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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on November 7, 2012, at 23:52:36
More combos on the rise. Phillipa
Medscape Medical News > Psychiatry
Anticonvulsant Use for Psychiatric Illness in Children Doubles
Deborah Brauser
Nov 06, 2012Authors & Disclosures
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Use of anticonvulsant medications to treat pediatric patients with various psychiatric conditions appears to be rising dramatically, new research suggests.
A study to assess national trends showed that clinical visits from 1996 to 2009 for anticonvulsants to treat youth diagnosed with any psychiatric illness increased 1.7-fold.
The individual disorders that saw the greatest increase in treatment with these medications were attention-deficit/hyperactivity disorder (ADHD), pediatric bipolar disorder, and disruptive behavior disorders.
Of 6 specific anticonvulsants examined, lamotrigine showed the greatest increase in use during the study period, whereas use of divalproex decreased significantly.
The overall proportions of this medication class used to treat youth with seizure-related illnesses did not change significantly.
"The number 1 takeaway is that anticonvulsant use for psychiatric indications is still prominent," coinvestigator Julie M. Zito, PhD, professor of pharmacy and psychiatry at the University of Maryland in Baltimore, told Medscape Medical News.
Dr. Julie Zito
She noted that although use of these medications increased from 1996 to 2004 and then decreased in 2009, the use is still quite high.
The study also showed that pediatric use of anticonvulsants along with stimulants increased significantly. This finding "underscores complex drug regimens that require monitoring for safety and benefits," write the investigators.
"Clinical review and monitoring can be mandated by policy makers in Medicaid and private insurance programs to ensure appropriate use of these...regimens," they add.
The study is published in the November issue of Psychiatric Services.
Low Effect Size
This study was conducted to "shed light on psychiatric practice patterns involving use of anticonvulsants in view of boxed warnings" from the US Food and Drug Administration, write the researchers.
They also note that previous pediatric clinical trials have shown "low effect size" when using these medications in this way and that there have been numerous safety concerns regarding off-label uses, "particularly for newer products, such as lamotrigine."
For the current study, the investigators examined outpatient data for youth between the time of birth to age 17 years from the National Ambulatory Medical Care Survey and from the National Hospital Ambulatory Medical Care Survey both of which are conducted annually by the National Center for Health Statistics.
All data were divided into the following 4 subgroups: 1996-1997, 2000-2001, 2004-2005, and 2008-2009.
Use of the following 6 anticonvulsant medications were assessed: lamotrigine, divalproex (which included valproic acid, sodium valproate, and divalproex sodium), gabapentin, carbamazepine, oxcarbazepine, and topiramate.
The designated primary outcome measure was "percentage prevalence of visits for anticonvulsants that included a psychiatric diagnosis as a proportion of total youth visits for an anticonvulsant."
Included psychiatric diagnoses were bipolar disorder, ADHD, conduct disorder, oppositional defiant disorder, depression, and anxiety disorders.
Visits Doubled
Results showed that total pediatric use of anticonvulsants increased from .33% to .68% (P < .001) during the total study period.
"Thus visits for anticonvulsant mood stabilizers essentially doubled...regardless of indications for use," write the investigators.
"As a proportion of total youth visits for anticonvulsants," visits with a psychiatric diagnosis increased significantly from 3.71% during the 1996-1997 period to 6.31% during the 2008-2009 period (P < .001).
Boys were significantly more likely to be prescribed an anticonvulsant in 2008-2009 than they were in 1996-1997 (P < .001).
Significantly more prescriptions for these medications were also found in the later years than in the earlier ones for all black youth (P = .002), all white youth (P = .011), and all Asian youth (P = .004).
Anticonvulsant use also increased significantly in 1996-1997 and 2008-2009 for ADHD, conduct disorder, or oppositional defiant disorder (from 24.1% to 62.1%, P < .001) and for bipolar disorder (from 24.8% to 56.8%, P < .001).
Lamotrigine showed the greatest increase in use during the study period (from 4.3% to 40.1%, P < .001). Interestingly, pediatric use of divalproex significantly decreased during the same period (from 72% to 30.7%, P = .002).
Use of carbamazepine, topiramate, or gabapentin also decreased (from 26.4% to 19.6%), but this was not deemed significant.
However, the use of the "newer product" oxcarbazepine (along with lamotrigine) began to increase substantially during the 2000-2001 period and accounted for 15.4% of the visits in 2008-2009.
Finally, the use of both stimulants and anticonvulsants increased significantly (from 17.7% in 1996-1997 to 54.8% in 2008-2009, P < .001).
"Serious Safety Problem"
Overall, "the use of [anticonvulsants] for psychiatric conditions rose to a dominant position," write the investigators.
"The growth of concomitant and off-label use to treat behavioral disorders raises questions about effectiveness and safety in community populations of youth," they add.
"I think we are operating in an era where we don't know enough about what is actually happening in community practice," said Dr. Zito.
She noted that there has been a constant increase in the use of drugs in combinations, which create "very complex regimens that are poorly evidenced."
In addition, sources such as Medicaid data have shown that many children do not stay on these drug regimens for very long, she added.
"So you have a long-term problem but very short-term and interrupted medication use. That's a management problem and a monitoring problem. And in terms of very young children, it's also a serious safety problem," said Dr. Zito.
"We don't know how their hearts, livers, kidneys, and brains are going to be functioning after 5 years or 10 years of exposure to medication regimens that aren't well evidenced."
Dr. Zito said an even bigger problem occurs when it turns out that a prescribed combination is not safe.
"Then I think the benefit-risk has changed, and nobody is calling anybody on it because these are all meds that are on the market and are being used increasingly. At least that's what the trend shows."
The study was supported by the Department of Pharmaceutical Health Services Research at the University of Maryland School of Pharmacy. The study authors have disclosed no relevant financial relationships.
Posted by jono_in_adelaide on November 9, 2012, at 0:07:24
In reply to Anticonvulsant Use In Youth Increases + Stimulants, posted by Phillipa on November 7, 2012, at 23:52:36
If current trends continue, and treatment threasholds continue to fall, in 20 years everybody will be on an antidepressant, a mood stabaliser, or both.
Posted by Phillipa on November 9, 2012, at 18:23:09
In reply to Re: Anticonvulsant Use In Youth Increases + Stimulants, posted by jono_in_adelaide on November 9, 2012, at 0:07:24
So true so many people I know both casually and even docs offices are on them. Phillipa
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