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Use of quetiapine in child and adolescent populations – Response to letter from Dr Lambe Erik Monasterio and Andrew McKean Hillmorton Hospital, Christchurch, New Zealand Corresponding author: Erik Monasterio, Hillmorton Hospital, Annex Road, Christchurch 8140, New Zealand. Email: erik.monasterio@cdhb.govt.nz DOI: 10.1177/0004867413498274 We are grateful to be given an opportu- nity to comment on the letter by Dr Lambe (Lambe, 2013) in response to our previous correspondence (Monasterio and McKean, 2013), which outlined our concern about the exten- sive off-label use of quetiapine in primary and specialist psychiatric care, despite the limited evidence base for its safety and efficacy (Monasterio and McKean, 2011). Dr Lambe acknowledges that there are many potential adverse effects associated with the use of quetiapine, particularly in child and adolescent psychiatry, but, despite this, comments that: ‘off-label prescribing of quetiapine for excessive anxiety and insomnia is often the best alternative, as long as one monitors for side effects’ (Lambe, 2013). In considering the appropriateness of off-label prescribing of atypical antipsychotic (AAP) medications in child and adolescent psychiatry, we encourage close attention to recent findings in the literature, which indi- cate that there has been a particularly rapid expansion in the use of these agents in this age group for reasons which remain largely unknown. • An analysis of drug dispensing data from community pharmacies in The Netherlands found that between 1997 and 2005 the use of antipsychotics increased from 3.0 to 6.8 per thousand for youths to 19 years of age; the use of AAPs increased almost ninefold. The increase in AAPs was most pro- nounced for 5–9 year olds (almost 10-fold) and for 10–14 year olds (almost 12-fold). The median duration of AAP use across all age groups was 2.9 years and longest for 5-9 year olds, at 5.1 years. (Kalverdijk et al., 2008). • An analysis of Medical Expen- ditures Panel Survey (MEPS) data on non-institutionalized individu- als in the USA found that the pro- portion of antipsychotic users who were under age 18 doubled between 1996/1997 and 2004/ 2005 from 7% to 15% of all users (Domino and Swartz, 2008). Analysis of data from the National Ambulatory Medical Care Survey (NAMCS), which collects informa- tion from office-based physician practices, found that the annual number of US office visits by those under age 21 that included pre- scription of an antipsychotic medi- cation jumped more than fivefold from 1993/1995 to 2002 (Olfson et al., 2006). Amongst privately insured 2–5-year-old children in the USA, the rate of antipsychotic use doubled in the period of 1999/2001 to 2007; this occurred at the same time that the use of antidepressants decreased (1.6 times less common in 2007) in this age group (Olfson et al., 2010). Data from long-term US trends in office-based physician use of antip- sychotic medications found that there was an eightfold increase in the number of treatment visits for children between 1995 and 2008 (Alexander et al., 2011). In British Columbia, there has been a 10-fold increase in the prescrip- tion of AAPs to children under 14 between 1997 and 2007 (Panagiotopoulos et al., 2010). • Data supplied by PHARMAC (the pharmaceutical funding agency in New Zealand) indicates that there has been a 56% increase in the use of antipsychotic medications in 10–19 year olds from 2008 to 2012 in New Zealand. • Children and adolescents may be at a higher risk of antipsychotic- associated weight gain, as well as sedation and movement disorders, when compared to adults (McKinney and Renk, 2011). Among 257 children taking sec- ond-generation antipsychotics for the first time, weight increased during the first 12 weeks of treat- ment. Among subjects taking olan- zapine, the mean weight gain was