On- and Off-Label Atypical Antipsychotic Prescription Trends Across a Nine-Year Period Among Adolescents Pre- to Post-COVID-19

Brianna Costales; Natalie E Slama; Robert B Penfold; Joshua R Nugent; Scott R Spalding; Stacy A Sterling; Esti Iturralde

doi:10.1016/j.acap.2024.03.003

On- and Off-Label Atypical Antipsychotic Prescription Trends Across a Nine-Year Period Among Adolescents Pre- to Post-COVID-19

Acad Pediatr. 2024 Mar 6:S1876-2859(24)00072-X. doi: 10.1016/j.acap.2024.03.003. Online ahead of print.

Authors

Brianna Costales¹, Natalie E Slama², Robert B Penfold³, Joshua R Nugent², Scott R Spalding⁴, Stacy A Sterling², Esti Iturralde²

Affiliations

¹ Division of Research (B Costales, NE Slama, JR Nugent, SA Sterling, and E Iturralde), Kaiser Permanente Northern California, Oakland, Calif. Electronic address: brianna.m.costales@kp.org.
² Division of Research (B Costales, NE Slama, JR Nugent, SA Sterling, and E Iturralde), Kaiser Permanente Northern California, Oakland, Calif.
³ Kaiser Permanente Washington Health Research Institute (RB Penfold), Seattle, Wash.
⁴ The Permanente Medical Group (SR Spalding), Oakland, Calif.

PMID: 38458489
DOI: 10.1016/j.acap.2024.03.003

Abstract

Objective: This study examined atypical antipsychotic prescribing by Food and Drug Administration (FDA) approved-use (on-label) status for adolescents before and during the COVID-19 pandemic.

Methods: Retrospective data were collected from electronic health records (EHRs) of adolescents aged 10-17 years in Kaiser Permanente Northern California. New outpatient atypical antipsychotic prescription orders during 2013-2021 were evaluated. Prescriptions were categorized as on-label if linked in EHRs to autism, psychosis, bipolar disorder, or Tourette's diagnoses; otherwise, they were potentially off-label (herein, off-label). Trend analysis of monthly prescribing rates assessed slope change at pandemic onset for the cohort and by sex and age groups.

Results: Among 5828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, P < .01) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, P = .01). Off-label prescriptions increased at a similar rate during the COVID-19 time period, but on-label prescriptions did not change significantly. Males and younger adolescents (ages 10-14 years) showed significant decreases until early 2020, while females and older adolescents (ages 15-17 years) did not. Females and younger adolescents exhibited significant increases in overall and off-label prescribing rates following pandemic onset; older adolescents exhibited increases in overall prescriptions while males had no detectable changes.

Conclusions: Antipsychotic prescribing declined slightly but then increased significantly following COVID-19 onset for overall and off-label prescriptions. Pandemic onset differentially impacted antipsychotic prescribing by sex and age, with overall and off-label prescribing driven by increases among female and younger adolescents.

Keywords: COVID-19; adolescents; antipsychotic agents; off-label use; pediatrics.