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This was published 6 years ago
Over 16,000 Australian children prescribed antipsychotics, PBS data shows
A mufti day at school, knee-length shorts and a teenage taunt triggered Kalei's first panic attack.
In hindsight, it is easy to see the warning signs. At the time, Kalei's mum Kim* thought it was just teenage angst.
Kim (left) with her daughter Kalei, son Xander and Xander's companion cat Orpheus. Credit: Wolter Peeters
"But when I found out she was cutting herself, that's when I realised: 'Oh my god, something's really wrong here' ... she was 15 years old," Kim said.
Kalei started seeing a psychologist and tried non-pharmacological strategies like cognitive behavioural therapy to keep her intrusive thoughts and anxiety in check.
But by the time she had turned 17, she had tried repeatedly to kill herself, and medication became the last resort.
A total of 16,570 toddlers, children and teenagers under 17 were prescribed antipsychotics in 2015, Pharmaceutical Benefits Scheme data seen by Fairfax Media shows, amounting to a cost of more than $4.1 million to the PBS.
The data builds on mounting evidence that the drugs are being overprescribed and too often used as a first line treatment in children, despite the risk of harmful side effects.
With the guidance of a psychiatrist and psychologist, Kalei and her mother decided Kalei should take the antipsychotic quetiapine, then later sodium valproate, along with an antidepressant, to treat her depression, anxiety and bipolar disorder.
But opting for medication was not a decision the family made lightly - and it was one they avoided completely for Kalei's younger brother Xander, 15, who has an autism spectrum disorder.
"In no way would we try antipsychotics without trying every other evidence-based strategy first," Kim said.
"Kalei needed [the medication], but she takes them in combination with psychological support and we review her medication regularly with her doctor."
Xander relies on non-pharmacological strategies to great effect, including a companion cat, Orpheus, and regular psychologist appointments covered by the National Disability Insurance Scheme, instead of taking risperidone, an antipsychotic used to treat severe ASD.
More children receiving antipsychotics
The latest PBS data suggests rates of antipsychotic prescribing among children are on the rise, with numbers growing by about 4000 between 2012 and 2015.
In 2012, an estimated 12,680 children and teenagers were taking antipsychotics, according to the Pharmaceutical Benefit Advisory Committee's Drug Utilisation Sub Committee report.
By 2015, 1,383 children aged two to six were being prescribed antipsychotics, predominantly risperidone, data obtained by the Citizens Committee on Human Rights shows. The figures from the Department of Human Services do not include private scripts.
Psychotropic drugs were prescribed to 6,030 children aged seven to 11, and 9,156 children aged between 12 and 16.
Risperidone significantly outstripped all other antipsychotics in all three age groups.Quetiapine - indicated for bipolar and schizophrenia - was the second-most prescribed antipsychotic, most notably among 12- to 16-year-olds.
Drugs used first line instead of last resort
Experts say the rising rates of prescribing go beyond the increasing numbers of children and teenagers being diagnosed with ASD or psychosis and the controversial widening of diagnostic boundaries.
Dr Paul Robertson, the chairman of the child and adolescent psychiatry faculty at the Royal Australian and New Zealand College of Psychiatrists, said he suspected the drugs were being prescribed inappropriately.
It's an assertion backed up by data from the Australian Commission of Safety and Quality in Healthcare, which found huge variations in PBS antipsychotic prescriptions across local areas.
The rates of antipsychotic prescriptions in the Southern Highlands (6,895 per 100,000) was 22.5 times higher than the areas with the lowest prescribing rates, in Western Australia's Augusta and Margaret River area (306 per 100,000).
"This sort of variation makes you wonder what's going on here. It's enough to say not everyone is providing treatment in the same way," Dr Robertson said.
"One of the concerns is that prescribing medication is easier to do than delivering evidence-based, high quality psychosocial interventions. Where there is a shortage of resources, you worry that medications are relied on too much."
Dr Robertson said the risperidone figures in particular were "very high".
"It suggests to me that there are children not getting access to early intervention and psychological interventions available for behavioural disturbance in autism spectrum disorder.
"These children should be severely impaired by ASD if they need this sort of treatment. They should have really big problems," Dr Robertson said, including high levels of distress and disturbed, disruptive behaviour.
He said antipsychotic medication should not be used in isolation, but in conjunction with psychological therapy and social support at home and school.
Used as a behaviour restraint, not psychosis treatment
Some doctors were inappropriately prescribing the drugs as a form of behaviour control in children with ADHD and oppositional defiant disorder, said Dr Emily Karanges, from the UNSW Centre for Big Data Research in Health.
"It's used as a calming agent," said Dr Karanges, whose research canvasses psychotropic use in children and adults.
Similarly, quetiapine was being prescribed for sleep and anxiety problems, she said.
The potential risk of damaging side effects alone was reason enough for doctors to exercise a high level of caution when considering prescribing antipsychotics to children.
"Many antipsychotics carry a high risk of weight gain. When you're talking five kilograms or more in the first three months it's just awful. It's an enormous amount of weight on a child."
Risperidone especially had a significantly high risk of prolactin elevation, which can sometimes cause breast development and milk production in children.
"In the worst, very rare cases you get breast development in boys.
"We [also] know antipsychotic treatment can damage certain areas of the brain in the long term.
"If you change the way the brain works in a child it can change the way that child's brain develops. This can have lasting effects in adulthood – on emotion, reasoning, social development and anxiety.
"The brain is so complex and we're using a very blunt instrument on a sensitive, very crucial organ at a very important stage of development.
"There are cases where it makes sense to use them, of course.
"If you have a child who is presenting with psychosis then you don't mess around. Or if they're floridly manic then giving them an antipsychotic is absolutely justifiable, but a cautious approach is best."
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*The family requested their surname not be published