“What you're showing us is very, very scary,” he told Dr. Newcomer, who replied that the metabolic impacts of other classes of drugs widely used in children, including benzodiazepines and high-dose antidepressants, are also potentially concerning.
“We're having this policy debate under a streetlamp as though second-generation antipsychotics are the only drugs that cause weight gain,” Dr. Newcomer said. “Let's not kid ourselves.”
One alternative raised at the session was intensive behavioral modification, such as a yearlong, school-based program for disruptive children described by Dr. Jacob Venter of Wellesley, Mass., and his colleagues at the same APA scientific session.
Dr. Newcomer pointed to the University of Arizona behavioral study as an example of how nonpharmacologic interventions can produce “some good results,” even among children with severe behavioral dysregulation.
“The problem is, I don't know about your town, but in St. Louis, there is a 6-month waiting list to see a child psychiatrist,” he told the audience.
By the time they can be seen, “these families are in great distress and sometimes aren't terribly interested in taking those referrals for behavioral treatments, either because they already tried some therapy or because they seek rapid change,” he said.
Families want the quick responses they associate with medication, and when a trial of behavioral modification is suggested as a starting place, “we can't give it away.”
As for trying to reduce prescribing of antipsychotic medications to children, particularly among those who do not have symptoms consistent with bipolar disorder or schizophrenia, Dr. Newcomer, who also chairs Missouri's Drug Utilization Review Board, was somewhat skeptical about the potential to substantially reduce that clinical practice.
“Like it or not, that horse is out of the barn. The clinical benefits can be obvious to parents, children, and their doctors, so there will continue to be interest in this therapeutic approach, even as we fully elaborate the risks. This is happening all over the country. The rates of prescriptions are going up. The off-label use is tremendous, suggesting a lot of unmet need,” he said.
Indeed, a series of studies conducted by a team led by Dr. Mark Olfson at Columbia University, New York, has found that prescribing of antipsychotic medications by psychiatrists and primary care physicians has skyrocketed in the United States since the mid-1990s, with treatment of disruptive behavior disorders, including attention-deficit/hyperactivity disorder, playing a significant role in the increase.
In one example, Dr. Olfson reported that antipsychotic use by 2- to 5-year-olds covered by private insurance rose from 0.78/1,000 to 1.59/1,000 from 1999 to 2007.
Less than half of the children in the study had received a mental health assessment, a psychotherapy visit, or a consultation with a psychiatrist.
Antipsychotic medication was prescribed in more than 1.2 million outpatient office visits by children in 2002, up from 201,000 in 1993, Dr. Olfson reported (Arch. Gen. Psychiatry 2006;63:679–85). Diagnoses of disruptive behavior disorders (37.8%), mood disorders (31.8%), pervasive developmental disorders or mental retardation (17.3%), and psychotic disorders (14.2%) accounted for most of those visits.
Dr. Newcomer disclosed that he has served as a consultant to several pharmaceutical companies but reported no financial conflicts of interest relevant to his study.