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Recent Trends in Medication Treatment
A recent report in Psychiatric Services (Bhatara, V.S. et al, 2002, 53, 244) highlights a striking increase in the use of combination pharmacotherapy in which stimulants are used with other medications for treating children with ADHD.
Data from this report comes from the National Ambulatory Medical Care Survey (NAMCS), an annual survey of a representative sample of U.S. office-based physicians. According to these data, the proportion of times during which a second medication was prescribed in addition to a stimulant medication (e.g. Ritalin, Adderall, Concerta) for treating ADHD patients under age 18 increased from about 5% during 1993-94 to almost 25% during 1997-98. This represents a five-fold increase. The most commonly prescribed medications in combination with a stimulant were Clonidine and various antidepressants.
What is concerning about this trend is that there is virtually no safety or efficacy data to support combined pharmacotherapy for ADHD youth. Thus, the rapid increase in this practice is occurring in the absence of any research-based support. Although most experts regard the safety and efficacy of stimulant medications as well established, there is little evidence that adding other agents to stimulant medication treatment results in significantly better outcomes for youth with ADHD. And, we know little about the long-term safety of combined medication treatment.
It is worth noting that in the MTA study -- the largest treatment study of ADHD ever conducted, there were very few children treated with stimulant medication where an additional medication was added to their treatment. This was true even though many of the children in the study had co-morbid conditions such as depression or anxiety disorders for which other agents might have been used and suggests that when stimulant medication treatment is carefully conducted, the need for combining stimulants with other medications is likely to be far less frequent than the increasing use of this practice would suggest.
The authors of this report close by emphasizing, "definitive safety and efficacy data are needed to support common forms of combined pharmacotherapy among youths." In the meantime, it is important for parents and physicians to be aware that these data are currently lacking, and that the increasingly frequent practice of combining stimulants with other medications may be necessary less often than it is recommended.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.