Mental disorders : harm psychotropic drugs children and adolescents?
They are fidgety, depressed or anxious, have aggressive thoughts or agonizing tics: About ten percent of all children and adolescents suffer from a mental illness. Whether attention deficit hyperactivity disorder (ADHD), depression or schizophrenia, medication is often part of the therapy – with an increasing tendency.
"Prescriptions of psychotropic drugs for children and adolescents in Germany are increasing", says Christian Bachmann, Professor of Child and Adolescent Psychiatry at the Faculty of Medicine at Philipps University in Marburg and an expert in psychopharmacoepidemiology. Although the health insurance company DAK recently reported a ten percent drop in prescriptions of the ADHD drug Ritalin since 2011. But other groups of medications, such as antipsychotics and antidepressants, are apparently used more frequently instead.
This article is included in Spektrum – Die Woche, 41/2015
More psychotropic drugs for young patients
This was shown in a large-scale study by Christian Bachmann. Together with his team, he evaluated data from the health insurer Barmer GEK on prescriptions of antipsychotics for children and adolescents up to 19 years of age in the period from 2005 to 2012. Antipsychotics are medications originally developed to treat schizophrenia or sleep disorders, but are now also commonly used for ADHD. A total of about 1.4 million insured people were involved in the study. The result: the proportion of children and adolescents prescribed antipsychotics increased by more than 40 percent over the period under consideration – especially among adolescents aged ten and older.
The reasons for the increase are many, says the study director. "The main reason is not that the children did not receive enough medication in the past. However, increased advertising by the pharmaceutical industry among pediatricians and pediatric psychiatrists for the use of antipsychotics certainly plays a role", says Christian Bachmann. Drug treatment is also more readily available and less costly than psychotherapy, and is therefore often the first choice for parents and doctors.
"For the treatment of most disorders, however, guidelines recommend a combination of psychotherapy and medication", says the child and youth psychiatrist. Representative studies that compare the effectiveness of individual therapy methods for specific disorders are complex, lengthy, expensive, and therefore rare. In most cases, it takes almost a decade from the first plans to the publication of the results. "We now know, for example, that psychological behavioral therapy alone is very effective against anxiety disorders, says the expert. "In other disorders such as ADHD, however, such psychotherapy before the age of about eight years is usually of little benefit." For younger children, parent training is much more important. Among other things, these learn how to better structure everyday family life and reward their child for positive behavior.
Medication, psychotherapy – or both?
For older children in adolescence, on the other hand, psychotherapy – at least for depression – appears to enhance long-term therapeutic success. In the extensive TAD study (Treatment for Adolescents with Depression) initiated by the U.S. National Institute of Mental Health in 1999, researchers observed more than 300 depressed adolescents over a period of 36 weeks. They found that antidepressants usually help more quickly than psychotherapy. The latter, however, was more likely to permanently reduce the risk of suicide attempts among the adolescents. The study leaders therefore recommend a combination of both therapy methods.
For ADHD, on the other hand, psychotropic drugs appear to be superior to psychotherapy. This was the finding of the MTA study (Multimodal Treatment of Attention-Deficit Hyperactivity Disorder), which was started by the National Institute of Mental Health as early as 1992. Scientists assigned nearly 600 elementary school children with ADHD to different treatment groups. Some of the young patients were treated with individually tailored medications, others with psychological behavioral therapy or with a combination of both methods. Two years after the start of therapy, there was no difference in treatment success between purely drug-based or combined treatment. However, both treatment methods were much more effective in reducing ADHD symptoms than psychotherapy alone, according to the expert.
Risks difficult to assess in the long term
But time and again there is talk of the sometimes considerable side effects of psychiatric pills. "Children are not small adults", warns the expert. For example, they break down active substances differently than fully-grown people. The drugs can also affect the development of the body and mind: Among other things, a follow-up study of the MTA study found that after three years on methylphenidate for ADHD, the children observed were two centimeters shorter than sufferers without the drug.
Under some antipsychotics, young patients gain more weight on average than older patients; their blood values can also change and they may experience long-lasting motor disturbances. Other studies indicate that the risk of suicide increases much more frequently in children than in adults when taking certain antidepressants. A similar conclusion was reached by the authors of a study published in 2015, in which the data of a study from 2001 were analyzed again: According to this study, two well-known antidepressants (paroxetine and imipramine) are no more effective than a placebo in treating depressed adolescents, but lead to an increased incidence of suicidal thoughts and actions as well as cardiovascular problems. Based on such findings, the U.S. Food and Drug Administration issued an official warning against the use of antidepressants in minors as early as 2004. However, there is now also evidence that while the rate of prescribing the drugs to children and adolescents has decreased following this warning, the incidence of suicide attempts has increased at the same time.
The additional adverse effects that may not become apparent until adulthood are usually unclear. Only a few studies show the effect of psychotropic drugs over a longer period of time. There is particularly little data on medications that are "off-label." are used. This means that the doctor is prescribing a drug that was not actually developed for the condition at hand or for patients at a young age. The reason: "There are very few psychotropic drugs that are approved for the treatment of children and adolescents", explains Christian Bachmann. Many potential drugs are also outdated – and if a new drug is developed, pharmaceutical companies rarely conduct registration studies with children and adolescents. "The market is simply too small for the pharmaceutical industry," explains Christian Bachmann, explains the psychiatrist.
For lack of modern drugs, specialists therefore began to treat their young patients also with psychotropic drugs for adults or for similar disorders – with success. The off-label use of drugs is common in child and adolescent psychiatry today. The liability is assumed by the physician. "Since we lack studies on long-term efficacy and side effects, risks and benefits must always be weighed against each other on an individual basis.", says Christian Bachmann.
Wrong and premature diagnoses
Many parents feel insecure because of the possible side effects and news of unnecessary medication administration. Christian Bachmann can well understand such concerns: "In fact, there are a large number of false diagnoses, especially in the case of disorders such as ADHD and autism." From previously unpublished data from a health insurance company, he found that several years after children were first diagnosed with autism, fewer than half of the "sufferers" were diagnosed nor had an autism diagnosis. "Autism does not simply "grow out", explains the expert. "It makes you think." How many diagnoses were simply wrong?
A similar question is raised by a recent study of the "Versorgungsatlas" in cooperation with the Ludwig-Maximilians-University Munich. She recently reported that a child’s age at school enrollment also appears to be crucial to an ADHD diagnosis. For their analysis, the scientists evaluated medical data from around seven million children and adolescents nationwide. Students who had their birthday shortly before the enrollment deadline, i.e. tended to be among the younger ones in the class, were found to have the condition more frequently than older classmates. Do less mature schoolchildren run the risk of being "labeled" as ADHD children? to be?