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Objective: This cross-sectional study evaluated the impact of Medicaid-eligibility category on the increased use of antipsychotic medication by Medicaid-insured youths across a decade., Methods: The authors analyzed computerized administrative claims data for 456,315 youths aged two to 17 years who were continuously enrolled in Medicaid in a mid-Atlantic state in 1997 (N=159,171) and 2006 (N=297,144). Bivariate and multivariable analyses quantified changes in antipsychotic use in relation to the youths' psychiatric diagnosis and eligibility category (Temporary Assistance for Needy Families [TANF], state Children's Health Insurance Program [SCHIP], Supplemental Security Income [SSI], and foster care). A second multivariable regression model examined changes in demographic and clinical characteristics of antipsychotic users with a psychiatric diagnosis., Results: The prevalence of antipsychotic use increased from 1.2% in 1997 to 3.2% in 2006. The increase in odds of antipsychotic use in 2006 was greatest among youths enrolled in SCHIP (adjusted odds ratio [AOR]=5.9), followed by youths enrolled in foster care (AOR=4.1), TANF (AOR=3.6), and SSI (AOR=2.8). Among users of antipsychotics who had a psychiatric diagnosis, youths with externalizing behavior disorders and bipolar disorder had 2.4- to 3.8-fold greater odds of using antipsychotics in 2006 versus 1997 compared with youths with schizophrenia or other psychoses and pervasive developmental disorders. The proportion of youths using antipsychotics between 1997 and 2006 increased significantly more among African Americans and Hispanics than among whites., Conclusions: The expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP) and reflects increased medication use for behavioral problems.

Objective: This research study aimed to assess national trends in pediatric use of anticonvulsants for seizures and psychiatric disorders., Methods: In a cross-sectional design, data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed. Outpatient visit information for youths (ages 0-17 years) was grouped by year for 1996-1997, 2000-2001, 2004-2005, and 2008-2009. Six of the most common anticonvulsant drugs used for psychiatric conditions were examined. Psychiatric diagnoses and seizure or convulsion diagnoses were identified with ICD-9-CM codes. The primary outcome measure was percentage prevalence of visits for anticonvulsants that included a psychiatric diagnosis as a proportion of total youth visits for an anticonvulsant. Total, diagnosis-stratified, and drug-specific visits, as well as visits for concomitant anticonvulsants and psychotropics, were analyzed., Results: As a proportion of total youth visits for anticonvulsants, visits with a psychiatric diagnosis increased 1.7 fold (p<.001), whereas the proportion of seizure-related visits did not change significantly. Regardless of diagnosis, anticonvulsant use significantly increased, from .33% to .68% of total youth visits in the 14-year period. There were significant increases in anticonvulsant use to treat pediatric bipolar disorder and disruptive behavior disorders. Visits noting divalproex decreased while visits noting lamotrigine increased among visits involving a psychiatric diagnosis. The concomitant use of stimulants and anticonvulsants significantly increased in visits noting a psychiatric diagnosis., Conclusions: Whereas anticonvulsant use for seizure disorders across the 14-year period was stable, the use of these drugs for psychiatric conditions rose to a dominant position. The growth of concomitant and off-label use to treat behavioral disorders raises questions about effectiveness and safety in community populations of youths.

Antidepressants are highly prescribed in youth although most products have not been approved for use in this population. Furthermore, regulatory warnings have led to changes in antidepressant use that might have differed across various countries. Our study aimed at determining factors associated with antidepressant prescribing practices and at assessing trends in use from 1997 to 2005 in Quebec youth.A retrospective cohort study was conducted through claims databases of the Quebec public health care program (RAMQ). The study included 5094 children (age 2-14) and 11,121 adolescents (age 15-19) who were incident users of antidepressant between 1997 and 2005. The characteristics of users and prescribers were the main independent variables.Tricyclics were the most frequently dispensed products among children (50.9%) and selective serotonin reuptake inhibitors among adolescents (58.8%). Selection of an antidepressant class was associated with patient characteristics and with prescriber specialty. The number of antidepressant users increased from 1997 until 2001 then decreased thereafter.The selection of an antidepressant class was associated with clinical and non-clinical characteristics. Although antidepressant use decreased after regulatory warnings, there appears to be a care gap between the evidence generated by efficacy studies and the products prescribed in a real-life setting., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: The study aims to compare cross-national prevalence of psychotropic medication use in youth., Methods: A population-based analysis of psychotropic medication use based on administrative claims data for the year 2000 was undertaken for insured enrollees from 3 countries in relation to age group (0-4, 5-9, 10-14, and 15-19), gender, drug subclass pattern and concomitant use. The data include insured youth aged 0-19 in the year 2000 from the Netherlands (n = 110,944), Germany (n = 356,520) and the United States (n = 127,157)., Results: The annual prevalence of any psychotropic medication in youth was significantly greater in the US (6.7%) than in the Netherlands (2.9%) and in Germany (2.0%). Antidepressant and stimulant prevalence were 3 or more times greater in the US than in the Netherlands and Germany, while antipsychotic prevalence was 1.5-2.2 times greater. The atypical antipsychotic subclass represented only 5% of antipsychotic use in Germany, but 48% in the Netherlands and 66% in the US. The less commonly used drugs e.g. alpha agonists, lithium and antiparkinsonian agents generally followed the ranking of US>Dutch>German youth with very rare (less than 0.05%) use in Dutch and German youth. Though rarely used, anxiolytics were twice as common in Dutch as in US and German youth. Prescription hypnotics were half as common as anxiolytics in Dutch and US youth and were very uncommon in German youth. Concomitant drug use applied to 19.2% of US youth which was more than double the Dutch use and three times that of German youth., Conclusion: Prominent differences in psychotropic medication treatment patterns exist between youth in the US and Western Europe and within Western Europe. Differences in policies regarding direct to consumer drug advertising, government regulatory restrictions, reimbursement policies, diagnostic classification systems, and cultural beliefs regarding the role of medication for emotional and behavioral treatment are likely to account for these differences.

The review presents pediatric adverse drug events from a historical perspective and focuses on selected safety issues associated with off-label use of medications for the psychiatric treatment of youth. Clinical monitoring procedures for major psychotropic drug classes are reviewed. Prior studies suggest that systematic treatment monitoring is warranted so as to both minimize risk of unexpected adverse events and exposures to ineffective treatments. Clinical trials to establish the efficacy and safety of drugs currently being used off-label in the pediatric population are needed. In the meantime, clinicians should consider the existing evidence-base for these drugs and institute close clinical monitoring.

Objective: Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population., Participants: Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention., Conclusions: This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

Investigators from a number of countries have linked temporal declines in the rate of completed suicide in children and adults to the increasing utilization of selective serotonin reuptake inhibitor (SSRI) antidepressants. They suggest that the relationship is causal. We undertook a thorough literature search of the rates of completed suicide using data from 1980 onwards, from the World Health Organization, the US National Center for Health Statistics, and related studies, in order to ascertain if a broad array of epidemiological evidence would or would not support a consistent association between suicide completion and SSRI utilization. The major findings were: (1) within and between countries, suicide rates vary prominently by age group; (2) national differences are marked with respect to a temporal association between rates of completed suicide and SSRI utilization; (3) in nearly half of the countries of the world, the decline in the suicide rate preceded the onset of the use of SSRIs; (4) suicide rates have fluctuated dramatically over the last century; and (5) the association between declining rates of completed suicides and increased SSRI use in the USA between 1990 and 1999 was no longer present between 2000 and 2004. We conclude that available ecological evidence does not support an inverse temporal relationship between rates of completed suicide and SSRI utilization.

Objective: To update knowledge of the prevalence of the use of psychotherapeutic medications in preschoolers with Medicaid insurance as requested by the Best Pharmaceuticals for Children Act of 2002 (BPCA)., Method: Prescription, enrollment, and outpatient visit data from 7 state Medicaid programs were used to identify 274,518 youths continuously enrolled in 2001 and aged 2 to 4 on January 1, 2001. Annual prevalence of use was defined as one or more dispensed prescriptions for a psychotherapeutic medication and adjusted for anticonvulsant and anxiolytic/sedative/hypnotic use according to ICD-9 diagnostic groupings. Prevalence ratios adjusted for age, race/ethnicity, and gender were estimated., Results: 2.30% (CI = 2.24, 2.36) of preschoolers received one or more dispensings for a psychotherapeutic medication in 2001, approximately doubling the usage of comparable youth from 2 other state Medicaid programs studied in 1995. Boys were 2.4 times more likely than girls to receive psychotherapeutic medication. Whites were 4 times more likely than Hispanics and twice as likely as Blacks to receive medication for psychiatric or behavioral conditions. Since the mid-1990s, usage increased, especially for atypical antipsychotics and antidepressants. The prominent use of anticonvulsants (78.8%) and anxiolytic/sedative/hypnotic drugs (91.4%) in those with no psychiatric diagnosis, but with other medical diagnoses, shows that much use therein reflects treatment for seizures, rather than mood stabilization, and for minor medical conditions, rather than psychiatric disorders., Conclusion: Preschool psychotherapeutic medication use increased across ages 2 to 4 for stimulants, antipsychotics, and antidepressants, reflecting use for psychiatric/behavioral disorders. However, the use of anxiolytic/sedative/hypnotics and anticonvulsants was more stable across these years, suggesting medical usage. Additional research to assess the benefits and risks of psychotherapeutic drugs is needed, particularly when such usage is off-label for both psychiatric and nonpsychiatric conditions.

Objective: To compare antidepressant prevalence data in youths across three western European countries (Denmark, Germany, and the Netherlands) with US regional data in terms of age and gender and to show proportional subclass antidepressant (ATD) use., Method: A population-based analysis of administrative claims data for the year 2000 was undertaken in 0 to 19-year-old enrollees who were part of the insured populations from four countries having a total of from 72,570 to 480,680 members., Results: ATD medication utilization in the US dataset (1.63%) exceeded that of three Western European countries (prevalence ranged from 0.11 to 0.54%) by at least 3-fold. There were major variations in the use of subclasses: tricyclic antidepressants (TCAs) predominated in Germany while selective serotonin reuptake inhibitors (SSRIs) predominated in the US, Denmark and the Netherlands., Conclusions: Cross-national variations should be further explored to understand the factors related to these differences and how prevalence differences relate to effectiveness and safety. Community-based cohorts should be followed to establish outcomes in the usual practice setting.

Objective: This study compared the prevalence of anticonvulsant treatment for youths with a diagnosis of a psychiatric disorder to youths with a diagnosis of a seizure disorder., Methods: Administrative claims from outpatient visits and prescriptions were organized for a data set of 258,472 youths who were younger than 18 years of age in a mid-Atlantic state Medicaid program and were continuously enrolled in 2000. Youths dispensed an anticonvulsant were grouped into the following ICD-9 diagnostic categories: a diagnosis of a psychiatric disorder without a seizure disorder, a diagnosis of a seizure disorder without a psychiatric disorder, and a diagnosis of both a psychiatric and a seizure disorder. Anticonvulsant use was analyzed for specific diagnostic classes by age, gender, race or ethnicity, and Medicaid eligibility categories., Results: A total of 4,522 youths in the one-year data set received an anticonvulsant (1.75 percent): 3,061 had a psychiatric disorder only, 251 had a seizure disorder only, and 611 had both psychiatric and seizure disorders. Among anticonvulsant-treated youths with diagnosis information in their records (3,923 of 4,522 youths), 81 percent had a psychiatric diagnosis and 19 percent had a seizure disorder; 71 percent of those with a seizure disorder also had a psychiatric disorder. Anticonvulsant use for seizure control was proportionally greater for those younger than five years. By contrast, a vast majority of anticonvulsant users with a psychiatric diagnosis were between five and 17 years. Among anticonvulsant-treated youths with a psychiatric diagnosis, males were approximately twice as common as females. For youths with a seizure disorder, no difference was found for gender. Mood disorders and attention-deficit hyperactivity disorder were the major psychiatric diagnoses associated with anticonvulsant use. Valproic acid products were the most commonly dispensed type of anticonvulsant., Conclusions: Recent state Medicaid data reveal that youths who use anticonvulsants are far more likely to have a psychiatric diagnosis than a seizure diagnosis. Widespread off-label use of anticonvulsants for psychiatric disorders among youths warrants attention to ensure benefits and minimize risks.

Objective: To determine the relationship between ziprasidone initial dose and treatment persistence among patients diagnosed with schizophrenia., Method: Adult Medicaid recipients (N=1096) diagnosed with schizophrenia who had ziprasidone prescription claims between July 1, 2001 and September 30, 2003, were categorized by initial dose: low (20-60 mg per day, n=464), medium (61-119 mg per day, n=320) and high dose (120-160 mg per day, n=312). Treatment persistence up to 365 days was measured using refill patterns, allowing 15-day gaps between expected refill dates. Multivariate survival analysis explored the simultaneous impact of age, gender, race, previous hospitalization, and concomitant medication usage, in addition to initial dose of ziprasidone. Sensitivity analysis tested the robustness of results with different definitions for persistence and allowable gaps between refills., Results: Discontinuation rates across the observation period (maximum, 12 months per individual) were lower for patients initiated with high-dose than low-dose ziprasidone (P=0.001). Other factors significantly associated with greater discontinuation of medication were monotherapy (versus combination therapy) and hospitalization within the 6 months prior to the index date of therapy. Black race was associated with greater discontinuation, although this was not consistent across sensitivity analyses., Conclusions: Patients with schizophrenia started on high doses of ziprasidone have lower discontinuation rates in a retrospective Medicaid database than patients started on low doses. These results were robust across various sensitivity analyses.

Objective: The aim of this study was to report the frequency of common treatment-emergent adverse events (AEs) from selective serotonin reuptake inhibitors (SSRIs) in children, adolescents, and adults., Method: AE data were obtained from all published double-blind, placebo-controlled SSRI studies of children and adolescents that separated AE findings by age group. The AE findings were pooled for purposes of age-group comparisons. Double-blind, placebo-controlled SSRI studies of adolescents (n = 2) and of adults identified in systematically identified trials (n = 22) were assessed to compare patterns and rates across the age span. Other reports, primarily from the published SSRI literature, were added to clarify the findings presented., Results: Activation and vomiting SSRI AEs were 2- to 3-fold more prevalent in children than in adolescents, and their rate was lowest in adults. Somnolence as a SSRI AE was uncommon in children; its rate increased with advancing age. Insomnia and nausea were common SSRI AEs across the age span. Activation AEs were a frequent reason for discontinuation from SSRI clinical trials in preadolescents, whereas somnolence, nausea, and insomnia AEs were the most common reasons for trial discontinuations in adults., Conclusions: Children are particularly vulnerable to specific AEs from certain medications, such as SSRIs. It is likely that the level of children's biological immaturity explains part of this phenomenon.

Objective: The expanded use of antidepressants in youth has been the subject of numerous studies and some concerns in recent years. This study describes prescription patterns of antidepressants (ATD) for youths in Germany for the years 2000-2003 and includes prescription use of St. John's Wort., Methods: Prescription data from a health insurance organization with 1.4 million members per year across Germany, of whom approximately 280,000 were under 20 years of age, were accessed. Total age- and gender-specific ATD yearly utilization rates were computed. Prevalence was defined as the dispensing of 1 or more prescriptions for an ATD per calendar year per 1000 continuously enrolled youth., Results: ATD prevalence was 3.43 per 1000 (95% Confidence Interval [CI], 3.21-3.65) in 2000 and 3.74 per 1000 (3.25-3.97) in 2003. St John's Wort products, which are approved for antidepressant use by the German drug agency, and tricyclic antidepressants (TCAs), accounted for more than 80% of antidepressant use. Although selective serotonin reuptake inhibitors (SSRIs) represented only 15% of antidepressant use, there was a doubling of its use over the 4-year period. Adolescent girls (age, 15-19 years) had utilization rates ranging from 11.44 to 13.82 per 1000, and accounted for most ATD use. Overall, females were twice as likely as males to get an antidepressant. Among users, there were low rates of multiple medication use (5.6% used more than one class of ATD, and 6.7% more than one drug)., Conclusions: Prescription patterns in Germany reveal predominate use of St. John's Wort and TCAs, which contrasts sharply with U.S. patterns, wherein SSRIs predominate. Also, in the United States, unlike Germany, 5-9- and 10-14 year olds receive sizable proportions of ATDs. Labeling status (only herbal hypericum preparations and TCAs are labeled for the treatment of depression in children and adolescents in Germany) and cost restrictions appear to influence the prescribing pattern of doctors in Germany. Recent treatment recommendations of national and international regulatory agencies need to take into account the different national situations.

Objective: The aim of this study was to compare multiple psychotropic use among youths enrolled in two U.S. mid-Atlantic state Medicaid and state Children's Health Insurance Programs (SCHIP)., Methods: Administrative data were used to examine multiple psychotropic use among youths less than 20 years of age and who were continuously enrolled in Medicaid or SCHIP programs in two states during 1999. Multiple psychotropic use referred to multiclass combinations and was defined by the number of months of multiple use. Main outcome measures were the prevalence of multiple psychotropic use and months of multiple use. Demographic and clinical characteristics, mental health visits, and common combinations were examined according to months of multiple use., Results: Among continuously enrolled youths, 21%-22% had at least one mental health-related visit, 8%-10% received a psychotropic medication, and 2%-3% received multiple psychotropic medications. Nearly one third (28%-30%) of youths with any psychotropic use received multiple medications, of which almost half was for 5-12 months. Multiclass use was more common in male, white, aged 10-14, disabled, and foster-care youths. Stimulants with antidepressants, antipsychotics, or alpha-agonists were the most common combinations., Conclusions: Multiple use occurred in nearly one third of youths with any psychotropic treatment. Additional research is needed to investigate switching patterns and the effectiveness of combined pharmacotherapy.

Objective: This study sought to determine the degree to which Medicaid eligibility categories modify disparities between black and white youths in the prevalence of psychotropic medication., Methods: Computerized claims for 189,486 youths aged two to 19 years who were continuously enrolled in a mid-Atlantic state Medicaid program for the year 2000 were analyzed to determine population-based annual prevalence of psychotropic medication by race or ethnicity and by whether the youths were eligible for Medicaid for reasons of family income, disability, or foster care placement. Logistic regression was used to assess the interaction of eligibility category and race., Results: The mean annual prevalence of psychotropic medication for the population was 9.9 percent. The prevalence was 2.17 times higher for white youths than for black youths (16.5 percent compared with 7.6 percent). However, within eligibility categories, the white-to-black disparity was 3.8 among youths who were eligible for Medicaid because their family income was below the federal poverty level and 3.2 for youths enrolled in the State Children's Health Insurance Program., Conclusions: Medicaid eligibility categories had a profound impact on the racial disparity associated with the prevalence of psychotropic medications for youths. Eligibility category should be taken into account when ascertaining the role of access, undertreatment, and culture in disparities in mental health treatment.

The one-year prevalence of use of psychotropic medications among youths enrolled in a Mid-Atlantic State Children's Insurance Program (SCHIP) in 1999 or 2000 was compared with the 1998-2000 prevalence findings for youths enrolled in four large multistate private medical insurance programs. Prevalence was significantly higher among youths enrolled in the SCHIP than among those with private insurance in all eight medication group comparisons. Unlike private insurance, the surveyed state SCHIP program did not require a copayment or have a restrictive formulary. These administrative differences may partly explain the comparatively higher rate of psychotropic use under the SCHIP.

The authors reviewed various statements describing the ethical use of placebo-controls in clinical trials involving minors. Attention was focused upon the Guidelines for the Ethical Conduct of Studies to Evaluate Drugs in Pediatric Populations, published by the American Academy of Pediatrics (AAP) (Kaufman et al. 1995). A brief review of certain key documents and a possible expansion of the guidelines are presented. Specifically, it is recommended that a review and update of guidelines for the use of placebo-controlled trials in children be undertaken by a working group comprised of stakeholders, including academic clinical and research professionals, bioethicists, consumers, members of key government agencies, and the pharmaceutical industry.

Objective: To identify approaches to improving methods for assessing tolerability and safety of psychotropic medications in children and adolescents., Method: Strengths and limitations of current methodology were reviewed and possible alternatives examined., Results: Research on the validity of safety evaluation has been extremely limited. No evidence-based "gold standard" exists. Clinical trials remain the best design to establish causality, but sample size limitations prevent the detection of infrequent, though serious, adverse events. Other designs, such as cohort and case-control studies, and approaches, such as mining of large databases, must be considered., Conclusion: The current lack of methodological standardization across studies prevents generalizations and meta-analyses. Because the issues relevant to drug safety are diverse, a variety of methodological approaches and instruments are needed. It is, however, possible to adopt standard basic definitions of adverse events, degree of severity, ascertainment methods, and recording procedures, as a common "core," to which more specific assessment instruments can be added. Systematic empirical testing and validation of safety methodology is needed.

Objective: Elicitation is an essential and critical step in ascertaining adverse events (AEs). This report reviews elicitation methods used in published clinical trials of psychopharmacological agents in children., Method: Pediatric psychopharmacology reports were reviewed for safety methods in the Medline database. Studies were included if they were published 1980 or later, provided data on AEs, and described the ascertainment methodology used for determining them., Results: A review of 196 pediatric psychopharmacology articles depicting safety assessments in clinical studies over the past 22 years revealed that there was no common method used for eliciting or reporting AE data., Conclusion: The current inconsistency in safety data ascertainment is a major limitation that likely impairs the ability to promptly and accurately identify drug-induced AEs. Research on how best to standardize safety methods should be considered a priority in pediatric psychopharmacology.

Objective: To improve the methods for long-term assessment of drug-associated side effects and advance knowledge of the safety profile of psychotropic medications in children and adolescents., Method: A multidisciplinary, interactive workshop was hosted by the National Institute of Mental Health (NIMH) and the Research Units on Pediatric Psychopharmacology network. Participants were experts in child and adolescent psychiatry, psychopharmacology, pharmacoepidemiology, and statistics from academia, the pharmaceutical industry, the Food and Drug Administration (FDA), and the NIMH. Evaluation of drug safety was examined from five perspectives: research design and methods, industry, regulatory requirements, bioethics, and practice settings. For each of these areas, special emphasis was placed on identifying barriers and generating solutions., Results: A major obstacle is the lack of standardization of the methods used for collecting safety data. The limitations of both randomized clinical trials and passive postmarketing surveillance in assessing long-term safety were recognized. The need to consider alternative approaches, such as registries and trend analysis of population-based databases, was highlighted. Recommendations were proposed together with possible approaches to implementation., Conclusions: A concerted effort by academic researchers, industry, FDA, practitioners, and NIMH is needed to standardize methods and lay the foundations for systematic research on the long-term safety of psychotropic medications in children.

Few reports have documented parental perceptions of stimulants for attention-deficit hyperactivity disorder (ADHD), despite the recent increased use of stimulants among youths. Of 302 parents recruited from six pediatric primary care clinics, 84% completed a survey of their knowledge, attitudes, and satisfaction with the medication their child was taking for ADHD. Two thirds of the parents believed that sugar and diet affect hyperactivity. Although few parents believed that stimulants could lead to drug abuse, 55% initially were hesitant to use medication on the basis of information in the lay press, and 38% believed that too many children receive medication for ADHD. Parents were more satisfied with the behavioral and academic improvement relative to improvement in their child's self-esteem. Attitudes were positively correlated with satisfaction and were more positive among white than nonwhite parents. The findings highlight parental misconceptions and reservations about ADHD medication treatment that require clarification as to whether race/ethnicity, income, and social status influence their views and use of treatments.

Objective: This study reviewed the clinical research and practice literature relating to the prevalence and patterns of concomitant psychotropic medication given to youths with emotional and behavioral disorders., Method: A MEDLINE search from 1996 through spring 2002, including a review of references from relevant published articles and reports, was undertaken to identify available information on concomitant psychotropic medication for youths., Results: The data supporting concomitant psychotropic medication for youths are almost exclusively based on case reports and small-scale, nonblind assessments. In the mid-1990s, over 20% of outpatient youths treated in community mental health centers and over 40% of youths treated in inpatient psychiatric facilities were given concomitant psychotropic medication. The rate has since increased. Psychiatrists more than primary care physicians prescribe concomitant psychotropic medication, and they show great variability in their prescribing habits. Youths with aggressive behavior, male gender, severe emotional illness, and disabling social maladjustment are most likely to receive concomitant psychotropic medication., Conclusions: Substantive systematic evidence is needed to clarify this increasingly common, inadequately researched child psychopharmacologic practice.

This study investigated racial differences in the prescription of psychopharmacologic treatments to individuals with schizophrenia. Data were derived from a patient survey and medical record review for 344 persons with schizophrenia recruited from outpatient psychiatric facilities in two States in the Schizophrenia Patient Outcomes Research Team study. African-Americans were three times more likely to receive depot antipsychotic medications (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.68-5.01) and 76 percent less likely to receive new-generation antipsychotic medications (OR: 0.24; 95% CI: 0.12-0.46), compared to their Caucasian counterparts. Chlorpromazine-equivalent antipsychotic dosages did not differ significantly between African-American and Caucasian patients. Compared to Caucasians, a larger proportion of African-Americans received antiparkinsonian medications (63% vs. 48%, chi2 = 7.01; df = 1; p = 0.008), but African-Americans were less than half as likely to receive adjunctive psychopharmacologic treatments (OR: 0.43; 95% CI: 0.27-0.71). Pronounced racial variations in the psychopharmacologic management of schizophrenia in typical clinical practice settings were observed and persisted when analyses were adjusted for selected patient demographic and clinical characteristics. A prospective, longitudinal evaluation is warranted to determine whether the observed patterns of prescribing are associated with poorer therapeutic outcomes in minority patients.

Objective: To examine changes in the full spectrum of psychotropic medication treatment for youths from 1987 to 1996., Methods: A population-based analysis of community treatment data on nearly 900,000 youths enrolled in 2 US health care systems included (1) computerized Medicaid data from 2 states (a midwestern state and a mid-Atlantic state) composed of outpatient prescription claims and enrollment records and (2) computerized prescription dispensing records from a group-model health maintenance organization. Ten 1-year cross-sectional data sets from 1987 through 1996 were analyzed., Results: Total psychotropic medication prevalence for youths increased 2- to 3-fold and included most classes of medication. The rapid growth since 1991 of alpha-agonists, neuroleptics, and "mood stabilizer" anticonvulsants was particularly notable. The 1996 prevalence of any psychotropic medication among youths younger than 20 years was remarkably similar (5.9%-6.3%) across all 3 sites, with stimulants and antidepressants consistently ranked first and second. Medicaid rates almost always exceeded health maintenance organization rates by large margins, particularly for alpha-agonists, neuroleptics, "mood stabilizer" anticonvulsants, and lithium. Youths in health maintenance organizations had rates similar to Medicaid-insured youths for antidepressants and hypnotics. Over the decade, there was a proportional increase in females receiving stimulants and in males receiving antidepressants, particularly for the 10- to 14-year-old group. The prevalence ratios of whites to African Americans narrowed substantially in 1 Medicaid site., Conclusions: Youth psychotropic treatment utilization during the 1990s nearly reached adult utilization rates. Youth findings can be used to accurately assess the duration of treatment and unforeseen practice pattern changes, and to identify safety concerns.

Objective: Adjunctive pharmacological agents are extensively used in the treatment of patients with schizophrenia. This cross-sectional study examined the prevalence of the use of adjunctive agents, the extent to which their use conforms with Schizophrenia Patient Outcomes Research Team (PORT) recommendations for adjunctive pharmacological treatment and the relationship of conformance with treatment recommendations to demographic and clinical variables and to symptoms and level of function., Method: Outpatients with schizophrenia (N=344) underwent an extensive interview, and their medical records were reviewed. Data on demographic and clinical characteristics, medications, and role functioning were collected., Results: More than two-thirds of the outpatients received antiparkinsonian agents, and 50% received an adjunctive agent other than an antiparkinsonian agent. Fifty-four (15.7%) outpatients received two or more non-anti-parkinsonian adjunctive agents. Rates of conformance with the PORT treatment recommendations for the use of adjunctive agents ranged from 49% to 65%, depending on the type of agent. Ethnicity and diagnosis were the only two patient characteristics that were consistently related to conformance with PORT treatment recommendations. The treatment recommendation for adjunctive mood stabilizers was the only recommendation for which conformance was related to multiple measures of patients' symptoms and level of function., Conclusions: Adjunctive agents are widely used in the pharmacological treatment of patients with schizophrenia, but there is a limited relationship between use of these agents in conformance with treatment recommendations and measures of symptoms and level of function. Longitudinal, prospective studies are needed to demonstrate the clinical utility of adjunctive agents.

Objective: To examine changes in antidepressant (ATD) prevalence and the sociodemographic and clinical correlates of ATD use among youths who are treated in community practice settings., Methods: A retrospective study was undertaken using large data sets from 3 US sites. Outpatient prescription and clinical service records of youths who were aged 2 to 19 and enrolled in Midwestern Medicaid (MWM) and mid-Atlantic Medicaid (MAM) state programs and a group-model health maintenance organization (HMO) were organized into seven 1-year cross-sectional data sets from 1988 through 1994 to evaluate ATD utilization patterns., Results: In 1994, ATD prevalence per 1000 youths was 19.10 (MWM), 17.78 (MAM), and 12.85 (HMO), which represented a consistent increase in prevalence from 1988-1994: 2.9-fold (MWM), 4.6-fold (MAM), and 3.6-fold (HMO). Despite the rapidly expanding use of selective serotonin reuptake inhibitors prescribed mainly for depression, more than half of ATD use in 1994 was still attributable to tricyclic antidepressants prescribed mainly for attention-deficit/hyperactivity disorder. ATD prevalence was generally predominant among 10- to 14-year-old boys and among 15- to 19-year-old girls. In the Medicaid populations, 42% (MAM) and 72% (MWM) of ATD-treated youths had primary care services, whereas the bulk of the remainder had psychiatric services. Attention-deficit/hyperactivity disorder followed by depression led the physician-reported primary care diagnoses associated with ATD use, whereas that diagnostic rank order was reversed for youths who received psychiatric services., Conclusions: ATD treatments among youths substantially increased in the 1990s. This was generated primarily by primary care providers, and thus evaluations of the outcome of ATD treatment need to target primary care in addition to psychiatric providers. Longitudinal study designs are needed to evaluate the use of ATDs in youths in regard to the duration of treatment, combination medications, and the reasons for treatment.

This cross-sectional study examines conformance to four of the Schizophrenia Patient Outcomes Research Team (PORT) antipsychotic treatment recommendations, patient and treatment setting characteristics assocated with conformance, and the relationship of conformance with outcome. Two hundred twenty-four inpatients and 358 outpatients with schizophrenia underwent an interview and review of their medical records. Demographic, clinical, and role function data were collected. Almost all inpatients and outpatients with schizophrenia or schizoaffective disorder were prescribed an antipsychotic. The majority of inpatients were prescribed an antipsychotic within the recommended dose range, whereas the majority of outpatients were prescribed an antipsychotic either below or above the recommended dose range. There were no consistent relationships between patient, geographic, and treatment characteristics and antipsychotic dose. Patients treated with conventional antipsychotic doses below the recommended dose range had significantly better role function. Prospective longitudinal studies are required to delineate the factors that may underlie this relationship.

Antipsychotic medications have been first line treatment for schizophrenia for half a century, yet few studies have assessed outpatient maintenance treatment in large populations. This article describes oral antipsychotic dosing patterns and psychotropic treatments using computerized Medicaid claims data for individuals who were diagnosed with schizophrenia and received treatment on an outpatient basis during 1991. The findings show that the mean daily oral antipsychotic dose was 729 +/- 586 chlorpromazine equivalents (CPZ-EQ) for high-potency agents and 304 +/- 328 CPZ-EQ for low-potency agents. Males, younger individuals, and African-Americans received larger mean daily doses of high-potency agents, ranging from 747 to 800 CPZ-EQ. Antiparkinsonian agents were prescribed for over 90 percent of the outpatient antipsychotic treatment exposure. In summary, young adults, males, and African-Americans were given high-potency antipsychotic medications at outpatient maintenance doses that exceeded the maximum recommended levels, despite well-established evidence that high-dose treatment offers no additional benefit. Likewise, concurrent antiparkinsonian treatment exceeded the 1990 World Health Organization recommendations.

Objective: Although there is a global concern about the increased use of psychotropic agents in children, most research literature originates in the United States and is based on figures from the first half of the 1990s. Also, few studies document the use of various types of psychotropic agents. The objective of this study was to investigate the use of psychotropic medication in children in the Netherlands and to determine whether this corresponds with previously reported figures from the United States., Methods: A drug utilization study based on computerized pharmacy dispensing records was conducted from 1995 to 1999 for children aged 0 to 19 years in the north of the Netherlands., Results: Stimulants were the most widely used psychotropic agents among 0- to 19-year-olds (prevalence: 7.4/1000 in 1999), followed by hypnotics/anxiolytics (6.9/1000) and antidepressants (4.4/1000). Prevalence rates of stimulants increased from 1.5/1000 in 1995 to 7.4/1000 in 1999. Incidence rates, proportion of girls, and duration of stimulant treatment increased as well. Changes in prevalence rates of other psychotropic agents were much smaller than those of stimulants. Finally, the vast majority of children who were treated with psychotropic agents used only 1 agent at a time., Conclusion: The prevalence of stimulant use in the Netherlands is much lower than reported previously (28/1000 children in 1995) from the United States, and differences also existed with regard to the use of other psychotropic agents and combinations of psychotropic agents. However, the increase in Dutch stimulant use agrees with the previously reported 2.5-fold increase in the United States and shows that the increased use of stimulants is not limited to the United States.

Between 1988 and 1994, data from 3 large sites revealed a 3-5 fold increase in the prevalence of antidepressant (ATD) treatment for U.S. youths aged 2-19 years. In 1994, the ATD prevalence for youths of this age ranged from 13 per 1000 (in the HMO) to 18 per 1000 (in 2 state Medicaid systems). Males predominated in the 10-14-year-olds treated with ATDs, whereas females predominated among 15-19-year-olds. Caucasians were more than twice as likely to receive ATD therapy than their African-American counterparts. Primary care providers were the major source of ATD prescriptions for youths. The leading diagnoses in primary care were ADHD followed by depression, whereas the diagnostic order was reversed for youths who received psychiatric services. This review provides details concerning these patterns and trends in ATD treatment of youths from community-based clinical data sources. In addition, the role of these data in an expanded, comprehensive psychotropic knowledge base is discussed. Finally, the implications of an expanded knowledge base for ATD treatments are discussed in regard to generating research questions on effectiveness and safety and to improve treatment consensus within a public-health perspective.

Objective: To review the numerous reports of hepatotoxic adverse drug reactions (ADRs) ascribed to pemoline that were sent to the U.S. Food and Drug Administration (FDA) between 1975 and 1996 and to describe the medical community's lack of awareness of these reports., Method: All ADR reports from 1975 through 1996 wherein pemoline was the suspect agent were obtained from the FDA MedWatch Internet site, and some details of nine pemoline-related deaths in youths were obtained directly from the FDA. The published literature on this subject was fully reviewed., Results: (1) In premarketing clinical trials with pemoline in the early 1970s, hepatic abnormalities were noted in enzyme levels (1%-3% of youths receiving maintenance treatment), during rechallenges (6 of 6), and in biopsies (2 of 2). (2) Between 1975 and 1989, 12 cases of jaundice and 6 deaths in youths ascribed to pemoline hepatotoxicity were reported to the FDA. (3) The first medical literature report of a serious ADR ascribed to pemoline was in a 1989 letter to the editor. (4) Physicians generally only became aware of serious pemoline hepatotoxicity in December 1996. (5) Pemoline use increased until 1997., Conclusion: Limitations in postmarketing surveillance and public reporting in the United States, particularly in the 1980s, largely accounted for delays in an appropriate response to pemoline hepatotoxicity.

This review of antidepressant treatments in children and adolescents emphasizes the gap between efficacy data derived from randomized clinical trials (RCTs) and the limited effectiveness data from community-based practices. Part one is a brief review of data from randomized, double-blind clinical trials to assess the evidence base for the major approved indications for antidepressants in youths. Part two reviews information gaps in the evidence from RCTs. Part three discusses nonexperimental evidence of the use of antidepressants, including surveys of prescription sales, physician surveys, and population-based data. Part four presents a comprehensive model for assessing the use of antidepressants in youths in the community. The model aims to answer a range of public health-oriented questions and is intended to improve treating physicians' and clinical care providers' ability to manage medications for optimal patient benefit. Suggestions are made for engaging health service providers, health insurers, academicians, advocates, and the government in building the necessary infrastructure to make effectiveness as vital as efficacy to the model of drug therapy evaluation.

This study's objective was to develop a methodology to apply pharmacoepidemiological research toward understanding and improving psychotropic drug use among children enrolled in Medicaid. Using Kansas Medicaid data for 1995-1996, we summarized drug claims, diagnoses, and demographics for children under 20 who received at least one psychotropic drug prescription over either year. The sequence of steps needed to assure a quality improvement role is discussed. Use of key personnel in less regulatory and more clinical data applications is critical. Illustrating this approach, we found disproportionate numbers of children receiving psychotropic drugs who were young boys and larger numbers of white children receiving psychotropic prescriptions relative to their Medicaid enrollment than either African-American or Hispanic children. Medicaid agencies can expand epidemiological capacity to understand service use among segments of the population they insure as part of an overall commitment to improving quality.

Context: Recent reports on the use of psychotropic medications for preschool-aged children with behavioral and emotional disorders warrant further examination of trends in the type and extent of drug therapy and sociodemographic correlates., Objectives: To determine the prevalence of psychotropic medication use in preschool-aged youths and to show utilization trends across a 5-year span., Design: Ambulatory care prescription records from 2 state Medicaid programs and a salaried group-model health maintenance organization (HMO) were used to perform a population-based analysis of three 1-year cross-sectional data sets (for the years 1991, 1993, and 1995)., Setting and Participants: From 1991 to 1995, the number of enrollees aged 2 through 4 years in a Midwestern state Medicaid (MWM) program ranged from 146,369 to 158,060; in a mid-Atlantic state Medicaid (MAM) program, from 34,842 to 54,237; and in an HMO setting in the Northwest, from 19,107 to 19,322., Main Outcome Measures: Total, age-specific, and gender-specific utilization prevalences per 1000 enrollees for 3 major psychotropic drug classes (stimulants, antidepressants, and neuroleptics) and 2 leading psychotherapeutic medications (methylphenidate and clonidine); rates of increased use of these drugs from 1991 to 1995, compared across the 3 sites., Results: The 1995 rank order of total prevalence in preschoolers (per 1000) in the MWM program was: stimulants (12.3), 90% of which represents methylphenidate (11.1); antidepressants (3.2); clonidine (2.3); and neuroleptics (0.9). A similar rank order was observed for the MAM program, while the HMO had nearly 3 times more clonidine than antidepressant use (1.9 vs 0.7). Sizable increases in prevalence were noted between 1991 and 1995 across the 3 sites for clonidine, stimulants, and antidepressants, while neuroleptic use increased only slightly. Methylphenidate prevalence in 2- through 4-year-olds increased at each site: MWM, 3-fold; MAM, 1.7-fold; and HMO, 3.1-fold. Decreases occurred in the relative proportions of previously dominant psychotherapeutic agents in the stimulant and antidepressant classes, while increases occurred for newer, less established agents., Conclusions: In all 3 data sources, psychotropic medications prescribed for preschoolers increased dramatically between 1991 and 1995. The predominance of medications with off-label (unlabeled) indications calls for prospective community-based, multidimensional outcome studies.

Objectives: (1) To describe temporal patterns of office visits for attention-deficit/hyperactivity disorder (ADHD) and stimulant treatment for 5- to 14-year-old US youths; (2) to compare youth visits for ADHD with and without melication according to patient demographics, physician specialty, reimbursement source, and comorbid diagnoses; and (3) to compare office visits for youths with ADHD in relation to common medication patterns (stimulants alone, stimulants with other psychotherapeutic medication, and nonstimulant psychotherapeutic medications alone)., Design: Survey based on a national probability sample of office-based physicians in the United States., Setting: Physician offices., Participants: A systematically sampled group of office-based physicians., Main Outcome Measures: National estimates of office visits for ADHD and psychotherapeutic drug visits for ADHD for each year and for a combined 8-year period., Results: Youth visits for ADHD as a percentage of total physician visits had a 90% increase, from 1.9% in 1989 to 3.6% in 1996. Stimulant therapy within ADHD youth visits rose from 62.6% in 1989 to 76.6% in 1996. While the majority of non-ADHD youth visits were conducted by primary care physicians, one third of ADHD youth visits were managed by psychiatry and neurology specialists. Health maintenance organization insurance was the reimbursement source for 17.9% of non-ADHD youth visits but only 11.7% of ADHD youth visits. Complex medication therapy was more likely to be prescribed by psychiatrists and less likely to be related to visits with health maintenance organization reimbursement., Conclusions: National survey estimates in the 1990s confirm the substantial increase in visits for youths diagnosed as having ADHD, with more than three quarters of these visits associated with psychotherapeutic medication treatment. Physician specialty and reimbursement source variables identify distinct patient populations with a gradient in psychotherapeutic medication patterns from single-drug standard (stimulant) therapy to complex multidrug treatment regimens for which evidence-based scientific information is lacking.

Objective: To capture information about the clinical characteristics of, and treatments for, children with attention-deficit/hyperactivity disorder (ADHD) in psychiatric practice., Method: A mailed, self-administered questionnaire was sent to 81 practicing psychiatrists for them to complete on the next three consecutive patients aged 14 years and younger with ADHD seen during the 12-day study period. Information collected included the sociodemographic, clinical, and treatment characteristics of sampled patients., Results: Patients in the study were predominantly white (85%), male (78%), and between 10 and 14 years old (58%). The most common ADHD subtype was combined/predominantly hyperactive (86%); 31% had no other comorbidity. Ninety-seven percent were receiving medications, with 49% receiving two or more. The single most common medication reported was methylphenidate (51% of patients) followed by clonidine (20%). Psychotropics other than psychostimulants were used in a majority of patients (55%)., Conclusions: Psychiatrists, and child and adolescent psychiatrists in particular, see a more severely impaired and complex group of patients than would be expected of primary care providers. The treatment patterns of psychiatrists for these patients do not reflect the simpler treatments usually studied in clinical trials.

Background: The authors examined recent changes in the number and proportion of patients prescribed antidepressants by psychiatrists in outpatient private practice and characterized antidepressant prescription patterns by patient age, sex, race, payment source, and clinical diagnosis., Methods: The authors analyzed physician-reported data from the 1985 and 1993-1994 National Ambulatory Medical Care Survey, focusing on visits to physicians specializing in psychiatry. Logistic regressions were used to examine associations between survey year and antidepressant prescription, adjusting for the presence of other variables., Results: The proportion of outpatient psychiatric visits in which an antidepressant was prescribed increased from 23.1% (95% confidence interval [CI], 19.7%-26.5%) in 1985 to 48.6% (95% CI, 47.5%-49.7%) in 1993-1994. After controlling for several patient variables, psychiatric patients were approximately 2.3 (95% CI, 1.8-2.9) times more likely to receive an antidepressant in 1993-1994 than in 1985. In 1993-1994, selective serotonin reuptake inhibitors accounted for approximately half of the psychiatric visits with an antidepressant prescription. Increases in the rate of antidepressant prescription were particularly evident for children and young adults; whites; new patients; and patients with adjustment disorders, personality disorders, depression not otherwise specified or dysthymia, and some anxiety disorders., Conclusions: During the late 1980s and early 1990s, there was a significant increase in the prescription of antidepressants by office-based psychiatrists. This increase was greatest for patients with less severe psychiatric disorders.

Inevitably, the greater availability of more costly antipsychotic medications has resulted in attempts to regulate the use of these agents. Early objections over the cost of treatment with clozapine or risperidone have in part been mollified by preliminary statistics on the cost effectiveness of these agents. However, this issue is complex and requires careful consideration of pharmacoeconomic principles in the development and clinical distribution of novel antipsychotics. Future cost-effectiveness studies need to consider a balance of public and private perspectives. These studies should be conducted in several settings, preferably also within the context of broader, multimodal treatment intervention strategies.

Design: A retrospective analysis was conducted using state Medicaid prescription drug reimbursement claims for youths aged 5 through 14 years according to the race of the recipients of psychotropic and medical drugs., Method: A person-based data set was created from Medicaid administrative data for fiscal year 1991 from the state of Maryland to yield the following: (1) estimates of prevalence of prescription recipients per 100 eligible enrollees; (2) relative prescription use ratios according to race (African-American versus Caucasian); and (3) the interrelation of race and geographic region on prescription prevalence., Results: Five major findings were observed: (1) African-American youths with Medicaid insurance aged 5 through 14 were less than half (39% to 52%) as likely to have been prescribed psychotropic medications as Caucasian youths with Medicaid insurance; (2) the relative difference for nonpsychotropic medication classes was much less pronounced: African-American youths were prescribed nonpsychotropic medications at a rate 60% to 87% of the Caucasian youths' rate; (3) the stimulants (essentially methylphenidate) had the most disparate African-American/Caucasian ratio (1:2.5); (4) the racial disparity for psychotropics was not altered by partial (noncontinuous enrollment) eligibility status; and (5) although geographic variation reduced the racial disparity, the substantial racial difference (1:2.0) remained., Conclusion: Compared with Caucasians, African-American youths aged 5 through 14 with Medicaid insurance coverage showed a distinctly lower rate of treatment with psychopharmacological agents.

Background: How clozapine exerts superior antipsychotic efficacy in treatment-resistant schizophrenia is not known. Moderate (rather than "full") occupancy of D2 postsynaptic receptors may be crucial, perhaps by achieving a more effective D1/D2 or serotonin-2a/D2 ratio. The objective of this study was to test the moderate occupancy hypothesis of clozapine's superior efficacy., Methods: Data from the New York effectiveness of clozapine study were used to compare 6-week clozapine treatment results in patients discontinuing oral neuroleptic medication with similar patients discontinuing long-acting depot neuroleptic. The latter group is assured "full" D2 occupancy during the 6-week clozapine treatment., Results: If moderate occupancy is crucial for superior efficacy, the oral discontinuation group should manifest more improvement. Both groups showed the 6-week improvement expected with clozapine therapeutics [31% and 29% reduction in Brief Psychiatric Rating Scale (BPRS) scores in the depot and oral groups, respectively]. An analysis of covariance (for baseline BPRS) revealed no difference in change scores (df = 1,100; F = 0.17; p = ns)., Conclusions: The reduced D2 occupancy hypothesis is rejected.

This study was undertaken to clarify several aspects of the estimation of prevalence of three commonly use pediatric psychotropic agents, namely, methylphenidate, desipramine, and imipramine. The study aims are threefold: (1) to show the variability of drug prevalence by comparing estimates from three data sources; (2) to show the misleading impression that can be created by reporting drug prevalence estimates based on counts of prescriptions rather than persons; (3) to show the utility of gender-by-age-specific prevalence of drug use as a marker for diagnosis. Two data sources that yield population-based prescription estimates were available: 1991 Medicaid administrative claims data for prescriptions from a mid-Atlantic state and 1991 prescription records of the northwest region of Kaiser Permanente, a staff-model health maintenance organization (HMO). Another source of data consists of the 1991 National Ambulatory Medical Care Survey, which records medication information reported during physician office visits. Data analysis consists of quantitative estimates of (1) drug prevalence from each source; (2) the ratio of prescription claims to persons; and (3) the proportion of drug use according to age and gender. Methylphenidate and desipramine prevalence had a twofold greater use among state Medicaid enrollees compared with HMO enrollees. Average claims-to-person ratios of 5:1 suggest better accuracy using persons with medication rather than prescription counts. Gender-by-age-specific prevalence rates showed that 75% of the drug use for desipramine among those less than 15 years old was found among males, whereas 75% of the desipramine use among those 15 or older was found among females, suggesting its use for the treatment of attention deficit-hyperactivity disorder among young males and for depression among older females. The variability of community physician decision making in pediatric psychopharmacology is better understood by observing drug prevalence rates from different settings. National sampling efforts should be undertaken to verify regional and setting-specific prevalence findings and to learn the reasons for their fluctuation.