Are Children's Psychotropic Medicines Green?

By Janis Prince Inniss

The number of children taking psychotropic medications has sky-rocketed in recent years. This increase is not evident across all categories of medications, but primarily due to the exploding numbers of children given atypicals– a new class of antipsychotic drugs.

What is driving the increase? If the stigma associated with seeking and treating mental health has diminished, this is great news. If more children who need treatment for mental illness are receiving benefits from medications, that is more good news. There are, however, indications that this spike is less a response to the needs of children, than drug companies and physicians profiting from a lucrative—and until recently, mostly untapped—market.

The rise in medication being prescribed to children is taking place at a time when Medicaid and insurance companies have become increasingly less likely to pay for psychotherapy. Psychotropic medications, on the other hand, are reimbursable. This means that for financial reasons, parents seeking help for their children see talk therapy as less of an option than drug therapy. 

In order to understand these issues, it is useful to consider the role of the U.S. Food and Drug Administration (F.D.A.)—the governmental agency charged with regulating drugs. The F.D.A. approved the use of atypicals to treat bipolar disorder and schizophrenia in adults, but the drugs have become popular in the treatment of children. The FDA oversees marketing by drug companies, but not prescriptions by physicians. Therefore, in a practice known as “off-label” use, physicians are free to prescribe FDA approved medications for populations and conditions not approved by the FDA. Because many of the psychotropic medications that are prescribed to children have not been studied for children’s use, there are many unanswered questions about their effectiveness and side effects. Because children are continuing to develop, they can be particularly vulnerable to the sometimes very serious side effects of medications.

Another issue is the over diagnoses and misdiagnoses of mental illnesses in children. For example, despite a tremendous rise in the number of children being diagnosed as bipolar, many mental health practitioners question the existence of this disorder in children. (Chapter Four of Frontline's “The Medicated Child” offers video of a five year old diagnosed with bipolar disorder; viewing it may give some sense of the desperation parents may feel about the behavior of their children and why they would be willing to try drugs despite their side effects.)

Adding to the suspicion that financial concerns may motivate some diagnoses is The New York Times analysis of drug company financial relationships with psychiatrists in Minnesota (the only state that makes it mandatory to report such relationships). The analysis revealed that between 2000 and 2005drug company payments to doctors increased six-fold, to $1.6 million, while prescriptions for antipsychotics to children receiving Medicaid increased nine-fold. The doctors who received the most money from drug companies are the same ones who were most inclined to prescribe medications to children. Psychiatrists are not the only physicians who receive payments from drug companies, and some high prescribers receive no money from the companies. But the Times analysis found that between 2000 and 2005, psychiatrists received more money from drug companies than doctors of other specialties. For example, payments to psychiatrists in Minnesota ranged from $51 to $689,000, with a median of $1,750. 

The relationship between drug companies and physicians is further complicated by the fact that drug companies finance research on their medications. In some cases the companies retain control over the data, leaving room for doubt about the truthfulness of their reports. 

It’s also important to consider the drug company budgets devoted to advertising psychotropic medications to the public. In 2000, money spent on such advertising skyrocketed to $1.5 billion—a six-fold increase from 1996. Television and other advertisements have armed parents with the names of medications for any number of disorders and some physicians bow to pressure from parents to provide a medication they have seen marketed. Much of the prescriptions for psychotropic medications are written by pediatricians who lack the expertise needed to treat and monitor children on these drugs. 

It is hard to escape the profit motive in medicating children; these drugs are not cheap and their manufactures earn billions. Figures of what Medicaid spent in only two states illustrate the kind of money at stake: In 2006, Medicaid spent $27.5 million for atypicals for children in Florida, while Minnesota spent $7.1 million in 2005. 

Drug companies reap billions of dollars with “off-label“ prescribing, so there is little incentive for the companies to learn more about the impact of their medications on children. And how much of this increase in medication, is an unwillingness of some parents and teachers to accept what is in fact normal—if highly challenging—childhood behavior? There does not have to be an either/or choice—psychotherapy or medication—in responding to the mental health needs of children; research conducted by the National Institute of Mental Health indicates that a combination of psychotherapy and medication is best for some mental health issues faced by children.