In the United States, around two million teens suffer from Attention Deficit Hyperactivity Disorder (ADHD) every year and 10% of them are diagnosed with ADHD at some point in their lives [1]. About two-thirds of these individuals have other co-existing disorders like Oppositional Defiant Disorder, Tics disorder, Tourette’s syndrome, learning disorders, Bipolar disorder and Conduct disorder [2]. One of the most common reasons for prescribing antipsychotics in adolescents with ADHD was to either control behavioural symptoms of ADHD (inattention, hyperactivity, impulsivity, aggression) or to treat the associated comorbid psychiatric disorders. About 60% of older children and 35% of teens who were prescribed antipsychotics had ADHD [3]. In 2010 about 280 million antipsychotics (aripiprazole, risperidone, quetiapine, olanzapine) prescriptions were distributed to adolescents [3, 4]. This could be due to the reduced rate at which behavioural therapy and other psychosocial interventions for ADHD are reimbursed by the insurance companies. In the past fifteen years, six new antipsychotics have been developed which could also be another reason why there is a rapid rise in prescribing these drugs [5]. These medications have serious adverse effects and their efficacy in treating ADHD has not been determined yet. These drugs have not been approved by the United States Food and Drug Administration (FDA) in the treatment of ADHD and are considered off-label. In spite of being considered off-label, they are one of the most common and costly classes of prescription drugs in the US with the expenditure exceeding $13 billion annually [6].
Since the discovery second-generation antipsychotics (SGAs) or atypical antipsychotics in the 1990s, there has been a rapid rise in prescribing these drugs for ADHD as they were advertised as having fewer side effects compared to first-generation antipsychotics or typical antipsychotics which were developed much before SGAs but were associated with extrapyramidal effects [7]. Hence, over the past two decades, prescribing SGAs to the adolescent population has increased substantially. Antipsychotics received FDA approval only for Schizophrenia, Tourette syndrome, Bipolar mania and irritability associated with Autism spectrum disorder [5, 8]. Therefore, it became very common to prescribe SGAs for conditions not approved by the FDA. In spite of having some serious adverse effects like cardiovascular complications, metabolic syndrome, etc. SGAs are one of the top-selling group of drugs in the United States. About 34% of adolescents who received prescription SGAs were diagnosed with one of the conditions for which the FDA had approved the drugs with the majority of them (24%) having ADHD as the only diagnosis. From the year 1995 until 2000 the prescription of SGAs increased steadily, but from 1999 till 2003 the number doubled and after 2003 there was a fluctuating pattern in prescribing SGAs [8]. Adolescents and children who were covered by Medicaid insurance and those who were not insured were more likely to receive prescription SGAs for ADHD [7]. During 1996 to 2001 prescribing antipsychotics for ADHD in adolescents almost tripled [7]. It is concerning because a high percentage of the adolescent group is being exposed to the dangerous adverse effects of these drugs like metabolic syndrome and diabetes and the effectiveness of these drugs has not been established for conditions like ADHD [9].
In the early 2000s, ziprasidone and aripiprazole were developed. These drugs were used for conditions other than psychosis especially ADHD. Aripiprazole and risperidone are the most common SGAs prescribed for ADHD in adolescents in the recent years. Some of the side effects of SGAs are dry mouth, sedation, weight gain, constipation, hypotension and photosensitivity [10]. But some of the potential adverse effects are metabolic syndrome and movement disorders [10]. Keeping these in mind complete blood count (CBC), metabolic profile, liver function tests (LFTs), fasting blood glucose, and prolactin levels should be monitored on a regular basis. In order to check for movement disorders a baseline, Abnormal Involuntary Movement Scale (AIMS) should be done before starting the drug [10].
Few other reasons for prescribing antipsychotics are rapid improvement in the behavioural symptoms associated with ADHD. Hence, doctors are prescribing antipsychotics to about 72% of adolescents with ADHD compared to adults (50%). Some of the treatments that are effective and have more potential than is currently being realized by physicians for adolescents with ADHD are cognitive problem skills training and parent management training [6]. Due to the rapid development of antipsychotics in a short span of time and due to the instantaneous response to these drugs by adolescents with ADHD, there has been a tremendous increase in prescribing these drugs rather than finding out the underlying cause of ADHD.
Therefore, to prevent misuse of antipsychotics, some insurance companies need prior authorization before distributing the drug in the market. But, it would be best for the physician to check the benefits and risks before prescribing these drugs to the adolescent population.
Monitoring Editor: Rikinkumar S. Patel MD, MPH
Author: Dr. Namrata Reddy Jannareddy MBBS
Author Affiliation: Kamineni Institute of Medical Sciences (Telangana, India)
Correspondence on Email: namratareddy.2@gmail.com
References: are available on request
