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                                Increased prescribing trends of paediatric
                                psychotropic medications
                                I C KWong, M L Murray, D Camilleri-Novak and P Stephens

                               Arch. Dis. Child. 2004;89;1131-1132
                               doi:10.1136/adc.2004.050468


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                                                                                                                           1131



   SHORT REPORT

Increased prescribing trends of paediatric psychotropic
medications
I C KWong, M L Murray, 0 Camilleri-Novak, P Stephens

                                                                Arch Dis Child 2004;89: 113 1-1 132. doi: 10.1136/odc.2004.050468



 Psychotropic medicotion use by children in the USA has           IMS MIDAS Prescribing Insights is an audit drawn from a
                                                                representative sample of medical practitioners in each
 increased. We used the IMS MIDAS Prescribing Insights to
                                                                country; table I summarises the details of data collection of
 examine prescribing trends in nine countries between the
                                                                each country. The prescribing data of sampled doctors were
 years 2000 and 2002. Trends in seven countries rose            then adjusted according to thc stratifications, and a projected
 significantly h-om year 2000 to 2002; the UK hod the highest   national total of prescriptions data per year and 95.5%
 increase (68%).                                                confidence intervals were calculated for each country. The
                                                                within country differences of the data between years 2000
                                                                and 2002 were compared for significance.
     LUdies in the USA have shown that the use of

S    psychotropic medications has increascd considerably in
     recent years.' We have previollsly reported a similar
trend in the UK.' However. there is little information on the
                                                                RESULTS
                                                                Figure I shows that the number of psychotropic prescriptions
                                                                for children has risen between the years 2000 and 2002 in all
prescribing trends in other countries; we do not know           nine countries, and seven have shown a significant increase.
whether this is a global trend or a trend in English speaking   The UK has the highest percentage increase (68%); the lowest
countries. For the above rl'ason, we used the IMS MIDAS         was Germany (13%).
Prescribing Insights to examine the prescribing trend of
psychotropic medications in children in nine cOllntries         DISCUSSION
between the years 2000 and 2002.                                The results suggest that the increase in psychotropic
                                                                prescribing in children is not only confined in the USA and
METHODS                                                         UK but is also evident in other countries. The increase
Children are defined as under 18 years old. The psychotropic    probably represents the improved recognition of paediatric
medications investigated include antidepressants, stimulants,   psychopathology; there is also a concern that drugs arc being
anlipsychotics, bcnzodiazl'\lines, and other anxiolytics.       used to replace non-drug treatments.' However, there is
   IMS MIDAS Prescribing Insights contains the prescrib-        insufficient research to confirm or refute the above sugges-
ing data from different countries. We obtained the paedia-      tiollS. There are limitations to our data, especially as there is
tric psychotropic prescription data in the UK and three         no information on the average prescription duration by drug
other European countries with the largest markets for these     or frequency, which may differ between years due to changes
medications (France, Gl'rmany, and Spain), three South          in prescribing practice. However, the observed increase in so
American countries with the largest markets for these           many countries should raise concern, as little research has
medications (Argentina, Brazil. and Mexico) and North           been conducted in children to study the effects of most
America (Canada and the USA).                                   psychotropic medications.

   Table 1 Method of data collection in each country




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1132                                                                                                                                                     Wong, Murray, Camilleri-Novak, et al



         2500   ~
                                                                                                                                                                  Figure 1 Psychotropic medication
                                                                                                                                                                  prescriptions given to patients aged
                              ~ Year 2000                                                                                                                         0-17 years by country and year 195.5%
                                                                                                                                                                  canfidence intervals shown).
::g 2000 I-                   c::J
                              c::J
                                     Year 2001
                                     Year 2002
  51
  :>

=
  o
....c:                                                                                                ..                                  ..
  ~      1500   -                                                                       1
.Q
 :g-                                                                       "m                         ,
  ill
 ~ 1000 -
                                              ..                                                      ~i




'0                       ..                                            "
                                                                                                       >
                                                                                                       ;                                  ,            .~
  Q;                                                                                                                                       o'

...0                                                                                                   j                                   ~
  §      500    >-
                                                                                                       l
                                                                                                                          "~
                                                                                                                                      l

                                                                                                                                           ,
Z

                                                                                                                      I~;
                                                                           J                                                               ;
                    li
                                                                           ,
                                                                           j
                                                                                            l


                               I        I            I             I            I   I            I          1                     I             .1            I
            o
                         UK                 France       Germany       Spain            Canada       USA'             Argentina       Brazil         Mexico


                 • USA data is by hundred thousand prescriptions
                ., Stotisically different between the years 2000 and 2002



   The recent recommendation by the Medicines and                                                               Authors' affiliations
Healthcare products Regulatory Agency to withdraw selective                                                     I C KWong, M L Murray, 0 Camilleri-Novak, Centre for Paediatric
serotonin inhibitors (SSRls) from the treatment of paediatric                                                   Phanmacy Research, School of Pharmacy and the Institute of Child
depressive disorders' should serve as a lesson to all of us. The                                                Health, University of london, UK
percentage of SSRI prescriptions from all antidepressants                                                       P Stephens, VP Public Health Affairs Europe, IMS Health, london, UK
prescriptions issued to children and adolescents in the UK                                                      Carrespondence 10: Dr I C K Wong, Centre for Paediatric Pharmacy
increased considerably between 1992 and 2001;' it is probable                                                   Research, The School of Pharmacy, University of london, 29-39
that the rationale for drug choice is nor based on the research                                                 Brunswick Square, londan WCl N 1AX, UK; ian.wong@ulsop.ac.uk
evidence in children, but based on the evidence in adults.
This highlights an important point which paediatric clinical                                                    Accepted 19 February 2004
pharmacologists and pharmacists always advocate-"chil-
dren are not small adults".
                                                                                                                REFERENCES
   Certainly we need more well designed clinical trials to
investigate the safety and efficacy of psychotropic medica-                                                        Zito JM, Sofer OJ, DosReis S, et al. Psycholropic pracfice patterns for youth: 0
                                                                                                                   10-yeor perspective. Arch Pediatr Adolesc Med 2003;157:17-25.
tions in children; it is also necessary to study how and why                                                     2 Wong leK, Comilleri-Novok 0, Stephens P. Rise in psychotropic drug
these medications are being prescribed, through the applica-                                                       prescribing in children in the UK-an urgent public health issue. Drug Safely
tion of pharmacoepidemiology. We believe the usc of                                                                2003;26:1117-18.
                                                                                                                 3 Wiznitzer M, Findling RL. Why do psychiotric drug research in children?
psychotropic medications in children is a global public health                                                     Lance12003;361 :1147-8.
issue, which should be studied in partnership with pharma-                                                       " Anon. Selective serotonin reuptoke inhibitors (SSRls): overview of regulatory
ceutical companies. governments, and researchers to grow                                                           stolus and CSM odvice reloting 10 major depressive disorder (MDD) in
and expand the evidence base for their usc in children.'                                                           children and odolescents including a summory of ovoiloble safety and efficacy
                                                                                                                   dora. http://medicines.mhra.gov.uk/ourwork/monitorsolequolmed/
Children should not be deprived of safe and efficacious                                                            soletymessoges/ssrioverview_1 01203.htm. Accessed 23 December, 2003.
treatments.                                                                                                      5 Murray Mt, de Vries CS, Wong ICK, Prescribing Irends 01 ontidepre"onts in
                                                                                                                   children and adolescents. Electronic 8M) 5 Jonuary 2004. http://
                                                                                                                   bmj.bmjjoumols.com/cgi/ele"ers/328/7430/3/145608. Accessed
ACKNOWLEDGEMENTS                                                                                                   5 Jonuory 2004.
IW's post is funded by the Department of Health Public Health Career                                             6 Wong Ie, Sweis D, Cope J, elal. Children medicines research in Ihe UK-how
Scientist Award. We thank IMS for providing the data.                                                              ra move forword? Drug Safely 2003;26:529-37.




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218                                                                                                                  Arch Dis Child 2005;90:218-219




PostScript                                                                                                                                             .
                                                     in" by a guilty carer who has distorted the         (10) Parents often find interviews such as
                 LETTERS                             history. This can result in the paediatrician       this very stressful. This is only jllstified if
                                                     being drawn inappropriately inlU ad~'ocating        there is clear benefit.
                                                     for the carer and failing to be objective about     (II) Finally, Professor David's views imply
Expert witnesses: opinion and                        the other medical ,,,·idence. It may even           that avoidance of parental upset is a priority.
dogma are pitfalls in medical                        result in the paediatrician meeting with the        It is to be expected that parents \vill be upset
journalism as well as in reports                     carers, deciding whether they feel that they        about the diagnosis of abuse, particularly if
                                                     are telling the truth or not. and then              they are inlplicated. However. there is no
Professor David's leading iHlicJc' proviues a        inappropriately interpreting the medical evi-
welcome summary of the Code of Guidance                                                                  evidence of which we are aware to suggest
                                                     dence in a way that supports that view. We          that the parents will be less upset, or less
for Expert Witnesses in Family I'roceedings.         must not forget that the paediatrician's prime
All paediatricians who un,krwke this type of                                                             likely to complain, if the paediatrician meets
                                                     role is to consider whether the child has           with them.
work should be familiar with Ihe Code of             suffered harm, not to allribute guilt.
Guidance and have due rcg<lfel to it. However,
Proeessor David also goes on 10 express some         (2)    Given the long delay between the             Last year, the President of the Royal College
highly personal opinions whic'h, while force-        suspected abuse event and the involvement           of Paediatrics and Child Health drew atten-
fully argued, are unreferenced and nOI               of the Expert Witness, there is a risk that         tion to an "orchestrated campaign" against
evidence based. The most '.lhvious example           perfectly innocent errors may creep into the        paediatricians involved in child protection.
in the article is Professor David's views on         history provided by the carers. There is a risk     Certain well known campaigners, accused
inlerviewing the parents or carers. He com-          tha t the doctor or the court wou ld be             patenls, and journalists often refet to the fact
ments that "a paediatrician who does not             prejudiced against the parents in this situa-       tllat a Paediatric Expert Witness had not met
attempl to interview the parents risks being         tion.                                               the family before coming to a diagnosis, in an
criticised for by-passing the usual routines         (3)    There is a further risk for the unwary in    attempt to discredit them. In this context, the
and failing to consider all aspects of the           potentially becoming prejudiced against par-        idea that interviews with parents or carers
case". He goes on to say that paediatricians         ents who have mental health problems.               should be conducted purely to appease them
willing to make a conlident diagnosis of             learning difficulties, unusual personalilies,       and reduce the likelihood of them complain-
abuse without ever meeting Ihe parents risk          or strange affecl. This is also to be guarded       ing is highly controversial and there is no
making parents exceptionally aggrieved,              againsl, as it is essential for paediatricians to   reason to believe that goal would be achieved.
alluding to recent press publicity.                  remain objective.                                   Where complaints are received, for example
   The undersigned are all experienced in the        (4)    The Experl Witness Guidance spel'ifi-        by an NBS Trust or the GMG, it is important
fielt.! of chilt.! protection aod between us have    cally forbids paediatricians to seek to resolve     that the doctor's performance is judged on
considerable experience 01 expert witness            disputed issues of facI in their repons. There      the basis of currently accepted and "reason-
work. In our experience, il subslanlial pro·         is a risk that in interviewing the family and       able" medical practice, and that the opinions
portion ol Expert Witnes.' J{cports ilre pre-        generating new information the paediatrician        of those making these judgements are not
pared on the basis ol a paper redew. This has         mal' be drawn inlo this particular Irap.           infiuenced by skilfully argued, but personal
hitherto been regarded as perlectly sound                                                                and controversial views such as those
medical practice, which is nOI explicitly            (5)    In some cases there may be a risk of
                                                     physical harm or intimidation of the Expert         expressed by Professor David.
discouraged in any of the published Expert                                                                  In some cases, of course the Expert Witness
Wirness guidance. We would suggest that              Witness. Often we are invited to meet with
                                                      the family in their own home and without           will wish to meet with the carers before
Prolessor David's views should not be                                                                    coming to a diagnosis. We would not argue
accepted unquestioningly, and that this issue        chaperones. This also leaves doctors vulner-
                                                     able to false accusations concerning their          that it is wrong to do so subject to lhe
should be debaled openly.                                                                                cautions mentioned above, but it should not
    II is undeniable that treating paediatricians
                                                      behaviour in interviews. The carers may try to
                                                     challenge or "cross-examine" the doctor at          be obligatory as suggested by Professor
need to take a good history erom parents,                                                                David. Ultimately the more objective evidence
carers or olhers, espel'ially where child abuse      interview. Doctors need to consider carefully
                                                      their own health and safety in these circum-       is contained in the medical records. A careful
is being considered in the differential diag-                                                            review of this basic informalion is often
nosis. The situation is differclll, hl.lwever, fot   stances.
                                                                                                         needed before deciding whether to take a
an Expert Witness who asseS'es the case               (6)    The parents may misinterpret, misre-
                                                                                                          fUllher history from Ihe parents. Whether or
 many months after the parents have been              present or take "false hope" from things that       not the parents or carers have been inter-
confronted with the initial concerns about            the paediatrician has said to them. or may         viewed should not be regarded as a measure
child abuse. The parems arc likely to have            press for a provisional opinion on the case,       of the quality of the report, and there are
had many opportunities to e1isolss their case         which of course should not be given.                many occasions when reports based on paper
and rehearse their history; for example in            (7)    Not infrequently, parents or their          reviews have been highly commended by
case conferences, meetings (If professionals,         advocates arc suspicious about the paedia-         courts. In each case pacdiatricians need to
 and with their lawyers. Usually they will have       trician's motive in wanting to interview the        carefully weigh up the pros and cons of
 produced detailed witness statements in              family, even when the doctor is jointly             interviewing the carers and justify their
connection with civil andior criminal pro-            instructed and acting in a completely neutral       actions.
,~eedings. Interviewing carers in this context        capacity. They may insist on the interview             Professor David quite correctly entreats all
 is not something which paediatric training           being recorded and transcribed, which adds          paediatricians to consider both sides of the
 fully prepares you for, and even experienced         delay and expense. If the interview is not
 paediatricians may have liule experience of                                                              argument, acknowledge where opinions are
                                                      recorded the carer may later deny something         controversial or open to challenge, and
 this. Thete are significalll risks:                  that they said to the paediatrician if it is        present material that does not support the
                                                      unhelpful to their case.                            Expert's opinion as well as that which does.
(I) Parents, whether innocent or not, will
naturally attempt to idealise lheir histories         (8)    Giv'en that the courts are experiencing      He also points out that non-medical profes-
and portray themselves or olher carers in a           extreme difficully in recruiting Expert             sionals such as lawyers and judges may O\'er-
favourable light. Guilty carers are likely to be      Witnesses, adding a further obligatory inter·       interpret medical theories. These cautions arc
untrlllhfui. It is therelore impossible for Ihe       view, regardless of its relevance, may deter        well made, but we would suggest that they
paelliarrician to know how much weight to             paediatricians even further from taking on          should also apply to controversial opinions
alLach 10 lhe history givell by the carer at this    cases.                                               expressed in lhe medical literature, particu-
poinl in time. This poses dual risks: paedia·        (9)   The new protocol for Family Law cases          larly where they relale to Expert Witness
tricians may become prejudked against an             was introduced to avoid delay in proceedings         work and could have serious unwanted
innocent carer if they p<'fr.·ive them as            and a requirement to interview carers in all         consequences if they were to pass without
unreliable; or converseiy, they may be "taken        cases would inevitably add delay.                    comment into medical or judicial dogma.




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