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December 12, 2018

Antipsychotics, Excess Deaths, and Paradoxes of Child Psychiatry

Author Affiliations
  • 1Department of Psychiatry, Washington University in St Louis, St Louis, Missouri
JAMA Psychiatry. Published online December 12, 2018. doi:10.1001/jamapsychiatry.2018.3409

Before commenting on the Ray et al article1 that reports an increased risk of unexpected deaths in patients 6 to 24 years old who received antipsychotics, it might be useful to consider the findings vis-à-vis diagnostic and treatment paradoxes of child psychiatry. Intuitively, many consider child psychiatry as a subspecialty that deals with little patients and little problems, but the reality is that psychiatrically ill children are not adult “lite.” Rather, they have the same disorders as adults, including those that have pediatric US Food and Drug Administration indications for antipsychotic use (eg, schizophrenia, bipolar disorder). Notably, 50% of psychiatry disorders begin by age 14 years,2 and childhood age at onset is a risk factor for a more severe longitudinal course in mood and other disorders. Suicide occurs across the child and adolescent spectrum, including in children 5 to 11 years old, who use similar methods to their adult counterparts (eg, hanging, firearms).3 Although the gravity of childhood-onset psychosis is similar to adult diagnoses, some manifestations, such as delusional content, vary developmentally (eg, children believe that school personnel rather than the Federal Bureau of Investigation are plotting to kill them). Given that serious psychopathology occurs in childhood, it is not surprising that major psychotropics are a therapeutic option.