Pediatrics – Psychiatry
Guideline: Metformin to Prevent Antipsychotic-Induced Weight Gain
23 Dec, 2024 | 20:55h | UTCIntroduction:
This guideline was developed to address a pressing need for strategies to prevent antipsychotic-induced weight gain (AIWG), a frequent and troubling adverse effect of treatment in individuals with severe mental illness (SMI). Although metformin has shown consistent benefits in mitigating weight gain when initiated alongside antipsychotics, clinical uptake remains limited. The guideline follows the AGREE II framework and synthesizes both randomized and observational research, including Cochrane and meta-analytic data. The primary objective is to outline explicit indications, dosing approaches, and duration for using metformin to avert AIWG.
Key Recommendations:
- Co-initiation With High-Risk Agents: In patients requiring higher-risk antipsychotics (olanzapine, clozapine), start metformin simultaneously. Evidence suggests that concurrent treatment may lessen weight gain by 3 to 5 kg in the early months, potentially yielding greater benefits over time.
- Co-initiation With Medium-Risk Agents: For individuals prescribed quetiapine, paliperidone, or risperidone who have at least one cardiometabolic risk factor (such as diabetes, prediabetes, hypertension, or BMI above 25) or who are 10 to 25 years old, begin metformin at antipsychotic initiation to curb rapid weight changes.
- Initiation During the First Year: If, at any point in the first year of antipsychotic treatment, weight gain exceeds 3% over baseline, consider adding metformin regardless of the antipsychotic being used.
- Titration Schedule and Safety: The guideline advises starting at 500 mg once daily, then moving to 500 mg twice daily after about two weeks, with subsequent increases every two weeks up to 1 g twice daily (2 g/day) as tolerated. Metformin must be discontinued if lactic acidosis is suspected, if BMI falls below 20, or if the antipsychotic is stopped. Avoid its use in harmful alcohol consumption.
- Additional Treatment Options: In cases of obesity (BMI ≥30) or comorbid metabolic disorders, clinicians should consider adding glucagon-like peptide-1 receptor agonists (GLP-1) where available. If cost, supply, or access is limited, metformin remains a practical alternative.
Conclusion:
This is the first evidence-based guideline focused on preventing AIWG by starting metformin at the time of antipsychotic initiation or upon early weight gain signs. By reducing the magnitude of weight increase, metformin may alleviate health risks tied to obesity, as well as psychological distress and nonadherence to treatment. Implementing the guideline involves continuous weight monitoring, structured dose adjustments, and shared decision-making. Ensuring clear communication about benefits and potential side effects will be crucial for sustaining adherence and improving patient outcomes.
Reference:
Carolan A, Hynes-Ryan C, Agarwal SM, Bourke R, Cullen W, Gaughran F, Hahn MK, Krivoy A, Lally J, Leucht S, et al. Metformin for the Prevention of Antipsychotic-Induced Weight Gain: Guideline Development and Consensus Validation. Schizophrenia Bulletin. 2024; sbae205.
DOI: https://doi.org/10.1093/schbul/sbae205
Additional Commentaries:
- Psychiatric News Alert: https://alert.psychnews.org/2024/12/new-guideline-advises-metformin-to.html
- Zagorski N. Metformin May Reduce Weight Gain in Youth Taking Antipsychotics. Psychiatric News. 2024; 59(01). https://psychiatryonline.org/doi/full/10.1176/appi.pn.2024.01.1.22
Cohort Study: Prenatal opioid exposure linked to modest increase in neuropsychiatric disorders – The BMJ
25 May, 2024 | 19:50h | UTCThis nationwide birth cohort study from South Korea investigated the impact of prenatal opioid exposure on the risk of neuropsychiatric disorders among children. The study followed 3,128,571 infants born between 2010 and 2017 until the end of 2020. Researchers found that infants exposed to opioids prenatally showed a slightly increased risk of developing neuropsychiatric disorders, including mood disorders, attention deficit hyperactivity disorder, and intellectual disability. The increased risk was more pronounced with higher opioid doses, longer duration of use, and exposure during the first trimester of pregnancy. However, this association was not significant in sibling comparison cohorts, indicating a modest overall clinical impact. The study emphasizes the need for cautious interpretation due to its observational design and the specific conditions under which risk increases.
Reference (link to free full-text):
APA workgroup update maintains skepticism on pharmacogenomic tools for depression – Am J Psychiatry
25 May, 2024 | 19:47h | UTCA recent review by the American Psychiatric Association (APA) Council of Research Workgroup on Biomarkers and Novel Treatments revisits the use of pharmacogenomic (PGx) tools for selecting depression treatments. The review assesses new clinical trials and meta-analyses conducted from 2017 to 2022. Of the studies analyzed, few demonstrated significant efficacy in treatment response using PGx tools, with many suffering from methodological flaws such as lack of full blinding and insufficient control measures. Despite some trials showing promise, the overall evidence remains insufficient to support the widespread clinical application of PGx tools in managing major depressive disorder. The Workgroup reaffirms the 2018 conclusions and aligns with the U.S. Food and Drug Administration’s stance, recommending that future research should focus on more rigorous study designs and explore other potential benefits of pharmacogenomics, such as predicting rare adverse drug reactions.
Reference (link to abstract – $ for full-text)
Clinical Trial Follow-up: Antenatal corticosteroids not associated with adverse neurodevelopmental outcomes in late preterm births – JAMA
2 May, 2024 | 23:25h | UTCStudy Design and Population:
This research involved a prospective follow-up study of a multicenter randomized clinical trial, specifically focusing on children aged 6 years or older whose birthing parents were enrolled in the Antenatal Late Preterm Steroids (ALPS) trial. The trial initially examined the impact of administering 12 milligrams of intramuscular betamethasone, given twice 24 hours apart, on late preterm infants (34-36 completed weeks). The follow-up study involved 949 children from 13 centers in the Maternal-Fetal Medicine Units (MFMU) Network, assessed for neurodevelopmental outcomes.
Main Findings:
The primary outcome measured was the General Conceptual Ability score less than 85 on the Differential Ability Scales, 2nd Edition (DAS-II). Results showed no statistically significant differences between the betamethasone group (17.1%) and the placebo group (18.5%) in achieving this score. Secondary outcomes related to motor function and social responsiveness also showed no significant differences between the groups. Sensitivity analyses further confirmed these findings, suggesting that the administration of betamethasone did not adversely affect neurodevelopmental outcomes at age 6 or older.
Implications for Practice:
These findings support the continued use of antenatal corticosteroids for improving short-term neonatal respiratory outcomes in late preterm deliveries without concern for long-term neurodevelopmental harm. Clinicians can consider these results reassuring, as the study effectively dispels earlier concerns about potential negative long-term effects related to neurodevelopment from antenatal steroid use in late preterm infants.
Reference (link to abstract – $ for full-text):
Cohort Study: No increased risk of autism, ADHD, or intellectual disability from acetaminophen use in pregnancy
29 Apr, 2024 | 12:34h | UTCThis cohort study investigated the association between acetaminophen use during pregnancy and the risk of autism, ADHD, and intellectual disability in children. The study utilized a population-based sample of nearly 2.5 million Swedish children born between 1995 and 2019, with data analyzed up to 2021. Initial findings without sibling controls suggested a marginal increase in the risks of autism and ADHD. However, sibling control analyses, which help adjust for familial confounding, showed no significant associations (HR for autism and ADHD at 0.98, and intellectual disability at 1.01). These results imply that earlier observed risks might be due to unaccounted familial factors, not acetaminophen exposure.
Reference (link to abstract – $ for full-text):
Review | Adverse effects of antidepressant medications and their management in children and adolescents
9 Aug, 2023 | 15:25h | UTC
M-A | Absence of evidence for antipsychotics in youth unipolar depression; limited evidence in bipolar depression
9 Aug, 2023 | 15:23h | UTC
USPSTF Draft Statement | Insufficient evidence for screening children under 5 years for speech and language delay
2 Aug, 2023 | 14:13h | UTCSpeech and Language Delay and Disorders in Children: Screening – U.S. Preventive Services Task Force
Commentary:
USPSTF: Evidence Lacking for Screening for Speech Delays in Young Children – HealthDay
M-A | Comparing the efficacy of different types of exercise for the treatment and prevention of depression in youths
30 Jun, 2023 | 14:40h | UTC
Evidence Analysis | ADHD: evidence to help you decide how best to manage the condition
19 Jun, 2023 | 13:45h | UTCADHD: evidence to help you decide how best to manage the condition – Evidently Cochrane
Review | Diagnosis and management of depression in adolescents
13 Jun, 2023 | 14:05h | UTCDiagnosis and management of depression in adolescents – Canadian Medical Association Journal
News Release: How to diagnose and manage depression in adolescents: A new review for clinicians – Canadian Medical Association Journal
Cohort Study | Cannabis use disorder linked to increased risk of depression and bipolar disorder
5 Jun, 2023 | 13:26h | UTCCannabis Use Disorder and Subsequent Risk of Psychotic and Nonpsychotic Unipolar Depression and Bipolar Disorder – JAMA Psychiatry (link to abstract – $ for full-text)
Author Interview: Cannabis Use Disorder and Subsequent Risk of Unipolar Depression and Bipolar Disorder
Commentary: Expert reaction to study of cannabis use disorder, bipolar disorder, and depression – Science Media Centre
Guideline | Assessment and treatment of children and adolescents with major and persistent depressive disorders
10 May, 2023 | 15:37h | UTC
Cohort Study | There is no association between labor epidural analgesia and risk of offspring autism and ADHD
4 May, 2023 | 13:30h | UTC
Commentary with video on Twitter
AJOG Presents: Labor epidural analgesia and subsequent risk of offspring autism spectrum disorder and attention-deficit/hyperactivity disorder: a cross-national cohort study of 4.5 million individuals and their siblings https://t.co/XFbedq7SAz pic.twitter.com/J4Mu5xSwT6
— AJOG (@AJOG_thegray) February 4, 2023
Review | Suicide in young people: screening, risk assessment, and intervention
2 May, 2023 | 13:56h | UTCSuicide in young people: screening, risk assessment, and intervention – The BMJ
ADHD Medication Misuse | 25% of students in some US schools report nonmedical use for stimulant effect
26 Apr, 2023 | 14:21h | UTCNews Release: In some US schools, 1 in 4 students report misusing prescription stimulants – University of Michigan
Commentary on Twitter
Prescription stimulant misuse varies from 0% to >25% across US secondary schools. Schools with highest rates of stimulant therapy for #ADHD had 36% increased odds of misuse, offering targets for prevention and risk reduction strategies. https://t.co/4XHGpooBjz
— JAMA Network Open (@JAMANetworkOpen) April 18, 2023
Cohort Study | Prenatal exposure to antiseizure medication and incidence of childhood-onset psychiatric disorders
24 Apr, 2023 | 13:10h | UTCPrenatal Exposure to Antiseizure Medication and Incidence of Childhood- and Adolescence-Onset Psychiatric Disorders – JAMA Neurology (link to abstract – $ for full-text)
Author Interview: Prenatal Exposure to Antiseizure Medication and Psychiatric Disorders – JAMA
Commentary on Twitter
Study strengthens the evidence for the warning against the use of valproate in pregnancy, supports concerns about the use of topiramate, and provides a preliminary indication for caution with the use of levetiracetam in pregnancy. https://t.co/BZzZP0tSZs
— JAMA Neurology (@JAMANeuro) April 17, 2023
Comprehensive clinical practice guidelines for the management of psychiatric emergencies
18 Apr, 2023 | 13:34h | UTCClinical Practice Guidelines for Management of Suicidal Behaviour
Clinical Practice Guidelines for Assessment and Management of Aggressive and Assaultive Behaviour
Clinical Practice Guidelines on Breaking Bad News
Clinical Practice Guidelines for the Use of Electroconvulsive Therapy
Clinical Practice Guidelines for the Use of Transcranial Direct Current Stimulation in Psychiatry
The earlier the better: an RCT of treatment timing effects for toddlers on the autism spectrum
17 Apr, 2023 | 12:52h | UTC
SR | Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)
17 Apr, 2023 | 12:39h | UTC
Perspective | Teen girls are faring worse than boys on nearly all mental health measures—here’s why
3 Apr, 2023 | 13:33h | UTCTeen Girls Are Faring Worse Than Boys on Nearly All Mental Health Measures—Here’s Why – JAMA (free for a limited period)
Commentary on Twitter
The latest @CDCgov Youth Risk Behavior Survey, administered in 2021, shows that mental health has worsened for all adolescents, but especially for girls. Nearly a third of teen girls said they seriously considered suicide. https://t.co/gVHoLYtI5b #MedicalNews
— JAMA (@JAMA_current) March 28, 2023
Review | Navigating the new eating disorder landscape: atypical anorexia and avoidant/restrictive food intake disorder
24 Mar, 2023 | 13:03h | UTCPitfalls and Risks of “New Eating Disorders”: Let the Expert Speak! – Nutrients
Commentary: A review on two novel eating disorders – News Medical
RCT | Impact of sleep deprivation on health-related quality of life in healthy children
23 Mar, 2023 | 12:57h | UTCCommentaries:
Sleep Disruption Linked to Lower HRQOL in Children – HealthDay
How just 39 minutes of sleep can make or break your child’s health, happiness and school day – CNN
COVID-19 pandemic measures may have caused reduced cognitive abilities among German students, study shows
20 Mar, 2023 | 13:50h | UTCSummary: This study investigated the impact of the COVID-19 pandemic on the cognitive abilities of secondary school students in Germany. The study compared the intelligence test performance of 424 students in Grades 7 to 9, tested after the first six months of the pandemic, to the results of two highly comparable student samples tested in 2002 and 2012.
The study found that the 2020 sample had substantially lower intelligence test scores than both the 2002 and 2012 samples. The study also retested the 2020 sample after another full school year of COVID-19-affected schooling in 2021 and found no signs of catching up to previous cohorts or further declines in cognitive performance.
It can be inferred from the article that the lower intelligence test scores of the 2020 sample may have been caused by the prolonged disruption of regular schooling due to the COVID-19 pandemic, including lockdowns and school closures.
The study highlights the potential negative impact of the COVID-19 pandemic on the cognitive abilities of secondary school students and suggests that these consequences should be taken into account when conducting intelligence assessments in the post-pandemic era. It also recommends that appropriate compensatory measures be implemented to address any learning loss or cognitive deficits that may have resulted from the disruption of regular schooling during the pandemic.
M-A | Comparison of pediatric emergency department visits for attempted suicide before and during the COVID-19 pandemic
15 Mar, 2023 | 14:56h | UTC