September 25, 2008

Study: US Kids Get Two To Three Times As Much ADHD Meds, Anti-Depressants As Euro Kids

A new study is out in Child and Adolescent Psychiatry and Mental Health (abstract here, full paper here). In it, authors compare use of ADHD meds, anti-depressants and antipsychotics in children and youths aged 0 to 19 years old in the US, the Netherlands and Germany and come away with about what you'd expect: children and youths in the US get psych meds far more often than do Dutch and German children and youths.

The short story is that anti-depressant and stimulant use in the US was three times greater or more than in other countries and antipsychotic use was about twice as much.

As cross-cultural studies do, this one has its limitations--ADHD is defined a bit more tightly (good) in Western Europe than in the US, access to health care is different, psych med use overall is different, and so on. What's more, the study's US subjects were all clustered in one Middle Atlantic state (unidentified in the paper) and were all in that state's CHIP program (which the authors claim mirrors children and youths in private insurance, but I'm not so sure of that). It would have been preferable for the study to have used US data from a sampling of US states east, west, north and south. From what I know anecdotally, psych med prescribing patterns and attitudes differ across the US (more so on the East Coast, less so on the West Coast). It would also have been nice if the study had had some British data, since that country is much more culturally close to the US than Western Europe per se. The study also only examined data from one year, 2000. As a result, the study is likely not capturing the rise of the bipolar child paradigm and is likely missing the spike in antipsychotic use in America which really happened after 2000.

Those caveats aside, the study's results are dramatic and certainly point to how the US is willing to diagnose children and youths with mental disorders and slap them with the psych meds. This is, as the authors speculate, as a result of how drugs are advertised and regulated in the US compared with other countries. For example, in France stimulants were banned for kids until recently and that country does not allow DTC ads. Neither do the Netherlands and Germany.

I wish the authors had also pointed to differences in how mental disorders are marketed to Americans in ways that they are not in other countries. In the US, we have several non-profits and affiliated activists and flag wavers for almost all of the major DSM diagnoses and their job is to raise awareness and lobby the media to cover their cause. I don't know of a correlate for these sorts of groups in Germany, especially when it comes to children.

Julie Zito, the lead author, noted:

"'Direct to consumer drug advertising, which is common in the US, is also likely to account for some of the differences. The increased use of medication in the US also reflects the individualist and activist therapeutic mentality of US medical culture.'"

Oh, but you wanted to see the study's results I bet, so here they are by drug class and percentage use among children and youths:

ADHD stimulants:

US--4.29 percent
Germany--.71 percent
Netherlands--1.18 percent

Antipsychotics:

US--.76 percent
Germany--.34 percent
Netherlands--.51 percent

Anti-depressants:

US--2.71 percent
Germany--.17 percent
Netherlands--.53 percent

Lithium:

US--.15 percent
Germany--0 percent
Netherlands--.01 percent

It's worth noting that antipsychotic use was skewed heavily toward males, as was stimulant use. This was true in the US, Germany and the Netherlands.

BTW, for those of you who pay close attention to the paper, there is a bit of a labeling problem on Table 6.

Posted by Philip Dawdy at September 25, 2008 10:48 AM
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Comments

I agree with all Philip.
But just would like to say that there are many people - children and adults, males uses it a lot - taking Ritalin in Brazil alone.
We have no data whatsoever. I don't know about other countries down here.

Posted by: Ana at September 25, 2008 01:13 PM

It should be noted that it is common, extremely common, practice in the U.S. to have kids on 2 drugs (at least) at once, while this is much less common in Europe.

But why are more American kids on the meds? I think the answer is threefold.

1. Social ills are socialized in Europe, while social ills are medicalized here. (e.g. truancy=ADHD.)
2. Doctors here have no other options except medications-- in fact, their "sessions" are actually called "medication management visits."
3. American adults are taught/conditioned/socialized to think that kids' problems are fundamentally medical, not behavioral, or, to put it another way, parents often lack any resources or knowledge on how to manage behavioral problems of their children. Not a slam against them, just an observation.

Of course an important majority of the parents of these kids are often on meds themselves--their bias is to turn to psychiatry.

Posted by: TheLast Psychiatrist at September 25, 2008 02:16 PM

2. Doctors here have no other options except medications-- in fact, their "sessions" are actually called "medication management visits."

because they have a gun to their head??

oh yeah, insurance acts like a gun we don't have free will anymore. we can't suggest to a parent that there might be alternatives...

Posted by: Gianna at September 25, 2008 04:05 PM

It is certainly unfortunate that so many children are on unnecessary medications when behavioral interventions by the parents would be sufficient. However, just because many -- if not most -- are on medications for the wrong reasons does not imply that many others are on them for the right reason. Better diagnostic assessments and more community resources to help parents manage their children would go a long way towards alleviating this problem.

Posted by: dguller at September 25, 2008 04:05 PM

"American adults are taught/conditioned/socialized to think that kids' problems are fundamentally medical, not behavioral, or, to put it another way, parents often lack any resources or knowledge on how to manage behavioral problems of their children."

ThelastPsychiatrist,
It's not only American parents. It' the same here.
And yes, they are also on drugs.

Posted by: Ana at September 25, 2008 07:24 PM

Just curious: How many parents are on medications who have children on medications? I can't find any data on the subject, and yet everyone here is so sure that only drug-induced parents would agree to medicating their children. So, please cite the evidence.

Posted by: dguller at September 25, 2008 08:08 PM

As you said, the collection base is very limited and I would argue almost unscientific. You're using data based on lower income children living in one state and comparing it to the entire US population? Come on now.

http://www.cdc.gov/ncbddd/adhd/

As you can see, ADHD is more commonly diagnosed, and treated, in the Mid-Atlantic states. There goes the study.

What grounds did France use to ban stimulant medications from children. Yes, I agree, you should have to have ADHD to be taking Ritalin. Yes, I agree, children with a history of cardiac problems, or those at high risk for developing cardiac problems, probably shouldn't be taking Ritalin. But a kid that clearly has ADHD, benefits from medication therapy and experiences no side effects?

Posted by: adhd pt at September 26, 2008 01:14 AM

adhd:

Good points.

Thank you.

Posted by: dguller at September 26, 2008 11:40 AM

I agree with dguller and adhd. There was also a study done by, I think, NIMH about the entire issue of ADHD and it being under/over diagnosed. If I remember correctly what if found is that both are true. Doctors (PCP's) overdiagnosed it and only about 1/3 admitted to using the DSM criteria to diagnose it. Where as mental health professionals tended to underdiagnose it. Go figure.

I think the statement about direct to consumer advertising is being underestimated by the study. I personally wish they would ban the practice.

Posted by: JD at October 5, 2008 04:18 AM
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