"This is a critical issue - it's not uncommon to find a child on an anti-depressant, a mood stabilizer, and a sleep agent all at the same time, but there's no research to see how these drugs interact with each other" says co-author Joseph Penn, MD a child psychiatrist with the Bradley Hasbro Children's Research Center (BHCRC) in Providence, RI and Brown Medical School.
The authors reviewed 10 years of scholarly articles pertaining to polypharmacy in pediatric settings, and found that all the studies comparing these rates across time showed an increase in the practice.
However, the authors warn there are almost no studies or published research on which to justify prescribing multiple medications for psychiatric disorders in children.
According to the study, the most frequent combination were stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine, Adderall) commonly used to treat ADHD, with another psychotropic medication.
Another contributing factor to the increased risks of prescribing multiple drugs is the prevalence of off-label prescriptions – the practice of prescribing a medication to children when there is not a FDA approved indication for that disorder in children.
"For example, aytpicals like risperidone are sometimes used to symptomatically treat psychosis or aggression in children, but most of these medications don't have FDA approval for use on psychiatric symptoms in the pediatric age group," says co-author Henrietta Leonard, MD, a child psychiatrist with the Bradley Hasbro Children's Research Center and Brown Medical School. "We just don't have the efficacy or safety data to back up what is common clinical practice."
Because there are limits to the data available on the efficacy of a single medication in the pediatric age group, the authors express deep concern over the rise in polypharmacy because it could multiply the risk of adverse events.
"The FDA recently questioned whether there is a link between the use of antidepressants in children and suicidal thoughts – if there is so much concern over the effects of a single drug, how much riskier is it to prescribe multiple drugs?" Penn says.
The authors cite examples of a child on two medications for ADHD who died suddenly, and additionally describe serotonin syndrome, a serious and potentially fatal illness that can result when a child receives two medications with serotonergic properties.
In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) has issued a policy statement saying, "Little data exist to support advantageous efficacy for drug combinations, used primarily to treat co-morbid conditions."
The authors concur. "We need more systematic studies to establish the safety and efficacy of medications in the pediatric age group," says Penn.
Founded in 1931 as the nation's first psychiatric hospital for children, Bradley Hospital (www.bradleyhospital.org) remains a premier medical institution devoted exclusively to the research and treatment of childhood psychiatric illnesses. Bradley Hospital, located in Providence, RI, is a teaching hospital for Brown Medical School and ranks in the top third of private hospitals receiving funding from the National Institutes of Health. Its research arm, the Bradley Hasbro Children's Research Center (BHCRC), brings together leading researchers in such topics as: autism, colic, childhood sleep patterns, HIV prevention, infant development, obesity, eating disorders, depression, obsessive-compulsive disorder (OCD) and juvenile firesetting. Bradley Hospital is a member of the Lifespan health system.