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Outcomes in Child Psychiatry.

The longitudinal assessment of clinically relevant outcomes is necessary to inform diagnostic and prescribing decisions. Two recent articles (Santosh et al. 2017; Zito and Burcu 2017) in JCAP address the need for systematic outcomes research in pediatric psychopharmacology. Each article highlights gaps in current knowledge, as well as the complexity of measuring outcomes in child psychiatry. Santosh et al. (2017) review the now widespread use of secondgeneration antipsychotic medications in youth, especially in the United States. Most antipsychotic prescriptions in children are for off-label indications, in particular disruptive behavior disorders and aggression. Increased prescribing can be attributed, at least in part, to marketing, expanding diagnostic categories (e.g., bipolar disorder, autism), and the perception of enhanced tolerability, compared to traditional neuroleptics. As it stands, there is little evidence supporting the long-term efficacy and safety of second-generation antipsychotics in children, especially for off-label indications. As with all pediatric psychopharmacology, much of the support for using antipsychotic medications in children is based on short-term single-agent trials. Acute-phase treatment trials (typically 8 weeks or less) are important to first determine whether there is justification for longer maintenance treatment studies. However, short-term reductions in symptoms may not equate to long-term functional improvements, and significant safety concerns may only be evident after longterm exposure, for example, metabolic side effects. Furthermore, most clinical research trials use narrowly defined inclusion and exclusion criteria, thus limiting the generalizability of research findings to community settings. Also, given the lack of head to head medication trials, there is a lack of evidence regarding which agent is best to choose for any given clinical situation. Santosh et al. (2017) raise two critical needs: (1) the identification of factors that predict whether (and for which youth) prescribed medications will significantly improve long-term functioning, including social, academic, and mental health outcomes and (2) the need to incorporate systematic medication monitoring into routine clinical practice. The Centre for Interventional Pediatric Psychopharmacology and Rare Diseases has developed a web-based health monitoring platform that gathers information regarding symptoms, treatment response, and side effects. These assessments, coupled with guidelines for standardized dosing and treatment monitoring, are designed to promote appropriate care and to provide clinicians with relevant long-term safety and effectiveness data to better guide clinical decision-making. Zito and Burcu (2017) review the risk of adverse cardiovascular events with stimulant medications. Rare cases of sudden death in individuals exposed to mixed amphetamine salts have been linked to underlying cardiac structural abnormalities (which may go unrecognized in clinical settings) or to unexplained toxic drug levels on typical dosages (possibly rare genetic outliers). Populationbased data vary in regard to whether stimulant use is statistically associated with an increased risk of sudden death, with differences in methods and the rarity of severe adverse outcomes likely explaining discrepant findings. More consistent associations are noted between stimulant use and other cardiac-related events, for example, syncope, alterations in pulse and blood pressure that result in emergency room visits. The potential risk of cardiovascular side effects with stimulant medications supports the need for systematic monitoring of heart rate and blood pressure; routine assessment of medical problems and family medical history; and adequate informed consent. More intensive screening, such as electrocardiogram monitoring, should be considered for patients with known cardiovascular risks, or for patients on multiple agents, including combinations of stimulants, antidepressants, and antipsychotics. Zito and Burcu (2017) highlight the need for longitudinal population-based monitoring to detect rare severe adverse events. These types of studies are complicated by the complexity and heterogeneity of clinical populations, including exposure to different agents, and the challenge of ascribing causal relationships to rare outcomes given a multitude of potential risk factors, known and unknown. Furthermore, there may be impediments or disincentives for reporting such findings given medico-legal concerns, the lack of a clear definitive relationship between treatment and any rare adverse event, and the implications within the larger debate regarding the relative risks and benefits of psychotropic agents in children. Standard pediatric prescribing guidelines require the systematic assessment of symptoms, treatment response, and side effects (American Academy of Child and Adolescent Psychiatry 2009). Incorporating user-friendly and clinically relevant tools into routine practice helps engage patients in treatment and provides psychoeducational information in regard to expected treatment responses and self-monitoring. The longitudinal assessment and active surveillance of key outcomes in medical practice are important