Daniel J. Safer

OBJECTIVE: To examine changes in the full spectrum of psychotropic medication treatment for youths from 1987 to 1996. METHODS: A population-based analysis of community treatment data on nearly 900,000 youths enrolled in 2 US health care systems included (1) computerized Medicaid data from 2 states (a midwestern state and a mid-Atlantic state) composed of outpatient prescription claims and enrollment records and (2) computerized prescription dispensing records from a group-model health maintenance organization. Ten 1-year cross-sectional data sets from 1987 through 1996 were analyzed. RESULTS: Total psychotropic medication prevalence for youths increased 2- to 3-fold and included most classes of medication. The rapid growth since 1991 of alpha-agonists, neuroleptics, and "mood stabilizer" anticonvulsants was particularly notable. The 1996 prevalence of any psychotropic medication among youths younger than 20 years was remarkably similar (5.9%-6.3%) across all 3 sites, with stimulants and antidepressants consistently ranked first and second. Medicaid rates almost always exceeded health maintenance organization rates by large margins, particularly for alpha-agonists, neuroleptics, "mood stabilizer" anticonvulsants, and lithium. Youths in health maintenance organizations had rates similar to Medicaid-insured youths for antidepressants and hypnotics. Over the decade, there was a proportional increase in females receiving stimulants and in males receiving antidepressants, particularly for the 10- to 14-year-old group. The prevalence ratios of whites to African Americans narrowed substantially in 1 Medicaid site. CONCLUSIONS: Youth psychotropic treatment utilization during the 1990s nearly reached adult utilization rates. Youth findings can be used to accurately assess the duration of treatment and unforeseen practice pattern changes, and to identify safety concerns.

OBJECTIVE: To estimate the increased use and the prevalence of methylphenidate (Ritalin) treatment of youth with attention deficit disorder (ADD) during the 1990s. DESIGN: Using time-trend findings from two large population-based data sources, three pharmaceutical databases, and one physician audit, a best-fit estimate of the usage and the usage trends for methylphenidate treatment over the half decade from 1990 through 1995 was sought. SETTING: Five regions in the United States (US) and the nation as a whole. PATIENTS: Youths on record as receiving methylphenidate for ADD. RESULTS: The findings from regional and national databases indicate that on average, there has been a 2.5-fold increase in the prevalence of methylphenidate treatment of youths with ADD between 1990 and 1995. In all, approximately 2.8% (or 1.5 million) of US youths aged 5 to 18 were receiving this medication in mid-1995. The increase in methylphenidate treatment for ADD appears largely related to an increased duration of treatment; more girls, adolescents, and inattentive youths on the medication; and a recently improved public image of this medication treatment. CONCLUSION: The database findings presented serve to correct exaggerated media claims of a 6-fold expansion of methylphenidate treatment, although they do not clarify the issue of the appropriateness of this treatment.

Since 1971, the Baltimore County Health Department has conducted nine biannual surveys of school nurses in all of the county's public and private schools to determine the prevalence of medication treatment for hyperactivity/inattentiveness among students. The results reveal a consistent doubling of the rate of medication treatment for hyperactive/inattentive students every four to seven years such that in 1987, 5.96% of all public elementary school students were receiving such treatment. Related trends from 1971 to 1987 have been that stimulants increased from 76% to 99% of the medication prescribed; methylphenidate hydrochloride rose from 40% to 93% of the total; the male-female ratio dropped from an average of 8:1 to 5:1; the rate of medication treatment for hyperactive/inattentive students rose faster in secondary than in elementary schools; and 25% of students receiving stimulant medication in 1987 were in special education classes or schools.

CONTEXT: Studies have revealed that youth in foster care covered by Medicaid insurance receive psychotropic medication at a rate > 3 times that of Medicaid-insured youth who qualify by low family income. Systematic data on patterns of medication treatment, particularly concomitant drugs, for youth in foster care are limited. OBJECTIVE: The purpose of this work was to describe and quantify patterns of psychotropic monotherapy and concomitant therapy prescribed to a randomly selected, 1-month sample of youth in foster care who had been receiving psychotropic medication. METHODS. Medicaid data were accessed for a July 2004 random sample of 472 medicated youth in foster care aged 0 through 19 years from a southwestern US state. Psychotropic medication treatment data were identified by concomitant pattern, frequency, medication class, subclass, and drug entity and were analyzed in relation to age group; gender; race or ethnicity; International Classification of Diseases, Ninth Revision, psychiatric diagnosis; and physician specialty. RESULTS: Of the foster children who had been dispensed psychotropic medication, 41.3% received > or = 3 different classes of these drugs during July 2004, and 15.9% received > or = 4 different classes. The most frequently used medications were antidepressants (56.8%), attention-deficit/hyperactivity disorder drugs (55.9%), and antipsychotic agents (53.2%). The use of specific psychotropic medication classes varied little by diagnostic grouping. Psychiatrists prescribed 93% of the psychotropic medication dispensed to youth in foster care. The use of > or = 2 drugs within the same psychotropic medication class was noted in 22.2% of those who were given prescribed drugs concomitantly. CONCLUSIONS: Concomitant psychotropic medication treatment is frequent for youth in foster care and lacks substantive evidence as to its effectiveness and safety.

In 29 hyperactive children, dextroamphetamine (10 or 15 mg per day) and methylphenidate (30 or 40 mg per day) caused suppression of weight gain. Mean yearly weight gain of nine children on medication for two years was 1.8 kg as compared to the expected gain of 3.1 kg. Depression of growth in height varied in degree; however, children whose growth was depressed also had proportional depression of growth in height. Thirteen children who took stimulant drugs for nine or more months showed a rebound weight gain when medication was abruptly stopped. Dextroamphetamine inhibition of weight gain was not related to dose and was significantly greater than that observed with methylphenidate. Daily doses of 20 mg of methylphenidate did not inhibit weight gain.