Introduction
Psychotropic medications are valuable tools in the multimodal approach for the treatment of mental health difficulties in children and adults. There is an acknowledgement of a huge increase in the prescribing, consumption and development of medications over the years. Currently, one in five American adults (one in four women) is taking at least one psychotropic medication, reflecting a 22% increase from 2001 to 2010 (Smith, Reference Smith2012).
The prescription of psychotropic medications to children remains an emotive issue with individuals (professionals and laymen alike) often polarised into two camps, those who agree and those who do not. There have been real concerns regarding increased prescribing. Between 1987 and 1996 in the United States, there was an almost threefold increase in all psychotropic medication use, which cut across age, race, and gender and across insurance groups (Olfson et al. Reference Olfson, Marcus, Weissman and Jenson2002). Whereas the increased use was most evident for attention-deficit hyperactivity disorder (ADHD) medications (0.6 to 2.4/100 children and adolescents), in adults there was a significant increase for antidepressants (0.3–1.0/100) with the rates of antipsychotics remaining stable (0.2/100). However, between 1994 and 2005, there has been an increase in rates of antipsychotic prescribing both in the United States and United Kingdom (America’s State of Mind, 2011; Rani et al. Reference Rani, Murray, Byrne and Wong2008).
It is difficult to know whether such a marked increase constitutes overuse, misuse or more appropriate use of medication. On the one hand, following the development of new effective medications, and perhaps coming from a low prescription base, one would want to witness an increase in their judicious use in individuals meeting diagnostic and impairment criteria for the disorder. However, recent studies suggest a levelling off of prescribing rates or even a decline disputing the perception by the popular media of a ‘runaway train’ (America’s State of Mind, 2011; Zuvekas et al. Reference Zuvekas, Vitiello and Norquist2006). The analysis by Medco Health Solutions was among 2.5 million insured Americans and reported a decline in both ADHD and antidepressant medication use in children since 2005 (America’s State of Mind, 2011). On the other hand, the public are right to be concerned about risk of ‘the medicalization of society’ and the establishment of a culture of ‘a pill for every ill’, and the unknown consequences of the use of psychotropic medication on the developing brains (Timini Reference Timini2010).
Across the United States, Europe and Australia, treatment of mental health is becoming the province of the primary care physician (Trott et al. Reference Trott, Badura, Wirth, Friese, Hollman-Wehren and Warnke1995). A study examining the trends in range and number of psychological problems presenting to general practitioners (GPs) in Australia highlights the increasing involvement by the GP in mental health management (Charles et al. Reference Charles, Harrison and Britt2011). Consequently, psychotropic medications are increasingly being prescribed by both paediatricians and GPs in addition to child psychiatrists (McNicholas, Reference McNicholas2001a, Reference McNicholas2001b; Rowe et al. Reference Rowe, Tonge and Melvin2004). The 22% increase in antidepressant use referred to by Smith was primarily attributed to the GP (Smith, Reference Smith2012). One-third of all prescriptions were written by paediatricians or family medicine physicians (Cooper et al. Reference Cooper, Arbogast, Ding, Hickson, Fuchs and Ray2006). Irish GPs are also recognised to prescribe the majority of psychotropic medication. Data from the 2006 Health Research Board National Psychological Wellbeing and Distress Survey of over 2700 adults in Ireland identified 14.3% of respondents to have a ‘mental, nervous or emotional problem’ (Doherty et al. Reference Doherty, Moran, Kartalova-O’Doherty and Walsh2007). Of these, 36.4% had used psychotropic medication in the previous year, either an antidepressant (27.4%), tranquilliser (6.8%) or some other class (6%). GPs had prescribed in 73% of cases, with only 18% having been prescribed by a psychiatrist and 9% by a different medical specialist. Another Irish study found that of the 6% of the population who had used psychotropic medication in the past year, with 4% in the previous month, 91% had received this from their GP (Department of Health and Children, 2012). Furthermore, in a large European study, the Irish as a nation were the most likely to seek help for mental health issues from their GP (91%) compared with the other nations (70%) (Gallagher & Doherty, Reference Gallagher, Doherty and Tedstone2010). This means that in Ireland the GP is in a central position to identify and manage many mental health difficulties.
Despite the increased use of medication in children, and the increased rate of prescribing by GPs and paediatricians, levels of competence among prescribers are low. Studies have identified concerns by respondents with regard to prescribing and safety information (Bramble, Reference Bramble1997; McNicholas, Reference McNicholas2001a, Reference McNicholas2001b). There has been very little pharmaco-epidemiological studies carried out in the paediatric population in Ireland and no studies have considered physicians’ attitudes to prescribing and their perceived competence levels. Therefore, the aim of this study was to examine the attitudes, knowledge and prescribing of psychotropic medication in children from clinical practitioners in Ireland.
Method
Study-specific questionnaires were sent to all consultant and senior registrars in child psychiatry, Consultant Paediatricians and GPs who operate in the Lucena Clinic Catchment area (South County Dublin and East Wicklow) (total n=300). The study-specific questionnaire was one that had been created by the first author, used previously in similar studies carried out in the United Kingdom and is attached as an appendix (McNicholas, Reference McNicholas2001a, Reference McNicholas2011b). It asked about prescribing the practice of psychotropic medication in children and adolescents. Doctors were asked the frequency of prescription, medications commonly prescribed and use of combination therapy. They were also asked about their attitude towards medication effectiveness along with the attitudes of their medical and non-medical colleagues, and the impact this had on their own practice. Questions about actual clinical practice included the age range prescribed for and the use of medication for the various disorders was considered justified. Questions were also asked in relation to doctor’s perceived competence levels and interest in psychopharmacology seminars. Chi squared analysis was carried out for categorical data, Student’s t-test for group comparisons of continuous parametric data and Mann–Whitney U-test for group comparisons of ordinal (non-parametric) data.
Results
Of the 300 questionnaires, 116 were returned yielding an overall response rate of 39%. Of the people who indicated their profession (n=111), 41 (36.9%) were child psychiatrists, 46 (41.4%) paediatricians and 24 (24%) were GPs. The majority were at the consultant level (81.3%) with 15 senior registrars. The mean age of respondents was 45.12 years (s.d.=9.46, age range 30–65), with 57% women and 43% men. Nine people did not indicate their sex.
Prescribing practices
Although half of the total sample (51.3%) had made a recent prescription, they prescribed at a low frequency (less than monthly 60.4%). They had initiated medication both for children over 12 (52.3%) and under 12 years of age (43.1%). The vast majority of child psychiatrists had been prescribed in the last 6 months (39, 95.1%), initiated both for young (95.1%) and older (97.6%) children, prescribed weekly (57.5%) and in combination (87.2%) (Table 1). Most of the respondents informed the family regarding side effects (79.4%) and the licensed indications (61.9%) a practice most commonly seen in the child psychiatry group (Table 1). Whereas more than half of the child psychiatrists (55.3%) had experienced adverse side effects with children on psychotropic medication, only 4.5% of the paediatricians and none of the GPs had this experience.
Prescribing practices
Medications prescribed frequently
Clinicians were asked to list the medications they most frequently prescribe. As a group, antidepressants (58.7%), antipsychotics (57.1%) and ADHD medication (36.5%) were the most commonly cited (Table 2). There were differences in choice of medication used across disciplines (Table 2). Nearly all child psychiatrists listed the medications they used (39/41, 95%). Atypical antipsychotics (76.9%), methylphenidate (69.2%) and fluoxetine (61.5%) were the most commonly cited medications. When other selective serotonin reuptake inhibitors (SSRIs) were listed, this was almost always (66.7%) in those clinicians also using fluoxetine. Other ADHD medications commonly used by child psychiatrists included atomoxetine (listed by 41%), with just one clinician commonly using either clonidine or dexedrine. Very few paediatricians responded to this question (n=7) and they generally restricted their prescribing to ADHD medication, almost exclusively methylphenidate. Fourteen of the 24 GPs responded (58%). Methylphenidate was the only ADHD medication commonly used by GPs (35.7%). Although antidepressants were ‘commonly’ used (64.3%), GPs were more likely to cite another SSRI (42.9%) more often than fluoxetine (21.4%). Typical antipsychotics (haloperidol, n=1) and tricyclic antidepressants (amitriptyline, n=1) were reported to be ‘commonly used’ but only within the GP group. Benzodiazepines were listed by two GPs and one child psychiatrist.
Medication commonly prescribed
Knowledge and attitudes
Respondents were asked whether there was a lower age, below which they would not consider psychotropic medication as justified. Of the respondents, 48.5% agreed with a lower age limit, with this being advocated more by child psychiatrists (76.3%) than the other two groups (34.2% paediatricians and GPs, 20%). The lower age limit differed between specialists, with GPs citing a mean lower limit of 9.8 years, paediatricians 7.9 and child psychiatrists 4.3 (age range 1–13) (Table 3).
Attitudes to prescribing medication
All respondents were asked about their overall level of competence in prescribing medication and their specific knowledge regarding adverse side effects. Child psychiatrists were fully informed of side effects, either rating their knowledge as good (51.2%) or adequate (48.8%). GPs and paediatricians were less confident. Twelve paediatricians (26.7%) rated it as poor, and a further 12 (26.7%) requested more information. Respective numbers for GPs were two (8.7%) and eight (34.8%) (Table 4). Respondents were asked whether they were aware of the ‘black box’ warnings on various psychotropic medication and all child psychiatrists who responded were (100%) compared with four (19%) paediatricians and three GPs (30%). Respondents were equally divided into those who believed that the warnings reduced the use of psychotropic medication (46.6%) and those who did not (43.8%) (Table 4).
Most respondents lacked in competence regarding their psychotropic prescribing practices (56%). From the three groups, eight paediatricians (19.5%) felt least competent, with almost half (46.5%) requesting regular seminars. Only nine GPs (39.1%) reported feeling competent, yet few indicated any interest in psychopharmacology seminars (28.6%). The majority of child psychiatrists felt competent (53.7%), but nearly all requested regular psychopharmacology seminars (92.7%). Respondents from all three groups believed that if better informed they would use psychotropic medication more often (45%) (Table 4).
All the child psychiatry responders (100%) and most GPs (84.2%) valued the use of psychotropic medication in their practice but only a third of paediatricians (32.6%) (Table 3). There was a general consensus (78.6%) that child psychiatrists should initiate psychotropic medication, but 14 (13%) felt that this could be started by either a paediatrician or child psychiatrist. Where applicable, respondents reported that their medical colleagues regularly prescribe (45.7%) and their non-medical colleagues (other non-medical professional groups working in their service) support this practice (61.9%). When this was considered by professional groups, GPs (27.8%) were most likely to believe that their non-medical colleagues would not value psychotropic medication (Table 3). A significant number of responders felt that the belief of their colleagues would influence their practice, with the child psychiatrists being most influenced (43.6%).
Medication use justification in child mental health disorders
Clinicians were asked to indicate in which child psychiatry disorders medication use was justified and to indicate whether it applied for mild, moderate or severe cases (Table 5). Nearly all clinicians felt medication was justified and had an important role to play in the treatment of most child psychiatry disorders, although in general reserving use for more ‘severe’ presentations. This was particularly true for substance use disorder (70% responded medication use was justified in severe cases only), eating disorder (63.5%), sleep (62.5%) and conduct disorder (61.7%).
Medication Justified
MDD, major depressive disorder; ADHD, attention deficit hyperactivity disorder; OCD, obsessive–compulsive disorder.
When restricted to those disorders where even mild presentations may warrant psychotropic medication use, only psychoses (59.4%), depression (20.8%) and ADHD (16.3%) were viewed by a significant proportion of the group. However, there were significant differences of opinion considering medication justification by professional group. Child psychiatrists were most likely to consider prescribing in mild psychosis (73.2%) compared with paediatricians (53.3%) and GPs (38.1%). Paediatricians and GPs were more likely to consider medication in ‘mild’ cases of depression (25.8% for paediatricians, 28.6% for GPs and 14.6% for child psychiatrists) and sleep (40% for GPs, 7.7% for paediatricians and 0% for child psychiatrists). GPs were the only group who would consider medication use in ‘mild’ cases of attachment disorders (50%), Tics/Tourette’s (37.5%), autism (33.3%) and conduct disorder (25%). Five child psychiatrists specifically mentioned the role of medication in anxiety, and Post Traumatic Stress Disorder (PTSD) and one paediatrician in neuropathic pain.
Comparisons were made using χ 2-test between those who prescribed at least monthly (39.6%) and those who seldom or never prescribed (60.4%). Clinicians who prescribed more often were more likely to be a child psychiatrist [χ 2 (1, n=108)=61.916, n=0.000], more likely to value the use of psychotropic medication [χ 2 (1, n=86)=13.647, p=0.000] and to have non-medical colleagues who value medication [χ 2 (1, n=71)=11.779, n=0.001]. They were better informed than less frequent prescribers with regard to medication side effects [χ 2 (1, n=107) 22.046, p=0.000], black box warnings [χ 2 (1, n=60)=20.706, p=0.000] but were also more likely to request additional information and psychopharmacological seminars [χ 2 (1, n=100)=13.895, p=0.000]. Junior doctors are more likely to prescribe more often than senior colleagues [χ 2 (1, n=79)=4.133, p=0.042] but do not necessarily feel more competent [χ 2 (1, n=69)=0.295, p=0.587). Clinicians were more likely to prescribe whether others in their department regularly prescribe [χ 2 (1, n=88)=5.881, p=0.015]. There was an association with professional group and perceived competence, with significantly more child psychiatrists feeling competent [χ 2 (2, n=91)=7.048, p=0.029].
Discussion
This survey suggests that psychotropic medication are generally well regarded and judiciously prescribed among the respondents. They are considered for a range of mental health conditions in children, most notably psychoses, depression and ADHD, with other indications being generally reserved for those with severe presentations. Three main drug classes stand out as being most commonly prescribed antipsychotics, antidepressants and ADHD medication corresponding with the disorder groups listed most frequently. This corresponds with the literature where the increased rates of medication use was most evident for ADHD medications, followed by a significant increase in antidepressant prescription, thus followed by an increased use of antipsychotics (Olfson et al. Reference Olfson, Marcus, Weissman and Jenson2002; America’s State of Mind, 2011).
There are interesting differences in both medication choice and indication between professional groups and seniority level. As a group, junior doctors were more likely to prescribe more often; however, once the professional group was controlled for, this was no longer significant. Within the child psychiatry group, their frequent prescribing might reflect the role the junior has on the team, perhaps being primarily involved in ADHD/medication clinics; however, it could also be that, given their more recent training, they have been more exposed to, and mindful of, recent new developments in medication, along with the increased effectiveness data and a cultural shift to increased acceptance in psychotropic medication use.
Child psychiatrists were more likely than the other groups to feel medication was justified in mild cases of psychosis (73.2%) perhaps being more aware of the need to identify prodromal stages of psychosis, to keep the period of untreated psychosis to a minimum and institute medication at the earliest phase of the illness. They were less likely that the other groups (14.6%) to feel medication was indicated in mild depression, this being consistent with the NICE guidelines that advocate Cognitive behavioral Therapy as first line treatment in such cases [National Institute for Health and Clinical Excellence (NICE), 2005]. The paediatricians who responded in general were least likely to prescribe and when they did, it was primarily restricted to methylphenidate use in ADHD. In Europe, Australia and the United States, paediatricians play a leading role in providing primary/secondary level intervention to children with psychiatry problems, and ADHD in particular (Trott et al. Reference Trott, Badura, Wirth, Friese, Hollman-Wehren and Warnke1995); McNicholas, Reference McNicholas2001a; Rowe et al. Reference Rowe, Tonge and Melvin2004). Although paediatricians in Ireland have expressed a wish to be more involved in the diagnosis and management of both ADHD and autism, from those responding it would seem that this is not, as yet, the case (O’Keeffe & McNicholas, Reference O’Keeffe and McNicholas2011). One paediatrician reported common use of both carbamazepine and gabapentin. Although the invitation letter expressly asked for psychotropic medication use in conditions other than epilepsy, it is not possible to infer whether these antiepileptic medications have been used as mood stabilisers or for other indications.
The medication class most frequently used by GPs were antidepressants with 9/14 reporting they commonly use them. Three GPs used fluoxetine most commonly, but six GPs preferred to use a different SSRI. Of these, one GP was aware of a black box warning (reporting epilepsy/febrile convulsions), one was not aware and the other seven did not respond. Three of these respondents felt that the black box warning would not reduce their prescribing practice; the other six left the question unanswered. Recent concerns regarding an increase in suicidal thinking in young children when prescribed SSRIs led to a number of regulatory warnings. The FDA placed a black box warning on all SSRIs in 2004 and the UK committee on Safety and Medicines approved fluoxetine as the only SSRI in adolescents with major depressive disorder, recommending its prescription to be by a specialist in child mental health (US Food and Drug Administration, 2004; Medicines and Health Care Products Review Agency, 2004). The Irish Medicine Board reminded clinicians that there is no licensed SSRI for use in adolescent depression in Ireland (Irish Medicines Board, 2003). It is also recommended that the family is informed of this suicidal risk, and although all responded that they verbally alert the family to side effects, given the lack of knowledge of black box warnings, the data do not instil confidence that the specific suicidal risk is being communicated. The use of typical antipsychotics and tricyclic antidepressants in child psychiatry have generally been replaced by newer developments based on enhanced efficacy and side effect profile (Rani et al. Reference Rani, Murray, Byrne and Wong2008). Both classes were listed by two GP respondents as being medications they frequently used. Benzodiazepines were also listed by two GPs and one child psychiatrist, although it is now acknowledged that their usefulness is severely limited by risk of dependence and reserved for use in acute agitation, psychosis or for short-term use in severe anxiety (College of Psychiatry in Ireland, 2012). GPs were more likely to consider medication use in ‘mild’ cases of attachment disorders (50%), Tics/Tourette’s (37.5%), autism (33.3%) and conduct disorder (25%).
Accepting the small sample size, these differences might suggest differences by professional group based on knowledge (or lack of), patient type presenting to their service or may reflect idiosyncratic practice. It is well known that individual variation contributes to significant difficulty establishing accurate pharmaco-epidemiological data. It highlights the importance of ensuring that those clinicians, who are prescribing, even if at a low frequency rate, are well informed of efficacy and safety data.
Most of the respondents reported feeling reasonably confident in their knowledge of side effects and in their level of competent prescribing. Despite this, the majority requested ongoing psychotropic medication seminars and believed that more knowledge would lead to increased prescribing. This links with previous research studies, which have shown that self-assessed levels of competence in prescription practice among prescribers is low, with many feeling that they have inadequate information in relation to drug safety (Bramble, Reference Bramble1997; McNicholas, Reference McNicholas2001a, Reference McNicholas2001b). A study carried out in the United Kingdom assessing child psychiatrists’ competency levels in psychotropic prescribing found that only 25% of the sample (n=107) felt competent (McNicholas, Reference McNicholas2001a, Reference McNicholas2001b). Similarly, a study on paediatricians revealed that, despite more than half the group believing that they should have a leading role in such prescribing, only 21.2% felt sufficiently competent and two-thirds requested additional information (McNicholas, Reference McNicholas2001a).
It was noteworthy that GPs were least likely to request additional seminars (28.6%), even when they valued psychotropic medication in their own clinical practice (84.2%), rated their competence level as low (60.9%) and recognised that increased knowledge would lead them to prescribe more often (45%). There was an overwhelming belief that such medication prescribing should be initiated by a child psychiatrist (82.6%). This suggests perhaps that GPs do not perceive themselves as having a lead role in regular prescribing for mental health disorders.
The reality, however, is different as increasing mental health needs outstrip available child psychiatry services and by default or design, community services and GPs play a lead role. Irish GPs do in fact prescribe psychotropic medication regularly to both adults and older adolescents and there is an acceptance by the population of that role, with the Irish patients more likely than other European nations to seek psychological help and treatment from their GP (Doherty et al. Reference Doherty, Moran, Kartalova-O’Doherty and Walsh2007; Gallagher & Doherty, Reference Gallagher, Doherty and Tedstone2010). This need for GPs to take on this role requires that GPs are adequately trained and follow guidelines particularly when they are prescribing in the paediatric population (Rowe et al. Reference Rowe, Tonge and Melvin2004). The finding in this study that GPs frequently use an SSRI other than fluoxetine in the paediatric population, and that 70% were unaware of any black box warnings, suggests a lack of knowledge regarding established clinical guidelines and regulatory advice. The recommendation to restrict SSRI use in depression to fluoxetine has been specifically included in clinical guidelines for GPs, which make the responses of this study alarming (Rowe et al. Reference Rowe, Tonge and Melvin2004).
The overwhelming majority of non-medical colleagues were supportive of the role of medication (61.9%). It is regrettable that the study questionnaire did not elicit what non-medical staff worked in each setting. Typically, Child and Adolescent Mental Health Services (CAMHS) are multidisciplinary, with clinicians from psychology, social work, nursing, occupational therapy, and speech and language therapy. Paediatricians who work in a hospital setting may have non-medical colleagues from physiotherapy, dieticians, as might GPs. Non-medical colleague support was understandably most pronounced in child psychiatry settings (92.5%), where staff may well have been familiar with the evidence-based literature regarding medication effectiveness, and where they may be exposed to real-life scenarios of beneficial response. However, a significant number of non-medical staff were perceived to be unsupportive of psychotropic medication use (5%), within child psychiatry settings (16.2%), paediatric and (27.8%) in general practice. Nearly one-third of respondents (31.2%) reported being influenced by the beliefs of their non-medical colleagues with regard to medication use, the highest in the child psychiatry group (43.6%). This emphasises the need to provide appropriate psycho-education in medication use to non-medical colleagues, parents and society at large.
There continues to be significant controversy regarding the overuse of medication in child mental health disorders (Sparks & Duncan, Reference Sparks and Duncan2004). There has been some qualitative work carried out between 2009 and 2011 in Ireland, which highlights parental concern regarding over-reliance on medication in ADHD (Edwards & Reference Edwards and HowlettHowlett, Reference Edwards and Howlett2013). Parents’ desire to expand the therapeutic options in ADHD beyond medication was met with the commissioning of research. Another qualitative study highlighted parental concern (n=486) and guilt over the use of psychotropic medication in children, in this case, children with autism (Mackintosh & Goin-Kochel, Reference Mackintosh, Goin-Kochel and Myers2013). Parents expressed concern about giving their children medication, even when they believed these were effective. There was a sense that ‘it was inherently wrong to give medication to children’.
Sensational reporting adds to the illusion that clinicians, egged on by pharmaceutical companies, are overprescribing dangerous medication for children with diagnoses that better reflect social constructs rather than true neurobiological disorders (Timini, Reference Timini2010). While public concern and close vigilance is essential to ensure the most appropriate and unbiased practice, such polarised views are not helpful, and may deny children in need of medication an improved quality of life. In fact, a recent American study on over 10 000 adolescents aged 13–18 found that in adolescents with mental health disorders only a minority (14.2%) had received any psychotropic medication in the previous year, with treatment for ADHD being most common (31% of cases) followed by mood disorders (19.7%), suggesting neither overuse nor misuse (Merikangas et al. Reference Merikangas, Jian-ping, Rapoport, Vitiello and Olfson2013).
Rates of medication use are not well established in Ireland especially among the paediatric population. Within the general adult population, 6% had used psychotropic medication in the past year, 4% in the previous month [National Advisory Committee on Drugs (NACD) & Drug and Alcohol Information and Research Unit (DAIRU), 2007]. This rate is similar to the European average of 7% and significantly lower than American rates of 20% (Gallagher & Doherty, Reference Gallagher, Doherty and Tedstone2010; Smith, Reference Smith2012). The only available data in Irish paediatric groups refer to children prescribed an antidepressant between the years 2001 and 2004 (Bennett et al. Reference Bennett, Teeling and Feely2005). Using the General Medical Service (GMS) claims database, Bennett et al. estimate a rate of antidepressant use in 0.43% of the eligible population (under 16) compared with rates of 16.9% of the adult (>16) population. The rate of prescribing was highest in the 12–15 year age group with a rate of 8.7/1000. It must be noted that the GMS database is a means-tested scheme, providing free medication and other services, and only about 28% of children fall into this category. There was no significant increased use of SSRIs during this period. The willingness to accept psychotropic medication as an accepted part of a multimodal treatment for children are probably multifactorial, including factors such as accepted practice, cultural beliefs, availability of other treatments, previous personal or family experience, to name a few.
Professionals view is also important. This study reports that more than a quarter of GPs (27.8%) believe their non-medical colleagues do not support the use of such medications. The study also reports that for a significant number of responders, particularly child psychiatrists (43.6%), their prescribing practice is influenced by the belief of their non-medical colleagues. More recently, in Ireland, prescriptive authority for nurses has come into force since 2007, and despite significant legislative and clinical barriers, it has generally been welcomed by the clinical nurse specialists and perceived positively by patients, including parents of paediatric patients (Lockwood & Reference Lockwood and FealyFealy, Reference Lockwood and Fealy2008; Drennan et al. Reference Drennan, Naughton, Allen, Hyde, O’Boyle, Felle, Treacy and Butler2011). Future research in medication attitudes and knowledge will need to include this professional group.
Limitations
This study is limited by the relatively low response rate (39%) with the possibility of response bias. There was also a very low number of GPs compared with national numbers, although the GPs were all selected from one CAMHS area limiting the generalizability of the results within this professional group to that specific CAMHS area. However, it includes a more representative number of both child psychiatrists and paediatricians. It offers subjective views of practice rather than any objective measure, and the possibility of poor recall or socially desirable responses cannot be ruled out. Given the paucity of data on psychotropic medication use in children in Ireland, despite the limitations cited, it offers initial and important insights into clinician practice and attitudinal beliefs.
Conclusions
There is an increasing evidence base of the effectiveness of medication in the management of many childhood mental health disorders. This study suggests that Irish child psychiatrists are prescribing on a regular basis in a wide range of disorders and together with their colleagues value the role of medication in their own practice. If we believe that in certain conditions medication is warranted, and maybe even be the treatment of choice, as recommended by various clinical guidelines, then the barrier of insufficient knowledge having an impact on prescribing rates is of concern. The study also suggests an increasing role for paediatricians and GPs in this area, but with an acknowledgement of lack of perceived competency in this area. While nearly all child psychiatrists expressed a wish for regular seminars in this area, fewer of the other groups did. Despite the lack of enthusiasm for regular seminars, particularly among the GPs responders, ongoing knowledge in this area should be encouraged and is essential to good clinical practice, particularly as there is a recognised increasing reliance on primary care services to respond to mental health problems. This study adds to the research gap in the use of psychotropic medication by different professionals in Ireland by examining the attitudes, knowledge and prescribing practices from clinical practitioners. It highlights attitudinal and practice differences across professional groups, including educational requests and knowledge deficits. By monitoring trends of psychotropic medication use and type, within paediatric and CAMH services, and comparing individual clinics with national averages, along with reference to international data, this should ensure appropriate and evidenced base medication use. A nationwide database relating to the prescription of psychotropic drugs would help in this regard and should be established. By including the service users’ perspective on treatment offered, including access to ‘a comprehensive range of interventions in primary care’ as set out by A Vision for Change (2006), this will ensure that biomedical–scientific therapeutic advances are linked with holistic and effective care and rooted in good clinical practice (Department of Health and Children, 2006).
This study has highlighted certain deficits in knowledge from practitioners and the need for ongoing professional development.
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