Medication Prescribing Patterns at a Youth Mental Health Service: A Single Center Retrospective Cross-sectional Study

Introduction

Globally, one in seven people aged 10–17 years old experience a mental disorder, most commonly depression, anxiety, and behavioral concerns (World Health Organization, 2021). In Australia, young people report higher rates of mental illness than any other age-group, with almost two in five people (38.8%) aged 16–24 years experiencing a mental illness in any 12-month period, representing close to half (45.5%) of females and one third (32.4%) of males in this age-group (Australian Bureau of Statistics, 2020–22). Young people are more likely to seek help for mental health concerns compared with other age-groups, yet rates of mental illness in young people remain high, and the utilization of mental health services is expected to increase (Australian Bureau of Statistics, 2020–22).

Psychosocial interventions, such as psychoeducation or psychological therapies, are considered first-line treatment for young people with depression and anxiety disorders before pharmacological interventions are trialed (National Institute for Health and Care Excellence [NICE], 2019; Andrews et al., 2018). Despite this, and in line with global trends (Zito et al., 2008; Barczyk et al., 2020; Tsai et al., 2017), the dispensing of psychotropic medications for Australian children and adolescents doubled from 2013 to 2021 (Wood et al., 2023), as did the prevalence of psychotropic polypharmacy in this age-group (Wood et al., 2023). Psychotropic medication use in young people remains a subject of debate due to the limited safety and efficacy data in this age-group (Hetrick et al., 2021; Vitiello et al., 2009). The impacts of adverse effects in young people may be less well known compared with adults, partially attributable to concerns regarding inclusion of young people in clinical research (Wolraich, 2003). Despite limited data, untreated mental illness during childhood can have a lasting impact in later life, leading to lower life satisfaction, poorer health outcomes, and suicidal ideation (Schlack et al., 2021). Hence, psychotropic medications may be used despite the lack of licensed indications for this age-group (Parens and Johnston, 2008).

While there is research exploring the prevalence of psychotropic medication use in young people in Australia with population-level data (Wood et al., 2023; Rasmussen et al., 2019; Karanges et al., 2014), little is known about the use of medications within youth mental health services (Rickwood et al., 2023; Rickwood et al., 2015). One previous study focusing on psychotropic medication use in young people with moderate to severe mental health problems found over half of young people aged 12–17 were prescribed psychotropic medications, with one fifth receiving psychotropic polypharmacy (Dharni and Coates, 2018). The use of psychotropic medications within early intervention youth mental health services focusing on mild to moderate mental illness, such as headspace, is unknown (Rickwood et al., 2023).

The youth-specific model of care plays a critical role in encouraging readiness to seek help in young people and has been successful in achieving improved outcomes such as increased service uptake and quality of care, in comparison to other non-age-specific models of care (Brimblecombe et al., 2017; Hawke et al., 2019). headspace is Australia’s National Youth Mental Health Foundation, founded in 2006 in response to the increasing prevalence of mental illness among young people and structural problems with existing models of care (McGorry et al., 2007). headspace centers provide youth-friendly, integrated primary care health services to address mental health, physical and sexual health, alcohol and drug use, as well as work and study issues (Rickwood et al., 2023). It has since expanded with over 150 centers across the country and has attracted substantial government funding ($44 million AUD in 2022) (Department of Health and Aged Care, 2022). Despite significant financial investment, there are limited data available about the prescribing of psychotropic medications within youth mental health services and hence a need to better understand the real-world applications of psychotropic medication use in young people within settings such as headspace. Hence, the aim of this study was to explore medication prescribing patterns at a single headspace center.

Materials and Methods

A retrospective cross-sectional study was conducted through an audit of medical records for a cohort of young people who attended an intake assessment at headspace Camperdown in Sydney, Australia, over a 13-month period, between February 1, 2021, and February 28, 2022.

Results

In total, 617 people were booked for an intake assessment during the 13-month audit period. Of the young people who were able to be contacted for consent (n = 616), 8 people declined, 15 provided consent, and 585 did not respond to the two text messages and were therefore included. Overall, a total of 608 participants were included in the audit.

Discussion

To the best of the authors’ knowledge, this is the first study to present data on the use of psychotropic medications within an early intervention Australian youth mental health service. Previous evaluations of headspace have not included data on medication use or outcomes (Jorm, 2015; Rickwood et al., 2023), yet psychotropic medication use is common in this population and an important part of treatment. Understanding psychotropic medication use in young people is critical to assist with identifying gaps in care. For example, exploring if real-world use aligns with relevant policies and guidelines or if medications are being used for appropriate populations and indications. This study builds on the findings from Dharni and Coates, which found psychotropic medication use is common for young people with moderate to severe mental illness, with medications commonly used “off-label” (Dharni and Coates, 2018).

This audit identified medications possibly being used for indications where the effectiveness or safety evidence is lacking, particularly the use of melatonin and quetiapine for the management of sleep difficulties. This is in line with other recent Australian findings which found quetiapine to be commonly prescribed for insomnia (Dharni and Coates, 2018). Medication use is suspected to be outside of approved indications; however, this was difficult to ascertain due to a lack of documented formal diagnoses at headspace. The frequent prescribing of these medications may suggest that sleep difficulties are prevalent among young people, secondary to primary presenting concerns such as anxiety and low mood. Treatment of depression and anxiety disorders may warrant the use of antidepressants, which accounted for more than half of all psychotropic medications prescribed during the auditing period. For people under the age of 18, clinical practice guidelines recommend fluoxetine (National Institute for Health and Care Excellence [NICE], 2019; Malhi et al., 2021) however, some young people were prescribed antidepressants only approved for use over 18 years of age. More than half of participants who were prescribed an antidepressant also concurrently received psychotherapy at headspace, which aligns with recommendations in clinical practice guidelines (Malhi et al., 2021).

Melatonin was the most common medication reported at intake and prescribed by headspace clinicians in this study. In Australia, melatonin is approved for use in people over the age of 55 with primary insomnia and has recently been approved for use in young people aged 2–18 years with autism spectrum disorder (Therapeutic Goods Administration, 2020; Therapeutic Goods Administration, 2009). However, melatonin continues to be used beyond approved age-groups and indications due to its perceived safety compared with traditional hypnotics (Boafo et al., 2020). Unlike benzodiazepines and non-benzodiazepine hypnotics, melatonin does not appear to cause dependence, and its use has become increasingly popular as a sleep aid for children in recent decades (Hartz et al., 2015; Hartz et al., 2012; Ferracioli-Oda et al., 2013; Lee et al., 2023). Despite increasing use (Klau et al., 2022), there is conflicting evidence on the efficacy of melatonin in young people with sleep difficulties, with a lack of evidence on impacts on quality of sleep and daytime functioning (Edemann-Callesen et al., 2023). Furthermore, the short- and long-term safety of melatonin use in children with insomnia is unknown, with higher relative risks of adverse effects in people under the age of 20 being reported (Händel et al., 2023), highlighting a need for larger and more robust trials investigating the safety and efficacy of melatonin use in young people.

Similarly, this audit revealed substantial prescribing of quetiapine for young people with sleep difficulties. Prescribers may perceive quetiapine as a safer alternative to benzodiazepines due to the potential risk of benzodiazepine addiction; however, the evidence for its use in sleep difficulties is lacking (Kelly et al., 2018; Boafo et al., 2020). Approved indications for quetiapine in young people aged 10–17 years are schizophrenia and bipolar mania (Therapeutic Goods Administration, 2010). Although quetiapine has been shown to be an effective sedative, its safety for insomnia has not been established, hence use for sleep difficulties is off-label (Karsten et al., 2017; Anderson and Vande Griend, 2014). Limited studies have explored quetiapine use for insomnia in the absence of comorbidities, with most studies conducted in adults, and evidence is not necessarily generalizable to younger populations (Anderson and Vande Griend, 2014). Quetiapine, even when prescribed at low doses (<200 mg/day), has been found to result in significant adverse effects such as weight gain and daytime sedation (Coe and Hong, 2012; Anderson and Vande Griend, 2014). Furthermore, quetiapine may be subject to diversion and non-medical use (Kim et al., 2017; Sansone and Sansone, 2010). In light of increasing rates of quetiapine use in Australia (Klau et al., 2022; Brett et al., 2017), there is a need for further prescriber education about the risks of off-label medication use and further research into the safety of this medication in young people.

Findings from this study revealed a variety of medications being used to treat young people experiencing low mood. For the management of depression in young people, practice guideline recommendations differ depending on the severity of illness: mild, moderate, or severe depression. Empirically based guidance recommends psychotherapy as first-line treatment for mild depression, while for moderate to severe depression, combined pharmacology and psychotherapy is recommended (National Institute for Health and Care Excellence [NICE], 2019; Malhi et al., 2021). However, as headspace does not always award or document formal diagnoses, this presents a challenge when assessing the appropriateness of antidepressant choices.

During the audit period, fluoxetine was the only antidepressant licensed in Australia for use in the management of depression in people under the age of 18 and is commonly recommended as first-line treatment for moderate to severe depression in Australian guidelines (Malhi et al., 2021; Therapeutic Goods Administration, 2021). However, escitalopram and sertraline (which is only licensed for the treatment of OCD in people under 18 years of age) were the most prescribed antidepressants at headspace, and, at times, prescribed to people under the age of 18. This is in contrast to population-level studies of young people in Australia that report fluoxetine as the most common antidepressant choice (Klau et al., 2022) and further demonstrates that guidelines are not always adhered to in real-world clinical settings. Clinical practice guidelines may be developed and implemented to improve prescribing and clinical management of certain conditions and patient groups. However, the implementation of such guidelines may not always result in improved prescribing practice. A systematic review of the effects of clinical practice guidelines on the prescribing of mental health medications found that changes in practice are infrequent or minimal, and further work is needed to improve the creation and implementation of such guidelines (Nguyen et al., 2020). Furthermore, many factors are thought to influence prescribing practices (Murshid and Mohaidin, 2017), and prescribing in mental health relies on the management of reported symptoms, unlike objective clinical markers, which can be used when prescribing for many physical health conditions. Future research should investigate how to optimize appropriate psychotropic prescribing in young people.

headspace utilizes a clinical staging model to differentiate between the severity of mental illnesses, which presents challenges to the Australian regulatory framework used for medication prescribing (Hickie et al., 2013). Diagnostic clarity is often needed to justify the prescribing of certain medications listed on the Pharmaceutical Benefits Scheme (PBS). ³ For example, medications classified as “restricted benefit” can only be prescribed for specific therapeutic uses or for specific patient groups. As headspace services focus on early intervention, most people are often transdiagnostic at presentation or do not meet criteria for a mental health diagnosis. Without formal diagnoses, it is difficult to ascertain if medications are being used appropriately and for the approved indications. There are a variety of problems associated with using diagnostic labels in young people, such as associated stigmatization, which may have a psychological impact of increased anxiety, perceived severity of the diagnosis and preference for more invasive treatments (Sims et al., 2021). However, there has been previous research exploring the potential benefits of implementing an indication-based prescribing system in primary care settings (Schiff et al., 2016). The implementation of such a system could permit the identification of drug-indication mismatches and could be utilized to assess medication effectiveness, including for off-label medication use (Grissinger, 2019; Schiff et al., 2016). Despite the lack of formal diagnoses documented, it could be inferred that a medication was prescribed for a mental health purpose based on documented presenting concerns and past medication histories, which demonstrates the importance of conducting an accurate and comprehensive medical and medication history so that indications for medication use can be clearly determined and documented.

Challenges were encountered when gathering data on medications prescribed prior to intake, as medication information was not stored in one cohesive part of the medical record. The level of detail of medication information collected during intake assessments varied, with many records lacking details such as strength, dose, and frequency. However, it is unknown whether these details were prompted by the clinician conducting the intake assessment or if this level of detail could not be recounted by the young person. Accurate medication histories are crucial in preventing treatment-related harms. They are essential in detecting changes in clinical signs, which may be the result of drug therapy, and exploring factors which may lead to unnecessary avoidance of a drug (Fitzgerald, 2009). There are various ways to improve medication history taking, including additional education and training for staff who conduct intake assessments or the potential role of a pharmacist within youth mental health services (Shah et al., 2021). Future research could explore interventions and processes to improve medication history taking and the appropriate use of psychotropic medications in youth mental health services, such as exploring the role of an embedded pharmacist. Non-dispensing pharmacists in primary care settings, such as general practice, can provide medication reviews and clinical audits and have demonstrated beneficial clinical outcomes in areas such as asthma and smoking cessation (Deeks et al., 2023).

Conclusions

This study provided insight into the real-world prescribing patterns at a single Australian youth mental health service. The most prescribed medications were melatonin and quetiapine for sleep difficulties and escitalopram, sertraline, and fluoxetine for low mood. Caution is needed when prescribing medications for potential off-label use, especially when safety and efficacy have not yet been established for use in young people. Further research is warranted to explore the use of clinical practice guidelines in youth mental health settings.

Clinical Significance

This single-centre study found psychotropic medications being prescribed that may not have aligned with presenting concerns, with the most commonly prescribed medications being melatonin and quetiapine.