Psychotropic drugs are prescribed to children in the United States at three times the rate of children in Europe, according to one of the first studies to rigorously compare such prescription patterns between different countries.
“There is significantly greater use of atypical antipsychotics and selective serotonin reuptake inhibitor (SSRI)-type antidepressants for child mental health treatment in U.S. than in Western Europe,” lead researcher Julie Zito said.
Zito and colleagues from the University of Maryland’s School of Pharmacy examined the prescription of psychotropic drugs, including stimulants such as Ritalin and antidepressants such as Prozac, to more than 600,000 people under the age of 20 in the United States, Germany and the Netherlands between 1999 and 2000. They found that 6.7 percent of children in the United States, 2.9 percent of those in the Netherlands and 2 percent of those in Germany were taking at least one psychotropic drug at the time.
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Among U.S. children between the ages of five and nine, the rate was more than 8 percent, or four times the European rate. The use of more than one drug at a time by U.S. children was also widespread.
Looking specifically at different classes of medications, the researchers found that U.S. children were prescribed antidepressants and stimulants at three or more times the rate of children in Europe, and antipsychotics at between 1.5 and 2.2 times the European rate.
In the United States, more than 75 percent of psychotropic drugs were prescribed to children “off-label,” for uses not approved by the FDA.
The findings were published online in the journals Child and Adolescent Psychiatry and Mental Health and BioMed Central.
Zito noted that the prescription of psychotropics in the United States has probably increased in the eight years since the study’s completion.
“The US trends appear to be continuing,” she said.
The researchers proffered several possible explanations for the vast differences in prescription rates between the United States and Europe.
Part of the difference may be due to different diagnosis systems, with less stringent requirements in the United States for a diagnosis of mental illness in children. For example, the criteria for a U.S. diagnosis of attention deficit hyperactivity disorder (ADHD) are much easier to meet than for the equivalent European hyperkinetic disorder. Likewise, a diagnosis of childhood bipolar disorder is much more common in the United States.
Other differences in the medical establishments include a much higher per capita number of child psychiatrists in the United States (meaning there are more people to write psychotropic prescriptions) and the European public health system’s aversion to prescribing expensive, patented antidepressants and antipsychotics. European doctors are also less comfortable prescribing stimulants to children; the practice was actually banned in France while the study was being conducted.
Another possible explanation is cultural: doctors and patients in the United States are much more likely to turn to pharmaceutical remedies than Europeans are.
“Direct-to-consumer drug advertising, which is common in the U.S., is also likely to account for some of the differences,” the researchers wrote. “The increased use of medication in the U.S. also reflects the individualist and activist therapeutic mentality of U.S. medical culture.”
“It has been said many times that the U.S. has a sick-care system, rather than a health-care system, with a particular emphasis on use of drugs and procedures for diagnosed conditions,” said David L. Katz, director of the Prevention Research Center at Yale University School of Medicine. “This study reaffirms that pattern, with more use of medication for various mental health conditions among children in the U.S than other countries.”
Zito warned that with most psychotropics being used by children off-label, much more caution is needed in prescribing and post-prescription monitoring.
“Until we have better evidence, we need to be conducting close monitoring of off-label use to assure parents that the benefits of medications outweigh the risks of unnecessary use (when the benefit is inadequate) or risk of adverse events such as increased glucose levels and lipid levels for youth receiving atypical neuroleptics,” she said.