Misuse of Psychotropics in Kids More Fiction Than Fact?

Caroline Cassels

December 03, 2012

A new study challenges the perception that there is widespread overmedication and misuse of psychotropic drugs among adolescents in the United States with mental illness.

The large, cross-sectional study conducted by investigators at the National Institute of Mental Health in Bethesda, Maryland, shows that 14.2% of teens aged 13 to 18 years with any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis had been treated with a psychotropic medication in the past 12 months.

Dr. Kathleen Merikangas

"There was no compelling evidence for either misuse or overuse of psychotropic medications. Only 14.2% of youth with a mental disorder during the past year reported psychotropic use, and the majority who had been prescribed medications, particularly those who received treatment in specialty mental health settings, had a mental disorder with severe consequences and impairment, functional impairment, suicidality, or associated behavioral and developmental difficulties," the authors, led by Kathleen R. Merikangas, PhD, write.

The study was published online December 3 in Archives of Pediatrics and Adolescent Medicine.

Striking Increase

According to the authors, there is widespread concern about the inappropriate prescribing of psychotropic medications to children and adolescents. However, they note that this unease has been fueled primarily by "studies of small unrepresentative clinical samples, and secondary analyses of large databases on prescription drug use that lack detailed clinical information about individual patients."

Although the investigators note that there has been a "striking increase" in the prescription of psychotropic medications in youth over the past decade, the drivers behind this phenomenon are unclear.

"This study provides the first evaluation, to our knowledge, of the prevalence, sociodemographic and clinical correlates, and appropriate use of psychotropic medications with specific mental disorders in a nationally representative sample of adolescents with comprehensive evaluations of psychiatric disorders."

To evaluate the prevalence, demographic and clinical correlates, and specificity of classes of psychotropic medications indicated for mental disorders, the investigators analyzed data from the National Comorbidity Survey Adolescent Supplement, a nationally representative sample of US adolescents based on direct interviews.

The study included 10,123 adolescents aged 13 to 18 years who participated in the survey between February 2001 and January 2004. The investigators examined mental and neurodevelopmental disorders from the DSM-IV.

Among those with any DSM-IV mental disorder, 14.2% reported that they had been treated with a psychotropic medication. The highest prevalence of medication use was in adolescents with attention-deficit/hyperactivity disorder (ADHD), at 31%. This was followed by those with mood disorders (19.7%), eating disorders (19.3%), behavior disorders (19.3%), substance use disorders (14.4%), and anxiety disorders (11.6%).

Results showed that antidepressants were most frequently used among those with primary mood disorders (14.1%); stimulant use was most common among those with ADHD (20.4%); and antipsychotic use, which was infrequent, was mostly seen among those with serious developmental disorders.

Not Generalizable

In an accompanying editorial, David Rubin, MD, MSCE, of PolicyLab, Children's Hospital of Philadelphia, and Perelman School of Medicine, University of Pennsylvania, takes issue with some of the authors' conclusions.

"Evidence-based therapies and nonpharmacologic treatment options act as competitive buffers and/or adjuncts to pharmacologic therapy. When viewed through this lens, the end result is that fewer children than we would expect are taking medications.

"But such a conclusion is not the end of this story. Rather, Merikangas et al fail to consider that their population is, in fact, not generalizable to many children in this country," writes Dr. Rubin.

He points out that compared with their privately insured counterparts, treatment options for children enrolled in Medicaid are often very limited.

"The norm in such public systems," notes Dr. Rubin, "is longer waiting lists and a strong gravitational pull toward 15-minute medication checks with psychiatrists."

Given this scenario, he adds, it is "not surprising that claims analyses from the Medicaid program have consistently demonstrated high rates of use among those accessing care."

"The unfortunate epiphany is that the risk for overprescribing or underprescribing medication is not the same for all children in this country. For many, the challenge of accessing care acts as a natural barrier to prevent excessive medication use, even if those barriers prevent needed treatment for a child," Dr. Rubin adds.

The authors and Dr. Rubin have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. Published online December 3, 2012. Abstract, Editorial