Taking Antipsychotics
Why Are So Many Foster Care Children Taking Antipsychotics?
More than 8% of children in foster care have received antipsychotic medication, and just over one quarter of those in foster care who also receive disability benefits take these drugs, according to a recent study in the journal Pediatrics.
By MAIA SZALAVITZ Tuesday, November 29, 2011
More than 8% of children in foster care have received antipsychotic medication, and just over one quarter of those in foster care who also receive disability benefits take these drugs, according to a recent study in the journal Pediatrics.
The question is why? Children in foster care have typically been neglected or abused — indeed, simply removing a young child from his or her parents, even abusive ones, is in itself traumatic — so, not surprisingly, kids in foster care are more likely to suffer from psychiatric and behavioral problems than those who have stable families. Previous data suggest that foster-care children are about twice as likely as those outside the system to receive psychiatric medications.
Whether these problems are leading to higher rates of antipsychotic use, however, is not clear. “I think we have clinicians facing some very challenging situations,” says Susan dosReis, associate professor at the University of Maryland School of Pharmacy and lead author of the study. “But we don’t have information as to why the prescribers decided on these medications for [these particular] youths.”
The numbers suggest that the influence of pharmaceutical company marketing cannot be overlooked. Ninety-nine percent of youth receiving antipsychotic medications in the study were given atypical antipsychotics — the newer generation of these drugs, which are expensive and mostly unavailable in generic form and have been heavily advertised.
All of the major manufacturers of these drugs have been fined by the Food and Drug Administration for illegal marketing practices — in part, for marketing the drugs for unapproved use in children — with some convicted of criminal charges.
Eli Lilly, which manufactures the atypical antipsychotic Zyprexa, paid out $1.42 billion in 2009 — $615 million of that to settle criminal charges. The charges against Lilly involved selling Zyprexa to doctors for use in children, despite the fact that it was not approved for this age group.
Bristol Myers Squibb paid $515 million in 2007 to settle charges that it also illegally pushed its antipsychotic Abilify to child psychiatrists. Pfizer paid out $301 million in a similar case related to its drug Geodon. AstraZeneca paid out $520 million to settle charges over the drug Seroquel. In all of these cases, the drugs were sold for unapproved use in youth.
The new study by dosReis and colleagues included records of more than 600,000 children enrolled in Medicaid in 2003, including those in foster care, those receiving disability benefits for mental diagnoses, and those on the welfare program called Temporary Assistance for Needy Families.
Overall, nearly 3% of all youth on Medicaid received at least one prescription for an antipsychotic medication that year, which is itself a high proportion, especially given that the main condition that antipsychotics are approved to treat —schizophrenia — is extremely rare in children.
The rate of schizophrenia in children under 12 is an estimated 2 cases per 1 million children; it affects fewer than 1% of older teens. Antipsychotics are also approved to treat bipolar disorder, a diagnosis that is highly controversial in children. Some studies suggest that it affects 0.2% to 0.4 % of children, and up to 1% of adolescents.
And yet, between 1994 and 2003, rates of bipolar diagnoses in youth under 19 rose by a factor of more than 40, according to the National Institute on Mental Health. It seems unlikely to be a coincidence that this rise occurred during the period when atypical antipsychotics were being illegally marketed for children.
MORE: Do Psychotic Delusions Have Meaning?
Indeed, most of the antipsychotics used in foster-care youth were for conditions that the drugs were not approved to treat. Fifty-three percent of prescriptions were written for attention deficit/hyperactivity disorder (ADHD), a condition that is ordinarily managed with drugs that have the opposite pharmacological effects as antipsychotics. The stimulant medications like Adderall and Ritalin, widely used for ADHD, tend to increase levels of dopamine, while antipsychotics tend to decrease it.
Moreover, 38% of youth in foster care and 34% of foster-care youth receiving disability benefits received simultaneous prescriptions for more than one atypical antipsychotic, for more than three months — a practice that the researchers said “has demonstrated greater adverse effects with only marginal benefits.” Worryingly, black youth were 27% more likely to receive two or more antipsychotics than whites.
“Essentially, medications like antipsychotics can help with mood instability and aggressivity,” says dosReis, explaining that the drugs are often used to treat symptoms rather than conditions. Very little research is available on medication use in children to guide these practices.
“One of the things I would like to see come out of this research is starting to think about monitoring and evaluating the quality of care [these children are receiving]. We’re not supporting or condoning these practices. One extreme says that no one should get these medications, and that’s as irrational as saying we should be using more,” she says.
The risks of long-term prescribing of atypical antipsychotics to children, whose brains are still developing, are not known. What is known, however, is that the drugs cause severe weight gain in children, and that taking more than one antipsychotic drug may double, even quintuple, the risk of diabetes in youth. In adults, the weight gain associated with use of just one antipsychotic medication increase the risk of diabetes two- to four-fold, which has serious deleterious consequences for long-term health.
Although children in foster care may be genetically and environmentally at higher risk for mental illness, the disproportionately widespread use of antipsychotics in this group is troubling. “This study confirms the need for developmentally and trauma-informed practices in the vulnerable foster-care population,” says Dr. Bruce Perry, founder of the ChildTrauma Academy. “Misunderstanding the pervasive effects of abuse and neglect leads to the mislabeling of behavioral and emotional symptoms in these children and then to overmedication.” (Full disclosure: Dr. Perry is my co-author on two books.)
“The frustrating reality is that there are many evidence-based non-pharmacological interventions that have proven effectiveness and have no adverse effects,” Perry says. Sadly, however, no one is spending billions to push them.
Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz.
Drugging the Vulnerable: Atypical Antipsychotics in Children and the Elderly
By MAIA SZALAVITZ Thursday, May 26, 2011
Pharmaceutical companies have recently paid out the largest legal settlements in U.S. history — including the largest criminal fines ever imposed on corporations — for illegally marketing antipsychotic drugs. The payouts totaled more than $5 billion. But the worst costs of the drugs are being borne by the most vulnerable patients: children and teens in psychiatric hospitals, foster care and juvenile prisons, as well as elderly people in nursing homes. They are medicated for conditions for which the drugs haven’t been proven safe or effective — in some cases, with death as a known possible outcome.
The benefit for drug companies is cold profit. Antipsychotics bring in some $14 billion a year. So-called “atypical” or “second-generation” antipsychotics like Geodon, Zyprexa, Seroquel, Abilify and Risperdal rake in more money than any other class of medication on the market and, dollar for dollar, they are the biggest selling drugs in America. Although these medications are primarily approved to treat schizophrenia and bipolar disorder, which combined affect 3% of the population, in 2010 there were 56 million prescriptions filled for atypical antipsychotics.
In a presentation this week at an American Psychiatric Association meeting, Dr. John Goethe, director of the Burlingame Center for Psychiatric Research in Connecticut, reported that over the last 10 years, more than half of all children aged 5 to 12 in psychiatric hospitals were prescribed antipsychotics — and 95% of these prescriptions were for second-generation antipsychotics.
Many of these children didn’t have a condition for which the drugs have been shown to be helpful: 44% of youngsters with post-traumatic stress disorder (PTSD) and 45% of children with attention deficit hyperactivity disorder (ADHD) were treated with them.
Pharmacologically, the ADHD prescriptions make no sense: FDA-approved drugs for the condition raise levels of the neurotransmitter dopamine, while antipsychotics do the opposite, lowering them.
Goethe also noted another study that showed that the number of office visits by children and teens that included antipsychotic drug prescriptions rose 600% from 1993 to 2002. “The obvious second-generation bias is very apparent in these data, as is the irrational use of antipsychotics for indications such as PTSD and ADHD for which there is no controlled evidence whatsoever that these are safe or effective treatments,” says Dr. Bruce Perry, senior fellow at the ChildTrauma Academy in Houston. (Full disclosure: Dr. Perry is my co-author on two books.)
The situation is similar in state-run juvenile detention systems. Late last week, an exposé by the Palm Beach Post revealed that antipsychotics were among the top drugs purchased by the Florida Department of Juvenile Justice (DJJ), and were largely used in kids for reasons that were not approved by the government — for instance, sleeplessness or anxiety. The Post reported:
In 2007, for example, DJJ bought more than twice as much Seroquel as ibuprofen. Overall, in 24 months, the department bought 326,081 tablets of Seroquel, Abilify, Risperdal and other antipsychotic drugs for use in state-operated jails and homes for children.
That’s enough to hand out 446 pills a day, seven days a week, for two years in a row, to kids in jails and programs that can hold no more than 2,300 boys and girls on a given day.
Among the psychiatrists hired by the state to evaluated incarcerated kids, about a third received drug company money, the Post reported. Those 17 psychiatrists wrote 54% of the prescriptions for antipsychotics; the 35 doctors who did not take such payments wrote the rest. In other words, one-third of doctors — all of whom were paid by drug companies — wrote more than half of all antipsychotic prescriptions for the state’s locked-down youth.
The statistics on children in foster care are equally alarming. Youth in foster care are not only three times as likely to be medicated as comparable low-income youth on Medicaid, but more than half are treated with antipsychotics. It is not likely that all or even most of these children have a condition for which antipsychotics have been approved by the government to treat.
Among the problems with unnecessary use of antipsychotic medications is that they can cause serious, sometimes irreversible, damage. Atypical antipsychotics are associated with weight gain and may double users’ risk of Type 2 diabetes. Recent research also suggests that they may shrink the brain and there is little data on how they affect brain development during the teen years, when the brain grows more than at any other time but infancy. Indeed, youth are more vulnerable than any other group to the drugs’ worst side effects (with the possible exclusion of death).
“The majority of antipsychotic medication use in children and adolescents has not been limited to the few age groups or conditions for which there is credible evidence of efficacy and safety,” says Perry. “There is no reason to expect irrational prescribers to change their bad habits.”
He adds that many experts would argue that if doctors began prescribing antipsychotics “responsibly and cautiously” — that is, being mindful of the lack of efficacy data and the evidence of harm — the rate of prescriptions in children would drop by 90%.
Meanwhile, prescribing at the other end of the lifespan is also out of control. In nursing homes, 14% of residents have been given at least one prescription for a second-generation antipsychotic, according to a government investigation. A full 88% of these prescriptions are given to people with dementia, despite the fact that these drugs may double the risk of death in these patients (there is a black box warning on the drug to this effect). The investigation estimated that $116 million Medicare dollars have been spent filling antipsychotic prescriptions that never should have been written.
So why are these drugs so widely prescribed? Aggressive drug company marketing is only one part of the story. A key reason they are overused in institutional settings is that they are sedating, making patients easier to manage. Secondly, unlike other sedative drugs, they are not associated with misuse (except perhaps Seroquel, which has fans among some addicts). In fact, most people resist taking antipsychotics, which is why overmedication is much more common in settings where people are locked-in and compliance can be forced.
The fact that the drugs are not associated with addiction is another big part of why drug companies have been able to get away with so much misleading marketing and the resultant overprescribing. Unlike traditional sedatives like benzodiazepines (Valium or Xanax), which are controlled substances, few people enjoy misusing antipsychotics. With side effects like weight gain, pleasurelessness, movement disorders, and low energy and motivation, there’s not much of a recreational market.
Consequently, they can be prescribed for unapproved uses like behavior control and sleep-inducement in children and the elderly, without government scrutiny or fear of prosecution for “overprescribing.”
In other words, addiction is basically seen as a worse side effect than, say, death (or any other outcome such as Type 2 diabetes or the complete inability to feel pleasure). The fact that the most vulnerable youth and elderly often cannot advocate for themselves has made it easier to sweep the problem under the rug.
Fortunately, there is at least one bright spot in this depressing picture. The main patent on Risperdal expired in 2007, and those for Zyprexa and Seroquel expire this year. Geodon’s patent expires next year, while Abilify’s comes up in 2015. When most drugs go off-patent, drug companies’ marketing pressure — and profits — will subside, perhaps keeping children and the elderly safer from inappropriate medication.