Three Studies of American Prescribing Patterns

In a study in the January issue of the Archives of General Psychiatry, researchers found increasing a trend of psychotropic polypharmacy in office-based psychiatry prescription patterns.  Visits with 2 or more prescriptions increased by nearly a third from 1996 to 2006, while visits with 3 or more prescriptions nearly doubled in the same period.  This trend was largely similar across visits by different patient groups and persisted after controlling for background characteristics. The authors noted in press that while some of these polypharmeceutical combinations are supported by clinical trials, many are of unproven efficacy. Accordingly, a trend towards increasing psychotropic polypharmacy puts patients at increased risk of drug-drug interactions with uncertain gains for quality of care and clinical outcomes.

A study in the January issue of the Journal of the American Academy of Child & Adolescent Psychiatry found that from 1999 to 2007, the rate of children aged 2 to 5 who are prescribed antipsychotic medications has doubled.  Lead author and Professor of Psychiatry Mark Olfson of Columbia University notes that this is a “worrisome trend, partly because very little is known about the short-term, let alone the long-term, safety of these drugs in this age group”. He suggests that for 4-5 year olds, antipsychotic medications should be used only as a last resort for treatment, while in 2-3 year olds, it is debatable whether antipsychotics should be used at all.

A recent study in Health Affairs found that children in the Medicaid programs of a number of states (including New York, Texas, and California) were prescribed antipsychotics at four times the rate that kids whose parents have private insurance (a rate of 4% as compared to 1%). Many of these prescriptions were found to be for off-label indications, and many were for indications less severe than those for which their privately insured counterparts were prescribed anti-psychotics.  Some doctors have suggested that the increase in prescriptions may even indicate that Medicaid children are receiving superior treatment, while others are starkly in disagreement.

All of these studies in some respect or another appear to suggest that many popular American prescribing habits are at a disconnect in some respect from evidence-based medicine.  By the metric of these studies, prescriptions are not infrequently issued in the absence of evidence of clinical efficacy, for unindicated conditions and under-researched age groups, and disproportionately to certain groups for reasons which are ostensibly non-medical. These studies focus on psychotropic medications.  Would similar results be found in other areas of medicine popularly treated with pharmaceuticals? Why or why not? Are these prescriptions patterns indicative of a common underlying problematic mechanism, multiple heteregeneous mechanisms, or are they in fact not to be interpreted pejoratively in the first place?

CJ Murdoch