Use of powerful antipsychotic medications to control youngsters with attention-deficit/hyperactivity disorder (ADHD) and other behaviour problems has skyrocketed in recent years, a new study finds.
Antipsychotics are approved to treat bipolar disorder, schizophrenia, other serious mental problems and irritability related to autism. But they don't have US Food and Drug Administration approval for ADHD or other childhood behaviour problems, and their use for this purpose is considered "off label."
"Only a small proportion of antipsychotic treatment of children (6%) and adolescents (13%) is for FDA-approved clinical indications," said lead researcher Dr Mark Olfson, a professor of clinical psychiatry at Columbia University Medical Center in New York City. "These national trends focus attention on the substantial and growing extent to which children diagnosed with ADHD and other disruptive behavioural disorders are being treated with antipsychotic medications."
What the researchers found
The researchers found that doctor visits between 1993-1998 and 2005-2009 that involved a prescription of antipsychotic medication for children jumped sevenfold -- from 0.24 to 1.83 per 100 people. For teens, 14 to 20 years old, the rate rose from 0.78 to 3.76 per 100 people, and for adults, it just about doubled, from 3.25 to 6.18 per 100 people.
Many of the prescriptions for children were ordered by doctors who are not psychiatrists, the researchers found.
Although these drugs can deliver rapid improvement in children with severe conduct problems and aggressive behaviours, it is not clear whether they are helpful for the larger group of children with ADHD, he said. Nor has their long-term effect on children's developing brains been studied.
Olfson said most children and adolescents treated with antipsychotics are not receiving psychotherapy. "This suggests that more needs to be done to increase access and availability of psychosocial interventions," he said.
"Parent management training and cognitive problem-solving skills training are examples of effective but underused treatments for young people with disruptive behavioural problems," he said.
How the study was done
The study, published in the Archives of General Psychiatry, used data from the National Ambulatory Medical Care Surveys from 1993 to 2009. More than 484 000 people were included in total.
The researchers found prescriptions for antipsychotics increased for children and adults. But doctors prescribed more antipsychotics to children and adolescents (68% and 72%, respectively) than to adults (50%).
For children 13 and younger, the most prescribed drug was risperidone (Risperdal). Other drugs included aripiprazole (Abilify), quetiapine (Seroquel) and olanzapine (Zyprexa). Of these drugs, Abilify was most commonly prescribed to adolescents, aged 14 to 20, the study found.
All of these antipsychotics, developed since the 1990s, are considered "atypical" or second-generation antipsychotics.
For elderly patients, the FDA recently issued a Public Health Advisory about atypical antipsychotic medications after determining that death rates are higher for elderly people with dementia when taking atypical antipsychotics.
Dr Peter Breggin, a psychiatrist from Ithaca, NY, and an outspoken critic of widespread antipsychotic use in children, said these drugs damage developing brains.
"We have a national catastrophe," said Breggin. "This is a situation where we have ruined the brains of millions of children."
In controlling behaviour, antipsychotics act on the frontal lobes of the brain -- the same area of the brain targeted by a lobotomy, Breggin said.
"These are lobotomising drugs," he added. "Of course, they will reduce all behaviour, including irritability," he said.
Disruptive behaviour and medication
Olfson's team found that most children treated with antipsychotic medications are diagnosed with ADHD, oppositional behaviour and unspecified disruptive behavioural disorders.
Between 2005 and 2009, controlling "disruptive behaviour" accounted for 63% of the reason antipsychotics were given to children and almost 34% for adolescents, the researchers found.
In contrast, bipolar disorder and depression were the most common reasons these drugs were prescribed to adults during that time period.
Simon Rego, director of psychology training at Montefiore Medical Center/Albert Einstein College of Medicine in New York City, said these drugs have serious side effects, including weight gain, diabetes and heart problems.
"But, perhaps even more important is the finding that a substantial majority of the child antipsychotic visits were for young people diagnosed with disruptive behaviour disorders, for which there are currently no FDA-approved antipsychotic medications," he said.
Given the uncertain effects that antipsychotic medications have on cognitive (brain), social and physical development in children and adolescents, it may be necessary to reevaluate clinical practise patterns, Rego said.
Efforts to educate physicians about the safety and effectiveness of antipsychotic medications are also needed, he said.
ADHD is overdiagnosed
For more information on antipsychotics, visit the U.S. National Institute of Mental Health.
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