Only about 50% of antipsychotic prescriptions for children and youth who have been newly diagnosed with attention-deficit/hyperactivity disorder (ADHD) have an identifiable clinical indication. Furthermore, fewer than half of these patients receive initial treatment with stimulants ― the recommended first-line pharmacologic therapy ― results of a national analysis show.

“Overall, we found that 2.6% of kids with a new diagnosis of ADHD were treated with an antipsychotic medication despite no FDA [US Food and Drug Administration–approved] indication,” study investigator Ryan S. Sultan, MD, assistant professor of clinical psychiatry, Columbia University, New York City, told Medscape Medical News.

“Among these, 52.7% had a potential clinical explanation for the administration of an antipsychotic, such as evidence of treatment-resistant ADHD. That still leaves approximately half of them who have no identifiable reason for receiving an antipsychotic. But they did nonetheless,” he added.

The findings were presented at the recent American Academy of Child & Adolescent Psychiatry (AACAP) 66th Annual Meeting.

To determine the percentage of youth for whom antipsychotic prescriptions were filled in the year following an initial diagnosis of ADHD, the investigators examined clinical and demographic factors associated with antipsychotic prescribing in children and youth with ADHD.

With coinvestigator Mark Olfson, MD, MPH, Sultan obtained data from the Truven Health MarketScan Commercial Database for January 1, 2010, to December 31, 2015. This database includes a host of medical and prescription drug data for more than 110 million patients.

The retrospective, longitudinal cohort analysis included 187,563 children and youth (aged 3 years to 24 years) who were newly diagnosed with ADHD but who did not have FDA-approved or evidence-based indications for antipsychotic treatment.

The researchers examined several outcome measures, including the percentage of patients who were prescribed an antipsychotic in the first year following a new diagnosis of ADHD and the percentage for whom an antipsychotic prescription was filled before a prescription for a stimulant was filled.

They also examined a subset of youth who were prescribed antipsychotic medications. They assessed the percentage of those who received a diagnosis of conduct disorder, oppositional defiant disorder, or a disorder that was an FDA-approved indication with respect to at least one antipsychotic medication.

Similarly, 43.8% (95% CI, 42.4% – 45.1%) received a drug of one stimulant class, and only 8.4% of patients (95% CI, 7.6% – 9.1%) received methylphenidate or a methylphenidate derivative and an amphetamine derivative.

The mean age of the children and youth included in the study was 13.74 ± 5.61 years; 114,305 (60.9%) were male. The investigators found that within 1 year of their being newly diagnosed with ADHD, antipsychotics were initiated in 4869 patients (2.6%; 95% confidence interval [CI], 2.5% – 2.7%).

The investigators found that there was a potential clinical diagnostic rationale for treatment with antipsychotic medications for only 52.7% of patients who received them.

“I would understand these results if these children had complicated cases with aggression, and the stimulant was tried and didn’t work. But that was not the case, because half of the antipsychotic-treated youth with ADHD never got a stimulant medication before they got an antipsychotic. It’s deeply concerning. These youth have no clear indication for an antipsychotic, and stimulants are bread-and-butter treatment for ADHD,” said Sultan.

“Assuming they aren’t very young or only have mild symptoms, the treatment recommendations for ADHD are that you give adequate treatment trials for each psychostimulant class first; you don’t jump right to an antipsychotic,” he said.


REFERENCE: American Academy of Child & Adolescent Psychiatry (AACAP) 66th Annual Meeting: Abstract 2.3, American Academy of Child & Adolescent Psychiatry
(AACAP) 66th Annual Meeting: Abstract 2.3,