We thank our correspondents for their responses to our article (1). We agree with Neraal that antipsychotic prescriptions (if indicated at all) should generally take second place to psychotherapeutic treatments in conduct disorders. In several regions of Germany the deficit in psychotherapeutic services is indeed still substantial.
On the other hand, it needs to be pointed out in this context that traditional individual psychotherapy is usually not indicated in conduct disorders and that there are no indications of its efficacy in this setting (2). The current UK guidelines are methodologically of a high quality and recommend, depending on age group, primarily parent training programs or multimodal interventions (for example, multisystemic therapy) (3). Especially the latter forms of therapy are hardly available at all in Germany and should be disseminated, in order to help avoid unwarranted antipsychotic prescribing.
As far as the prescribing specialty is concerned it needs to be borne in mind that we analyzed all antipsychotic prescriptions (first prescriptions and subsequent ones). If a pediatrician issues a follow-on prescription for risperidone for a child with conduct disorder and substantial impulsiveness after the initial diagnostic assessment and prescription has been performed by a child and adolescent psychiatrist, then we think that this is most likely safer (and guideline conform ), as long as potential adverse events are monitored appropriately, than if the therapy had been initiated by a colleague from another specialty.
With regard to Kohns’ mention of the KiGGS study, we would like to point out that, by contrast to the meta-analysis cited in our article, the KiGGS data is cross sectional and not based on clinical diagnoses, but on symptom screenings of various child and adolescent psychiatric disorders.
In our study, 19.4% of all patients with a prescription for risperidone (data not shown in the article) had a diagnosis of ADHD without comorbid conduct disorder. In our opinion, this would indicate a significant proportion of non-guideline-conform treatments.
We wholeheartedly agree with the complaints raised by both Kohns and Calia regarding the unsatisfactory service provision for children and adolescents with conduct disorders. In our view, however, what is particularly aggravating is the lack of evidence based therapeutic services (for example, the popular anti-aggression training sessions with a group consisting only of children with conduct disorders are ineffective and therefore contraindicated). Happily, many of our European neighbors have long risen to the huge societal challenges posed by conduct disorders and antisocial behavior not only in childhood but also in adulthood and have accordingly initiated comprehensive changes to the provision of healthcare services. These initiatives have sprung not least from solid economic considerations, since high quality evidence based therapeutic and prevention programs can save costs in the long term (4). In view of the enormous extent of the “new morbidity,” such an initiative would be extremely welcome in Germany too.
apl. Prof. Dr. med. Christian J. Bachmann
Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie,
Fachbereich Medizin, Philipps-Universität Marburg
PD Dr. P.H. Falk Hoffmann, MPH
Gesundheitspolitik und Versorgungsforschung, Zentrum für Sozialpolitik,
Conflict of interest statement
Prof. Bachmann has received lecture fees from Actelion, Novartis, and Ferring as well as payment from BARMER GEK for writing a chapter in a book. He has served as a study physician in clinical trials for Shire and Novartis.
PD Dr. Hoffmann is active on behalf of a number of statutory health-insurance companies (BARMER GEK, DAK, TK, and various corporate health-insurance funds]) in the setting of contracts for third-party payment.
|1.||Bachmann CJ, Lempp T, Glaeske G, Hoffmann F: Antipsychotic prescriptions in children and adolescents—an analysis of data from a German statutory health insurance company from 2005–2012. Dtsch Arztebl Int 2014; 111: 25–34. VOLLTEXT|
|2.||Bachmann M, Bachmann C, John K, Heinzel-Gutenbrunner M, Remschmidt H, Mattejat F: The effectiveness of child and adolescent psychiatric treatments in a naturalistic outpatient setting. World Psychiatry 2010; 9: 111–7. MEDLINE PubMed Central|
|3.||National Institute for Health and Care Excellence (NICE). Antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management. NICE Clinical Guideline 158. The British Psychological Society and The Royal College of Psychiatrists. Leicester/London 2013. |
|4.||Bachmann C, Lehmkuhl G, Petermann F, Scott S: Evidenzbasierte psychotherapeutische Interventionen für Kinder und Jugendliche mit aggressivem Verhalten. Kindh Entw 2010; 19: 245–54. CrossRef|