The reported results were, once again, not necessarily a surprise, nor were the sensationalized headlines in the popular press. However, the latest report of large increases in psychotropic prescriptions to children and adolescents over the last 10 to 15 years served to fuel hypotheses and questions regarding not only "how" but also "why."
A team from the University of Maryland—Baltimore and Johns Hopkins University School of Medicine reported in the January Archives of Pediatrics and Adolescent Medicine that psychotropic prescriptions written for children and adolescents in a study population totaling approximately 900,000 youths rose between 200 percent and 300 percent overall between 1987 and 1996.
"I think the main thing [about our data] is that the empirical data now back up the anecdotal data," lead author Julie Magno Zito, Ph.D., an associate professor of pharmacy and medicine at the University of Maryland—Baltimore, told Psychiatric News. "We have been more than aware of the fact that this [increase] has been occurring, and it is important to document that it is not just happening in one location and also that there are variations."
Zito and her colleagues analyzed computerized community treatment data on youths enrolled in three health care systems: a mid-Atlantic state Medicaid system, a Midwestern state Medicaid system, and a national group health maintenance organization. Ten one-year cross-sectional data sets were analyzed to produce yearly snapshots of prescribing of psychotropic medications in each system between 1987 and 1996.
Total psychotropic medication usage increased two- to threefold, depending on specific class of medication and the particular system analyzed. Confirming previous reports, the data revealed significant variations in prescribing patterns within and between systems and geographic locations. During the latter half of the study period, however, significant growth across the entire study population was seen in the use of α-agonists, mood-stabilizing anticonvulsants, and neuroleptics.
By the end of the study period in 1996, the use of any psychotropic medication among youths under 20 years old was similar across the three systems studied: Between 5.9 percent and 6.3 percent of all youths were prescribed at least one psychotropic medication during the study period. In all three populations, stimulants and antidepressants were ranked first and second, respectively, in terms of total prescriptions.
Youths covered through the two Medicaid systems studied had consistently higher rates of prescribing for α-agonists, neuroleptics, mood-stabilizing anticonvulsants, and lithium. Youths in the HMO had similar rates of prescriptions as those covered by Medicaid for both antidepressants and hypnotics.
Over the course of the 10-year study, greater increases were seen in females receiving prescriptions for stimulants and for males receiving prescriptions for antidepressants. This could reflect, Zito said, a growing recognition that these disorders are not believed to be more prevalent in one sex or the other.
"The most useful role that these data play are to generate hypotheses about the evidence base that we have," Zito told Psychiatric News, "and the motivation behind this prescribing. It is hoped that this process will shed some light on those variations."
Zito acknowledged, however, that the study does not attempt to conclude whether the data represent overprescribing, underprescribing, or appropriate or inappropriate prescribing practices.
"It certainly is a question of appropriateness, but I am just putting the data out there," Zito continued. Data from other studies have indicated that the vast majority of these medications are not prescribed by psychiatrists; they are prescribed by pediatricians and family practitioners, she said.
"Psychopharmacology—as a cottage industry of sorts—has a very high level of sophistication and understanding of how these medications work in the body and the brain," Zito said. "But we don’t have anywhere near that level of sophistication yet in figuring out how these medications are actually used in clinical practice."
In an accompanying editorial, Michael Jellinek, M.D., chief of the child psychiatry service at Massachusetts General Hospital, noted that while the data presented by Zito and her colleagues are useful, they are dated. Jellinek called for an up-to-date "health plan by health plan quality assurance effort, and a health services and basic research program," a notion Zito told Psychiatric News that she strongly supports.
"We undertake such activities in many areas of medical care, more for adults than for children," Jellinek wrote. "Will we value our children sufficiently to ask if we are prescribing the right psychotropic medications to the right children using the right treatment plan?"
Zito and her colleagues have ICD-9 codes available matching each prescription in their data set to specific diagnoses; however, she doubts that a coding analysis will reveal much about the appropriateness of prescribing.
Peter Jensen, M.D., the Ruane Professor of Child Psychiatry and director of the Center for the Advancement of Children’s Mental Health at Columbia University/New York State Psychiatric Institute, agreed that coding data are inherently flawed.
"The real critical issue here is not the chart diagnosis, although that would be useful," he told Psychiatric News. "But sometimes people use the chart diagnosis because that’s how they’re going to get the claim paid."
Even if the patient’s chart carried an ICD-9 code for attention-deficit/hyperactivity disorder, he said, it doesn’t mean that the child has had a complete and thorough psychiatric evaluation to back up the diagnostic code.
APA Trustee-at-Large David Fassler, M.D., a Burlington, Vt., child and adolescent psychiatrist, agreed with Jensen and Jellinek. "The real question here shouldn’t be, ‘Are we treating too many children?, but rather, ‘Are we treating the right children?’ "
Fassler, a member of the governing council of the American Academy of Child and Adolescent Psychiatry, noted that the academy’s guidelines on comprehensive evaluations emphasize that an evaluation often involves more than one visit and may last several hours. "This is not an assessment that can realistically or appropriately be done in a five- or 10-minute visit in the context of a busy pediatric or primary care practice," Fassler said.
Both Jensen and Fassler told Psychiatric News that the real importance of the Zito study is to draw attention to an important issue that needs to be studied in much more detail.
"I will say," Jensen noted, "that we have enough evidence from a variety of other settings—though not from Dr. Zito’s study—that there are problems in the use of these medications under some circumstances. You can look at clinicians’ treatment of this or that disorder and see that frequently medications are underused or overused."
Correcting those problems, Jensen said, is a matter of educating and training the family practitioners and pediatricians who are writing the vast majority of the prescriptions. His team at Columbia, as well as at numerous other centers, are working on projects to facilitate and improve that process.
"With Prozac recently being approved down to age 8, and other studies of Paxil and Zoloft and such that are showing at least some modest efficacy in children, the likelihood of increased prescribing by primary care providers has simply been staring us in the face," Jensen said. "For good or ill, that’s how it has been, and that’s probably how it’s going to continue to be."
With an estimated 7,500 child and adolescent psychiatrists in the United States and a population of 72 million under the age of 18, Jensen said, the numbers just don’t work—specialty consultation and comprehensive evaluation simply can’t be done for all of the estimated 12 million to 17 million children and adolescents with a psychiatric disorder.
"We also know," Jensen emphasized, "that the managed care environment has had a huge impact on what is done and how it is done."
Added Fassler, "Research has consistently demonstrated that child and adolescent psychiatric disorders remain underrecognized, underdiagnosed, and undertreated. Literally millions of children receive no treatment whatsoever. This is the real tragedy, since we can help many, if not most, of these kids."
An abstract of "Psychotropic Practice Patterns for Youth: A 10-Year Perspective" is posted on the Web at http://archpedi.ama-assn.org/issues/current/abs/poa20275.html. ▪
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