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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 26-32

The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study


1 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pediatrics, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Bilal Ahmad Bhat
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_13_19

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  Abstract 


Background: Psychiatric disorders are now frequently diagnosed in children and adolescents, and psychotropic medications are being used increasingly for the treatment of these disorders. Aims: The aim is to study the frequency and the pattern of prescription of psychotropic drugs in outpatient child and adolescent psychiatric facility. Settings and Design: This was a cross-sectional descriptive study conducted in outpatient child and adolescent psychiatric facility. Materials and Methods: The outpatient department prescription of all patients who were ≤18 years of age, who attended the Outpatient Child and Adolescent Facility of Department of Psychiatry, Government Medical College, Srinagar, over 1½-year period were studied. The following details were recorded – age, gender, diagnosis with comorbidity, and the psychotropic drugs which were prescribed. Results: A total of 624 patients attended the outpatient service during the study period. The mean age was 7.74 years (standard deviation = 3.76). 67.3% were male. Hyperkinetic disorder (27.1%) and mental retardation (26.3%) were the more frequent diagnosis. Comorbidity was present in 28.8%. 60.6% of the patients were prescribed psychotropic medication with 44.9% being prescribed a single psychotropic, 15.1% were prescribed two psychotropics simultaneously, and 0.6% were prescribed three psychotropics simultaneously. Stimulants (17.5%), risperidone (25.2%), and selective serotonin reuptake inhibitors (9.9%) were the commonly prescribed psychotropics. Statistical Analysis: Descriptive analysis was carried out with Statistical Package for the Social Sciences and results were presented as frequencies and percentages. Conclusion: Simulants, antipsychotics, and antidepressants were commonly prescribed psychotropics with stimulants and antidepressants mostly being prescribed for attention-deficit/hyperactivity disorder and depression, while most of the antipsychotics being prescribed for nonpsychotic conditions.

Keywords: Antipsychotics, psychotropic drugs, stimulants


How to cite this article:
Bhat BA, Hussain A, Qadir W, Dar SA. The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study. Muller J Med Sci Res 2019;10:26-32

How to cite this URL:
Bhat BA, Hussain A, Qadir W, Dar SA. The frequency and patterns of psychotropic use among children and adolescents in an outpatient psychiatric facility: An observational study. Muller J Med Sci Res [serial online] 2019 [cited 2019 Jun 18];10:26-32. Available from: http://www.mjmsr.net/text.asp?2019/10/1/26/259247




  Introduction Top


Although there are many initiatives planned at the international level to guarantee safe and effective pharmacological therapies for children, the lack of information on the safety and efficacy of drugs in childhood still exists.[1],[2] This is true for all drugs including psychotropic medications. Other than stimulants, psychotropic medication use has not been adequately studied in children and their use in children is mostly based on extrapolation of information from the adult studies.[3] The preferences for the use of psychotropic medications over nonpharmacological interventions have grown considerably in child and adolescent mental care.[3],[4],[5] The major factors which seem responsible for this preference include severity or type of psychiatric disorder, the need for quick symptom relief, and lack of multidisciplinary care, particularly in the low-resourced countries.[3],[4] The choice of psychotropic medications and patterns of their prescription vary in different settings.[6] In specialized settings for child and adolescent psychiatry, rational prescribing and the use of newer psychotropic agents are favored,[3],[4],[5] but in settings without specialized units for children, the pattern of psychotropic prescription remains largely unclear, mainly due to lack of data.[7] For instance in West, where specialized child and adolescent psychiatric services are available, psychosocial management is more preferred, especially for mild-to-moderate conditions.[3],[4],[5] In pharmacotherapy, newer agents such as second-generation antipsychotics and fluoxetine are preferred to older ones such as haloperidol and amitriptyline in these settings.[3],[4] A Cochrane review on use of antidepressants in young people agrees that fluoxetine has the best evidence of efficacy in children and should be tried first in childhood and adolescent depression with sertraline and escitalopram tried as the second-line agents.[8] In a systematic review and meta-analysis on the long-term efficacy of immediate release methylphenidate, it was found efficacious for childhood attention deficit hyperactivity disorder for periods longer than 12 weeks.[9] A multinational comparison of antipsychotic drug use in children and adolescents from 2005 to 2012 has found an annual increase in use of antipsychotics.[10] This comparison study further showed the prescription of the second-generation antipsychotics increased in relation to the first-generation antipsychotics.[10] Nonetheless, increase in the rate of off-label use and polypharmacy of psychotropic medications among children and adolescents in these centers has also been reported.[4],[11],[12] Although the use of psychotropic medications has been shown to effectively treat mental health problems, there are concerns about the efficacy of polypharmacy and its potential long-term impact on health, particularly among children. There is limited data about the prescription pattern of psychotropic medications in child and adolescent outpatient services in our country. The purpose of our study was to describe the pattern of psychotropic prescription in child and adolescent psychiatry clinic of the Department of Psychiatry, Government Medical College, Srinagar.


  Materials and Methods Top


This was a cross-sectional study conducted among patients attending the Outpatient Child and Adolescent Psychiatric Facility of Postgraduate Department of Psychiatry, Government Medical College, Srinagar, over a period of 1½ year, from February 2016 to June 2017. Approval for the study was obtained from the institutional ethics committee. Children and adolescents of age 1–18 years whose parent/guardian gave the consent for this study constituted the study population. All the diagnosis were made clinically on the basis of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (↱ICD-10)↱ criteria.[13] The diagnosis was confirmed by the consultant in-charge child psychiatry facility. The diagnosis and types of psychotropic medications prescribed to each child and adolescent on their first visit were documented, in order to find the pattern of prescription from the child and adolescent psychiatric facility. Those patients who were already on some psychotropic medication were excluded from the study. The data about various parameters were entered into Microsoft Excel. Descriptive analysis was carried out with SPSS version 16 (Statistical Package for Social Sciences; IBM Software, Armonk, NY). Chi-square test was used for comparison and P < 0.05 was considered as statistically significant. The information thus generated was presented in tables as frequencies and percentages.


  Results Top


A total of 624 patients were included in the study. Most of the patients were in 5–10 years age group (n = 267, 43%). The average age of the patients was 7.74 years (standard deviation = 3.76). Males outnumbered females by an approximate ratio of 2:1, with 67.3% (n = 420) males and 32.7% (n = 204) females. 55.1% (n = 344) were from rural background, whereas 44.9% (n = 280) were from urban background [Table 1].
Table 1: Sociodemographics

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Out of 624 patients, 83.7% (n = 522) received ICD-10 diagnosis, whereas 16.3% (n = 102) did not receive any diagnosis. Hyperkinetic disorder was the most frequent diagnosis occurring in 27.1% (n = 169) of the patients followed by mental retardation (MR) which occurred in 26.3% (n = 164). 9% (n = 56) had pervasive developmental disorder (PDD), anxiety disorders were present in 5.9% (n = 37), depressive episode was found in 5.4% (n = 34), conduct disorders were found in 4% (n = 25), bipolar affective disorder was present in 2.4% (n = 15), schizophrenia in 1.3% (n = 8), dissociative disorders in 1.6% (n = 10), and enuresis in 0.6% (n = 4) [Table 2].
Table 2: International Classification of Disease-10 diagnosis

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Comorbidity was present in 28.8% (n = 180) as is shown in [Table 3].
Table 3: Comorbidity

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Of the 624 patients included in our study, 39.4% (n = 246) were not prescribed any psychotropic medication, whereas 60.6% (n = 378) were treated with some psychotropic medication (Chi-square test = 27.923, P = 0.0001). Out of 444 patients without comorbidity, 224 were treated with psychotropics, whereas out of 180 patients with comorbidity, 154 were treated with psychotropics (Chi-square test = 66.093, P = 0.0001) [Table 4].
Table 4: Prescription of psychotropics versus comorbidity

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44.9% (n = 280) of patients were treated with a single psychotropic agent, 15.1% (n = 94) were treated with two psychotropics simultaneously, and 0.6% (n = 4) were treated with three psychotropics simultaneously. Out of 180 patients with comorbidity, 27 were not on any psychotropic, whereas 63, 86, and 4 patients were, respectively, on one, two, and three psychotropics. Out of 444 patients without co-morbidity, 219 were on no psychotropic, whereas 217 and 8 patients were on one and two psychotropics respectively. Difference between the two groups was statistically significant. (Chi-square test = 2.334, P = 0.0001) [Table 5].
Table 5: Number of psychotropics prescribed versus comorbidity

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Risperidone was prescribed in 25.2% (n = 157), stimulant (methylphenidate) in 17.5% (n = 109), selective serotonin reuptake inhibitor (SSRI) (fluoxetine) in 9.9% (n = 62), aripiprazole in 7.5% (n = 47), benzodiazepines in 7.5% (n = 47), atomoxetine in 5.3% (n = 33), mood stabilizer (divalproex sodium) in 2.7% (n = 17), and tricyclic antidepressant (imipramine) in 1.9% (n = 12) [Table 6].
Table 6: Psychotropic prescription

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  Discussion Top


Higher number of patients in 5–10 years age group, males outnumbering females and rural predominance in our study are consistent with other hospital-based studies and epidemiological studies from India as well as outside India.[14],[15],[16],[17],[18]Hyperkinetic disorder was the most frequent diagnosis in our patients. A recent study from the same center found attention-deficit/hyperactivity disorder (ADHD) as the most frequent diagnosis in outpatient child psychiatry.[17] However, this finding is inconsistent with other hospital-based studies from India.[19],[20] Epidemiological studies from India and hospital-based studies from the West have also shown higher frequency of hyperkinetic syndromes.[15],[16],[21],[22] MR was the second most frequent diagnosis in our patients, a pattern consistent with other Indian studies.[17],[18] PDDs, anxiety disorders, conduct disorders, mood disorders, schizophrenia, and enuresis were less frequent disorders in our study which is similar to other studies from India.[17],[18],[19],[20] Low comorbidity in our study is also supported by other Indian studies which have looked into comorbidity.[17],[20]

The purpose of this study was to look into the pattern of prescription of psychotropics in children and adolescents who attend the outpatient child psychiatry facility. Although there is a lot of literature on pattern of psychotropic prescription in adults, there is very little of it on children, particularly from India. A study by Kaplan et al. in the early 90's showed that the prescription of psychotropic medications in children is modest.[23] There are studies which have documented an increasing trend over time in the prescription of psychotropic medications to children.[24],[25],[26] In our study also, a high proportion of children and adolescents were prescribed a psychotropic on their first visit. High rates of psychotropic prescription have been found in some other studies.[27],[28] Overall, the use of psychotropic medication in children and adolescents has increased remarkably in the recent past, and the gap between the rate of prescribing psychotropics in adults and children has narrowed down substantially.[29] Stimulants (methylphenidate), antipsychotics (risperidone and aripiprazole), and SSRI (fluoxetine) as most prescribed class of psychotropics in our study is in accordance with various studies from the West[30],[31],[32] but is in contrast to the study from Nigeria which although found atypical antipsychotics being the most prescribed psychotropic, but at the same time, found stimulants and antidepressants not commonly prescribed.[33] The time trends in the prevalence rates of dispensed prescriptions of psychotropics in Denmark over 15 years increased markedly which was most pronounced for the stimulants but was also evident in prescription of antipsychotics and antidepressants.[34] Rapoport, in a recent overview on pediatric psychopharmacology, concluded that the use of new treatments, such as stimulants and SSRIs, in addition of helping otherwise treatment-refractory patients, also contributed to an overacceptance of reductionistic biology.[35]

Methylphenidate and atomoxetine were prescribed in hyperkinetic disorder with Methylphenidate being prescribed more frequently in comparison to atomoxetine. Studies in the West have found a marked increase in use of medication in ADHD since 2005/2006, mostly stimulants and less frequently atomoxetine and other medication for ADHD.[36],[37],[38] In view of Garbe et al., rate of prescribing medications to ADHD children has shown a dramatic increase in the past two decades.[39] In the UK primary care, methylphenidate was the most commonly prescribed drug for ADHD in 6–24 year age group during the study period of 20 years making up 89.9% of all prescriptions.[40] Pharmacotherapy, usually stimulants, is one of the most frequent evidence-based interventions in children with ADHD.[41] However, there are concerns with regard to short- and long-term side effects of stimulants. There is a US Food and Drug Administration (FDA) warning for cardiovascular risks of stimulants in ADHD.[42] Other side effects can include insomnia, decreased appetite, headache, dizziness, and mood changes.[43] Although administration of stimulants with drug holidays have not a long-term influence on height, these drugs have raised a controversy with their more sustained and longer use.[44] In addition, controversy regarding long-term benefits of stimulant medications persists, as there is lack of evidence in this regard. A recent review on educational and behavioral outcome in children with ADHD highlighted that the use of stimulants increased without improving medium or long-term outcomes, there was no improvement even in children with the worst preexisting ADHD symptoms and increases in drug use were associated with increase in depression among girls,[45] whether the increased use of medications in ADHD is a desirable compensation of former undertreatment, or it is a reason for concern is not clear.[36]

Among the antipsychotics, atypical agents risperidone and aripiprazole were exclusively prescribed to our patients. Conventional antipsychotics were not prescribed at all. Moreover, >4% of our patients were psychotic, and thus the antipsychotics were prescribed for nonpsychotic conditions, particularly in behavioral dysregulation. A retrospective descriptive analysis of antipsychotic prescriptions among patients aged 1–24 years concluded that antipsychotic use increased from 2006 to 2010 for adolescents and young adults but not for children aged 12 years or younger and the clinical diagnosis patterns are consistent with the management of developmentally limited impulsive and aggressive behaviors rather than psychotic symptoms.[46] The use of antipsychotics mostly for nonpsychotic conditions in children is consistent with other studies.[47],[48] In addition, there is an evidence of steady increase in antipsychotic use in children and adolescents, most of which have been for nonpsychotic indications such as behavioral and emotional problems.[49],[50] Over the recent years from Western countries, there have been reports of increase in the use of atypical antipsychotics.[51],[52]

Among antidepressants, fluoxetine and imipramine were the antidepressants prescribed with fluoxetine prescribed more frequently than imipramine. Fluoxetine was exclusively used for depression and anxiety disorders, particularly obsessive and compulsive disorder, while imipramine was exclusively used for enuresis. A review on “research on antidepressants in India” found only two studies with imipramine use in children, and these studies have shown it useful in enuresis and behavioral problems such as temper tantrums and obstinacy.[53] A systematic review and meta-analysis of trials of treatment of depression from India concluded that there is a lack of data from India in special populations like children and adolescents.[54] Although studies from the West have also shown fluoxetine being prescribed more frequently in children, they have also found antidepressants being prescribed at much higher rate than our study.[30],[32] This can be explained by higher rates of anxiety and mood disorders in Western outpatient child and adolescent psychiatry.[15],[16] Although risk–benefit balance is less clear for most SSRIs in childhood and adolescent depression, for fluoxetine use, it is favorable.[55] A black box warning was issued by the US FDA in October 2004 indicating an increased risk of suicidal ideation in children and adolescents treated with SSRIs.[56] Consequent to this warning, there was a sudden decline in antidepressant use in children and adolescents within 2 years, but this trend did not persist, and there was a substantial increase in antidepressant use in youth cohorts from five Western countries.[56] Nevertheless, the children and adolescents who are treated with SSRIs should be closely monitored for suicidal ideations, especially during the first few weeks of treatment.

Other psychotropics (benzodiazepines and mood stabilizers) were less frequently prescribed. This is because of lower hospital prevalence for mood and anxiety disorders. Although the studies from the West and other developing countries have also found lower prescription for mood stabilizers, the prescription of benzodiazepines is quite high among patients in these studies.[6],[44],[45],[46],[47],[48]

The prevalence of polypharmacy in our study was around 16%. This is in accordance with other studies which have shown higher percentage of patients on polypharmacy.[46],[47],[48] Moreover, studies have shown an increasing trend in polypharmacy of psychotropics in children.[15],[57] In our study, children and adolescents with comorbidity were more likely to get a prescription with two or more psychotropics as compared to those without comorbidity. A recent study on polypharmacy of children and adolescents found that the presence of comorbidity was significantly associated with polypharmacy.[58] Studies have consistently shown the presence of psychiatric comorbidity and complex presentation as a risk factor for psychotropic polypharmacy.[59],[60] Fewer avenues for nonpharmacological management of childhood and adolescent psychiatric disorders in our setup and pressure to quickly resolve the symptoms in patients, make nonpharmacological treatment less attractive which further endorse the polypharmacy.


  Conclusion Top


Very little is known about the prescribing pattern of psychotropic drugs in outpatient child and adolescent psychiatry in India. Our study was an attempt to find such a pattern. Like the studies in the West, our study found stimulants, antidepressants, and antipsychotics being prescribed oftenly in children and adolescents. Stimulants and antidepressants were prescribed for ADHD and depression, while most of the antipsychotics were prescribed for nonpsychotic conditions. Further studies need to be conducted to look for safety of psychotropic drugs in children particularly.

Limitations

This was an hospital-based descriptive study and thus the results cannot be generalized onto the children and adolescents in the community. Logistical factors such as transportation barrier and availability of services in tertiary care setting may have influenced the presentation and hence prescription pattern in our study. Bias on the part of clinicians can also be due to their preference of pharmacotherapy over psychological interventions. Being a cross-sectional study, trends in prescribing psychotropics over a period of time cannot be discerned. Furthermore, sometimes psychotropics are prescribed later in the course of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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