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Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005–2012

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Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (019 years) for the calendar years 2005/6–2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 1519 year olds in Denmark, Germany and UK cohorts, and for 1014 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries.,L21DWJPv
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Trends and patterns of antidepressant
use in children and adolescents from ve
western countries, 20052012
Christian J. Bachmann
, Lise Aagaard
, Mehmet Burcu
Gerd Glaeske
, Luuk J. Kalverdijk
, Irene Petersen
Catharina C.M. Schuiling-Veninga
, Linda Wijlaars
Julie M. Zito
, Falk Hoffmann
Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience,
Kings College London, London, United Kingdom
Institute of Public Health, Clinical Pharmacology, Faculty of Health Sciences, University of Southern
Denmark, Denmark
Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, MD, USA
Division of Health Economics, Health Policy and Health Services Research, Ce ntre for Social Po licy Research,
University of Bremen, Ge rmany
Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands
Department of Primary Care and Population Health, University College London Medical School,
London, United Kingdom
Department of Pharmacoepidemiology and Pharmacoeconomics, University Centre of Pharmacy,
University Groningen, The Netherlands
Population, Policy and Practice, University College London Institute of Child Health, London,
United Kingdom
Department of Psychiatry, University of Maryland, Baltimore, MD, USA
Department of Health Services Research, Carl von Ossietzky University Oldenburg, Germany
Received 20 September 2015; received in revised form 15 January 2016; accepted 1 February 2016
Black box warning;
Prevalence trends
Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use
were observed within 2 years in children and adolescents in several countries. However,
whether these reductions were sustained is not known. The objective of this study was to assess
more recent trends in ATD use in youth (0 19 years) for the calendar years 2005/62012 using
data extracted from regional or national databases of Denmark, Germany, the Netherlands, the
United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the
0924-977X/& 2016 Elsevier B.V. and ECNP. All rights reserved.
Correspondence to: Department of Child and Adolescent Psychiatry Institute of Psychiatry, Psychology & Neuroscience, Kings College
London, 16 De Crespigny Park, London SE5 8AF, United Kingdom.
E-mail address: (C.J. Bachmann).
European Neuropsychopharmacology (2016) 26, 411419
annual prevalence of ATD use was calculated and stratied by age, sex, and according to
subclass and specic drug. Across the years, the prevalence of ATD use increased from 1.3% to
1.6% in the US data ( + 26.1%); 0.7% to 1.1% in the UK data (+ 54.4%); 0.6% to 1.0% in Denmark
data (+ 60.5%); 0.5% to 0.6% in the Netherlands data ( + 17.6%); and 0.3% to 0.5% in Germany
data (+ 49.2%). The relative growth was greatest for 15 19 year olds in Denmark, Germany and
UK cohorts, and for 10 14 year olds in Netherlands and US cohorts. While SSRIs were the most
commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still
displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively).
Despite the sudden decline in ATD use in the wake of government warnings, this trend did not
persist, and by contrast, in recent years, ATD use in children and adolescents has increased
substantially in youth cohorts from ve Western countries.
& 2016 Elsevier B.V. and ECNP. All rights reserved.
1. Introduction
The safety of selective serotonin reuptake inhibitors (SSRIs)
for the treatment of depression in children and adolescents
has been a subject of much concern and debate (Brent,
2004; Friedman, 2014). In October 2004, the U.S. Food and
Drug Administration (FDA) issued a black-box, now
termed boxed warning, indicating an increased risk of
suicidal ideation/suicidal behavior in children and adoles-
cents treated with SSRIs (Friedman, 2014). This followed
similar action in the United Kingdom by the Medicines and
Healthcare Products Regulatory Agency (MHRA), and was
soon followed by similar warnings by other regulatory bodies
(e.g. European Medicines Agency (EMA) warning against the
use of SSRIs in youthso18 years, August 2005). Within
2 years after these warnings, the use of antidepressants
(ATDs) decreased markedly in children and adolescents in
Canada, the UK and the USA (Bergen et al., 2009; Busch and
Barry, 2009; Katz et al., 2008; Kurian et al., 2007 ; Olfson
et al., 2008). However, such decreases occurred mostly for
youth diagnosed with less severe depression while psy-
chotherapy use increased substantially (Valluri et al.,
2010). Whether diminished ATD use has persisted is
not known.
A decade after government warnings, the controversy
continues on the evidence for the risk of suicidal events
associated with ATD use in children and adolescents.
Notably, the majority of ATDs are not licensed in youth less
than 18 years of age, and thus are commonly prescribed
off-label. Considering the broader international context
in which there is a signicant inuence of cultural and
health system factors on psychotropic medication use in
general (Schomerus et al., 2014; Steinhausen, 2013), infor-
mation on how ATD use has evolved over recent years in
different countries is needed. While there are a few studies
assessing multinational patterns of psychotropic medication
use in youth (Zito et al., 2006 ), to date, there is no recent
multinational epidemiological data on trends in ATD use in
children and adolescents. Single country comparisons (Dörks
et al., 2013; Hoffmann et al., 2014; Pottegard et al., 2014;
Wijlaars et al., 2012; Zoega et al., 2009) are often
hampered by dissimilar study methods (e.g. different time-
spans or age groups). The objective of this study is to assess
more recent trends in ATD use in youth (0 19 years) using
data extracted from regional or national databases of
Denmark, Germany, the Netherlands, the United Kingdom
(UK), and the United States (US). We also assess patterns of
antidepressant use according to age group, sex, ATD sub-
class and entity.
2. Experimental procedures
2.1. Data sources
2.1.1. Denmark
To perform this study we used the Danish Registry of Medicinal
Products Statistics (RMPS). The registry is a national prescription
database on all outpatient pharmacy-dispensed prescription med-
ications in Denmark (5.53 million inhabitants) and is updated
monthly. Each prescription record contains detailed information
on the drug dispensed (incl. ATC code). With the use of an
estimation of the underlying population (denominator), the pre-
valence can be calculated.
2.1.2. Germany
We used claims data of the single largest German health insurance
company, the BARMER GEK (insuring about 9.1 million persons,
representing more than 10% of the German population). Although
there are several differences between the statutory insurance
system and private insurances, both provide full-coverage health
insurance. As compared to the entire German population, the
BARMER GEK insures a higher proportion of females, but there are
no differences regarding socioeconomic status (as measured by
education level) (Hoffmann and Bachmann, 2014). For each year, all
insurees who were insured at least 1 day in all four quarters were
included. Each prescription record contains detailed information on
the drugs dispensed including ATC code.
2.1.3. The Netherlands
This study was performed with pharmacy dispensing data from (Visser et al., 2013). Dutch patients usually register at a
single community pharmacy, so a single pharmacy provides an
almost complete listing of each subject's prescribed drugs. The
database comprises all prescription drug dispensing data from 59
pharmacies since 1994 for about 600,000 persons in the northern
and eastern parts of the Netherlands. It includes all prescriptions,
regardless of prescriber, reimbursement status, or insurance. Over-
the-counter drugs and in-hospital prescriptions are not included.
The population in the database is representative of the whole Dutch
population (Visser et al., 2013).
C.J. Bachmann et al.412
2.1.4. United Kingdom
We used The Health Improvement Network (THIN) primary care
database, which contains information on prescriptions issued in
primary care in all four UK countries. Approximately 98% of the
population in the UK is registered with a general practitioner (GP),
with GPs issuing 93.4% of all ATD prescriptions dispensed by
community pharmacies in the UK (Health and Social Care
Information Centre, 2015). THIN is broadly representative of the
UK population in terms of demographics and consultation behavior
(Blak et al., 2011). We included only practices with good quality
data recording (Horsfall et al., 2013; Maguire et al., 2009). We
analyzed data from 2005 to 2012 and included 552 practices,
covering 6% of the UK population. Prescribing data in THIN has
been shown to reect dispensed prescriptions with a mean practice
redemption rate for all prescribing of 98.5% in 2008 (NHS National
Information Centre, 2011). The redemption rate for antidepressants
was slightly lower (96.7%), although still high.
2.1.5. United States
For the United States (US) data, computerized Medicaid adminis-
trative claims for the calendar years 2006 through 2012 were
analyzed for a narrowly-dened population of youth (019 years)
enrolled in Children's Health Insurance Program (CHIP) in a mid-
Atlantic state. Such youth are eligible for Medicaid coverage due to
family income (upper limit is three-times the federal poverty level;
The Henry J Kaiser Family Foundation (2015)) and are similar to
privately-insured youth in the US with respect to age distribution,
race and family composition, and general health status, with
moderately lower parental education, employment, and income
(Byck, 2000). Each youth was assigned an encrypted identication
number, which was then used to link the enrollment data les to
prescription drug claim les. Youth who were not continuously
enrolled in the CHIP program in a given year were excluded from
the analyses in that year.
2.2. Data analysis
Annual prevalence was dened as the percent of youth (019 years)
with one or more dispensings for antidepressant medication among
continuously enrolled youths in a given calendar year in the 2005/6
2012 period. The data extracted from the above-mentioned data-
bases are presented as total prevalence per 100 youths and
stratied according to age groups [0 4, 5 9, 10 14, 15 19
years (Zito et al., 2006)], and gender. In addition, among
antidepressant-treated youths, we compared the proportional dis-
tribution of antidepressant subclasses [SSRI (e.g. uoxetine, parox-
etine), TCA (e.g. imipramine, amitriptyline), other (e.g. mirta-
zapine, duloxetine, St John's wort)] between 2005/6 and 2012
separately for each country.
2.3. Ethical approval
2.3.1. United Kingdom
The CSD Medical Research Scientic Review Committee approved
this study in February 2015 (reference number 14-086). The scheme
for THIN to obtain and provide anonymous patient data to
researchers was approved by the National Health Service South-
East Multicentre Research Ethics Committee in 2002.
2.3.2. USA
The study related to the US data was reviewed and approved by the
Institutional Review Board of the University of Maryland, Baltimore.
2.3.3. Denmark, Germany and The Netherlands
According to the respective national regulations, ethical approval
was not necessary for this study.
3. Results
In 2012, the number of youths receiving ATD per studied
population of youths between 0 19 years were as follows:
Germany: 6849/1,414,623, Denmark: 11,774/1,203,817,
Netherlands: 790/131,954, United Kingdom: 8680/827,906,
and United States: 1667/105,188.
Across seven years from 2005/6 through 2012 (Figure 1), the
annual prevalence of ATD use for children and adolescents
increased in all studied cohorts as follows: USA cohort: 1.3% to
1.6% (+ 26.1%), UK cohort: 0.7% to 1.1% ( + 54.4%), Denmark
cohort: 0.6% to 1.0% ( + 60.5%), Netherlands cohort: 0.5% to
0.6% (+ 17.6%), and Germany cohort: 0.3% to 0.5% ( + 49.2%).
Cross-national differences in ATD use were up to 2.1-fold in
2005 and up to 3.3-fold in 2012.
The prevalence of ATD use stratied by sex is provided in
Table 1, showing a female preponderance in ATD use
throughout all years and all countries, with the exception
of the USA in 2006. Across countries, female/male ratios in
ATD use ranged from 1.7 to 2.3 in 2005 and from 1.1 to
2.4 in 2012.
The ATD use was most common among 1519 year olds,
ranging from 0.8% to 2.4% in 2005/6, and from 1.4% to 6.2%
in 2012 (Table 2). There was a consistent linear relation
between age and the prevalence of ATD medication use.
When looking at the trends in ATD use by age group from
2005/62012, ATD use increased most markedly in 1519
year olds and in 1014 year olds (Table 2). Time trends in the
age group 04 years were not calculated, as the number of
children in this age group was very small (Nr 10 in most
databases in 2012).
Concerning subclasses, both in 2005 and 2012, in most
countries, the majority of ATD use was for SSRIs, with
Denmark leading in SSRI use (81.8% of all ATD prescriptions
in 2012) (Figure 2). The only exception was Germany, where
in 2005 tricyclic antidepressant (TCA) prescriptions margin-
ally outnumbered SSRI prescriptions (39.6% vs. 37.7%). In
2012, this trend had inverted, but the percentage of TCA
prescriptions to children and adolescents in Germany
(23.0%) and also in the UK (19.5%) was still notable.
The entities most frequently prescribed differed mark-
edly between countries (Table 3). While citalopram was rst
2005 2006 2007 2008 2009 2010 2011 2012
Prevalence in percent
Figure 1 Percent prevalence of antidepressant use in children
and adolescents (019 years) in youth cohorts from ve
countries, 20052012.
Annotation: DE= Germany, DK= Denmark, NL= Netherlands, UK=
United Kingdom, USA= United States of America.
413Trends and patterns of antidepressant use in children and adolescents
Table 1 Percent prevalence of antidepressant medication use for children and adolescents (019 years) in youth cohorts from ve countries, by sex, 20052012 (numbers in brackets = 95%
condence interval).
2006 2007 2008 2009 2010 2011 2012 Difference
T Trend p-
Denmark 0.40
2.11 0.61
2.17 0.98
+ 60.5% o.0001
Germany 0.24
1.65 0.32
1.79 0.48
+ 49.2% o.0001
Netherlands 0.37
1.76 0.51
1.59 0.60
+ 17.6% o.0001
UK 0.41
2.34 0.68
2.35 1.05
+ 54.4% o.0001
US N/A N/A 0.90
N/A 1.32
1.09 1.58
+ 26.1% o.0001
Annotation: F= Females, M= Males, T = Total.
For the US, only data from 20062012 were available.
Ratio from 2006 data.
C.J. Bachmann et al.414
Table 2 Percent prevalence of antidepressant medication use from 20052012, by age group in youth cohorts from ve countries (numbers in brackets= 95% condence
2005 2006 2007 2008 2009 2010 2011 2012 Difference
04 years 0.01 [0.000.01] 0.00 [0.000.01] 0.01 [0.000.01] 0.01 [0.000.01] 0.01 [0.000.01] 0.01 [0.000.01] 0.01 [0.000.01] 0.01 [0.010.01] N/A
59 years 0.05 [0.040.05] 0.05 [0.040.06] 0.05 [0.040.06] 0.05 [0.050.06] 0.06 [0.050.07] 0.06 [0.050.07] 0.06 [0.050.07] 0.05 [0.040.06] + 4.6%
1014 years 0.34 [0.320.36] 0.38 [0.350.40] 0.39 [0.370.41] 0.41 [0.390.44] 0.44 [0.420.46] 0.49 [0.470.52] 0.46 [0.440.49] 0.46 [0.440.49] + 34.9%
1519 years 2.20 [2.152.26] 2.47 [2.412.53] 2.77 [2.712.83] 2.99 [2.933.05] 3.28 [3.213.34] 3.67 [3.603.73] 3.46 [3.393.52] 3.19 [3.133.26] + 45.1%
04 years 0.02 [0.010.02] 0.01 [0.010.02] 0.01 [0.010.01] 0.01 [0.010.01] 0.01 [0.000.01] 0.01 [0.000.01] 0.00 [0.000.01] 0.00 [0.000.01] N/A
59 years 0.10 [0.090.11] 0.10 [0.090.11] 0.10 [0.090.11] 0.07 [0.060.08] 0.07 [0.060.07] 0.06 [0.060.07] 0.05 [0.040.06] 0.04 [0.030.05] 60.6%
1014 years 0.20 [0.180.21] 0.18 [0.170.20] 0.20 [0.190.22] 0.20 [0.190.22] 0.20 [0.190.22] 0.19 [0.180.21] 0.20 [0.180.21] 0.21 [0.190.22] + 5.3%
1519 years 0.83 [0.800.85] 0.78 [0.760.81] 0.89 [0.870.92] 1.01 [0.981.04] 1.10 [1.071.14] 1.28 [1.241.31] 1.40 [1.361.41] 1.41 [1.381.45] + 71.0%
04 years 0.01 [0.000.03] 0.01 [0.000.03] 0.01 [0.000.03] 0.01 [0.000.02] 0.01 [0.000.03] 0.02 [0.010.04] 0.02 [0.010.04] 0.01 [0.000.03] N/A
59 years 0.07 [0.050.11] 0.05 [0.030.08] 0.07 [0.050.11] 0.07 [0.040.10] 0.05 [0.030.08] 0.09 [0.060.13] 0.11 [0.080.15] 0.09 [0.060.13] + 22.8%
1014 years 0.34 [0.280.41] 0.34 [0.280.41] 0.26 [0.210.32] 0.30 [0.240.37] 0.32 [0.260.39] 0.33 [0.270.40] 0.40 [0.330.47] 0.48 [0.410.56] + 41.5%
1519 years 1.59 [1.461.72] 1.53 [1.411.67] 1.52 [1.401.65] 1.65 [1.531.79] 1.43 [1.321.56] 1.43 [1.321.56] 1.62 [1.491.75] 1.68 [1.551.82] + 5.8%
04 years 0.00 [0.000.01] 0.00 [0.000.01] 0.00 [0.000.01] 0.00 [0.000.00] 0.00 [0.000.00] 0.00 [0.000.00] 0.00 [0.000.00] 0.00 [0.000.01] N/A
59 years 0.06 [0.050.07] 0.05 [0.040.06] 0.04 [0.040.05] 0.04 [0.040.05] 0.05 [0.040.06] 0.04 [0.030.05] 0.04 [0.030.05] 0.03 [0.030.04] 40.5%
1014 years 0.21 [0.190.23] 0.18 [0.160.20] 0.19 [0.170.21] 0.22 [0.210.24] 0.22 [0.200.24] 0.22 [0.200.24] 0.27 [0.250.29] 0.31 [0.290.33] + 46.3%
1519 years 2.37 [2.312.44] 2.33 [2.272.40] 2.45 [2.382.51] 2.45 [2.392.51] 2.66 [2.602.72] 3.03 [2.963.10] 3.19 [3.123.26] 3.19 [3.123.26] + 34.8%
04 years N/A 0.04 [0.030.06] 0.05 [0.040.07] 0.04 [0.020.05] 0.03 [0.020.05] 0.03 [0.020.05] 0.01 [0.010.03] 0.02 [0.010.04] N/A
59 years N/A 1.20 [1.071.35] 1.17 [1.041.31] 0.99 [0.871.12] 1.05 [0.921.19] 0.96 [0.841.10] 0.90 [0.781.03] 0.88 [0.761.01] 27.1%
1014 years N/A 3.49 [3.253.75] 3.48 [3.243.74] 3.39 [3.153.64] 3.57 [3.323.84] 3.45 [3.203.72] 3.55 [3.303.81] 3.50 [3.253.75] + 0,0%
1519 years N/A 5.35 [4.945.79] 5.36 [4.965.78] 5.86 [5.446.29] 5.93 [5.506.38] 5.82 [5.386.28] 6.08 [5.646.54] 6.24 [5.816.70] + 16.7%
For the US, only data from 20062012 were available.
Because of the small numbers of patients, difference in antidepressant use across time was not computed.
415Trends and patterns of antidepressant use in children and adolescents
choice in Denmark and in the Netherlands, uoxetine was
most frequently prescribed in Germany and in the UK, and
sertraline was the top ranking ATD in the US. In 2012, in the
UK, Germany and the Netherlands, TCAs (amitriptyline,
opipramol) were still among the top ve prescribed entities.
4. Discussion
The major ndings of this study are as follows: 1) From
2005/6 through 2012, the prevalence of ATD use in children
and adolescents increased substantially in cohorts from ve
Western countries, with both absolute and relative
increases being most pronounced in the UK and in Denmark.
2) Regarding age groups, the relative growth was greatest
for 15 19 year olds in Denmark, Germany and UK cohorts,
and for 10 14 year olds in Netherlands and US cohorts. 3)
While SSRIs were the most commonly used antidepressant
subclass, youth cohorts from Germany and the UK still
displayed notable proportions of tricyclic antidepressant
use (23.0% and 19.5%, respectively).
The current trend in ATD use is in line with international
prescription trends for other psychotropic classes in chil-
dren and adolescents, e.g. antipsychotics or ADHD drugs,
which show even greater increased rates (Bachmann et al.,
2014; Dalsgaard et al., 2013; Olfson et al., 2012; Rapoport,
2013; Ronsley et al., 2013). The reasons for this increase in
antidepressant use are not completely clear. An increase of
depressive disorders or other conditions demanding treat-
ment with ATDs as a reason for the increase in ATD
prescriptions can be largely ruled out, as there is substantial
evidence that there has been no signicant increase in the
rates of children's mental health conditions in Western
countries over recent years in studies of German and British
youth (Hölling et al., 2014; Sellers et al., 2015). Never-
theless, there is some evidence of an increase in child and
adolescent mental health service use, potentially indicating
under-treatment in previous years (Breland et al., 2014;
Steinhausen and Bisgaard, 2014).
Although there have been no substantial changes in
clinical guidelines that would have extended indications
for ATD prescriptions, in day-to-day practice there has been
a marked trend towards a broadening of indications by
prescribers. In terms of psychiatric and behavioral treat-
ments, the growth of comorbidities (Kessler et al., 2009)as
well as the increased trend for not otherwise specied
diagnostic categories, may contribute to expanded medica-
tion use (Safer et al., 2015). In the study of Dörks et al.
(2013) on ATD utilization in German children and adoles-
cents, more than one third of ATDs were prescribed off-
label for indications such as migraine, somatoform disor-
ders, personality disorders, sleeping problems and develop-
mental disorders, and in the US study of Lee et al. (2012),
only 9.2% of ATDs were prescribed according to indication.
Another potential reason for the increase in ATD use may be
the preference for pharmacotherapy because of the limited
availability of psychotherapy services or because of
patients' and clinicians' expectations of reaching treatment
goals faster with ATD use (Correll et al., 2013). Moreover,
the increased ATD use may also be related to an increased
marketing of ATD by pharmaceutical companies (Kesselheim
et al., 2011; Kondro and Sibbald, 2004). Such marketing
strategies have been demonstrated to be effective in
inuencing prescribers' preferences (Larkin et al., 2014).
Finally, as Taylor, (2013) argues, the rise in ATD use may be
addressing previous under-treatment of child psychiatric
disorders. Nevertheless, the ndings from this study cannot
address questions of overuse or underuse of ATDs in children
and adolescents. Further research is warranted on outcomes
of community treatment populations to assure effective,
appropriate, and quality care.
The greater proportion of ATD use in females compared
with males is consistent with prior
ndings (Zito et al.,
2006) and with the gender-specic incidence of depression
in youth (Merikangas et al., 2009). Concerning age groups,
the current ndings show that the proportional growth in
ATD use occurred mostly for older youth (10 19 year olds),
whereas younger aged children showed minimal changes or
sustained drops in ATD use. The marked rise of ATD use in
adolescents is a nding consistent with the majority of
recent studies on other psychotropic medication use in
children and adolescents (Acquaviva et al., 2009;
Bachmann et al., 2014; Kalverdijk et al., 2008; Meng
et al., 2014; Pottegard et al., 2014; Steinhausen, 2015;
Steinhausen and Bisgaard, 2014). In the current study, SSRIs
were the most commonly used antidepressant subclass in all
ve Western countries. However, Germany and the UK
displayed notable proportions of tricyclic antidepressant
use in 2012. The continuing use of tricyclic antidepressants
in youth contrasts with the long-standing negative ndings
on effectiveness (Hazell and Mirzaie, 2013). Regarding the
most commonly prescribed substances, there were several
antidepressants among the top ve which have no
approval for use in children or adolescents in the respective
country (e.g. amitriptyline in Germany and the Netherlands,
bupropion in the UK) or for which no trial evidence on safety
or effectiveness in minors is available (e.g. opipramol, St
John's worth). These off-label prescription practices in
minors might reect an extrapolation of ATD prescription
patterns in adults. The true rates of off-label use might
even be higher, as our data did not contain information
whether licensed ATDs were prescribed for the correspond-
ing indications.
Percentage of total antidepresant use
TCA 2005
TCA 2012
SSRI 2005
SSRI 2012
Figure 2 Trends in antidepressant medication use in children
and adolescents (019 years) in youth cohorts from ve
countries for tricyclic antidepressants and selective serotonin
reuptake inhibitors (2005 vs. 2012).
Annotation: DE = Germany, DK= Denmark, NL = The Nether-
lands, SSRI= Selective Serotonin Reuptake Inhibitors, TCA= Tri-
cyclic antidepressants, UK= United Kingdom, USA = United
States of America.
C.J. Bachmann et al.416
Among factors that may vary by country are formulary
differences, differences in reimbursement, availability of
alternative non-pharmacological treatments for emotional
and behavioral disorders, clinical guidelines and indications
for use, e.g. imipramine for nocturnal enuresis. Cultural
attitudes toward the use of psychotropic drugs vary by
country. For example, Schomerus et al. (2014) found that US
patients embrace psychotropic medications more readily
than Germans.
The main limitation of this study is the diversity of the
underlying databases in terms of several factors, e.g.
representativeness of the full population, prescribing phy-
sician specialty (GPs vs. specialists) and socio-economic
status (von Soest et al., 2012). These differences in data
sources also hamper the inter-country comparability of
data. An example for this is the UK database, which
contains only GPs' prescriptions. Thus, it lacks prescriptions
issued by (child and adolescent) psychiatrists, which might
lead to an underestimation of ATD prescription rates.
However, as prescriptions are often initiated by psychia-
trists and then continued by GPs, GPs' prescribing patterns
probably reect fairly completely ATD prescription trends in
children and adolescents originally seen by psychiatrists.
Nevertheless, as the databases also reect the differ-
ences of the respective national health systems (including
e.g. prescribing restrictions), the comparability of prescrip-
tion data between countries will never be completely
harmonized. Therefore, the individual countries' relative
prescription trends reported in our study are probably a
more robust feature than absolute prescription rates.
Moreover, we did not have information on factors that
may inuence ATD prescribing to children and adolescents
such as the underlying indication, co-medication, ethnic
background (Wittkampf et al., 2010), foster care status
(Fontanella et al., 2011, 2014), adequacy of dosage, dura-
tion of pharmacotherapy, adherence, symptom severity and
symptom duration. Also, we did not consider medication
bought over-the-counter (mainly St John's wort).
In conclusion, despite the sudden decline in ATD use in
the wake of government warnings, the trend did not persist,
and by contrast, across recent years, ATD use in children
and adolescents has increased substantially in youth cohorts
in ve Western countries. While it is not clear whether this
trend reects overuse or underuse of ATDs in youth, further
assessment is warranted. The ndings support the need for
outcomes research in community-treated populations, and,
in the policy arena, for the development of harmonized
international clinical guidelines.
Role of funding source
No funding was secured for this study.
Dr. Bachmann conceptualized and designed the study, drafted the
initial manuscript, and approved the nal manuscript as submitted.
Prof. Aagard acquired, analyzed and interpreted data, revised the
manuscript critically, and approved the nal manuscript as sub-
mitted. Mehmet Burcu acquired, analyzed and interpreted data,
revised the manuscript critically, and approved the nal manuscript
as submitted. Prof. Glaeske acquired, analyzed and interpre-
Table 3 The top 5 antidepressant entities in children and adolescents (019 years) in youth cohorts from ve countries (2005 vs. 2012), as a percentage of total
antidepressant use.
Rank Denmark Germany Netherlands UK US
2005 % 2012 % 2005 % 2012 % 2005 % 2012 % 2005 % 2012 % 2006
% 2012 %
1 CIT 33.5 CIT 40.9 FLX 12.2 FLX 24.3 CIT 28.8 CIT 33.8 FLX 35.2 FLX 31.7 SER 20.6 SER 27.5
2 VEN 11.2 SER 16.8 SJW 11.0 CIT 15.7 PAR 15.6 FLX 16.6 CIT 19.3 CIT 29.2 FLX 20.5 FLX 21.9
3 SER 11.1 VEN 14.7 OPI 10.0 OPI 7.6 VEN 14.6 AMI 8.2 AMI 14.5 AMI 16.4 ESC 14.5 ESC 10.9
4 MIR 10.0 MIR 10.0 CIT 9.4 MIR 7.3 FLX 13.2 ESC 7.1 SER 7.2 SER 14.0 BUP 10.0 CIT 8.9
5 ESC 9.5 ESC 7.9 IMI 8.1 AMI 5.5 FLV 7.0 MIR 6.4 ESC 6.6 MIR 3.1 TRA 9.0 TRA 8.2
Annotation: AMI= Amitriptyline, BUP= Bupropion, CIT= Citalopram, ESC = Escitalopram, FLX= Fluoxetine, FLV = Fluvoxamine, IMI= Imipramine, MIR= Mirtazapine, OPI = Opipramol,
PAR = Paroxetine, SER= Sertraline, SJW= St John's Wort, TRA= Trazodone, VEN= Venlafaxine.
For the US, only data from 20062012 were available.
417Trends and patterns of antidepressant use in children and adolescents
ted data, revised the manuscript critically, and approved the nal
manuscript as submitted. Dr. Kalverdijk acquired, analyzed
and interpreted data, revised the manuscript critically, and
approved the nal manuscript as submitted. Dr. Petersen acquired,
analyzed and interpreted data, revised the manuscript critically,
and approved the nal manuscript as submitted. Dr. Schuiling-
Veninga acquired, analyzed and interpreted data, revised the
manuscript critically, and approved the nal manuscript as sub-
mitted. Dr. Wijlaars acquired, analyzed and interpreted data,
revised the manuscript critically, and approved the nal manuscript
as submitted. Prof. Zito acquired, analyzed and interpreted data,
revised the manuscript critically, and approved the nal manuscript
as submitted. Prof. Hoffmann conceptualized and designed the
study, undertook the statistical analysis, drafted the initial manu-
script, and approved the nal manuscript as submitted. All authors
mentioned above agree to be accountable for all aspects of
the work.
Conict of interest
Christian Bachmann has received lecture fees from Actelion,
Novartis, and Ferring as well as payment from BARMER GEK and
from AOK for writing book chapters. He has served as a study
physician in clinical trials for Shire and Novartis. Gerd Glaeske and
Falk Hoffmann are active on behalf of a number of statutory health-
insurance companies (BARMER GEK, DAK, TK, and various corporate
health-insurance funds) in the setting of contracts for third-party
payment. Lise Aagaard has received traveling grants from Pzer and
Swedish Orphan BioVitrum. Luuk J. Kalverdijk has received lecture
fees from Eli-Lilly, Janssen-Cilag and Shire and has served as a study
physician in clinical trials of Eli-Lilly. Catharina Schuiling-Veninga,
Irene Petersen, Linda Wijlaars, Julie M. Zito and Mehmet Burcu
declare no conict of interest.
The authors are grateful to the insurance funds, databases and
government agencies that provided the data on antidepressant use.
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419Trends and patterns of antidepressant use in children and adolescents
... In clinical practice, major depressive and obsessive compulsive disorders (OCD) are FDAapproved indications, and SSRIs have also been used with several other indications, including anxiety and post-traumatic stress disorders. CDC data show that, between 2011 and 2014, 12.7% of young people aged 12 years and older received antidepressant treatment in the USA (1)(2)(3)(4). Although the overall efficacy and safety of SSRIs are supported by large controlled multicenter studies, the adverse effects of SSRI treatment in children and adolescents may be different from adults mainly due to the pharmacodynamic and pharmacokinetic developmental differences between these age groups (5,6). ...
... Prescribing of medications used to treat mental health conditions in children has increased in various international contexts [10,11] with notable rises in prescriptions of antidepressants [12,13] and medications to treat Attention Defecit Hyperactivity Disorder particularly among boys [14,15] from the 1990s up until the 2010s. Analysis of mental health prescribing in parts of the United Kingdom has previously been conducted for people of all ages, but this did not include a detailed exploration of trends in younger age groups [16,17]. ...
Full-text available
Background One in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. The COVID-19 pandemic has negatively impacted mental health and disrupted the delivery of care. Prevalence of poor mental health is not evenly distributed across age groups, by sex or socioeconomic groups. Equity in access to mental health care is a policy priority but detailed socio-demographic trends are relatively under-researched. Methods We analysed records for all mental health prescriptions and referrals to specialist mental health outpatient care between the years of 2015 and 2021 for children aged 2 to 17 years in a single NHS Scotland health board region. We analysed trends in prescribing, referrals, and acceptance to out-patient treatment over time, and measured differences in treatment and service use rates by age, sex, and area deprivation. Results We identified 18,732 children with 178,657 mental health prescriptions and 21,874 referrals to specialist outpatient care. Prescriptions increased by 59% over the study period. Boys received double the prescriptions of girls and the rate of prescribing in the most deprived areas was double that in the least deprived. Mean age at first mental health prescription was almost 1 year younger in the most deprived areas than in the least. Referrals increased 9% overall. Initially, boys and girls both had an annual referral rate of 2.7 per 1000, but this fell 6% for boys and rose 25% for girls. Referral rate for the youngest decreased 67% but increased 21% for the oldest. The proportion of rejected referrals increased steeply since 2020 from 17 to 30%. The proportion of accepted referrals that were for girls rose to 62% and the mean age increased 1.5 years. Conclusions The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid greater demand, and the changing demographics of those accepted, indicate clinical prioritisation and unmet need. Persistent inequities in mental health prescribing and referrals require urgent action.
... Currently, there are no clear indications approved by the Food and Drug Administration (FDA) [28] or European Medicines Agency (EMA) [29] for psychopharmacological medications in medically ill children with delirium, depression, or anxiety [30][31][32][33]. ...
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Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.
... [36] Despite the lack of signi cant statistical or clinical improvement in pediatrics, antidepressants were used widely in recent years. [37] A network meta-analysis conducted to evaluate the e cacy of antidepressants in children (9-18 years old) concluded that only uoxetine showed statistical signi cance when compared to placebo. ...
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Background Major depressive disorder (MDD) is a global health condition related to mental and physical consequences, functional impairment, and medical expenses. A wide range of antidepressant drugs could be prescribed for MDD patients. In this study, we aim to investigate the efficacy and safety of Vilazodone treatment for relieving MDD symptoms upon valid scores. Methods Five databases were searched for literature search and seven included randomized clinical trials were finally meta-analyzed. All data were presented either as a mean difference (MD) in pooling continuous outcomes or risk ratio (RR) in pooling dichotomous outcomes with 95% confidence intervals (CIs). Results We included 7 randomized controlled trials (RCTs) with a total number of 3804 patients; 3390 of them were eligible to be pooled in our analysis. Patients' ages ranged from 13 to 42.4 years. vilazodone was given orally once a day with different doses throughout the included trials ranging from 10 to 40 mg for the duration of 8 to 12 weeks. The results significantly favored vilazodone over the placebo regarding the Montgomery–Åsberg Depression Rating Scale (MADRS) (MD =-4.69, 95% CI: [-6.83, -2.55], P < 0.0001), Clinical Global Impression (CGI) severity (MD=-0.29, 95% CI: [-0.41, -0.17], P < 0.00001), and CGI improvement (MD =-0.36, 95% CI: [-0.44, -0.28], P < 0.00001). The pooled effect size significantly favored Vilazodone in terms of nausea, vomiting, diarrhea, somnolence, dry mouth, insomnia, and dizziness compared to controls. Conclusion Vilazodone treatment is an effective, well-tolerated, and safe drug for MDD patients in terms of multiple outcomes.
... SSGİ'lerden fluoksetin ve essitalopram, majör depresif bozukluk için; fluoksetin, sertralin, fluvoksamin ve klomipramin obsesif kompulsif bozukluk için; duloksetin yaygın anksiyete bozukluğu için; fluoksetin ve olanzapin kombinasyonu bipolar depresyon için FDA tarafından, değişik yaş gruplarındaki çocuk ve ergenlerde kullanılmak üzere onaylanmıştır (Bachmann et al., 2016). Bunun dışında çoğu SSGİ, benzer moleküler yapıları ve etki mekanizmaları nedeni ile çocukluk çağının anksiyete ve depresif bozukluklarında kullanılmaktadır. ...
Full-text available
Günümüzde çocuk ve ergen psikiyatrisinin gelişmesi ve çocukluk çağı psikiyatrik bozukluklarının daha iyi tanınmasıyla birlikte psikotrop ilaçların çocuk ve ergen yaş grubunda kullanımı giderek artmaktadır. Çocuk ve ergenlerde kullanım onaylı olan ilaçların yanı sıra erişkinlerde kullanılan diğer ilaçlar da kliniklerde kullanılmakta- dır. Ancak çocuk ve gençlerde ilaçların beden üzerindeki etkileri (farmakodinamik) ile ilaçların emilimi, dağılımı, metabolize edilmesi ve atılımı (farmakokinetik) eriş- kinlerden farklı olduğu için doğrudan çocuk ve ergenler üzerinde yapılmış kont- rollü çalışmalara gerek vardır. Bu bölümde çocuk ve ergenlerde ilaç kullanımının temel ilkeleri, farmakodinamik ve farmakokinetik özellikleri ele alınmıştır. Ayrıca çocuk ve ergenlerde kullanılan ilaçların temel özellikleri ile ilaç etkileşimleri gözden geçirilmiştir.
General practitioner (GP) prescribing of psychotropic medicines to paediatric patients is increasing across countries, sparking the need for additional research into this field. We examined prescribing rates, GP and patient characteristics and indications associated with prescribing psychotropic medicines to paediatric patients in Australian general practice, using data from the Bettering the Evaluation and Care of Health (BEACH) program. We extracted all encounters with children aged 3 to 17 from 2000 to 2016. Psychotropic medicines were defined as those in the ATC codes N05 (Psycholeptics) and N06 (Psychoanaleptics). Of the 144,397 encounters, GPs prescribed 1829 psychotropic medicines to paediatric patients at an average rate of 1.16 prescriptions per 100 encounters (95% confidence interval 1.09–1.23). We found that the rate of psychotropic medicines prescribed to paediatric patients in Australian general practice increased. Patients who were adolescent, female, socio-economically disadvantaged or from an English-speaking background were significantly more likely to be prescribed a psychotropic medicine. GP practices in remote or regional areas and Australian graduate GPs were more likely to prescribe psychotropic medicines to paediatric patients. Depression, attention deficit hyperactivity disorder, anxiety and autism were the most common psychiatric indications managed with psychotropic medicines. Antidepressants, psychostimulants, benzodiazepines, antipsychotics and other psychotropic medicines were prescribed, signifying a high rate of off-label use. Sertraline was the most common psychotropic medicine prescribed, followed by fluoxetine and methylphenidate. Future studies involving data from other prescribers, e.g. paediatricians and psychiatrists, and studies linking prescribed medicines to their indications may widen our understanding of psychotropic medicine prescribing in Australian paediatric patients.
Introduction Recent studies show an increase in the use of antidepressants in minors (younger than 18 years), although few antidepressants are indicated for this age group. The aim of our study was to calculate the annual prevalence of antidepressant use in children and adolescents and to review the adherence of prescription to current indications. Methods Study of the prevalence of antidepressant use in minors based on the records of the Electronic Database for Pharmacoepidemiologic Studies in Primary Care (BIFAP) of Spain for the 2013–2018 period, considering at least one prescription per year for each patient. Results The prevalence of antidepressant prescription in patients from the BIFAP cohort increased between 2013 (7.97 prescriptions per 1000 patients) and 2018 (8.87 prescriptions per 1000 patients), in most groups and in both sexes. In this period, female patients received the most prescriptions, surpassing prescriptions in male patients by up to 2.5 points in the overall rates. In patients younger than 13 years, this trend was inverted and antidepressant use was higher in male patients. The prevalence of prescription rose with increasing patient age, as did the proportion of off-label prescriptions. The use of off-label medication decreased over time. Conclusions There was a gradual increase in the prevalence of antidepressant prescription in minors younger than 18 years, with a predominance of the female sex. The high proportion of unapproved medication use in this age group calls for more thorough investigation of the risk-benefit balance of these treatments and of safer treatment alternatives.
Background Selective serotonin reuptake inhibitors (SSRIs) have been associated with type 2 diabetes mellitus (T2DM) in youths, possibly via 5-HT2C, H1 receptors and serotonin transporter (SERT). SSRIs have similar affinity for SERT but variable affinity for 5-HT2C and H1. This study assessed whether SSRIs with strong affinity for 5-HT2C and H1 (relative to SERT) were associated with T2DM risk compared with weak-affinity SSRIs. Methods Using the UK Clinical Practice Research Datalink, we assembled a cohort of patients aged 5–24, newly prescribed a strong-affinity SSRI (citalopram, escitalopram, fluoxetine) or weak affinity (paroxetine, sertraline, fluvoxamine) between 1990 and 2019. We controlled for confounding using standardized mortality ratio weighting, estimated from calendar time-specific propensity scores. We used weighted Cox proportional hazards models to estimate hazard ratios (HRs) of incident T2DM with 95 % confidence intervals (CIs). Results The cohort included 347,368 new users of strong-affinity SSRIs and 131,359 of weak-affinity SSRIs. Strong-affinity SSRIs were not associated with an increased T2DM risk compared with weak-affinity SSRIs (incidence rate 2.8 vs 2.7 per 1000 person-years; HR 1.03, 95 % CI 0.85–1.25). T2DM risk did not vary with duration of use, age or sex. However, the HR was numerically higher in youths with normal or low weight (HR 1.30, 95 % CI 0.85–1.98) and with prior antipsychotic use (HR 1.62, 95 % CI 0.83–3.18). Limitations Median duration of SSRI use, in line with real-world SSRI prescribing, was relatively short. Conclusion T2DM risk did not differ between strong- and weak-affinity SSRIs, providing reassurance for clinicians when choosing between SSRIs in youths.
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This article provides a review of the magnitude of mental disorders in children and adolescents from recent community surveys across the world. Although there is substantial variation in the results depending upon the methodological characteristics of the studies, the findings converge in demonstrating that approximately one fourth of youth experience a mental disorder during the past year, and about one third across their lifetimes. Anxiety disorders are the most frequent conditions in children, followed by behavior disorders, mood disorders, and substance use disorders. Fewer than half of youth with current mental disorders receive mental health specialty treatment. However, those with the most severe disorders tend to receive mental health services. Current issues that are now being identified in the field of child psychiatric epidemiology include: refinement of classification and assessment, inclusion of young children in epidemiologic surveys, integration of child and adult psychiatric epidemiology, and evaluation of both mental and physical disorders in children.
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Patterns and trends of subthreshold DSM-IV mental health diagnoses for youth within US community treatment settings merit systematic research. To quantify and assess temporal patterns of DSM-IV diagnoses not otherwise specified (NOS) among youth during physician office visits. We conducted a retrospective study using psychiatric diagnostic data from the US National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (n = 16 295) from 1999 through 2010, combined in 4-year intervals. Using diagnoses from visits to physicians, we compared trends of the proportional distribution of the major psychiatric diagnoses with subthreshold criteria (coded as NOS) with proportions of diagnoses reaching full criteria. Specific common psychiatric diagnoses NOS compared with full-criteria psychiatric diagnoses. Between the 1999-2002 and 2007-2010 periods, the proportion of US medical visits reporting DSM-IV NOS psychiatric diagnoses compared with the proportion reporting full psychiatric diagnostic criteria for youth aged 2 to 19 years rose prominently for major mood diagnostic subtypes. Among all visits for mood disorders, NOS visits grew proportionally 1.5-fold from 45.3% in the 1999-2002 period to 68.8% in the 2007-2010 period (P < .001). Among visits for bipolar disorder, NOS visits increased more than 18-fold, from 3.6% in the 1999-2002 period to 72.6% in the 2007-2010 period (P < .001). In addition, anxiety disorder NOS increased from 44.6% in the 1999-2002 period to 58.1% in the 2007-2010 period. Overall, NOS visits constituted 35.0% of the total psychiatric visits in 2007-2010 but represented 55.9% when attention-deficit/hyperactivity disorder codes were excluded. The expansion of subthreshold (NOS) DSM-IV diagnoses of mood disorder, bipolar disorder, and anxiety disorder in youth that has occurred since 1999 in all likelihood will continue in the DSM-5 era unless administrative efforts are made to alter this practice. Unspecified diagnoses lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medication.
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Prescriptions of psychotropic medications have become an important intervention for many children and adolescents with mental disorders, and the rise of these prescriptions is debated intensively both among experts and the public. This review reports some recent international findings on point prevalence rates, cross-country comparisons, and time trends in psychotropic medication prescriptions for children and adolescents. Besides the total prescription rates, figures for antidepressants, antipsychotics, stimulants, and anxiolytics prescriptions are provided. The overall prescription rates of psychotropics in general and the major medication subgroups prescribed to children and adolescents vary substantially between countries with the US consumption being markedly higher than the use in European countries. However, even among the latter there are marked variations in findings. Studies reporting on time trends clearly indicate that there was a marked increase in the use of psychotropics for children and adolescents in the recent past. However, only a single study adjusted prevalence rates for the increasing number of children and adolescents assessed and treated in institutions providing mental health care. Considering the increasing numbers of children and adolescents seen in psychiatric services, the increase of psychotropic medications is less strong though still pronounced enough to stimulate further reflections on the use of these interventions.
Child and adolescent mental health problems burden not only the individual, but also their families and their social environment and may, therefore, be regarded as a highly relevant public health issue. The data on mental health problems of children and adolescents from the KiGGS Wave 1 study (sample period 2009-2012) make it possible to report on both current prevalence rates and time trends over the 6-year period beginning with the KiGGS baseline survey (2003-2006). The assessment of emotional and behavioral problems in KiGGS Wave 1 was carried out with the symptoms questionnaire of the Strengths and Difficulties Questionnaire (SDQ) in a telephone interview with 10,353 guardians of children and adolescents aged 3-17 years. Moreover, using the SDQ impact supplement, the KIGGS Wave 1 data provide information on psychosocial impairment following child and adolescent mental health problems. Subjects with a borderline or abnormal SDQ score, according to German normative data, were considered at risk. A total of 20.2 % (95 % CI: 18.9-21.6 %) of the study subjects were identified as being at risk for a mental health disorder, compared with 20.0 % (19.1-20.9 %) during the KiGGS baseline study (age-standardized based on population from 12 December 2010). Thus, no significant changes over time in the prevalence of mental health problems were detected. Also, there were no statistically significant differences in prevalence by sex, age group, or socioeconomic status between the KiGGS baseline survey and KiGGS Wave 1. The statistical comparison of the subscale mean values for both girls and boys showed higher values with respect to the subscales for emotional problems, behavioral problems, and prosocial behavior and lower mean values for the peer problems subscale in KiGGS Wave 1. These partly small temporal trends, however, may be due to possible mode effects (written questionnaire in the KiGGS baseline study versus telephone interview in KiGGS Wave 1). The hyperactivity subscale remained stable across the two sample periods. Regarding impairments following mental health problems at the second sample period, boys were more affected in the areas of chronicity, family burden, and impact score. The high and stable prevalence rates and magnitude of emotional and behavioral problems should prompt increased preventive efforts.
Objective: This study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income). Methods: Serial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes). Results: Both types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]=1.12, 99% confidence interval [CI]=1.10-1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09-1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07-1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants. Conclusions: Polypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.
Psychische Auffälligkeiten bei Kindern und Jugendlichen belasten die Betroffenen, die Familie und das soziale Umfeld und besitzen eine hohe Public-Health-Relevanz. Mit der Studie KiGGS Welle 1 (Erhebungszeitraum 2009–2012) liegen Daten zu psychischen Auffälligkeiten im Kindes- und Jugendalter vor, die es ermöglichen, sowohl aktuelle Prävalenzen als auch Trends mit Bezug auf die KiGGS-Basiserhebung (2003–2006) über einen 6-Jahres-Zeitraum zu berichten. Das Screening psychischer Auffälligkeiten in KiGGS Welle 1 erfolgte mit dem Symptomfragebogen des Strengths and Difficulties Questionnaire (SDQ) bei 10.353 Sorgeberechtigten im telefonischen Interview. In KiGGS Welle 1 wurde zusätzlich auch der SDQ-Impactfragebogen eingesetzt. Insgesamt 20,2 % (95 %-KI: 18,9–21,6 %) der Kinder und Jugendlichen im Alter von 3 bis 17 Jahren ließen sich in der KiGGS Welle 1 mit dem SDQ-Symptomfragebogen einer Risikogruppe für psychische Auffälligkeiten (grenzwertig auffällig oder auffällig im SDQ-Gesamtproblemwert, deutsche Normierung) zuordnen: In der KiGGS-Basiserhebung waren dies 20,0 % (19,1–20,9 %; altersstandardisiert auf die Bevölkerung zum 31.12.2010, deutsche Normierung). Damit ließ sich insgesamt keine bedeutsame Veränderung über die Zeit in der Häufigkeit psychischer Auffälligkeiten nachweisen. Auch in der Stratifizierung nach Geschlecht, Altersgruppen und Sozialstatus zeigten sich in Bezug auf die Risikogruppe keine statistisch signifikanten Prävalenzunterschiede zwischen der KiGGS-Basiserhebung und KiGGS Welle 1. Der statistische Vergleich der Skalenmittelwerte zeigte sowohl bei Mädchen als auch bei Jungen höhere Werte bezüglich der Subskalen für emotionale Probleme, Verhaltensprobleme und prosoziales Verhalten sowie geringere Mittelwerte für die Subskala Peer-Probleme in KiGGS Welle 1. Die zum Teil gering ausgeprägten Veränderungen über die Zeit könnten jedoch auf Modeeffekte (schriftliche Befragung in der KiGGS-Basiserhebung vs. Telefoninterview in der KiGGS Welle 1) zurückzuführen sein. Die Subskala Hyperaktivität blieb über beide Messzeiträume unverändert. In Bezug auf Beeinträchtigung infolge psychischer Probleme, erhoben mit dem SDQ-Impactfragebogen, ergaben sich für den Impactscore sowie für Chronizität und familiäre Belastungen mehr und länger andauernde Beeinträchtigungen bei Jungen. Die anhaltend hohe Prävalenz und das gleichbleibend hohe Ausmaß von emotionalen und verhaltensbedingten Auffälligkeiten sollten Anlass zu vermehrten präventiven Anstrengungen geben.