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Clinical and Research NewsFull Access

Rise in Antidepressant Prescriptions for Youth Raises Questions About Why

Published Online:https://doi.org/10.1176/appi.pn.2018.2a10

Abstract

After an initial decline in the use of antidepressants by youth following actions taken by the Food and Drug Administration in 2004, one study finds antidepressant use among youth has rebounded.

In October 2004, the Food and Drug Administration (FDA) directed pharmaceutical companies to issue a black-box warning about the potential link between the use of antidepressants and increased suicidal ideation among youth. Following this directive, the number of depression diagnoses and antidepressant prescriptions for children and adolescents—which had been on the rise—fell over the next few years.

Though there is an extensive body of research exploring this initial decline in prescriptions, fewer studies have looked at long-term prescribing trends. A study published last December in Psychiatric Services in Advance found that following that initial decline, the rate of antidepressant prescribing to children eventually returned to pre-2004 levels.

Nilay Kafali, Ph.D., of RTI International and colleagues found that 2.26 percent of children aged 5 to 17 were prescribed antidepressants in 2009, similar to the 2003 level of 2.29 percent. Between 2004 and 2008, that rate had dropped to below 2 percent.

The authors calculated these rates using data from the Medical Expenditure Panel Survey (a set of nationally representative surveys of individuals, medical providers, and employers that detail the use and costs of health care services and health insurance coverage). They included available data on children aged 5 to 17 between 2000 and 2011. To estimate how the impact of the black-box warning on antidepressant use among children changed over time, the authors divided the entire sample period into four periods: early prewarning (2000–2001), prewarning (2002–2003), early postwarning (2004–2007), and late postwarning (2008–2011).

They found that there was a 0.5 percent statistically significant decline in antidepressant use during the early postwarning years compared with prewarning years, with a particularly strong decrease among children rated as having non-severe psychological impairment. (The authors defined non-severe psychological impairment as a Columbia impairment Scale score of <16). Antidepressant use was 1.1 percent for this group in 2003, dropped to around 0.7 percent between 2004-2007, and rose to 1.09 percent in 2008.

Rates of antidepressant use for children with severe psychological impairment showed a gradual decline from 2003 to 2007, but then also rose to pre-2004 levels.

“These findings suggest that providers and families of youth may have reacted to the black-box warning in an appropriate manner, weighing the warning with the risks and benefits of the treatment,” Kafali and colleagues wrote. “A return to the rates of antidepressant use before the black-box warning raises concern that this thoughtful accounting of the risks and benefits may have dissipated over time.”

A central question for future research is what factors drove this rise in use after 2008.

“It is possible that over time physicians have become somewhat inured to the safety warnings,” said Mark Olfson, M.D., M.P.H., a professor of psychiatry and epidemiology at Columbia University Medical Center. “However, it is also possible that increasing prevalence of depression or anxiety among young people during the great recession played a role,” he added.

Olfson, who was not involved with this study, noted that other community surveys including the Youth Risk Behavior Survey, the National Survey on Drug Use and Health, and the Monitoring the Future surveys have revealed a recent increase in depressed mood and major depressive episodes among children and adolescents.

“An important policy implication of our findings could be that more frequent updates of FDA risk warnings might be necessary to prevent patients and the providers from ‘forgetting’ the potential risks outlined in the original warning,” Kafali and colleagues wrote. ■

An abstract of “Long-Run Trends in Antidepressant Use Among Youths After the FDA Black Box Warning” can be accessed here.