39.4: Other Controversial Issues

Juveniles and Psychopharmacology

A recent Centers for Disease Control (CDC) report has suggested that as many as 1 in 5 children between the ages of 5 and 17 may have some type of mental disorder (e.g., ADHD, autism, anxiety, depression) (CDC, 2013). The incidence of bipolar disorder in children and adolescents has also increased 40 times in the past decade (Moreno et al., 2007), and it is now estimated that 1 in 88 children have been diagnosed with an autism spectrum disorder (CDC, 2011). Why has there been such an increase in these numbers? There is no single answer to this important question. Some believe that greater public awareness has contributed to increased teacher and parent referrals. Others argue that the increase stems from changes in criterion currently used for diagnosing. Still others suggest environmental factors, either prenatally or postnatally, have contributed to this upsurge.

We do not have an answer, but the question does bring up an additional controversy related to how we should treat this population of children and adolescents. Many psychotropic drugs used for treating psychiatric disorders have been tested in adults, but few have been tested for safety or efficacy with children or adolescents. The most well-established psychotropics prescribed for children and adolescents are the psychostimulant drugs used for treating attention deficit hyperactivity disorder (ADHD), and there are clinical data on how effective these drugs are. However, we know far less about the safety and efficacy in young populations of the drugs typically prescribed for treating anxiety, depression, or other psychiatric disorders. The young brain continues to mature until probably well after age 20, so some scientists are concerned that drugs that alter neuronal activity in the developing brain could have significant consequences. There is an obvious need for clinical trials in children and adolescents to test the safety and effectiveness of many of these drugs, which also brings up a variety of ethical questions about who decides which children and adolescents will participate in these clinical trials, who can give consent, who receives reimbursements, etc.

The Elderly and Psychopharmacology

Another population that has not typically been included in clinical trials to determine the safety or effectiveness of psychotropic drugs is the elderly. Currently, there is very little high-quality evidence to guide prescribing for older people— clinical trials often exclude people with multiple comorbidities (other diseases, conditions, etc.), which are typical for elderly populations (see Hilmer & Gnjidic, 2008; Pollock et al., 2008). This is a serious issue because the elderly consume a disproportionate number of the prescription medications prescribed. The term polypharmacy refers to the use of multiple drugs, which is very common in elderly populations in the United States. As our population ages, some estimate that the proportion of people 65 or older will reach 20% of the U.S. population by 2030, with this group consuming 40% of the prescribed medications. As shown in Table \(\PageIndex{1}\), it is quite clear why the typical clinical trial that looks at the safety and effectiveness of psychotropic drugs can be problematic if we try to interpret these results for an elderly population.

Table \(\PageIndex{1}\): Characteristics of Clinical Trial Subjects vs. Actual Patients

*OTC = over the counter

Reprinted by permission from Schwartz and Abernethy (2008).

Clinical Trial Subjects	Aged Patients Who Receive Drug Therapies
One drug	Drug of interest and medications
Single dose	Chronic administration
No disease	Multiple diseases
No alcohol, tobacco, OTC* drugs, nutraceuticals	OTC* drugs, nutraceuticals, alcohol, tobacco, and other
20–40 years (vs. 60–75 years)	65–100+ years
Caucasians	Caucasians and minorities
Selection bias	All comers/socioeconomic basis

Metabolism of drugs is often slowed considerably for elderly populations, so less drug can produce the same effect (or all too often, too much drug can result in a variety of side effects). One of the greatest risk factors for elderly populations is falling (and breaking bones), which can happen if the elderly person gets dizzy from too much of a drug. There is also evidence that psychotropic medications can reduce bone density (thus worsening the consequences if someone falls) (Brown & Mezuk, 2012). Although we are gaining an awareness about some of the issues facing pharmacotherapy in older populations, this is a very complex area with many medical and ethical questions.

This module provided an introduction of some of the important areas in the field of psychopharmacology. It should be apparent that this module just touched on a number of topics included in this field. It should also be apparent that understanding more about psychopharmacology is import- ant to anyone interested in understanding behavior and that our understanding of issues in this field has important implications for society.

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