Objective: To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada. Method: We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics Section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used. Results: Ninety-four percent of the child psychiatrists (95%CI, 90% to 97%) and 89% of the developmental pediatricians (95%CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed. Conclusions: Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group.

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Included in their excellent review of suicidal behaviour in children and adolescents, Dr Margaret Steele and Dr Tamison Doey discuss the literature on hospital-based services for suicidal adolescents. 1 They state that "there is no empirical evidence that hospitalization or day treatment is effective in reducing rates of suicidal ideation, attempts, or completed suicide among adolescents" and reference the Gould et al 2 review of the past 10 years published in 2003. While we cannot comment on completed suicide, in the time since the Gould et al review, our group has published a study suggesting the possibility that inpatient treatment may reduce suicidal ideation, suicidal behaviour, and nonsuicidal self-injurious behaviour.

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Doey discuss the literature on hospital-based services for suicidal adolescents.1 They state that "there is no empirical evidence that hospitalization or day treatment is effective in reducing rates of suicidal ideation, attempts, or completed suicide among adolescents" and reference the Gould et al 2 review of the past 10 years published in 2003. While we cannot comment on completed suicide, in the time since the Gould et al review, our group has published a study suggesting the possibility that inpatient treatment may reduce suicidal ideation, suicidal behaviour, and nonsuicidal self-injurious behaviour. 3Our study looked at the effect of a dialectical behaviour therapy (DBT) program modified for suicidal adolescent inpatients (n = 32), compared with suicidal adolescents hospitalized for treatment as usual (TAU), that being a psychodynamically oriented treatment unit (n = 30). The adolescents were assessed at baseline, at time of discharge, and then at a one-year follow-up. In summary, the groups were equivalent at baseline and both groups demonstrated significant reductions in suicidal ideation, suicidal behaviour, nonsuicidal self-injurious behaviour, depression, and hopelessness. However, DBT was more effective in reducing behavioural incidents (for example, aggression or self-harm) during hospitalization than TAU and had consistently larger effect sizes on depression, suicidal ideation, and hopelessness (a larger sample size will be required to determine if these differences are significant). Recently, the Journal of the American Academy of Child and Adolescent Psychiatry endorsed the use of DBT on adolescent inpatients in psychiatric wards for the management of emotionally and behaviorally dysregulated adolescents, referencing this study in its review of the evidence for the management of this population. 4 These findings suggest that hospitalization of suicidal adolescents is associated with improvements in these variables; however, definitive conclusions await a randomized controlled trial comparing DBT-based inpatient treatment with outpatient treatment to determine whether hospitalization in fact leads to improvement in suicidality in adolescents. Given that hospitalization of suicidal adolescents consumes an enormous amount of health care resources, we would suggest that the addition of this information enhances Dr Steele and Dr Doey's otherwise excellent review. REPLY Dear Sirs:We thank Dr Katz, Dr Cox, and Dr Miller for their remarks. As acknowleged in our review, Dialectical Behaviour Therapy (DBT) is one of the few evidenced-based practices that have been shown to reduce suicidal behaviour both for inpatients and outpatients. Our point is that admission to the hospital alone, as an intervention, has not been shown to reduce suicidal behaviour and, in fact, may be associated with an increased incidence of recurrent attempts. We would agree that definitive conclusions about DBT's effectiveness in improving suicidal behaviour of hospitalized adolescents awaits a randomized controlled trial comparin...