gms | German Medical Science

Background: Adolescents are often presenting with adjustment disorders (AjD) or MDD in emergency departments [1]. There are recommendations for the pharmacological treatment of severe major depression in adolescents, but actual guidelines for the treatment of AjD are missing [2], [3], [4]. Abbas et al. described an increase in antipsychotic drug prescriptions in German adolescents [5]. We investigated the outpatient psychotropic drug treatment of suicidal adolescents suffering from adjustment disorders and compared it with the treatment of suicidal adolescents diagnosed with (severe) depressive disorders.

Materials and methods: The urine and plasma levels of adolescents, hospitalized due to their acute suicidality, but without a known actual suicide attempt (i.e. no acute intoxication or serious self-injuries), were investigated routinely between 01.03.2017 and 31.01.2018. Urine (N=205, GCMS screening, no detection of aripiprazole) and blood samples (N=193) were taken at the beginning of closed inpatient admission, i.e. the results of the laboratory analysis reflect outpatient drug intake. The serum levels of psychopharmacological medication (particularly antidepressants, second generation antipsychotics (SGAPs)) were measured. We used the following therapeutic reference ranges: aripiprazole 100–350 ng/ml, quetiapine: 100–500 ng/ml, risperidone (i.e. risperidone plus 9-hydroxy-risperidone): 20–60 ng/ml, fluoxetine (i.e., fluoxetine plus N-Desmethylfluoxetine): 120–500 ng/ml; mirtazapine: 30–80 ng/l, sertraline: 10–150 ng/ml, pipamperone: 56.0–180.5 ng/ml [6], [7].

Results: Our sample consists of 231 cases (males: N=54; females: N=177, ratio: 1:3.3), aged 12-17 years (average age: 15.4 years). The main psychiatric diagnoses were (recurrent) moderate or severe depressive episodes (55%, males: N=13, females: N=111, male/female ratio: 1: 9.5, p<.0001) and adjustment disorders (24%, males: N=14, females N=41, male/female ratio: 1:2.9). The most often prescribed psychotropic drugs with GCMS screening in our sample were antipsychotics and/or antihistamines (total: N=87, quetiapine: N=23; promethazine: N=21; chlorprothixene: N=18; pipamperone: N=17; diphenhydramine: N=3; phenotiazine: N=5), followed by antidepressant agents (total: N=67, mostly SSRIs, e.g., fluoxetine: N=27, sertraline and citalopram N=15 each). We found 28 cases (males: N=3; females: N=25) fulfilling criteria of severe MDD (i.e. ICD 10 diagnoses: F32.3, F33.1, F33.2). Almost half of patients with adjustment disorders (N=26, 47%) received prescribed psychotropic medication, mostly aripiprazole (N=10, only females, always supratherapeutic blood levels) and/or low potential antipsychotics. Polypharmacy (i.e., ≥2 psychotropic drugs) was frequent in female patients suffering from AjD (63%). About one third (32%) of adolescents with severe MDD had ≥2 prescribed psychotropic drugs. Thirteen adolescent cases diagnosed with severe MDD showed antidepressant medication (fluoxetine (on-label): N=6, 1 supratherapeutic drug level: 665 ng/l, sertraline (off-label): N=7). Suicidal adolescents suffering from severe MDD did not receive more on-label psychotropic medication than suicidal adolescents with non-recurrent mild or moderate depressive symptoms (p=0.48, n.s.).

Conclusion: Depressive and/or anxiety symptoms do not seem to be in focus of outpatient psychotropic drug treatment of adolescents with AjD. The severity of depression is not reflected in a more intensive psychopharmacological treatment. Our results suggest that off-label used aripiprazole necessitates a more intensive monitoring of blood levels and their adjustment within the therapeutic range than off-label used sertraline. There seems to be a strong need for epidemiological studies about the pharmacological treatment of adolescent patients suffering from AjD.