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Trends in the Prescribing of Psychotropic
Medications to Preschoolers
Julie Magno Zito, PhD
Context Recent reports on the use of psychotropic medications for preschool-aged
children with behavioral and emotional disorders warrant further examination of trendsin the type and extent of drug therapy and sociodemographic correlates.
Objectives To determine the prevalence of psychotropic medication use in preschool-
aged youths and to show utilization trends across a 5-year span.
Design Ambulatory care prescription records from 2 state Medicaid programs and a
salaried group-model health maintenance organization (HMO) were used to performa population-based analysis of three 1-year cross-sectional data sets (for the years 1991, THEPREVALENCEOFPSYCHO- 1993,and1995).
Setting and Participants From 1991 to 1995, the number of enrollees aged 2 through
4 years in a Midwestern state Medicaid (MWM) program ranged from 146 369 to 158 060; in a mid-Atlantic state Medicaid (MAM) program, from 34 842 to 54 237; orders has significantly increased in the and in an HMO setting in the Northwest, from 19 107 to 19 322.
Main Outcome Measures Total, age-specific, and gender-specific utilization preva-
cades, particularly in the last 15 years.
lences per 1000 enrollees for 3 major psychotropic drug classes (stimulants, antide- pressants, and neuroleptics) and 2 leading psychotherapeutic medications (methyl- phenidate and clonidine); rates of increased use of these drugs from 1991 to 1995, Results The 1995 rank order of total prevalence in preschoolers (per 1000) in the MWM
program was: stimulants (12.3), 90% of which represents methylphenidate (11.1); anti- depressants (3.2); clonidine (2.3); and neuroleptics (0.9). A similar rank order was observedfor the MAM program, while the HMO had nearly 3 times more clonidine than antide- pressant use (1.9 vs 0.7). Sizable increases in prevalence were noted between 1991 and 1995 across the 3 sites for clonidine, stimulants, and antidepressants, while neuroleptic use increased only slightly. Methylphenidate prevalence in 2- through 4-year-olds increased at each site: MWM, 3-fold; MAM, 1.7-fold; and HMO, 3.1-fold. Decreases occurred in the relative proportions of previously dominant psychotherapeutic agents in the stimulant and antidepressant classes, while increases occurred for newer, less established agents.
Conclusions In all 3 data sources, psychotropic medications prescribed for pre-
schoolers increased dramatically between 1991 and 1995. The predominance of medi- cations with off-label (unlabeled) indications calls for prospective community-based, sis (6-year-olds and older); and am-phetamines for ADHD in those 3 years Author Affiliations: School of Pharmacy (Drs Zito,
dosReis, and Mr Gardner) and School of Medicine (Dr Zito), University of Maryland, and School of Medi-cine, Johns Hopkins University (Dr Safer), Baltimore, lates to off-label (unlabeled) use, ie, for Md; and Center for Health Research, Kaiser Perma- nente, Portland, Ore (Drs Boles and Lynch).
Corresponding Author and Reprints: Julie Mango Zito,
PhD, University of Maryland, 100 Greene St, Room 5-13,
For editorial comment see p 1059.
Baltimore, MD 21201 (e-mail:
2000 American Medical Association. All rights reserved.
JAMA, February 23, 2000—Vol 283, No. 8 1025
Study Measures
stantially since the early 1990s. All the medication per 1000 enrolled youths.
tion by the institutional review board– Total Psychotropic Medication
were grouped into 4 age strata (aged 2-4, Prevalence
years. We were unable to investigate psy- corded in a 2-digit field. Thus, “95” roleptics (0.9) (TABLE). Within classes,
Data Sources
in a mid-Atlantic state. The third set of school-aged children by year of age.
Psychotropic Medications
tinuous enrollees for each study year.
Time Trends in Psychotropic
Medication Prevalence Across
a 5-Year Span
cording to general statistical profiles of 1026 JAMA, February 23, 2000—Vol 283, No. 8
2000 American Medical Association. All rights reserved.
fold), and antidepressants (2.2-fold). By Changes in Drug Utilization
and Off-Label Use
crease substantially during this time.
were similar in all 3 sites, with minor de- viations for neuroleptics and antidepres- matic when the base prevalence was low.
Gender-Specific Methylphenidate
Medication Prevalence
HMO (FIGURE 2). Thus, antidepres-
Age-Specific Methylphenidate
Medication Prevalence
(FIGURE 1). By comparison, children 2
program (4:1 in 1991 to 3:1 in 1995).
5- through 14-year-old counterparts.
Table. Annual Prevalence Rate per 1000 2- Through 4-Year-Old Children for Selected Psychotropic Medications in 3 Health Care Sites
(1991, 1993, 1995)*
MWM (n = 151 675)
MAM (n = 51 970)
HMO (n = 19 322)
(95% Confidence Interval)
(95% Confidence Interval)
(95% Confidence Interval)
*Prevalence (confidence interval) gives the upper and lower limits of the mean prevalence estimate with 95% probability of accuracy. Confidence intervals were truncated at 0.
MWM indicates a Midwestern state Medicaid program; MAM, a mid-Atlantic state Medicaid program; and HMO, health maintenance organization. N represents the number ofenrollees aged 2 through 4 years in 1995 for the health care site.
2000 American Medical Association. All rights reserved.
JAMA, February 23, 2000—Vol 283, No. 8 1027
clinical studies to evaluate the efficacy largely uncharted,17,18 and its increased with questions of safety16,21 and has been stimulants across the 3 time periods.
tions; age- and gender-specific data; and older youths to preschoolers is often not sored data do not create artifactual find- schoolers’ developmental immaturity.
Prevalence Findings
lant and clonidine use is consistent with efit of rigorous data to support it as a safe Figure 1. Methylphenidate Prevalence per 1000 Enrollees Across a 5-Year Span (1991-1995)
Trends in age-specific methylphenidate prevalence per 1000 enrollees by age for the Midwestern state Medicaid population. Left, Enrollees aged 2 through 19 years.
Right, Enrollees aged 2 through 4 years.
1028 JAMA, February 23, 2000—Vol 283, No. 8
2000 American Medical Association. All rights reserved.
derlie families’ decisions to accept or re- zling. It is also likely that some use of prevalence rates, collectively, were sub- tions in this analysis, thus limiting in- presence of less severely disabled youths plain a large part of the differences, but ber of variables to describe the clinical tors need to be considered as well. Also, patterns in the usual practice settings.
scribing the usual practice setting with- out the artificiality and the interference Age- and Gender-Specific
sicians’ decisions about medication and Prevalence Findings
patients’ decisions about treatment.
The study is limited in several ways.
tices, therapy variations, and treatment.
extends even to the very young. It isnotable that the largest gains in use Figure 2. Distribution of Antidepressant Subclasses Among Preschoolers in 3 Health Care
dents (15- through 19-year-olds), atrend that has been documented from Geographic and Health Care
System Variations
Disparities in psychotropic medica-tion prevalence data between the 2 state vocative and suggest numerous hypoth-eses. These include differences be- eligibility or access to continuing care; Trends in the percent distribution of antidepressant subclasses among preschoolers in 3 health care sites. MWM indicates a Midwestern state Medicaid program; MAM, a mid-Atlantic state Medicaid program; HMO, health maintenance organization; TCA, tricyclic antidepressant; and SSRI, selective serotonin reuptake inhibitor. Theproportions exceed 100% because more than 1 class may have been used in the same individual.
2000 American Medical Association. All rights reserved.
JAMA, February 23, 2000—Vol 283, No. 8 1029
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Clinical Research
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Funding/Support: This study was supported by fund-
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vices Branch (grant R01 MH55259), and the George 16. Swanson JM, Flockhart DA, Udrea D, Cantwell
DP, Connor DF, Williams L. Clonidine in the treat-
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