“sunlight is the best disinfectant”…

Posted on Thursday 13 December 2012

National Trends in the Office-Based Treatment of Children, Adolescents, and Adults With Antipsychotics
by Mark Olfson, MD, MPH; Carlos Blanco, MD, PhD; Shang-Min Liu, MS; Shuai Wang, PhD; and Christoph U. Correll, MD
Archives of General Psychiatry. 2012 69[12]:1247-1256.

Context: Although antipsychotic treatment has recently increased, little is known about how this development has differentially affected the office-based care of adults and young people in the United States.
Objective: To compare national trends and patterns in antipsychotic treatment of adults and youths in officebased medical practice.
Design: Trends between 1993 and 2009 in visits with antipsychotics for children (0-13 years), adolescents (14-20 years), and adults (21 years) are described on a per population basis and as a proportion of total medical office visits. Background and clinical characteristics of recent (2005-2009) antipsychotic visits are also compared by patient age.
Setting: Outpatient visits to physicians in office-based practice.
Participants: Visits from the 1993-2009 National Ambulatory Medical Care Surveys (N=484 889).
Main Outcome Measures: Visits with a prescription of antipsychotic medications.
Results: Between 1993-1998 and 2005-2009, visits with a prescription of antipsychotic medications per 100 persons increased from 0.24 to 1.83 for children, 0.78 to 3.76 for adolescents, and 3.25 to 6.18 for adults. The proportion of total visits that included a prescription of antipsychotics increased during this period from 0.16% to 1.07% for youths and from 0.88% to 1.73% for adults. From 2005 to 2009, disruptive behavior disorders were the most common diagnoses in child and adolescent antipsychotic visits, accounting for 63.0% and 33.7%, respectively, while depression (21.2%) and bipolar disorder (20.2%) were the 2 most common diagnoses in adult antipsychotic visits. Psychiatrists provided a larger proportion of the antipsychotic visits for children (67.7%) and adolescents (71.6%) than to adults (50.3%) (P<.001). From 2005 to 2009, antipsychotics were included in 28.8% of adult visits and 31.1% of youth visits to psychiatrists.
Conclusions: On a population basis, adults make considerably more medical visits with a prescription of antipsychotics than do adolescents or children. Yet antipsychotic treatment has increased especially rapidly among young people, and recently antipsychotics have been prescribed in approximately the same proportion of youth and adult visits to psychiatrists.
The data source for this survey came from the National Center for Health Statistics:
Data were obtained from the National Ambulatory Medical Care Survey (NAMCS). The NAMCS, which is conducted annually by the National Center for Health Statistics, samples a nationally representative group of visits to physicians in officebased practice. Following National Center for Health Statistics recommendations, data from contiguous survey years were combined to derive more stable estimates (1993-1998, 1999-2004, and 2005-2009). Across the 17 survey years, response rates varied between 58.9% (2006) and 73.1% (1993), with a mean of 66.1%. For each visit, the treating physician or member of the physician’s staff provided information about patient sociodemographic and clinical characteristics, as well as the medications prescribed or supplied to the patient.
This is a piece of a table from the article [% refers to the % of office visits in the survey]:
Here’s the Summary Table for 2005-2009 showing the Demographics of people treated with antipsychotics [% refers to %visits where antipsychotics were prescribed]:
And their conclusions:
In summary, over a 17-year period, antipsychotic medicationsbecame more commonly used in office-based practice. The increase, which has been broad-based, has been especially concentrated among children and adolescents, particularly among youths diagnosed with mood disorders and those treated by nonpsychiatrist physicians. A substantial majority of child antipsychotic visits are for young people diagnosed with disruptive behavior disorders. In light of known safety concerns and uncertainty over long-term risks and benefits, these trends may signal a need to reevaluate clinical practice patterns and strengthen efforts to educate physicians, especially primary care physicians, concerning the known safety and efficacy of antipsychotic medications. At the same time, a new generation of clinical trials is needed to evaluate the safety and efficacy of antipsychotic medications in conditions for which they are commonly prescribed but for which the evidence base remains underdeveloped.
My friends from before-retirement wonder why I spend so much time messing around blogging about psychopharmacology. They knew me as someone who saw psychotherapy cases, mostly long term, and used little medication in my practice. My non-medical retirement friends living around our little lake know I do something with my time besides just being old and happy, but aren’t quite sure what it is. I even wonder at times myself why I spend so much time poring over these papers, papers I had actually usually ignored before I retired. Then an article like this one comes along, and I’m reminded all over again that when I began to see general clinic patients as a volunteer five years or so ago, and saw what medications people were taking, I didn’t even recognize my own specialty. So I started reading, and then later started writing.

I’m encouraged here at the end of 2012 that things might be better than they were when this survey was done. I certainly hope I’m right about that. But these number are still staggering. 30% of patients [adults and children] were given antipsychotic prescriptions in the survey weeks between 2005 and 2009! 63% of the antipsychotic visits in children were for disruptive behavior! 94% of antipsychotic visits were off label in children! 71 % off label in adults! Polypharmacy for the majority on antipsychotics!

Simply decrying these numbers isn’t enough. I’m not even sure writing about them day after day makes a dent in the problem, but frankly I don’t know what else to do. I do know that every time I see an article in the press, or a new book comes out, or another pharmaceutical suit is settled, I think that more kindling is laid for reform. And I’m encouraged when I see an article like this one in the peer reviewed literature. So I take my solace in Dr. Ben Goldacre’s comment at the end of his Ted talk [something of value…], "Sunlight is the best disinfectant"…
    Steve Lucas
    December 13, 2012 | 8:40 AM

    You are making a dent. A friend is a pediatrician and becomes very upset when I talk medicine in the terms outlined by this article. There is the ego that says I, a mere mortal, cannot understand the pressures of a modern medical practice. I being a mere mortal remind them this is about numbers and business, and I am very good at business.

    The good news is this reinforces this doctor’s desire to stay out of prescribing for behavior problems. Sadly, a large number of prescription request come from school teachers who just do not want to deal with a bored energetic child.

    Sometimes you make my head hurt with the math, and I have to go back and review some old concepts, but the effort is worth it. There is stuff here I will never see anyplace else, and I am able to engage in a more robust discussion of the pharma/medical complex because of it.

    Steve Lucas

    Bernard Carroll
    December 13, 2012 | 9:22 AM

    Well, it’s not like this is surprising information… it says that Pharma marketing achieved what it set out to achieve – to expand the niche for antipsychotic drugs in NONPSYCHOTIC patients. Did you see those numbers, by the way, for anxiety disorders!

    The game plan was to expand the niche and to hell with the downside in tardive dyskinesia and metabolic syndrome and diabetes mellitus. They counted on venal KOLs like Charles Nemeroff and his ilk to pull this off, and they succeeded. Here are some warning links going back a few years now: here and here and here. Readers might also check out PubMed IDs 19142117 and 20123926.

    December 13, 2012 | 10:46 AM

    Curious, are you privy to stats re the percentage of Rxs written by non psychiatrists of late? My guess is while lower than the antidepressant figure, I would painfully surmise about 40% now?

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