Antidepressant prevalence for youths: a multi-national comparison

Psychotropic medication in children and adolescents in Germany: prevalence, indications, and psychopathological patterns

OBJECTIVE

The aim of this study was to identify the "real-life" prevalence of psychotropic medications in children and adolescents in Germany and related behavioral and emotional problems. Data from the nationwide representative National German Health Interview and Examination Survey for Children and Adolescents (KiGGS) were analyzed.

METHOD

A total of 17,450 subjects aged 0-17 years from 167 communities were examined as part of the KiGGS in Germany between 2003 and 2006 to determine their use of antidepressants, antipsychotics, anxiolytics, and sedatives within the 7 days prior to being interviewed. Medication use was assessed by a medical doctor who conducted a computer-assisted personal interview (CAPI) with the parents, and related emotional and behavioral problems were assessed using the Strength and Difficulties Questionnaire (SDQ).

RESULTS

The overall prevalence for these medications was moderate (4.81/1000; 95% confidence interval [CI], 3.70-6.26), but prevalence varied across the different classes of drugs (sedatives > antipsychotics > antidepressants > anxiolytics). Rates of off-label use were high for antipsychotics and antidepressants. About 30% of the medication, especially sedatives, was used without prescription. Subjects using psychotropic medication obtained higher scores in the screening for emotional or behavioral problems than the total sample, but 40% of the children did not show abnormal scores.

CONCLUSION

The indication for antipsychotics was mostly behavioral symptomatology, while antidepressants were used for a wide variety of symptoms. The high proportion of children and adolescents using psychotropic medication with normal scores in the emotional and behavioral screening was remarkable. It cannot be determined whether in these cases low scores were related to improvement in symptoms or whether medication was being misused.

Psychotropic medication in the French child and adolescent population: prevalence estimation from health insurance data and national self-report survey data

BACKGROUND

The aim of this work is to estimate the French frequencies of dispensed psychotropic prescriptions in children and adolescents. Prevalence estimations of dispensed prescriptions are compared to the frequencies of use of psychotropic reported by 17 year-old adolescents.

METHODS

Prescription data is derived from national health insurance databases. Frequencies of dispensed prescriptions are extrapolated to estimate a range for the 2004 national rates. Self-report data is derived from the 2003 and 2005 ESCAPAD study, an epidemiological study based on a questionnaire focused on health and drug consumption.

RESULTS

The prevalence estimation shows that the prevalence of prescription of a psychotropic medication to young persons between 3 and 18 years is about 2.2%.In 2005, the self-report study (ESCAPAD) shows that 14.9% of 17 year-old adolescents took medication for "nerves" or "to sleep" during the previous 12 months. The same study in 2003 also shows that 62.3% of adolescents aged 17 and 18 reporting psychotropic use, took the medication for anxiety and 56.8% to sleep. Only 49.7% of these medications are suggested by a doctor.

CONCLUSION

This study underlines a similar range of prevalence of psychotropic prescriptions in France to that observed in other European countries. Nevertheless, the proportion of antipsychotics and benzodiazepines seems to be higher, whereas the proportion of methylphenidate is lower.Secondly, a disparity between the prevalence of dispensed prescriptions and the self-report of actual use of psychotropics has been highlighted by the ESCAPAD study which shows that these treatments are widely used as "self-medication".

Mental health treatment patterns in perinatally HIV-infected youth and controls

BACKGROUND

Youths perinatally infected with HIV often receive psychotropic medication and behavioral treatment for emotional and behavioral symptoms. We describe patterns of intervention for HIV-positive youth and youth in a control group in the United States.

METHODS

Three hundred nineteen HIV-positive youth and 256 controls, aged 6 to 17 years, enrolled in the International Maternal Adolescent AIDS Clinical Trials 1055, a prospective, 2-year observational study of psychiatric symptoms. One hundred seventy-four youth in the control group were perinatally exposed to HIV, and 82 youth were uninfected children living in households with HIV-positive members. Youth and their primary caregivers completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-referenced symptom-rating scales. Children's medication and behavioral psychiatric intervention histories were collected at entry. We evaluated the association of past or current psychiatric treatment with HIV status, baseline symptoms, and impairment by using multiple logistic regression, controlling for potential confounders.

RESULTS

HIV-positive youth and youth in the control group had a similar prevalence of psychiatric symptoms (61%) and impairment (14% to 15%). One hundred four (18%) participants received psychotropic medications (stimulants [14%], antidepressants [6%], and neuroleptic agents [4%]), and 127 (22%) received behavioral treatment. More HIV-positive youth than youth in the control group received psychotropic medication (23% vs 12%) and behavioral treatment (27% vs 17%). After adjusting for symptom class and confounders, HIV-positive children had twice the odds of children in the control group of having received stimulants and >4 times the odds of having received antidepressants. Caregiver-reported symptoms or impairment were associated with higher odds of intervention than reports by children alone.

CONCLUSIONS

HIV-positive children are more likely to receive mental health interventions than control-group children. Pediatricians and caregivers should consider available mental health treatment options for all children living in families affected by HIV.

Review on use of German health insurance medication claims data for epidemiological research

PURPOSE

The objective was to evaluate the use of German health insurance claims data on medications over the last 10 years by a review of published studies.

METHODS

PubMed and Scopus were searched for relevant studies published in 1998 through 2007.

RESULTS

A total of 70 studies were included. Use of these data increased from 32 reports (45.7%) between 1998 and 2005 to 38 (54.3%) over the last 2 years (2006-2007). Over half of the studies (57.1%; n = 40) were written in English and the most frequent research types were health service utilization (51.4%; n = 36) and cost analyses (18.6%; n = 13). In most of the studies (65.7%; n = 46), medication data were linked with other health care utilization claims (e.g. hospitalization data and physicians' outpatient services). Data validity was not taken into consideration in 40.6% (n = 13) of the 32 studies that also analysed hospitalization or physicians' outpatient diagnoses.

CONCLUSIONS

German health insurance medication claims data were increasingly used for research purposes over the last 10 years. Especially methodological and validation studies are clearly needed.

Drug monitoring in child and adolescent psychiatry for improved efficacy and safety of psychopharmacotherapy

Most psychotropic drugs used in the treatment of children and adolescents are applied "off label" with a direct risk of under- or overdosing and a delayed risk of long-term side effects. The selection of doses in paediatric psychiatric patients requires a consideration of pharmacokinetic parameters and the development of central nervous system, and warrants specific studies in children and adolescents. Because these are lacking for most of the psychotropic drugs applied in the Child and Adolescent and Psychiatry, therapeutic drug monitoring (TDM) is a valid tool to optimise pharmacotherapy and to enable to adjust the dosage of drugs according to the characteristics of the individual patient. Multi-centre TDM studies enable the identification of age- and development-dependent therapeutic ranges of blood concentrations and facilitate a highly qualified standardized documentation in the child and adolescent health care system. In addition, they will provide data for future research on psychopharmacological treatment in children and adolescents, as a baseline for example for clinically relevant interactions with various co-medications. Therefore, a German-Austrian-Swiss "Competence Network on Therapeutic Drug Monitoring in Child and Adolescent Psychiatry" was founded 1 introducing a comprehensive internet data base for the collection of demographic, safety and efficacy data as well as blood concentrations of psychotropic drugs in children and adolescents.

Child and adolescent psychiatry for the future: challenges and opportunities

In this article, the authors focus on three particularly salient sets of issues that face the field of child and adolescent psychiatry as a sub-specialty of general psychiatry today-those related to workforce, public perception, and professional identity. In an article directed at the general psychiatrist, the authors present possibilities for refocusing the activities of the child and adolescent psychiatrist to emphasize consultative and collaborative roles. The authors embrace working in systems of care with communities and families as partners. Finally, they discuss the training implications of such shifts in professional identity, and the need to maintain the centrality of a scientifically-based developmental biopsychosocial formulation.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7-17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.

TRIAL REGISTRATION

NCT00074815.

Ethical issues in psychopharmacology of children and adolescents

PURPOSE OF REVIEW

This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice.

RECENT FINDINGS

The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years.

SUMMARY

The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.

A three-country comparison of psychotropic medication prevalence in youth

BACKGROUND

The study aims to compare cross-national prevalence of psychotropic medication use in youth.

METHODS

A population-based analysis of psychotropic medication use based on administrative claims data for the year 2000 was undertaken for insured enrollees from 3 countries in relation to age group (0-4, 5-9, 10-14, and 15-19), gender, drug subclass pattern and concomitant use. The data include insured youth aged 0-19 in the year 2000 from the Netherlands (n = 110,944), Germany (n = 356,520) and the United States (n = 127,157).

RESULTS

The annual prevalence of any psychotropic medication in youth was significantly greater in the US (6.7%) than in the Netherlands (2.9%) and in Germany (2.0%). Antidepressant and stimulant prevalence were 3 or more times greater in the US than in the Netherlands and Germany, while antipsychotic prevalence was 1.5-2.2 times greater. The atypical antipsychotic subclass represented only 5% of antipsychotic use in Germany, but 48% in the Netherlands and 66% in the US. The less commonly used drugs e.g. alpha agonists, lithium and antiparkinsonian agents generally followed the ranking of US>Dutch>German youth with very rare (less than 0.05%) use in Dutch and German youth. Though rarely used, anxiolytics were twice as common in Dutch as in US and German youth. Prescription hypnotics were half as common as anxiolytics in Dutch and US youth and were very uncommon in German youth. Concomitant drug use applied to 19.2% of US youth which was more than double the Dutch use and three times that of German youth.

CONCLUSION

Prominent differences in psychotropic medication treatment patterns exist between youth in the US and Western Europe and within Western Europe. Differences in policies regarding direct to consumer drug advertising, government regulatory restrictions, reimbursement policies, diagnostic classification systems, and cultural beliefs regarding the role of medication for emotional and behavioral treatment are likely to account for these differences.

Psychotropic medication use in children and adolescents: a study from France

OBJECTIVE

In Europe, little information exists on the pediatric use of psychotropic medication. This study aimed to describe the extent and patterns of psychotropic medication use in children and adolescents enrolled in a large health plan (MGEN) in France, and its evolution in recent years.

METHODS

MGEN affiliates aged 0 to 17 years were randomly selected at the end of three consecutive years, 2003 (n = 6534), 2004 (n = 6625), and 2005 (n = 6704). Reimbursement claims were organized into three 1-year cross-sectional data sets. Results are detailed for the year 2003 only.

RESULTS

In 2003, psychotropic medication, principally anxiolytics and hypnotics, concerned 3.3% of children and adolescents, of whom 35.0% used only herbal drugs. General practitioners were found to be behind most of these prescriptions (63.5%) and, worryingly, 15.1% were drugs restricted to adult use. Nevertheless, most psychotropic medication users (71.0%) had only one prescription. In general, psychotropic medication users received a relatively good medical follow-up. Similar results were found for the years 2004 and 2005.

CONCLUSION

No increasing trend in prevalence was found. However, a subject for concern is the proportion of psychotropic drugs with no market authorization for pediatric use that were prescribed to young patients.

An international perspective on pediatric psychopharmacology

The use of pharmacotherapy for children and adolescents with mental disorders varies widely across countries. More than 80% of the world use of stimulant medications occurs in the USA. The use of antidepressants and antipsychotics is many times greater in the USA than in other countries. Factors likely to influence the pediatric use of psychotropic medications are here examined and discussed. Variability in use reflects differences in diagnostic systems, clinical practice guidelines, drug regulation, health services organization, availability and allocation of financial resources, and cultural attitudes towards childhood behavioral and emotional disturbances. Cultural context seems to exert a greater influence on the identification and management of psychiatric disorders than on other areas of medicine. It is currently unknown if the heterogeneity in treatment approaches results in differential clinical outcomes and prognosis. A better understanding of the factors underlying international variability may help clarify the process of diagnosis and treatment selection in child and adolescent psychiatry.

Antidepressants and youth: healing or harmful?

A series of drug innovations that began in 1987, including the introduction of several selective serotonin reuptake inhibitors (SSRIs), has led to a tremendous growth in the use of antidepressants in the United States. This growth, however, has been accompanied by a growing concern about the risks of prescribing antidepressants, particularly to children. Indeed, research linking the use of antidepressant drugs to an increased risk of suicidal behaviors in youth motivated the US Food and Drug Administration to direct antidepressant drug manufacturers to include warning labels about the potential dangers. This paper examines the relationship between antidepressants and suicide among youth in the USA. Using state-level data on youth suicides and age-specific prescriptions for antidepressants, we find no relationships between suicides for adolescents aged 15-19 and prescriptions for SSRIs/serotonin-norepinephrine reuptake inhibitors or tricyclic and tetracyclic antidepressants. In contrast, we find that newer generation antidepressants are associated with lower numbers of suicides for this age group. For younger children aged 10-14, we find no relationship with suicides for any type of antidepressant.

[The effects of the 12th and 14th amendments to the AMG (Medical Preparations Act) on paediatric pharmaceutical research--a survey of the new regulations]

OBJECTIVE

The 12th amendment to the German Medical Preparations Act (Arzneimittelgesetz, AMG) implements EU-Directive 2001/20EC in national law and introduces changes with regard to academic research in child and adolescent psychiatry. The 14th amendment implements labelling regulations for drugs.

METHOD

This article analyses the effects of these new regulations on safety aspects, on the performance of clinical trials with and without sponsoring (investigator-initiated trials, IITs), and on the development of paediatric drugs. The former regulatory directives are compared with the changes mandated by the 12th amendment, and their effects on off-label use, long-term safety, and so-called dose-finding studies will be pointed out.

RESULTS

Current law no longer allows post marketing surveillance studies ("Anwendungsbeobachtungen" and "Therapieoptimierungsstudien"). Requirements and procedural regulations are now standardized for all clinical trials with human beings. The term "group benefit" has now been introduced into German law, which excludes research without any direct or group benefit for children participating in a study.

CONCLUSION

While prerequisites for drug development in accordance with GCP guidelines on a high medical and ethical standard are now granted, due to multiple regulatory requirements, investigator-initiated studies in paediatric psychopharmacology will be more difficult to conduct. Moreover, because of the strict regulations, it is very improbable that academic research will be undertaken without sponsoring (IITs).