A European perspective on paedo‐psychiatric pharmacoepidemiology
Authors: Hans-Christoph Steinhausen
Journal: World Psychiatry (2013)

J. Rapoport's paper confronts the reader with the central statement that in the recent past some over-acceptance of drug treatment for children and adolescents with mental disorders has emerged, contributing to the development of a reductionist psychobiology. This may be regarded as a major current threat to the identity of child and adolescent psychiatry. The present commentary concentrates on findings indicating that this over-prescribing of psychotropic medications in children and adolescents differs in magnitude in the various countries. More detailed analyses are needed for a better understanding of these differences. International studies have shown that the prescription rates of psychotropic medications in children and adolescents vary substantially across countries. The prevalence of any prescription of psychotropic drugs in youth in the year 2000 was substantially greater in the US (67 per 1,000 people) than in the Netherlands (29 per 1,000) and in Germany (20 per 1,000) 1. Marked differences among countries have been observed also for individual groups of drugs. For instance, the utilization of antidepressants in 0–19 year olds in the year 2000 in an US dataset (16.3 per 1,000) largely exceeded that of three Western European countries (1.1–5.4 per 1,000) 2. There have been also changes over time in both the total number of prescriptions and the utilization of the various drugs. The number of all psychotropic prescriptions for children has risen between the years 2000 and 2002 in Europe, South America, and North America 3. In the Netherlands, the prescription rate of all antipsychotics, benzodiazepines, antidepressants, and psychostimulants increased from 11.1 per 1,000 in 1995 to 22.9 per 1,000 in 2001 4. These time trends have been also observed for individual groups of drugs, including stimulants, the most widely prescribed psychotropics in children and adolescents, but also antidepressants and antipsychotics. However, most of the data on time trends are biased by the unrepresentativeness of the study populations and the short and rather accidental observation periods. The long-standing tradition and quality of Scandinavian registers, including data on prescriptions, allow studies which are not affected by these biases. Our own recent study 5 based on the Danish register, analyzing all dispensed prescriptions in the population aged 0–17 years between the years 1996 and 2010, allowed a consistent analysis of patterns of psychotropic medication over fifteen consecutive years. The major findings were the following. First, the prevalence of all dispensed psychotropic medications over these fifteen years showed a nine-fold increase. This increase was much reduced after adjustment for the increasing number of patients seeking help from public health services. However, even after adjustment, there was still a two-fold higher rate of dispensed prescriptions over the observation period. Secondly, this trend was most pronounced for stimulants, with a twenty-three-fold increase in non-adjusted prevalence rates and a still eight-fold increase in adjusted prevalence rates. For antidepressants, there was a 9.5-fold increase (1.8-fold increase after adjustment). For antipsychotics, there was a 6.6-fold increase (two-fold increase after adjustment). Despite increasing numbers, these Danish rates were lower than in many other European countries and particularly in the US. Vitiello 6 suggested that many factors affect prescription of medications in children, including variations in health service organization, differences in diagnostic systems, adherence to clinical practice guidelines, drug regulations, availability and allocation of financial resources, and cultural attitudes towards child and adolescent mental disorders. It remains unclear whether the Danish public health system counteracts to some extent the impact of market forces on prescriptions. However, given the similar organization of health services in Scandinavian countries and some indication of markedly different prescription rates for psychotropic medications in these countries 7, there is not much room for the argument that public health services per se unfold strong control of market processes through strict drug regulations and restrictive allocations of financial resources. Differences in diagnostic systems, with Denmark using the ICD-10 rather than the DSM-IV classification, and a potentially less strict adherence to clinical guidelines in most European countries compared to the US, may have exerted some impact. The main factor involved may still be represented by the different cultural attitudes towards child and adolescent mental disorders among both lay people and experts. Without having solid studies and data in this respect, one may only argue that some characteristics of the Danish society, including no marked social gradients, a stable large middle class, free public health services for citizens, and a predominant feeling of a high quality of life, may have had an impact against the tendency to over-prescribe psychotropic medications to children and adolescents. It is also possible that the current status of Danish and European child and adolescent psychiatry is encouraging a patient-oriented assessment and treatment, beyond evidence-based guidelines. However, more detailed analyses are needed in order to understand inter-country differences in drug prescriptions in young people with mental disorders.