Psychotropic medications were prescribed two to three times more often to
American children and adolescents than to their peers in the Netherlands or
Germany, according to a study by investigators from all three countries. The
study was based on data from the year 2000.
"The annual prevalence of any psychotropic medication in youth was
significantly greater in the United States (6.7 percent) than in the
Netherlands (2.9 percent) and in Germany (2.0 percent)," wrote Julie
Zito, Ph.D., of the University of Maryland School of Pharmacy and seven
colleagues who posted their findings September 25 in the open-access online
journal Child and Adolescent Psychiatry and Mental
About 19.2 percent of U.S. youth taking these medications were prescribed
more than one drug, twice the rate in the Netherlands and three times that in
Germany, they said.
The researchers used administrative claims data from 2000 to look at
prescribing patterns. Data covered children up to age 19: 110,944 in the
Netherlands, 356,520 in Germany, and 127,157 in the United States, the last
drawn from enrollees in the State Children's Health Insurance Program. Classes
of drugs included antidepressants, antipsychotics, alpha-agonists,
anxiolytics, hypnotics, lithium, and antiparkinsonian agents. Prevalence was
defined as dispensing one or more prescriptions for those classes of
medications per 100 youth.
Zito and colleagues suggested several reasons for the differences, starting
"U.S. medical treatment is more interventionist and activist across
the board," said Zito in an interview. In the study, more than half
(51.7 percent) of the patients prescribed these medications in the United
States were under age 5, compared with 24.7 percent in the Netherlands and 21
percent in Germany. The authors used statistical methods to adjust the
disparity caused by the U.S. data to the age distribution found in the 2000
Lithium, antiparkinsonian agents, anxiolytics, and antipsychotics were used
by less than 1 percent of youth in all three countries. However, among
patients prescribed antipsychotics, just 5 percent of German children were
prescribed atypical antipsychotics, compared with 48 percent in the
Netherlands and 66 percent in the United States.
"Furthermore, among 0-4 year-olds, German youth had the highest
antipsychotic prevalence (0.64 percent), followed by the Netherlands (0.10
percent), and the United States (0.07 percent), a stark reversal of the
leading usage trends observed in other drug classes, [such as] antidepressants
and stimulants," wrote the authors.
Prevalence of stimulant prescriptions across the entire age range was 4.3
percent in the United States, 1.2 percent in the Netherlands, and 0.7 percent
Overall antidepressant prevalence was 2.7 percent in the United States, 0.5
percent in the Netherlands, and 0.2 percent in Germany. Within this class, 15
percent of U.S. youth received tricyclic antidepressants, compared with 48
percent in the Netherlands and 73 percent in Germany.
There may be a number of reasons for the differences in prescribing
patterns among the three countries, said Zito. For one, in Europe, regulations
limit or prohibit prescription of amphetamines, and cost restrictions limit
use of many expensive, on-patent drugs.
The use of the International Classification of Diseases-10 rather
than DSM-IV as a standard in Europe may also affect diagnoses and
treatment choices. Specialists such as pediatricians and psychiatrists
prescribe these drugs more often in the United States, while in Europe general
practitioners prescribe most psychotropics.
Higher rates of prescribing more than one medication may represent more
than a quick reach for the prescription pad in the United States, said
"It may be because the response of children in the community to drugs
is not as high as among the carefully selected clinical trials cohorts,"
she said. In those cases, a second drug may be added.
But children also need a comprehensive treatment plan, one involving the
whole family and not focused on the child alone.
"Sending a child home on five medications after four days in the
hospital can only lead to bad outcomes and wasted treatment
opportunities," she said. "Maybe we could invest more in
behavioral training of children."
Her study should be viewed as a starting point for further research that
will follow cohorts of children over longer periods, not merely assess the
efficacy of a drug over a few weeks, she added.
"A Three-Country Comparison of Psychotropic Medication
Prevalence in Youth" is posted at<www.capmh.com/content/pdf/1753-2000-2-26.pdf>.▪