Abstract
Significant concern exists over treating youths with attention-deficit/hyperactivity disorder (ADHD) with antipsychotic medications, yet little is known about the factors associated with antipsychotic treatment. To describe the percentage of youths who fill antipsychotic prescriptions in the year following a new diagnosis of ADHD and characterize the clinical and demographic factors associated with antipsychotic initiation. A retrospective longitudinal cohort analysis of antipsychotic treatment was performed in 187 563 youths, aged 3 to 24 years, with a new diagnosis of ADHD (without recent diagnosis of any US Food and Drug Administration [FDA]-indicated conditions for antipsychotic treatment). The sample was derived from the 2010 to 2015 MarketScan Commercial Database, with the analysis completed between November 1, 2018, and May 30, 2019. The percentage of youths prescribed an antipsychotic in the first year following a new diagnosis of ADHD. Among those prescribed antipsychotic medications, the percentage who received a diagnosis of conduct disorder, oppositional defiant disorder, or a disorder for which 1 or more antipsychotic medication has received an indication for use in youths from the FDA (schizophrenia, bipolar disorder, and Tourette disorder) and the percentage that filled an antipsychotic prescription before filling a stimulant prescription (methylphenidate or amphetamine derivative). Of the 187 563 youths included in the study, 114 305 (60.9%) were male with a mean (SD) age of 13.74 (5.61) years. In the year following a new ADHD diagnosis, 4869 youths (2.6%; 95% CI, 2.5%-2.7%) with ADHD were prescribed an antipsychotic. Youths treated with antipsychotics with ADHD were more likely than their peers who were not receiving an antipsychotic to have recently received diagnoses of self-harm and/or suicidal ideation (adjusted odds ratio [aOR], 7.5; 95% CI, 5.9-9.6), oppositional defiant disorder (aOR, 4.4; 95% CI, 3.9-4.9), and substance use disorder (aOR, 4.0; 95% CI, 3.6-4.5). The youths who received antipsychotics were also more likely to have received inpatient treatment (aOR, 7.9; 95% CI, 6.7-9.3). During the year following the new ADHD diagnosis, 52.7% (95% CI, 51.3%-54.1%) of youths treated with antipsychotics received a diagnosis for which antipsychotics have either an FDA or evidence-supported indication for their use. Among youths who initiated antipsychotic medications, 47.9% (95% CI, 46.5%-49.3%) did not receive a stimulant prescription between their ADHD diagnosis and antipsychotic initiation. Antipsychotic prescribing was proportionally highest for preschool-aged children (4.3%) and associated with neurodevelopmental disorders (aOR, 3.9; 95% CI, 1.3-11.2) and recent inpatient mental health treatment (aOR, 8.9; 95% CI, 1.7-45.8). Approximately half of youths with a new ADHD diagnosis may have an evidence-supported indication for an antipsychotic medication. Less than half of these youths received a stimulant; the evidence-supported first line treatment for ADHD, before the antipsychotic was initiated. Use of antipsychotic prescribing appears to be associated with high levels of psychiatric comorbidity.
Highlights
Youths treated with antipsychotics with attention-deficit/hyperactivity disorder (ADHD) were more likely than their peers who were not receiving an antipsychotic to have recently received diagnoses of self-harm and/or suicidal ideation, oppositional defiant disorder, and substance use disorder
During the year following the new ADHD diagnosis, 52.7% of youths treated with antipsychotics received a diagnosis for which antipsychotics have either an Food and Drug Administration (FDA) or evidence-supported indication for their use
Among youths who initiated antipsychotic medications, 47.9% did not receive a stimulant prescription between their ADHD diagnosis and antipsychotic initiation
Summary
There has been an increase in the prescription of antipsychotic medications to children and adolescents.[1,2,3,4] Between 1999 and 2014, antipsychotic prescribing for young people in the United States increased by 50%.4 Some of the increase in antipsychotic medication use in youths was for clinical indications that have been approved by the US Food and Drug Administration (FDA), including schizophrenia, bipolar disorder, irritability associated with autistic disorder, and Tourette disorder.[5,6,7,8,9] much of the increase has been associated with non–FDA-indicated prescribing, most commonly, attention-deficit/hyperactivity disorder (ADHD).[2,3,10,11]Antipsychotic medications can have significant adverse effects in youths. There has been an increase in the prescription of antipsychotic medications to children and adolescents.[1,2,3,4] Between 1999 and 2014, antipsychotic prescribing for young people in the United States increased by 50%.4. Some of the increase in antipsychotic medication use in youths was for clinical indications that have been approved by the US Food and Drug Administration (FDA), including schizophrenia, bipolar disorder, irritability associated with autistic disorder, and Tourette disorder.[5,6,7,8,9] much of the increase has been associated with non–FDA-indicated prescribing, most commonly, attention-deficit/hyperactivity disorder (ADHD).[2,3,10,11]. These medications frequently cause adverse metabolic effects, including weight gain, hyperlipidemia, and increased risk of type 2 diabetes.[2,12,13] Recent evidence further suggests that antipsychotic treatment in youths is associated with an increased risk of unexpected death.[14]
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