Runaway Psychotropic Prescribing: Better Diagnosis or Overuse?

Jeffrey A. Lieberman, MD


November 27, 2012

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Hi. This is Dr. Jeffrey Lieberman of Columbia University, speaking to you today for Medscape. Today I want to talk about psychotropic drug prescribing practices and the issue of performance enhancement and behavioral control. I was prompted to talk about this by an article that I read in the New York Times, which was published on October 9.[1] It was about a general practitioner in a small town who was prescribing stimulants and, at times, antipsychotic drugs to children who were in a school system that was not performing well. Kids were not progressing. This caring, well-intentioned physician thought that, since the boards of education were not addressing the needs of the school and parents were unable to do what was necessary to augment the children's education, he might prescribe medications that enhance performance and control disruptive and attention-distracting behaviors in order to enhance their educational performance and benefits derived from school.

The article went on to say that this practice is not unique to this general practitioner; it is being increasingly adopted by other pediatricians and general practitioners in different parts of the country. It reminded me of other articles that I have read over the past several years as well as commentary in the media about the increased rates of psychotropic drug use and prescription in the United States relative to other countries in the developed world, particularly in Europe. One article described a survey that found that the rate of psychotropic drug use in the United States was 3 times as high as in various countries in Europe, particularly for psychostimulant drugs, antidepressants, and antipsychotics.

Why is that the case? Is it that we are identifying frequency rates of attentional disorders, mood disorders in children, and psychotic disorders that require treatment with antipsychotics, mood stabilizers, antidepressants, and psychostimulants, and that because diagnoses of these conditions in children was previously not widely appreciated, we are simply identifying an unmet clinical need and prescribing to meet the true population frequencies of these disorders? Or are our prescribing practices really serving some other purpose beyond that of treating conditions for which these medications are indicated? It is puzzling because we don't know whether the prescribing rates in Europe are a result of undertreating because they are overly conservative or if people in the United States are excessive and going beyond the boundaries of what would be considered to be appropriate therapeutic uses. Adding to this concern is the fact that many of the psychotropic drug prescriptions are for treating conditions in children and are off-label, indicating that there is clearly a deviation from the use of these medications for which they were approved by the US Food and Drug Administration. Off-label prescription is an important element and mechanism in medical practice. We have to be able to use medications for other purposes for which they are rationally justified and potentially useful, but the fact that there is such a high proportion of off-label use in pediatric populations adds to the level of concern.

If we were a little too cavalier with the use of these drugs without having strict justification for treating conditions for which these medications are indicated or without having a very well-substantiated reason for off-label use, what would the reasons be? Possible reasons that have been suggested in comments, the media, and the literature have to do with our culture. Our culture has become a more permissive culture, a culture that allows a broader range of behaviors and is more tolerant. We also know that there may be questions about the degree of discipline imposed by parents, and that parents may not be providing the necessary structure and setting of limits that children should have, which carries over to the school setting or finds its way into the pediatrician's or child psychiatrist's office. Another possibility is the fact that, with cost containment being a constant pressure on the activities of clinicians, practitioners need to see a larger number of people in shorter periods of time for lower rates of reimbursement. This pressured process may provide clinicians less time to be able to talk to patients and to be able to carefully and thoroughly evaluate their conditions before determining what treatment to prescribe. When treatment needs to be prescribed, it is much more efficient to prescribe the medication than it is to approach nonpharmacologic management.

It is very likely that many of these prescriptions are being written by nonpsychiatric physicians. They are general practitioners and pediatricians. Nonpsychiatric physicians who are seeing the kids are receiving complaints from families or perceiving disruptive or symptomatic behaviors or mental functions, and then resorting to treating the children themselves. Again, in the context of busy practices, they are not requesting a psychiatric evaluation by a specialist but prescribing medication because it is more expedient to do so. All of these factors could be playing into this.

As a result, it behooves us to understand that the dictum in medicine is primum non nocere -- first do no harm. That dictum applies more so when it comes to children. It is clear that we have forged new ground in recent decades by identifying psychopathologic conditions in children, although previously they were predominantly felt to occur only in adults. In characterizing mood disorders and attentional disorders and using psychotropic medications, we have provided a valuable service to treat symptoms that children previously suffered from. However, because of the changes in our culture, declining reimbursements, and the pressures of cross-containment, clinical practice, and complicated reimbursement mechanisms, we have to be careful to not go beyond the bounds of good, justifiable clinical practice.

I wanted to point this out because the article in the New York Times prompted my attention to the issue of practitioners resorting to pharmacologic means, not just to treat conditions that they perceive and observe in their patients, but also to try to remedy problems that they see in the environment of our patients as well. When it comes to using pharmacologic agents, we have to be very careful in the way that we do this, no matter what our intentions are or how well meaning they may be.

Thank you for listening. This is Dr. Jeffrey Lieberman speaking to you from Columbia University for Medscape.