Trends in Psychotropic Medication Costs for Children and Adolescents, 1997-2000 Andrés Martin, MD, MPH; Douglas Leslie, PhD Objective: To examine trends in psychotropic medi- cation utilization and costs for children and adolescents between January 1, 1997, and December 31, 2000. Methods: Pharmacy claims were analyzed for mental health users 17 years and younger (N = 83 039) from a national database covering 1.74 million privately in- sured youths. Utilization rates and costs for dispensed medications were compared across psychotropic drug cat- egories and individual agents over time. Results: Overall use of psychotropic drugs increased from 59.5% of mental health outpatients in 1997 (a 1-year prevalence of 28.7 per 1000) to 62.3% in 2000 (33.7 per 1000), a 4.7% increase. The largest changes in utiliza- tion were seen for atypical antipsychotics (138.4%), atypi- cal antidepressants (42.8%), and selective serotonin re- uptake inhibitors (18.8%). The average prescription price increased by 17.6% ($7.90 per prescription), a change in turn attributed to a shift toward costlier medications within the same category (55.1% of the increase, or $4.35) and to pure inflation (44.9% of the increase, or $3.55; P for trend �.001 for all comparisons). Almost half (46.7%) of the $2.7 million gross sales differential was accounted for by only 3 of the 39 drugs identified (am- phetamine compound, risperidone, and sertraline), and 75% was accounted for by 7 drugs (the previous 3 and bupropion, paroxetine, venlafaxine, and citalopram). Conclusions: Psychotropic drug expenditure increases during the late 1990s resulted from more youths being prescribed drugs, a preference for newer and costlier medi- cations, and the net effects of inflation. The impact of man- aged care and pharmaceutical marketing effects on these trends warrants further study. Arch Pediatr Adolesc Med. 2003;157:997-1004 T HE USE of psychotropic medications in children has become a highly visible is- sue, receiving regular at- tention from academics (for a recent summary, see Jensen et al1), poli- cymakers,2,3 and the lay press alike.4-6 In contrast to the controversial and at times charged reactions that the topic can en- gender, reliable national estimates of the extent of pediatric use of psychotropic drugs have only recently started to be- come available.7-9 Previous studies10,11 have documented that most psychotropic medi- cations are not prescribed by mental health specialists but rather by general practi- tioners, a pattern that is certainly appli- cable to stimulants, the most widely used psychotropic drug class for children: in 1995, pediatricians prescribed 50% of stimulants, family practitioners 20%, and psychiatrists only 13%.8 The financial implications of pediat- ric pharmacotherapy have gone largely un- examined, an important shortcoming given that in the US expenditures for prescrip- tion drugs have continued to be the fastest growing component of health care across a ...

1. Trends in Psychotropic Medication Costs
for Children and Adolescents, 1997-2000
Andrés Martin, MD, MPH; Douglas Leslie, PhD
Objective: To examine trends in psychotropic medi-
cation utilization and costs for children and adolescents
between January 1, 1997, and December 31, 2000.
Methods: Pharmacy claims were analyzed for mental
health users 17 years and younger (N = 83 039) from a
national database covering 1.74 million privately in-
sured youths. Utilization rates and costs for dispensed
medications were compared across psychotropic drug cat-
egories and individual agents over time.
Results: Overall use of psychotropic drugs increased from
59.5% of mental health outpatients in 1997 (a 1-year
prevalence of 28.7 per 1000) to 62.3% in 2000 (33.7 per
1000), a 4.7% increase. The largest changes in utiliza-
tion were seen for atypical antipsychotics (138.4%), atypi-
cal antidepressants (42.8%), and selective serotonin re-
uptake inhibitors (18.8%). The average prescription price
increased by 17.6% ($7.90 per prescription), a change
in turn attributed to a shift toward costlier medications
within the same category (55.1% of the increase, or $4.35)
and to pure inflation (44.9% of the increase, or $3.55;
P for trend �.001 for all comparisons). Almost half
(46.7%) of the $2.7 million gross sales differential was
accounted for by only 3 of the 39 drugs identified (am-
phetamine compound, risperidone, and sertraline), and
75% was accounted for by 7 drugs (the previous 3 and

2. bupropion, paroxetine, venlafaxine, and citalopram).
Conclusions: Psychotropic drug expenditure increases
during the late 1990s resulted from more youths being
prescribed drugs, a preference for newer and costlier medi-
cations, and the net effects of inflation. The impact of man-
aged care and pharmaceutical marketing effects on these
trends warrants further study.
Arch Pediatr Adolesc Med. 2003;157:997-1004
T
HE USE of psychotropic
medications in children has
become a highly visible is-
sue, receiving regular at-
tention from academics (for
a recent summary, see Jensen et al1), poli-
cymakers,2,3 and the lay press alike.4-6 In
contrast to the controversial and at times
charged reactions that the topic can en-
gender, reliable national estimates of the
extent of pediatric use of psychotropic
drugs have only recently started to be-
come available.7-9 Previous studies10,11 have
documented that most psychotropic medi-
cations are not prescribed by mental health
specialists but rather by general practi-
tioners, a pattern that is certainly appli-
cable to stimulants, the most widely used
psychotropic drug class for children: in
1995, pediatricians prescribed 50% of
stimulants, family practitioners 20%, and
psychiatrists only 13%.8

3. The financial implications of pediat-
ric pharmacotherapy have gone largely un-
examined, an important shortcoming given
that in the US expenditures for prescrip-
tion drugs have continued to be the fastest
growing component of health care across
all ages.12 The financial burden of medica-
tion-related expenditures is substantial:
whereas overall health costs increased by
7% in 2000, prescription drug spending
grew by 15%. For example, Medicaid spend-
ing on prescription drugs more than tripled
in the 1990s, from $4.8 billion (6.6% of total
Medicaid costs) in 1990 to $17.0 billion
(9.4% of total Medicaid costs) in 1999.13
The most recent national data on men-
tal health utilization and costs specific for
children and adolescents are from 1998,14
when overall national expenditures were es-
timated to be $11.7 billion ($172 per child).
Outpatient services accounted for 57% of
the total costs, inpatient services for 33%,
and psychotropic drugs for 9%. A study
based on privately insured youths15 showed
that during the same interval (1997 to 2000)
that outpatient and inpatient psychiatric
costs for American youths decreased (by
18.4% and 14.4%, respectively), medica-
tion-related expenditures increased by
12.1%. Although it is plausible that higher
psychotropic drug use may relate to cost
savings in overall mental health services (by
decreasing or obviating the need for other

4. services, such as psychotherapy), no pedi-
ARTICLE
From the Child Study Center
(Dr Martin) and the
Departments of Psychiatry and
Epidemiology and Public Health
(Dr Leslie), Yale University
School of Medicine, New Haven,
Conn; and the Northeast
Program Evaluation Center,
West Haven, Conn (Dr Leslie).
Dr Martin has received
honoraria from Janssen
Pharmaceuticals and Alza Corp
and has been involved in an
industry-sponsored clinical trial
for Bristol-Myers Squibb.
Dr Leslie has served as a
consultant to Pfizer and Purdue
Pharmaceuticals and has
received grants from
Bristol-Myers Squibb and
AstraZeneca.
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157,
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997
©2003 American Medical Association. All rights reserved.
atric cost-benefit studies have empirically addressed this
possibility, to our knowledge.

5. Both of the cited studies14,15 analyzed aggregate psy-
chotropic medication expenditures and did not provide
information on the drug classes or specific agents re-
sponsible for driving cost changes. It is against this back-
drop that this study aims to describe the main drivers un-
derlying psychotropic medication cost changes at the level
of drug classes and specific agents involved.
METHODS
STUDY DESIGN
A cross-sectional design for each of 4 years (1997-2000) was
used to characterize psychotropic medication utilization and
cost trends for youths 17 years and younger.
DATA SOURCE
We used a research database (MarketScan; Medstat, Ann Arbor,
Mich) to describe patterns of health care utilization and costs.
The database, a publicly available fee-for-service medical and
pre-
scription claims resource, contains claims information for indi-
viduals nationwide who are insured through the benefit plans
of large employers and includes more than 200 different insur-
ance companies. The working sample consisted of all individu-
als in the database 17 years and younger who had a claim for
mental health services and possible pharmacy claims data avail-
able during the study (N = 83 039). We specifically did not ex-
clude children younger than 3 years, as there is epidemiologic
evidence for increasing rates of psychotropic medication use in
this age group.16,17 Demographic information on the entire en-
rolled population (N = 1 735 486) was also available. Individual
information was stripped of any personal identifiers, stored
anony-

6. mously, and exclusively referenced through study-specific
unique
identifiers following published guidelines.18
STUDY POPULATION AND PROCEDURES
The number and 1-year prevalence of enrolled children receiv-
ing mental health services and psychotropic medications were
calculated. Mental health claims were defined as those with a
di-
agnosis within the 290.00 to 319.99 range of International Clas-
sification of Diseases, Ninth Revision, codes. Potentially
relevant
codes (eg, 799.2 for “nervousness” or 780.5 for “sleep distur-
bance”) were not included, in keeping with earlier methods.15
In contrast to that earlier study,15 in which individual youths
were
the primary unit of analysis, this study focuses on prescrip-
tions. Thus, sociodemographic and diagnostic trends seen dur-
ing the study (such as an increase in the diagnosis of bipolar
dis-
order) are examined in detail in that complementary study.15
Psychotropic medications were identified on the basis of a
comprehensive National Drug Code registry and were assigned
to 1 of 6 drug classes: (1) �-agonists, (2) antidepressants, (3)
antipsychotics, (4) mood stabilizers, (5) stimulants, and (6) anx-
iolytics and sedative-hypnotics. Antihistamines (including hy-
droxyzine hydrochloride), �-blockers, and anticholinergic
agents
were specifically excluded from analysis given the potential for
ambiguity in determining their use as psychotropic agents.
Charges associated with pharmacy claims were measured
as the actual paid amounts instead of the billed charges to pro-

7. vide a more accurate measure of cost. Paid amounts included
patient payments (deductibles or copayments) and payments
made by the patient’s insurance plan(s). Costs were adjusted for
inflation using the medical care component of the Consumer
Price
Index, with all amounts expressed as 1997 dollars.
After calculating costs for psychotropic medications as an
aggregate annual amount, costs were estimated across psycho-
tropic drug category and specific agent. Costs were estimated
as overall and per-prescription amounts. Each drug’s share of
utilization was then calculated by dividing the number of pre-
scriptions filled by (1) the number of all prescriptions in that
category and (2) the overall number of prescriptions filled in
that year. Each drug’s share of overall and class-specific utili-
zation, as well as mean prescription price, was compared across
the 4 years of study.
Next, the gross difference in psychotropic drug sales was
calculated between 2000 and 1997, and the proportion of the
total difference attributable to each medication category and
each individual agent was determined. Each drug’s attribut-
able proportion served as a weighting factor by which change
in price and change in category utilization was multiplied. By
summing the weighted price changes, an overall estimate of the
impact of medication inflation was obtained; a measure of medi-
cation shift (from one agent to another within the same cat-
egory) was similarly arrived at by summing the weighted uti-
lization changes. The fraction of overall psychotropic drug sales
that could be attributed to an increase in the number of pre-
scriptions filled was calculated by multiplying the difference
in the number of prescriptions by the mean prescription price
across the first and last study years. This amount, in turn, was
divided into portions attributable to (1) larger membership en-
rollment, (2) changing proportion of medicated enrollees, and
(3) enrollees continuing drug treatment for longer periods.

8. DATA ANALYSIS
Linear trends over time were assessed for categorical variables
by using the Cochran Mantel-Haenszel �2 test (df = 1) and for
continuous variables by using general linear models (df = 3).
Cost
trends were calculated based on log-transformed amounts.
RESULTS
POPULATION CHARACTERISTICS
Demographic and clinical characteristics of outpatient men-
tal health users in this study group have been described in
detail previously.15 Briefly, of 352 413 individuals 17 years
and younger with linked pharmacy data who were en-
rolled in 1997, 17 670 (5.0%) received outpatient mental
health services vs 26 677 (5.6%) of 473 954 in 2000, rep-
resenting a 34.5% increase in membership enrollment and
a 12.2% increase in outpatient mental health utilization rates.
PATTERNS OF PSYCHOTROPIC
MEDICATION USE
More than half of all outpatient users (60.1% across the 4
study years) were prescribed at least 1 psychotropic medi-
cation during any given year. Table 1 gives the 1-year
prevalence of psychotropic drug use across the various medi-
cation categories. In addition to giving the proportions of
outpatient mental health users dispensed psychotropic
agents, 1-year prevalence per 1000 enrollees are also given,
using the number of annual enrollees with pharmacy ben-
efits as the denominator. The overall use of psychotropic
drugs increased from 59.5% of mental health outpatients
in 1997 (a 1-year prevalence of 28.7 per 1000) to 62.3% in

9. 2000 (33.7 per 1000), representing a 4.7% increase. The
largest increases in utilization were seen for atypical anti-
psychotics (138.4%), other antidepressants (42.8%), and
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998
©2003 American Medical Association. All rights reserved.
selective serotonin reuptake inhibitors (SSRIs) (18.8%). All
categories had an increase in utilization, except for typical
antipsychotics (–58.4%) and tricyclic antidepressants
(TCAs) (–41.5%). Although the proportion of outpa-
tients dispensed stimulants remained steady at 39% (P=.14),
the prevalence of stimulant use at the enrollee level in-
creased over time, increasing from 19.4 to 21.8 per 1000
(P�.001). Except for stimulants and �-agonists, all classes
had statistically significant changes in utilization (Table 1).
AGGREGATE PSYCHOTROPIC MEDICATION
EXPENDITURES AND USE
Table 2 reports aggregate medication use and expen-
ditures. Gross expenditures increased from $4.1 mil-
lion in 1997 to $6.8 million in 2000, a 65.2% increase.
The increase represents more than just a larger enroll-
ment base, as evidenced by the fact that psychotropic drug
expenditures per enrollee increased by 22.8%. During this
time, the average prescription increased in price by 17.6%
($7.90 per prescription) (P for trend �.001). Although
46.7% more prescriptions were filled in 2000, individu-
als were, on average, dispensed fewer prescriptions an-
nually (8.1 vs 8.7 in 1997; P for trend �.001), suggest-

10. ing that most additional prescriptions were for children
continuing psychotropic drug therapy for longer peri-
ods or for newly treated youngsters.
CATEGORY-SPECIFIC PSYCHOTROPIC
MEDICATION EXPENDITURES AND USE
Table 3 presents the costs and clinical share (overall and
by category) of all psychotropic medications identified. As
anticipated, stimulants were the most commonly pre-
scribed class, accounting for 45.6% of all psychotropic pre-
scriptions in 2000. Despite the large volume of stimulant
prescriptions filled, they represented a relative reduction
(–14.4%) from the 1997 total share, a reflection of the rapid
rise in the prescription of other nonstimulant medica-
tions to this age group, notably, antidepressants and mood
stabilizers. Indeed, antidepressants increased their share
of all psychotropic drug prescriptions by 16.5%, a mean
change that does not capture the wide variability seen across
subcategories: the atypical antidepressant and SSRI shares
increased by 61.4% and 27.9%, respectively, compared with
the large reduction (–51.4%) seen for TCAs. Mood stabi-
lizers had an increase in their share (13.7%) and ac-
counted for a larger volume of psychotropic prescrip-
tions (8.6% in 2000) than did antipsychotics (5.7%). The
latter experienced a radical shift from traditional to atypi-
Table 1. Psychotropic Medication Prevalence by Drug Category
Among MarketScan* Enrollees Aged 0 to 17 Years
Psychotropic Drug Category
No. (%) per 1000 Enrollees
Change in Proportion

11. 1997
(n = 17 670)
2000
(n = 26 677) % �21† P for Trend
Any 10 516 (59.5) 28.7 16 622 (62.3) 33.7 4.7 56.55 �.001
�-Agonists 818 (4.6) 2.3 1207 (4.5) 2.6 −2.3 0.20 .65
Antidepressants 4409 (25.0) 12.5 7480 (28.0) 15.8 12.4 61.80
�.001
SSRIs 2932 (16.6) 8.3 5257 (19.7) 11.1 18.8 82.02 �.001
TCAs 1053 (6.0) 3.0 930 (3.5) 2.0 −41.5 157.12 �.001
Other 1237 (7.0) 3.5 2667 (10.0) 5.6 42.8 115.11 �.001
Antipsychotics 565 (3.2) 1.6 1344 (5.0) 2.8 57.6 105.52 �.001
Atypical 329 (1.9) 0.9 1184 (4.4) 2.5 138.4 245.52 �.001
Typical 156 (0.9) 0.4 98 (0.4) 0.2 −58.4 46.29 �.001
Mood stabilizers 972 (5.5) 2.9 1660 (6.2) 3.5 13.1 10.66 .001
Stimulants 6845 (38.7) 19.4 10 345 (38.8) 21.8 0.1 2.18 .14
Anxiolytics 685 (3.9) 1.9 1162 (4.4) 2.5 12.4 5.38 .02
Abbreviations: SSRIs, selective serotonin reuptake inhibitors;
TCAs, tricyclic antidepressants.
*Medstat, Ann Arbor, Mich.
†Cochran Mantel-Haenszel �2.
Table 2. Aggregate Psychotropic Medication Expenditures and
Use, 1997-2000*
Variable 1997 2000
Year Effect
Change, % F df †

12. Psychotropic drug expenditures, $ 4 118 337 6 803 123 65.2 NA
NA
Prescriptions, No. 91 862 134 724 46.7 NA NA
Enrollees, No. 352 413 473 954 34.5 NA NA
Psychotropic drug expenditures per enrollee, mean, $ 11.7 14.4
22.8 NA NA
Psychotropic drug expenditures per prescription, mean (SD), $‡
45.1 (64.2) 53.0 (53.0) 17.6 505.82 429 188§
Annual prescriptions per medicated outpatient, mean (SD), No.
8.7 (8.8) 8.1 (8.3) −7.2 20.47 52 560§
Abbreviation: NA, not applicable.
*All dollar amounts are adjusted for inflation and are expressed
as 1997 equivalents.
†Denominator df ; numerator df is 3.
‡For a 30-day supply; not adjusted for dose equivalence.
§P for trend �.001.
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cal agents. In fact, atypical antipsychotics had the most pro-
nounced change in their share of all psychotropic drug pre-
scriptions (113.6%). Although no attempt was made to
categorize anticonvulsants according to their primary in-
dication (psychiatric vs neurologic), the possible effect of
misclassification is small given that all patients in the da-
tabase had a psychiatric condition and that non–mood sta-
bilizing anticonvulsants (such as phenytoin) were ex-
cluded from analysis.

13. In addition to TCAs and traditional antipsychotics,
several drugs had their category share eroded by newer
and generally more expensive agents. The clearest case is
that of stimulants, where methylphenidate hydrochlo-
ride decreased its category share by 23.4%. The stimulant
class balance was largely affected by the introduction in
1996 of amphetamine compound (Adderall; Shire Rich-
wood US Inc, Florence, Ky), whose share grew to 27.3%,
offsetting the declines in the use of dextroamphetamine
sulfate (–1.1%) and pemoline (–2.8%). In a similar man-
ner, the 7.7% decrease in fluoxetine’s share of the antide-
pressants was offset by increases in the use of newer SS-
RIs (including citalopram, introduced in 2000) and atypical
antidepressants. The price of fluoxetine did not change sub-
stantially (+5.3%), reflective of the fact that generic fluox-
etine, introduced after the patent exclusivity of Prozac (Eli
Lilly & Co, Indianapolis, Ind) expired on December 31,
2000, was not yet captured in the interval covered by this
data set. Older mood stabilizers, such as lithium carbon-
ate, carbamazepine, and valproate, in turn, had their class
shares eroded by newer-generation anticonvulsants, which
experienced the most turbulent prescription shifts of any
agents. For example, the number of topiramate, gabapen-
tin, and lamotrigine prescriptions increased by 13.6-, 6.4-
and 3.3-fold, respectively.
With few exceptions, most of the newly intro-
duced agents were more expensive—at times signifi-
cantly so—than those they were supplanting. For ex-
ample, atypical antipsychotic drug costs per prescription
were on average 3.8 times higher than those of their con-
ventional counterparts; SSRIs and atypical antidepres-
Table 3. Psychotropic Medication Expenditures and Use, by

14. Drug Category, 1997-2000*
Psychotropic
Drug Category
1997 2000
Change in Share, %‡
Prescriptions
Filled, No.
Prescription
Cost,
Mean, $†
Share, %
Prescriptions
Filled, No.
Prescription
Cost,
Mean, $†
Share, %
Of
Category
Of All
Prescriptions
Of

15. Category
Of All
Prescriptions
Of
Category
Of All
Prescriptions
Stimulants
Methylphenidate
hydrochloride
38 092 35 78.2 41.7 32 081 35 54.8 25.0 −23.4§ −40.0§
Amphetamine
compound
4699 33 9.6 5.1 21 619 39 36.9 16.9 27.3§ 227.5§
Dextroamphetamine
sulfate
4016 30 8.2 4.4 4179 34 7.1 3.3 −1.1§ −25.9§
Pemoline 1917 65 3.9 2.1 647 73 1.1 0.5 −2.8§ −76.0§
Subtotal 48 724 36 100.0 53.4 58 526 36 100.0 45.6 NA −14.4§
Antidepressants
SSRIs
Sertraline
hydrochloride

16. 4340 73 17.1 4.8 8223 69 19.8 6.4 2.7§ 34.9§
Fluoxetine 6353 85 25.0 7.0 7183 89 17.3 5.6 −7.7§ −19.5§
Paroxetine 2819 65 11.1 3.1 5721 66 13.8 4.5 2.7§ 44.5§
Citalopram NA NA NA NA 2725 57 6.6 2.1 NA NA
Fluvoxamine
maleate
715 122 2.8 0.8 1717 116 4.1 1.3 1.3§ 71.0§
Subtotal 14 227 79 56.0 15.6 25 569 76 61.5 19.9 5.5§ 27.9§
Other
Bupropion
hydrochloride
3204 55 12.6 3.5 6288 64 15.1 4.9 2.5§ 39.7§
Venlafaxine
hydrochloride
717 65 2.8 0.8 2840 79 6.8 2.2 4.0§ 182.0§
Mirtazapine 126 79 0.5 0.1 855 59 2.1 0.7 1.6§ 383.1§
Other atypical 1232 24 4.9 1.3 1984 25 4.8 1.5 −0.1 14.6§
Subtotal 5279 49 20.8 5.8 11 967 61 28.8 9.3 8.0§ 61.4§
TCAs
Imipramine
hydrochloride
3414 12 13.4 3.7 2140 14 5.1 1.7 −8.3§ −55.4§
Nortriptyline
hydrochloride

17. 814 36 3.2 0.9 580 23 1.4 0.5 −1.8§ −49.3§
Clomipramine
hydrochloride
531 56 2.1 0.6 406 47 1.0 0.3 −1.1§ −45.6§
Other TCA 1130 13 4.4 1.2 898 12 2.2 0.7 −2.3§ −43.4§
Subtotal 5889 20 23.2 6.4 4024 18 9.7 3.1 −13.5§ −51.4§
Subtotal 25 395 59 100.0 27.8 41 560 66 100.0 32.4 NA 16.5§
(continued)
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sants were 4.1 and 3.4 times, respectively, more expen-
sive than TCAs, and the price ratio between lamotrigine
and lithium reached a high of 7.9.
PSYCHOTROPIC MEDICATION SALES
DIFFERENTIAL AND UNDERLYING FACTORS
Figure 1 presents the gross differential in psychotropic
drug sales between 1997 and 2000 as proportionally at-
tributed to various psychotropic drug classes and indi-
vidual agents. Antidepressants accounted for the largest
fraction of the overall sales change (46.6%), with most of
the share driven by SSRIs (30.6%). Antipsychotics fol-
lowed as a category (21.1%), with virtually all change due

18. to atypical agents. Other antidepressants, stimulants, and
mood stabilizers accounted for a similar fraction each (ap-
proximately 15%). Almost half of the overall sales differ-
ential (46.7%) was accounted for by only 3 of the 39 drugs
identified (amphetamine compound, risperidone, and ser-
traline hydrochloride), and 75% by 7 drugs (the previous
3, together with bupropion hydrochloride, paroxetine, ven-
lafaxine hydrochloride, and citalopram). Five of the 7 agents
are antidepressants, and all of them are available only as
brand name preparations given their recent introduction
to the marketplace.
The seemingly low share of the overall sales differen-
tial accounted for by stimulants (14.5%) can be under-
stood on the basis of the cost shift seen within the cat-
Table 3. Psychotropic Medication Expenditures and Use, by
Drug Category, 1997-2000* (cont)
Psychotropic
Drug Category
1997 2000
Change in Share, %‡
Prescriptions
Filled, No.
Prescription
Cost,
Mean, $†
Share, %

19. Prescriptions
Filled, No.
Prescription
Cost,
Mean, $†
Share, %
Of
Category
Of All
Prescriptions
Of
Category
Of All
Prescriptions
Of
Category
Of All
Prescriptions
Mood stabilizers
Valproate 3533 57 50.9 3.9 5328 62 48.1 4.2 −2.8§ 7.4�
Carbamazepine 1798 33 25.9 2.0 1988 33 17.9 1.5 −8.0§ −21.3§
Lithium 1238 16 17.8 1.4 1499 22 13.5 1.2 −4.3§ −13.8§
Gabapentin 192 79 2.8 0.2 1229 91 11.1 1.0 8.3§ 356.7§
Topiramate 43 95 0.6 0.0 586 150 5.3 0.5 4.9§ 870.1§
Lamotrigine 135 234 1.9 0.1 450 174 4.1 0.4 2.1§ 137.3§

20. Subtotal 6939 48 100.0 7.6 11 080 64 100.0 8.6 NA 13.7§
Antipsychotics
Atypical
Risperidone 1616 110 50.9 1.8 4240 118 58.4 3.3 7.5§ 86.8§
Olanzapine 427 218 13.5 0.5 1167 189 16.1 0.9 2.6¶ 94.6§
Quetiapine
fumarate
6 143 0.2 0.0 947 125 13.1 0.7 12.9§ NA
Clozapine 125 230 3.9 0.1 170 134 2.3 0.1 1.6¶ −3.2
Subtotal 2174 138 68.5 2.4 6524 132 89.9 5.1 −21.4§ 113.6§
Typical
Haloperidol 356 23 11.2 0.4 196 14 2.7 0.2 −8.5§ −60.8§
Pimozide 146 36 4.6 0.2 194 46 2.7 0.2 1.9§ −5.4
Thioridazine 345 13 10.9 0.4 168 16 2.3 0.1 −8.6§ −65.3§
Molindone
hydrochloride
17 41 0.5 0.0 38 78 0.5 0.0 0.0 59.1
Other typical 136 27 4.3 0.1 136 58 1.9 0.1 2.4§ −28.8§
Subtotal 1000 22 31.5 1.1 732 34 10.1 0.6 −21.4§ −47.9§
Subtotal 3174 102 100.0 3.5 7256 123 100.0 5.7 NA 62.7§
Agonists
Clonidine 3858 14 80.3 4.2 5093 14 77.1 4.0 −3.2§ −6.0§
Guanfacine
hydrochloride
948 44 19.7 1.0 1512 37 22.9 1.2 3.2§ 13.5¶

21. Subtotal 4806 20 100.0 5.3 6605 19 100.0 5.1 NA −2.2§
Anxiolytics
Buspirone
hydrochloride
762 79 33.3 0.8 1356 92 41.6 1.1 8.3§ 26.7§
Clonazepam 579 42 25.3 0.6 633 29 19.4 0.5 −5.9§ −22.2§
Lorazepam 314 50 13.7 0.3 367 54 11.2 0.3 −2.5¶ −16.8¶
Zolpidem tartrate 166 61 7.3 0.2 271 55 8.3 0.2 1.0 16.2
Other 468 26 20.4 0.5 636 39 19.5 0.5 −1.0 −3.3
Subtotal 2289 54 100.0 2.5 3263 62 100.0 2.5 NA 1.5§
Abbreviations: NA indicates not applicable; SSRIs, selective
serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.
*All dollar amounts are adjusted for inflation and are expressed
as 1997 equivalents.
†For a 30-day supply; not adjusted for dose equivalence.
‡Significance tested by Cochran Mantel-Haenszel �21.
§P�.001.
�P�.05.
¶P�.01.
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egory: the single largest increase of cost differential (25.3%)
was that of amphetamine compound (Adderall), but it was
largely offset by the 2 single largest decreases seen for the
generic stimulants methylphenidate (–8.6%) and pemo-

22. line (–2.9%). Although these opposing trends provide an-
other line of evidence for the shift effect seen within this
drug category, it is not exclusive to stimulants. Indeed, the
shift toward newer and generally more expensive medica-
tions can be conceptualized as one of the two drivers to
prescription-related cost shifts over time. The other factor
is “pure” price inflation, reflective of higher costs for the
same medications due to cost increases at the manufac-
turer, wholesale, retail, pharmacy, or all levels combined.
Figure 2 depicts the various factors accounting for
the increase in psychotropic drug expenditures. The larg-
est component, responsible for 78.3% of the increment
seen, is the volume of prescriptions filled, a change that
can be attributed to a larger enrollment base (52.9%), to
more medicated enrollees (17.5%), and to enrollees con-
tinuing medication use for longer periods (8.7%). In ad-
dition, prescription price changes, through shifts to newer
medications and pure inflation, accounted for similar parts
of the remaining portion: 11.3% and 9.6%, respectively.
COMMENT
In this study, data from a national group of privately in-
sured children and adolescents were used to examine
changes in psychotropic drug expenditures. We found that
relatively few drugs accounted for a large portion of the
change in psychotropic medication expenditures over time
and that a combination of more drugs being prescribed, a
preference for newer and costlier drugs, and the net effect
of inflation had a compounded effect on price trends.
Gross psychotropic drug expenditures for this sample
showed a $2.7 million (65.2%) increase between 1997 and
2000. Most of that change (78.3%) was due to the large in-

23. crease in the volume of prescriptions filled (46.7%). This
finding is in keeping with the observation that, particu-
larly after 1994, growth in utilization, rather than price, has
been the primary driver of increased pharmaceutical spend-
ing.19 In addition, a shift toward newer (and generally more
By Class
SSRIs
Atypical APs
Other ADs
Stimulants
Mood Stabilizers
Anxiolytics
α-Agonists
Typical APs
TCAs
By Agent
Amphetamine Compound
Risperidone
Sertraline Hydrochloride
Bupropion Hydrochloride
Paroxetine
Venlafaxine Hydrochloride
Citalopram
All Others
Olanzapine
Valproate

24. Quetiapine Fumarate
Fluvoxamine Maleate
Fluoxetine
Gabapentin
Topiramate
Buspirone Hydrochloride
Pemoline
Methylphenidate Hydrochloride
–10 – 5 2520151050 30 35
Attributed Proportion, %
Figure 1. Psychotropic medication overall sales differential,
1997-2000. Totals by class and by agent sum to 100% ($2.7
million) each. SSRI indicates selective
serotonin reuptake inhibitor; APs, antipsychotics; ADs,
antidepressants; and TCAs, tricyclic antidepressants.
9.6%
Price 2:
Pure Inflation
11.3%
Price 1:
Shift Effect
8.7%
Volume 3:
Longer Time

25. on Medication
17.5%
Volume 2:
Proportion of Medicated Enrollees
52.9%
Volume 1:
Membership
Enrollment
Figure 2. Prescription-related factors contributing to increased
psychotropic
drug expenditures, 1997-2000. The values are the percentages of
the $2.7
million difference in gross sales (equivalent to a 65.2% increase
in gross
sales between 1997 and 2000).
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expensive, brand name–only) agents and a pure inflation-
ary effect explained almost one quarter of the price change.
Expressed at the prescription level, at a time when the av-
erage price increased by 17.6% (or $7.90 per prescrip-
tion), it is estimated that 55.1% ($4.35) was attributable
to the shift effect and 44.9% ($3.55) to pure inflation.

26. The fact that the large number of new prescriptions
did not lead to a parallel increase in the number of pre-
scriptions per treated youth (a number that in fact de-
creased slightly), combined with the constant rates of mul-
tiple psychotropic pharmacotherapy20 seen (approximately
7.5 per 100 outpatients,21 data not shown), indicate that
most of the additional prescriptions in 2000 were written
for newly treated children. Stated alternatively, more in-
dividual youths were initially given or continued taking for
longer periods of time psychotropic medications rather than
a growing number being medicated with multiple agents.
A few psychotropic agents accounted for a dispro-
portionate fraction of the observed cost shifts. Almost half
of the overall sales differential (46.7%) was accounted for
by only 3 individual drugs, and 25.3% was accounted for
by amphetamine compound (Adderall) alone. Although
the price ratio between amphetamine compound and meth-
ylphenidate was low (1.1), a series of new, nongeneric
stimulant preparations had only recently been intro-
duced to the marketplace. Thus, these may be conserva-
tive estimates of price differentials given that newer and
more expensive agents that have gained stimulant market
share since then (eg, Concerta [Alza Corp, Mountain View,
Calif]) had not yet been introduced to market in 2000.
Several factors may help explain the observed trends:
1. Improved newer products and an expanding evi-
dence base. The virtual shifts from traditional to atypical
antipsychotics, or from TCAs to SSRIs, are supported by
a growing body of clinical trials specifically tailored to the
pediatric population.22 As pertinent examples, random-
ized controlled trials have documented the short-term
efficacy in children and adolescents of the SSRIs parox-
etine in major depression,23 sertraline in obsessive-

27. compulsive disorder,24 and fluvoxamine in generalized
anxiety disorder25 and of the atypical antipsychotic ris-
peridone in the treatment of disruptive behaviors in chil-
dren with subaverage intelligence26 or autism.27
2. Preference. Clinicians may have lower thresholds
to prescribe medication for conditions amenable to phar-
macologic treatment, especially when using newer agents
with more favorable safety and adverse effect profiles that
may not require as intense monitoring by specialists (eg,
serum levels with lithium or electrocardiographic moni-
toring with TCAs). Despite the steadily growing range of
effective pharmacologic treatments for psychiatrically ill
youths, a cautionary note is warranted, as clinicians may
use more psychotropic agents in the context of fewer in-
patient and outpatient resources to rely on; for example,
the increase in the use of mood stabilizers to target bipolar
and other externalizing disorders has limited underlying
supportive evidence, particularly for newer-generation an-
ticonvulsants.28 Moreover, there is a paucity of informa-
tion regarding long-term effects on the developing brain
of early and prolonged exposure to psychotropic drugs.29
3. Marketing pressures. Few truly new (ie, mecha-
nistically distinct) agents have been introduced to the mar-
ketplace during the past decade. Instead, variations of suc-
cessful compounds are crowding an existing repertoire,
a pattern that was most apparent for stimulants and SS-
RIs. Pharmaceutical industry marketing-sales and mar-
keting-research ratios have to be successively higher for
newer agents to overcome the advantages of early mov-
ers in the marketplace19: direct-to-consumer and direct-
to-prescriber advertising practices have been an increas-
ingly common mechanism for the pharmaceutical industry
to gain market share for their products.30 The effects of

28. these advertising practices on clinical practice are still
poorly understood but are likely to be substantial, as sug-
gested by the large shifts within category share occur-
ring during the relatively short interval of this study.
The public largely experiences (and pays for) the es-
calating costs of their pharmaceuticals indirectly—
through more expensive insurance premiums. Indeed, the
generous pharmacy benefits typically associated with pri-
vate insurance plans lead to increasing costs as consum-
ers become “price insensitive” and request and feel en-
titled to the latest (and more expensive) drugs.1 3
Conversely, the uninsured often pay the highest price for
drugs, as they are not covered by copayments and they lack
the bargaining clout that large insurers and pharmacies
have to obtain medications at a discount.13 As a result, those
who are insured take more medications and fill prescrip-
tions more often, and the uninsured often go without nec-
essary treatment. As a case in point, for the approxi-
mately 1 in 6 children in the United States without health
insurance, use of psychotropic agents remained far be-
low that for those covered under public or private plans
in 1996 (1.5%, 5.3%, and 4.1%, respectively).7
Such economic disparities, and the overall trends de-
scribed herein, need to be considered in the context of
potential cost savings, as it is plausible that effective phar-
macotherapy may be related to reduced expenditures in
other areas, such as hospitalization or outpatient costs.
Similar to our earlier study,15 this descriptive study can-
not provide the formal cost-benefit analyses that the field
of pediatric psychopharmacology is in need of.
This study has several shortcomings, including lim-
ited generalizability. The psychotropic utilization rates

29. reported herein (28.7 per 1000 in 1997) are signifi-
cantly lower than recently published prevalence esti-
mates derived from 1996 nationally representative samples
(39 per 1000)7 or population-based analyses of regional
community practices (59-63 per 1000).9 Although the ex-
clusively privately insured nature of our study popula-
tion can explain part of the difference in prevalence, the
estimates presented herein are also lower than those of
comparable employer-insured samples; for example, our
2000 prevalence for stimulant use (21.8 per 1000) is well
below the 1999 rate of 26.5 per 1000 reported in a re-
cent study.8 (SSRI prevalence rates were more similar
across the two studies: 11.1 and 10.3 per 1000, respec-
tively.) The prevalence estimates presented herein are in-
tended as a general guide only, as MarketScan data are
not obtained in any systematic or randomly stratified man-
ner and are thus not intended to be epidemiologically rep-
resentative. A second important limitation is the lack of
information regarding quality of care, clinical out-
comes, or patient satisfaction variables, which does not
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 157,
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©2003 American Medical Association. All rights reserved.
allow for a full cost-benefit analysis of these findings.
Third, the fact that prescription prices were not ad-
justed for dosage equivalence may have resulted in bi-
ased cost estimates, especially relevant to the calcula-
tion of market share within given drug categories.
Although real, the impact of such a factor is likely to be
small and nondifferentially distributed across drugs.

30. In conclusion, despite its limitations, this study docu-
ments how a relatively few drugs accounted for a large por-
tion of the change in psychotropic drug expenditures seen
during this interval and how a combination of more youths
being prescribed drugs, a preference for newer and cost-
lier medications, and the net effect of inflation had a com-
pounded effect on price trends. These results expand on
earlier evidence of a shift toward medication-based men-
tal health treatment modalities in children and adoles-
cents. Future studies should further address the impact
of managed care and pharmaceutical marketing effects on
these trends of clinical care.
Accepted for publication April 24, 2003.
This study was supported in part by Scientist Career
Development Award K01 MH01792 (Dr Martin); by grants
M01 RR06022, 5P01 HD1DC35482, and 5P01 HD03008
from the Public Health Service; by Research Units on Pedi-
atric Psychopharmacology contract MH97 CR0001 to Yale
University; and by a grant from the Child Health and De-
velopment Institute of Connecticut, Farmington.
This work on the costs of child psychiatry is dedi-
cated to our teacher and mentor, the late Donald J. Cohen,
MD (1940-2001), who taught us so much about the values
at the very core of our field.
We thank Robert Rosenheck, MD, John Schowalter, MD,
and James F. Leckman, MD, for their helpful comments on
earlier drafts of this manuscript.
Corresponding author: Andrés Martin, MD, MPH, Child
Study Center, Yale University School of Medicine, 230 S
Frontage Rd, PO Box 207900, New Haven, CT 06520 (e-mail:

31. [email protected]).
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What This Study Adds
Psychotropic drug use prevalence among children and
adolescents has steadily increased during the past de-
cade, with most medications prescribed by pediatri-
cians and family practitioners.
Previous studies have shown increasing psycho-

36. tropic drug expenditures at the aggregate level but have
not provided information on the drug classes or spe-
cific agents responsible for such cost trends.
Half of the gross sales differential seen in this study
was accounted for by only 3 drugs (amphetamine com-
pound, risperidone, and sertraline), and 75% was ac-
counted for by 7 drugs (the previous 3, together with
bupropion, paroxetine, venlafaxine, and citalopram).
Children receiving psychotropics more often and
for longer periods, a shift toward newer (and costlier)
agents within a same therapeutic class, and the net ef-
fects of inflation all had an impact on increased phar-
maceutical spending.
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