One in four children in the United States are on chronic medications

The Wall Street Journal reported that a study of prescription patterns in 2009, conducted by IMS Health, showed that 25% of children in the US were on regular medication.

IMS Health is a firm that provides “marketing intelligence” to pharmaceutical companies. The firm’s job is to keep the $800 billion per year global pharmaceutical industry on a continued pattern of growth.  Hopefully these consultants accomplished something quite different this week. Hopefully they provided our citizens with an overdue wake-up call.

One in four children in the U.S. are on chronic  medications.

And this doesn’t even include all the prescriptions we write to treat acute illness, or use of over-the-counter products. It is an astounding number.  We either have the sickest pediatric population in the world, or there is something very wrong with the way therapies are driven in our health care system.

The WSJ article goes on to discuss some very significant concerns about the situation – like how difficult it is to run clinical studies on children, and how much of our pharmaceutical data – including dosing and side effects – is drawn from adult populations and applied to children (fingers crossed!)  These are serious concerns to be sure, but it’s a modern version of “The Emperor’s New Clothes.”  Those of us on the sideline are worrying if the emperor’s hat clashes with his shoes, when what we should really be paying attention to – and shouting about – is the fact that Good lord, he’s naked!

One in four children in the U.S. are on chronic medications.

According to IMS Health data, forty-five million children are on asthma medications, twenty-four million are on ADHD medications, almost ten million are on antidepressants with another six and a half million on other antipsychotics.  Then there are the antihypertensives, the sleep aids, the medications for type II diabetes and high cholesterol, and on and on.

Are the conditions these medications are designed for like ADHD and bipolar disorders real?  Absolutely. Are our diagnostic criteria usually clear and well established?  No.

Is the scientific information that doctors rely on for diagnosis and treatment free of bias and conflict of interest?  Absolutely not.

Do our third party insurers reimburse physicians and psychologists in such a manner that mood disorders, attentional problems and other conditions in the psychoeducational realm are being evaluated and managed by the most appropriate professionals?  The answer, again, is too often no.

Some of these children are certainly benefiting from long term medication. Optimal asthma control, for instance, can be life changing for a child. But over the broad range of approximately one hundred million children taking daily medication in this country, do we have a handle on the degree to which the benefits of a prescription outweigh the risks, or the medication’s effectiveness compared to meaningful nonpharmaceutical intervention?  No.

No.  Absolutely not. No.  No!

 

Our system of private, fee-for-service insurance is basically a business model that focuses on the top of the health care pyramid (the doctor) and pays for quick fixes (prescriptions) with immediately observable (short term) results.   That works great for bacterial pneumonia; not so much for a kid bouncing off the walls, or gaining too much weight, or who is sad.  Nowhere is this more glaring than in the realm of mental health.

Health insurance companies have determined, by virtue of their reimbursement strategies, that the work of treating serious mental illness would shift to primary care providers. A recent study by the AAP predicts that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. To put this trend in perspective, an earlier study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did.  If they don’t, who will?  This is just one example of the growing disconnect between rational medical practice and the way we deliver healthcare.  Furthermore, where do both pediatricians and psychiatrists get most of their information about these psychotropic medications that are now flying off prescription pads?  The pharmaceutical companies that produce them, through the hundreds of millions of dollars they spend each year on marketing and the clinical studies they fund.  The insurers and pharmaceutical companies aren’t necessarily the bad guys here. They are doing what they are tasked to do: run a business.

What should be driving our health care? Should it be evidenced-based medical science, wrapped up in a little common sense and kept at a distance from special interest? Should the emphasis be on clinical effectiveness rather than customer service? Should the financial incentives foster improved longterm health for all of us rather than enhanced quarterly profits? If that’s what we want than we need to redesign the system from the bottom up.

If we are to frame meaningful health care debate in this country, we have to look at the consequences of doing business-as-usual.  This data from the pharmaceutical industry illustrating the degree to which to we medicate our children underscores the ways our health care system has gone off track. We need to acknowledge that naked truth.

One in four children in the U.S. are on chronic medications.

 

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine, from Chelsea Green Publishing, and blogs at Barkingdoc’s Blog.

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  • http://natickpediatrics.net Rob Lindeman

    “Are the conditions these medications are designed for like ADHD and bipolar disorders real? Absolutely”.

    Nonsense. The diagnostic criteria are unclear and poorly established because there are no objective markers for ADHD or bipolar disorders. Ditto for the remainder of psychiatric nosology.

    • http://barkingdoc.com maggie kozel

      Do you mean to say that ADHD and bipolar disorders don’t exist? That may be the pendelum swinging a little too far in the other direction. My ;oint is that we are not very good at diagnosing or even treating them. That does not mean they are not real.

      • http://natickpediatrics.net Rob Lindeman

        I did not say the phenomena we are discussing are not real. Only a philistine would say so, and certainly not a board-certified pediatrician in full-time private practice (which I am)!

        We are “not very good at diagnosing or treating” ADHD because we have no objective criteria for making the diagnosis and no idea at all what are the neurophysiological correlates of these behaviors. No wonder! Imagine if we had no objective criteria for diagnosing diabetes mellitus and no idea about the pathophysiology!

  • skeptikus

    Lindeman’s right re: adhd and most of the other psychiatric diagnoses–he should add that the effectiveness of these drugs are far from proved. (I guess that’s a logical corollary–if you do not have clear criteria for disease states, you will not get data showing any particular drug improves them.)

    More basically, if doctors insist upon the legal monopoly to prescribe drugs, then THEY and THEY ALONE are responsible. Every child taking who is taking these useless drugs had a doctor (well, maybe a np or pa) give it to them.

    Either the docs take responsibility–or they should get out of the business and let consumers decide what drugs are good for them.

  • http://robinsonfamilymedicine.com Stacey Robinson, MD

    I would argue that the pharmaceutical and insurance industry are at the top of the bad-guy list. The pharmaceutical industry uses million dollar marketing campaigns to create disease and make people think they need medications to cure all of their ills. The insurance industry is the for-profit 3rd party that forces primary care physicians into their quick-fix mentality by reimbursing for disease instead of wellness.

  • http://natickpediatrics.net Rob Lindeman

    Of course, Skeptikus! If there are no objective diagnostic criteria for a condition, there can be no objective criteria for therapeutic intervention!

    We part company on the issue of “legal monopoly” on the availability and purchase of drugs. The rights AND ATTENDANT RESPONSIBILITIES associated with purchase of drugs belong to the buyer, not the seller. The seller is obliged only to certify purity of the contents.

  • aa

    Dr. Lindeman and Skeptikus,

    Thank you for your responses. As an adult, I feel my life was destroyed by these psych meds that I have been off of for close to a year after long term use. I am still recovering from withdrawal symptoms even though I tapered very slowly.

    I shudder to think what life is going to be like for these kids who started more powerful drugs than I was on such as antipsychotics at such a young age. It brings me to tears.

    Finally, another point to consider is that many psych meds will cause side effects that look like ADHD and bipolar disorder but aren’t. As a result, kids get additional bp and ADHD meds and have difficulty getting off of the psych med treadmill. It is a disgrace and it seems like no one gives a damm about this.

  • http://natickpediatrics.net Rob Lindeman

    “The insurance industry is the for-profit 3rd party that forces primary care physicians into their quick-fix mentality by reimbursing for disease instead of wellness.”

    Whew! I actually thought I had personal responsibility for my actions! Sure glad I don’t.

    BTW, if payors encourage ANY behavior on the part of pediatricians, they encourage us to do more well-child care rather than disease managment. The evidence basis for benefits of routine well-child care is weak to say the least (see the discussion on gun safety over at Shrink Rap). Third parties would get more bang for the buck reimbursing us for disease management alone.

  • http://natickpediatrics.net Rob Lindeman

    aa, it’s even worse.

    Many children I followed on a locked in-patient unit started out their therapeutic careers on central nervous stimulants and then STAYED on them as they “acquired” additional diagnoses. So it would not be atypical for a child to be taking methylphenidate (Ritalin), aripiprazole (Abilify), and Citalopram (Celexa) as ADHD, psychosis and depression were added sequentially to his problem list

  • http://fertilityfile.com IVF-MD

    These revelations are scary. I think it’s bad enough if misinformed parents are encouraged to start their children on harmful medications against their better judgment. However, I’ve learned of cases where it was even worse. Some parents VEHEMENTLY opposed to medication for their children were FORCED by the state to medicate their children. For both sides of the story, search “maryanne godboldo”.

  • http://natickpediatrics.net Rob Lindeman

    IVF-MD, in the cases of involuntary hospitalizations, including those of children, forced medication (for the patient’s own good) is common, I daresay it is the rule as opposed to the exception. In the old days it was forced ECT and lobotomy.

  • Kristin

    And yet, psychological disorders exist.

    I don’t think we need to medicate as much as we do–not for children and not for adults. But some of the language that comes uncomfortably close to dismissing mental illness altogether is problematic. There are people with depression who benefit from anti-depressants; there are people with schizophrenia who benefit from anti-psychotics; there are people with bipolar disorder who benefit from lithium or other mood stabilizers. Some of these people are children.

    Psychology is a painfully young science, and we still don’t know why the theoretical backgrounds behind different schools of talk therapy almost never seem to matter to the success rates of that therapy. Psychiatry isn’t in tune with the most recent recommendations out of psychological research. It’s a messed-up system.

    But dismissing parents who seek medication for their children is wrong. The overwhelmingly vast majority of parents who look for psychoactive medications for their children face a heartbreaking dilemma: medicate their children with all its attendent risks, or watch their children be miserable and/or violent. My sister needed help of some kind–the ADD medication she was prescribed wasn’t it. I don’t blame our parents, I don’t blame her doctor. I don’t even blame her therapist. No one knew what to do for her, not because they were lazy or weren’t trying, but because her problems weren’t responsive to the only tools available at the time.

    Pediatricians aren’t prescribing because they’re evil. Parents aren’t looking for prescriptions because they’re evil. People are confused and they don’t know what the right thing to do is because, right now, no one knows what the right thing to do is. The psychological data simply aren’t there, in most cases. The people who research the behavioral effects aren’t the same people who research the physical effects; the people who compare therapies aren’t talking to the doctors who prescribe pills; the insurance companies reimburse for fewer therapy sessions than have demonstrated effectiveness (about 35 in adults, I don’t know if the number is different for children), or fail to cover talk therapy at all.

    • http://barkingdoc.com maggie kozel

      Thank you for such a reasoned comment. We want to be careful about our drug therapies, and less influenced (or manipulated) by special interests in their use, but we don’t want to be “deniers” either. Mental disorders are not less pathological because we don’t have a blood test for them.

      • http://natickpediatrics.net Rob Lindeman

        Okay, let’s stipulate no blood test. How about an objective test of any kind?

  • rob lindeman

    Kristin,

    The phenomena we are discussing exist, but they are not diseases, in the sense that diabetes is a disease. Just look at the words you use to descibe them: “psychological disorders”. If there were neurological substrates for ADHD (for example) we’d call it a neurological disease or a brain disease. We commit a category error when we say the ADHD is a disease. We mean to say “ADHD is like a disease”. When we literalize the simile we end up stuck where we are

  • http://www.BodyFitLife.com Suzanna Aaring

    Stepping back and looking at the situation from a worldwide perspective, the US population as a whole consumes more drugs per capita than all the other countries in the world put together.

    http://healthquiz.wordpress.com/2010/06/17/acidity-and-obesity/

  • skeptikus

    “Pediatricians aren’t prescribing because they’re evil. Parents aren’t looking for prescriptions because they’re evil. People are confused and they don’t know what the right thing to do is because, right now, no one knows what the right thing to do is. The psychological data simply aren’t there, in most cases.”

    Who cares the intentions of pediatricians or parents? The question is whether or not they are doing in harm when faced with the pressure of “doing something.”

    There are zillions of therapies to dealing with ADHD and other behavioral problems that do not involve drugs and their side effects. Try them first.

    • http://natickpediatrics.net Rob Lindeman

      Just as an aside, what are “psychological data”? Our interlocutor claims that “[t]he psychological data simply aren’t there, in most cases.” In what cases ARE there psychological data?

  • http://briarcroft.wordpress.com Emily Gibson

    What concerns me most about parents and health care professionals being so willing to medicate children is that we have pathologized the human condition. What child doesn’t have times of distractibility and inattention, what adolescent isn’t angry or moody, what toddler doesn’t have fears and phobias? Of course there are extremes that need intervention but our society has such an expectation of “behavioral norms” and perfection that we seek to chemically fix anything that does not fit that standard. The college students I see don’t seem to understand that suffering sadness or feeling angry or lonely is part of everyone’s life, and their resiliency has been sabotaged by the “quick fix” offered by adults whenever there is a level of distress or dis-ease. No wonder our adolescents are so willing to self-medicate with alcohol or marijuana, simply because they don’t want to “feel” uncomfortable feelings.

    We physicians are enabling this generation of individuals who can’t cope. We have seen the enemy and he is us.

  • Chris Bode

    Great discussion about an important and scary report. Could you provide a link to the WSJ article you referenced? Or at least the date the article appeared? Thanks.