by Elisa Cascade; Amir Kalali, MD; and Robert Findling, MD
Ms. Cascade is Vice President, Quintiles Inc./iGuard, 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. Findling is Professor of Psychiatry and Pediatrics
Case Western Reserve University, Cleveland, Ohio.
Psychiatry (Edgemont) 2009;6(6):21–23
Financial Disclosure
Dr. Findling receives or has received research support, acted as a consultant, and/or served on a speaker’s bureau for Abbott, Addrenex, AstraZeneca, Biovail, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson and Johnson, KemPharm Lilly, Lundbeck, Neuropharm, Novartis, Organon, Otsuka, Pfizer, Sanofi-Aventis, Sepracore, Shire, Solvay, Supernus Pharmaceuticals, Validus, and Wyeth.
Abstract
Over the 2004 through 2008 period, total second-generation antipsychotic prescriptions grew 33 percent from 6.9 million to 9.2 million; second-generation antipsychotic prescriptions for patients under age 18 also increased, but at a slightly slower rate: 24-percent increase from 1.0 million to 1.2 million prescriptions. One-third of patients under age 18 who are prescribed second-generation antipsychotics use them for the treatment of affective psychoses, primarily bipolar disorder (34%). Other common uses for second-generation antipsychotics include hyperkinetic syndrome (12%), pervasive developmental disorders (10%), emotional disorders of children/adolescents (10%), and conduct disturbance (7%). A discussion of the data is provided.
Key Words
Children, adolescents, second-generation antipsychotics, bipolar disorder, hyperkinetic syndrome, pervasive developmental disorders, conduct disorder, emotional disorder
Introduction
Although second-generation antipsychotics are being studied for an increasing number of indications, questions regarding the safe use of antipsychotics in children and adolescents remain. In this article, we examine trends in prescriptions of second-generation antipsychotics overall and in pediatrics specifically.
Methods
We examined quarterly retail pharmacy prescription data from SDI/Verispan from January 2004 through December 2008. The data capture more than 1.4 billion patient-centric prescriptions per year, nearly half of all prescription activity in the US. We also obtained data on reasons for product use from SDI/Verispan’s Prescription Drug and Diagnosis Audit (PDDA) database for patients taking second-generation antipsychotics in 2004 through 2008. PDDA captures data on disease state and associated therapy from 3,100 office-based physicians representing 29 specialties across the United States.
Results
Figure 1 displays quarterly growth trends for the overall market and for prescriptions in patients under age 18. Over the 2004 through 2008 period, total second-generation antipsychotic prescriptions grew 33 percent from 6.9 million to 9.2 million. Second-generation antipsychotic prescriptions for patients under age 18 also increased, but at a slightly slower rate: 24-percent increase from 1.0 million to 1.2 million. Reasons for the use of second-generation antipsychotics in patients under the age of 18 are shown in Figure 2. As seen in Figure 2, one-third of patients under age 18 use second-generation antipsychotics for the treatment of affective psychoses, primarily bipolar disorder (34%). Other uses for second-generation antipsychotics include hyperkinetic syndrome (12%), pervasive developmental disorders (10%), emotional disorder of children/ adolescents (10%), conduct disturbance (7%), and schizophrenia ( 3%). Although total prescriptions for second-generation antipsychotics have increased steadily over the past few years, the reasons for use did not change between 2004 and 2008.
Expert Commentary
by Robert Findling, MD
The observation that second-generation antipsychotics are being prescribed to youths at increasing rates is an important one. This may be due, in part, to the fact that there is a growing body of evidence from clinical trials that has described that many of these agents have acute efficacy in youngsters suffering from a variety of conditions. However, because these medications may be associated with substantive side effects, it is important to know more about the young patients that are having these agents prescribed to them. It is also very relevant to characterize the effects, both salutary and detrimental, that these drugs are having on young people in real-world settings.
The reasons for use that are described in this article begin to provide some information about the diagnoses given to youths who are prescribed these medications. However, it is important to point out the potential limitations of diagnostic data obtained from such sources. For example, only diagnoses for which insurance coverage is available may be listed. As a result, some secondary or comorbid “uncovered” diagnoses may not be listed. Therefore, the primary reason for which the antipsychotic is being prescribed may not be available. Similarly, treatment history is not always readily forthcoming from such data sources. It might be important to know whether or not these patients have been prescribed second-generation antipsychotics as first-line treatment, or whether they have failed other interventions (both pharmacological and nonpharmacological). Another issue of note is that a substantive number of these young people have been given the diagnosis of bipolar disorder. Considering the large increase with which this diagnosis is being applied to youths, diagnostic accuracy may also be an important empiric question.
Regardless of the limitations of these data, it appears reasonably clear that youngsters are indeed being prescribed second-generation antipsychotics in real-world settings at higher rates. Due to the putative risks associated with these agents as well as the limitations of the extant data pertaining to these compounds, more needs to be learned about who is receiving these agents. In addition, a thorough characterization of the treatment outcomes and risks associated with these drugs could provide much-needed data. With such information, prescribers, youths, and their families will have available to them important facts that could assist them in making treatment decisions regarding second-generation antipsychotics as a treatment option.
