Increased Use of Psychotropics in Children
Increased Use of Psychotropics in Children
ABSTRACT & COMMENTARY
Source: Zito JM, et al. Trends in the prescribing of psychotropic medications to preschoolers. JAMA 2000;283(8): 1025-1030.
In order to quantify the use of psychotropic medications for preschool-aged children, Magno and colleagues evaluated ambulatory care prescription records from three large data sets, in cross-sectional analyses, for the years 1991, 1993, and 1995. Included were outpatient data sets from two geographically distinct Medicaid populations, one in a Midwestern state and one in a mid-Atlantic state, and a health maintenance organization (HMO) serving a predominantly employed population in the northwest region of the United States.
Psychotropic medication prevalence was defined for each study year as the frequency of persons with one or more HMO pharmacy records or Medicaid prescription claims for a psychotropic medication class, subclass, or specific medication per 1000 enrolled youths. Data analyses focused on children aged 2 through 4 years. From 1991-1995, the number of enrollees aged 2 through 4 years ranged from 146,369 to 158,060 in the Midwestern Medicaid program; from 34,842 to 54,237 in the mid-Atlantic Medicaid program; and from 19,107 to 19,322 in the HMO. Three psychotropic medication classes were examined: stimulants (methylphenidate, other stimulants), antidepressants (selective serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs], and other antidepressants), and neuroleptics. Selection was based on the frequent use of stimulants and antidepressants and the public health significance of the use of neuroleptics in the very young (presumably because of the risk of tardive dyskinesia). In addition, two specific medications (methylphenidate and clonidine) were examined because their use has increased substantially since the early 1990s for the treatment of attention deficit hyperactivity disorder (ADHD).
Several prominent trends characterized the use of psychotropic medications in preschoolers during the early to mid-1990s. Overall, there were large increases for all study medications (except the neuroleptics). Stimulant treatment in preschoolers increased approximately three-fold. Hypothesized reasons for the overall increased stimulant use include: 1) a larger pool of eligible youths because of expanded diagnostic criteria for ADHD since 1980; 2) more girls being treated for ADHD, as evidenced by the narrowing of the gender ratio even among preschoolers; 3) greater acceptance of biological treatments for a behavioral disorder; and 4) the expanded role of school and preschool health personnel in identifying medical needs. Clonidine had the most dramatic increases, although its use in 1995 was only 15%-35% of the prevalence rate of stimulants. Clonidine use is particularly notable because its increased prescribing is occurring without the benefit of rigorous data to support it as a safe and effective treatment for attentional disorders. Antidepressants were the second most commonly prescribed psychotropic class of drugs for preschoolers, and their use increased substantially from 1991-1995. Tricyclic antidepressants still represent the bulk of early childhood antidepressant use.
Comment by Lauren B. Marangell, MD
The current study is clearly important, given the large databases involved. The use of medications in young children is of concern because of the significant paucity of data regarding efficacy, tolerability, and the possibility of longer-term side effects. However, computerized database analysis does not provide information on treatment outcome. Further data on efficacy and tolerability of psychotropic medication in children is clearly needed. However, utilization data in the absence of outcome measures cannot provide the basis for conclusions about appropriate use. As recently reviewed here (Trifiletti R. Psychiatr Med Prim Care 1999;1:57-58), some data indicate that the appropriate use of stimulants to treat ADHD is associated with decreases in future substance abuse. It is also important to emphasize nonmedication approaches to treatment in children.
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