To our knowledge, this is the first national estimation of psychotropic prescriptions in children and adolescents in France. Its originality is the comparison of official national health insurance data with epidemiological data based on a self-completed questionnaire. These epidemiological statistics provide some interesting information about the reasons for psychotropic drug use among adolescents.
The main limitation of the study is the restricted access to the CNAM-TS database (only one region) and the absence of access to the MSA database. However, we constructed a model which is liable to deal with this limitation: a range estimate is provided, which takes into account the absence of data from the MSA insurance
This calculation of a nationwide estimate highlights several trends:
In comparison with other European and North American countries, the frequency of overall psychotropic prescription in France is similar to that in United Kingdom (approximately 2%), Netherlands (2.9%), and Germany (2.0%). It is higher than Italy (0.3%) and lower than the USA (6.7%) [17–27].
A recent study conducted in France in MGEN affiliates found similar rates of overall psychotropic frequencies of 2.1% vs 2.2% in our study . The frequency of methylphenidate and SSRI prescription is a bit higher in our study (0,1% for psychostimulants and 0.4% for antidepressants in the MGEN study versus 0.15% for methylphenidate and 0.5% for SSRI). For anxiolytics, the comparison is difficult because the MGEN study takes herbal medicines into account.
In France, the profile of prescriptions is however different. Antipsychotics and benzodiazepines seem to be prescribed at a higher level than in many European countries, whereas methylphenidate appears to be less prescribed. A hypothesis can be proposed to explain this point: under-diagnosis of ADHD and the use of symptomatic treatments such as antipsychotics and benzodiazepines to deal with externalized disorders in children and adolescents.
For methylphenidate prescriptions, the maximum of prevalence rate is obtained at 8 years for boys and at 10 years for girls. This probably reflects the delay in the diagnosis of ADHD between boys and girls.
The ESCAPAD survey is based on a self-completed questionnaire. Its analysis provides some additional and complementary information. Almost 15% of the adolescents aged 17 in 2005 took medication "for nerves or to sleep".
If homeopathy and plants are removed, we obtain prevalence for consumption of psychotropics of 9% in 17 year-old adolescents. This percentage is higher than the prescription prevalence derived from the social security databases (4.1-4.4% at the age of 17).
This suggests that either some adolescents obtain psychotropic drugs without medical prescriptions, or that they take psychotropic drugs legally obtained with earlier medical prescriptions.
Indeed, in 2003, 49.7% of the adolescents aged 17 who took some kind of medication for their nerves or to sleep in previous 12 months reported that they obtained it via a doctor the last time they took it (table 7); this corresponds to almost 4.5% of the 17 year-old adolescent population. This prevalence appears very close to the prevalence noted in the prescriptions (4.1%).
ESCAPAD also gave some indications about the purpose of psychotropic medication for adolescents. The main purpose is different between boys and girls. Girls use psychotropics to deal with anxiety whereas boys use pyschotropics to treat sleep disorders. The use of psychotropics for stimulation or for fun reaches 10% for girls and approximately 15% for boys. It would be interesting to study how this type of use evolves, and which drugs are the most widely consumed in these indications.
In addition, psychotropics can be used to treat physical heath problems in children.
We checked all official physical indications for the psychotropics studied and looked for information on non official indications.
It appears that tricyclic antidepressants are used to treat enuresis in children and could be marginally use to treat pain. In this study, only SSRIs were taken into account to avoid this bias. There are no physical indications found for this therapeutic class.
Methylphenidate has another official indication which is narcolepsy. We cannot know the proportion of methylphenidate used to treat narcolepsy. Empirically, it is likely to be very rare.
Antipsychotics have no official indication to treat physical health problems in children. Haloperidol is used although infrequently as an antiemetic drug.
Concerning benzodiazepines, the question is more difficult. Indeed, benzodiazepines are also indicated to treat epilepsy in children and in rare instances used as analgesic. In our study, it is impossible to know whether benzodiazepines are used to treat anxiety or epilepsy. To our knowledge, in France, there is no publication giving an estimation of the rates of benzodiazepines used against anxiety or epilepsy. Empirically, the proportion of benzodiazepines used to treat epilepsy is likely to be very low compared to psychiatric indications. In addition, other prevalence studies in children do not specify the aim of the prescription for benzodiazepines. Thus, the prevalence estimation in our study can be compared to other studies.