Adolescent mental health has garnered increased concern due to rising youth suicide rates, youths’ own reports of widespread sadness and hopelessness, and the continued aftermath of Covid-19 pandemic disruptions to education and socialization (1). Data from Denmark and Canada indicate a rise in psychotropic prescriptions and incident psychiatric diagnoses among youth since March 2020, including new use of atypical antipsychotics 2, 3.

Pediatric behavioral and mental health treatment with antipsychotics has been a contentious topic for decades, partly due to safety concerns and prominent off-label prescribing 4, 5. Adverse metabolic effects are a critical safety concern given the potential for rapid onset of weight gain upon treatment initiation (6). Despite clinical guideline recommendations, cardiometabolic monitoring among youth receiving new atypical antipsychotic prescriptions remains suboptimal (7). Younger age groups are vulnerable to weight gain and other metabolic effects including hyperlipidemia, with downstream consequences such as reduced quality of life, diabetes, and early mortality risk (8). Moreover, there is a deficit of safety information available on adverse behavioral effects (9).

Although there are randomized clinical trial data available for pediatric (ages ≤ 18 years) uses approved by the U.S. Food and Drug Administration (FDA; autism, psychotic disorders, bipolar disorders, and Tourette’s), there is a paucity of safety and efficacy information for the various mental health conditions for which antipsychotics are most commonly prescribed (10). Trends in atypical antipsychotic prescribing among adolescents decreased following scrutiny by the Agency for Healthcare Research Quality (AHRQ) and others from 2011 onward, at which time AHRQ reported a majority of antipsychotic prescriptions for children and adolescents were for off-label uses (11). A more recent AHRQ systematic review of pediatric antipsychotic use concluded that the strength of clinical trial evidence supporting approved uses remains a delicate balance of benefits and harms, particularly for conditions for which alternatives exist (12). Prior to the Covid-19 pandemic, evidence showed antipsychotic use among younger age groups was declining and males were more likely to receive antipsychotics than females 5, 13. However, limited research has examined new on- and off-label prescribing of atypical antipsychotics to U.S. adolescents during the pandemic period. This study examined nine years of antipsychotic prescribing for adolescents within a large California health system starting in 2013, including proportions of on-label and potentially off-label prescriptions, and trends by sex and age.