Psychotropic drug use among 0-17 year olds during 2004-2014: a nationwide prescription database study

Considerable paediatric drug dispensing - A nationwide study of more than 2 million Swedish children

AIM

The aim of the nationwide study was to describe paediatric drug utilisation in Sweden.

METHODS

Drug prescriptions dispensed to all children aged 0-17 years in 2019 were analysed using data from the Swedish National Prescribed Drug Register.

RESULTS

We retrieved data on 2 180 508 unique children. Nearly 4.6 million prescriptions were dispensed to children aged 0-17 years, and 52% of these were to boys. Just under half of the children (47%) were dispensed at least one drug: 48% of girls and 45% of boys (p < 0.01). More than a third (34%) were dispensed three or more different drugs during 2019. The number of dispensed prescriptions per 1000 children was higher in boys than girls up to 12 years of age (p < 0.01), and the opposite trend was observed from 13 years and above, even when we excluded contraceptives (p < 0.01). The most common therapeutic areas were drugs for the respiratory tract (25%), namely antihistamines, antiasthmatics and cough medication. These were followed by psychoanaleptics and melatonin for the nervous system (19%) and dermatologicals (16%), namely cortisone creams and emollients.

CONCLUSION

Paediatric drug use was common, and a considerable proportion of children were dispensed multiple drugs.

Morbidity among Adolescent Hypnotic Drug Users in Norway: An Observational Population-Based Study

We have previously shown that the use of hypnotic drugs increased among young Scandinavians during 2012-2018. This study aimed to explore psychiatric and somatic morbidity among adolescent hypnotic drug users in a cohort study of 13-17-year-old individuals during 2008-2018 in Norway. Data sources were (i) prescription data from the Norwegian Prescription Database linked to specialist health care diagnoses from the Norwegian Patient Registry and (ii) sleep disorder diagnoses from the Primary Health Care Database. Hypnotic drugs were defined as the sedative antihistamine alimemazine and the ATC group "Hypnotics and Sedatives" (N05C), excluding midazolam. In 2017, 2519 girls (16.5/1000) and 1718 boys (10.7/1000) were incident (new) users of hypnotic drugs. Most of these new users (82% of girls, 77% of boys) were referred to secondary health care, where the most frequent diagnoses were mental and behavioral disorders (51.8% of girls, 46.2% of boys), while only 3.2% received a specific sleep disorder diagnosis. The most common mental and behavioral disorders were "Neurotic stress-related disorders" among girls (27.4%) and "Behavioral and emotional disorders" among boys (23.6%). In conclusion, the trend of increasing hypnotic drug use among adolescents reflects the initiation of hypnotic drugs in a subgroup of the population with a higher disease burden, mainly due to psychiatric disorders, than the general population.

Chronic oral methylphenidate plus fluoxetine treatment in adolescent rats increases cocaine self-administration

Background

Depression and attention deficit hyperactivity disorder are known to be comorbid. Treatment of these commonly coexisting diseases typically involves the combined prescription of methylphenidate (MP), a psychostimulant, and fluoxetine (FLX), a selective serotonin reuptake inhibitor (SSRI). MP and cocaine have similar mechanisms of action and this study examined the effects of chronic treatment of MP combined with FLX on cocaine consumption in rats.

Methods

Four groups of rats received access to drinking solutions of water (control), MP (30/60 mg/kg/day), FLX (20 mg/kg/day), or the combination of MP (30/60 mg/kg/day) plus FLX (20 mg/kg/day), during 8 h per day for one month. Following these drug treatments, rats were allowed to self-administer cocaine for 14 days.

Results

Our results showed that, during the first week of cocaine self-administration, the MP-treated rats had significantly greater numbers of active lever presses (plus 127%) and increased consumption of cocaine compared to the control rats. In contrast, during week two of cocaine self-administration, the rats treated with the MP + FLX combination showed significantly more lever presses (plus 198%) and significantly greater cocaine consumption (plus 84%) compared to the water controls.

Conclusion

Chronic oral treatment during adolescence with the combination of MP plus FLX resulted in increased cocaine use after 2 weeks of cocaine self-administration in rats. These novel findings suggest that the combined exposure to these two drugs chronically, during adolescence, may produce increased vulnerability towards cocaine abuse during young adulthood.

Killing pain?: a population-based registry study of the use of prescription analgesics, anxiolytics, and hypnotics among all children, adolescents and young adults in Norway from 2004 to 2019

The ongoing opioid epidemic has been a global concern for years, increasingly due to its heavy toll on young people's lives and prospects. Few studies have investigated trends in use of the wider range of drugs prescribed to alleviate pain, psychological distress and insomnia in children, adolescents and young adults. Our aim was to study dispensation as a proxy for use of prescription analgesics, anxiolytics and hypnotics across age groups (0-29 years) and sex over the last 15 years in a large, representative general population. The study used data from a nationwide prescription database, which included information on all drugs dispensed from any pharmacy in Norway from 2004 through 2019. Age-specific trends revealed that the prevalence of use among children and adolescents up to age 14 was consistently low, with the exception of a substantial increase in use of melatonin from age 5. From age 15-29, adolescents and young adults used more prescription drugs with increasing age at all time points, especially analgesics and drugs with higher potential for misuse. Time trends also revealed that children from age 5 were increasingly dispensed melatonin over time, while adolescents from age 15 were increasingly dispensed analgesics, including opioids, gabapentinoids and paracetamol. In contrast, use of benzodiazepines and z-hypnotics slightly declined in young adults over time. Although trends were similar for both sexes, females used more prescription drugs than their male peers overall. The upsurge in use of prescription analgesics, anxiolytics and hypnotics among young people is alarming.Trial registration The study is part of the overarching Killing Pain project. The rationale behind the Killing Pain research was pre-registered through ClinicalTrials.gov on April 7, 2020. Registration number NCT04336605; https://clinicaltrials.gov/ct2/show/record/NCT04336605 .

Trends in Prescribing Antipsychotics for Children and Adolescents in Japan: A Descriptive Epidemiological Study Using a Large-Scale Pharmacy Dataset

Little is known about antipsychotic prescription patterns among children and adolescents in Japan, particularly in outpatient settings. We investigated the prevalence and trends of antipsychotic prescription for outpatients aged ≤ 17 years receiving a first antipsychotic prescription from 2006 to 2012 based on a large-scale dispensation dataset. Measurements included age, sex, department of diagnosis and treatment, type of prescription (monotherapy or polytherapy), antipsychotic dosage, and concomitant psychotropic drugs. Of the 10,511 patients, 65.1% were aged 13-17 years, and 52.9% were males. Second-generation antipsychotic monotherapy prescriptions increased from 53.8% in 2006 to 78.3% in 2012. Risperidone was the most frequently prescribed antipsychotic, followed by aripiprazole and olanzapine. Approximately 25.0% of patients were prescribed an initial dose less than recommended. Second-generation antipsychotic monotherapy is currently the most frequent prescription pattern among outpatients aged ≤ 17 years receiving an initial antipsychotic prescription.

Dispensing of psychotropic medications to Australian children and adolescents before and during the COVID-19 pandemic, 2013-2021: a retrospective cohort study

OBJECTIVE

To determine longitudinal patterns of dispensing of antidepressant, anxiolytic, antipsychotic, psychostimulant, and hypnotic/sedative medications to children and adolescents in Australia during 2013-2021.

DESIGN

Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data.

PARTICIPANTS, SETTING

People aged 18 years or younger dispensed PBS-subsidised psychotropic medications in Australia, 2013-2021.

MAIN OUTCOME MEASURES

Population prevalence of dispensing of psychotropic medications to children and adolescents, by psychotropic class, gender, and age group (0-6, 7-12, 13-18 years).

RESULTS

The overall prevalence of psychotropic dispensing to children and adolescents was 33.8 per 1000 boys and 25.2 per 1000 girls in 2013, and 60.0 per 1000 boys and 48.3 per 1000 girls in 2021. The prevalence of psychotropic polypharmacy was 5.4 per 1000 boys and 3.7 per 1000 girls in 2013, and 10.4 per 1000 boys and 8.3 per 1000 girls in 2021. Prevalent dispensing during 2021 was highest for psychostimulants (boys, 44.0 per 1000; girls, 17.4 per 1000) and antidepressants (boys, 20.4 per 1000; girls, 33.8 per 1000). During 2021, the prevalence of dispensing was higher than predicted by extrapolation of 2013-2019 data for many classes, including antidepressants (boys: +6.1%; 95% CI, 1.1-11.1%; girls: +22.2%; 95% CI, 17.4-26.9%), and psychostimulants (boys: +14.5%; 95% CI, 8.0-21.1%; girls: +27.7%; 95% CI, 18.9-36.6%). The increases were greatest for girls aged 13-18 years (antidepressants: +20.3%; 95% CI, 16.9-23.7%; psychostimulants: +39.0%; 95% CI, 27.9-50.0%).

CONCLUSIONS

The prevalence of both psychotropic dispensing and psychotropic polypharmacy for children and adolescents were twice as high in 2021 as in 2013. The reasons and appropriateness of the marked increases in psychotropic dispensing during the COVID-19 pandemic, particularly to adolescent girls, should be investigated.

Prevalence and Factors Affecting the Use of Antipsychotics and Antipsychotic Polypharmacy in a Child and Adolescent Psychiatry Inpatient Service

Objective: We aimed to examine the antipsychotics used by patients hospitalized in the child and youth inpatient service providing tertiary care to investigate whether there is a difference between admission and discharge, polypharmacy, which antipsychotics are used, and which psychotropics are used concomitant with antipsychotics. Methods: Research data were collected retrospectively from all children and adolescents hospitalized in a child and adolescent psychiatry inpatient service in a university hospital in a 4-year period (2015-2019). The sociodemographic and clinical characteristics of the patients, the antipsychotics they used at admission and discharge, the other psychotropics concomitantly used with antipsychotics, and the side effects associated with antipsychotics during hospitalization were collected from the files of the 363 patients. Results: Patients on antipsychotics increased 12.1% from hospitalization to discharge. Antipsychotic polypharmacy increased from 16.2% at admission to 30.7% at discharge. Logistic regression analysis was performed to investigate the factors affecting antipsychotic and antipsychotic polypharmacy. Self-harm, aggression/violence, and extended hospitalization were factors associated with increased antipsychotic use. Psychotic symptoms, psychotic disorder, and extended hospitalization were factors associated with an increase in antipsychotic polypharmacy. Conclusions: Understanding the factors that may cause antipsychotic use and polypharmacy in inpatient services in children and adolescents may prevent unnecessary drug use and long-term side effects that may occur due to these drugs.

Combined Chronic Oral Methylphenidate and Fluoxetine Treatment During Adolescence: Effects on Behavior

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) can be comorbid with depression, often leading to the prescription of both methylphenidate (MP) and selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (FLX). Moreover, these drugs are often misused as cognitive enhancers. This study examined the effects of chronic oral co-administration of MP and FLX on depressive- and anxiety-like behaviors.

METHODS

Adolescent rats received daily either water (control), MP, FLX, or the combination of MP plus FLX in their drinking water over the course of 4 weeks.

RESULTS

Data analysis shows a decrease in food consumption and body weight for rats exposed to FLX or the combination of MP and FLX. Sucrose consumption was significantly greater in FLX or MP+FLX groups compared to controls. FLX-treated rats showed no effect in the elevated plus maze (EPM; open arm time) and forced swim test (FST; latency to immobility). However, rats treated with the combination (MP+FLX) showed significant anxiolytic-like and anti-depressive-like behaviors (as measured by EPM and FST), as well as significant increases in overall activity (distance traveled in open field test). Finally, the combined MP+FLX treatment induced a decrease in anxiety and depressive- like behaviors significantly greater than the response from either of these drugs alone.

CONCLUSION

These behavioral results characterize the long-term effects of these drugs (orally administered) that are widely co-administered and co-misused and provide important insight into the potential neurobiological and neurochemical effects. Future research will determine the potential risks of the long-term use of MP and FLX together.

Trends in prescription of psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018

OBJECTIVE

To examine trends in prescribing psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018.

METHOD

A retrospective cohort study examined prescriptions written by general practitioners using MedicineInsight, a large Australian primary care database, covering approximately 9% of all general practitioner practices. Numbers of patients receiving prescriptions for five main classes of psychotropics (antipsychotics, antidepressants, attention deficit hyperactivity disorder medications, anxiolytics, and hypnotics/sedatives [including benzodiazepines and Z-drugs, but excluding melatonin]) were examined annually by age-group (0-4, 5-9, 10-14, 15-18 years). Melatonin was analysed separately.

RESULTS

The number of patients prescribed any psychotropic increased from 25.6 to 36.2 per 1000 individuals from 2011 to 2018 (average annual increase +4.5%, 95% confidence interval [4.1%, 4.9%]; overall +41.4%). Among the five main classes, the largest annual increase was for attention deficit hyperactivity disorder medications (+9.6%, 95% confidence interval [8.8%, 10.5%]; overall +95.8%), followed by antipsychotics (+6.2%, 95% confidence interval [5.0%, 7.3%]; overall +62.8%) and antidepressants (+4.5%, 95% confidence interval [4.0%, 5.0%]; overall +42.8%). Hypnotic/sedative prescribing decreased on average 6.5% per year (95% confidence interval [-8.0%, -5.0%]; overall -40.2%). Anxiolytic prescribing remained steady. Melatonin prescriptions showed the highest increase of all (+24.7%, 95% confidence interval [23.7%, 25.8%]; overall +606.7%). The largest annual increase in antipsychotic, antidepressant or attention deficit hyperactivity disorder medication prescribing occurred in 10- to 14-year-olds (+7.5%, +6.5% and +10.4%, respectively). The largest point prevalence occurred in 2018 among 15- to 18-year-olds, with 98.5 per 1000 prescribed antidepressants. Antidepressants were more frequently prescribed to females; antipsychotics, attention deficit hyperactivity disorder medications and melatonin more often to males. The most prescribed antipsychotics were risperidone (<15 years) and quetiapine (15- to 18-year-olds). Fluoxetine was the most prescribed antidepressant in those aged 5+ years and amitriptyline in 0- to 4-year-olds.

CONCLUSION

General practitioner prescribing of melatonin, antipsychotics, antidepressants and attention deficit hyperactivity disorder medications to under-19-year-olds increased markedly from 2011 to 2018. Although benzodiazepine and Z-drug prescriptions declined, this was offset by a substantial increase in melatonin prescribing.

[Increasing methylphenidate abuse: Tracking and profiles during 13-years]

BACKGROUND

Methylphenidate is indicated for attention deficit hyperactivity disorder (ADHD). Several studies have evaluated its abuse in specific populations (students, drug users) and few in the general population. This work describes the extent of its abuse in a region of more than 5 million inhabitants.

METHOD

Based on regional health insurance data from 2005 to 2017, the clustering method identifies different methylphenidate use profiles according to several characteristics (number of different prescribers and pharmacies, number of dispensations, number of defined daily dose dispensed). The groups characterised by high values of these variables will be qualified as "deviant".

RESULTS

In 13 years, the number of patients with at least one dispensation in the first quarter has been multiplied by 5.8 times. The proportion of adults has increased (20% in 2017) and their number has been multiplied by 10. Five groups are identified, three of them are characterised by "deviant" behaviour. Group 5 (n=11, 0.04%) has higher values than 4 (n=112, 0.4%) and 3 (n=407, 1.6%). These patients are older and more frequently use benzodiazepines and opiate substitution drugs. Groups 1 (n=13,132, 51%) and 2 (n=11,941, 46.7%) are more likely to be taken up by young subjects. The number of subjects with "deviant" behaviour increased until 2011 and after a decrease, the highest number of subjects concerned has been observed since 2015.

CONCLUSION

In view of the increase of subjects with "deviant" behaviour, it is necessary to make the medical community and patients aware on the risk of abuse of methylphenidate. The recent extension of the indication for ADHD in adults and the broadening of the conditions of prescription require increased vigilance.

Divergent decennial trends in mental health according to age reveal poorer mental health for young people: repeated cross-sectional population-based surveys from the HUNT Study, Norway

OBJECTIVES

Public health trends are formed by political, economic, historical and cultural factors in society. The aim of this paper was to describe overall changes in mental health among adolescents and adults in a Norwegian population over the three last decades and discuss some potential explanations for these changes.

DESIGN

Repeated population-based health surveys to monitor decennial changes.

SETTING

Data from three cross-sectional surveys in 1995-1997, 2006-2008 and 2017-2019 in the population-based HUNT Study in Norway were used.

PARTICIPANTS

The general population in a Norwegian county covering participants aged 13-79 years, ranging from 48 000 to 62 000 000 in each survey.

MAIN OUTCOME MEASURES

Prevalence estimates of subjective anxiety and depression symptoms stratified by age and gender were assessed using the Hopkins Symptom Checklist-5 for adolescents and the Hospital Anxiety and Depression Scale for adults.

RESULTS

Adolescents' and young adults' mental distress increased sharply, especially between 2006-2008 and 2017-2019. However, depressive symptoms instead declined among adults aged 60 and over and anxiety symptoms remained largely unchanged in these groups.

CONCLUSIONS

Our trend data from the HUNT Study in Norway indicate poorer mental health among adolescents and young adults that we suggest are related to relevant changes in young people's living conditions and behaviour, including the increased influence of screen-based media.

Relative Age and the Use of Second-Generation Antipsychotics from 7 to 17 Years of Age: A Population-Based Register Study

Objective: The youngest children in a classroom have a higher risk of attention-deficit/hyperactivity disorders (ADHDs) and depression than their relatively older peers. However, there has been a lack of research on how relative age is related to second-generation antipsychotic (SGA) medication use. Methods: This study used the Finnish National Prescription Register data and comprised all 669,726 Finnish children and adolescents aged 7-17 in 2018. We extracted data for those who were dispensed SGAs (risperidone, quetiapine, aripiprazole, and olanzapine) and ADHD medication (methylphenidate, atomoxetine, dexamphetamine, and lisdexamfetamine). Odds ratios (OR) and 95% confidence intervals (CI) were calculated for medication dispensed to schoolchildren born from January to April (the relatively oldest), May to August, and September to December (the relatively youngest). Dispensed prescriptions were a proxy for medication use. Results: SGAs were dispensed to 9146 (1.4%) individuals in 2018. Their use was lower among girls aged 12-17 years born from September to December than January to April (OR 0.89; 95% CI 0.83-0.97), with no association between SGA use and birth month among boys. However, younger relative age was associated with combined SGA and ADHD medication, which was used by 2556 (0.4%) of the cohort: 2074 (0.6%) boys and 482 (0.1%) girls. The OR was 1.27 for boys aged 12-17 born from September to December (95% CI 1.10-1.46), compared with January to April. The OR for girls born from May to August was 1.35 (95% CI 1.04-1.76) and from September to December it was 1.33 (95% CI 1.02-1.74), compared with January to April. Conclusions: A novel discovery of this study was that using both SGA and ADHD medication at the age of 12-17 years was more common among the youngest subjects in a school year than their relatively older peers.

Psychological Distress and Use of Psychotropic Drugs Among University Students-the SHoT Study, Norway

Background: Students pursuing higher education are struggling with psychological distress, which in turn may negatively affect their academic self-efficacy and study progress. Although psychotropic drug use is widespread and increasing, patterns of psychotropic drug use among students are not well-known. Aim: To describe prevalence and gender differences in psychotropic drug use among Norwegian students in higher education, and to examine associations with level of psychological distress. Methods: The study is based on data from the Norwegian Student's Health and Well-being Study (SHoT), 2018, a national survey including all fulltime students aged 18-35 years in higher education. Our sample included 49,836 students, 69% females. Use of psychotropic drugs and psychological distress (The Hopkins Symptoms Checklist [HSCL-25]) were self-reported. Generalised linear models were used to assess associations between psychological distress and psychotropic drug use. Results: Psychotropic drug use was more frequent among female than male students: 4 vs. 2% daily antidepressants usage; 5 vs. 3% last month use of anxiolytics/tranquillisers; and 8 vs. 5% last month use of hypnotics. In contrast, male students reported use of performance enhancing drugs more often than females (7 vs. 5%). Adjusted associations between high level of psychological distress (HSCL-25 ≥ 2.0) and use of psychotropics, showed an about 2-fold increased relative risk, largely consequent across drug classes and genders. Conclusion: Prevalence and gender patterns of intake of the most common psychotropic drug classes among Norwegian students are comparable to previous studies. Unexpectedly, among students with moderate to severe psychological distress, the patterns of psychotropic drug use were more or less identical between genders.

Psychotropic use in children and adolescents in Scandinavia and Catalonia: a 10-year population-based study

RATIONALE

The use of psychotropic drugs in the paediatric population has not been the subject of many studies, due to the fact that this population is generally not included in clinical trials and these drugs are not authorized for use on minors.

OBJECTIVES

This study aims to provide an accurate description of psychotropic drug use in children and adolescents in the North of Europe and Catalonia.

METHODS

Data from 2008 to 2017 on psychotropic drug consumption in children and adolescents were retrieved from the databases of Catalonia, Denmark, Norway and Sweden. Psychotropic drugs were divided into antipsychotics, anxiolytics (also hypnotics and sedatives), antidepressants and psychostimulants. Data were stratified by group of age (0-4, 5-9, 10-14 and 15-19/15-17 for Denmark and Catalonia) and sex.

RESULTS

Overall, the group of anxiolytics shows the highest consumption and the group of antipsychotics the lowest. In 2017, Sweden was the country with the highest consumption of psychotropic drugs (6.67‰) and has the highest increase in consumption (152.8%), and Denmark has the lowest consumption for all groups (3.13‰). Catalonia shows a decrease in psychotropic drugs (-15.9%). Girls consume more than twice as many antidepressants as boys while the opposite is true for psychostimulants. Risperidone and quetiapine are among the most consumed antipsychotics in the Nordic countries, whereas in Catalonia they are risperidone and aripiprazole. Among antidepressants, sertraline is the most consumed. No differences are found among the psychostimulants.

CONCLUSIONS

Psychotropic consumption in younger populations is increasing, although there are differences between the countries as far as which drugs are used. Nordic countries show a higher prevalence of use than Catalonia. Psychotropic drug consumption increases with age, except for psychostimulants, which have the highest utilization rate among 10-14-year-olds.

[Anxiety in neurological practice]

Anxiety and related disorders are the most common type of mental disorders in both the general population and the neurological clinic. A current typology of anxiety disorders includes panic disorder, agoraphobia, simple (specific) phobias, social anxiety disorder, and generalized anxiety disorder. Anxiety disorders often accompany diseases of the nervous system, worsen their course and impede treatment, and the degree of anxiety usually corresponds to the severity of neurological symptoms. Anxiety may precede brain diseases, but the answer to the question of whether it contributes to these diseases or predicts them or can be an early manifestation of these diseases requires further studies. Modern approaches to the treatment of anxiety involve the use of benzodiazepines, antidepressants, some mood stabilizers, antipsychotics, as well as psychological interventions.

Young people's experiences with mental health medication: A narrative review of the qualitative literature

Background: With the growing prevalence of mental illness in young people, healthcare professionals require an understanding of the social and psychological implications of medication use in this population.Aim: To characterize the qualitative literature regarding the perceptions and experiences of young people taking medication for mental illness.Methods: A narrative review of qualitative studies involving young people (13-24 years) taking any medication as treatment for a mental illness. The Medication Experience Model guided analysis of quotes related to medication use.Results: Of the 27 included studies, the majority involved participants with depression and utilized interviews. Young people reported a wide range of mental health medication experiences, both negative and positive, which could influence medication acceptance. Lack of autonomy and the influence of family members were challenges faced by this population.Conclusions: Young people reported that medications had affected them in various ways across multiple dimensions. Lack of involvement in decision-making and a loss of autonomy were of particular relevance to young people, issues which should also be of interest to healthcare professionals.

New Users of Antipsychotics Among Children and Adolescents in 2008-2017: A Nationwide Register Study

INTRODUCTION

Recently, prescribing antipsychotics for children and adolescents has been increasing in many countries. These drugs are often prescribed off-label, although antipsychotics have been associated with adverse effects. We determined the recent incidence of antipsychotic use among children and adolescents in Finland.

METHODS

Finnish National Prescription Register including all Finnish inhabitants receiving reimbursement for pharmaceuticals was searched for subjects of 1 to 17 years of age who had started an antipsychotic drug between January 1, 2008, and December 31, 2017 (n = 26,353). Between 2008 and 2017, the range of number of Finnish children and adolescents aged 1 to 17 years was 1.01 to 1.03 million/year. The incidence was calculated by dividing the number of new users by all age- and sex-matched Finnish inhabitants in the year.

RESULTS

Between 2008 and 2017, the incidence of antipsychotic use among children and adolescents increased from 2.1 to 3.8 per 1000 individuals, respectively. In children aged 7 to 12 years, the incidence of antipsychotic use 1.4-folded (from 1.9 (95% CI: 1.8-2.0) to 2.7 (95% CI: 2.5-2.9) per 1000) with a cumulative increase of 0.2% per year (χ² = 51.0, p < 0.0001). In adolescents aged 13 to 17 years, the incidence 2.2-folded (from 4.3 (95% CI: 4.1-4.5) to 9.4 (95% CI: 9.1-9.8) per 1000) with a cumulative increase of 0.6% per year (χ² = 590.3, p < 0.0001). The increase in the incidence of use was steeper in girls (2.3-fold) than in boys (1.4-fold) (χ² = 85.6, p < 0.0001), especially between 2015 and 2017 (1.6-fold and 1.2-fold, respectively) (χ² = 151.7, p < 0.0001). The year 2011 was the turning point when the incidence in girls exceeded the incidence in boys, and the incidence of quetiapine use exceeded that of risperidone use.

CONCLUSIONS

The incidence of antipsychotic use increased between 2008 and 2017, especially in adolescent girls. The use of quetiapine increased, although it has few official indications in children and adolescents. Future studies should investigate the reasons for increasing use of antipsychotics, especially quetiapine, in children and adolescents.

Potential Explanations for Increasing Methylphenidate Use in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder in Germany From 2004 to 2013

BACKGROUND

Despite a decreasing population of children and adolescents, the cumulative total amount of dispensed methylphenidate (MPH), the first-choice treatment of attention-deficit/hyperactivity disorder (ADHD) in this age group, has increased dramatically in Germany. We investigated potential reasons for this increase such as changes in the ADHD prevalence over time and other potential explanations including the cumulative amount of dispensed MPH per person.

METHODS

Based on German claims data, we calculated standardized annual ADHD prevalence rates, proportions of ADHD cases treated with MPH and/or psychotherapy, and mean cumulative defined daily doses of ADHD drugs for 3- to 17-year-old children and adolescents from 2004 to 2013.

RESULTS

The ADHD prevalence increased continuously from 2004 to 2011 and remained stable thereafter. In ADHD cases, there was little variation in the proportion of individuals treated with drugs and in the frequency of psychotherapeutic treatment during the whole study period. The annual cumulative mean amount of MPH defined daily doses increased by approximately 30% from 2004 to 2008.

CONCLUSIONS

Our analyses suggest that the increase in MPH use in Germany was mainly influenced by an increasing ADHD prevalence and increasing amounts of dispensed MPH per person.

Leisure-time physical activity among adolescents and subsequent use of antidepressant and hypnotic drugs: a prospective register linkage study

In this prospective study, the association between physical activity and subsequent use of antidepressant and hypnotic drug use in adolescents aged 15-16 years was examined. This study is based on information retrieved from the Norwegian Youth Health Surveys (2000-2003) and linked to prescription data from the Norwegian Prescription Database (2004-2013). In total, the study included 10711 participants with a participation rate of 87%. Adolescents were asked how many hours per week they spent on physical activity that made them sweat and/or be out of breath outside of school. Incident psychotropic drug use (outcome measure) was defined as ≥ 1 prescription of one of the following psychotropic drugs: hypnotics and antidepressants registered in the Norwegian Prescription Database. In the crude model for the time period 2004-2007, the odds of incident hypnotic use were lower for those who were physically active 1-2 h per week (OR 0.48-0.64), compared to those who were physically inactive (< 1 h per week). However, the association become non-significant 4-year post-baseline (2008-2010 and 2011-2013). In the crude model for the time periods 2004-2007, 2008-2010 and 2011-2013, the odds of incident antidepressant use were lower for physically active adolescents (2004-2007: OR 0.46-0.71, 2008-2010: OR 0.40-0.67 and 2011-2013: OR 0.37-0.58, compared to those who were physically inactive < 1 h. However, after adjustment for confounders, the association became non-significant in all time periods except in physical activity 5-7 and 8-10 h in the period 2008-2010. Physical activity does not indicate any association with later use of antidepressants, and the significant association with incident hypnotic drug use was for short-term follow-up only and disappeared on longer term follow-up periods. Given the scarcity of longitudinal studies examining the association between physical activity and mental health as well as psychotropic drug use among young people, the current study adds to previous research.

[Use and misuse of benzodiazepines out of France]

Among 8 countries included in the report of ANSM, France is second behind Spain, when defined daily doses (DDD) are considered. Few studies, recent and based on representative samples of population, investigated the use of benzodiazepines in other countries and data are limited to compare France and other countries. In most countries, the use of benzodiazepines increases with age and is more frequent in women than in men. Variations of benzodiazepines use that were observed in other countries are similar to those observed in France, with a slight decrease but persistent high levels of use. In most countries, the long-term use of benzodiazepines is stable over time even though simple use decreases.

Psychotropic medication in children and adolescents in the United States in the year 2004 vs 2014

BACKGROUND

There is a global perception that psychotropic utilization in children and adolescents is increasing in the US.

METHODS

We present prevalent estimates for all psychotropics prescribed in the US (using commercial claims from Medicare and Medicaid) to children and adolescents in 2004 (total population N = 6,808,453) and in 2014 (total population N = 11,082.260). Further we evaluated if there has been a statistically significant change in prevalence during this time period. Analyses were stratified for the 6 major drug classes, all individuals' psychotropics (87 drugs), age and sex.

RESULTS

The prevalence of psychotropic drug prescription was 8.55% in 2004 and 9.00% in 2014 (age stratified in 2004 and 2014 toddlers: 3.08 and 2.63%, children: 8.74 and 8.73%, adolescents: 10.89% and 12.11). The prevalence for each drug class in 2004 and 2014 was: stimulants/other ADHD drugs 5.0 and 5.8%; antidepressants 2.8 and 2.7%; anxiolytic-hypnotic-sedative 2.2 and 2.3%; mood stabilizers 0.1 and 0.1%; antipsychotics 1.3 and 1.1%; and for drugs treating drug dependence 0.02 and 0.02%.

CONCLUSIONS

The perception that psychotropic utilization in children and adolescents is increasing in the US, derived from the 2 to 3 fold increase seen from the mid 80's to the mid 90's is not valid anymore. There has been a slowdown in the increase of prescribing psychotropics. In the last 10 years, in toddlers there was a decrease in the prescription; in children there was no change; and in adolescents there was a slight increase. The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall. Graphical abstract In the last 10 years there has been a slowdown in the increase of prescribing psychotropics. In toddlers there was a decrease in the prescription (3.08 and 2.63%); in children (8.74 and 8.73%) there was no change; and in adolescents there was a slight increase (10.89% and 12.11). The prescription of antidepressants, antipsychotics and mood stabilizers has decreased overall.

Increase in diagnosis of depressive disorders contributes to the increase in antidepressant use in adolescents

OBJECTIVE

To study if the observed increase in use of antidepressants (AD) among adolescents may be explained by higher incidence of depressive disorder diagnosis, increasing treatment of other mental disorders or more liberal prescribing practice.

METHODS

We used three different study populations of girls and boys aged 13-17 years in Norway: 1) individuals who were diagnosed with depressive disorders in primary health care, 2) individuals who were diagnosed with depressive disorders in secondary health care; 3) individuals who were dispensed ADs as recorded in the prescription database. Dataset 2) and 3) were linked.

RESULTS

Incidence of depressive disorders increased from 2010 to 2015 both in primary and secondary health care, especially in girls. One in four girls with incident depressive disorders was prescribed ADs and this proportion was stable over time. Among girls treated with ADs the proportion with a diagnosis where AD treatment is indicated increased from 61.1% to 66.0%. Furthermore, the proportion with moderate or severe episodes of major depressive disorders was stable and high, 72.9% in 2014.

CONCLUSION

The only issue studied that could explain increasing AD use in girls was increasing incidence of depressive disorders. Most adolescents with incident diagnosis of depressive disorders were not treated with ADs.

Decreasing Trend in the Use and Long-Term Use of Benzodiazepines Among Young Adults

OBJECTIVE

Patterns of benzodiazepine (BZD) use and long-term use among young adults are not well known. Our aim was to study trends in BZD use and long-term use among 18-25-year-old young adults by gender and active substance in a nationwide retrospective longitudinal register-based setting.

METHODS

All Finns aged 18-25 years with reimbursed purchases of BZDs in 2006-2014 recorded to the Finnish Prescription Register were included. Annual prevalence rates of BZD use and long-term use among young adults were reported overall, according to gender, drug group (anxiolytic or hypnotic), and active substance. Long-term use of BZDs was defined as purchasing ≥180 Defined Daily Doses (DDDs) in at least two drug purchases during a calendar year.

RESULTS

Overall prevalence of BZD use among young adults decreased from 24.0 to 18.8 users per 1000 inhabitants in 2006-2014. Prevalence of long-term use decreased from 5.5 to 3.3 users per 1000 inhabitants. Overall BZD use was higher among females, whereas long-term use was more common among males. Use of anxiolytics was more common than use of hypnotics. Oxazepam, alprazolam, zopiclone, and zolpidem were the most used BZDs, whereas alprazolam and clonazepam were the substances with most long-term use. The use and long-term use of BZDs have decreased annually since 2008 among Finnish young adults. Further research is needed to investigate the reasons behind the decline.

Patterns and profiles of methylphenidate use both in children and adults

AIM

The aim of the present study was to characterize patterns of use of methylphenidate (MPH), a prescription stimulant medication recommended in the treatment of attention deficit hyperactivity disorder (ADHD) and of narcolepsy, in France, both in children and adults, over a 3-year period.

METHODS

Using the French General Health Insurance database, limited to two areas covering approximately 4 million individuals, we made up a cohort of incident MPH users between July 2010 and June 2013. Splitting them into distinct age groups (18-24, 25-49 and ≥50 years of age for adults and <6, 6-11 and 12-17 years of age for children), we established the characteristics of these populations at MPH initiation and during follow-up according to the duration of treatment, quantities dispensed and coprescription with central nervous system (CNS) drugs.

RESULTS

We included a cohort of 3534 incident users, involving 30 238 dispensings of MPH, leading to an annual rate of 29 incident users per 100 000 in 2013. Children (66% of new users) were characterized by long-term use of MPH with few comedications. The group of 25-49-year-old patients were dispensed MPH more frequently than other groups, had the highest mean dose and were more often coprescribed other CNS drugs. The ≥50 year-old group was more often coprescribed antidepressants and antiparkinsonian drugs.

CONCLUSIONS

Our pharmacoepidemiological study involving incident MPH users with a large number of characteristics showed different patterns of MPH use among children and adults. The results from the 25-49-year-old group suggested that MPH might be being used for medical conditions other than ADHD or narcolepsy in adults, and that it might be subject to misuse and/or abuse.

Has life satisfaction in Norway increased over a 20-year period? Exploring age and gender differences in a prospective longitudinal study, HUNT

AIM

The aim of the present study was to investigate the change in overall life satisfaction for different age groups and between genders over a 20-year period.

METHODS

Data from 1984 to 2008 were extracted from a large prospective longitudinal health study of Nord-Trøndelag (HUNT), Norway. The study included more than 176,000 participants ranging from 20 to 70+ years of age. Data were analysed using logistic regression and adjusted for gender.

RESULTS

The analyses revealed an increase in life satisfaction for all age groups from 1984-1986 (HUNT 1) to 1995-1997 (HUNT 2), with the highest levels being reached at 2006-2008 (HUNT 3). For all age groups, the data showed an increase of about 20% for the period from 1984-1986 (HUNT 1) to 1995-1997 (HUNT 2). From 1995-1997 (HUNT 2) to 2006-2008 (HUNT 3), the increase in overall life satisfaction was 16% for the younger age groups, and about 32% for the older age groups (40-69 and 70+ years). Women's scores for overall life satisfaction were higher for nearly all age groups when compared to men using HUNT 3 as a reference.

CONCLUSIONS

These findings suggest an increase in life satisfaction for all age groups from 1984 to 2008, especially for the older age group (40-69 and 70+ years). The data indicate that women score higher on life satisfaction for most age groups as compared to men.

Movement Disorders in Children and Adolescents Receiving Antipsychotic Pharmacotherapy: A Population-Based Study

OBJECTIVES

To describe a cohort of young users of risperidone and quetiapine in the province of Manitoba (Canada) and assess the risk for movement disorders in the two treatments.

METHODS

This was a population-based study conducted on all residents of the province of 19 years of age and younger who received prescriptions for risperidone or quetiapine between April 1, 1996, and March 31, 2011. Incident rates of antipsychotic use were reported. The risk for movement disorders in patients treated with quetiapine compared with those treated with risperidone was assessed by time-to-event analysis using Cox proportional hazards models.

RESULTS

Between April 1, 1996, and March 31, 2011, 23,888 youth (age ≤19 years) were prescribed an antipsychotic agent. Among them, 8756 were identified as new incident users. After applying exclusion criteria, 2594 individuals comprised the cohort of users of risperidone and quetiapine. The use of quetiapine was associated with a lower risk of extrapyramidal symptoms (EPSs) adverse events. The unadjusted and adjusted hazard ratios (95% confidence interval [CI]) for quetiapine versus risperidone were 0.83 (0.56-1.25) and 0.53 (0.34-0.83), respectively.

CONCLUSION

EPS diagnoses have been detected in children treated with quetiapine; however, the risk of movement disorders appears to be higher with treatment with risperidone. Clinicians should always take into consideration the risk-benefit before treating children with antipsychotic medications and should be vigilant of the onset of drug-induced adverse events.

The predictive value of ABCB1, ABCG2, CYP3A4/5 and CYP2D6 polymorphisms for risperidone and aripiprazole plasma concentrations and the occurrence of adverse drug reactions

We investigated in ninety Caucasian pediatric patients the impact of the main polymorphisms occurring in CYP3A, CYP2D6, ABCB1 and ABCG2 genes on second-generation antipsychotics plasma concentrations, and their association with the occurrence of adverse drug reactions. Patients with the CA/AA ABCG2 genotype had a statistically significant lower risperidone plasma concentration/dose ratio (Ct/ds) (P-value: 0.007) and an higher estimated marginal probability of developing metabolism and nutrition disorders as compared to the ABCG2 c.421 non-CA/AA genotypes (P-value: 0.008). Multivariate analysis revealed that the ABCG2 c.421 CA/AA genotype was found associated to a higher hazard (P-value: 0.004) of developing adverse drug reactions classified as metabolism and nutrition disorders. The ABCB1 2677TT/3435TT genotype had a statistically significant lower aripiprazole Ct/ds if compared with patients with others ABCB1 genotypes (P-value: 0.026). Information obtained on ABCB1 and ABCG2 gene variants may result useful to tailor treatments with these drugs in Caucasian pediatric patients.

Clinical use of second-generation antipsychotics in children

Background

The use of second-generation antipsychotic (SGA) medication among child and adolescent psychiatric patients has increased worldwide in recent years. The increase appears to have been more extensive in the USA than in European countries, but the tendency is similar. However, after a peak the use seems to have declined in the USA. Simultaneously with the increasing numbers, the duration of SGA use has lengthened, indications have broadened, and off-label use has increased. Despite existing follow-up recommendations and evidence for the metabolic adverse effects of SGAs in children, research evidence has not translated into clinical practice.

Objective

The aim of this study was to assess the clinical use and follow-up practices of SGA medication among child psychiatric patients of one university hospital in Finland.

Method

This retrospective patient report-based study was conducted at the Child Psychiatric Clinic of Tampere University Hospital, Finland. The study sample consisted of 133 patients who were younger than 13 years when initiating SGA treatment and had an ongoing SGA medication during the study period. The study sample was divided into two groups according to diagnosis to examine whether there were differences between patients with an autistic or a developmental disorder (F83-84) and patients with other psychiatric diagnoses.

Results:

This study showed that SGA use in children younger than 13 years was mainly off-label. Irrespective of diagnosis, the most common indication was aggression. Especially children with psychiatric diagnoses other than developmental disorders had multiple socio-demographic risk factors and adverse life experiences in their background. The follow-up practices were diverse and partly irregular.

Conclusions:

A need for systematic SGA monitoring practices and dialogue between the medical specialities treating children and their families is evident.

Antidepressant drug use among adolescents during 2004-2013: a population-based register linkage study

OBJECTIVE

To study trends in use of antidepressants (ADs) by adolescents, and psychiatric morbidity and use of other psychotropic drugs as a measure of psychiatric comorbidity.

METHODS

One-year prevalence of AD drug use was analyzed for 13- to 17-year-old Norwegians during 2004-2013. Use of other psychotropic drugs and specialist healthcare services was analyzed for incident AD users in 2012, using linked data from the Norwegian Prescription Database and the Norwegian Patient Register.

RESULTS

The 1-year prevalence of AD drug use increased from 6.4/1000 to 9.1/1000 during 2004-2013, with the steepest increase from 2010, particularly among girls. The highest prevalence was found in 17-year-old girls (17.8/1000 in 2010, 27.5/1000 in 2013). Of incident AD drug users in 2012, 84.4% had been in contact with specialist health care. As the first drug, 78.4% were prescribed a selective serotonin reuptake inhibitor. The most common types of other psychotropic drugs were melatonin (24.6%), antipsychotic drugs (13.2%), stimulants (8.8%), and anxiolytics (6.0%).

CONCLUSIONS

Use of ADs among adolescents has increased over the last 3-4 years, particularly among 16- to 17-year-old girls. A total of 85% of incident users had been in contact with specialist health care, which may indicate that drug-therapy is used by adolescents with more severe symptoms.

Mental disorder diagnoses among children and adolescents who use antipsychotic drugs

Antipsychotic drugs are used increasingly by children and adolescents and there is concern about off-label use. We aimed to study which substances, and for which mental disorder diagnoses, antipsychotic drugs were prescribed to 0-18-year-old boys and girls in Norway. Linked data from the national health registry for prescription drugs in 2010 and mental disorder diagnoses in 2008-2012 were used to study the prevalence of antipsychotic drug use, the type of antipsychotic drug substances used, mental disorder diagnoses in users and distribution of drugs per diagnostic category across gender. In total, 0.18% of Norwegian children and adolescents were prescribed antipsychotic drugs during 2010, of which there were more boys (0.23%) than girls (0.13%). Risperidone was the most frequently used substance among boys (57.4%) and girls (32.3%), followed by aripiprazole (19.4%) in boys and quetiapine (27.4%) in girls. The most common mental disorder diagnoses among male users were hyperkinetic (49.9%) and autism spectrum disorder (27.1%), while anxiety disorders (41.5%) and depressive illness (33.6%) were most common among female users. A schizophrenia-like psychosis diagnosis was given to 11.1% of the male and 18.2% of the female users. A hyperkinetic disorder was diagnosed among 56.9% and 52.4% of the male risperidone and aripiprazole users, respectively. Among female quetiapine users, 57.1% were diagnosed with anxiety disorders and 52.4% with depressive illness. These results demonstrate that children and adolescents who use antipsychotic drugs are predominantly diagnosed with non-psychotic mental disorders such as hyperkinetic disorder among boys and anxiety disorder or depressive illness among girls.

Classics in Chemical Neuroscience: Methylphenidate

As the first drug to see widespread use for the treatment of attention deficit hyperactivity disorder (ADHD), methylphenidate was the forerunner and catalyst to the modern era of rapidly increasing diagnosis, treatment, and medication development for this condition. During its often controversial history, it has variously elucidated the importance of dopamine signaling in memory and attention, provoked concerns about pharmaceutical cognitive enhancement, driven innovation in controlled-release technologies and enantiospecific therapeutics, and stimulated debate about the impact of pharmaceutical sales techniques on the practice of medicine. In this Review, we will illustrate the history and importance of methylphenidate to ADHD treatment and neuroscience in general, as well as provide key information about its synthesis, structure-activity relationship, pharmacological activity, metabolism, manufacturing, FDA-approved indications, and adverse effects.