Deprescribing psychotropic medications in children: results of a national qualitative study.

BACKGROUND AND OBJECTIVE: Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children. METHODS: We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding. RESULTS: Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians. CONCLUSION: Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

State-wide implementation and clinical outcomes associated with evidence-based psychotherapies for traumatized youth.

BACKGROUND: Highly efficacious evidence-based psychotherapies (EBPs) exist for children and youth exposed to trauma, yet very few who need the treatments in the community receive them. Research within real-world settings is needed to better understand what is required to translate treatments into the community. PURPOSE: We aimed to examine the implementation and clinical outcomes of a multiyear project installing 2 EBPs for trauma-exposed youth in community agencies across the state of New Hampshire. METHOD: We invited clinicians to 2 days of training plus weekly group consultation calls for 9 or 12 months in Trauma-Focused Cognitive Behavioral Therapy or Child Parent Psychotherapy. Implementation metrics included clinician adherence to training, consultation, and treatment delivery expectations. Clinical outcomes included treatment dropout, as well as posttraumatic stress (PTS) symptoms. RESULTS: Of the 292 clinicians meeting eligibility and agreeing to participate, 243 (83%) attended trainings, 168 (58%) began consultation calls, and 70 (24%) adhered to implementation expectations by attending 80% of consultation calls and beginning the treatment with 2 youths. According to (completing) clinicians' reports, of the 363 youths tracked over the 9 to 12 month consultation periods, 47% dropped out of treatment and 44% were ongoing. Pre-post PTS scores (n = 82) demonstrated clinically meaningful reductions for 59% of youth. CONCLUSIONS: Clinical outcomes were robust for those who completed treatment, rivaling those of highly controlled trials. However, implementation outcomes indicate an uphill battle in reaching youth who need the treatment. Implementation outcomes were mixed compared with those of more resource-intensive implementation models. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The activity-dependent transcription factor NPAS4 regulates domain-specific inhibition.

A heterogeneous population of inhibitory neurons controls the flow of information through a neural circuit. Inhibitory synapses that form on pyramidal neuron dendrites modulate the summation of excitatory synaptic potentials and prevent the generation of dendritic calcium spikes. Precisely timed somatic inhibition limits both the number of action potentials and the time window during which firing can occur. The activity-dependent transcription factor NPAS4 regulates inhibitory synapse number and function in cell culture, but how this transcription factor affects the inhibitory inputs that form on distinct domains of a neuron in vivo was unclear. Here we show that in the mouse hippocampus behaviourally driven expression of NPAS4 coordinates the redistribution of inhibitory synapses made onto a CA1 pyramidal neuron, simultaneously increasing inhibitory synapse number on the cell body while decreasing the number of inhibitory synapses on the apical dendrites. This rearrangement of inhibition is mediated in part by the NPAS4 target gene brain derived neurotrophic factor (Bdnf), which specifically regulates somatic, and not dendritic, inhibition. These findings indicate that sensory stimuli, by inducing NPAS4 and its target genes, differentially control spatial features of neuronal inhibition in a way that restricts the output of the neuron while creating a dendritic environment that is permissive for plasticity.