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National Estimates of Antidepressant Medication Use Among U.S. Children, 1997-2002
National Estimates of Antidepressant Medication Use Among U.S. Children, 1997Y2002 BENEDETTO VITIELLO, M.D., SAMUEL H. ZUVEKAS, PH.D., AND GRAYSON S. NORQUIST, M.D., M.S.P.H.
ABSTRACT Objective: A threefold increase in the use of antidepressants has been reported among children (18 years old and younger) between 1987 (0.3%) and 1996 (1.0%). The aim of this study was to determine whether pediatric use of antidepressants continued to rise at a national level during the period 1997Y2002. Method: The Medical Expenditure Panel Survey (MEPS) database for the years 1997Y2002 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Healthcare Research and Quality. Overall response rate ranged between 64% and 68%. Results: An estimated 1.4 million (95% confidence interval [CI] 1.1Y1.7) children received antidepressant medication in 2002 as compared to 0.9 million (95% CI 0.7Y1.2) in 1997 (p = .01). The percentage of users increased from 1.3% (95% CI 0.9Y1.6) in 1997 to 1.8% (95% CI 1.5Y2.1) in 2002 (p G .01). Adolescent use (2.1% in 1997 versus 3.9% in 2002 (p G .001) accounted for the increase, with no change among children younger than 13 years. Also among adolescents, the use rate remained stable during the 2000Y2002 period. The increase was caused by use of selective serotonin reuptake inhibitors and other newer antidepressants, whereas use of TCAs remained stable in adolescents (p = .84) and declined in prepubertal children (p = .04). Antidepressant use was similar among males and females and higher among whites than blacks and Hispanics. Conclusions: Nationwide, the use of selective serotonin reuptake inhibitor antidepressant medications continued to increase in adolescents in the late 1990s and until the year 2000, with no further increase through 2002, and remained stable in prepubertal children. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(3):271Y279. Key Words: antidepressants, children, adolescents, use, pharmacoepidemiology.
Antidepressant medications are used in the treatment of children and adolescents with a variety of disorders,
Accepted September 13, 2005. Dr. Vitiello is with the Child and Adolescent Treatment and Preventive Intervention Research Branch, National Institute of Mental Health, Bethesda, MD; Dr. Zuvekas is with the Division of Social and Economic Research, Center for Financing, Access, and Cost Trends, Agency for Health Care Research and Quality, Rockville, MD; and Dr. Norquist is with the Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS. Funded by Agency for Healthcare Research and Quality and National Institute of Mental Health. The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the Agency of Healthcare Research and Quality, the National Institute of Mental Health, or the U.S. Department of Health and Human Services. Correspondence to Dr. Benedetto Vitiello, NIMH, Room 7147, 6001 Executive Blvd. Bethesda, MD 20892-9633; e-mail: [email protected]. 0890-8567/06/4503Y0271Ó2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000192249.61271.81
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including depression, anxiety, attention-deficit/hyperactivity disorder, and enuresis. A number of antidepressants have indications for pediatric use (defined as use in subjects 18 years of age and younger) approved by the U.S. Food and Drug Administration. Clomipramine, fluvoxamine, fluoxetine, and sertraline are approved by the U.S. Food and Drug Administration for the treatment of obsessive-compulsive disorder, fluoxetine for the treatment of major depression, and imipramine for the treatment of enuresis in children and adolescents (American Academy of Child and Adolescent Psychiatry, 2004; Emslie et al., 2002; March et al., 1998). ‘‘Offlabel’’ use is, however, common and various antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), are prescribed for the treatment of childhood depressive and anxiety disorders (Hughes et al., 1999; RUPP Anxiety Study Group, 2001). In addition, tricyclic antidepressants (TCAs), such as nortriptyline
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VITIELLO ET AL.
and desipramine, are efficacious in decreasing symptoms of attention-deficit/hyperactivity disorder in children, but their use is limited by safety concerns (Pliszka et al., 2000; Spencer et al., 2004). The point prevalence of major depression has been estimated to be in the range of 1% to 6% among adolescents and about three times lower among prepubertal children (Costello et al., 2003; Kessler and Walters, 1998; Lewinsohn et al., 1998; Simonoff et al., 1997). Subsyndromal depression, defined as presence of symptoms of depression that do not meet full diagnostic criteria for depressive disorder, is estimated to be much more prevalent (Kessler et al., 2001). Estimates ranging from 0.8% to 3% have been reported for the prevalence of obsessive-compulsive disorder among adolescents (Flament et al., 1988; Valleni-Basile et al., 1994). The nationwide use of antidepressants in children (younger than 18 years of age) was estimated to be 0.3% in 1987 and 1.0% in 1996, which is about a threefold increase during this period (Olfson et al., 2002a). Use was lower in blacks, in the West, among insured people, and among youth ages 15 years and older. Based on two regional Medicaid data sets and one health maintenance organization data set, antidepressant use among children 2Y17 years of age was estimated to be between 1.3% and 1.9% in 1994, with a 2.9- to 4.6-fold increase from 1988 (Zito et al., 2002). In 1994, the estimated use of SSRI medications was between 0.6% and 0.8% across the three data sets, and TCAs still accounted for more than half of the total antidepressant use. More recently, an increase in pediatric use of antidepressants from 0.9% in 1994 to 2.1% in 2003 was reported in an health maintenance organizationYinsured population in Northern California (Hunkeler et al., 2005). The increase in pediatric use of antidepressants is consistent with an increased proportion of children treated for depression, which went from 0.28% in 1987 to 0.68% in 1997 (Olfson et al., 2002b). During the period 1996Y1999, the mean annual rate of outpatient treatment for depression was 0.93% among children (Olfson et al., 2003a). A similar increase occurred in adults, whose antidepressant use more than doubled from 3% to 7% between 1988 and 1994 and 1999 and 2000, according to the National Ambulatory Health and Nutrition Examination Survey (National Center for Health Statistics, 2004).
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There are suggestions that the pediatric use of antidepressants may have continued to rise in the late 1990s and early 2000s. Based on the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, the annual number of visits by children 5 to 17 years old with an antidepressant prescription increased from 1.1 million to 3.1 million between 1994 and 1996 and 2000 and 2002, with a rate twice as high among adolescents as younger children. In 2000Y2002, the estimated annual antidepressant visits (defined as the number of visits to a physician that involved antidepressant medication per 100 subjects per year) was 3.4% for 5- to 11-year-old children and 8.8% for adolescents 12Y17 years of age (National Center for Health Statistics, 2004). It is, however, difficult to infer medication use from the number of visits because patients typically pay multiple visits to their health provider during a year. Based on pharmacy claim data from commercially insured health plans, the estimated nationwide prevalence use of antidepressants among children continued to rise during the period 1998Y2002, going from 1.6% in 1998 to 2.4% in 2002 (Delate et al., 2004). Commercially insured health plans, however, are not fully representative of the general population because they exclude uninsured and Medicaid-covered subjects. Surveys that use nationally representative samples of individuals, such as the publicly funded Medical Expenditure Panel Survey (MEPS), offer an opportunity to estimate use in the general population across a variety of demographics and socioeconomic variables. Analysis of MEPS data allow us to determine whether the use of antidepressant medications among children (i.e., subjects 18 years of age and younger) in the United States has continued to increase after 1996 and up until the time recent concerns were raised about suicidality during antidepressant treatment. The purpose of this study was to estimate the use of antidepressant medication during the period 1997Y2002 using the most recent available data from the MEPS. METHOD Data Sources The data are drawn from the 1997 through 2002 years of the MEPS. The MEPS is a nationally representative household survey of health care use and costs conducted by the Agency for Healthcare Research and Quality, in conjunction with the National Center for Health Statistics. The MEPS uses an overlapping panel design,
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PEDIATRIC USE OF ANTIDEPRESSANTS
with a new panel starting each year, and combines two panels to produce estimates for each calendar year (with the exception of 1996, when the survey began). Households for each panel were interviewed 5 times during a 2.5-year period to determine their medical care use and expenditures during a 2-year period. The sample for each panel was drawn from the sample of all households responding to the National Health Interview Survey in the year before the panel start date in MEPS. Overall response rates for the 1997Y2002 MEPS were 66.4% (1997), 67.9% (1998), 64.3% (1999), 65.8% (2000), 66.3% (2001), and 64.7% (2002). Our analytical sample includes all children under age 19 in each year. Final sample sizes were, respectively, 10,285 (1997), 7,282 (1998), 7,235 (1999), 7,286 (2000), 9,710 (2001), and 11,713 (2002). The larger sample sizes of children in 1997 and 2002 reflect the greater number of households surveyed in those years. The MEPS sample is poststratified by income, age, and race/ethnicity to the Current Population Survey and is representative of the civilian noninstitutionalized population in each year. Data on prescription drug use in the MEPS were collected both directly from households and from a pharmacy follow-back survey. For each surveyed household, the interviewer asked to speak to the adult family member (usually one of the parents) most knowledgeable about the family’s medical care use. The adult respondent was f irst asked details about every off ice visit, hospital outpatient visit, emergency department visit, and hospital stay that each child in the household had had during the past 12 months and to name each of the medications that were prescribed to the child during those visits and obtained at the time or subsequently f illed. The respondent was then asked about any other medications the child may have obtained. Recall is further assisted by asking the respondents to gather together all of their prescription drug bottles, containers, or bags. Additional information about when the child started taking the medication, the number of times the prescription was f illed, and which pharmacies f illed their prescriptions is then requested. More complete information about the medications taken by each household member is then obtained from printouts provided by pharmacies during the follow-back survey, including the National Drug Code (NDC), which more specif ically identif ies the formulation and strength of each medication taken by the household. We used these NDC codes, supplemented with branded and generic medication names when the NDC codes were not available, to identify the antidepressant medications from all of the prescriptions reported in the MEPS public use prescription drug files for the years 1997Y2002. We def ined antidepressants to include the following compounds in various formulations: TCAs, which included amitriptyline, amoxapine, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, and trimipramine; SSRIs, which included citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline; and other newer antidepressants, which included bupropion, mirtazapine, nefazodone, trazodone, and venlafaxine. The monoamine oxidase inhibitor medications isocarboxazid, phenelzine, and tranylcypromine were also included, but there was only one reported use between 1997 and 2002. Professional coders classif ied the household-reported conditions for which these medications were taken into standard ICD-9-CM codes. We def ined mental health conditions to include ICD-9-CM codes 291, 292, and 295-314 as well as ICD-9-CM codes that indicate mental health treatment; specif ically, V11, V15.4, V40, V60, V62, V66.3, V67.3, V70.1, V70.2, V71.0, V79, and 799.2 (‘‘nervousness’’). ICD-9-CM codes indicating depression include 296.2, 296.3, 300.4, and 311. Additional details on the household and pharmacy data collections are available on the public use data f iles and in a detailed methodology report
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produced by Agency for Healthcare Research and Quality (Moeller at et al., 2001). We also replicated previously reported estimates of antidepressant use for the population younger than age 19 using data from the TABLE 1 Distribution of Population Characteristics, 1997 and 2002 Percentage 1997Y2002 Distribution Difference 1997 Age, yr 0Y5 31 (30Y33) 6Y12 37 (36Y39) 13Y18 31 (30Y33) Sex Male 51 (50Y52) Female 49 (49Y50) Race/ethnicity (mutually exclusive White 65 (62Y67) Black 16 (14Y17) Hispanic 15 (13Y17) Other 04 (03Y05) Family incomea Poor/nearly 25 (23Y27) poor (G125%) Low/middle 50 (48Y52) (125%Y 400%) High income 25 (23-26) (9400%) Region Northeast 18 (16Y20) Midwest 24 (21Y26) South 34 (32Y37) West 24 (21Y26) Urban Non-MSA 20 (17Y22) MSA 80 (78Y82) Insurance Any private 69 (67Y71) Public only 20 (18Y21) Uninsured 11 (10Y12) CIS (ages 5Y17 yr) Not impaired 87 (86Y89) (CIS score G16) Impaired 13 (11Y14) (CIS score Q16)
2002
Z Score p Value
30 (29Y31) 37 (36Y38) 33 (31Y34)
1.34 0.31 1.60
.182 .754 .110
51 (50Y52) 49 (49Y50) categories) 60 (58Y62) 16 (14Y17) 18 (17Y20) 06 (05Y07)
0.11 0.11
.912 .912
2.88 0.10 3.00 1.77
.004 .919 .003 .077
22 (21Y24)
2.10
.037
50 (49Y52)
0.08
.935
27 (26Y29)
2.47
.014
18 (16Y20) 22 (20Y25) 35 (33Y38) 24 (21Y27)
0.06 0.90 0.64 0.26
.953 .368 .524 .799
18 (16Y19) 82 (80Y84)
1.62 1.62
.106 .106
66 (64Y67) 26 (25Y28) 08 (07Y09)
1.72 2.71 5.81
.087 .007 G.001
87 (86Y88)
0.96
.337
12 (11Y13)
0.96
.337
Note: Authors’ calculations from the Medical Expenditure Panel Survey 1997Y2002; 95% confidence intervals are given in parentheses. MSA = metropolitan statistical area; CIS = Columbia Impairment Scale. a Relative to federal poverty line.
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TABLE 2 Trends in Antidepressant Use in the U.S. Population 18 Years and Younger, 1997Y2002 1997Y2002 Difference No. of users (millions) 0Y5 yr 6Y12 yr 13Y18 yr % with use 0Y5 yr 6Y12 yr 13Y18 yr Total population (millions) 0Y5 yr 6Y12 yr 13Y18 yr Sample size 0Y5 yr 6Y2 yr 13Y18 yr
1997
1998
1999
2000
2001
2002
Z Score
0.9 (0.7Y1.2) 0.0 (0.0Y0.1) 0.4 (0.2Y0.6) 0.5 (0.3Y0.6) 1.3 (0.9Y1.6) 0.1 (0.0Y0.3) 1.5 (0.9Y2.1) 2.1 (1.4Y2.7) 75.6 23.8 28.3 23.5 10,285 3,081 4,008 3,196
0.9 (0.6Y1.1) 0.0 (0.0Y0.1) 0.4 (0.2Y0.5) 0.5 (0.3Y0.6) 1.1 (0.8Y1.4) 0.1 (0.0Y0.3) 1.3 (0.7Y1.9) 1.9 (1.3Y2.5) 76.5 23.8 28.4 24.4 7,282 2,116 2,844 2,322
0.8 (0.6Y1.1) 0.0 (0.0Y0.1) 0.4 (0.2Y0.6) 0.4 (0.3Y0.6) 1.1 (0.8Y1.4) 0.1 (0.0Y0.2) 1.4 (0.8Y1.9) 1.8 (1.2Y2.4) 76.7 23.9 29.3 23.5 7,235 2,158 2,872 2,205
1.3 (0.9Y1.6) 0.0 (0.0Y0.0) 0.3 (0.2Y0.5) 1.0 (0.7Y1.2) 1.7 (1.3Y2.0) 0.0 (0.0Y0.1) 1.1 (0.6Y1.6) 4.0 (3.0Y4.9) 76.7 24.1 28.5 24.0 7,286 2,221 2,851 2,214
1.4 (1.1Y1.7) 0.0 (0.0Y0.1) 0.3 (0.2Y0.4) 1.0 (0.8Y1.3) 1.8 (1.4Y2.2) 0.2 (0.0Y0.3) 1.0 (0.7Y1.4) 4.2 (3.2Y5.3) 77.0 23.7 28.5 24.8 9,710 2,924 3,733 3,053
1.4 (1.1Y1.7) 0.0 (0.0Y0.0) 0.4 (0.3Y0.5) 1.0 (0.8Y1.2) 1.8 (1.5Y2.1) 0.1 (0.0Y0.2) 1.4 (1.0Y1.8) 3.9 (3.1Y4.7) 77.0 23.3 28.6 25.1 11,713 3,455 4,498 3,760
2.59 0.71 0.19 3.69 2.59 0.69 0.23 3.62
p Value .010 .475 .852 G.001 .010 .488 .816 G.001
Note: Rates are given for all pediatric population (G19 years) and by age group. Authors’ calculations from the Medical Expenditure Panel Survey 1996Y2002; 95% confidence intervals are given in parentheses. 1996 MEPS and the 1987 National Medical Expenditure Survey, the predecessor to MEPS, to compare more recent trends (1997Y2002) to previously reported trends between 1987 and 1996 (Olfson et al., 2002a). Data Analysis We report national estimates of the annual use of antidepressants for the U.S. civilian, noninstitutionalized population of children 18 years old and younger for calendar years 1997 through 2002 using MEPS, our replicated estimates of calendar year 1996 from MEPS,
and replicated estimates for 1987 use from National Medical Expenditure Survey. We also report changes between 1997 and 2002 for the following population subgroups: age, sex, race/ethnicity, family income relative to the federal poverty line, census region, metropolitan statistical areas versus nonYmetropolitan statistical areas, health insurance coverage, and impairment as measured by the Columbia Impairment Scale (Bird et al., 1996). We use 1997 instead of 1996 as the beginning time point for these subgroup analyses because the larger sample sizes in 1997 provide greater power to detect differences and because 1997 is more fully comparable to 2002 with the overlapping panel design than 1996 when the survey
Fig. 1 Trends in prevalence of antidepressant use in the U.S. population 18 years of age and younger, 1987Y2002. Authors’ calculations from the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Survey 1996Y2001.
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PEDIATRIC USE OF ANTIDEPRESSANTS
TABLE 3 Antidepressant Use by Selected Population Characteristics, 1997 and 2002 1997Y2002 % With Use Difference 1997
2002
Age, yr 0Y5 0.1 (0.0Y0.3) 0.1 (0.0Y0.2) 6Y12 1.5 (0.9Y2.1) 1.4 (1.0Y1.8) 13Y18 2.1 (1.4Y2.7) 3.9 (3.1Y4.7) Sex Male 1.5 (1.1Y1.9) 1.8 (1.3Y2.2) Female 1.0 (0.6Y1.5) 1.9 (1.4Y2.3) Race/ethnicity (mutually exclusive categories) White 1.7 (1.2Y2.2) 2.5 (2.0Y3.0) Black 0.3 (0.1Y0.6) 0.9 (0.5Y1.3) Hispanic 0.6 (0.3Y1.0) 0.8 (0.5Y1.1) Other 0.1 (0.0Y0.3) 0.4 (0.0Y0.9) Family incomea Poor/nearly 0.8 (0.5Y1.2) 1.6 (1.1Y2.1) poor (G125%) Low/middle 1.3 (0.8Y1.8) 1.9 (1.4Y2.3) (125Y 400%) High income 1.6 (0.9Y2.2) 1.9 (1.3Y2.5) (9400%) Region Northeast 1.5 (0.9Y2.1) 2.0 (1.2Y2.8) Midwest 1.2 (0.7Y1.8) 1.9 (1.2Y2.7) South 1.3 (0.7Y1.8) 1.6 (1.2Y2.0) West 1.1 (0.5Y1.7) 1.9 (1.2Y2.6) Urban Non-MSA 1.1 (0.6Y1.6) 2.2 (1.4Y2.9) MSA 1.3 (0.9Y1.6) 1.8 (1.4Y2.1) Insurance Any private 1.4 (1.0Y1.8) 1.8 (1.4Y2.2) Public Only 1.0 (0.6Y1.5) 2.0 (1.5Y2.6) Uninsured 0.4 (0.0Y0.9) 1.3 (0.4Y2.2) CIS (ages 5Y17 yr) Not impaired 0.8 (0.5Y1.1) 1.2 (0.9Y1.5) (CIS score G16) Impaired 7.9 (5.7Y10.0) 11.7 (9.1Y14.3) (CIS Q16)
Z Score p Value 0.69 0.23 3.62
.488 .816 G.001
1.13 2.40
.259 .017
2.38 2.14 0.68 0.99
.018 .034 .495 .322
2.46
.015
1.63
.104
0.76
.445
0.98 1.52 1.08 1.60
.326 .131 .280 .112
2.30 1.85
.023 .066
1.27 2.76 1.74
.205 .006 .082
1.65
.099
2.39
.018
Note: Author’s calculations from the Medical Expenditure Panel Survey 1997Y2001; 95% CI given in parentheses. a Relative to federal poverty line. began. Table 1 provides the distribution of these subgroups across the population ages 18 and under in 1997 and 2002. MEPS sampling weights, which adjust for the complex sample design and nonresponse, are used throughout in the analyses. We use standard Z score tests, computed with these weights and accounting for the complex sample design and correlation across individuals, to assess changes in antidepressant use between 1997
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and 2002, as well as differences between population subgroups in each year. We also tested whether the average annual increase in the decade between 1987 and 1997 was the same as the average annual increase between the 5-year period between 1997 and 2002, accounting for the design of the National Medical Expenditure Survey and MEPS surveys. We have 90% power to detect an average 0.20 percentage point change per year during a 5-year period at the .05 level. All statistical analyses and tests were performed using STATA Version 8.2 (Stata Corporation, College Station, TX). RESULTS
The estimated prevalence of antidepressant medication use in the U.S. population younger than 19 years of age for the years 1997Y2002 is presented in Table 2. The percentage of all children receiving an antidepressant increased from 1.3% (95% confidence interval [CI], 0.9Y1.6) in 1997 to 1.8% (95% CI 1.5Y2.1) in 2002 ( p G .01). The 2002 figure corresponds to an estimate of 1.4 million (95% CI 1.1Y1.7) users in 2002. Use was highest among 13- to 18-year-olds (3.9% in 2002), followed by the 6- to 12-year-old group (1.4% in 2002), and lowest among children younger than 6 years (0.1% in 2002). The increase in use was accounted by changes adolescents (ages 13Y18 years), while no increase occurred among younger children (Table 2 and Fig. 1). Among adolescents, use increased abruptly between 1999 and 2000 and then remained stable from 2000 through 2002. The use of antidepressants was higher in males in 1996, but because of a more marked increase among females in subsequent years, it was similar in males (1.8%) and females (1.9%) in 2002 (Table 3). Use increased among both white (from 1.7% in 1997 to 2.4% in 2002, p G .05) and black children (from 0.3% in 1997 to 0.9% in 2002, p G .05), but not among Hispanic children (0.6% in 1997 versus 0.8% in 2002, p = .49). Despite the significant increase in use among blacks, antidepressant use remained higher in whites (2.5%) than in blacks (0.9%) and Hispanics (0.8%; p G .001) in 2002. Use also increased more markedly among children from lower income families and on public insurance (Table 3). By 2002, there were no statistically signif icant differences in use among private, public, or uninsured children. No significant differences in use across the main geographic areas of the United States were found. We subdivided antidepressants into two categories: (1) TCA and (2) SSRI and other newer non-TCA antidepressants. Percent use for these two categories
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VITIELLO ET AL.
TABLE 4 Trends in Antidepressant Use in the U.S. Population 18 Years and Younger by Type of Medication, 1997Y2002 % With Use 1997Y2002 Difference 1997 1998 1999 2000 2001 2002 Z Scorea p Value Tricyclic overall 0Y5 yr 6Y12 yr 13Y18 yr SSRIb overall 0Y5 yr 6Y12 yr 13Y18 yr
0.5 (0.3Y0.6) 0.1 (0.0Y0.2) 0.7 (0.4Y1.1) 0.5 (0.2Y0.8) 0.8 (0.6Y1.1) 0.0 (0.0Y0.1) 0.8 (0.4Y1.3) 1.7 (1.1Y2.2)
0.3 (0.1Y0.5) 0.1 (0.0Y0.3) 0.5 (0.2Y0.9) 0.2 (0.0Y0.4) 0.9 (0.6Y1.1) 0.0 (0.0Y0.1) 0.8 (0.3Y1.2) 1.8 (1.2Y2.4)
0.3 (0.2Y0.5) 0.1 (0.0Y0.2) 0.6 (0.2Y0.9) 0.2 (0.0Y0.5) 0.8 (0.6Y1.1) 0.0 (0.0Y0.0) 0.9 (0.5Y1.3) 1.6 (1.0Y2.2)
0.2 (0.1Y0.4) 0.0 (0.0Y0.0) 0.3 (0.1Y0.5) 0.4 (0.0Y0.8) 1.4 (1.1Y1.8) 0.0 (0.0Y0.1) 0.9 (0.5Y1.2) 3.5 (2.5Y4.5)
0.2 (0.1Y0.3) 0.0 (0.0Y0.0) 0.2 (0.1Y0.4) 0.2 (0.0Y0.4) 1.7 (1.3Y2.0) 0.2 (0.1Y0.3) 0.8 (0.5Y1.2) 4.1 (3.0Y5.1)
0.3 (0.2Y0.4) 0.0 (0.0Y0.1) 0.3 (0.1Y0.5) 0.5 (0.3Y0.8) 1.6 (1.3Y1.9) 0.0 (0.0Y0.1) 1.1 (0.8Y1.5) 3.6 (2.8Y4.4)
1.50 0.77 2.11 0.20 4.00 0.18 1.09 3.91
.136 .440 .036 .843 G.001 .861 .278 G.001
Note: Authors’ calculations from the Medical Expenditure Panel Survey 1996Y2002; 95% percent CI given in parentheses. SSRI = selective serotonin reuptake inhibitors. a Z score statistic for 1996Y2002 difference is 2.05 ( p = .042). b Including also other newer antidepressants (venlafaxine, bupropion, mirtazapine, nefazodone, trazodone).
during the period 1997Y2002 is reported in Table 4. Overall, SSRI and other newer antidepressant use increased from 0.8% (95% CI 0.6%Y1.1%) in 1997 to 1.6 % (95% CI 1.3%Y1.9%) in 2002 ( p G .001), whereas the use of TCA was not statistically different between years at 0.5% (95% CI 0.3%Y0.6%) in 1997 and 0.3% (95% CI 0.2%Y0.4%) in 2002. The proportion of antidepressant users who used TCA declined from 36% in 1997 (95% CI 26%Y46%) to 16% in 2002 (95% CI 10%Y22%), as SSRI and other nonTCA antidepressant use grew. Use of TCAs declined among children ages 6 to 12 from 0.7% (95% CI 0.4%Y1.1%) in 1997 to 0.3% (95% CI 0.1%Y0.5%) in 2002 (Table 4). Most of the increase in the use of SSRI and other non-TCA antidepressants came from adolescents. Mental health conditions were reported for 96% of the SSRI or non-TCA antidepressant prescriptions in 2002, whereas a mental health condition was reported only about 50% of the time for TCA used in 2002 (data not shown). When a TCA was used for a mental health condition, depression was listed as the most common reason in 2002, and in 1997 ADHD was listed about 70% of the time. Among nonYmental health conditions, migraine was listed most of the time as the reason for TCA prescriptions in 2002. In earlier years, nocturnal enuresis was the most common reason given for TCA prescriptions. DISCUSSION
These analyses of a nationally representative annual survey of U.S. families during the 6-year period
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1997Y2002 indicate that overall the pediatric use of antidepressant medication significantly increased from 1.3% in 1997 to 1.8% in 2002 ( p G .01). The increase was the result of the use of SSRI and other novel antidepressants, whereas the use of TCAs declined during this period. The increase in SSRI antidepressants during the 1997Y2002 period was limited to adolescents (13Y18 years of age), but the use did not change for younger children. Use among children younger than 6 years of age was almost undetectable (Table 2). Among adolescents, antidepressant use increased through 2000, with a particularly sharp rise from 1999 (1.8%) to 2000 (4.0%), and then remained unchanged during 2001 and 2002. Being a female, from a lower income family, or covered by public insurance was associated with a statistically significant increase in antidepressant use during the 1997Y2002 period. The increase in antidepressant use was most evident in groups that previously had a lower utilization, such as girls, blacks, and children from lower income families and covered by public insurance. Thus, by 2002 there was no statistically significant difference in use among privately insured, publicly insured, and uninsured children or between higher-income and lower-income children. Use increased especially among children who were functionally impaired, according to the Columbia Impairment Scale (Table 3). These data are consistent with the previously reported increase in treatment of depression in the pediatric age group during the late 1990s and with the higher recognized prevalence of depression in adolescents (about 6%) than in prepubertal children (about
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PEDIATRIC USE OF ANTIDEPRESSANTS
2%). Use was similar in boys and girls, despite the fact that depression is reported to be twice as common in female compared with male adolescents (Kessler et al., 2001). The increased use of antidepressants is also consistent with reports that antidepressants accounted for a much greater portion of all medication prescriptions filled for youths ages 10 to 19 years in 2000 (7.3%) than in 1990 (1.1%; Olfson et al., 2003b). An analysis of pharmacy claim data has yielded higher estimates of prevalence use among commercially insured children (1.6% in 1998 and 2.4% in 2002) than we report (1.1% in 1998 and 1.8% in 2002; Delate et al., 2004). By definition, databases of commercially insured populations do not include uninsured subjects or those on Medicaid. However, even when only privately insured children are considered, our estimates of use (1.8%, 95% CI 1.4Y2.2) remain lower than those reported by Delate et al. The dramatic doubling of antidepressant use among adolescents between 1999 (1.8%) and 2000 (4.0%) is noteworthy. The late 1990s saw the publication of the first controlled clinical trials showing the efficacy of SSRI antidepressants in childhood depression (Emslie et al., 1997) and obsessive-compulsive disorder (March et al., 1998). The practice parameters of the American Academy of Child and Adolescent Psychiatry for the treatment of depression included pharmacotherapy with SSRI antidepressants among the possible treatment options for depressed children and adolescents (Birmaher et al., 1998). In 1999, the first algorithm for pharmacological treatment of adolescent depression was also released (Hughes et al., 1999). It is possible that these publications gradually influenced clinical practice and prompted the increase. Also, it must be pointed out that estimates of antidepressant use based on either pharmacy claim data or an HMO-insured local sample did not demonstrate any major changes between 1999 and 2000 but rather a gradual increase across years (Delate et al., 2004; Hunkeler et al., 2005). Thus, this finding needs to be investigated further. In addition to documenting a declining use of TCA antidepressants, the data also indicate a changed pattern of use for these drugs, which were less likely to be prescribed for the treatment of attention-deficit/hyperactivity disorder or for enuresis in 2002 than in 1997. In 2002, depression had become the most common mental health reason and migraine the most common medical condition for taking a TCA antidepressant in this age group.
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In more recent years, the pediatric use of antidepressants is likely to have been affected by concerns about a possible drug-induced increase in the risk of suicidal behavior (Mitka, 2003). A meta-analysis of 24 placebo-controlled clinical trials of antidepressants in a total of about 4,400 children was conducted by the U.S. Food and Drug Administration, and it was found that although no suicide had occurred, the incidence of ‘‘suicidality’’ (defined as suicidal attempts or ideation) was 4% on antidepressant versus 2% on placebo (Hammad, 2004). Consequently, a highly visible warning was added to the labeling information of all antidepressants alerting clinicians and families of the increased risk of suicidality and of the need to monitor closely for possible suicide-related adverse events whenever these medications are used in children or adolescents (U.S. Food and Drug Administration, 2004, 2005). Given the highly publicized concerns, the strength of the warning, and the additional requirements for use, it is suspected that the use of antidepressants has been declining. Some indicators based on drug prescription data suggest that this is the case (Rosack, 2005). Limitations
There are several limitations in this study that should be underscored. The MEPS data do not contain clinical information for deriving valid diagnostic determinations. Thus, these data cannot address the issue of whether antidepressants are appropriately prescribed. However, the estimated 2002 use of 1.4% (95% CI 1.0Y1.8) among 6- to 12-year-old subjects and 3.9% (95% CI 3.1Y4.7) among 13- to 18-year-old subjects is well within the limit of the estimated prevalence of the conditions for which antidepressants can be an effective treatment. For example, major depression has an estimated prevalence of about 2% in prepubertal children and 6% in adolescents, and obsessivecompulsive disorder has an estimated prevalence of about 0.8% to 3.0% in adolescents. In addition, there is empirical support for the use of antidepressants for the treatment of enuresis, nonYobsessive-compulsive disorder, anxiety disorders, and attention-def icit/ hyperactivity disorder. Even though the estimated use can be consistent with the prevalence of these disorders, we cannot determine how many users had a condition for which antidepressant use would be indicated. Selfreport surveys such as the MEPS rely on the responders’
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ability to accurately and completely recall and their willingness to provide information. Theoretically, recall and reporting biases can occur that would result in underreporting and consequently underestimating use. Yet, the validity of the MEPS data is supported by their consistency with data on drug expenditures from other sources (Selden et al., 2002; Zuvekas, 2005). Clinical Implications
The considerable increase in antidepressant use among adolescents (13- to 18-year-old subjects) from 1999 (1.8%) to 2000 (4.0%), which followed the reporting of the first controlled clinical trials of SSRIs in youths (Emslie et al., 1997; March et al., 1998), suggests that prescribing practices are strongly influenced by available research findings, but with a delay of about 2 years from publication date. The apparent reliance of clinicians on clinical trial findings underscore the need to ensure that the results of all controlled clinical trials be promptly published, regardless of study outcome, to ensure complete and unbiased access to clinically relevant information. These data indicate that the use of SSRI antidepressant medications in adolescents has doubled nationwide during the period between 1997 and 2000 but has remained stable afterward through 2002. No increase was detected among children younger than 13 years during the 6-year period 1997Y2002.
Disclosure: The authors have no f inancial relationships to disclose. REFERENCES American Academy of Child and Adolescent Psychiatry (2004), Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 43:1540Y1550 Bird H, Andrews H, Schwab-Stone M et al. (1996), Global measures of impairment for epidemiologic and clinical use with children and adolescents. J Methods Psychiatr Res 6:295Y307 Birmaher B, Brent DA, Benson RS (1998), Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 37:1234Y1238 Costello EJ, Mistillo S, Erkanli A, Keeler G, Angold A (2003), Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 60:837Y844 Delate T, Gelenberg AJ, Simmons VA, Motheral BR (2004), Trends in the use of antidepressants in a national sample of commercially insured pediatric patients, 1998 to 2002. Psychiatr Serv 55:387Y391 Emslie GJ, Heligenstein JH, Wagner KD et al. (2002), Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled randomized clinical trial. J Am Acad Child Adolesc Psychiatry 41:1205Y1215 Emslie GJ, Rush AJ, Weiberg WA et al. (1997), A double-blind,
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randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 54:1031Y1037 Flament MF, Whitaker A, Rapoport JL et al. (1988), Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc Psychiatry 27:764Y771 Hammad TA (2004), Results of the analysis of suicidality in pediatric trials of newer antidepressants. Presented at the U.S. Food and Drug Administration, Psychopharmacologic Drugs Advisory Committee and the Pediatric Advisory Committee, September 13, 2004; http://www.fda. gov/ohrms/dockets/ac/04/slides/2004-4065s1_08_fda-hammad_files/frame. htm, accessed September 29, 2005 Hughes CW, Emslie GJ, Crismon ML et al. (1999), The Texas Children’s Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. J Am Acad Child Adolesc Psychiatry 38:1442Y1454 Hunkeler EM, Fireman B, Lee J et al. (2005), Trends in use of antidepressants, lithium, and anticonvulsants in Kaiser Permanenteinsured youths, 1994Y2003. J Child Adolesc Psychopharmacol 15:26Y37 Kessler RC, Avenevoli S, Merikangas KR (2001), Mood disorders in children and adolescents: an epidemiologic perspective. Biol Psychiatry 49:1002Y1014 Kessler RC, Walters EE (1998), Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety 7:3Y14 Lewinsohn PM, Rohde P, Seeley JR (1998), Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clin Psychol Rev 18:765Y794 March JS, Biederman J, Wolkow R et al. (1998), Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial. JAMA 280:1752Y1756 Mitka M (2003), FDA alert on antidepressants for youth. JAMA 290:2534 Moeller JF, Stagnitti MN, Horan E (2001), Outpatient prescription drugs: data collection and editing in the 1996 Medical Expenditure Survey (HC010A) (Pub. No. 01Y0002). Rockville, MD: Agency for Healthcare Research and Quality National Center for Health Statistics (2004), Health, United States, 2004. With Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics Olfson M, Gameroff MJ, Marcus SC, Waslick BD (2003a), Outpatient treatment of child and adolescent depression in the United States. Arch Gen Psychiatry 60:1236Y1242 Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA (2002b), National trends in the outpatient treatment of depression. JAMA 287:203Y209 Olfson M, Marcus SC, Weissman MM, Jensen PS (2002a), National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry 41:514Y521 Olfson M, Shaffer D, Marcus SC, Greenberg T (2003b), Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 60:978Y982 Pliszka SR, Greenhill LL, Crimson ML et al. (2000), The Texas Children’s Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood AttentionDeficit/Hyperactivity Disorder. Part I. Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 39:908Y919 Rosack J (2005), New data show declines in antidepressant prescribing. Psychiatr News 40:1 RUPP Anxiety Study Group (2001), RUPP Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344:1279Y1285 Simonoff E, Pickles A, Meyer JM, Silberg JL, Maes HH, Loeber R, Rutter M, Hewitt JK, Eaves LJ (1997), The Virginia Twin Study of Adolescent Behavioral Development. Influences of age, sex, and impairment on rates of disorder. Arch Gen Psychiatry 54:801Y808 Spencer T, Biederman J, Wilens T (2004), Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 27:373Y383 Selden TM, Levit KR, Cohen JW et al. (2002), Reconciling medical expenditure estimates from the MEPS and the NHA, 1996. Am J Public Health 92:231Y234
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PEDIATRIC USE OF ANTIDEPRESSANTS U.S. Food and Drug Administration (2004), FDA launches a multi-pronged strategy to strengthen safeguards for children treated with antidepressant medications. FDA News, October 15, 2004; http://www.fda.gov/bbs/ topics/news/2004/new01124.html, accessed June 1, 2005 U.S. Food and Drug Administration (2005), Class suicidality labeling language for antidepressants, February 3, 2005; http://www.fda.gov/cder/ drug/antidepressants/pi_template.pdf, accessed June 1, 2005
Valleni-Basile LA, Garrison CZ, Jackson KL et al. (1994), Frequency of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry 34:128Y129 Zito JM, Safer DJ, dosReis S et al. (2002), Rising prevalence of antidepressants among US youth. Pediatrics 109:721Y727 Zuvekas SH (2005), Prescription drugs and the changing patterns of treatment for mental disorders, 1996Y2001. Health Affairs 24:195Y205
Pediatric Use of Complementary Therapies: Ethical and Policy Choices Michael H. Cohen, JD, MBA, Kathi J. Kemper, MD, MPH, Laura Stevens, BA, Dean Hashimoto, JD, MD, Joan Gilmour, LLB, JSD Objective: Many pediatricians and parents are beginning to integrate use of complementary and alternative medical (CAM) therapies with conventional care. This article addresses ethical and policy issues involving parental choices of CAM therapies for their children. Methods: We conducted a literature search to assess existing law involving parental choice of CAM therapies for their children. We also selected a convenience sample of 18 states of varying sizes and geographic locations. In each state, we inquired within the Department of Health and Human Services whether staff were aware of (1) any internal policies concerning these issues or (2) any cases in the previous 5 years in which either (a) the state initiated proceedings against parents for using CAM therapies for their children or (b) the department received telephone calls or other information reporting abuse and neglect in this domain. We asked the American Academy of Pediatrics and the leading CAM professional organizations concerning any relevant, reported cases. Results: Of the 18 state Departments of Health and Human Services departments surveyed, 6 reported being aware of cases in the previous 5 years. Of 9 reported cases in these 6 states, 3 involved restrictive dietary practices (e.g., limiting children variously to a watermelon or raw foods diet), 1 involved dietary supplements, 3 involved children with terminal cancer, and 2 involved religious practices rather than CAM per se. None of the professional organizations surveyed had initiated proceedings or received telephone calls regarding abuse or neglect concerning parental use of CAM therapies. Conclusions: Pediatric use of CAM therapies raises complex issues. Clinicians, hospitals, state agencies, courts, and professional organizations may benefit from a policy framework to help guide decision making. Pediatrics 2005;116:e568Ye575.
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ABSTRACT Objective: A threefold increase in the use of antidepressants has been reported among children (18 years old and younger) between 1987 (0.3%) and 1996 (1.0%). The aim of this study was to determine whether pediatric use of antidepressants continued to rise at a national level during the period 1997Y2002. Method: The Medical Expenditure Panel Survey (MEPS) database for the years 1997Y2002 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Healthcare Research and Quality. Overall response rate ranged between 64% and 68%. Results: An estimated 1.4 million (95% confidence interval [CI] 1.1Y1.7) children received antidepressant medication in 2002 as compared to 0.9 million (95% CI 0.7Y1.2) in 1997 (p = .01). The percentage of users increased from 1.3% (95% CI 0.9Y1.6) in 1997 to 1.8% (95% CI 1.5Y2.1) in 2002 (p G .01). Adolescent use (2.1% in 1997 versus 3.9% in 2002 (p G .001) accounted for the increase, with no change among children younger than 13 years. Also among adolescents, the use rate remained stable during the 2000Y2002 period. The increase was caused by use of selective serotonin reuptake inhibitors and other newer antidepressants, whereas use of TCAs remained stable in adolescents (p = .84) and declined in prepubertal children (p = .04). Antidepressant use was similar among males and females and higher among whites than blacks and Hispanics. Conclusions: Nationwide, the use of selective serotonin reuptake inhibitor antidepressant medications continued to increase in adolescents in the late 1990s and until the year 2000, with no further increase through 2002, and remained stable in prepubertal children. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(3):271Y279. Key Words: antidepressants, children, adolescents, use, pharmacoepidemiology.
Antidepressant medications are used in the treatment of children and adolescents with a variety of disorders,
Accepted September 13, 2005. Dr. Vitiello is with the Child and Adolescent Treatment and Preventive Intervention Research Branch, National Institute of Mental Health, Bethesda, MD; Dr. Zuvekas is with the Division of Social and Economic Research, Center for Financing, Access, and Cost Trends, Agency for Health Care Research and Quality, Rockville, MD; and Dr. Norquist is with the Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS. Funded by Agency for Healthcare Research and Quality and National Institute of Mental Health. The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the Agency of Healthcare Research and Quality, the National Institute of Mental Health, or the U.S. Department of Health and Human Services. Correspondence to Dr. Benedetto Vitiello, NIMH, Room 7147, 6001 Executive Blvd. Bethesda, MD 20892-9633; e-mail: [email protected]. 0890-8567/06/4503Y0271Ó2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000192249.61271.81
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including depression, anxiety, attention-deficit/hyperactivity disorder, and enuresis. A number of antidepressants have indications for pediatric use (defined as use in subjects 18 years of age and younger) approved by the U.S. Food and Drug Administration. Clomipramine, fluvoxamine, fluoxetine, and sertraline are approved by the U.S. Food and Drug Administration for the treatment of obsessive-compulsive disorder, fluoxetine for the treatment of major depression, and imipramine for the treatment of enuresis in children and adolescents (American Academy of Child and Adolescent Psychiatry, 2004; Emslie et al., 2002; March et al., 1998). ‘‘Offlabel’’ use is, however, common and various antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), are prescribed for the treatment of childhood depressive and anxiety disorders (Hughes et al., 1999; RUPP Anxiety Study Group, 2001). In addition, tricyclic antidepressants (TCAs), such as nortriptyline
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and desipramine, are efficacious in decreasing symptoms of attention-deficit/hyperactivity disorder in children, but their use is limited by safety concerns (Pliszka et al., 2000; Spencer et al., 2004). The point prevalence of major depression has been estimated to be in the range of 1% to 6% among adolescents and about three times lower among prepubertal children (Costello et al., 2003; Kessler and Walters, 1998; Lewinsohn et al., 1998; Simonoff et al., 1997). Subsyndromal depression, defined as presence of symptoms of depression that do not meet full diagnostic criteria for depressive disorder, is estimated to be much more prevalent (Kessler et al., 2001). Estimates ranging from 0.8% to 3% have been reported for the prevalence of obsessive-compulsive disorder among adolescents (Flament et al., 1988; Valleni-Basile et al., 1994). The nationwide use of antidepressants in children (younger than 18 years of age) was estimated to be 0.3% in 1987 and 1.0% in 1996, which is about a threefold increase during this period (Olfson et al., 2002a). Use was lower in blacks, in the West, among insured people, and among youth ages 15 years and older. Based on two regional Medicaid data sets and one health maintenance organization data set, antidepressant use among children 2Y17 years of age was estimated to be between 1.3% and 1.9% in 1994, with a 2.9- to 4.6-fold increase from 1988 (Zito et al., 2002). In 1994, the estimated use of SSRI medications was between 0.6% and 0.8% across the three data sets, and TCAs still accounted for more than half of the total antidepressant use. More recently, an increase in pediatric use of antidepressants from 0.9% in 1994 to 2.1% in 2003 was reported in an health maintenance organizationYinsured population in Northern California (Hunkeler et al., 2005). The increase in pediatric use of antidepressants is consistent with an increased proportion of children treated for depression, which went from 0.28% in 1987 to 0.68% in 1997 (Olfson et al., 2002b). During the period 1996Y1999, the mean annual rate of outpatient treatment for depression was 0.93% among children (Olfson et al., 2003a). A similar increase occurred in adults, whose antidepressant use more than doubled from 3% to 7% between 1988 and 1994 and 1999 and 2000, according to the National Ambulatory Health and Nutrition Examination Survey (National Center for Health Statistics, 2004).
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There are suggestions that the pediatric use of antidepressants may have continued to rise in the late 1990s and early 2000s. Based on the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, the annual number of visits by children 5 to 17 years old with an antidepressant prescription increased from 1.1 million to 3.1 million between 1994 and 1996 and 2000 and 2002, with a rate twice as high among adolescents as younger children. In 2000Y2002, the estimated annual antidepressant visits (defined as the number of visits to a physician that involved antidepressant medication per 100 subjects per year) was 3.4% for 5- to 11-year-old children and 8.8% for adolescents 12Y17 years of age (National Center for Health Statistics, 2004). It is, however, difficult to infer medication use from the number of visits because patients typically pay multiple visits to their health provider during a year. Based on pharmacy claim data from commercially insured health plans, the estimated nationwide prevalence use of antidepressants among children continued to rise during the period 1998Y2002, going from 1.6% in 1998 to 2.4% in 2002 (Delate et al., 2004). Commercially insured health plans, however, are not fully representative of the general population because they exclude uninsured and Medicaid-covered subjects. Surveys that use nationally representative samples of individuals, such as the publicly funded Medical Expenditure Panel Survey (MEPS), offer an opportunity to estimate use in the general population across a variety of demographics and socioeconomic variables. Analysis of MEPS data allow us to determine whether the use of antidepressant medications among children (i.e., subjects 18 years of age and younger) in the United States has continued to increase after 1996 and up until the time recent concerns were raised about suicidality during antidepressant treatment. The purpose of this study was to estimate the use of antidepressant medication during the period 1997Y2002 using the most recent available data from the MEPS. METHOD Data Sources The data are drawn from the 1997 through 2002 years of the MEPS. The MEPS is a nationally representative household survey of health care use and costs conducted by the Agency for Healthcare Research and Quality, in conjunction with the National Center for Health Statistics. The MEPS uses an overlapping panel design,
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PEDIATRIC USE OF ANTIDEPRESSANTS
with a new panel starting each year, and combines two panels to produce estimates for each calendar year (with the exception of 1996, when the survey began). Households for each panel were interviewed 5 times during a 2.5-year period to determine their medical care use and expenditures during a 2-year period. The sample for each panel was drawn from the sample of all households responding to the National Health Interview Survey in the year before the panel start date in MEPS. Overall response rates for the 1997Y2002 MEPS were 66.4% (1997), 67.9% (1998), 64.3% (1999), 65.8% (2000), 66.3% (2001), and 64.7% (2002). Our analytical sample includes all children under age 19 in each year. Final sample sizes were, respectively, 10,285 (1997), 7,282 (1998), 7,235 (1999), 7,286 (2000), 9,710 (2001), and 11,713 (2002). The larger sample sizes of children in 1997 and 2002 reflect the greater number of households surveyed in those years. The MEPS sample is poststratified by income, age, and race/ethnicity to the Current Population Survey and is representative of the civilian noninstitutionalized population in each year. Data on prescription drug use in the MEPS were collected both directly from households and from a pharmacy follow-back survey. For each surveyed household, the interviewer asked to speak to the adult family member (usually one of the parents) most knowledgeable about the family’s medical care use. The adult respondent was f irst asked details about every off ice visit, hospital outpatient visit, emergency department visit, and hospital stay that each child in the household had had during the past 12 months and to name each of the medications that were prescribed to the child during those visits and obtained at the time or subsequently f illed. The respondent was then asked about any other medications the child may have obtained. Recall is further assisted by asking the respondents to gather together all of their prescription drug bottles, containers, or bags. Additional information about when the child started taking the medication, the number of times the prescription was f illed, and which pharmacies f illed their prescriptions is then requested. More complete information about the medications taken by each household member is then obtained from printouts provided by pharmacies during the follow-back survey, including the National Drug Code (NDC), which more specif ically identif ies the formulation and strength of each medication taken by the household. We used these NDC codes, supplemented with branded and generic medication names when the NDC codes were not available, to identify the antidepressant medications from all of the prescriptions reported in the MEPS public use prescription drug files for the years 1997Y2002. We def ined antidepressants to include the following compounds in various formulations: TCAs, which included amitriptyline, amoxapine, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, and trimipramine; SSRIs, which included citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline; and other newer antidepressants, which included bupropion, mirtazapine, nefazodone, trazodone, and venlafaxine. The monoamine oxidase inhibitor medications isocarboxazid, phenelzine, and tranylcypromine were also included, but there was only one reported use between 1997 and 2002. Professional coders classif ied the household-reported conditions for which these medications were taken into standard ICD-9-CM codes. We def ined mental health conditions to include ICD-9-CM codes 291, 292, and 295-314 as well as ICD-9-CM codes that indicate mental health treatment; specif ically, V11, V15.4, V40, V60, V62, V66.3, V67.3, V70.1, V70.2, V71.0, V79, and 799.2 (‘‘nervousness’’). ICD-9-CM codes indicating depression include 296.2, 296.3, 300.4, and 311. Additional details on the household and pharmacy data collections are available on the public use data f iles and in a detailed methodology report
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produced by Agency for Healthcare Research and Quality (Moeller at et al., 2001). We also replicated previously reported estimates of antidepressant use for the population younger than age 19 using data from the TABLE 1 Distribution of Population Characteristics, 1997 and 2002 Percentage 1997Y2002 Distribution Difference 1997 Age, yr 0Y5 31 (30Y33) 6Y12 37 (36Y39) 13Y18 31 (30Y33) Sex Male 51 (50Y52) Female 49 (49Y50) Race/ethnicity (mutually exclusive White 65 (62Y67) Black 16 (14Y17) Hispanic 15 (13Y17) Other 04 (03Y05) Family incomea Poor/nearly 25 (23Y27) poor (G125%) Low/middle 50 (48Y52) (125%Y 400%) High income 25 (23-26) (9400%) Region Northeast 18 (16Y20) Midwest 24 (21Y26) South 34 (32Y37) West 24 (21Y26) Urban Non-MSA 20 (17Y22) MSA 80 (78Y82) Insurance Any private 69 (67Y71) Public only 20 (18Y21) Uninsured 11 (10Y12) CIS (ages 5Y17 yr) Not impaired 87 (86Y89) (CIS score G16) Impaired 13 (11Y14) (CIS score Q16)
2002
Z Score p Value
30 (29Y31) 37 (36Y38) 33 (31Y34)
1.34 0.31 1.60
.182 .754 .110
51 (50Y52) 49 (49Y50) categories) 60 (58Y62) 16 (14Y17) 18 (17Y20) 06 (05Y07)
0.11 0.11
.912 .912
2.88 0.10 3.00 1.77
.004 .919 .003 .077
22 (21Y24)
2.10
.037
50 (49Y52)
0.08
.935
27 (26Y29)
2.47
.014
18 (16Y20) 22 (20Y25) 35 (33Y38) 24 (21Y27)
0.06 0.90 0.64 0.26
.953 .368 .524 .799
18 (16Y19) 82 (80Y84)
1.62 1.62
.106 .106
66 (64Y67) 26 (25Y28) 08 (07Y09)
1.72 2.71 5.81
.087 .007 G.001
87 (86Y88)
0.96
.337
12 (11Y13)
0.96
.337
Note: Authors’ calculations from the Medical Expenditure Panel Survey 1997Y2002; 95% confidence intervals are given in parentheses. MSA = metropolitan statistical area; CIS = Columbia Impairment Scale. a Relative to federal poverty line.
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TABLE 2 Trends in Antidepressant Use in the U.S. Population 18 Years and Younger, 1997Y2002 1997Y2002 Difference No. of users (millions) 0Y5 yr 6Y12 yr 13Y18 yr % with use 0Y5 yr 6Y12 yr 13Y18 yr Total population (millions) 0Y5 yr 6Y12 yr 13Y18 yr Sample size 0Y5 yr 6Y2 yr 13Y18 yr
1997
1998
1999
2000
2001
2002
Z Score
0.9 (0.7Y1.2) 0.0 (0.0Y0.1) 0.4 (0.2Y0.6) 0.5 (0.3Y0.6) 1.3 (0.9Y1.6) 0.1 (0.0Y0.3) 1.5 (0.9Y2.1) 2.1 (1.4Y2.7) 75.6 23.8 28.3 23.5 10,285 3,081 4,008 3,196
0.9 (0.6Y1.1) 0.0 (0.0Y0.1) 0.4 (0.2Y0.5) 0.5 (0.3Y0.6) 1.1 (0.8Y1.4) 0.1 (0.0Y0.3) 1.3 (0.7Y1.9) 1.9 (1.3Y2.5) 76.5 23.8 28.4 24.4 7,282 2,116 2,844 2,322
0.8 (0.6Y1.1) 0.0 (0.0Y0.1) 0.4 (0.2Y0.6) 0.4 (0.3Y0.6) 1.1 (0.8Y1.4) 0.1 (0.0Y0.2) 1.4 (0.8Y1.9) 1.8 (1.2Y2.4) 76.7 23.9 29.3 23.5 7,235 2,158 2,872 2,205
1.3 (0.9Y1.6) 0.0 (0.0Y0.0) 0.3 (0.2Y0.5) 1.0 (0.7Y1.2) 1.7 (1.3Y2.0) 0.0 (0.0Y0.1) 1.1 (0.6Y1.6) 4.0 (3.0Y4.9) 76.7 24.1 28.5 24.0 7,286 2,221 2,851 2,214
1.4 (1.1Y1.7) 0.0 (0.0Y0.1) 0.3 (0.2Y0.4) 1.0 (0.8Y1.3) 1.8 (1.4Y2.2) 0.2 (0.0Y0.3) 1.0 (0.7Y1.4) 4.2 (3.2Y5.3) 77.0 23.7 28.5 24.8 9,710 2,924 3,733 3,053
1.4 (1.1Y1.7) 0.0 (0.0Y0.0) 0.4 (0.3Y0.5) 1.0 (0.8Y1.2) 1.8 (1.5Y2.1) 0.1 (0.0Y0.2) 1.4 (1.0Y1.8) 3.9 (3.1Y4.7) 77.0 23.3 28.6 25.1 11,713 3,455 4,498 3,760
2.59 0.71 0.19 3.69 2.59 0.69 0.23 3.62
p Value .010 .475 .852 G.001 .010 .488 .816 G.001
Note: Rates are given for all pediatric population (G19 years) and by age group. Authors’ calculations from the Medical Expenditure Panel Survey 1996Y2002; 95% confidence intervals are given in parentheses. 1996 MEPS and the 1987 National Medical Expenditure Survey, the predecessor to MEPS, to compare more recent trends (1997Y2002) to previously reported trends between 1987 and 1996 (Olfson et al., 2002a). Data Analysis We report national estimates of the annual use of antidepressants for the U.S. civilian, noninstitutionalized population of children 18 years old and younger for calendar years 1997 through 2002 using MEPS, our replicated estimates of calendar year 1996 from MEPS,
and replicated estimates for 1987 use from National Medical Expenditure Survey. We also report changes between 1997 and 2002 for the following population subgroups: age, sex, race/ethnicity, family income relative to the federal poverty line, census region, metropolitan statistical areas versus nonYmetropolitan statistical areas, health insurance coverage, and impairment as measured by the Columbia Impairment Scale (Bird et al., 1996). We use 1997 instead of 1996 as the beginning time point for these subgroup analyses because the larger sample sizes in 1997 provide greater power to detect differences and because 1997 is more fully comparable to 2002 with the overlapping panel design than 1996 when the survey
Fig. 1 Trends in prevalence of antidepressant use in the U.S. population 18 years of age and younger, 1987Y2002. Authors’ calculations from the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Survey 1996Y2001.
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PEDIATRIC USE OF ANTIDEPRESSANTS
TABLE 3 Antidepressant Use by Selected Population Characteristics, 1997 and 2002 1997Y2002 % With Use Difference 1997
2002
Age, yr 0Y5 0.1 (0.0Y0.3) 0.1 (0.0Y0.2) 6Y12 1.5 (0.9Y2.1) 1.4 (1.0Y1.8) 13Y18 2.1 (1.4Y2.7) 3.9 (3.1Y4.7) Sex Male 1.5 (1.1Y1.9) 1.8 (1.3Y2.2) Female 1.0 (0.6Y1.5) 1.9 (1.4Y2.3) Race/ethnicity (mutually exclusive categories) White 1.7 (1.2Y2.2) 2.5 (2.0Y3.0) Black 0.3 (0.1Y0.6) 0.9 (0.5Y1.3) Hispanic 0.6 (0.3Y1.0) 0.8 (0.5Y1.1) Other 0.1 (0.0Y0.3) 0.4 (0.0Y0.9) Family incomea Poor/nearly 0.8 (0.5Y1.2) 1.6 (1.1Y2.1) poor (G125%) Low/middle 1.3 (0.8Y1.8) 1.9 (1.4Y2.3) (125Y 400%) High income 1.6 (0.9Y2.2) 1.9 (1.3Y2.5) (9400%) Region Northeast 1.5 (0.9Y2.1) 2.0 (1.2Y2.8) Midwest 1.2 (0.7Y1.8) 1.9 (1.2Y2.7) South 1.3 (0.7Y1.8) 1.6 (1.2Y2.0) West 1.1 (0.5Y1.7) 1.9 (1.2Y2.6) Urban Non-MSA 1.1 (0.6Y1.6) 2.2 (1.4Y2.9) MSA 1.3 (0.9Y1.6) 1.8 (1.4Y2.1) Insurance Any private 1.4 (1.0Y1.8) 1.8 (1.4Y2.2) Public Only 1.0 (0.6Y1.5) 2.0 (1.5Y2.6) Uninsured 0.4 (0.0Y0.9) 1.3 (0.4Y2.2) CIS (ages 5Y17 yr) Not impaired 0.8 (0.5Y1.1) 1.2 (0.9Y1.5) (CIS score G16) Impaired 7.9 (5.7Y10.0) 11.7 (9.1Y14.3) (CIS Q16)
Z Score p Value 0.69 0.23 3.62
.488 .816 G.001
1.13 2.40
.259 .017
2.38 2.14 0.68 0.99
.018 .034 .495 .322
2.46
.015
1.63
.104
0.76
.445
0.98 1.52 1.08 1.60
.326 .131 .280 .112
2.30 1.85
.023 .066
1.27 2.76 1.74
.205 .006 .082
1.65
.099
2.39
.018
Note: Author’s calculations from the Medical Expenditure Panel Survey 1997Y2001; 95% CI given in parentheses. a Relative to federal poverty line. began. Table 1 provides the distribution of these subgroups across the population ages 18 and under in 1997 and 2002. MEPS sampling weights, which adjust for the complex sample design and nonresponse, are used throughout in the analyses. We use standard Z score tests, computed with these weights and accounting for the complex sample design and correlation across individuals, to assess changes in antidepressant use between 1997
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and 2002, as well as differences between population subgroups in each year. We also tested whether the average annual increase in the decade between 1987 and 1997 was the same as the average annual increase between the 5-year period between 1997 and 2002, accounting for the design of the National Medical Expenditure Survey and MEPS surveys. We have 90% power to detect an average 0.20 percentage point change per year during a 5-year period at the .05 level. All statistical analyses and tests were performed using STATA Version 8.2 (Stata Corporation, College Station, TX). RESULTS
The estimated prevalence of antidepressant medication use in the U.S. population younger than 19 years of age for the years 1997Y2002 is presented in Table 2. The percentage of all children receiving an antidepressant increased from 1.3% (95% confidence interval [CI], 0.9Y1.6) in 1997 to 1.8% (95% CI 1.5Y2.1) in 2002 ( p G .01). The 2002 figure corresponds to an estimate of 1.4 million (95% CI 1.1Y1.7) users in 2002. Use was highest among 13- to 18-year-olds (3.9% in 2002), followed by the 6- to 12-year-old group (1.4% in 2002), and lowest among children younger than 6 years (0.1% in 2002). The increase in use was accounted by changes adolescents (ages 13Y18 years), while no increase occurred among younger children (Table 2 and Fig. 1). Among adolescents, use increased abruptly between 1999 and 2000 and then remained stable from 2000 through 2002. The use of antidepressants was higher in males in 1996, but because of a more marked increase among females in subsequent years, it was similar in males (1.8%) and females (1.9%) in 2002 (Table 3). Use increased among both white (from 1.7% in 1997 to 2.4% in 2002, p G .05) and black children (from 0.3% in 1997 to 0.9% in 2002, p G .05), but not among Hispanic children (0.6% in 1997 versus 0.8% in 2002, p = .49). Despite the significant increase in use among blacks, antidepressant use remained higher in whites (2.5%) than in blacks (0.9%) and Hispanics (0.8%; p G .001) in 2002. Use also increased more markedly among children from lower income families and on public insurance (Table 3). By 2002, there were no statistically signif icant differences in use among private, public, or uninsured children. No significant differences in use across the main geographic areas of the United States were found. We subdivided antidepressants into two categories: (1) TCA and (2) SSRI and other newer non-TCA antidepressants. Percent use for these two categories
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TABLE 4 Trends in Antidepressant Use in the U.S. Population 18 Years and Younger by Type of Medication, 1997Y2002 % With Use 1997Y2002 Difference 1997 1998 1999 2000 2001 2002 Z Scorea p Value Tricyclic overall 0Y5 yr 6Y12 yr 13Y18 yr SSRIb overall 0Y5 yr 6Y12 yr 13Y18 yr
0.5 (0.3Y0.6) 0.1 (0.0Y0.2) 0.7 (0.4Y1.1) 0.5 (0.2Y0.8) 0.8 (0.6Y1.1) 0.0 (0.0Y0.1) 0.8 (0.4Y1.3) 1.7 (1.1Y2.2)
0.3 (0.1Y0.5) 0.1 (0.0Y0.3) 0.5 (0.2Y0.9) 0.2 (0.0Y0.4) 0.9 (0.6Y1.1) 0.0 (0.0Y0.1) 0.8 (0.3Y1.2) 1.8 (1.2Y2.4)
0.3 (0.2Y0.5) 0.1 (0.0Y0.2) 0.6 (0.2Y0.9) 0.2 (0.0Y0.5) 0.8 (0.6Y1.1) 0.0 (0.0Y0.0) 0.9 (0.5Y1.3) 1.6 (1.0Y2.2)
0.2 (0.1Y0.4) 0.0 (0.0Y0.0) 0.3 (0.1Y0.5) 0.4 (0.0Y0.8) 1.4 (1.1Y1.8) 0.0 (0.0Y0.1) 0.9 (0.5Y1.2) 3.5 (2.5Y4.5)
0.2 (0.1Y0.3) 0.0 (0.0Y0.0) 0.2 (0.1Y0.4) 0.2 (0.0Y0.4) 1.7 (1.3Y2.0) 0.2 (0.1Y0.3) 0.8 (0.5Y1.2) 4.1 (3.0Y5.1)
0.3 (0.2Y0.4) 0.0 (0.0Y0.1) 0.3 (0.1Y0.5) 0.5 (0.3Y0.8) 1.6 (1.3Y1.9) 0.0 (0.0Y0.1) 1.1 (0.8Y1.5) 3.6 (2.8Y4.4)
1.50 0.77 2.11 0.20 4.00 0.18 1.09 3.91
.136 .440 .036 .843 G.001 .861 .278 G.001
Note: Authors’ calculations from the Medical Expenditure Panel Survey 1996Y2002; 95% percent CI given in parentheses. SSRI = selective serotonin reuptake inhibitors. a Z score statistic for 1996Y2002 difference is 2.05 ( p = .042). b Including also other newer antidepressants (venlafaxine, bupropion, mirtazapine, nefazodone, trazodone).
during the period 1997Y2002 is reported in Table 4. Overall, SSRI and other newer antidepressant use increased from 0.8% (95% CI 0.6%Y1.1%) in 1997 to 1.6 % (95% CI 1.3%Y1.9%) in 2002 ( p G .001), whereas the use of TCA was not statistically different between years at 0.5% (95% CI 0.3%Y0.6%) in 1997 and 0.3% (95% CI 0.2%Y0.4%) in 2002. The proportion of antidepressant users who used TCA declined from 36% in 1997 (95% CI 26%Y46%) to 16% in 2002 (95% CI 10%Y22%), as SSRI and other nonTCA antidepressant use grew. Use of TCAs declined among children ages 6 to 12 from 0.7% (95% CI 0.4%Y1.1%) in 1997 to 0.3% (95% CI 0.1%Y0.5%) in 2002 (Table 4). Most of the increase in the use of SSRI and other non-TCA antidepressants came from adolescents. Mental health conditions were reported for 96% of the SSRI or non-TCA antidepressant prescriptions in 2002, whereas a mental health condition was reported only about 50% of the time for TCA used in 2002 (data not shown). When a TCA was used for a mental health condition, depression was listed as the most common reason in 2002, and in 1997 ADHD was listed about 70% of the time. Among nonYmental health conditions, migraine was listed most of the time as the reason for TCA prescriptions in 2002. In earlier years, nocturnal enuresis was the most common reason given for TCA prescriptions. DISCUSSION
These analyses of a nationally representative annual survey of U.S. families during the 6-year period
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1997Y2002 indicate that overall the pediatric use of antidepressant medication significantly increased from 1.3% in 1997 to 1.8% in 2002 ( p G .01). The increase was the result of the use of SSRI and other novel antidepressants, whereas the use of TCAs declined during this period. The increase in SSRI antidepressants during the 1997Y2002 period was limited to adolescents (13Y18 years of age), but the use did not change for younger children. Use among children younger than 6 years of age was almost undetectable (Table 2). Among adolescents, antidepressant use increased through 2000, with a particularly sharp rise from 1999 (1.8%) to 2000 (4.0%), and then remained unchanged during 2001 and 2002. Being a female, from a lower income family, or covered by public insurance was associated with a statistically significant increase in antidepressant use during the 1997Y2002 period. The increase in antidepressant use was most evident in groups that previously had a lower utilization, such as girls, blacks, and children from lower income families and covered by public insurance. Thus, by 2002 there was no statistically significant difference in use among privately insured, publicly insured, and uninsured children or between higher-income and lower-income children. Use increased especially among children who were functionally impaired, according to the Columbia Impairment Scale (Table 3). These data are consistent with the previously reported increase in treatment of depression in the pediatric age group during the late 1990s and with the higher recognized prevalence of depression in adolescents (about 6%) than in prepubertal children (about
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PEDIATRIC USE OF ANTIDEPRESSANTS
2%). Use was similar in boys and girls, despite the fact that depression is reported to be twice as common in female compared with male adolescents (Kessler et al., 2001). The increased use of antidepressants is also consistent with reports that antidepressants accounted for a much greater portion of all medication prescriptions filled for youths ages 10 to 19 years in 2000 (7.3%) than in 1990 (1.1%; Olfson et al., 2003b). An analysis of pharmacy claim data has yielded higher estimates of prevalence use among commercially insured children (1.6% in 1998 and 2.4% in 2002) than we report (1.1% in 1998 and 1.8% in 2002; Delate et al., 2004). By definition, databases of commercially insured populations do not include uninsured subjects or those on Medicaid. However, even when only privately insured children are considered, our estimates of use (1.8%, 95% CI 1.4Y2.2) remain lower than those reported by Delate et al. The dramatic doubling of antidepressant use among adolescents between 1999 (1.8%) and 2000 (4.0%) is noteworthy. The late 1990s saw the publication of the first controlled clinical trials showing the efficacy of SSRI antidepressants in childhood depression (Emslie et al., 1997) and obsessive-compulsive disorder (March et al., 1998). The practice parameters of the American Academy of Child and Adolescent Psychiatry for the treatment of depression included pharmacotherapy with SSRI antidepressants among the possible treatment options for depressed children and adolescents (Birmaher et al., 1998). In 1999, the first algorithm for pharmacological treatment of adolescent depression was also released (Hughes et al., 1999). It is possible that these publications gradually influenced clinical practice and prompted the increase. Also, it must be pointed out that estimates of antidepressant use based on either pharmacy claim data or an HMO-insured local sample did not demonstrate any major changes between 1999 and 2000 but rather a gradual increase across years (Delate et al., 2004; Hunkeler et al., 2005). Thus, this finding needs to be investigated further. In addition to documenting a declining use of TCA antidepressants, the data also indicate a changed pattern of use for these drugs, which were less likely to be prescribed for the treatment of attention-deficit/hyperactivity disorder or for enuresis in 2002 than in 1997. In 2002, depression had become the most common mental health reason and migraine the most common medical condition for taking a TCA antidepressant in this age group.
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In more recent years, the pediatric use of antidepressants is likely to have been affected by concerns about a possible drug-induced increase in the risk of suicidal behavior (Mitka, 2003). A meta-analysis of 24 placebo-controlled clinical trials of antidepressants in a total of about 4,400 children was conducted by the U.S. Food and Drug Administration, and it was found that although no suicide had occurred, the incidence of ‘‘suicidality’’ (defined as suicidal attempts or ideation) was 4% on antidepressant versus 2% on placebo (Hammad, 2004). Consequently, a highly visible warning was added to the labeling information of all antidepressants alerting clinicians and families of the increased risk of suicidality and of the need to monitor closely for possible suicide-related adverse events whenever these medications are used in children or adolescents (U.S. Food and Drug Administration, 2004, 2005). Given the highly publicized concerns, the strength of the warning, and the additional requirements for use, it is suspected that the use of antidepressants has been declining. Some indicators based on drug prescription data suggest that this is the case (Rosack, 2005). Limitations
There are several limitations in this study that should be underscored. The MEPS data do not contain clinical information for deriving valid diagnostic determinations. Thus, these data cannot address the issue of whether antidepressants are appropriately prescribed. However, the estimated 2002 use of 1.4% (95% CI 1.0Y1.8) among 6- to 12-year-old subjects and 3.9% (95% CI 3.1Y4.7) among 13- to 18-year-old subjects is well within the limit of the estimated prevalence of the conditions for which antidepressants can be an effective treatment. For example, major depression has an estimated prevalence of about 2% in prepubertal children and 6% in adolescents, and obsessivecompulsive disorder has an estimated prevalence of about 0.8% to 3.0% in adolescents. In addition, there is empirical support for the use of antidepressants for the treatment of enuresis, nonYobsessive-compulsive disorder, anxiety disorders, and attention-def icit/ hyperactivity disorder. Even though the estimated use can be consistent with the prevalence of these disorders, we cannot determine how many users had a condition for which antidepressant use would be indicated. Selfreport surveys such as the MEPS rely on the responders’
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VITIELLO ET AL.
ability to accurately and completely recall and their willingness to provide information. Theoretically, recall and reporting biases can occur that would result in underreporting and consequently underestimating use. Yet, the validity of the MEPS data is supported by their consistency with data on drug expenditures from other sources (Selden et al., 2002; Zuvekas, 2005). Clinical Implications
The considerable increase in antidepressant use among adolescents (13- to 18-year-old subjects) from 1999 (1.8%) to 2000 (4.0%), which followed the reporting of the first controlled clinical trials of SSRIs in youths (Emslie et al., 1997; March et al., 1998), suggests that prescribing practices are strongly influenced by available research findings, but with a delay of about 2 years from publication date. The apparent reliance of clinicians on clinical trial findings underscore the need to ensure that the results of all controlled clinical trials be promptly published, regardless of study outcome, to ensure complete and unbiased access to clinically relevant information. These data indicate that the use of SSRI antidepressant medications in adolescents has doubled nationwide during the period between 1997 and 2000 but has remained stable afterward through 2002. No increase was detected among children younger than 13 years during the 6-year period 1997Y2002.
Disclosure: The authors have no f inancial relationships to disclose. REFERENCES American Academy of Child and Adolescent Psychiatry (2004), Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 43:1540Y1550 Bird H, Andrews H, Schwab-Stone M et al. (1996), Global measures of impairment for epidemiologic and clinical use with children and adolescents. J Methods Psychiatr Res 6:295Y307 Birmaher B, Brent DA, Benson RS (1998), Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 37:1234Y1238 Costello EJ, Mistillo S, Erkanli A, Keeler G, Angold A (2003), Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 60:837Y844 Delate T, Gelenberg AJ, Simmons VA, Motheral BR (2004), Trends in the use of antidepressants in a national sample of commercially insured pediatric patients, 1998 to 2002. Psychiatr Serv 55:387Y391 Emslie GJ, Heligenstein JH, Wagner KD et al. (2002), Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled randomized clinical trial. J Am Acad Child Adolesc Psychiatry 41:1205Y1215 Emslie GJ, Rush AJ, Weiberg WA et al. (1997), A double-blind,
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Pediatric Use of Complementary Therapies: Ethical and Policy Choices Michael H. Cohen, JD, MBA, Kathi J. Kemper, MD, MPH, Laura Stevens, BA, Dean Hashimoto, JD, MD, Joan Gilmour, LLB, JSD Objective: Many pediatricians and parents are beginning to integrate use of complementary and alternative medical (CAM) therapies with conventional care. This article addresses ethical and policy issues involving parental choices of CAM therapies for their children. Methods: We conducted a literature search to assess existing law involving parental choice of CAM therapies for their children. We also selected a convenience sample of 18 states of varying sizes and geographic locations. In each state, we inquired within the Department of Health and Human Services whether staff were aware of (1) any internal policies concerning these issues or (2) any cases in the previous 5 years in which either (a) the state initiated proceedings against parents for using CAM therapies for their children or (b) the department received telephone calls or other information reporting abuse and neglect in this domain. We asked the American Academy of Pediatrics and the leading CAM professional organizations concerning any relevant, reported cases. Results: Of the 18 state Departments of Health and Human Services departments surveyed, 6 reported being aware of cases in the previous 5 years. Of 9 reported cases in these 6 states, 3 involved restrictive dietary practices (e.g., limiting children variously to a watermelon or raw foods diet), 1 involved dietary supplements, 3 involved children with terminal cancer, and 2 involved religious practices rather than CAM per se. None of the professional organizations surveyed had initiated proceedings or received telephone calls regarding abuse or neglect concerning parental use of CAM therapies. Conclusions: Pediatric use of CAM therapies raises complex issues. Clinicians, hospitals, state agencies, courts, and professional organizations may benefit from a policy framework to help guide decision making. Pediatrics 2005;116:e568Ye575.
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