Editorial: Safer Use of Antipsychotics in Youth (SUAY): Should Treatment Be Guided by Symptoms?

Child and adolescent psychiatrists have company as they wrestle with clinical decision making regarding when it is appropriate to prescribe an antipsychotic. Pediatricians face a similar challenge in trying to determine under what circumstances to prescribe an antibiotic. Both classes of medications are powerful and can be lifesaving, but they are not without the risk of associated adverse events and cumulative exposure. Concerns regarding the widespread use of antipsychotics in children and adolescents have been supported by national trends indicating predominance of prescriptions for conditions (attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, and impulsive aggression)^1,2 other than those approved by the U.S. Food and Drug Administration (psychotic disorders, bipolar disorder with mania, irritability associated with autism spectrum disorder, and tic disorders); the risks of weight gain, diabetes mellitus, and other adverse effects to which youths appear to be more vulnerable than adults³; and potential disparities related to the absence of race and ethnicity in large administrative datasets.⁴ Previous studies of antipsychotic prescribing patterns predate the widespread use of the diagnosis of disruptive mood dysregulation disorder. A recent study found that 58.9% of youths given a diagnosis of disruptive mood dysregulation disorder were prescribed antipsychotics compared with 51% of youths with a diagnosis of bipolar disorder.⁵ In this issue of the Journal, Penfold et al.⁶ report on a novel approach to antipsychotic prescribing focused on symptoms rather than diagnoses developed as the initial phase of a pragmatic clinical trial, Targeted and Safer Use of Antipsychotics in Youth (SUAY), funded by the National Institute of Mental Health and designed to test the effectiveness of targeted interventions on the use of antipsychotics for youth 4 to 17 years old in large health care systems. We offer some perspectives on differences that distinguish this approach; the process used in its development; and its promise, potential pitfalls, and policy and clinical implications.