by Elisa F. Cascade; Amir H. Kalali, MD; and David Feifel, MD, PhD
Ms. Cascade is Vice President, Strategic Research and Safety, Quintiles Inc., Falls Church, Virginia; Dr. Kalali is Vice President, Global Therapeutic Group Leader CNS, Quintiles Inc., San Diego, California, and Professor of Psychiatry, University of California, San Diego; and Dr. Feifel is Associate Professor In Residence, Department of Psychiatry; Director, Neuropsychiatry and Behavioral Medicine Program; Director, UCSD Adult ADHD Program, University of California, San Diego Medical Center, San Diego, California.
Disclosures
Dr. Feifel has received research funding, consulting, or speaking fees from the following pharmaceutical companies: Abbott Laboratories, AstraZeneca, Argolyn Biosciences, Eli Lilly and Co., Bristol-Myers Squibb, Solvay, Janssen, Wyeth, Macneil, and Shire.
Abstract:
In this article, we investigate the range of treatments prescribed to children with autism. The data suggest that approximately 58 percent of patients with a diagnosis of childhood autism receive some type of pharmaceutical treatment. The majority of those treated, 68 percent, receive only one pharmaceutical. The most commonly prescribed products are antipsychotics (66%), antidepressants (32%), and stimulants (17%). An expert commentary is included.
Key words
autism, child, adolescent, antipsychotic, antidepressant, stimulant, psychopharmacology
Introduction
While there is no cure for autism, risperidal (Risperdone®) recently became the first medication approved for the treatment of irritability associated with autistic disorder in children. Because autistic children often suffer from multiple problems, they may also receive treatment for comorbid conditions, such as depression or seizures. To better understand current practice patterns, in this article, we investigate the range of treatments prescribed to autistic children.
Methods
We obtained data on product treatment regimen from Verispan’s Prescription Drug & Diagnosis Audit (PDDA) database from October, 2006, to November, 2007, for Autism in children as defined by ICD-9 diagnosis code 299.0. PDDA captures data on disease state and associated therapy from 3,100 office-based physicians representing 29 specialties across the United States.
Results
According to practice data from Verispan, approximately 50 percent of children with autism have a secondary diagnosis. The two most common comorbid conditions are Down’s syndrome (12% of all autistic children) and attention deficit disorder (10% of all autistic children).
Figure 1 displays the prevalence of pharmaceutical use among children with autism. As seen in Figure 1, 58 percent of patients with a diagnosis of childhood autism receive some type of pharmaceutical treatment. Of those treated, two-thirds are managed with one pharmaceutical agent, 18 percent receive two products, and 14 percent are prescribed three or more drugs.
The agents most commonly prescribed to autistic children are antipsychotics. As seen in Figure 2, 66 percent of children receiving treatment are prescribed an antipsychotic (primarily atypicals). In addition, antidepressants are prescribed to one-third of patients, and approximately 17 percent of autistic children receive stimulants.
Commentary
Autism remains one of the most intractable neuropsychiatric conditions. No effective treatment for the core features of this disorder has been developed despite the fact that the recognition and diagnosis of this disorder continues to grow dramatically. In the absence of effective treatments to reverse the core features, clinicians have turned to using medication to manage specific problematic behaviors and associated syndromes seen in people with autism.
Stimulants are commonly used to address attention deficit hyperactivity disorder (ADHD) or ADHD-like behaviors, such as hyperactivity and limited attention span. Previous surveys[1,2] show most antidepressants prescribed in this population are from the selective serotonin reuptake inhibitor (SSRI) category, and they are more commonly prescribed in an effort to address perseverative and repetitive (obsessive-compulsive like) behaviors than to improve mood. Psychosis is a relatively rare occurrence in patients with autism and cannot account for the large percentage of antipsychotics prescribed. Most of the antipsychotics prescribed are second generation and are being used to target maladaptive, irritability driven behaviors, including tantrums, aggression, deliberate self-injurious behavior, and volatile displays of mood.
A similar analysis of medication use in 2002 among children with autism drawn from a different commercial clinical service database[2] found that a similar percentage (52%) of this population received psychotropic medication. The percent of patients prescribed antidepressants in that analysis was virtually identical (32.1%) and the amount of stimulants was somewhat higher (26.9%), but the amount of antipsychotics was significantly lower (23.5%). Contrasting that analysis of 2002 data to the current one spanning 2006/2007 suggests that the biggest change in prescribing patterns for autism over the past five years is a dramatic increase in second generation antipsychotics. This may be contributed to by the fact that one of the second generation antipsychotics, risperidone, became the first medication to receive a US Food and Drug Administration (FDA) indication for autism, albeit for the irritable, aggressive behaviors and not the core features of the condition. The increased use of antipsychotics may be driving down the use of stimulants possibly by decreasing hyperactivity. Indeed a recent study found that a second generation antipsychotic was as effective as a stimulant in reducing ADHD symptoms in children with mental retardation.[3] The apparent increase in antipsychotic prescriptions in autistic people is consistent with our findings from a previous Trend Watch analysis[4] that antipsychotic use was increasing faster among the pediatric population (1–17 years of age) than any other age group. Clearly pediatricians and child psychiatrists are finding the new generation antipsychotics to be useful as broad-spectrum medication for ameliorating abnormal mood and behavioral problems in children and adolescence. This underscores the need we described previously4 to cease referring to these medications as “antipsychotics” in favor of a more neutral label, such as serotonin-dopamine antagonist.
References
1. Aman MG, Lam KS, Van Bourgondien ME. Medication patterns in patients with autism: Temporal, regional, and demographic influences. J Child Adolesc Psychopharmacol 2005;15(1):116–26.
2. Oswald ad S. Medication use among children with autism spectrum disorders. J Child Adolesc Psychopharmacol 2007;1:348–55.
3. Correia Filho AG, Bodanese R, Silva TL, et al. Comparison of risperidone and methylphenidate for reducing ADHD symptoms in children and adolescents with moderate mental retardation. J Am Acad Child Adolesc Psychiatry 2005;44(8):748–55.
4. Cascade EF, Kalali AH, Penn JV, Feifel D. Recent changes for prescriptions in antipsychotics in children and adolescents. Psychiatry (Edgemont) 2006;3(9):18–20.
