ANN ARBOR, Mich. - The 1990s saw a dramatic rise in the number of children and adolescents receiving Ritalin-type stimulant drugs and Prozac-type antidepressants among a population of children studied by researchers at the University of Michigan. The new study also documents the rise of a newer phenomenon: kids who are prescribed both kinds of drugs at the same time.
The trend toward giving two behavioral drugs to the same child raises questions, the authors say, about how physicians diagnose and treat children's mental disorders. Thirty percent of children in the study who were on the newer type of antidepressants called selective serotonin reuptake inhibitors, or SSRIs, also took stimulants.
"New drugs nearly always experience a rise in prescriptions over the first few years of their lifespan, but the consistent increase in SSRI use and in dual prescriptions is especially surprising," says U-M pediatrician and lead author Jerry Rushton, M.D., MPH. "We need further information about whether this is due to new unrecognized mental disorders, substitution for other therapies, or overprescription."
SSRIs have only gained approval for select indications in children during the last two to three years, and little research has been done on the safety of medications in very young children and the safety of combining them with stimulants. But some physicians seem to be prescribing them nonetheless.
Rushton discussed data from the study of prescription claims among young Medicaid recipients in North Carolina today in his presentation to the annual meeting of the Pediatric Academic Societies and the American Academy of Pediatrics.
Though the data are limited to a single state's Medicaid population, they provide a unique preliminary indication of how quickly stimulant and antidepressant use rose among children from 1990 to 1998, and how many children are receiving both types of medication.
It is not clear from the study whether the prescriptions for SSRIs and for combination prescriptions were for ADHD alone, or for multiple concurrent psychiatric disorders. SSRIs are not approved for the treatment of attention deficit hyperactivity disorder.
The study also reveals demographic trends among those who are being given the medications. Prescription rates for the two different drugs in the studied population differed widely: 1.7 percent of children aged 6 to 14 received SSRIs in 1998, versus 10.7 percent for stimulants. The mean age of stimulant recipients is holding steady at around 9 years, while the mean age of those getting SSRIs has dropped from 15 years to around 13 years.
Three times as many boys as girls are on Ritalin and other stimulants, according to the study, while the gender gap in SSRI prescriptions that once saw twice as many girls on the drugs has closed.
Meanwhile, it appears that white children might be more likely to get SSRIs than those of other races or ethnicities, while Hispanic children could be less likely to be prescribed stimulants, reflecting known trends in access and medication rates shown earlier for other types of drugs.
Stimulants such as Ritalin and Dexedrine are most often used to treat children diagnosed with attention-deficit hyperactive disorder, while antidepressants such as Prozac, Zoloft and Paxil are used in the treatment of serious depression, school phobias and other serious anxiety disorders, bedwetting, some bulimic-type eating disorders, and, rarely, for attention-deficit hyperactive disorder.
Says Rushton, "One of the biggest questions this study raises is whether the children who are prescribed both types of medication have both types of disorders, or whether their physicians are recommending these medications for other reasons."
Rushton is also the author of a recently published study on physicians' treatment strategies for childhood depression. In that research, he found that most primary care physicians still rely mostly on referral and counseling, rather than medications like SSRIs, for their young patients. But he also found that many physicians reported a lack of comfort with diagnosing and treating depression in young patients.
The new study looks at the same issue from a different perspective. Instead of asking primary care physicians what they do about depressed patients, it examines the actual prescription claim records for all types of physicians in the North Carolina Medicaid program. His co-author on the study was J. Tim Whitmire, Ph.D., of the North Carolina Department of Health and Human Services' Center for Health Statistics.
Besides gauging the difference in prescription rates and demographics of recipients, the study looked at the nature of the prescriptions. Says Rushton, "The steep climb in numbers of children receiving either or both of these drugs was accompanied by an increase in the dose and duration of the stimulants and antidepressants that were prescribed."
Approximately 5 percent of children and adolescents may suffer from depression, which if left untreated can lead to suicide or more severe depression in adulthood. The symptoms, including a persistent sad or irritable mood, loss of interest in previously enjoyed activities, and difficulty sleeping or oversleeping, are often mistaken as part of the normal course of growing up. But if the disorder is spotted early, treatments like psychotherapy, medications and changes in the home or school environment are believed to help a large percentage of patients.
Rushton's study, initiated while he was at the University of North Carolina, was supported by the Robert Wood Johnson Clinical Scholars Program.