The challenges of addressing behavioral health problems in children and adolescents remain an ongoing dilemma because of the high incidence of youth with significant problems, coupled with the ongoing difficulties for families and providers in accessing and optimizing care in a coordinated and comprehensive manner. Particularly in the arena of prescribing psychotropic medications, there are concerns coming from many corners over “when” and “when not” to prescribe. While innumerable studies document the importance of coordinating pharmacologic treatment to include both evidence-based psychotherapies and family, school and community supports, achieving this gold standard treatment is almost universally a challenge.
Additional issues arise with the prevalence of youth presenting with complex clinical presentations with multiple co-morbidities, varying symptomatic profiles over the course of time, and innumerable stressors impacting them during their years of growth and development. In the face of these challenges, there are often pressures for physicians and other prescribers to seek clinical benefit through the use of more than one medication— sometimes this makes perfect sense (as with the concurrent use of stimulants and α-agonists) but sometimes it may be a sign of a prescriber being stretched or overwhelmed and/or families being over invested in medication and underinvested in psychotherapy and behavioral interventions. While the rationale for using polypharmacy can often be quite substantial, there are obvious concerns about problems emerging. Current trends, discussed below, highlight the importance for providers using a cautious and thoughtful approach to using multiple medication treatments in the population.
In an article published in JAMA Pediatrics (C. Zhang, MPH, and colleagues) reported on findings of a retrospective analysis of prescriptions detailing the increase in psychotropic polypharmacy over the course of 15 years, from 1999 through 2015.
With a definition of polypharmacy being the use of two or more psychotropic medications, there has been a substantial increase in youth being prescribed multiple medications for behavioral health concerns. Medication classes included in the study included stimulants, antidepressants, mood stabilizers, antipsychotics, anxiolytics, sedatives, and α-agonists.
Among the findings of the study:
1. ADHD: Not surprisingly, the largest cohort of youngsters being treated with multiple medication were those who carried a diagnosis of ADHD (80%) as this is among the most common disorders in the population and one that is often associated with co-occurring behavioral concerns.
2. Diagnosis: There have been increased rates of diagnosing Mood Disorders (anxiety and depression) and Autism Spectrum Disorder.
3. Antipsychotic agents: Prescriptions for antipsychotics in youth prescribed multiple psychiatric medications doubled from the first to the third time periods, rising from 38% of youth in 1999-2005 to 75% between 2011 and 2015.
4. Alpha Agonists (guanfacine and clonidine) show significant increased rates of use.
5. Mood Stabilizers: In contrast, there was a significant decline in mood stabilizer use (from 61% of youth between 1999 and 2004 to 38% of youth between 2011 and 2015).
6. Antidepressants: Still frequently prescribed, but with a modest decrease in use noted
7. Three or more medications: Broken into five-year segments (1999-2005; 2005-2010, 2011-2015) the study demonstrated a greater than doubling (~ 210%) from the first time segment to the second with a subsequent increase for the third at ~130% over the 2005-2010 segment– all told the number of youth receiving multiple medications increased nearly threefold.
8. Racial disparities: the use of polypharmacy is significantly higher in youth of color – this, as with other issues of racial disparity is an arena of concern and one for further inquiry and sensitivity.
Some Practical Guidelines:
Dr. Oliver Wendall Holmes Sr. (1809-1894) who lived and worked in a different era, is reported to have said that ‘if all the medications in our pharmacopeia were to be dumped into the oceans, it would be all the worse for the fishes and all the better for mankind’.
We live in a different era with quite a bit more science and far better tools at our disposal, so that, in the face of rapid changes in practice patterns as described in the referenced study, it can be all too attractive to get on a “Medications are (or Polypharmacy is) Bad” soap box. But we know that proper medication regimes can be life enhancing for many and at times lifesaving for others.
The following guidelines are suggested:
1. Prescribe with care, basing treatment on clarity of diagnosis and clear review of presenting symptoms. Consider issues of co-morbidity and support a focus on behavioral and psychotherapeutic interventions.
2. Seek to coordinate care with a qualified and clinically astute therapist who can address psychosocial issues with the youth, the family and with school and community partners and one that is committed to ongoing dialogue about the patient.
3. If you are prescribing, see your patient frequently enough to monitor their progress and assess for ongoing or newly developing concerns. Be clear in your own mind what symptoms are being targeted with medications you are prescribing and monitor for efficacy and side effects with regular contacts.
4. When clearly indicated, titrate dosing to optimize response and accept polypharmacy approaches if they make sense— but keep it simple and avoid the temptation to simply add medications when things are not getting better.
5. Sometimes careful and thoughtful de-prescribing makes more sense than ramping up dose or adding extra agents. Discontinuing a medication can often be more difficulty to do, but if an agent has not shown evidence of efficacy or benefit, removing it from the treatment regimen should seriously be considered. In general, gradual down-titration with a med that doesn’t seem to be helpful is a good practice.
6. Utilize both clinical inquiry and screening tools to monitor progress and/or lack thereof. Encourage parents and patients to call you if they have concerns.
7. Consult with a peer or colleague in your practice to seek input and learn collaboratively. When in doubt, refer to a trusted consultant – what you learn will help with your current patient and will enhance your comfort and capacity to address similar issues with other patients in the future.
Characteristics of Youths Treated with Psychotropic Polypharmacy in the United States, 1999 to 2015
JAMA Pediatr. Published online November 2, 2020. doi:10.1001/jamapediatrics.2020.4678
Brunette MF, de Nesnera A, Swain K, et al.: Public-academic partnerships: a program to improve the quality of antipsychotic prescribing in a community mental health system. Psychiatric Services 62:1004–1006, 2011
Parameters 3.8 for Use of Psychotropic Medications in Children and Adolescents; Los Angeles County Department of Mental Health, July 15, 2020 (revised) http://file.lacounty.gov/SDSInter/dmh/1071988_Paremeters3.8ForUseOfPsychotropicMedicationInChildrenAndAdolescents.pdf