Nationwide Time Trends of Psychiatric Inpatient Medications for Children and Adolescents in Finland from 2000 to 2018

Abstract

Background:

The use of psychotropic medication among children and adolescents has increased, but long-term studies on inpatients are scarce.

Methods:

In Finland, nationwide inpatient data among children and adolescents (<18 years) were collected on one day from three different years, 2000, 2011, and 2018. Medication use was analyzed according to medication groups, individual medications, and the number of medications. Additional information included diagnoses and severity measures of suicidality, violence, and functional impairment. Logistic regression was used to analyze the changes between 2000 and 2018 and between 2011 and 2018.

Results:

The most robust increase was observed in attention-deficit/hyperactivity disorder medications (between 2000 and 2018 odds ratio [OR]: 21.74, 95% confidence interval [CI]: 7.75–58.82 and between 2011 and 2018 OR: 2.20, 95% CI: 1.37–3.52), followed by antipsychotics (OR: 3.15, 95% CI: 2.34–4.24 and OR: 1.35, 95% CI: 1.02–1.81, respectively), and antidepressants (between 2000 and 2018 OR: 1.87, 95% CI: 1.36– 2.57). The use of benzodiazepines decreased notably between 2011 and 2018 (OR: 0.09, 95% CI: 0.03–0.22). When diagnoses and severity measures were included in the multivariate analysis, the increases were associated with respective diagnoses, being adolescent, and the severity of the condition.

Conclusions:

Medication use increased vastly between 2000 and 2018, but levelled off between 2011 and 2018. Explanations include changes in clinical practices, the surface of new medications, increased awareness of neuropsychiatric disorders, and the replacement of benzodiazepines. More information on the long-term effects of increased use of antipsychotics and multi-medication is warranted.

Keywords

adolescent psychiatry child psychiatry inpatients longitudinal studies psychotropic drugs

Introduction

Child and adolescent mental health treatment rates have increased substantially, and psychotropic medication use has become more common (Hartz et al., 2016; Olfson et al., 2014; Steinhausen, 2015). Whereas the majority of children and adolescents who receive psychiatric care are treated in outpatient services (Duong et al., 2021), the most intensive and acute treatment is provided in inpatient care. Patients in psychiatric wards typically suffer from severe disorders, suicidality, aggression, functional impairment, and multimorbidity. Thus, these patients need effective care, and psychotropic medications are often used. Information on inpatient treatment is important for improving treatment and its cost-effectiveness.

Previous time-trend studies have found that the use of psychotropic medication among child and adolescent inpatients increased during the 2010s. These studies reported increased use of antidepressants, namely selective serotonin reuptake inhibitors (SSRIs), second-generation antipsychotics, and mood stabilizers (Gilat et al., 2011; Kronström et al., 2018; Meagher et al., 2013; Song and Guo, 2013). The number of medications increased while the length of stay decreased (Kronström et al., 2018; Meagher et al., 2013). The trends in diagnoses varied between the studies. Meagher et al. (2013) observed an increase in anxiety and bipolar disorders and a decrease in unipolar depression and trauma diagnoses, whereas Song and Guo (2013) observed a decrease in schizophrenia. Most of these studies have covered periods limited to 10 years. Meagher and colleagues (2013) observed a time period of 17 years, but the last year in the analysis was 2008. Other limitations of previous studies are that some have used hospital records to collect data retrospectively (Gilat et al., 2011; Meagher et al., 2013; Song and Guo, 2013). The data was therefore limited to diagnoses and medication, and, moreover, was restricted to a certain hospital or region. Only one study conducted in Finland has used nationwide data by collecting repeated cross-sectional questionnaires from clinicians (Kronström et al., 2018).

In Finland, the changes in psychotropic medication use for child and adolescent inpatients have been studied for almost 30 years (Kronström et al., 2018; Piha et al., 1992; Sourander, 2004; Sourander et al., 2002). Increases began as early as the 1990s, as the share of adolescent inpatients treated with medication increased from 30% in 1991% to 68% in 1998(Haapasalo–Pesu et al., 2004). FTime-trends were further studied by Kronström and colleagues (2018) among both children and adolescents: the use of psychotropic medication among both child and adolescent inpatients increased between 2000 and 2011 from 19% to 40% and from 57% to 70%, respectively. However, these increases were not associated with the severity or diagnostic profiles of children and adolescents (Kronström et al., 2018). The data collected in Finland are unique considering the study’s nationwide approach and repeated cross-sectional design, covering a 20-year period. The data was collected through surveys of clinicians, which enabled an examination of the severity of the cases by asking about suicidal and violent behavior and functional impairment.

The present study is a continuation of the previous nationwide studies on inpatient data in Finland (Kronström et al., 2018; Piha et al., 1992; Sourander, 2004; Sourander et al., 2002). The aim was to observe the overall trends in psychotropic medication use, trends in attention-deficit/hyperactivity disorder (ADHD) medications, antidepressants, antipsychotics, and anxiolytics, as well as trends in the use of individual medications. In addition, the aim was to observe whether the trends differed among children and adolescents. The hypothesis was that overall psychotropic use increased between 2000 and 2018 and between 2011 and 2018 in both children and adolescents.

Methods

Sample

The data for the current study were gathered cross-sectionally at three timepoints, in 2000, 2011, and 2018, covering 18 years of inpatient medication trends. Nearly all child and adolescent inpatient units in Finland participated in the study (64/69 in 2000; 75/79 in 2011; 54/58 in 2018), which enabled the observation of national time trends. The study design has been thoroughly described previously (Kronström et al., 2018; Sourander et al., 2002). Questionnaires were sent to all child and adolescent psychiatry wards in Finland, and the clinicians filled in the questionnaires for every inpatient admitted to the ward on one chosen study day. The clinicians were requested to provide information on the continuous medications (previously ongoing or recently started daily medication, not including “when-needed” medications) of each patient. Day patients who were treated in the wards on that day were also considered inpatients for this study. In Finland, children younger than 13 years old are treated in children’s wards, whereas adolescents aged 13–17 are treated in adolescent wards. Patients aged 18 or older are treated in adult wards and are therefore not included in this study. The sample sizes for each study year are described in Table 1. The number of child and adolescent inpatients varied between 360 (in 2018) and 504 (in 2000). The response rate of the ward clinicians was good, varying from 93% (in 2000 and 2018) to 95% (in 2011).

Table 1.

Sample

Study year	Total sample size^a	Girls n (%)	Boys n (%)	Missing n (%)	Mean age (SD)	CGAS 1–30 n (%)	Suicidal acts n (%)	Violent acts n (%)
2000
Total	504	191 (38)	294 (58)	19 (4)	12.4 (3.4)	37 (7.9)	54 (10.8)	135 (27.2)
Children	239	46 (19)	185 (77)	8 (3)	9.5 (2.0)
Adolescents	263	145 (55)	108 (41)	10 (4)	15.1 (1.4)
2011
Total	412	205 (50)	207 (50)	0	12.8 (3.2)	68 (17.2)	42 (10.3)	93 (24.6)
Children	169	34 (20)	135 (80)	0	9.2 (1.9)
Adolescents	229	162 (71)	67 (29)	0	15.2 (1.4)
2018
Total	360	199 (55)	161 (45)	0	12.7 (3.1)	71 (19.8)	52 (14.4)	73 (20.5)
Children	154	55 (36)	99 (64)	0	9.7 (2.0)
Adolescents	206	144 (70)	62 (30)	0	15.1 (1.3)

Inpatient units (participated units/all units): 64/69 in 2000; 75/79 in 2011; 54/58 in 2018.

CGAS, Children’s Global Assessment Scale.

Outcomes

Changes in continuous medication use were observed between 2000 and 2018 and between 2011 and 2018. Medications were examined as groups of (1) ADHD medications, (2) antidepressants, (3) antipsychotics, and (4) benzodiazepines. Additionally, specific medications were examined separately if the number of users for each medication was sufficient (>than 20 or 4% of inpatients having the medication in one of the study years 2000, 2011, or 2018). The number of medications that a patient was taking, from the same or different medication groups, was recorded as (1) No medications, (2) one medication, (3) two medications, or (4) ≥3 medications. Changes were examined among the whole population, and supplementary analyses were conducted for children under 13 and adolescents aged 13–18 separately, due to an observed age–study year interaction.

Other variables

The questionnaire administered to clinicians provided background information on patients’ gender, age and family structure and included the following severity assessments: (1) general functioning measured with the Children’s Global Assessment Scale (CGAS) (Shaffer et al., 1983) (categories: CGAS 1–30; 31–50; 51–100), (2) suicidality measured with the Spectrum of Suicidal Behavior Scale (Pfeffer et al., 1982) (categories: no suicidal thoughts or acts; suicidal thoughts; suicidal acts) and (3) violence measured with the Spectrum of Assaultive Behavior Scale (Pfeffer et al., 1993) (categories: no violent thoughts or acts; violent thoughts; violent acts). In addition, clinicians were requested to fill in the diagnoses in the patient records according to the International Classification of Diseases, Tenth Revision. For this study, the first diagnosis and any possible second diagnosis were included in the analyses. One patient could appear in more than one diagnostic group. However, a diagnosis was only included if it applied to more than 10 inpatients, or 3% of the study cohort, in at least one year’s sample. The observed diagnoses are listed in Supplementary Table S1.

Ethics

Ethical approval for this study (data collected in 2018) was received from the Ethics Committee of the Hospital District of Southwest Finland (now called the Ethics Committee of the Wellbeing Services County of Southwest Finland). For the previous data collections, the ethics board of the University of Turku stated that, considering the methodology of the study, no ethical approval was needed. The data did not include identifiable information of the study population in any of the study years.

Statistical methods

Frequencies were calculated for each outcome: medication groups, each individual medication, and number of medications, and potential confounders. The differences between the confounding factors were tested with Pearson’s chi-square test or Fisher’s exact test at different timepoints, 2018 versus 2000 (reference being 2000) and 2018 versus 2011 (reference being 2011). For each outcome, odds ratios (OR) and 95% confidence intervals (95% CI) of increased medication use in 2018 compared with 2000 and 2011 were calculated using univariate logistic regression. In the multivariate logistic regression model, the year 2000 was used as a reference. Age group–study year interaction was tested (children vs. adolescents). p Values of less than 0.05 were considered significant. All statistical analyses were carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Results

A description of the sample is provided in Table 1. Of the total samples for each year, 52%–57% were adolescents. Boys made up a total of 45% (2018) to 58% (2000) of all patients. The proportion of girls increased from 19% to 36% among child inpatients and from 55% to 70% among adolescent inpatients during the study period (2000–2018). The mean age of the patients was 12.6 (3.2 SD) in the whole sample, 9.5 (1.9) among children, and 15.1 (1.4) among adolescents. Further details of the sample have been described in Table 1, including the frequencies of CGAS, suicidality, and aggression each year.

The overall medication use was examined among the whole study population. First, the medications were examined as medication groups (ADHD medications, antidepressants, antipsychotics, and benzodiazepines). The use of ADHD medications increased vastly from 0.79% in 2000 to 15.0% in 2018 (OR: 21.74, 95% CI: 7.75–58.82) and doubled between 2011 (7.0%) and 2018 (OR: 2.20, 95% CI: 1.37–3.52). The use of antidepressants increased from 19.7% in 2000 to 31.3% in 2018 (OR: 1.87, 95% CI: 1.36–2.57). The use of antipsychotics increased from 23.9% in 2000 to 49.7% in 2018 and also increased between 2011 (42.2%) and 2018 (OR: 3.15, 95% CI: 2.34–4.24 and OR: 1.35, 95% CI: 1.02–1.81, respectively). The use of benzodiazepines decreased extensively from 13.8% in 2011 to 1.4% in 2018 (OR: 0.09, 95% CI: 0.03–0.22).

Second, medications were examined individually. The use of various medications increased between 2000 and 2018, but the use of notably fewer medications increased between 2011 and 2018. Between 2011 and 2018, increases were observed for sertraline (3.6%–7.5%; OR: 2.15, 95% CI: 1.12–4.10), aripiprazole (5.1%–9.2%; OR: 1.88, 95% CI: 1.07–3.31), and methylphenidate (5.6%–10.6%; OR: 2.00, 95% CI: 1.17–3.42). Detailed data are presented in Table 2.

Table 2.

Change in Individual Medications Among Children and Adolescents

Continuous medication,	2000 n (%)	2011 n (%)	2018 n (%)	2018 vs. 2000 OR (95% CI)	2018 vs. 2011 OR (95% CI)
Antidepressants	93 (19.7)	118 (29.7)	113 (31.3)	1.87 (1.36 to 2.57)^***	1.09 (0.80 to 1.48)
Citalopram	36 (7.1)	2 (0.49)	1 (0.28)	0.04 (0.005 to 0.27)^**	0.57 (0.05 to 6.32)
Escitalopram	0 (0.0)	30 (7.3)	19 (5.3)	NA	0.71 (0.39 to 1.28)
Fluoxetine	26 (5.2)	55 (13.4)	50 (13.9)	2.97 (1.81 to 4.86)^***	1.05 (0.69 to 1.58)
Mirtazapine	18 (3.6)	20 (4.9)	9 (2.5)	0.69 (0.31 to 1.56)	0.50 (0.23 to 1.12)
Sertraline	7 (1.4)	15 (3.6)	27 (7.5)	5.76 (2.48 to 13.37)^***	2.15 (1.12 to 4.10)^*
Antipsychotics	113 (23.9)	168 (42.2)	179 (49.7)	3.15 (2.34 to 4.24) ^***	1.35 (1.02 to 1.81)^*
Aripiprazole	0 (0.0)	21 (5.1)	33 (9.2)	NA	1.88 (1.07 to 3.31)^*
Olanzapine	29 (5.8)	28 (6.8)	33 (9.2)	1.65 (0.98 to 2.78)	1.38 (0.82 to 2.34)
Quetiapine	0 (0.0)	72 (17.5)	71 (19.7)	NA	1.16 (0.81 to 1.67)
Risperidone	29 (5.8)	58 (14.1)	59 (16.4)	3.21 (2.01 to 5.12)^***	1.20 (0.81 to 1.77)
ADHD medications	4 (0.79)	30 (7.0)	53 (15.0)	21.74 (7.75 to 58.82)^***	2.20 (1.37 to 3.52)^**
Methylphenidate	4 (0.79)	23 (5.6)	38 (10.6)	14.75 (5.22 to 41.73)^***	2.00 (1.17 to 3.42)^*
Benzodiazepines	8 (1.6)	57 (13.8)	5 (1.4)	0.87 (0.28 to 2.70)	0.09 (0.03 to 0.22)^***
Oxazepam	4 (0.79)	24 (5.8)	0 (0.0)	0.17 (0.009 to 3.30)	NA
Other psychotropic medication
Melatonin	1 (0.2)	44 (10.7)	43 (11.9)	68.23 (9.35 to 498)^***	1.13 (0.73 to 1.77)

p value <0.05.

<0.01.

***

<0.001.

ADHD, attention-deficit/hyperactivity disorder; 95% CI, 95% confidence intervals; OR, odds ratios.

There was significant interaction between age and study year for antipsychotic medication (p = 0.02) but not for ADHD medications (p = 0.08) or antidepressants (p = 0.3). The medication groups were also studied separately for child and adolescent inpatients due to the observed interaction. There was a significant increase in the use of antipsychotics among children from 2000 to 2018 (OR: 4.41, 95% CI: 2.54–7.68) but no longer between 2011 and 2018 (OR: 1.02, 95% CI: 0.64–1.63). No other medication group showed significant changes among children. Among adolescents there were significant increases in the use of ADHD medication between 2011 and 2018 (OR: 3.98, 95% CI: 1.67–9.52), in the use of antidepressants between 2000 and 2018 (OR: 2.06, 95% CI: 1.40–3.04) and in antipsychotics from 2000 to 2018 (OR: 2.06, 95% CI: 1.40–3.04) and from 2011 to 2018 (OR: 1.69, 95% CI: 1.15–2.48), and a significant decrease in the use of benzodiazepines between 2011 and 2018 (OR: 0.09, 95% CI: 0.04–0.25). These results are presented in Supplementary Tables S2 and S3.

The number of medications (individual medications from one or several medication groups) among child and adolescent inpatients increased significantly between 2000 and 2018 (for all changes p < 0.001) but not between 2011 and 2018 (0 vs. 1 medication p = 0.08; 0 vs. 2 medications p = 0.1; 1 vs. 2 medications p = 0.9; <3 vs. ≥3 medications p = 0.4) (Fig. 1). In 2000, 60% of the patients had no continuous medication, whereas in 2018, the rate was below 30% and multi-medication had simultaneously become more common. Noteworthy, the category of ≥3 medications was included in the data only from 2011.

FIG. 1.

Number of medications among children and adolescents. In 2000, the response categories were: 0; 1; ≥2. In 2011 and 2018, the response categories were: 0; 1; 2; ≥3.

When diagnoses of ADHD, depression, and psychosis, as well as severity measures of suicidality, violence, and functional impairment were included in the analyses as confounders, increases in antidepressants (OR: 1.65, 95% CI: 1.12–2.43) and antipsychotics (OR: 4.87, 95% CI: 3.29–7.20) were seen in all inpatients between 2000 and 2018. The increase in antidepressant use was associated with being an adolescent, being depressed, displaying suicidal actions, and not displaying violent actions, whereas the increase in the use of antipsychotics was associated with being an adolescent, having psychosis, and displaying suicidal acts, violent acts, and low general functioning. These results are presented in Table 3.

Table 3.

Multivariate Analysis. Change in Medication Between 2000, 2011, and 2018

	ADHD MEDICATIONS			ANTIDEPRESSANTS			ANTIPSYCHOTICS
Years	n (%)	Unadjusted	Adjusted	n (%)	Unadjusted	Adjusted	n (%)	Unadjusted	Adjusted
2000	0 (0)	NA	NA	84 (20)	—	—	101 (23)	—	—
2011	30 (8)	—	—	103 (28)	1.58 (1.13, 2.19)^**	1.46 (1.00, 2.12)^*	154 (41)	2.30 (1.70, 3.12)^***	3.66 (2.51, 5.34)^***
2018	51 (14)	1.91 (1.19, 3.08)^**	1.72 (0.99, 3.01)	111 (31)	1.87 (1.35, 2.60)^***	1.65 (1.12, 2.43)^*	176 (50)	3.20 (2.36, 4.35)^***	4.87 (3.29, 7.20)^***
Background variable
Age <13	53 (17)	—	—	58 (11)	—	—	124 (24)	—	—
Age 13–18	28 (7)	0.37 (0.23, 0.60)^***	0.93 (0.50, 1.76)	240 (38)	4.88 (3.56, 6.70)^***	2.88 (1.99, 4.17)^***	307 (48)	3.02 (2.34, 3.90)^***	3.42 (2.40, 4.87)^***
Boy	61 (17)	—	—	92 (15)	—	—	208 (34)	—	—
Girl	20 (5)	0.27 (0.16, 0.46)^***	0.72 (0.37, 1.40)	206 (38)	3.49 (2.63, 4.62)^***	1.32 (0.94, 1.87)	223 (41)	1.37 (1.08, 1.74)^*	0.72 (0.51, 1.02)
No psychosis	77 (12)	—	—	281 (27)	—	—	327 (31)	—	—
Psychosis	4 (7)	0.54 (0.19, 1.52)	0.70 (0.21, 2.32)	17 (14)	0.45 (0.27, 0.77)^**	0.54 (0.30, 0.96)	104 (88)	16.17 (9.11, 28.67)^***	19.17 (10.04, 36.60)^***
No depression	72 (14)	—	—	145 (17)	—	—	318 (36)	—	—
Depression	9 (5)	0.31 (0.15, 0.62)^**	0.63 (0.27, 1.47)	153 (54)	5.92 (4.41, 7.94)^***	3.03 (2.17, 4.24)^***	113 (40)	1.16 (0.88, 1.53)	1.00 (0.70, 1.43)
No ADHD	32 (5)	—	—	286 (28)	—	—	386 (37)	—	—
ADHD	49 (49)	18.25 (10.74, 31.03)^***	14.33 (7.90, 26.01)^***	12 (10)	0.29 (0.16, 0.53)^***	0.52 (0.27, 1.02)	45 (37)	0.98 (0.67, 1.45)	1.48 (0.93, 2.35)
no suicidal ideation or acts	52 (13)	—	—	105 (17)	—	—	178 (29)	—	—
suicidal acts	2 (2)	0.58 (0.40, 0.85)^**	0.83 (0.52, 1.33)	60 (44)	2.02 (1.67, 2.44)^***	1.63 (1.30, 2.04)^***	81 (60)	1.85 (1.55, 2.20)^***	1.80 (1.44, 2.26)^***
no violent ideation or acts	31 (7)	—	—	229 (34)	—	—	241 (35)	—	—
violent acts	24 (15)	1.60 (1.23, 2.07)^***	1.37 (0.98, 1.92)	38 (14)	0.53 (0.44, 0.63)^***	0.76 (0.61, 0.95)^*	116 (41)	1.13 (0.98, 1.30)	1.36 (1.12, 1.65)^*
CGAS 51–100	17 (10)	—	—	74 (23)	—	—	75 (24)	—	—
CGAS 1–30	11 (9)	0.98 (0.69, 1.41)	1.42 (0.89, 2.25)	35 (22)	1.01 (0.82, 1.25)	0.84 (0.65, 1.08)	110 (69)	2.52 (2.05, 3.11)^***	1.82 (1.43, 2.32)^***

p value <0.05.

<0.01.

***

<0.001.

ADHD, attention-deficit/hyperactivity disorder; CGAS, Children’s Global Assessment Scale.

Discussion

The present study’s uniqueness is in the use of nationwide data covering over 18 years of child and adolescent inpatient medication use, measured at three timepoints. Substantial increases were found between 2000 and 2018, whereas the increases between 2011 and 2018 were observed for fewer medications and tended to occur more among the adolescent sample.

First, the use of antipsychotics was found to have increased vastly among child and adolescent inpatients between 2000 and 2018. Moreover, the increase among adolescents did not happen only in the first decade of the 2000s but continued between 2011 and 2018. The gap between youth and adult psychotropic medication has tapered (Steinhausen, 2015). Interestingly, the increase seemed to continue among adolescents, which could reflect a more cautious approach among children. The increases were observed for antipsychotics, namely for aripiprazole, quetiapine, and risperidone, which are the most commonly used antipsychotics in Finland as well as in North America (Kakko et al., 2017; Pringsheim et al., 2019; Varimo et al., 2020). The increased use of second-generation antipsychotics can probably partly be explained by the introduction of the medications at the turn of the millennium. It has previously been found that, when outpatient data is included, antipsychotic prescriptions increase in Europe and New Zealand but not in the United States or Canada, where the rates are nevertheless high in global comparison (Barczyk et al., 2020; Kalverdijk et al., 2017; Pringsheim et al., 2019).

In our study, the increase of antipsychotic medication was associated with psychotic symptoms, violent acts, suicidal acts, and severe functional impairment. These factors reflect the severity of the inpatients’ mental health, and it is understandable that medications are used for difficult situations. Suicidal symptoms have previously been associated with increased antipsychotic treatment (Kronström et al., 2018), as have impulsiveness and aggression (Olfson et al., 2014), as well as low functioning (Kronström et al., 2018; Sourander et al., 2002). The increase in antipsychotics has previously been found to be higher among girls than boys (Varimo et al., 2020). In our study, this phenomenon between genders was seen in the unadjusted multivariate model, but no longer in the adjusted model. In Finland, adolescent girls seemed to have an increasing trend in the symptoms of anxiety disorders, depression, and suicidality (Kiviruusu et al., 2024; Sourander et al., 2025). Although there are no official indications of antipsychotics for treating anxiety and suicidality, the increase in these symptoms could contribute to the increased use of antipsychotics among girls.

The off-label use of medications is common among children and adolescents as evidence-based recommendations and indications are often lacking (Braüner et al., 2016). The off-label use of antipsychotics has indeed widened. Similar to our study, the previously observed increases have predominantly been among adolescents (Kalverdijk et al., 2017; Varimo et al., 2020). Quetiapine use for adolescent insomnia has increased vastly. A Canadian study found that 56.6% of ward patients receiving quetiapine were taking it only for insomnia, whereas only 2.4% were taking it for psychosis (Chow et al., 2017). In 2006, one study found that approximately 25% of adolescent quetiapine users were having it for off-label indications (Palomaa et al., 2019). Aripiprazole was found to increase in our study between 2011 and 2018. Aripiprazole is often preferred due to its lesser metabolic side effects, and off-label use is common (Nielsen et al., 2016). The main concerns regarding off-label use are the adverse effects of antipsychotics. Adverse effects include daytime sedation, involuntary movements, and metabolic adversities, such as weight gain, disturbances in glucose and lipid metabolism (Cohen et al., 2012). Official indications for antipsychotics in Finland are disruptive behavior in children with intellectual disability (risperidone) and schizophrenia and bipolar disorders among children and adolescents (aripiprazole, lurasidone, ziprasidone) (Pharmaca Fennica, 2024). A Finnish study reported that out of 133 children who received off-label medication, 40% of them did not have the indication for antipsychotic treatment written in their records (Kakko et al., 2017). Treatment times with antipsychotic medications are often long among children and adolescents (Kakko et al., 2017; Varimo et al., 2021), and inadequate surveillance and follow-up occur when prescribing these medications, despite the national recommendations (Antoniou et al., 2023; Chen et al., 2018; Kakko et al., 2017). Improvements in clinical practices, prescribing, and monitoring antipsychotics are warranted.

The second finding in this study was that antidepressant use increased between 2000 and 2018. Being an adolescent, having diagnosed with depression, and suicidal acts were associated with an increase. Increases in depression, anxiety, and eating disorder diagnoses were observed as well, and this self-evidently explains the increases in antidepressant use. The use of antidepressants has increased globally among children and adolescent patients (Bachmann et al., 2016; Barczyk et al., 2020; Pringsheim et al., 2019; Rasmussen et al., 2025). When the whole population was examined in the present study, there was increased use of many SSRIs between 2000 and 2018, but between 2011 and 2018, only the use of sertraline increased. Proportional use of sertraline among antidepressants seems to have also increased in Norway and Denmark (Rasmussen et al., 2025). The increase in sertraline use could relate to its benefits compared to fluoxetine, with more rapid effectiveness and the easier change to another antidepressant due to its pharmacokinetic profile. Sertraline has an official indication for obsessive-compulsive disorder among children and adolescents in Finland (Pharmaca Fennica, 2024), although it is also widely used for other anxiety disorders and depression.

A third finding was that, whereas ADHD medications were minimally used among inpatients in 2000, the rate increased vastly between 2000 and 2011 and continued increasing among adolescents between 2011 and 2018. This can be explained by the increase in the diagnoses and by the surface of new ADHD medications, which have improved pharmacological treatment for patients with ADHD (Coghill et al., 2017). ADHD medication use has increased specifically in Europe, reaching the levels of the United States (Bachmann et al., 2017). In Finland, the use of ADHD medications increased vastly between 2015 and 2022 in children and adolescents, with 8.3% usage among boys and 3.3.% among girls in 2022 (Vuori et al., 2022). These trends follow the increased prevalence rates of ADHD diagnoses, which were about three times higher in boys and five times higher in girls in 2022 than in 2015 (Vuori et al., 2022). Quite understandably, this increase in diagnoses and overall use is reflected in the inpatient population.

Whereas increases were observed in previously discussed medications, the story of benzodiazepines is somewhat different. In our sample, benzodiazepine use diminished by 2018. Their use was somewhat common in 2011, but in 2018, no child inpatients and only five adolescent inpatients had continuous benzodiazepine medication. This phenomenon seems to describe the overall situation of benzodiazepine use in Finland: Finnish child and adolescent psychiatric guidelines instruct avoiding benzodiazepines for this age group, and they are mostly used among inpatients who suffer from severe problems. One possibility is that the use of benzodiazepines for anxiety and insomnia has been replaced by the use of low-dose antipsychotics, such as quetiapine. The findings of previous studies have been contradictory, and international variation exists. In New Zealand, use increased between 2008 and 2016 (Barczyk et al., 2020), and Valtuille and colleagues (2024) reported increases in France (Valtuille et al., 2024). A Nordic study found that the use of z-medications (i.e., zopiclone, zolpidem, zaleplon) had decreased in Norway, Sweden, and Denmark (Wesselhoeft et al., 2021). As national guidelines are likely to guide prescriptions, considering the Finnish recommendations, the decrease in benzodiazepine use is a desired outcome (Valvira, 2025).

Finally, our study found that the use of multiple medications became more common after 2000. However, no significant longer changes were observed between 2011 and 2018. Interestingly, multi-medication is not likely to be associated with the severity of problems. The inpatients in our study did not seem to have more severe problems in 2018 than they did in 2000 (Kronström et al., 2023). There could be several possible reasons for the increased medication use and polypharmacy. First, new medications emerged in the late 1990s and the early 21st century, which have enabled the improved pharmacological treatment of psychiatric disorders. Another reason could be the decrease in inpatient beds and units, and therefore the increased pressure to treat the patients quickly and effectively. In Finland, the duration of child and adolescent inpatient treatment periods has decreased while the number of treatment periods has increased (Kronström et al., 2023). In the present study sample, there were 11 fewer units in 2018 than there were in 2000. A previous Finnish study has reported the number of children treated annually in wards remaining somewhat stable, whereas the number of adolescents has increased notably (Kyrölä, 2024This study was carried out before the COVID-19 pandemic. The mental well-being deteriorated after the pandemic among adolescent girls in Finland (Kiviruusu et al., 2024; Sourander et al., 2025). Studies have shown increased use of psychotropic medication during the pandemic (Bliddal et al., 2023), but the effect might have been temporary (Amill-Rosario et al., 2022). Whether the deterioration and increased medication use also concern the most severe cases and inpatient populations remains to be studied.

The strengths of this study include the good national representativeness of the sample, as more than 90% of the inpatient units of the country participated in the study. Measures included severity measures rated by the clinicians, which widened the understanding of the case severity beyond diagnostic codes. In addition, the data was gathered at three timepoints, which enabled the time-trend estimation of the medication practices. There are also limitations. First, the sample was collected on one day in each designated year, and the inpatient population may vary from day to day. Second, the data were limited to the questionnaire completed by clinicians. The validation of diagnoses and CGAS scoring could not be done, and further inspection of the indications for the medications was not possible. We do not know whether the patients received some other interventions or if the availability of interventions varied between the study years. This may have also impacted the prescription of medications. Furthermore, the data was collected in Finland, and the use of medications can vary between regions and countries. Therefore, the results may not be generalizable to other populations.

Conclusion

While medication use increased vastly among child and adolescent inpatient populations between 2000 and 2018, some levelling could be observed by 2011, especially among children. Increased use is likely to be associated with the changes in clinical practices; new medications have surfaced since 2000, the awareness of neuropsychiatric disorders has significantly improved, and the decrease in inpatient beds and duration of hospital treatment also likely explains the increase. Although it is crucially important to acknowledge the risks of overmedication among children and adolescents, inpatients often have complex situations, several comorbidities, and severe impairment, and medication use is therefore easily justified. To improve clinical practices and offer children and adolescents the best possible treatment, follow-up studies and cross-cultural comparison studies are warranted. More information is needed on the long-term effects of the increased use of antipsychotics and multi-medication.

Ethical Information

Authors’ Contributions

T.S. was responsible for planning the statistical analysis, drafting, and revising the article. K.K. contributed to planning the study, collecting the data, and commenting on the article. E.T. was involved in planning the study, collecting the data, and commenting on the article. A.K. was responsible for the statistical analysis and had complete access to the data. A.S. planned the study, collected the data, and commented on the article. All authors have accepted the final article. The contributions made by the hospital wards and clinicians are greatly appreciated.

Footnotes

Author Disclosure Statement

The authors have no relevant financial or non-financial interests to disclose.

Data Availability Statement

The data are available upon request from the authors.

Supplemental Material

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