The Wall Street Journal recently reported that a study of prescription patterns in 2009, conducted by IMS Health, showed that 25 percent of children in the U.S. were on regular medication.
IMS Health is a firm that provides marketing intelligence to pharmaceutical companies. The firm's job is to keep the $800 billion per year global pharmaceutical industry on a continued pattern of growth. Hopefully these consultants accomplished something quite different this week. Hopefully they provided our citizens with an overdue wake-up call.
One in four children in the U.S. are on chronic prescription medications. This doesn't even include all the prescriptions we write to treat acute illness, or the use of over-the-counter products. It is an astounding number. We either have the sickest pediatric population in the world, or there is something very wrong with the way therapies are driven in our health care system.
The WSJ article goes on to discuss some very significant concerns about the situation -- like how difficult it is to run clinical studies on children, and how much of our pharmaceutical data -- including dosing and side effects -- is drawn from adult populations and applied to children (fingers crossed!) These are serious concerns to be sure, but it's a modern version of "The Emperor's New Clothes." Those of us on the sideline are worrying if the emperor's hat clashes with his shoes, when what we should really be paying attention to -- and shouting about -- is the fact that good lord, he's naked!
One in four children in the U.S. are on chronic medications!
According to IMS Health data, 45 million children are on asthma medications, 24 million are on ADHD medications, almost 10 million are on antidepressants with another six and a half million on other antipsychotics. Then there are the antihypertensives, the sleep aids, the medications for Type 2 diabetes and high cholesterol, and on and on.
Are the conditions these medications are designed for, like ADHD and bipolar disorders, real? Absolutely. Are our diagnostic criteria usually clear and well established? No.
Is the scientific information that doctors rely on for diagnosis and treatment free of bias and conflict of interest? Absolutely not.
Do our third party insurers reimburse physicians and psychologists in such a manner that mood disorders, attentional problems and other conditions in the psychoeducational realm are likely to be evaluated and managed by the most appropriate professionals? Again, more often than not, no.
Some of these children are certainly benefiting from long term medication. Optimal asthma control, for instance, can be life changing for a child. Depression is real and needs to be treated seriously. But over the broad range of approximately 100 million children taking daily medication in this country, have we consistently formulated long range goals and benefits?
Do we understand the longterm effectiveness of these medications compared to meaningful nonpharmaceutical intervention? No.
No. Absolutely not. No. No!
Our system of private, fee-for-service insurance is basically a business model that focuses on the top of the health care pyramid (the doctor) and pays for quick fixes (prescriptions) with immediately observable (short term) results. That works great for bacterial pneumonia; not so much for a kid bouncing off the walls, or gaining too much weight, or who is sad. Nowhere is this disconnect more glaring than in the realm of mental health.
Health insurance companies have determined, by virtue of their reimbursement strategies, that the work of treating serious mental illness would shift to primary care providers. A recent study by the AAP predicts that treatment of mental illness and mood disorders will soon make up 30-40 percent of a pediatrician's office practice (1).
To put this trend in perspective, an earlier study that appeared in the journal Pediatrics revealed that 8 percent of pediatricians felt they had adequate training in prescribing antidepressants, 16 percent felt comfortable prescribing them, but 72 percent actually did.
Well of course they did. If they don't, who will? This is just one example of the growing disconnect between best medical practice and the way we deliver health care.
Furthermore, where do both pediatricians and psychiatrists get most of their information about these psychotropic medications that are flying off prescription pads? The pharmaceutical companies that produce them, through the hundreds of millions of dollars they spend each year on marketing and the clinical studies they fund. Health insurers and pharmaceutical companies are not necessarily the bad guys here. They are doing what we have tasked them to do: run a business.
What should be driving our health care? Should it be evidenced-based medical science, wrapped up in a little common sense and kept at a distance from special interest? Should the emphasis be on clinical effectiveness rather than customer service (I'd like my hip replacement next week, thank you very much)? Should the financial incentives foster improved longterm health for all of us rather than healthy quarterly profits? If that's what we want then we need to redesign the system from the bottom up.
In order to frame meaningful health care debate in this country, we have to look at the consequences of doing business-as-usual. This data from the pharmaceutical industry illustrating the degree to which to we medicate our children underscores the ways our health care system has gone off track. We need to acknowledge that naked truth.
One in four children in the U.S. are on chronic medications.
1. AAP department of Community and Specialty Pediatrics. "Resources Help Primary Care Clinicians Address Mental Health Concerns." AAP News 31 (7) 34
2. Jerry L. Rushton, et al. "Pediatrician and Family Physician Prescription of Selective Serotonin Reuptake Inhibitors." Pediatrics 105 (6): e82
Maggie Kozel, M.D. is the author of "The Color of Atmosphere: One Doctor's Journey In and Out of Medicine," forthcoming from Chelsea Green Publishing. Follow her blog at barkingdoc.com