Trends in ADHD medication use in children and adolescents in five western countries, 2005–2012
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a psychiatric disorder with a male preponderance and a worldwide prevalence estimate of 3.4% in childhood and adolescence (Polanczyk et al., 2015), with European studies reporting lower prevalences (Döpfner et al., 2008, Green et al., 2005, Kvist et al., 2013, Meltzer et al., 2000, Russell et al., 2014) and US studies reporting higher prevalences (8.7%–10.6% (Visser et al., 2014; Wolraich et al., 2014)). Generally, studies employing DSM-IV ADHD criteria yield higher prevalences than those based on ICD-10 criteria (Döpfner et al., 2008, Ford et al., 2003). This is due to the fact that the ICD-10 equivalent of ADHD, the so-called “hyperkinetic disorder”, is a narrower and more severe subtype of the DSM-IV “attention-deficit/hyperactivity disorder”. For the sake of brevity, in the following text both disorders will be subsumised under the term “ADHD”.
In school-age children, most international clinical guidelines on the management of ADHD recommend a stepwise approach to treatment, starting with non-pharmacological interventions (Thapar and Cooper, 2016) and, if this is not successful, pharmacological treatment should be initiated. In contrast, US guidelines recommend an individual treatment plan that can include pharmacotherapy, behavioral therapy and/or psychosocial interventions, but which is not designed in a stepwise fashion (Pliszka, 2007). In preschool children with ADHD, parent training should be given priority, and – with the exception of the US (Pliszka, 2007) – prescription of ADHD medication is not encouraged (National Institute for Health and Care Excellence, 2008).
In recent years, the prevalence of ADHD medication use has increased in several countries (Burcu et al., 2016, Dalsgaard et al., 2013, Visser et al., 2014). These increases have been seen across all age groups, from young children to adolescents, and the use is increasingly continued into adulthood (Dalsgaard et al., 2013, Johansen et al., 2015).
For decades, methylphenidate has been the most commonly prescribed drug for treatment of ADHD symptoms, however, use of other drugs for the treatment of ADHD (e.g. atomoxetine, lisdexamfetamine) is increasing (Health and Social Care Information Centre, 2015). According to international treatment guidelines, methylphenidate or dexamfetamine are recommended as first-line pharmacological treatment and atomoxetine as second line in both children and adolescents (Thapar and Cooper, 2016). Long-term effectiveness and safety data are lacking, and there are concerns about safety aspects of prescribing ADHD medication in the pediatric population (Zito and Burcu, 2016). Despite largely similar treatment guidelines, the use of medication and psychosocial treatment for ADHD varies significantly between countries (Hinshaw et al., 2011, Setyawan et al., 2015). Therefore, an international comparison of medication trends is useful in order to compare medication use patterns.
In this study, we aimed to compare trends in prevalence of ADHD medication use in children and adolescents (0–19 year-olds) in Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US), stratified by sex and age. Additionally, we aimed to assess the most commonly prescribed ADHD medications.
Section snippets
Denmark
This study was performed using data from the Danish Registry of Medicinal Products Statistics (RMPS). The RMPS constitutes a national prescription database of all outpatient pharmacy-dispensed prescription medications for the 5.5 million Danish inhabitants. Each prescription record contains detailed information on the drug dispensed (including ATC code). The prevalence of ADHD medication use was calculated using an estimation of the underlying population of 0- to 19-year olds as denominator.
Germany
We
Results
In 2012, the number of children and adolescents who received ADHD medication among eligible youth were as follows: Germany: 30,747/1,414,623; Denmark: 18,585/1,203,817; the Netherlands: 5157/131,954; the United Kingdom: 4489/827,906; and the United States: 3869/105,188. From 2005/6 to 2012, there was an increase in the annual prevalence of ADHD medication use in all included cohorts (Figure 1): Netherlands cohort: 1.8%–3.9%; Germany cohort: 1.3%–2.2%; Denmark cohort: 0.4%–1.5%; UK cohort:
Discussion
The main results of this study are as follows:
1. From 2005/6 to 2012, the prevalence of ADHD medication use grew markedly in children and adolescents in European countries in contrast to a more modest change in US youth. 2. There were substantial differences between countries regarding ADHD medication use. In 2012, while the US youth had nearly seven-fold more extensive use of ADHD medications than in the UK, youth in other European countries, particularly the Netherlands and Denmark, were
Role of funding source
No funding was secured for this study.
Contributors
Dr. Bachmann conceptualized and designed the study, drafted the initial manuscript, and approved the final manuscript as submitted. Dr. Burcu acquired, analyzed and interpreted data, revised the manuscript critically, and approved the final manuscript as submitted. Prof. Glaeske acquired, analyzed and interpreted data, revised the manuscript critically, and approved the final manuscript as submitted. Dr. Kalverdijk acquired, analyzed and interpreted data, revised the manuscript critically, and
Conflict of interest
Dr. Bachmann has received lecture fees from Actelion, Novartis, and Ferring as well as payment from BARMER GEK and from AOK for writing book chapters. He has served as a study physician in clinical trials for Shire and Novartis. Prof. Glaeske and Prof. Hoffmann are active on behalf of a number of statutory health-insurance companies (BARMER GEK, DAK, TK, and various corporate health-insurance funds) in the setting of contracts for third-party payment. Prof. Aagaard has received traveling grants
Acknowledgments
The authors are grateful to the insurance funds, databases and government agencies that provided the data on ADHD use.
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Both authors contributed equally.