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In recent years the use of psychotropic medications for treating children and adolescents has grown dramatically. Much of this use has been "off-label," meaning specific dosages for particular populations--in this case, children--have not been established through clinical trials. Since 1999, Community Partnerships, Inc. has been managing Dane County's Children Come First program, which provides wraparound services for children and youth with severe and persistent mental illnesses. BJ: There has been a dramatic increase in recent years in the number of drugs prescribed to children for behavioral disorders and other mental health problems. What is driving this trend? TW: Those are global issues, and I'm not sure I'm the best expert to describe broad trends like that, which are market trends in some ways. One of the problems with children's mental health and medications has been that children don't have much political clout or financial clout, so often medications aren't tested for them. So there's been very little research historically on how some medications work on kids. The government took steps to try to fix that about 10 years ago. They allowed manufacturers of pharmaceuticals to extend their patents on certain medications if they did good, controlled studies with kids, as well as other populations that had typically been neglected in studies. As a result of that, a lot of the pharmaceutical companies did start looking at medications for kids, because it probably served them as a business decision at that time. So when that happened, a much larger number of studies started being done, looking at clinical trials of medications in kids, and as a result, we have better data. So with better data and FDA (U.S. Food and Drug Administration) approval, people are more likely to use a drug than if they don't have any good data. That's one of the things that happened. But you don't always need to test medications on special populations, whether it's kids or women or African Americans or Hispanics. There can be a lot of physiological differences based on a lot of different criteria, and children happen to be one of them. We call that off-label use, when something hasn't been FDA-approved specifically for use in children. Generally, clinicians have no problem with this when clinical practice out there has demonstrated safety. It's a very laborious and expensive process to get FDA approval for use of a certain medication in a certain special population, and for pharmaceutical companies it just may not be a good business decision to go through that process if they already have a lot of evidence that the drug is safe and effective. Which is okay to do if the medical community has accepted it based on whatever data is out there, even if they aren't FDA-sanctioned clinical studies. BJ: Is this escalation in the use of these meds in children driven more by medical necessity or by business concerns? TW: I think there's a business angle when a pharmaceutical company tries to get FDA approval for something, but I'm not sure if that's the reason...I don't really know enough about the global trend to say what's behind the increased use, or how much of the increase could be attributed to pharmaceutical companies pushing their drugs on doctors and the public. I just don't know the answer. BJ: Does it seem like in some cases there are other lower-risk interventions that are being bypassed because it's easier to write a prescription than to do a difficult, non-chemical kind of intervention? TW: Medications always need to be looked at as part of broader treatment strategy; there's often other types of treatments, and it shouldn't be an either/or situation, like we either do medication or we do psychotherapy. For many disorders that medications have proven to be useful in treating, the best studies have also shown that psychotherapy or family intervention or school intervention can either work as well as the medication, or if used in combination with medication, people often improve faster or need lower dosages of the medications. I think most people want the easiest way out. I don't think it's just clinicians or just pharmaceutical companies. I think parents tend to think this way too. To do psychotherapy on a kid requires a fair amount of time and a fair amount of money and a fair amount of commitment. Sometimes it's easier on parents just to give a medication. It would be very convenient if parents just needed to come in once a month to get a refill, but there's always something else that's supposed to go along with it. Whether parents or families or schools always follow through is another question. What is happening everywhere in health care is a growing emphasis on cost-benefit ratio. What's gonna cost the least to get the most benefit? And I think that leads a lot of people to believe that medication is the most favorable part of the treatment, since everything else costs more and takes longer. In my opinion one of the reason's medications are being used so much more in kids these day is that families are very busy, and we're oriented toward very fast results. Probably as a whole, medications have a quicker effect than psychotherapy or family therapy or school interventions do, so I think both families and schools are eager to change behaviors quickly. So there's a pressure to do whatever they think will work fastest. Another factor is how health care is being run these days. Many managed care organizations will only pay for a certain amount of time for a particular individual for a particular illness. It may be that physicians are pressured to see kids very quickly and so sometimes thorough evaluations don't get done. And I think education doesn't happen in the office as much as it should because clinicians are under pressure to see so many kids in such a short period of time. Medications are more compatible with a quick visit than other kinds of treatments are. The third thing is that there's a shortage of child psychiatrists nationally. Not that child psychiatrists always do a better job with medications than family practitioners or pediatricians...in fact there are many family practitioners and pediatricians I know who do a great job with it...but I think we spend a lot more time training about evaluation and choosing medications relative to those other kinds of doctors. But because of the shortage, a lot of times kids end up going to the pediatrician and often they just don't have the same knowledge base. And certainly primary care physicians are much more oriented toward the biological treatments available compared to a psychiatrist. BJ: Why should somebody reading an article about the surge in medication for kids, often more than one drug in combination, be concerned about this? TW: Any kind of intervention being done with your kids, you should be concerned about. This polypharmacy (use of multiple drugs in combination), that's really uncharted territory. We can't study all the combinations that could come up, like do a really gold standard study on high does of this with a low dose of that, etc....I mean there are all sorts of combinations that never will be studied and never could be studied. We have to rely on our clinical judgment in order to make good decisions in those situations, but that's really uncharted territory that to me is a little scary and needs to be approached cautiously. Sometimes parents and kids are left with no other choices. If a behavior problem is pretty significant and if they've done everything they can therapeutically and behaviorally, sometimes people feel like they don't have any other options. BJ: Suppose I'm a parent of a child who's starting to show some problematic symptoms or behaviors and there's a doctor who wants to start my kid on a battery of meds. What can I do to make sure the best practices are being followed? TW: Parents need to ask a lot of questions and make sure they are receiving the necessary information, both through discussion with the doctor but also from other sources. All medications have side effects and other risks, and parents, and the kids themselves if they're old enough, need to work together with doctors and other professionals to weigh out the risks versus the benefits. But it's up to them to gather all the information they can so they can make the best decision for their family. And always ask what other alternatives there are besides medication, and what evidence there is that those alternatives might be useful. I don't think any parent or adolescent should do anything just because their doctor says so. They should look at their doctor as a consultant who is giving them information and a recommendation, but it's up to the family to make the treatment decision based on the best information available to them. The doctor shouldn't be their ONLY source of information. | ||||
