Are Too Many Children Being Treated with Methylphenidate?* JEAN-M. RUEL, M.D. l AND

C. PETER HICKEY, B.S.(Pharm)2

teria used to establish the diagnosis, and, for children with ADHD, whether or· not there was communication with the school and interruption of the medication during the summer recess. The information provided was reviewed and was found to . be adequate in most instances. However, in certain cases, the criteria used to establish the diagnosis or the reasons stated for using methylphenidate were questionable. The term "questionable" does not mean that the diagnosis was inappropriate but rather that the information provided did not indicate that the diagnosis was adequately established. Neither, does it mean that the treatment was inadequate; rather, the information provided did not sufficiently explain the reason methylphenidate was prescribed. Some examples of this controversial information are noted below. A complete listing is not presented because it would be too lengthy, but is available from the authors on request.

A survey was conducted of the use of methylphenidate in British Columbia during a six month period to determine if a disproportionate number of children are being treated with methylphenidate for hyperactivity. The data obtained do not indicate a problem regarding the diagnosis ofattention deficit hyperactivity disorder in children. However, the data pertaining to adults indicate that the reasons stated for prescribing methylphenidate are controversial in a significant number of cases.

A

re too many young people being misdiagnosed and medicated (l)? Concerns over whether or not too many children are being misdiagnosed and prescribed stimulant medication for alleged hyperactivity have been raised in the lay press (1,2) and scientific literature (3,4). To answer this question, a survey of methylphenidate use was conducted in British Columbia, in cooperation with the College of Pharmacists and the College of Physicians and Surgeons of British Columbia.

Results

Method

The data obtained from the pharmacies in the area identified 772 practitioners who had prescribed methylphenidate during the survey period. All the practitioners were contacted, and 600 returned the completed questionnaires pertaining to 1,131 patients (see Table I).

The greater Vancouver area and the lower mainland were surveyed; an area with a population of slightly over 1,500,000. It is bounded by Whistler to the north and the US border to the south. Pharmacists in the area were asked to report to the Bureau of Dangerous Drugs all prescriptions for methylphenidate during a six month period (March through August 1989). We then wrote to the practitioners who had prescribed methylphenidate The purpose of the survey was explained, and they were asked to complete a questionnaire for each patient for whom methylphenidate was prescribed. The questionnaire (available from the authors on request) asked for the following information: date of birth, sex, diagnosis for which methylphenidate was prescribed (attention deficit hyperactivity disorder (ADHD), narcolepsy or "other"), daily dosage, cri-

Although the diagnosis of depression was not listed on the questionnaire, it was often mentioned as the condition for which methylphenidate was prescribed. It was therefore decided to treat depression as a separate group in the analysis of the results. The diagnoses were reported as follows: ADHD - 745; narcolepsy - 227; depression - 75; "other" - 79. For five patients the diagnosis was not indicated on the questionnaire. Among the 745 patients with a diagnosis of ADHD, 533 were between five and 14 years of age (439 males and 94 females). This subgroup was studied in greater detail because of concerns about the use of methylphenidate for treating hyperactive children (see Table II).

*Manuscript received July 1991, revised September 1991. IMedical Officer, Bureau of Dangerous Drugs, Health and Welfare Canada, Ottawa, Ontario. 2Head, Prescription Assessment Section, Bureau ofDangerous Drugs, Health and Welfare Canada, Ottawa, Ontario. Addressreprintrequests to: Jean-M, Ruel, M.D., Medical Officer, Bureau of Dangerous Drugs, Health and Welfare Canada, Ottawa, Ontario KIA IB9

The daily dosage of methylphenidate was specified for 515 of these children; 499 children (97%) were prescribed 60 mg or less per day. The majority of the children, 389 (75%), received less than 40 mg per day. The average daily dosage was slightly less than 30 mg per day (26.8 mg/day). The diagnosis of ADHD was substantiated in 411 cases (77%) by communicating with the child's school. The criteria used to

Can. J. Psychiatry Vol. 37, October 1992

570

October, 1992 Table I

Number of Institutions Contacted and Questionnaires Completed

Pharmacies Practitioners

Institutions Contacted

Questionnaire Completed

Completed

362

326

90.1

772

600

77.7

%

establish the diagnosis of ADHD were considered questionable for 12 of 533 children (2.2%). With the exception of one patient with a diagnosis of epilepsy and one with a diagnosis of enuresis, the patients with a diagnosis other than ADHD were all 18 years of age or older. The majority of these patients were prescribed a daily dosage of methylphenidate of 60 mg or less. The criteria used to establish the diagnosis of narcolepsy were rated as questionable in 48 of 227 cases (21%). The following are examples of so called "questionable" criteria: "diagnosed in Vancouver Island, details not known"; "sleeps in my waiting room"; "A visitor to Canada"; "sleepiness through the day, lack of interest in work and physical exhaustion"; "Intermittent somriolence. Problems with somnolence when driving." Of the 75 patients who were diagnosed with depression, the reported criteria used for prescribing methylphenidate were judged to be questionable in 21 of the cases (28%). Examples of these controversial criteria are as follows: "Depression, lassitude. Started on this by MDs in Vancouver before her move here. They and I have tried to wean her off, but no success yet"; "Depression due to marital problems, Table II Data on Subjects with ADHD Aged Five to 14 Years n=533

Dosage • :S 60mg • >60mg • Not specified Diagnostic Criteria • Consultation • DSM-III-R • History • Diagnosis Questionable • Diagnosis not specified Treatment • Interrupted duringsummer • Not interrupted duringsummer • Not specified Consultation with the child's school • Yes

• No • Not specified

571

CHILDREN TREATED WITH METHYLPHENIDATE

499 16 18

227 135

150 12 9

351 127 55 411

87 35

lack of communication and affection. Low self-esteem" "Depression and personality disorder. Was using methyl;henidate when I took over present practice"; "Excessive fatigue and mild depression." The category of diagnosis "other" was selected for 79 ~atients. The conditions stated included the following: fangue, obesity, personality disorder, post-influenzal inanition, schizophrenia and somnolence. In 25 of these cases (32%), the criteria for prescribing methylphenidate were considered questionable. For example: "has been on methylphenidate for 15 years"; "excessive unexplained fatigue"; "obesity"; "general fatigue and drowsiness."

Discussion Although the majority of pharmacists and physicians who were contacted responded to the survey, it should be noted that some did not. It is possible that some of the practitioners who did not reply were treating patients with ADHD or narcolepsy. Also, the data pertain only to patients who were prescribed methylphenidate during the survey period. Some patients with ADHD or narcolepsy may not have been prescribed methylphenidate because other treatments were being used. For these reasons, extrapolating prevalence data from the number of cases of ADHD and narcolepsy reported in this survey would not be accurate. The greater number of male children with a diagnosis of ADHD found in this survey (approximately five males to one female) is consistent other reported findings (5). The data presented do not substantiate the existence of a problem with the diagnosis of ADHD in children nor in the dosage of methylphenidate used for that condition. However, they do not address the use of other treatments such as behaviour modification or family therapy. This is because the information requested was kept to a minimum to maximize the cooperation of practitioners involved. The data on adults however, indicate problems. In a significant number of cases (94 subjects), the criteria used to establish the diagnosis of narcolepsy and the rationale for prescribing methylphenidate for depression and other conditions were cause for concern. Also, the large number of cases (75 subjects) for whom methylphenidate was prescribed for depression was an unexpected finding. It should be noted that these observations apply only to the area surveyed and that a more extensive survey would be necessary to allow us to generalize these findings to the rest of Canada. Acknowledgements The authors thank the numerous practitioners whose co-operation made this survey possibleand ColleenTurnerfor her technical assistance.

References I. Toufexis A. Worries aboutoveractivekids:aretoomanyyoungsters being misdiagnosed and medicated? Time 1989; January 16: 65.

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2. Citizens Commission on Human Rights. Ritalin: a warning for parents and teachers. Los Angeles CA: Church of Scientology, 1987. 3. Weiss G. Controversial issues of the pharmacotherapy of the hyperactive child. Can J Psychiatry 1981; 26: 385-392. 4. Ouellette EM. Legal issues in the treatment of children with attention deficit hyperactivity disorder. J Child Neurology 1991; 6(Suppl): S68-S75. 5. Diagnostic and statistical manual of mental disorders, third edition, revised. Washington DC: American Psychiatric Press, Inc., 1987.

Resume Afin de determiner si trop d' enfants hyperactifs sont traites avec du methylphenidate, une etude a porte sur les prescriptions de methylphenidate en Colombie Britannique pendant une periode de six mois, soit du mois de mars au mois d' aout 1989. Les resultats de cette etude ne permettent pas de conclure a l' existence de problemes relies au diagnostic du trouble deficitaire de l' attention avec hyperactivite chez les enfants. Cependant les donnees relatives aux adultes indiquent que les raisons enoncees pour justifier la prescription de methylphenidate apparaissent discutables dans plusieurs cas.

Are too many children being treated with methylphenidate?

A survey was conducted of the use of methylphenidate in British Columbia during a six month period to determine if a disproportionate number of childr...
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