More teens are on drugs—the legal kind
From the November/December ACP Observer, copyright © 2007 by the American College of Physicians.
By Stacey Butterfield
Homework, relationships, college applications, prom ... the list of issues worrying American adolescents is long. And according to the findings of some recent studies, many teenagers have one more concern to add to the list—remembering to take their medication.
The percentage of adolescents taking prescriptions for chronic diseases has increased—for diabetes, dramatically so—over the past five years, according to an analysis released earlier this year by Medco, a pharmacy benefits management company. Medications for type 2 diabetes topped Medco's survey for increases among girls 10-19 years old. Between 2001 and 2006, the prevalence of the medications went from 1.03 per 1,000 girls to 2.73, a 167% increase.
"There are definitely more adolescents coming in with these problems compared to 10 years ago—way more kids with obesity, hypertension, diabetes type 2," said Corinne E. Lehmann, FACP, an adolescent medicine specialist at Cincinnati Children's Hospital.
During the same period, Medco reported, girls’ use of antipsychotics increased 117%, sleep aids were up 81% and attention deficit hyperactivity disorder (ADHD) medications grew by 74%. The trends among boys followed the pattern, albeit less dramatically—a 71% increase for antipsychotics, 64% for sleep aids, 37% for ADHD meds and 33% for type 2 diabetes.
There is no single explanation for the gender difference, agreed experts interviewed on the topic. What is certain is that as these patients enter adulthood, internists are going to be caring for them and dealing with the causes and consequences of their medication use.
Drugs and diabetes
The cause of the most dramatic shift—in type 2 diabetes medications—could be tied to differences in lifestyle among other factors, according to diabetes experts.
"Three things—heritage, obesity and lifestyle—combine to make this huge increase. Think about who is the least active and the most overweight. It's the girls," said Larry C. Deeb, MD, president of medicine and science for the American Diabetes Association.
The statistics for boys as well as girls are cause for serious concern, said Dr. Deeb. "Even a 33% increase over five years is pretty dang dramatic," he noted.
Although lifestyle is likely the cause of the problem, it is not an effective solution, Dr. Deeb said, noting the ADA's 2005 consensus statement that metformin should be prescribed to all newly diagnosed diabetes patients. "We know that lifestyle doesn't work. It doesn't work in adults and it doesn't work in kids."
The take-away message from the survey results is that internists should be screening for diabetes, even among their youngest patients. "It's clearly there and there's clearly more of it," said Dr. Deeb. "Screening for diabetes is not unreasonable. It's a simple blood test."
Uncovering sleep problems
Screening and lifestyle also come up in experts' analyses of the statistics on teenagers and sleep aids. Milap S. Nahata, PharmD, conducted a study of treatment for pediatric sleep difficulties, which, like the Medco study, found that adolescents' use of prescription sleep aids is growing. Out of 18.6 million office visits for sleep problems reviewed in the study, 81% resulted in sleep aid prescriptions for the under-18-year-old patients.
Dr. Nahata's research did not investigate the causes of patients' sleep difficulties, but he attributes the problem to the busy lifestyles of today's teenagers—constant connectivity, late nights out combined with early school days, and caffeine use.
Those problems could be effectively remedied by lifestyle changes, but that option appears to be unpopular with impractical with adolescents, noted Dr. Nahata, who is a professor of internal medicine and pediatrics at Ohio State University College of Pharmacy. "Those things are harder to do--cognitive behavioral therapy requires a greater effort on the part of caregivers and young patients--and medication is easier to seek and prescribe to achieve an effect."
There are many possible causes of adolescent sleep problems, and most of them require investigation of underlying problems, not prescription of hypnotics, according to sleep researcher and pediatrician Judith Owens, MD, who is an associate professor of pediatrics at Brown University. "Just as you would not continue to give a patient who has pain analgesics, you should not just automatically prescribe sleep medication for someone who has insomnia," she said.
Dr. Owens noted that the increases in sleep aid prescriptions may be tied to another trend highlighted by the Medco study. "It looks like a big portion of what's driving the use of these medications are kids who have comorbid psychiatric diagnoses," she said. "Some of that is because kids who have psychiatric diagnoses also have sleep problems and part of it is because the medications that are used to treat psychiatric disorders can cause sleep problems."
Several recent studies have confirmed that diagnoses, as well as prescriptions, are increasing for some adolescent psychiatric conditions, mostly notably ADHD and bipolar disorder.
Psychologist Stephen Hinshaw, PhD, published two studies on ADHD last year—one finding that the use of ADHD medications is rapidly increasing around the world, and another which showed that girls with ADHD exhibit fewer signs of hyperactivity than boys but may face more lasting consequences of the disorder.
Dr. Hinshaw, a professor and chair of the department of psychology at the University of California-Berkeley, attributes the increase in prescriptions to new understanding that ADHD does not go away at puberty. He was also not surprised that girls are outpacing boys in medication use growth.
"There is increasing recognition that girls can and do have ADHD—though overall boys' rates are higher—and that the impairments for girls may well be even stronger than those for boys—increased risk for delinquency, substance use, school failure, early pregnancy, depression," he said. Still, he noted, the optimal results are usually obtained by combining medication with behavioral therapies.
Gonzalo Laje, MD, of the National Institute of Mental Health, has studied trends in antipsychotic prescriptions and found that between the 1993 and 2002, prescriptions for children and adolescents increased six-fold. He also more recently completed a study finding that youth physician visits for bipolar diagnoses grew from 25 per 100,000 people in 1994 to 1,003 per 100,000 in 2003.
In addition to more diagnoses of disorders, the growth in prescriptions may be due in part to declining availability of inpatient psychiatric facilities, Dr. Laje said. "This would call for physicians to treat this more severely ill group as outpatients."
Psychiatrists, rather than internists, are writing the vast majority of antipsychotic prescriptions, Dr. Laje said. However, internist and adolescent medicine specialist Sarah L. Stevens, ACP Member, of the Allentown (Pa.) Medical Center, finds herself called upon to deal with psychiatric medications more than she would like.
"In my mind, that should all be managed by a psychiatrist. It's not my realm," she said.
Dr. Stevens frequently gets requests for ADHD medications from adolescent patients who have diagnosed themselves with the disorder. "I insist that they all get a thorough evaluation, but the schools take a very long time to do this," she said.
She refers patients to private therapists, but that option can be costly and also entail a long wait. In the meantime, parents and teenagers are impatient to obtain ADHD medication, Dr. Stevens said.
They are less enthused about other psychiatric medications. "I see more patients and families requesting ADHD medications than anti-depressants. Kids don't want to be on anti-depressants," Dr. Stevens said.
Physicians also appear to have lost interest in anti-depressants. The Medco survey found that antidepressant use—in contrast to the other medications—declined between 2003 and 2006.
A study published in the September American Journal of Psychiatry confirmed those findings, concluding that adolescent prescriptions for selective serotonin reuptake inhibitors (SSRIs) declined 22% after government regulators added a black box warning of an association between the drugs and suicide. The study authors linked those statistics to a dramatic increase in adolescent suicides, observed in data collected by the CDC.
John March, MD, chief of child and adolescent psychiatry at Duke University Medical Center, is not fully convinced of the association.
"There's no way to relate these two facts to each other from the data but most of the experts in the field believe that all these drugs slightly increase the attempt rate and they also decrease the death rate," he said. "The FDA has done us a real public service by highlighting a relatively small but public-health relevant side effect of these medications."
It is the job of clinicians to accurately explain the risks versus the benefits of these medications, said Dr. March. "The basic take-home message is that the drugs do work in clinically meaningful ways. Like all compounds in medicine, they have side effects and one of the rarer side effects is an increase in suicidality."
The drugs have been shown to be most effective when used in conjunction with cognitive behavioral therapy (CBT), he noted. In addition to accelerating recovery from depression, therapy reduces the risk of adverse events including suicidal ideation, said Dr. March. "The important thing to point out about CBT is that it's the equivalent of diet and exercise in a patient who has diabetes. It's very tightly focused on its targets."
Of course, connecting adolescents with a provider of CBT can be as difficult as motivating a diabetic patient to exercise. "At least it needs to be mentioned, even if the doctor says, 'We don't have anyone around here who can do that,'" said Dr. March.
The debate over the black box at least proves that research is ongoing about the effects of SSRIs on young patients. The same cannot be said for many other medications prescribed to adolescents, said Dr. Nahata.
Despite the fact that more than 4 out of 1,000 girls are taking them, no sleep medications are FDA-approved for adolescents, and just this summer, risperidone (Risperdal) became the first atypical antipsychotic approved for adolescents with bipolar disorder or schizophrenia.
"We're conducting a giant experiment with the lives of America's children by providing them not just one drug, but often two or three drugs in combination, with no data to know whether these drugs are effective or safe over the short term, much less the long term."
—John March, MD
Overall, about 75% to 80% of approved adult medications are not labeled for children, said Dr. Nahata. "The approval system is far from perfect, but at least it assures us what the dose should be, how long we should give it. When we don't have it, I think a lot of decisions have to be made arbitrarily," he added.
Dr. March shares his concern. "We're conducting a giant experiment with the lives of America's children by providing them not just one drug, but often two or three drugs in combination, with no data to know whether these drugs are effective or safe over the short term, much less the long term."
He advocates changing the incentives for drug research, to better reward efforts that evaluate the safety and efficacy of medications for pediatric patients, as well as improving communication between providers of child and adolescent psychology and the broader medical community.
The medical community will soon have reason to take note of the issues surrounding adolescent prescribing, as these young patients grow up and enter the age range in which Americans are most likely to be without health insurance.
"Most of these are not cheap medications," noted Dr. Stevens. "If these are legitimate uses of these medicines, how are we going to help them stay on them?"
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