52	1.139 (0.767–1.691)
Suicidality	–	–	0.308	0.735 (0.407–1.328)
Psychotic symptoms	–	–	0.009^*	2.469 (1.25–4.879)
Impulsivity	–	–	0.071	2.722 (0.919–8.057)
Multiple Model 3
Length of hosp.	–	–	0.000^*	1.043 (1.023–1.063)
Number of hosp.	–	–	0.748	1.068 (0.716–1.592)
ASD	–	–	0.093	2.494 (0.858–7.247)
Intellectual disabilities	–	–	0.08	2.473 (0.898–6.814)
Bipolar disorder	–	–	0.108	2.23 (0.838–5.937)
Psychotic disorder	–	–	0.000^*	3.943 (1.956–7.947)

It could not be modeled due to the small number of subjects.

p-Value < 0.05.

ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; CI, confidence interval; Hosp., hospitalization.

The variables that had a statistically significant effect on antipsychotic use at discharge were the length of hospitalization, aggression/violence, and self-harm in univariate analyzes. None of the diagnoses had a statistically significant effect. The multivariate model (multiple models 1) was established with the variables of the length of hospitalization, aggression/violence, and self-harm. All of them had a statistically significant effect on antipsychotic use at discharge. The presence of aggression/violence (OR = 2.885, 95% confidence interval [CI] = 1.157–7.195, p = 0.023), self-harm (OR = 3.579, 95% CI = 1.22–10.497, p = 0.02), and the extended length of hospitalization (OR = 1.043, 95% CI = 1.01–1.076, p = 0.009) significantly increased the risk of using antipsychotics at discharge.

In univariate analyses, the variables that had a statistically significant effect on antipsychotic polypharmacy at discharge were the length of hospitalization, number of hospitalizations, suicidality, psychotic symptoms, impulsivity, ASD, intellectual disabilities, bipolar disorder, and psychotic disorder. In multiple models 2, reasons for hospitalization and multiple models 3, diagnosis were examined in multivariate models (When establishing multivariate models, separate models were established because the reasons for hospitalization and diagnoses may overlap.). As a result of the multivariate model (multiple model 2—established with the variables of the length of hospitalization, the number of hospitalizations, suicidality, psychotic symptoms, and impulsivity), the length of the hospitalization and the psychotic symptoms had a statistically significant effect on antipsychotic polypharmacy at discharge.

The presence of psychotic symptoms (OR = 2.469, 95% CI = 1.25–4.879, p = 0.009) and the extended length of hospitalization (OR = 1.046, 95% CI = 1.027–1.065, p = 0.000) significantly increased the risk of antipsychotic polypharmacy at discharge. As a result of the multivariate model (multiple model 3—established with the variables of the length of hospitalization, the number of hospitalizations, ASD, intellectual disabilities, bipolar disorder, and psychotic disorder), the length of the hospitalization and psychotic disorder had a statistically significant effect on antipsychotic polypharmacy at discharge. The presence of psychotic disorder (OR = 3.943, 95% CI = 1.956–7.947, p = 0.000) and the extended length of hospitalization (OR = 1.043, 95% CI = 1.023–1.063, p = 0.000) significantly increased the risk of antipsychotic polypharmacy at discharge.

Discussion

In this study, we investigated the use of antipsychotics in patients treated in a child and youth psychiatry inpatient service. Significant effects were found of extended hospitalization on both antipsychotic use and antipsychotic polypharmacy, aggression/violence and self-harm on antipsychotic use, and of the presence of psychosis on antipsychotic polypharmacy.

Our study found that antipsychotics such as risperidone, aripiprazole, olanzapine, and quetiapine were used more frequently than other antipsychotics. A study in an inpatient unit at a public hospital in the United States and another one in Korea had similar findings with risperidone, olanzapine, quetiapine, and aripiprazole, which were the most commonly used atypical antipsychotics (Kelly et al., 2004; Lee et al., 2018). Aripiprazole has FDA approval for the diagnosis of Tourette's disorder, aripiprazole, and risperidone for irritability in children with ASD, and risperidone, aripiprazole, olanzapine, and quetiapine for bipolar 1 and schizophrenia diagnoses in children and adolescents (Education Medicaid Integrity Contractor for the CMS and Education Medicaid Program Integrity, 2015). Our study found that these four antipsychotics are used more often, which might be due to the fact that they are approved and effective in this age group.

Antipsychotics could be used in many different diagnoses in children and adolescents. Nesvag et al. found the most common psychiatric use of antipsychotics in children and adolescents as hyperkinetic disorders, anxiety disorders, ASDs, and depressive disorders (Nesvåg et al., 2016). In another study investigating the use of antipsychotics in the inpatient service, anxiety disorders, disruptive behavior disorders, depression, and psychotic disorders were the most common diagnoses (Procyshyn et al., 2014). Our results are similar to the literature.

Depending on the use of antipsychotics in children and adolescents, side effects such as extrapyramidal syndrome (EPS), changes in blood prolactin level, cardiac arrhythmias, and changes in consciousness may occur (Minjon et al., 2019). Our study found side effects such as EPS (dystonia and akathisia), hyperprolactinemia, and hypersalivation occur with antipsychotics. Side effects such as EPS and hyperprolactinemia may happen in the short term due to the use of antipsychotics in children and adolescents (Cohen et al., 2012). In our study, side effects related to antipsychotics were followed up only during hospitalization. Therefore, it is not surprising that we found short-term side effects. Our study found that the group of psychotropics most concomitantly used with antipsychotics was antidepressants. Data about psychotropics used in combination with antipsychotics in hospitalized patients is limited.

The study of Dean et al. in the child and adolescent mental health service showed that serotonin-selective reuptake inhibitors are the most concomitantly used of psychotropics with atypical antipsychotics in the inpatient service (Dean et al., 2006). In a Finnish study investigating polypharmacy in patients who were started on antipsychotics between 2008 and 2016, antidepressants were the most commonly used psychotropics with antipsychotics (Varimo et al., 2022). We found that 40.7% of the patients who received treatment in our inpatient service had a diagnosis of depressive disorder. Antipsychotics augmented with antidepressants in adults with depressive disorder reduce depressive symptoms (Spielmans et al., 2013). The high diagnosis rate of depressive disorder in our hospitalized patients, the need for antipsychotic augmentation in some patients with depressive disorder, and conditions such as aggression and self-harm that may accompany depressive disorder may explain these results.

Our study found that 31% of the patients had antipsychotic polypharmacy at discharge, and the majority (26%) used two antipsychotics. A systematic review in 2012 found inpatient treatment to be predictive of antipsychotic polypharmacy (Gallego et al., 2012). In a study by Saldana et al. examining antipsychotic polypharmacy in psychiatric hospitalized children and adolescents, 13.8% of the patients were treated with antipsychotic polypharmacy (Saldaña et al., 2014). It was found that 0%–33% of patients had antipsychotic polypharmacy at different rates at discharge from public hospitals in the United States (Ortiz, 2018). High polypharmacy rates are expected since our study was conducted in an inpatient service that caters to a large population in the region and treats cases with more severe symptoms.

In logistic regression analysis, aggression/violence and self-harm significantly increased antipsychotic use. Self-harm may accompany many mental disorders and symptoms (Plener et al., 2018). It leads to implementing various approaches to prevent the behavior in individuals with self-harm. Antipsychotics could be prescribed for outpatients with self-harm (Morgan et al., 2017; Yektaş and Tufan, 2018). It might be thought that the clinical conditions of the individuals hospitalized due to self-harm in the inpatient service were severe, and antipsychotics were preferred to control it. Antipsychotics are preferred in outpatient and inpatient treatment to control aggression in children and adolescents with aggression (Deshmukh et al., 2010). If the staff reports that the inpatient has dangerous or destructive behavior, it may cause the doctor to feel pressure to use antipsychotics (Pappadopulos et al., 2002).

Patients hospitalized in our service due to aggressive or violent behavior may have created a similar pressure and led to the study's results. In this regard, training the staff on managing aggression can positively affect their ability to cope with patients. It may lead to less preference for antipsychotics. Another point is that although psychotherapeutic interventions are applied in our inpatient unit, it is necessary to be more careful in patients with aggression/violence and self-harm and to apply approaches specific to these situations. These approaches may also reduce the use of antipsychotics.

It was found that extended hospitalization significantly increased the risk of antipsychotic use and antipsychotic polypharmacy at discharge. Lekhwani et al. found that extended length of stay was associated with using psychotropic agents in inpatient service in children (Lekhwani et al., 2004). A study in the United States showed that long hospitalization time was a predictor of antipsychotic polypharmacy (Saldaña et al., 2014). Another study on adult patients found that the long hospitalization period was significantly associated with antipsychotic polypharmacy (Farrell and Brink, 2020). A longer duration may mean that the symptoms cannot be controlled or a more severe illness. Both conditions may result in antipsychotic use and antipsychotic polypharmacy for symptom control during hospitalization.

Antipsychotics are among the medical treatments used in children and adolescents with psychotic disorder (Ayub et al., 2018). Many studies have shown that psychotic disorder in outpatient admissions (Baeza et al., 2014; Constantine et al., 2010; Toteja et al., 2014) and in inpatients (Saldaña et al., 2014) were associated with antipsychotic polypharmacy in children and adolescents. Antipsychotic polypharmacy in psychotic disorder may have some causes. First, some cases may not benefit from antipsychotic monotherapy in children and adolescents with a diagnosis of psychotic disorder followed in the inpatient service. Second, the clinical manifestation of this condition can be severe. Finally, psychotic symptoms may not improve as quickly on some occasions. Depending on this situation, the length of hospitalization may be prolonged, and the prolongation may put the medical team under pressure. This situation may cause polypharmacy.

Our study should be evaluated with some limitations. The research was conducted in a single center, and this creates a limitation on the generalizability of the results of the study. Second, the study was conducted in a child and adolescent psychiatry inpatient service serving a large region, and cases with higher severity were generally followed. This should also be considered during the evaluation of the results. Another limitation is that although the information about the cases included in the study was kept in detail, the study was retrospective. Finally, there may be national and regional differences in inpatient accessibility, adequacy of preventive and curative mental health services other than inpatient services, and discrepancies and diversity in available and approved psychotropic drugs. Therefore, the results of our study should be evaluated in this context.

Conclusions

As a conclusion, according to our study, the factors that lead to an increased number of patients on antipsychotics or antipsychotic polypharmacy can also represent more severe illnesses and may be interrelated, such as aggression/violence, self-harm, psychotic symptoms, and psychotic disorder that are likely to increase hospitalizations. Knowing these reasons and making specific approaches to these reasons can reduce the use of antipsychotics and protect children and adolescents, especially regarding metabolic side effects that may occur due to antipsychotics.

Clinical Significance

There are few studies on antipsychotics in inpatient services in children and adolescents. Self-harm, aggression/violence, and length of hospitalization may affect the use of antipsychotics in inpatient services. In terms of antipsychotic polypharmacy, being aware of factors such as length of hospitalization, psychotic symptoms, and psychotic disorder may be helpful to prevent polypharmacy.

Footnotes

Authors' Contributions

All authors contributed to the study's concept, design, and writing. A.B. wrote the first draft, A.B. and E.G.G. contributed to data collection, and H.Ş. and A.B. to data analysis. All authors provided article editing and critically reviewed. All authors read and approved the final article.

Disclosures

The authors have no competing financial interests that might pose a conflict of interest.

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