More Kids Receiving Psychiatric Drugs
Question of 'Why' Still Unanswered
By Shankar Vedantam Washington Post Staff Writer January 14, 2003
The number of American children being treated with psychiatric drugs has grown
sharply in the past 15 years, tripling from 1987 to 1996 and showing no sign
of slowing, researchers said yesterday.
A newly published study, the most comprehensive to date, found that by 1996,
more than 6 percent of children were taking drugs such as Prozac, Ritalin and
Risperdal, and the researchers said the trajectory continued to rise through
2000.
While the increase may partly reflect better diagnosis of mental illness in
children, the authors said they fear that cost-saving techniques by insurance
companies, marketing by the pharmaceutical industry and increased demands on
parents and doctors may be driving the increase.
"There are fewer options other than medication," said Michael Jellinek, chief
of child psychiatry at Massachusetts General Hospital, who reviewed the new
study.
Insurers have increased their profits by decreasing the use of psychotherapy,
which is more expensive than drugs in the short run, he said. "The insurance
system gave an incentive for medications and a disincentive for therapy."
The insurance industry disputes that interpretation, suggesting instead that
more children are getting drugs because more effective medicines have been
developed. Most psychiatrists say that a combination of psychotherapy and
medication often provides the best treatment.
The new research found steep increases in the use of most classes of
medicines, including antipsychotic drugs. Such powerful medications, normally
meant to treat schizophrenia, were increasingly being prescribed to children
on Medicaid, said the study's lead author, Julie Zito -- possibly as a way to
restrain difficult children.
"Other than zonking you, we don't know that behavioral management by drug
control is the way to learn to behave properly," said Zito, a researcher at
the University of Maryland in Baltimore. "If we are using drugs to control
behavior, that doesn't change the underlying problem if someone doesn't know
how to get along with their peers."
Zito's study evaluated 900,000 children on Medicaid in a Midwest state, a
mid-Atlantic state and in a private HMO in the Northwest. Zito said the large
study made it likely that the data are representative of the nation's
population. A re-evaluation of one of the health plans in 2000 found that the
increase had continued, she added.
"The medicine may help the symptoms but not address issues of self-esteem,
interpersonal relationships and family relationships -- all of which are part
of recovery," said Jellinek, who analyzed Zito's study. In
obsessive-compulsive disorder, for example, he said, "you can get a lot of
benefit from behavioral treatments. If someone is getting medicines for OCD, I
would like to see them be given a trial of behavioral therapy to see if that
helps them and maybe decrease the medication."
Both Zito's study and Jellinek's analysis were published in the most recent
issue of the Archives of Pediatrics and Adolescent Medicine.
Susan Pisano, vice president of communications at the American Association of
Health Plans, whose members provide managed care to about 160 million people,
said the study did not address the quality of care the children received.
"The research doesn't say, 'There is a greater use of drugs and that's having
a deleterious effect on children,' " she said. "It just says there is a
greater use of drugs." Pisano said more analysis was needed to answer the
quality question.
Zito agreed that her study could not determine whether the trend represented a
growing awareness of mental illness or was evidence of over-medication and
mistreatment. That is because she tracked medication records, not individual
children. Without comprehensive studies that tracked the outcome of medication
treatment of children, she and Jellinek said, it was difficult to say whether
the children were getting the right treatment.
Noting that children are being medicated at almost the same rate as adults,
Zito pointed out that few safety studies of the drugs have been done in
children. Pharmaceutical companies largely do studies on adults to get new
medicines approved or to show that one drug is superior to another.
Jellinek, who is also a professor of psychiatry at Harvard University, said
insurance companies should be required to share data about the number of
children getting comprehensive treatment in addition to those getting only
medicine. Without such information, policymakers cannot independently evaluate
whether the treatment is appropriate, he said.
Pamela Greenberg, executive director of the American Managed Behavioral
Healthcare Association, which represents companies that cover mental health
services to about 110 million Americans, said criticizing the insurance
industry for the trend is wrong.
"I don't believe providers are saying, 'We will just provide a medication
because that's going to be the highest profit margin for me,' " she said.
Besides raising ethical issues, she said, inadequate treatment could result in
a child continuing to be sick. "A sick patient from the economic standpoint
still costs you money and could end up in the hospital."
Greenberg said the industry might be willing to make some of its internal
information public, so long as it was to a national authority that could
properly interpret the data.
David Fassler, a psychiatrist at the University of Vermont at Burlington who
has testified on children's mental health issues on Capitol Hill for the
American Psychiatric Association, said parents should push for comprehensive
evaluations of children who develop psychiatric symptoms.
Such evaluations, he said, may entail several sessions with professionals,
reviewing a child's developmental history and school records, analyzing the
child's functioning at school and with friends and family, and having mental
health professionals spend time with children and families.
"You can't do that evaluation in a 5-10 minute office visit," he said. "The
reality of contemporary pediatric practice makes it difficult to devote the
time necessary to do a full and comprehensive evaluation."
Source:
http://www.washingtonpost.com/ac2/wp-dyn/A51843-2003Jan13?language=printer
Study Finds More Children Taking Psychiatric Drugs
By ERICA GOODE Schenectady Daily Gazette January 14, 2003
The number of children and adolescents who take a wide variety of psychiatric
drugs more than doubled from 1987 to 1996, researchers are reporting today.
Stimulants like Ritalin, prescribed for attention deficit disorder, and
antidepressants were the most commonly prescribed drugs, according to the
study, which experts said was the most comprehensive on the topic.
The investigators, led by Dr. Julie Magno Zito, an associate professor of
pharmacy and medicine at the University of Maryland, also found precipitous
growth in the use of antipsychotics, so-called mood stabilizers prescribed for
mania or aggression, and other classes of potent psychoactive medications.
The study, experts said, further confirms that pediatricians and child
psychiatrists are increasingly turning to pharmacology as the treatment of
choice for depression, attention disorder, severe anxiety, obsessive disorder,
manic depression and other conditions. The effects of the trend, or whether it
is good or bad, are unclear, the experts added.
On one hand, the findings reflect the emergence of new treatments, advances
that have spilled into the care of severely troubled children. On the other
hand, little research exists to indicate whether psychiatric drugs are being
responsibly prescribed or whether they are overprescribed, in part because
health insurers are reluctant to pay for "talk" therapies and other
nonmedication treatments.
The Food and Drug Administration specifically approves just a few psychiatric
medications for children, despite their widespread use. This month, Prozac was
approved to treat depression in children ages 7 to 17.
The long-term effects of such drugs, particularly on the brain, are largely
unknown.
"The studies can't tell you anything at all about the quality of care or the
outcomes of those treatments," said Dr. James March, a professor of child and
adolescent psychiatry at the Duke University Medical Center. "What we know is
that mental illness is bad for your life, and an optimist's view would be that
treatments, by reducing or ameliorating the symptoms of mental illness, are
supporting a more normal developmental trajectory."
Dr. James Leckman, a professor of child psychiatry, pediatrics and psychology
at the Yale School of Medicine, said psychiatric drugs were useful, but added
that animal studies had hinted that some might have lasting effects on the
brain when given before puberty. In the absence of added studies in animals
and humans, Dr. Leckman said, "we're doing these experiments more or less with
our own children."
Dr. Zito and her colleagues found that of the 900,000 children and adolescents
they studied, 6.2 percent took at least one psychiatric drug in 1996, compared
with 2.5 percent in 1987. The participants in the study, which appears today
in The Archives of Pediatrics and Adolescent Medicine, were in Medicaid
programs in two states and in a large health maintenance organization in the
Northwest.
In 1996, twice as many boys as girls took psychiatric drugs, the study found.
Over the 10 years, the increases in the use of stimulants were greater for
girls than boys, especially in the H.M.O. Boys and girls appeared to be taking
the drugs for longer periods than they did a decade before. In 1987, children
ages 5 to 9 were most likely to be taking Ritalin or another stimulant. In
1996, children ages 10 to 19 took the medications most frequently. The use of
stimulants and antidepressants was comparable in the Medicaid and H.M.O.
groups.
That was not the case for other classes of drugs. The children and adolescents
in Medicaid were significantly more likely to be taking antipsychotic drugs
and mood stabilizers. The prescribing of drugs like clonidine, an
antihypertensive often prescribed for the insomnia produced by stimulants like
Ritalin or Adderall, also increased significantly, especially among Medicaid
patients. Clonidine, Dr. Zito noted, was almost never prescribed in 1987 but
ranked among the five most popular drugs in 1996.
In an editorial with the study, Dr. Michael Jellinek, a professor of
psychiatry and pediatrics at the Harvard Medical School, called the findings
"an imperfect mirror of the scientific, clinical, financial and systems
changes that impacted the mental health care of children."
The study, Dr. Jellinek said, may reflect new understanding and "thoughtful
efforts" to use adult drugs in children "to treat children with serious mental
health needs."
But he added, "There are some disturbing clinical trends."
Dr. Zito said the challenge for researchers was to establish the need for
drugs, effective doses, duration of medication, and the risks.
"What we want to do," Dr. Zito said, "is to get the right medicine to the
right child at the right time, assuming that behavioral approaches are not
sufficient by themselves."
Source:
http://www.nytimes.com/2003/01/14/health/14DEPR.html?tntemail0=&pagewanted=print&position=top
This 'Mental Health E-News' posting is a service of the New
York Ass'n of Psychiatric Rehabilitation Services, a statewide coalition of
people who use and/or provide community mental health services dedicated to
improving services and social conditions for people with psychiatric
disabilities by promoting their recovery, rehabilitation and rights.
To join our list, e-mail us your request and, where
appropriate, the name of your organization to
NYAPRS@aol.com.
Last Updated on
04/14/04
webmaster@namiscc.org
