Adolescents Often Get 'Red Flag' Drugs for First Episode of Mental Illness

By Anne Harding

October 01, 2020

NEW YORK (Reuters Health) - The care adolescents receive for a first episode of mental illness varies widely across the U.S., and many are prescribed "red flag" drugs, according to new findings.

Overall, nearly 30% did not receive follow-up treatment in the three months after their initial episode, and more than 45% were prescribed benzodiazepines, tricyclic antidepressants (TCAs) or another medication not approved by the U.S. Food and Drug Administration (FDA) for first-line treatment of mental illness in children, Dr. Janet Currie and Dr. Emily Cuddy of Princeton University found.

The FDA has approved two selective serotonin-reuptake inhibitors (SSRIs) for children with depression, fluoxetine and escitalopram, the authors note in the Proceedings of the National Academy of Sciences. One TCA and six atypical antipsychotics are FDA-approved for obsessive compulsive disorder (OCD) in children, and several SSRIs are approved for OCD and anxiety in kids.

The American Psychiatric Association recommends fluoxetine as an initial treatment for depression in adolescents. The American Academy of Child and Adolescent Psychiatry states that selective serotonin-reuptake inhibitors (SSRIs) are well tolerated in adolescents, and recommends against benzodiazepines for anxiety in children as they have not been shown to be effective and can lead to dependence.

To investigate variations in care for a first episode of mental illness, Dr. Currie and Dr. Cuddy looked at claims data on more than 2.2 million children covered by Blue Cross Blue Shield, 202,066 of whom had one or more mental-illness-related claims (9.2%). Children were 12, on average, when they had their first mental-illness claim, while 88.7% were between 10 and 14 years old.

Most children received therapy alone as an initial treatment (42.2%), 29.4% received no treatment, 22.5% were prescribed drugs only, and 5.9% were prescribed drugs and received therapy.

Among the patients who were prescribed medication, 55.2% got a non-red flag drug, 14.7% were prescribed benzodiazepines, 13.1% were prescribed more than one red-flag drug, 12.7% received a drug not approved by the FDA for adolescents, and 4.3% were prescribed a TCA.

Girls were significantly more likely to receive drug therapy, and were more likely to be prescribed a red-flag drug.

While nearly 90% of children received follow-up care within three months of their initial episode in the best-performing zip codes, just half received follow-up care in the worst-performing areas.

The percentage of children receiving only therapy ranged from 17% to 62%, while the percentage of those who received therapy and medication ranged from 0% to 17%. The percentage receiving only drug treatment ranged from 0 to 45%, and the percentage receiving red-flag drug treatment ranged from 0 to 100%.

Some investigators have suggested that geographic variations in care are related to the number of practitioners in a given region, the authors note. While the supply of mental-health practitioners played a role in the type of care patients received, it explained "relatively little" of the treatment variation they observed.

"There is evidence that many doctors tend to prescribe the same treatments for a wide variety of patients," Dr. Currie said. "In this case, doctors who have had success with these drugs in older patients (including perhaps older patients who previously tried selective serotonin-reuptake inhibitors but weren't helped) believe that they will be equally successful with young, medication-naive patients."

She added: "Since we are using claims data, we don't have a lot of detail about the health condition of any particular patient. So, we could never say, 'this individual patient should have received an SSRI instead of benzodiazepines. But since we know that adolescent medication-naive patients should only rarely be treated with benzodiazepines, the fact that we see a lot of this type of prescribing indicates that there is a problem that merits investigation. So large-scale data analyses can be a useful complement to clinical studies by highlighting where improvements are needed."

SOURCE: Proceedings of the National Academy of Sciences, online September 21, 2020.