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US study finds prescription of psychotropic drugs doubled 1995-2010


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Study suggests overprescription might be a "quality of care" issue among non-psychiatrist physicians.
Kids' Psychiatric Visits a Growing Concern
Published: Nov 27, 2013
By John Gever, Deputy Managing Editor, MedPage Today

    [*]Note that this analysis of National Ambulatory Medical Care Survey Data reveals increasing utilization of psychiatric practitioners among children and adolescents over the past 15 years. [*]Be aware that this increase in access ran parallel to an increase in psychotropic medication use.

Sixteen years of data from a large federal survey indicated that outpatient visits resulting in mental health diagnoses increased significantly in the U.S., especially in children and adolescents.

Rates of such visits for individuals younger than 21 nearly doubled from 1995 to 2010 (from 7.78 to 15.30 per 100 population), while those for adults 21 and older rose from 23.23 to 28.48 per 100, according to Mark Olfson, MD, MPH, of Columbia University in New York City, and colleagues.

Visits resulting in prescriptions for psychotropic drugs doubled in both age groups during the study period, the researchers reported online in JAMA Psychiatry from their analysis of National Ambulatory Medical Care Survey data.

Use of psychotherapy increased moderately in youths, but declined in adults, Olfson and colleagues also found.

"The bulk of the increased provision for child and adolescent mental health care in office-based medical settings occurred outside of psychiatric practice," the investigators noted.

"With these evolving practice patterns, tensions will inevitably arise between access and quality of care. To meet this challenge, there is a pressing need to develop and implement effective models of collaboration among pediatricians, family practitioners and other nonpsychiatrist physicians who treat children and adolescents, and suitably trained mental health care specialists."

Their analysis covered some 447,000 outpatient office visits during the 16-year study period, reported by physician offices during a specified week to the National Center for Health Statistics. Response rates went from about 58% to 73% during this time. The survey requested patients' sociodemographic and clinical data (including ICD-9 codes for diagnoses made) along with medications prescribed or given at the visits.

Olfson and colleagues reported results for four 4-year periods spanning the study interval.

Diagnoses of any mental disorder trended steadily upward for adults through the four periods. In the younger age group, the rates increased during the first three periods, ending in 2006, at which point it stood at 15.37 per 100 population (95% CI 12.50-18.24), then stayed essentially the same during the 2007-2010 quadrennium.

The odds ratio for receiving a psychiatric diagnosis in individuals younger than 21 during the fourth versus first quadrennium was 1.90 (95% CI 1.55-2.33). For those 21 and older, it was 1.07 (95% CI 0.94-1.21).

Rates of psychotherapy delivered during youths' visits rose from 2.25 per 100 population in 1995-1998 to 3.17 per 100 in 2007-2010, with an odds ratio of 1.24 (95% CI 0.87-1.77). In adults, it fell from 8.37 to 6.36 per 100 (OR 0.57, 95% CI 0.44-0.75).

Visits to psychiatrists approximately doubled in youths (from 2.86 to 5.71 per 100; OR 1.70, 95% CI 1.19-2.43). Adult psychiatric visits remained essentially flat, in the range of 10 to 11 per 100 population (OR 0.85, 95% CI 0.66-1.09).

The most common diagnoses in youths involved disruptive behaviors followed by mood disorders. Rates approximately doubled in every major category -- which also included anxiety and psychoses/developmental disorders -- except for "other."

The largest percentage increases in psychotropic drug prescriptions to youths were seen in ADHD medications, which tripled, and antipsychotics, which rose by about 10-fold.

The rate of antipsychotic prescriptions surpassed two per 100 population in the third and fourth quadrennia, Olfson and colleagues found.

ADHD drugs were prescribed at a rate of more than nine visits per 100 population in the 2007-2010 period, versus three in 1995-1998 and 5.5 in 2003-2006.

The researchers also examined children (age 0-13) and adolescents (age 14-20) separately. ....Findings for the corresponding categories of medications were similar.

Children were also less likely to receive diagnoses from psychiatrists; most were made by pediatricians. And Medicaid was associated with higher diagnosis rates compared with private or no insurance.

The study did not permit a direct comparison with rates of mental health services provided to young people with mental health diagnosis, which was the subject of a different analysis of federal survey data published last week. That study, involving data from the National Comorbidity Survey, found that fewer than half of teens with mental illness received treatment.

However, Olfson and colleagues commented that the increase in psychiatry-oriented visits over time in their data "suggests that progress has been made in reducing the large number of young people with untreated psychiatric disorders."

They were less sanguine about the rise in ADHD drugs prescribed to youths, which "raises potential safety concerns," they wrote.
Olfson and colleagues also expressed concern about the sharp increase in antipsychotic prescriptions to youths, most notably by nonpsychiatrists, for which they offered no potential justification.

"As pediatricians, family practitioners, and general practitioners assume a more prominent role in prescribing antipsychotics to children and adolescents, more consultations with psychiatrists and other mental health specialists will be needed to ensure appropriate diagnostic assessments together with appropriate symptom and adverse event monitoring," the investigators wrote.

These concerns were echoed in an accompanying editorial by Paramjit T. Joshi, MD, of George Washington University in Washington, D.C., who cited the influence of pharmaceutical companies and the time pressures on clinicians as factors.

The result is that pharmacotherapies have supplanted psychotherapy in many practices, Joshi wrote.

Olfson and colleagues devoted most of their discussion of the results to those related to youths, noting that the temporal changes among adults were relatively small.

Limitations to the analysis included the possibility that some patients may have been counted twice, arising from the National Ambulatory Medical Care Survey methodology that focuses on visits rather than patients; diagnoses were made according to clinicians' judgment and were not standardized; medication dosages were not known; and the survey excluded community mental health centers, hospital outpatient clinics, and emergency departments, such that visits by low-income patients were likely underrepresented.

"For these reasons, the population-based results should not be interpreted as representing population-wide mental health care use," Olfson and colleagues stressed.

The study was funded by the Agency for Healthcare Research and Quality and by the National Institute of Mental Health.

Study authors and Joshi had no relevant financial disclosures.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Medicaid is associated with being diagnosed, I believe, even among adults. It's even sadder that so many children are being labeled and drugged.


I watched an episode of 20/20 about how foster kids were labeled and drugged frequently. One little girl had a bag that contained 13 partially filled pill bottles and was off all of them. Several other families were interviewed and the children had all been on several meds. A couple were a little older but most were young, like 10 or under, if I recall correctly.

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