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By Shankar Vedantam
Washington Post Staff Writer
Tuesday, January 14, 2003
The number of American children being treated with psychiatric drugs has
grown sharply in the past 15 years, tripling from 1987 to 1996 and
showing no sign of slowing, researchers said yesterday.
A newly published study, the most comprehensive to date, found that by
1996, more than 6 percent of children were taking drugs such as Prozac,
Ritalin and Risperdal, and the researchers said the trajectory continued
to rise through 2000.
While the increase may partly reflect better diagnosis of mental illness
in children, the authors said they fear that cost-saving techniques by
insurance companies, marketing by the pharmaceutical industry and
increased demands on parents and doctors may be driving the increase.
"There are fewer options other than medication," said Michael
Jellinek, chief of child psychiatry at Massachusetts General Hospital,
who reviewed the new study.
Insurers have increased their profits by decreasing the use of
psychotherapy, which is more expensive than drugs in the short run, he
said. "The insurance system gave an incentive for medications and a
disincentive for therapy."
The insurance industry disputes that interpretation, suggesting instead
that more children are getting drugs because more effective medicines
have been developed. Most psychiatrists say that a combination of
psychotherapy and medication often provides the best treatment.
The new research found steep increases in the use of most classes of
medicines, including antipsychotic drugs. Such powerful medications,
normally meant to treat schizophrenia, were increasingly being
prescribed to children on Medicaid, said the study's lead author, Julie
Zito – possibly as a way to restrain difficult children.
"Other than zonking you, we don't know that behavioral management
by drug control is the way to learn to behave properly," said Zito,
a researcher at the University of Maryland in Baltimore. "If we are
using drugs to control behavior, that doesn't change the underlying
problem if someone doesn't know how to get along with their peers."
Zito's study evaluated 900,000 children on Medicaid in a Midwest state,
a mid-Atlantic state and in a private HMO in the Northwest. Zito said
the large study made it likely that the data are representative of the
nation's population. A re-evaluation of one of the health plans in 2000
found that the increase had continued, she added.
"The medicine may help the symptoms but not address issues of
self-esteem, interpersonal relationships and family relationships -- all
of which are part of recovery," said Jellinek, who analyzed Zito's
study. In obsessive-compulsive disorder, for example, he said, "you
can get a lot of benefit from behavioral treatments. If someone is
getting medicines for OCD, I would like to see them be given a trial of
behavioral therapy to see if that helps them and maybe decrease the
medication."
Both Zito's study and Jellinek's analysis were published in the most
recent issue of the Archives of Pediatrics and Adolescent Medicine.
Susan Pisano, vice president of communications at the American
Association of Health Plans, whose members provide managed care to about
160 million people, said the study did not address the quality of care
the children received.
"The research doesn't say, 'There is a greater use of drugs and
that's having a deleterious effect on children,' " she said.
"It just says there is a greater use of drugs." Pisano said
more analysis was needed to answer the quality question.
Zito agreed that her study could not determine whether the trend
represented a growing awareness of mental illness or was evidence of
over-medication and mistreatment. That is because she tracked medication
records, not individual children. Without comprehensive studies that
tracked the outcome of medication treatment of children, she and
Jellinek said, it was difficult to say whether the children were getting
the right treatment.
Noting that children are being medicated at almost the same rate as
adults, Zito pointed out that few safety studies of the drugs have been
done in children. Pharmaceutical companies largely do studies on adults
to get new medicines approved or to show that one drug is superior to
another.
Jellinek, who is also a professor of psychiatry at Harvard University,
said insurance companies should be required to share data about the
number of children getting comprehensive treatment in addition to those
getting only medicine. Without such information, policymakers cannot
independently evaluate whether the treatment is appropriate, he said.
Pamela Greenberg, executive director of the American Managed Behavioral
Healthcare Association, which represents companies that cover mental
health services to about 110 million Americans, said criticizing the
insurance industry for the trend is wrong.
"I don't believe providers are saying, 'We will just provide a
medication because that's going to be the highest profit margin for me,'
" she said. Besides raising ethical issues, she said, inadequate
treatment could result in a child continuing to be sick. "A sick
patient from the economic standpoint still costs you money and could end
up in the hospital."
Greenberg said the industry might be willing to make some of its
internal information public, so long as it was to a national authority
that could properly interpret the data.
David Fassler, a psychiatrist at the University of Vermont at Burlington
who has testified on children's mental health issues on Capitol Hill for
the American Psychiatric Association, said parents should push for
comprehensive evaluations of children who develop psychiatric symptoms.
Such evaluations, he said, may entail several sessions with
professionals, reviewing a child's developmental history and school
records, analyzing the child's functioning at school and with friends
and family, and having mental health professionals spend time with
children and families.
"You can't do that evaluation in a 5-10 minute office visit,"
he said. "The reality of contemporary pediatric practice makes it
difficult to devote the time necessary to do a full and comprehensive
evaluation."
© 2003 The Washington Post Company
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