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

OBJECTIVE: This study examined atypical antipsychotic prescribing by 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 5,828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, p <.001) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, p =.010). 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.

WHAT'S NEW: Within a large, diverse, integrated healthcare delivery system, Covid-19 pandemic onset coincided with a rebound in antipsychotic prescribing after a previous decline among adolescents; this change was driven by potentially off-label prescriptions, particularly among females and adolescents aged 10-14 years.