AACAP發表指引兒童使用精神藥物的執業規範


  September 18, 2009 — 美國兒童與青少年精神學會發表了一項新的執業規範指引兒童如何使用精神藥物。
  
  來自馬里蘭州巴爾的摩的主要作者John Walkup醫師在一項聲明中表示,這項執業規範的理由是基於處方精神藥物最佳執業原則。這不是標準照護文件,也不代表要減少處方這些藥物,而是呼籲建立系統性與全面性的方法來安全且有效地使用這些藥物於兒童身上。
  
  完整的規範發表在美國兒童與青少精神學期刊9月號。
  
  根據這篇文章,對於兒童精神疾病的瞭解已經顯著增加,且有越來越多證據支持對這個病患族群使用精神藥物。
  
  作者們指出,兒童的精神疾病是很常見的,且如果沒有治療,可能有短期與長期的不良影響。儘管如此,大部分有精神健康問題的兒童並沒有接受適當的評估與治療。
  
  作者們寫到,雖然精神藥物是治療的一個重點,但增加使用這些藥物已經導致某些兒童與青少年被過度診斷精神異常,且接受了不適合他們的藥物治療。
  
  他們附帶表示,降低不適當使用的策略,包括美國食品藥物管理局對於抗憂鬱藥物的黑框警示,可能對於造成照護與接下來負面預後有意外的效應。
  
  研究者們寫到,並非倡議限制使用這些藥物治療,該規範提倡高品質的評估與處方執業,以增進兒童預後,以及著眼於有精神異常兒童如何治療的社會關注。
  
  在制定這項規範時,由Walkup醫師領導的研究者們進行了詳盡的文獻回顧,包括與兒童及成人精神藥理學有關的發表文獻,他們也回顧兒童精神藥理學相關教科書,以及參考文獻清單。
  
  最後,關於規範的背景資訊,研究者們搜尋PubMed有關醫療照護品質的研究,以及過度使用醫療檢驗和其他被認為過度使用的醫療措施,例如常規性實驗室或放射檢驗,以及剖腹。除此之外,他們進行了一項過去被視為過度診斷或是誤診與不適當治療的醫療狀況分析。
  
  這項規範包括13個協助臨床醫師對其年輕病患們指引治療策略。這些包括精神與醫療評估的最佳執業、發展治療與追蹤計劃、教育病患與其家屬有關於該疾病與治療、執行治療計劃、以及藥物調整計劃處理。
  
  Walkup醫師表示接受禮來藥廠、輝瑞藥廠與亞培實驗室的研究經費;擔任禮來藥廠、葛蘭素史克、以及Cliffs社群的諮詢專家與顧問團;且接受或是已經接受CME的演講費。Walkup醫師的配偶擔任亞培實驗室的諮詢專家。Bukstein醫師接受或是已經接受研究經費、作為諮詢專家以及/或是擔任McNeil兒童公司與諾華藥廠的發言人。Bernet醫師與Walter醫師表示已無相關資金上的往來。
  

AACAP Releases New Practice Parameter to Guide Psychotropic Medication Use in Kids

By Caroline Cassels
Medscape Medical News

September 18, 2009 — A new practice parameter to guide the use of psychotropic medications in children has been released by the American Academy of Child and Adolescent Psychiatry.

"The reason for the parameter was to ground prescribers of psychotropic medication in the best practice principles. This is not a standard of care document and is not meant to reduce prescribing. Rather it is a call for action to create a systematic and comprehensive approach to using medications in children safely and effectively," principal author John Walkup, MD, from Baltimore, Maryland, said in a statement.

The full parameter is published in the September issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

According to the article, there has been a marked increase in the understanding of childhood psychiatric disorders and a developing evidence base supporting the use of psychotropic medications in this patient population.

The authors note that psychiatric disorders in children are common and, without treatment, can have negative short- and long-term consequences. Yet despite this, they say, the vast majority of children with mental health problems do not receive appropriate evaluation and treatment.

Although psychotropics are an important element of treatment, the increased use of these drugs has led to concerns that "some children and adolescents are being overdiagnosed with psychiatric disorders and are being treated with medication/s that are not appropriate for them," the authors write.

They add that strategies to reduce inappropriate use, including the US Food and Drug Administration's black box warning for antidepressants, may have the unintended effect of creating barriers to care and subsequent negative outcomes.

"Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated," the investigators write.

In developing the parameter, the researchers, led by Dr. Walkup, undertook an extensive literature review that included published articles pertaining to psychopharmacology in children and adults. They also reviewed textbooks on pediatric psychopharmacology, as well as their reference lists.

Finally, as background for the parameter, the researchers conducted a PubMed search on quality medical care and the overuse of medical testing and other medical procedures considered to be used excessively, such as routine laboratory or radiological testing and caesarean section. In addition, they did an analysis of any other medical conditions that have historically been overdiagnosed or misdiagnosed and treated inappropriately.

The parameter contains 13 principles to help guide clinicians in their treatment strategy for their young patients. These include best practices for psychiatric and medical assessment, development of the treatment and monitoring plan, education of both the patient and the family about the disorder and treatment, implementation of the treatment plan, and management of medication modification plans.

Dr. Walkup has disclosed that he receives or has received research support from Eli Lilly & Company, Pfizer, and Abbott Laboratories; acted as a consultant and/or served on an advisory board for Eli Lilly & Company, GlaxoSmithKline, and Cliffs communities; and receives or has received honoraria from CME. Dr. Walkup's spouse serves as a consultant to Abbott Laboratories. Dr. Bukstein receives or has received research support, acted as a consultant, and/or served on the speaker's bureaus of McNeil Pediatrics and Novartis Pharmaceuticals. Dr. Bernet and Dr. Walter have disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. 2009;48:961–973.

    
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