Psychiatric Drugs for Kids: How Many Is Too Many?

Studies showing that more and more children are using psychiatric medications have generated reactions--some would say overreactions--with ritualistic sameness. A researcher, after examining a data set maintained by a regulatory body, government health care program, or private HMO or insurance carrier, determines that the number of children currently on psychiatric medications is greater now than it was a few years ago. When news media report those results, they suggest that the increase bodes ill for the nation's kids, even though the study itself draws no such conclusions.

In June, for instance, a New York Times article reporting on one such study intoned that it was "likely to inflame a continuing debate about the risks of using psychiatric medication in children." But should it?

Ultimately, mental health professionals agree that more research could help ensure that children's illnesses are properly diagnosed and that the right medications are given to the right kids. But if the studies that measure utilization rates without relating those numbers to outcomes make it appear as if there is overuse of psychiatric medications, do they play a constructive role in developing mental health care goals? Or might research funds, already in tight supply, be better devoted to clinical outcomes studies?

"On the basis of current trends in practice, one can't make judgments about the quality, the effectiveness, or the safety of care," says Mark Olfson, MD, a professor of clinical psychiatry at the New York State Psychiatric Institute of the Columbia University Medical Center in New York City, whose study showing a significant increase in prescriptions of antipsychotic medications for children and adolescents generated the New York Times article. But he insists that knowing the number of children using the drugs helps researchers better understand what they need to learn about safety, efficacy, and effectiveness.

When the Journal of the American Medical Association published a study in February 2000¹ that reported prescription trends for psychotropic medications among preschoolers, articles in the media generated an apoplectic reaction. (See Psychiatric Times, May 2000.) Reacting to the outcry, then First Lady Hillary Clinton convened a White House conference to consider the study's implications, although critics claimed that this action related more to election year politics than genuine concern.

Today, the questions those early studies raised about whether children with mental illnesses received correct diagnoses and proper treatment--including medications--are well known, though still largely unanswered. So do the utilization studies still make sense when resources might be better spent on outcome studies and clinical research, especially when their release is often accompanied by distorted reports in the news media?

Despite the usefulness of epidemiologic research, Olfson acknowledges that the attention these studies receive in the media can sometimes have an unanticipated impact. "I am aware that at times the press exaggerates and sometimes even distorts these findings in ways that do not serve the public interest," Olfson said. "For instance, relatively little attention is given to the problem of untreated psychiatric disorders in the community. Studies concerning unmet need for treatment do not tend to garner the attention I feel they deserve. At the same time, I think it's important to have an understanding of current treatment patterns. If we're to make well-informed decisions about mental health care policy, we need to understand who is receiving what treatments."

While there is some value in knowing how many children are receiving psychiatric medications, Ricardo M. Vela, MD, director of pediatric pharmacology at Boston University Medical Center, says they don't help anyone understand whether physicians are diagnosing children's ailments correctly or whether they are prescribing medications appropriately. As a result, there are likely problems with both overdiagnosing and underdiagnosing mental illness in children.

"It's much easier to go into a database of numbers of prescriptions issued for each medication and count them because there you don't have to design a research project and start measuring outcomes," says Vela. It's more difficult to design and implement studies that measure outcomes and generate the kind of data that would help physicians know what to do for children, he adds. Plaguing the field is a shortage of child and adolescent psychiatrists and of researchers who can design and conduct the kinds of studies that would answer the substantive questions raised by the utilization reports. Reductions in research funds and the ethical conundrums that arise when children are the subjects of studies add to the reasons why years go by without more answers to thorny questions.

Vela agrees that journalists' reports about the studies often create trouble. "The media will pick on this--the reports of the use of medications, and . . . when parents hear this they get very scared, and understandably scared, and sometimes they come to me with information they got in the media."

Despite concerns that some reports may not describe utilization studies accurately, Benedetto Vitiello, MD, a psychiatrist who is chief of the Child and Adolescent Treatment and Preventive Interventions Research Branch at the National Institute of Mental Health, says that continued monitoring of medication use is important. In the early 1990s, he said, the numbers did trigger more research into outcomes for children. Today, they still help set priorities.

"The survey itself cannot really document or comment on the appropriateness of the [medication] use; it just indicates [that] the utilization has increased," Vitiello says. "However, what it can do is point out that the utilization seems to be disproportionate compared with a lack of adequate controlled clinical trials of these agents in kids." Over the years, efficacy and outcomes research has increased, he added.

Part of the problem is that often only one side of the story gets told, says David Fassler, MD, a child and adolescent psychiatrist in Burlington, Vt, and a clinical professor at the University of Vermont College of Medicine. What's worrisome, for instance, is that the research showing reductions in suicides among teens since the introduction of SSRIs is often buried beneath the avalanche of stories that cover the link between antidepressants and increased suicidal ideation among young people, he says. A 20% reduction in the prescriptions for antidepressants following FDA hearings does not necessarily mean something good is happening, he added, because it is also likely that children who need medications are not receiving them.

"In my mind, the issue is not how many kids are taking particular medications. The real issue is [whether] the right kids [are] getting the right treatment," Fassler says. "So, I worry that as a result of the extensive and sometimes inaccurate media coverage of these studies and of the FDA hearings, parents and some physicians will become reluctant to use medications when appropriate for children and adolescents with significant psychiatric disorders, including depression."

For Bob Carolla, a spokesperson for the National Alliance on Mental Illness, the prospect that epidemiologic studies can contribute to the stigma surrounding mental illness is an important issue. There is a disconnect between one set of numbers showing that the use of drugs in children is on the rise and the Surgeon General's report that some 80% of children who need care aren't receiving it.

"It's legitimate to be concerned about how many prescriptions are written for children, but you have to be concerned about other things equally if not more," Carolla says. "The worst possible outcome is [that there is] an overreaction to inflammatory concerns and [that] people stop getting into treatment."

Reference:1. Zito JM, Safer DJ, dosReis S, et al. Trends in the prescribing of psychotropic medications to preschoolers. JAMA. 2000;283:1025-1030.