While concerns continue to be raised about the safety of antipsychotic treatment for young children, a new study examining antipsychotic prescription patterns among young people in the United States has found that most office visits by children and adolescents that involve antipsychotic treatment do not include a clinical mental health diagnosis. The research, first published online in JAMA Psychiatry in July, will appear in print in September.
Clinical trials support the efficacy of several antipsychotics for child and adolescent bipolar mania, adolescent schizophrenia and irritability associated with autism in adolescents and children as young as 5 (risperidone) and 6 (aripiprazole), according to the study, “Treatment of Young People With Antipsychotic Medications in the United States.”
In this setting, the clinical diagnoses associated with antipsychotic treatment vary with patient age. For example, a larger percentage of child (63 percent) than adolescent (33.7 percent) visits with antipsychotic treatment include disruptive behavior disorder diagnoses, while the reverse is true of bipolar disorder diagnoses (12.2 percent for child vs. 28 percent for adolescent).
Concern, noted researchers, has particularly focused on the safety of antipsychotic treatment of young children. In preschool-aged children, a paucity of research on psychiatric diagnoses complicates patient selection, the known efficacy of antipsychotics is limited largely to irritability associated with developmental disorders, and adverse metabolic and endocrine effects are pronounced.
The national prevalence of antipsychotic use by young people is not known, say researchers. In the Medicaid program and some private insurance plans, antipsychotic use increased among young people during the late 1990s and early 2000s. A growing awareness of increasing use and safety concerns may have tempered antipsychotic treatment of young people, said researchers.
“This study represents the first national estimate of the trends in antipsychotic use among young people in the U.S.,” Mark Olfson, M.D., M.P.H., professor of clinical psychiatry and research psychiatrist at Columbia University and the New York State Psychiatric Institute, and lead researcher, told MHW. “There’s a lot of concern about the extent to which children are treated for conditions outside FDA-approved indicators.”
Olfson added, “We were particularly interested in which groups are most likely being treated and what they are being treated for.”
Researchers performed a retrospective descriptive analysis of antipsychotic prescriptions among patients ages 1 to 24 with data from calendar years 2006 (765,829), 2008 (858,216) and 2010 (851,874), including a subset from calendar year 2009 with service claims data (53,896). They retrieved data from the IMS LifeLink LRx Longitudinal Prescription database, which includes approximately 60 percent of all retail pharmacies in the United States. Denominators were adjusted to generalize estimates to the U.S. population.
In contrast with earlier reports of increasing antipsychotic treatment of U.S. children through the early 2000s, the percentage of children treated with antipsychotics was lower in 2010 than in 2006. Among adolescents and young adults, however, antipsychotic use increased during this period.
The research noted that boys ages 11–17 diagnosed with attention-deficit hyperactivity disorder (ADHD) represented the highest use of antipsychotic treatments, said Olfson. Antipsychotics are used to manage aggression and other symptoms in ADHD, especially in boys that age, Olfson said. Risperidone (Risperdal) has been used with stimulants to reduce the severity of the ADHD conduct disorder, he said. Antipsychotics are not approved by the Food and Drug Administration (FDA) to treat ADHD, Olfson said.
Olfson noted that if the antipsychotic medications have to be used for children with disruptive or aggressive behaviors that they are being used very sparingly and only for short periods of time.
Of all antipsychotics, risperidone is the most widely used in the young, said Olfson. There has been research that shows that it is effective in treating autism-related symptoms like irritability, he said.
Researchers found that the percentages of young people using antipsychotics in 2006 and 2010 were, respectively, 0.14 percent and 0.11 percent for younger children, 0.85 percent and 0.80 percent for older children, 1.10 percent and 1.19 percent for adolescents, and 0.69 percent and 0.84 percent for young adults.
In 2010, males were more likely than females to use antipsychotics, especially during childhood and adolescence: 0.16 percent vs. 0.06 percent for younger children, 1.20 percent vs. 0.44 percent for older children, 1.42 percent vs. 0.95 percent for adolescents and 0.88 percent vs. 0.81 percent for young adults.
Approximately 29.3 percent of younger children treated with antipsychotics in 2010 received one or more antipsychotic prescriptions from a child and adolescent psychiatrist. Among young people with claims for mental disorders in 2009 who were treated with antipsychotics, the most common diagnoses were ADHD in younger children (52.5 percent), older children (60.1 percent), and adolescents (34.9 percent), and depression in young adults (34.5 percent).
Researchers noted that in the merged 2009 medical claims and LRx sample, most of the younger children (60 percent), older children (56.7 percent), adolescents (62 percent) and young adults (67.1 percent) treated with antipsychotics had no outpatient or inpatient claim that included a mental health diagnosis.
The study found that among antipsychotic-treated children and adolescents with mental disorder claims, the most common diagnosis was ADHD (younger children, 52.5 percent; older children, 60.1 percent; adolescents, 34.9 percent). Depression was the most common diagnosis among young adults (34.5 percent), followed by bipolar (26.6 percent) and anxiety disorder (22.9 percent).
Psychological interventions lacking
Researchers also found a low rate of psychological intervention and counseling among young children receiving antipsychotic medication, said Olfson. “We were surprised that more prescriptions weren’t [prescribed] by child and adolescent psychiatrists, especially for younger children,” said Olfson.
Olfson added, “Most of the younger children were getting their medication from other kinds of physicians.” The research found that three of 10 children ages 1 through 6 treated with antipsychotics were being treated by a child psychologist, he said.
Another concern is that not enough children are going to see a specialist, said Olfson. “There are not enough child psychiatrists in the area where the child exists,” he said. “It’s a workforce issue.”
Despite the efforts of state education campaigns and others like the American Psychiatric Association’s “Choosing Wisely” campaign — which aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence and free from harm — it’s surprising to continue to see increases in antipsychotic medication use, said Olfson.
“We need to learn more about the sequences, about the children who are receiving the dosing and for how long and whether the medications are safe and effective,” said Olfson. “There’s a lot we need to learn.”
Preschool-aged children presenting for mental health care should receive a comprehensive psychiatric assessment and a trial of psychosocial intervention before considering psychopharmacologic treatment, study authors recommend.
Clinical policymakers have opportunities to promote improved quality and safety of antipsychotic medication use in young people through expanded use of quality measures, physician education, telephone- and Internet-based child and adolescent psychiatry consultation models, and improved access to alternative, evidence-based psychosocial treatments, researchers concluded.
It is recommended that preschool-aged children presenting for mental health care should receive a comprehensive psychiatric assessment and psychosocial intervention before considering psychopharmacologic treatment.