Evaluation of Psychotropic Drug Use in Adolescents Accessing a General Emergency Medical Department for Mental Disorders

Round 1

Reviewer 1 Report

Authors should be congratulated.

Author Response

Many thanks for yor kind comments

Reviewer 2 Report

Revision of the article:

Evaluation of Psychotropic Drug Use in Adolescents Accessing a General Emergency Medical Department for Mental Disorders

It is an interesting article insofar as the authors explain that few studies have evaluated the care of adolescents with acute episodes of mental disorders in the emergency departments. Furthermore, as the authors explain, it is important to monitor the prescription of psychotropic drugs in daily practice, identify the areas where more data on the effectiveness of treatments are needed and develop therapeutic protocols and guidelines. In this sense, this article opens the way to a new and interesting line of research.

However, there are some aspects that should be improved prior to publication:

- Keywords: It would be advisable to include as a keyword "Psychotropic Drug".

- Introduction: In this section appears the abbreviation ADHD. The first time it is recommended to write the whole concept (in this case, Attention-Deficit/Hyperactivity Disorder) followed by the abbreviation in parentheses (ADHD). In addition, the introduction section could be improved, providing a greater theoretical framework on the subject of the study.

- Materials and Methods:

• The subsection 1. Italian health care organization should be explained in the introduction, not in the materials and methods section.
• The methodology section needs to be vastly improved. It is important to write more clearly which are the variables finally investigated in the present study. It is also important to explain in detail if the study passed the ethical approval of the hospital committee.

- Results:

• Subsection 2. Data source and analyses (lines 80-82) explains that “Diagnoses were classified on the basis of ICD-9 codes as:“anxiety disorders” (ICD-9 codes 293.84, 300.01, 309.24, 300.11), “predominant psychomotor disturbance”(308.2), “mood disorders” (296.90, 311.00, 309.28), and “psychosis” (298.00 and 298.10)”, but then in the Results section, in Table 1 the diagnoses/disorders are not totally consistent with this classification.
• Results data are presented in a cumbersome way. It is recommended to present the results in a clearer way and preferably in tables when it is possible.

- Discussion: The first paragraph of the discussion section is a conclusion and should be at the end of the discussion section or in the conclusions section, not at the top of the discussion section.

- Conclusions: This section can also be improved by explaining in greater detail the conclusions of the present study and the specific implications for improving the practice.

- References: The reference number 29 has a different font size. In all references, the volume of the journal must be in italics. You can check the recommendations in:

https://0-www-mdpi-com.brum.beds.ac.uk/journal/ijerph/instructions

https://0-www-mdpi-com.brum.beds.ac.uk/authors/references

I hope that the suggested changes help to improve the quality of the article and that they are well received.

Kind regards

Author Response

Thank you for your valuable and helpful comments.

1) - Keywords: It would be advisable to include as a keyword "Psychotropic Drug".

Response to 1): The keyword psychotropic drug was added

2) - Introduction: In this section appears the abbreviation ADHD. The first time it is recommended to write the whole concept (in this case, Attention-Deficit/Hyperactivity Disorder) followed by the abbreviation in parentheses (ADHD). In addition, the introduction section could be improved, providing a greater theoretical framework on the subject of the study.

Response to 2): In the introduction section "attention deficit hyperactivity disorder" was added before the abbreviation ADHD. We included in the revised version a brief para underlying the lacking of information concerning the psychotropic drug prescription in the ED setting.

3) - Materials and Methods:

• A) The subsection 1. Italian health care organization should be explained in the introduction, not in the materials and methods section.

Response to 3A) In our opinion, this subsection is more pertinent to the methods section (as previously done in other papers), since it provides details concerning the setting/context of the study, but if needed we are willing to shift it to the introduction.

• B) The methodology section needs to be vastly improved. It is important to write more clearly which are the variables finally investigated in the present study. It is also important to explain in detail if the study passed the ethical approval of the hospital committee.

Response to 3B) The sentence "No ethics committee approval is required in Italy for epidemiological studies using healthcare administrative databases for research purposes and with individuals identified by an anonymous patient code." was added to the methods section. Moreover, we provided a more detailed description regarding the drug classification, the variables investigated and the statistical analyses.

4) - Results:

• A) Subsection 2. Data source and analyses (lines 80-82) explains that “Diagnoses were classified on the basis of ICD-9 codes as:“anxiety disorders” (ICD-9 codes 293.84, 300.01, 309.24, 300.11), “predominant psychomotor disturbance”(308.2), “mood disorders” (296.90, 311.00, 309.28), and “psychosis” (298.00 and 298.10)”, but then in the Results section, in Table 1 the diagnoses/disorders are not totally consistent with this classification.

Response to 4A) The ICD9 codes for "borderline personality disorsers were added in the methods section.

• B) Results data are presented in a cumbersome way. It is recommended to present the results in a clearer way and preferably in tables when it is possible.

Response to 4B) We added a table (table 1) with a summary of the characteristics of adolescents visited for psychiatric disoders and of adolescents treated with psychotropic drugs. We tried to report the results in a clearer way.

5) - Discussion: The first paragraph of the discussion section is a conclusion and should be at the end of the discussion section or in the conclusions section, not at the top of the discussion section.

Reponse to 5) The first paragraph was shifted to the end of the discussion section

6) - Conclusions: This section can also be improved by explaining in greater detail the conclusions of the present study and the specific implications for improving the practice.

Response to 6): We tried to improve the conclusions: "Overall, 4% of adolescents, mostly females 16-17 years old, attending an ED had mental disorders. Almost half of the patients received drug treatment, and in many cases it was off-label and with scant evidence of efficacy. A systematic monitoring of the management of acute mental health disorders in adolescents in the emergency care setting is needed in order to identify the area of inappropriateness and the unmet needs. This monitoring should include a follow-up of the clinical pathways and the outcomes of the patients visited in the ED. Finally, in our opinion the existing protocols should be reviewed and updated taking into account the available evidence, even if they are limited."

7)- References: The reference number 29 has a different font size. In all references, the volume of the journal must be in italics.

Response to 7): Fixed

Reviewer 3 Report

This is a small single centre study exploring prescribing of psychoactive drugs to adolescents presenting to the Emergency Department with mental health problems, demonstrating frequent prescription of off-label medication.  Despite the frequency of adolescents presenting in this setting with these complaints, there is surprisingly little data on this and thus this study provides pilot data to inform as well as guide further research.

The data collection and analysis are clear and the results are presented in a crisp manner that supports the conclusions.  The limitations of the study are acknowledged and discussed.

There are several areas in which clarification would be useful.  Was this study approved by an Institutional Review or Ethics Board?  Was the anonymized code the method used for protection of patient identity and privacy?  

When adolescents present to the Emergency Department suicidal ideation or attempted suicide is a common presentation.  It would appear from diagnostic codes that these patients were not included in the study.  This should probably be made clear in the manuscript.

Author Response

1) There are several areas in which clarification would be useful. Was this study approved by an Institutional Review or Ethics Board? Was the anonymized code the method used for protection of patient identity and privacy?

Response to 1) We clarified in the methods section that "No ethics committee approval is required in Italy for epidemiological studies using healthcare administrative databases for research purposes and with individuals identified by an anonymous patient code." The methods section was implemented to better explain the methodological aspects of the study (please responses to reviewer 2 for details).

2) When adolescents present to the Emergency Department suicidal ideation or attempted suicide is a common presentation. It would appear from diagnostic codes that these patients were not included in the study. This should probably be made clear in the manuscript.

Response to 2) We clarified this point in the results section: "In all, 5 adolescents with personality or mood disorders were visited in the ED for self-harm, in 2 cases associated with suicidal ideation."

Round 2

Reviewer 2 Report

Second revision of the article:

Evaluation of Psychotropic Drug Use in Adolescents Accessing a General Emergency Medical Department for Mental Disorders

Before being published this article still has the following aspects to improve:

• Introduction: this section could be improved providing a greater theoretical framework on the subject of the study.
• Materials and Methods:

- The subsection 1. Italian health care organization should be explained in the introduction, not in the materials and methods section.

- The methodology section still needs to be improved. It is important to write more clearly which are the variables finally investigated in the present study.

• Results: Some of the data in Table 1 of the results section are not consistent with some data provided in the abstract, for example the sample of male and women and the sample of adolescents with predominant psychomotor disturbance.
• Conclusions: This section still can be improved by explaining in greater detail the conclusions of the present study and the specific implications for improving the practice.

I hope that the suggested changes help to improve the quality of the article and that they are well received.

Kind regards

Author Response

Before being published this article still has the following aspects to improve:

• Introduction: this section could be improved providing a greater theoretical framework on the subject of the study.

Response 1: We added a few sentences in page 2, lines 47-52:
“The pattern of psychotropic drug prescription in outpatient children and adolescents is largely described [13], but little is known concerning therapies administered or prescribed in the ED setting [14, 15]. This finding does not reflect the increased use of emergency care services for acute episodes of mental disorders, in particular for anxiety and depressive symptoms [11,12], while the ED physicians maybe required to establish the first therapeutic interventions. It is therefore important to monitor the profile of psychotropic drugs used in the emergency departments."

• Materials and Methods:

- The subsection 1. Italian health care organization should be explained in the introduction, not in the materials and methods section.

Response 2: This subsection was shifted to the introduction

- The methodology section still needs to be improved. It is important to write more clearly which are the variables finally investigated in the present study.

Response 3: We clarified that the prevalence of psychotropic drug use was the main outcome measure (page 3, line 113) and we specified the variables considered for the comparison of prevalence in lines 115-121 (“In particular, a comparison of the prevalence of psychotropic drug use was performed for the following variables : gender, age, group of disorders (anxiety; predominant psychomotor disturbance; other disorders), physician specialty (child psychiatrist versus psychiatrist), urgency of the visit, and naïve versus non naïve patients. The comparison by gender and age was performed using a Mantel-Haenszel chi-square test. A p-value<0.05 was considered statistically significant.”)

• Results: Some of the data in Table 1 of the results section are not consistent with some data provided in the abstract, for example the sample of male and women and the sample of adolescents with predominant psychomotor disturbance.

Response 4: We apologize for the mistake. We fixed the errors in the abstract

• Conclusions: This section still can be improved by explaining in greater detail the conclusions of the present study and the specific implications for improving the practice.

Response 5: We modified the conclusion: “Overall, 4% of adolescents, mostly females 16-17 years old, attending an ED had mental disorders. Almost half of the patients received drug treatment, and in many cases it was off-label and with scant evidence of efficacy. Anxiety, treated with benzodiazepines, was the most frequent disorder in adolescents attending an ED for mental disorders, suggesting that many accesses may be avoided through an improvement of the role and organization of primary care physicians and child psychiatry outpatient services. A systematic monitoring of the management of acute mental health disorders in adolescents in the emergency care setting is needed in order to identify the area of inappropriateness and the unmet needs. This monitoring should include a follow-up of the clinical pathways and the outcomes of the patients visited in the ED. Finally, in our opinion the existing protocols should be reviewed and updated taking into account the available evidence, even if it is limited.”