A new study in the Archives of General Psychiatry reports on the increasing use of antipsychotic medications in youth. The study analyzed nearly half a million medical visits over a 17 year span (1993 through 2009).
Results showed that the number of medical visits that included an antipsychotic medication per 100 persons rose in children (defined as 13 years old and less) from 0.24 to 1.83. The rate increased from 0.78 to 3.76 for adolescents and from 3.25 to 6.18 for adults. Disruptive behavior disorders, including ADHD, are now the most common diagnoses associated with antipsychotic use in youth, accounting for 63% and 34% of the visits for children and adolescents, respectively, while there was also a sharp increase in their use for bipolar disorder in youth. Nearly 90% of antipsychotic use was off-label in children and adolescents. Risperidone was the most commonly prescribed antipsychotic medication. A large percentage of medical visits with non-psychiatrists that included antipsychotic medication had no psychiatric diagnosis attached to it at all.
The authors speculated that the increase use is likely due to many factors including the release of new medications during the study period, rise in autism and bipolar disorder diagnoses, reduced stigma for mental health conditions, and insurance limitations for psychotherapy. The authors expressed concern over these trends and advocated for reevaluation of current practice standards and additional education about medication risks.
In my view, the sharp increase in childhood antipsychotic use is alarming but not because of it being off-label. Aggression, likely the major reason for these medications, is a serious problem that spans multiple diagnoses. Targeting it for treatment is certainly appropriate, and it seems less important if its treatment is under a diagnosis of bipolar disorder or something else like conduct disorder or ODD. What is more concerning to me is how quickly antipsychotics seems to be appearing in the treatment algorithm ahead of other less risky medications and ahead of intensive psychotherapy directed both at the children and at the home environment, which can be chaotic and hostile. Further, the lack of any psychiatric diagnosis on so many outpatient visits with primary care clinicians suggests a continued discomfort with managing psychopathology and a disconnect with the patient’s mental health team. It is also interesting to note that this national trend of increased antipsychotic use seems less evident in Vermont (see previous blog posting “Vermont Youth are Taking Fewer Medications“).
Olfsen M, Blanco C, et al. National Trends in the Office-Based Treatment of Children, Adolescents, and Adults With Antipsychotics. Archives of General Psychiatry, online first.