A nationally representative survey of more than 10,000 adolescents and their parents found "no compelling evidence for either misuse or overuse of psychotropic medications," according to a report published online Dec. 3 in Archives of Pediatrics and Adolescent Medicine.
Only 2.5% of these youths who had no DSM-IV diagnosis reported psychotropic use during the preceding year, and the clear majority of them had severe impairment or suicidality that warranted the treatment, said Kathleen R. Merikangas, Ph.D., of the National Institute of Mental Health, Bethesda, Md., and her associates.
Far from confirming concerns about inappropriate prescribing of psychotropic medications in the pediatric population, these study findings suggest that the agents are in fact underused and that mental health disorders are underrecognized in children and adolescents, the investigators said.
The "substantial" controversy over this issue has been generated chiefly by "anecdotal reports, studies of small unrepresentative clinical samples, and secondary analyses of large databases on prescription drug use that lack detailed clinical information about individual patients," Dr. Merikangas and her colleagues said.
"To our knowledge, no previous study has examined patterns of specific classes of psychotropic medication use among youth across a full range of common mental disorders and service sectors in a large nationally representative sample of adolescents," they added.
Their study drew on data from the National Comorbidity Survey Adolescent Supplement, a survey of 10,123 youths aged 13-18 years across the United States who were interviewed directly in 2001-2004 regarding their use of mental health services and medications during the preceding year. This included a household sample of 879 subjects and a school sample of 9,244. Parents or their surrogates were interviewed separately via written questionnaire, providing information on the subjects’ sociodemographic status, development, and physical and mental health.
The mean age of the study population was 15.2 years, and it was equally divided between boys and girls. The sample was predominantly (65.6%) non-Hispanic white. Most of the adolescents’ parents (85%) had completed at least a high school education, and 78.6% of the subjects lived with either married or cohabiting parents.
The interviewers administered a modified version of the World Health Organization Composite International Diagnostic Interview, which generated DSM-IV diagnoses for mood, anxiety, eating, behavior, and substance use disorders. The subjects and their parents also detailed the use of psychotropic medication for behavioral or emotional problems during the preceding year. The drugs were categorized in broad classes as antidepressants, stimulants, anxiolytics, mood stabilizers, or antipsychotics.
Overall, 24.9% of the study subjects said they had received mental health services during the past year.
Only 2.5% of adolescents without a DSM-IV diagnosis had been given psychotropic medications, and the clear majority of them "had evidence of psychological distress or impairment reflected in a lifetime history of mental disorders, subthreshold conditions, or developmental disorders," the investigators said (Arch. Pediatr. Adolesc. Med. 2012 Dec. 3 [doi:10.1001/jamapediatrics.2013.431]).
The clear majority of adolescents who reported using psychotropics, "particularly those who received treatment in specialty mental health settings, had a mental disorder with severe consequences and impairment, functional impairment, suicidality, or associated behavioral and developmental difficulties. When neurodevelopmental disorders, lifetime history, and subthreshold conditions are considered, there are few youths treated with psychotropic medications who did not have a serious behavioral, cognitive, or emotional disturbance," they noted.
Even among adolescents with a DSM-IV disorder, only 14.2% said they had been treated with a psychotropic medication.
The disorder with the highest prevalence of medication use was attention-deficit/hyperactivity disorder; 31% of the subjects with ADHD reported using psychotropics, as did 19.7% of those with mood disorders, 19.3% of those with eating disorders, 19.3% of those with behavior disorders, 14.4% of those with substance use disorders, and 11.6% of those with anxiety disorders.
The prevalence rates of use of the strongest psychotropic agents in particular were "very low." Only 1% of subjects with DSM-IV disorders used antipsychotics, only 0.7% used mood stabilizers, and only 1.3% used anxiolytics.
"The highest rates of psychotropic medication use were observed among those with a developmental disorder/autism (42%) or self-reported suicidality (27.1%)," Dr. Merikangas and her associates said.
Antidepressants were used primarily by subjects with depression or bipolar disorder, and less often by those with anxiety disorders. "Only 1.3% of those with no DSM-IV disorder reported antidepressant use during the past year," the researchers said.
Similarly, stimulants were used primarily by subjects with ADHD, though a small proportion (6%) of youth with other behavior disorders used stimulants. "Only 0.8% of those without a DSM-IV disorder reported stimulant use," they noted.
The proportion of subjects who used antipsychotics was "very small." Only 2% of subjects with developmental disorders or learning disabilities, 1.7% with bipolar disorder, and 1.8% with behavioral disorders used the drugs. And among subjects without a DSM-IV disorder, "only 0.1% ... reported antipsychotic prescriptions."