Rapid Rise in Off-Label Antipsychotic Use in Kids

Megan Brooks

August 09, 2012

August 9, 2012 — Antipsychotic use in the United States is growing significantly faster among children and adolescents than among adults, a new study shows.

The study also showed that only a small proportion of children (6%) and adolescents (13%) who were prescribed an antipsychotic had diagnoses for which these medications have a US Food and Drug Administration (FDA)–approved indication.

In a "substantial majority" of office visits in which children are prescribed antipsychotic medications, the prescriptions are for treatment of attention-deficit/hyperactivity disorder (ADHD) and other disruptive behavior disorders, lead author Mark Olfson, MD, professor of clinical psychiatry at Columbia University and research psychiatrist at the New York State Psychiatric Institute in New York City, told Medscape Medical News.

The study was published online August 6 in Archives of General Psychiatry.

Risky Business?

"These national trends," Dr. Olfson said, "underscore the substantial and growing extent to which children are being treated with antipsychotic medications for conditions for which there is no strong evidence of treatment efficacy.

"Although antipsychotic medications can deliver rapid improvement in children with severe conduct problems and aggressive behaviors, it is not clear whether they are helpful for the larger group of children with ADHD.

"There are also uncertainties over the long-term effects of antipsychotic medications on the social, cognitive, and physical development of children," he added.

Commenting on the findings for Medscape Medical News, Cindy Parks Thomas, PhD, associate research professor at the Brandeis University Schneider Institute for Health Policy in Waltham, Massachusetts, said that the study extends "what we already know, that these medications are being widely used, particularly increasing for children and adolescents. We are not sure from this study exactly how and for what reasons this has grown."

"We found the same trend in a study of adolescents through 2000 in the same data," she said. "It suggests that all of the publicity in the early 2000s raising the question of overprescribing in children did not lead to a change in those increasing trends, as was the case for other types of medications," Dr. Thomas said.

Using data from the National Ambulatory Medical Care Surveys (1993 - 2009), Dr. Olfson and colleagues compared national trends in antipsychotic treatment of children (aged 0 - 13 years), adolescents (aged 14 - 20 years), and adults (21 years and older). The analysis included 484,889 office visits.

They report that in the periods 1993 to 1998 and 2005 to 2009, visits in which an antipsychotic medication was prescribed (per 100 population per year) rose from 0.24 to 1.83 for children, from 0.78 to 3.76 for adolescents, and from 3.25 to 6.18 for adults.

The proportion of total visits that included an antipsychotic prescription increased during this period from 0.16% to 1.07% (odds ratio [OR], 8.47; 95% confidence interval [CI], 5.37 - 13.35) for youths and from 0.88% to 1.73% (OR, 2.58; CI, 2.05 - 3.24) for adults.

Among children and adolescents, the increase was particularly evident among males, whites, privately insured and self-pay patients, patients treated by psychiatrists, and patients without psychotic diagnoses. "This new information helps to focus attention on patient groups at risk for overuse of antipsychotic medications," Dr. Olfson said.

Need for Safety, Efficacy Data

Whereas the treatment of adults with antipsychotic medications is concentrated among female patients diagnosed with bipolar disorder, depression, or schizophrenia, treatment of youth with antipsychotic medications predominantly involves male patients with disruptive behavior disorders, the researchers note.

From 2005 to 2009, disruptive behavior disorders were the most common diagnoses in children and adolescents who were prescribed antipsychotic medications, accounting for 63.0% and 33.7%, respectively, whereas depression (21.2%) and bipolar disorder (20.2%) were the 2 most common diagnoses for adults who were prescribed antipsychotics.

Risperidone (Risperdal, Janssen Pharmaceutica) was by far the most commonly prescribed antipsychotic among children during the period from 2005 to 2009. The authors note that there is considerable "uncertainty" regarding the appropriate role of this drug and other antipsychotic medications in the management of disruptive behavior disorders.

"Frontline healthcare professionals who treat aggressive and disruptive children must make management decisions in clinical situations for which there is little reliable research to guide their treatment selection.

"Rapidly rising antipsychotic treatment rates of nonpsychotic children and adolescents highlight the need for research to better define the boundaries of safe and effective antipsychotic use in young people," Dr. Olfson said.

The study also showed that when psychiatrists were the treating physicians, antipsychotic medications were prescribed in a larger proportion of visits by children (67.7%) and adolescents (71.6%) than by adults (50.3%) (P < .001). From 2005 to 2009, antipsychotics were included in 28.8% of adult visits and 31.1% of youth visits to psychiatrists.

Psychotherapy Uncommon

The data also suggest that most child and adolescent visits that include treatment with antipsychotics do not also include psychotherapy. This suggests that "more needs to be done to increase access and availability of psychosocial interventions. Parent management training and cognitive problem-solving skills training are 2 effective but underused treatments for young people with disruptive behavioral problems," Dr. Olfson said.

Although previous studies have found an increase in use of antipsychotics among youth and adults, "this article provides the first detailed comparison of national antipsychotic treatment trends across children, adolescents, and adults," he added.

"This study highlights the need for follow-up with more in-depth analysis of these trends, as the trends are too strong to represent just an expansion in screening and treatment options," said Dr. Thomas.

"At the same time, there are many unanswered questions. Hopefully, the expanded availability and use of electronic medical records will soon allow researchers to link clinical treatments and outcomes with psychotropic medication prescribing trends to elucidate the implications of some of the findings here," she added.

Funding for the study was provided by the Agency for Healthcare Research and Quality, the National Institute on Drug Abuse, and the National Institute of Mental Health. Dr. Olfson reports that he has worked with grants to Columbia University from Eli Lilly and Bristol-Myers Squibb. A complete list of author disclosures is in the original article. Dr. Thomas has disclosed no relevant financial relationships.

Arch Gen Psychiatry. Published online August 6, 2012. Full article

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