Journal of the American Academy of Child & Adolescent Psychiatry
Volume 49, Issue 10 , Pages 1001-1010 , October 2010

National Trends in Child and Adolescent Psychotropic Polypharmacy in Office-Based Practice, 1996-2007

  • Jonathan S. Comer, Ph.D.

      Affiliations

    • College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York
    • Corresponding Author InformationCorrespondence to: Jonathan S. Comer, Ph.D., Boston University, Department of Psychology, Center for Anxiety and Related Disorders, 648 Beacon Street 6th Floor, Boston, MA 02446
    • ,
  • Mark Olfson, M.D., M.P.H.

      Affiliations

    • College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York
    • ,
  • Ramin Mojtabai, M.D., Ph.D., M.P.H.

      Affiliations

    • Bloomberg School of Public Health and Johns Hopkins University, Baltimore

,Accepted 16 July 2010.

References 

  1. AACAP Work Group on Quality Issues. Practice parameter on the use of psychotropic medication in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009;48:961–973
  2. Swanson JM, Kraemer HC, Hinshaw SP, et al. Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry. 2002;40:168–179
  3. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297:1683–1696
  4. TADS Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807–820
  5. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Eng J Med. 2008;359:2753–2766
  6. Sikich L, Frazier JA, McClellan J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizoaffective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum disorders (TEOSS) study. Am J Psychiatry. 2008;165:1420–1431
  7. Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry. 2000;39:509–516
  8. Findling RL, Robb A, Nyilas M, et al. A multiple-center, randomized, double-blind, placebo-controlled study of oral aripiprazole for treatment of adolescents with schizophrenia. Am J Psychiatry. 2008;165:1432–1441
  9. Pavuluri MN, Henry DB, Moss M, Mohammed T, Carbray JA, Sweeney JA. Effectiveness of lamotrigine in maintaining symptom control in pediatric bipolar disorder. J Child Adolesc Psychopharmacol. 2009;19:75–82
  10. Wagner KD, Kowatch RA, Emslie G, et al. A double-blind, randomized, placebo-controlled trial of oxcarbazepine in the treatment of bipolar disorder in children and adolescents. Am J Psychiatry. 2006;163:1179–1186
  11. Wagner KD, Redden L, Kowatch RA, et al. A double-blind, randomized, placebo-controlled trial of divalproex extended-release in the treatment of bipolar disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009;48:519–532
  12. Correll CU, Manu P, Olshanskiy V, Napolitano B, Kane JM, Malhotra AK. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA. 2009;302:1765–1773
  13. Olfson M, Blanco C, Liu L, Moreno C, Laje G. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry. 2006;63:679–685
  14. Olfson M, Gameroff MJ, Marcus SC, Jensen PS. National trends in the treatment of attention deficit hyperactivity disorder. Am J Psychiatry. 2003;160:1071–1077
  15. Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry. 2002;41:514–521
  16. Zito JM, Safer DJ, dosReis S. Psychotropic practice patterns for youth: a 10-year perspective. Arch Pediatr Adolesc Med. 2003;157:17–25
  17. Zito JM, Safer DJ, dosReis S, Gardner JF, Boles M, Lynch F. Trends in the prescribing of psychotropic medications to preschoolers. JAMA. 2000;283:1025–1030
  18. Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032–1039
  19. Olfson M, Gameroff MJ, Marcus SC, Waslick BD. Outpatient treatment of child and adolescent depression in the United States. Arch Gen Psychiatry. 2003;60:1236–1242
  20. Feeney DJ, Klykylo W. Risperidone and tardive dyskinesia. J Am Acad Child Adolesc Psychiatry. 1996;35:1421–1422
  21. George AK, Kunwar AR, Awasthi A. Acute myocardial infarction in a young male on methyphenidate, bupropion, and erythromycin. J Child Adolesc Psychopharmacol. 2005;15:693–695
  22. Jaworowski S, Benarroch F, Gross-Tsur V. Concomitant use of atomoxetine and OROS methylphenidate in a 10-year-old child suffering from attention-deficit/hyperactivity disorder with comorbid bipolar disorder and Tourette syndrome. J Child Adolesc Psychopharmacol. 2006;16:365–370
  23. Schertz M, Steinberg T. Seizures induced by the combination treatment of methylphenidate and sertraline. J Child Adolesc Psychopharmacol. 2006;18:301–303
  24. Carlson GA, Rapport MD, Kelly KL, Pataki CS. The effects of methylphenidate and lithium on attention and activity level. J Am Acad Child Adolesc Psychiatry. 1992;31:262–270
  25. Emiroglu FN, Neslihan I, Gencer O, Ozbek A. Adjunctive olanzapine treatment in bipolar adolescents responding insufficiently to mood stabilizers (Four case reports). Eur Child Adolesc Psychiatry. 2006;15:500–503
  26. Pathak S, Johns ES, Kowatch RA. Adjunctive quetiapine for treatment-resistent adolescent major depressive disorder: a case series. J Child Adolesc Psychopharmacol. 2005;15:696–702
  27. Gonzalez-Heydrich J, Raches D, Wilens TE, Leichtner A, Mezzacappa E. Retrospective study of hepatic enzyme elevations in children treated with olanzapine, divalproex, and their combination. J Am Acad Child Adolesc Psychiatry. 2003;42:1227–1233
  28. Kafantaris V, Coletti D, Dicker R, Gina P, Kane J. Adjunctive antipsychotic treatment of adolescents with bipolar psychosis. J Am Acad Child Adolesc Psychiatry. 2001;40:1448–1456
  29. Marchand WR, Wirth L, Simon C. Quetiapine adjunctive and monotherapy for pediatric bipolar disorder: a retrospective chart review. J Child Adolesc Psychopharmacol. 2004;14:405–411
  30. Findling RL, McNamara NK, Stansbrey R, et al. Combination lithium and divalproex sodium in pediatric bipolar symptom restabilization. J Am Acad Child Adolesc Psychiatry. 2006;45:142–148
  31. Carlson GA, Dunn D, Kelsey D, et al. A pilot study for augmenting atomoxetine with methylphenidate: safety of concomitant therapy in children with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatry Mental Health. 2007;2:ArtID 10
  32. Gittelman-Klein R, Klein D. Comparative effects of methylphenidate and thioridazine in hyperkinetic children: I (Clinical results). Arch Gen Psychiatry. 1976;33:1217–1231
  33. Safer DJ, Zito JM, dosReis S. Concomitant psychotropic medication for youths. Am J Psychiatry. 2003;160:438–449
  34. Dorland's illustrated medical dictionary. 31st ed.. Philadelphia, PA: Saunders; 2007;
  35. Dean AJ, McDermott BM, Marshall R. Psychotropic medication utilization in a child and adolescent mental health service. J Child Adolesc Psychopharmacol. 2006;16:273–285
  36. Duffy FF, Narrow WE, Rae DS, et al. Concomitant pharmacotherapy among youths treated in routine psychiatric practice. J Child Adolesc Psychopharmacol. 2005;15:12–24
  37. Martin A, Van Hoof T, Stubbe D, Sherwin T, Scahill L. Multiple psychotropic pharmacotherapy among child and adolescent enrollees in Connecticut Medicaid managed care. Psychiatr Serv. 2003;54:72–77
  38. Safer DJ. Changing patterns of psychotropic medications prescribed by child psychiatrists in the 1990s. J Child Adolesc Psychopharmacol. 1997;7:267–274
  39. Sevilla-Dedieu C, Kovess-Masfety V. Psychotropic medication use in children and adolescents: a study from France. J Child Adolesc Psychopharmacol. 2008;18:281–289
  40. dosReis S, Zito JM, Safer DJ, Gardner JF, Puccia KB, Owens PL. Multiple psychotropic medication use for youths: a two-state comparison. J Child Adolesc Psychopharmacol. 2005;15:68–77
  41. Bhatara V, Feil M, Hoagwood K, Vitiello B, Zima B. National trends in concomitant psychotropic medication with stimulants in pediatric visits: practice versus knowledge. J Atten Disord. 2004;7:217–226
  42. McIntyre RS, Jerrell JM. Polypharmacy in children and adolescents treated for major depressive disorder: a claims database study. J Clin Psychiatry. 2009;70:240–246
  43. Cherry DK, Hing E, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2006 summary. Natl Health Stat Report. 2008;1–39
  44. Woodwell DA. National Ambulatory Medical Care Survey: 1996 summary. Adv Data. 1997;1–25
  45. Stata Statistical Software, Release 10 [computer program] Version. College Station, TX: Stata Corporation; 2008;
  46. Ghaemi SN. Polypharmacy in Psychiatry. New York: Dekker; 2002;
  47. Haider SI, Johnell K, Thorslund M, Fastbom J. Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992-2002. Int J Clin Pharm Ther. 2007;45:643–653
  48. Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. 2010;67:17–24
  49. Preskorn SH, Lacey RL. Polypharmacy: when is it rational?. J Psychiatr Pract. 2007;13:97–105
  50. Trivedi MH, Fava M, Wisniewski SR, et al. Medication augmentation after the failure of SSRIs for depression. N Engl J Med. 2006;354:1243–1252
  51. Toren P, Ratner S, Laor N, Weeizman A. Benefit-risk assessment of atypical antipsychotics in the treatment of schizophrenia and comorbid disorders in children and adolescents. Drug Saf. 2004;27:1135–1156
  52. Pappagallo M, Silva R. The effect of atypical antipsychotic agents on prolactin levels in children and adolescents. J Child Adolesc Psychopharmacol. 2004;14:359–371
  53. Findling RL, McNamara NK. Atypical antipsychotics in the treatment of children and adolescents: clinical applications. J Clin Psychiatry. 2004;65(Suppl 6):30–44
  54. Sikich L, Hamer RM, Bashford RA, Sheitman BB, Leiberman JA. A pilot study of risperidone, olanzapine, and haloperidol in psychotic youth: a double-blind, randomized 8-week trial. Neuropsychopharmacology. 2004;29:133–145
  55. King B, Zwi K, Nonn K, Longworth J, Dossetor D. Use of risperidone in a paediatric population: an observational study. J Paediatr Child Health. 2003;39:523–527
  56. Stahl SM. Stahl's Essential Pschopharmacology: Neuroscientific Basis and Practical Applications. 3rd ed.. New York: Cambridge University Press; 2008;
  57. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962–970
  58. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry. 2000;157(suppl 4):1–45
  59. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. Am J Psychiatry. 2002;159:1–50
  60. Wijkstra J, Lijmer J, Balk F, Geddes J, Nolen WA. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev. 2005;CD004044
  61. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 2009;40:57–87
  62. Costello EJ, Egger HL, Angold A. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Child Adolesc Psychiatr Clin North Am. 2005;14:631–648
  63. Drabick DAG, Gadow KD, Loney J. Source-specific oppositional defiant disorder: comorbidity and risk factors in referred elementary schoolboys. J Am Acad Child Adolesc Psychiatry. 2007;46:92–101
  64. Goren JL, Parks JJ, Ghinassi FA, et al. When is antipsychotic polypharmacy supported by research evidence? (Implications for QI). Jt Comm J Qual Patient Saf. 2008;34:571–582
  65. Meyer TJ, Van Kooten D, Marsh S, Prochazka AV. Reduction of polypharmacy by feedback to clinicians. J Gen Intern Med. 1991;6:133–136
  66. Thompson A, Sullivan SA, Barley M, et al. The DEBIT trial: an intervention to reduce antipsychotic polypharmacy prescribing in adult psychiatry wards – a cluster randomized controlled trial. Psychol Med. 2008;38(5):705–715
  67. Frank RG, Goldman HH, McGuire TG. Trends in mental health cost growth: an expanded role for management?. Health Affairs. 2009;28:649–659

 This work was supported by AHRQ U18 HS016097 and NIH T32 MH016434.

 The authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

 Disclosure: Dr. Olfson, in the past 5 years, has received investigator initiated grants from AstraZeneca, Bristol-Myers Squibb, and Eli Lilly and Co. He has served on the speakers' bureau for Janssen Pharmaceutica, and as a consultant to Pfizer, AstraZeneca, Eli Lilly and Co., and Bristol-Myers Squibb. Dr. Mojtabai has received research funding and consulting fees from Bristol-Myers Squibb. Dr. Comer reports no biomedical financial interests or potential conflicts of interest.

PII: S0890-8567(10)00561-7

doi: 10.1016/j.jaac.2010.07.007

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 49, Issue 10 , Pages 1001-1010 , October 2010

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