Who Knows
An interview with Bryan King, M.D., medical director of the Division of Developmental Services for New Hampshire and Professor of Psychiatry and Pediatrics at Dartmouth College.
Do you believe that ADHD is over- or under-diagnosed?
The evidence seems to suggest that both are true. There's a population that isn't being identified, and there's a group that probably doesn't have it and is being treated for it.
A number of states have considered legislation barring teachers and other school employees from suggesting medication for children who may have ADHD. Can you comment?
I think it's overly simplistic, and it isn't in the best interest of children or parents. The notion that school teachers are driving the prescription of medication is probably flawed. The assumption is that parents don't know what's best, and that doctors are mindless prescribers and just do what school personnel say. Do we really need to legislate against school teachers' concern for children?
What are your concerns about the prescription of psychotropics by physicians other than psychiatrists? How can they be handled? What about rural access?
There's a tremendous shortage of child and adolescent psychiatrists in this country, so we need to explore consultative models of mental health care delivery. Child and adolescent psychiatrists would then be the tools primary care doctors use, but there is little or no support in states to keep this ship afloat. Rural states could also consider supporting the infrastructure for telemedicine, which has been used successfully for the delivery of other types of health care.
Data indicate that Medicaid programs pay for a significant amount of psychotropic drugs to children under age 5. Why?
The first issue is how one defines a psychotropic drug. The broadest definition includes some drugs that aren't prescribed for mental health disorders. Anti-seizure medications aren't always given to regulate mood or some other disorder, but generally because of epilepsy. The other issue is that many of these psychotropics are given to young children for very specific reasons for short periods of time, such as for sedation before a procedure.
Are there ways to save states money on psychotropic drugs without negatively affecting the quality of care for Medicaid patients?
The percentage of the Medicaid budget that is devoted to medication is huge, and psychotropics are in the top five. One of the red flag issues, where legislators might look for savings, is the use of more than one drug in the same class. We're seeing the use of two or three anti-psychotic drugs, and there is no data to support that practice. It's the same for antidepressants or stimulants. It wouldn't be inappropriate to have prior authorization before two or more drugs can be prescribed from the same class. Also, in looking at drug formularies to save money, many SSRIs (newer anti-depressants, such as Paxil) now have gone off-patent, and this clearly is an area of potential savings.
An interview with Marilyn Benoit, M.D., President of the American Academy of Child and Adolescent Psychiatry.
Recent research indicates that the rate of children taking psychotropic drugs more than doubled from 1987 to 1996. What do you think this shows?
What it might suggest is better case finding, better diagnosing, and a realization that we do have active treatments that can benefit children. An increase in medication is not necessarily a bad thing.
Research has shown that a combination of therapy and psychotropic drugs works better than either one alone. Yet, overall, managed care has reduced the amount of therapy relative to drugs. Do psychotropic drugs work alone?
Studies have shown that, yes, they can work alone, but the benefit to the children and family and the improvement in functioning really are better when you can combine therapy with medication. Also, parents need a lot of support as you make changes. Handing them a piece of paper is not enough. We hope that people (in cash-strapped state systems) aren't just throwing medication at kids when they can't do the rest of the therapies.
A number of states have considered legislation barring teachers and other school employees from suggesting medication for children who may have ADHD. Can you comment?
I think it is inappropriate for teachers to recommend medication. They should recommend an evaluation. The teacher's job is to identify and monitor the behavior, label it, and let us know. It isn't the teacher's place to say a child needs medication. Child and adolescent psychiatrists are trained to look at the whole child and all the other possibilities that might be contributing to the child's behavior.
HHS has announced that it will begin testing 12 drugs that commonly are prescribed to children but are not tested on children. A couple of these drugs are psychotropics (lorazepam and lithium). What do you think of this announcement?
I applaud that the FDA has done this. We've wanted clinical trials of medication on children. This is true all across pediatrics. Drugs are often approved for ages 12 and up. We use them in practice, but we'd much rather have them run through trials because kids' physiology is different. We've been extrapolating from adult studies and doing guesswork, which isn't right for our kids. We all will be more comfortable because we'll be prescribing from a scientific base.
Do you think that the marketing practices of pharmaceutical companies (e.g. continuing education sponsorship) influences physician prescribing?
The best surveys will tell you that there is some effect. The most important thing is that we have to be critical about the kind of research that is presented by companies, because it comes to you with a bias, so the physician has to be critical. I look at some studies, and I can't accept what they say. To fall prey to marketing strategies is something we all have to guard against.
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