Use of Antipsychotics by the Young Rose Fivefold
By BENEDICT CAREY
Published: June 6, 2006
The use of potent antipsychotic drugs to treat children and adolescents for
problems like aggression and mood swings increased more than fivefold from
1993 to 2002, researchers reported yesterday.
The researchers, who analyzed data from a national survey of doctors' office
visits, found that antipsychotic medications were prescribed to 1,438 per
100,000 children and adolescents in 2002, up from 275 per 100,000 in the
two-year period from 1993 to 1995.
The findings augment earlier studies that have documented a sharp rise over
the last decade in the prescription of psychiatric drugs for children,
including antipsychotics, stimulants like Ritalin and antidepressants, whose
sales have slipped only recently. But the new study is the most
comprehensive to examine the increase in prescriptions for antipsychotics.
The explosion in the use of drugs, some experts said, can be traced in part
to the growing number of children and adolescents whose problems are given
psychiatric labels once reserved for adults and to doctors' increasing
comfort with a newer generation of drugs for psychosis.
Shrinking access to long-term psychotherapy and hospital care may also play
a role, the experts said.
The findings, published yesterday in Archives of General Psychiatry, are
likely to inflame a continuing debate about the risks of using psychiatric
medication in children. In recent years, antidepressants have been linked to
an increase in suicidal thinking or behavior in some minors, and reports
have suggested that stimulant drugs like Ritalin may exacerbate underlying
Antipsychotic drugs also carry risks: Researchers have found that many of
the drugs can cause rapid weight gain and blood lipid changes that increase
the risk of diabetes. None of the most commonly prescribed antipsychotics is
approved for use in children, although doctors can prescribe any medication
that has been approved for use.
Experts said that little was known about the use of antipsychotics in
minors: only a handful of small studies have been done in children and
"We are using these medications and don't know how they work, if they work,
or at what cost," said Dr. John March, a professor of child and adolescent
psychiatry at Duke University. "It amounts to a huge experiment with the
lives of American kids, and what it tells us is that we've got to do
something other than we're doing now" to assess the drugs' overall impact.
But many child psychiatrists say that antipsychotic medication is the best
therapy available for children in urgent need of help who do not respond
well to other treatments. Without them, they say, many unpredictable,
emotionally unstable children would end up institutionalized.
Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University
and the lead author of the study, financed in part by the National Institute
of Mental Health, said the popularity of antipsychotic drugs might result in
part from "the fact that psychiatrists have few other pharmacological
options in certain patients."
The study, which looked at visits to pediatricians and other doctors, found
that psychiatrists were the most likely to prescribe antipsychotic drugs.
In light of how little these drugs have been studied in children, Dr. Olfson
said, "to me the most striking thing was that nearly one in five psychiatric
visits for young people included a prescription for antipsychotics."
The Columbia investigators analyzed data from the National Center for Health
Statistics survey of office visits, which focuses on doctors in private or
group practices. They calculated the number of visits in which an
antipsychotic drug was prescribed to people under the age of 21 and
collected information on patients' medical histories. The total number of
visits that resulted in prescriptions for the drugs increased to 1,224,000
in 2002 from 201,000 1993 to 1995.
The researchers attributed some of the increase to the availability of a new
class of drugs for psychosis, called atypical antipsychotics, that were
introduced in the early and mid-1990's.
The newer drugs, heavily marketed by their makers, were attractive in part
because they appeared less likely than older types of antipsychotics to
cause side effects like tardive dyskinesia, a neurological movement disorder
similar to Parkinson's disease.
From 2000 to 2002, the new study found, more than 90 percent of the
prescriptions analyzed were for the newer medications, and most of the
patients were boys, predominantly Caucasian children, who were significantly
more likely to see psychiatrists than other ethnic groups.
Some experts also pointed to an increase in the diagnosis of bipolar
disorder in children as a contributing factor. In recent years,
psychiatrists have begun to diagnose the disorder in extremely agitated,
often aggressive children with mood swings — short surges of grandiosity or
irritation that alternate with periods of despair. These symptoms in
children are thought to be related to the classic euphoria and depressions
of adult bipolar disorder.
At the same time, several of the atypical antipsychotics, including
Risperdal from Janssen and Zyprexa from Eli Lilly, won approval for the
treatment of mania in adults.
Some psychiatrists now routinely prescribe atypical antipsychotics "off
label" for young people thought to have bipolar disorder, and researchers
have begun to study the drugs in children as young as preschool age.
In the new study, about a third of the children who received antipsychotics
had behavior disorders, which included attention deficit problems; a third
had psychotic symptoms or developmental problems; and another third were
suffering from mood disorders. Over all, more than 40 percent of the
children were also taking at least one other psychiatric medication.
"We feel the medications are effective in children with bipolar and have
some data to show that," said Dr. Melissa DelBello, an associate professor
of psychiatry at the University of Cincinnati, who has done several studies
of the drugs.
Dr. DelBello said that the field "desperately needs more research" to
clarify the effects of the antipsychotic drugs but that many children
struggling with bipolar disorder got more symptom relief on these drugs than
on others, allowing psychiatrists to cut down on the overall number of
medications a child is taking.
Lisa Pedersen of Dallas, the mother of a 17-year-old boy being treated for
bipolar disorder, said he was unpredictable, hostile and suicidal before
psychiatrists found an effective cocktail of drugs, which includes a daily
dose of antipsychotic medication.
"Believe me, I would never choose having him on these meds," Ms. Pedersen
said in a telephone interview. "It's not fun watching a child deal with the
side effects. But finding the right combination of medicine has made his
life worth living."
Yet this process is one of trial and error for many children. Ms. Pedersen
said her son had responded badly to the first two antipsychotic drugs he
received. And some experts think the way that psychiatric drugs are
prescribed is obscuring any understanding of underlying disorders and the
"If you're going to put children on three or four different drugs, now
you've got a potpourri of target symptoms and side effects," said Dr. Julie
Magno Zito, an associate professor of pharmacy and medicine at the
University of Maryland.
Dr. Zito added, "How do you even know who the kid is anymore?"