Prescribed stimulant use for ADHD continues to rise steadily

NIH and AHRQ study finds pace of the rise has slowed in recent years


Source: NIMH

The prescribed use of stimulant medications to treat attention deficit hyperactivity disorder (ADHD) rose slowly but steadily from 1996 to 2008, according to a study conducted by the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ). The study was published online ahead of print September 28, 2011, in the American Journal of Psychiatry continuing education for Social Workers

ADHD is one of the most common childhood disorders, and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). The condition is frequently treated with stimulants such as methylphenidate (e.g., Ritalin), amphetamines (e.g., Adderall) or other types of medications. Behavioral therapies can also be effective.

During the 1990s, stimulant prescription use increased significantly, going from a prevalence rate among youth of 0.6 percent in 1987 to 2.7 percent in 1997, with the rate stabilizing around 2.9 percent in 2002. Recent reports, however, suggest that the prescribed use of these medications and the diagnosis of ADHD have continued to rise. Based on the Health Resources and Services Administration's National Survey of Children's Health, the percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.

"Stimulant medications work well to control ADHD symptoms, but they are only one method of treatment for the condition. Experts estimate that about 60 percent of children with ADHD are treated with medication," said co-author Benedetto Vitiello, M.D., of NIH's National Institute of Mental Health (NIMH).

For this most recent survey, Dr. Vitiello and Samuel Zuvekas Ph.D., of AHRQ examined data from the AHRQ-sponsored Medical Expenditure Panel Survey, a nationally representative annual survey of U.S. households, to determine prescribed stimulant use among children under age 19 from 1996-2008. They found a slow but steady increase — from 2.4 percent in 1996 to 3.5 percent in 2008.The rate grew an average of 3.4 percent each year, which is substantially less than the growth rate between 1987 and 1996, which averaged about 17 percent per year.

Overall, prescription use among 6-12-year-olds was highest, going from 4.2 percent in 1996 to 5.1 percent in 2008. But the fastest growth of prescribed use occurred among 13-18-year-olds, going from 2.3 percent in 1996 to 4.9 percent in 2008. "This continuous increase among teens likely reflects a recent realization that ADHD often persists as children age. They do not always grow out of their symptoms," said Dr. Vitiello.

Prescription use among preschoolers remained very low at 0.1 percent from 2004 onward and decreased between 2002 and 2008, suggesting that stimulant use among very young children continues to be disfavored. Boys continued to be three times more likely to be prescribed a stimulant than girls, and use among white children continued to be higher than among black or Hispanic children (4.4 percent in 2008 among whites, compared to 2.9 percent in blacks and 2.1 percent in Hispanics). However, prescribed stimulant use is increasing among racial and ethnic minorities, likely suggesting more recognition of ADHD and acceptance of psychopharmacological treatment among these groups, according to the authors.

In addition, rates were substantially lower in Western states compared to other regions of the nation, with no increase in recent years, a finding consistent with other studies. In comparison, rates in the Northeast increased from 2.7 percent in 2002 to 4.6 percent in 2008.

"These persistent differences in prescribed stimulant use related to age, racial and ethnic background, and geographical location indicate substantial variability in how families and doctors approach ADHD treatment throughout the United States," said Dr. Zuvekas.

The researchers concluded that when comparing the rates of prescribed use with the estimated prevalence of ADHD diagnosis, it appears that many children with ADHD are not treated with stimulants. "The children with the most severe symptoms are more likely to be taking stimulants. Those with milder symptoms are more likely being treated with psychosocial treatments or other non-stimulant medications," they said.

Reference

Zuvekas S and Vitiello B. Stimulant medication use in children: a 12-year perspective. American Journal of Psychiatry. Online ahead of print September 28, 2011.

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The Agency for Healthcare Research and Quality (http://www.ahrq.gov) is part of the U.S. Department of Health and Human Services. AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. AHRQ's research helps people make more informed decisions and improve the quality of health care services.

The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Adding Psychotherapy to Medication Treatment Improves Outcomes in Pediatric OCD

Source: NIMH

Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association LCSW Continuing Education

Background

Several studies have shown that, among adults with OCD, a form of CBT involving controlled exposure to feared situations plus training that helps the person refrain from compulsions is effective both alone and in combination with antidepressant medication. However, few studies of this type of combination therapy have been conducted among children. In addition, many children with OCD tend to respond only partially to antidepressant medication. Studies have found that among adults who only partially respond to antidepressant medication, adding CBT can be effective. However, until now, there have been no studies testing this same approach in youth.

Martin Franklin Ph.D., of the University of Pennsylvania, Jennifer Freeman Ph.D., of Brown University, John March M.D.,MPH, of Duke University, and colleagues set out to determine whether CBT can effectively augment antidepressant treatment in children who partially respond to the medication. Among 124 children ages 7-17, they compared three treatment options:
Medication management only (MM), prescribed and managed by a physician. All patients were taking a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI).
MM plus Instructional CBT (I-CBT), a shorter, less intensive version of CBT administered by the prescribing physician.
MM plus CBT provided by a trained CBT therapist. The CBT included a type of therapy called exposure plus response prevention (ERP), in which children are exposed to feared situations and taught how to respond to the resulting anxiety without engaging in compulsions.

Results

After 12 weeks of treatment, nearly 69 percent of those receiving MM+CBT had responded to treatment, compared to 34 percent receiving MM+I-CBT and 30 percent receiving MM. Those receiving MM+CBT showed more improvement in all respects, compared to those receiving MM and MM+I-CBT.

Significance

The findings are consistent with other studies demonstrating that ERP is an effective treatment strategy for OCD, both alone and in combination with SSRIs. The researchers conclude that the full version of CBT with ERP should be widely disseminated as opposed to a brief version that may not be effective.

What’s next

The researchers were unsure why there was so little difference in treatment response between the MM group and the MM+I-CBT group. They reasoned that the I-CBT was generally ineffective because it was brief and less intensive than the CBT. It also did not include key treatment components that are central to the full CBT protocol, such as exposure practices during the treatment sessions themselves. Future efforts should focus on making the full CBT with ERP more widely available in community settings, they concluded.

Citation

Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive compulsive disorder: the Pediatric OCD Treatment Study (POTS II) randomized controlled trial. Journal of the American Medical Association. 21 Sept 2011.

Survey Assesses Trends in Psychiatric Hospitalization Rates

Source: NIMH

Short-term inpatient psychiatric stays increased for youth but declined for older adults between 1996 and 2007, according to an analysis published online ahead of print August 1, 2011, in the Archives of General Psychiatry.

Background

Joseph C. Blader Ph.D., of Stony Brook University, evaluated data from 1996-2007 from the National Hospital Discharge Survey, an annual survey conducted by the National Center for Health Statistics. He aimed to determine the rates of short-term hospitalizations and length of stays among children, adolescents, adults, and older adults due to psychiatric diagnosis. This time period roughly corresponds to the decline in use of long-term inpatient services for psychiatric illnesses, decrease in number of psychiatric beds made available, and stricter criteria for insurance authorization of hospital admission. Social worker continuing education

Results of the Study

The data showed that hospitalization rates increased the most for children ages 5-12, going from 155 per 100,000 children in 1996 to 283 per 100,000 children in 2007. Among teens, the rate increased from 683 to 969 per 100,000. Among adults, the rate increased from 921 to 995 per 100,000. By contrast, the rate declined among the elderly, going from 977 to 807 per 100,000.

Hospital stays were consistently shorter among children and teens, especially those with private insurance. The proportion of inpatient days paid by private insurers declined among children (going from 36 percent to 21 percent), adolescents (going from 52 percent to 22 percent) and adults (going from 35 percent to 23 percent.)

Significance

The trends likely reflect an increase in clinical need rather than an overuse of hospital resources, especially when taking into account the decline in number of psychiatric beds available, according to Blader. Admission information and diagnostic trends over the same time period indicate that the impairments and problems of hospitalized patients appear to have grown more acute. He also notes that the trend corresponds with an increase in bipolar diagnosis, especially among youth. Blader suggests that as long-term care facilities decreased their capacity, short-term facilities may have had to compensate for the shortage. Surveys among state mental health officials during the same time period indicate they were worried about a shortage of beds for acute care as well.

What’s Next

More research is needed to determine how these trends are affecting quality of care and insurance issues and reimbursement.

Citation

Blader JC. Acute inpatient care for psychiatric disorders in the United States, 1996 through 2007. Archives of General Psychiatry. Online ahead of print Aug 1, 2011.

Thinking Globally to Improve Mental Health

Source: NASA Jet Propulsion Laboratory (NASA-JPL)

Mental health experts are calling for a greater world focus on improving access to care and treatment for mental, neurological, and substance use (MNS) disorders, as well as increasing discoveries in research that will enable this goal to be met LPC Continuing Education

The Grand Challenges in Global Mental Health Initiative, led by the National Institutes of Health and the Global Alliance for Chronic Diseases, has identified the top 40 barriers to better mental health around the world. Similar to past grand challenges, which focused on infectious diseases and chronic, noncommunicable diseases, this initiative seeks to build a community of funders dedicated to supporting research that will significantly improve the lives of people living with MNS disorders within the next 10 years.

Twenty-five of the specific challenges and the process used to derive them are described in an article that will be published on July 7, 2011, in the journal Nature.

"Participating in global mental health research is an enormous opportunity, a means to accelerate advances in mental health care for the diverse U.S. population, as well as an extension of our vision of a world where mental illnesses are prevented and cured," said Thomas R. Insel, M.D., director of the National Institute of Mental Health (NIMH), the NIH institute heading this effort.

According to the paper's authors, the disorders targeted by the Grand Challenges in Global Mental Health—for example, schizophrenia, depression, epilepsy, dementia, and alcohol dependence—collectively account for more years of life lost to poor health, disability, or early death than either cardiovascular disease or cancer. Yet, compared to illnesses like cardiovascular disease and cancer, there are far fewer effective treatments or preventive methods. In addition, interventions are not widely available to those who need them most.

In recognizing the need to address this imbalance, Pamela Collins, M.D., M.P.H., of the NIMH Office for Research on Disparities and Global Mental Health, and colleagues assembled an international panel of experts to identify research priorities using the Delphi method, a widely accepted consensus-building tool. The panel consisted of 422 experts in fields such as neuroscience, basic behavioral science, mental health services, and epidemiology, and represented more than 60 countries.

Over the course of two months, NIMH staff pared the panel's initial list of 1,565 challenges down to 154, with input from a scientific advisory board. From this list, the expert panel selected the top 40, of which the top five challenges identified after the third and final round of ranking are:
Integrate screening and core packages of services into routine primary health care
Reduce the cost and improve the supply of effective medications
Improve children's access to evidence-based care by trained health providers in low- and middle-income countries
Provide effective and affordable community-based care and rehabilitation
Strengthen the mental health component in the training of all health care personnel.

These top five challenges were ranked according to the ability to reduce the burden of disease, ability to reduce inequalities in health and health care, length of time until results can be observed, and the ability for the topic to be researched effectively.

"Addressing these challenges could have far-reaching effects, including increasing access to services and ultimately, reducing the treatment gap associated with these disorders," said Dr. Collins.

The Grand Challenges in Global Mental Health Initiative is led by NIMH and the Global Alliance for Chronic Diseases, in partnership with the Wellcome Trust, the McLaughlin-Rotman Centre for Global Health, and the London School of Hygiene and Tropical Medicine. Other NIH components participating in the Grand Challenges in Global Mental Health include the Fogarty International Center; the National Heart, Lung, and Blood Institute; and the National Institute of Neurological Disorders and Stroke.

Reference

Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar A, on behalf of the Grand Challenges in Global Mental Health Scientific Advisory Board and Executive Committee. Grand Challenges in Global Mental Health. Nature. 2011 July 7. 474(7354):pp.

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The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Continued Use of Stimulants for ADHD Likely Does Not Increase Risk for Hypertension, but May Affect Heart Rate

Source: NIMH

Chronic use of stimulant medication to treat attention deficit hyperactivity disorder (ADHD) in children does not appear to increase risk for high blood pressure over the long term, but it may have modest effects on heart rate, according to follow-up data from the NIMH-funded Multimodal Treatment Study of Children with ADHD (MTA). The study was published online ahead of print Sept 2, 2011, in the American Journal of Psychiatry continuing education for counselors

Background

The MTA was the first major multi-site trial comparing different treatments for ADHD in childhood. The initial results of the 14-month study, in which 579 children were randomly assigned to one of three intensive treatment groups (medication management alone, behavioral treatment alone, a combination of both) or to routine community care, were published in 1999. The researchers found that medication management alone or in combination with behavioral therapy produced better symptomatic relief for children with ADHD than just behavioral therapy or usual community care.

After the study ended, participants returned to community treatment and were free to pursue whatever treatment course they wished. MTA researchers gathered follow-up data from MTA study participants at 2, 3, 6, 8, and 10 years after study entry.

ADHD is often a chronic condition that continues into adolescence, so some children take stimulants for years. Because stimulants can affect the heart, doctors are concerned about the possible risks for rapid heart rate, hypertension (high blood pressure) or other cardiovascular effects after many years of use. But studies have been inconsistent about whether the effects are long-lasting.

For this most recent data analysis, Benedetto Vitiello, M.D., of NIMH, and MTA colleagues examined the MTA follow-up data to determine if there was an association between chronic use of stimulant medication and changes in blood pressure or heart rate over a 10-year period.

Results of the Study

At the end of the 14-month study, children who were randomized to stimulant treatment in the study had, on average, higher heart rates compared to the children who were randomized to non-medication or community care. Heart rates for the children who continued to take stimulants after the end of the study were slightly elevated at subsequent checks, but they did not have an abnormally elevated heart rate (e.g., tachycardia).

The researchers concluded that stimulant medication did not appear to increase the risk for abnormal elevations in blood pressure or heart rate over a 10-year period. However, because some epidemiological studies have indicated that even modest elevations in heart rate may increase a person’s lifetime risk for cardiovascular problems, the persistent effect of continuous stimulant treatment on heart rate should not be dismissed.

Significance

The results of this study indicate that the effect of stimulants on heart rate can be detected even after years of use, suggesting that the body does not get completely used to it. However, after 10 years of treatment, researchers found no increased risk for hypertension. In addition, none of the children reported any adverse cardiovascular events over the 10-year period.

The researchers do note that the effect on heart rate may be clinically significant for individuals who have underlying heart conditions. Therefore, children taking stimulants over the long-term should be monitored regularly for potential cardiovascular complications.

Citation

Vitiello B, Elliott GR, Swanson JM, Arnold E, Hechtman L, Abikoff H, Molina BSG, Wells K, Wigal T, Jensen PS, Greenhill LL, Kaltman JR, Severe JB, Odbert C, Hur K, Gibbons R. Blood pressure and heart rate in the multimodal treatment of attention deficit/hyperactivity disorder study over 10 years. American Journal of Psychiatry. Online ahead of print Sept 2, 2011.

Autism Risk in Younger Siblings May be Higher Than Previously Thought

Autism Risk in Younger Siblings May be Higher Than Previously Thought

Parents of a child with autism spectrum disorder (ASD) face about a 19 percent chance that subsequent children will also develop ASD, according to a study partially funded by NIMH. This estimate is much higher than previous reports but may also be more accurate due to the study's size and design, according to the researchers. Their study was published August 15, 2011, online ahead of print in the journal Pediatrics ceus for social workers

Background

A few previous studies have explored the recurrence rate of ASD, or the likelihood of later-born siblings of children with ASD to also develop ASD. However, few studies addressed factors likely to influence risk estimates, such as:
Stoppage—the tendency for families to choose not to have more children after one child is diagnosed with ASD. Such families would not be included in research on ASD recurrence.
Overreporting—an error that can occur when researchers rely solely on parent reports or health records, which have been shown to inflate estimates.
Ascertainment bias—an example is overselection, which can occur when parents with one child who has ASD pay very close attention to a later child's development. They may be more likely to take part in ASD recurrence studies than other parents.

Taking a different approach, Sally Ozonoff, Ph.D., of the University of California-Davis, and colleagues evaluated data on 664 infants who were tested at 12 sites across the United States and Canada. All sites were members of the Baby Siblings Research Consortium (BSRC), an international network supported by the U.S. advocacy group Autism Speaks. All BSRC members contribute data to a centralized database that allows infant-sibling researchers to pool data across many sites and answer questions that require very large and geographically diverse samples to address.

The average age of the infant participants at the start of the study was 8 months, an age when signs of ASD are not usually present; two-thirds of the total study population were enrolled before age 6 months. All had at least one older sibling diagnosed with ASD, which was confirmed by a consortium doctor. The participants were themselves assessed for ASD multiple times in their first three years of life.

Results of the Study

Out of the total study sample, 18.7 percent of participants were diagnosed with ASD by age 3. Boys were nearly three times as likely as girls to be diagnosed with ASD. Participants who had more than one older sibling with ASD were about twice as likely to also be diagnosed with ASD, compared to participants who had only one older sibling with ASD.

Unlike some previous studies, the gender or IQ of the older sibling with ASD did not affect the later sibling's risk in the present study.

Significance

The findings indicate that ASD recurrence is 18 percent or higher, compared to 3-14 percent estimated in earlier studies. The researchers note that their study's size and design minimized the effects of stoppage, overreporting, and ascertainment bias.

Despite the strengths of their study, the researchers emphasize that recurrence estimates cannot provide information on an individual's risk. They highlight the need for careful and extensive counseling and thorough genetic work-ups for concerned parents, as well as close monitoring, especially of high-risk children, and prompt referrals for intervention by primary care providers.

What’s Next

According to the researchers, larger, population-based studies that include families of children with ASD who are not listed in the Baby Siblings Research Consortium may help to further refine recurrence estimates. Future studies will examine DNA collected from participants to examine genetic factors that may be associated with recurrence.

Reference

Ozonoff S, Young GS, Carter A, Messinger D, Yirmiya N, Zwaigenbaum L, Bryson S, Carver LJ, Constantino JN, Dobkins K, Hutman T, Iverson JM, Landa R, Rogers SJ, Sigman M, Stone WL. Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study. Pediatrics. 2011 Aug 15. [Epub ahead of print] PubMed PMID: 21844053.