Antidepressants
Antidepressant prescription rates showed a steep upward trend among females aged 10–19 years, which were significantly above model predictions in four (10–14 year-olds) and five (15–19 year-olds) out of six quarters, respectively. No comparable trend was found in the general population (all age groups combined), with only individual quarters significantly exceeding model predictions. Pre-pandemic rates showed a high degree of stability when looking at the pattern from 2013 onwards. A sharp decline was observed between 2016 and 2017. This coincided with a debate about the efficacy of SSRIs in adolescents based on a meta-analysis [
6], which received broad media coverage in Austria and Germany [
22,
36]. Shortly after the start of the pandemic, prescription rates for antidepressants began to increase steadily. Given that SSRIs are recommended as part of the treatment strategy for depression and anxiety in national guidelines [
1,
3]; (AWMF, 2013), these elevated prescription rates can be interpreted as part of an increased treatment effort to counter the rising mental health problems throughout the COVID-19 pandemic.
The increase in prescription rates was more pronounced in female than in male patients, with the steepest increase in antidepressant prescription rates found in female adolescents. This is consistent with findings of increasing rates of depressive symptoms reported worldwide. For instance, in a meta-analysis of 29 studies encompassing data from 80,879 children and adolescents globally, Racine et al., [
33] found a pooled prevalence rate of 25.2% for clinically elevated symptoms of depression, with higher rates of depressive symptoms reported in females. Recently, another meta-analysis based on 53 longitudinal studies from 12 countries also reported an increase in depressive symptoms in children and adolescents, which was stronger in female than in male participants [
24]. Besides data from international samples, studies on the mental health of Austrian adolescents during the pandemic point in the same direction, with an increase in depression and anxiety symptoms that was especially pronounced in female participants [
10,
28].
Antipsychotics
From all evaluated age groups, the strongest increase in prescription rates was observed in 15–19-year-old females. As the use of antipsychotics in minors is only licensed in Austria for the treatment of bipolar disorder, schizophrenia, or major impulsive aggressive behavior, these rising rates, particularly among females, are highly interesting. Despite research demonstrating a particularly severe impact of the COVID-19 pandemic on people with schizophrenia [
16], few studies have explored a potential increase in first episodes of schizophrenia. One study, conducted in Australia, reported an increase in first-episode admissions for schizophrenia among young people following the introduction of lockdown measures [
26]. Additionally, while the pandemic has been linked to first presentations of manic episodes [
34], evidence regarding potential increases in bipolar disorders is lacking. Atypical antipsychotics have been mentioned as part of an augmentation regime in the treatment of resistant depression [
14,
37], but are only suggested for the treatment of psychotic depression in minors [
25]. Therefore, the rise in prescriptions of antipsychotics might also be interpreted as indicating an increased off-label use for the treatment of depression in minors. Furthermore, some antipsychotics are used as an off-label medication for severe anorexia nervosa [
17]. As an increase in eating disorders has been reported throughout the pandemic [
13], increasing prescription rates of antipsychotic prescriptions may echo an increasing clinical demand in this field. This might further explain the higher prescription rates among females found in the present study, as the rise in eating disorders is especially pronounced among female adolescents [
13], potentially accompanied by increased psychopharmacological treatment. Unfortunately, we are unable to link prescriptions to diagnoses, as diagnostic ICD-10 codes are not currently available from the outpatient sector, from which this dataset is derived. Therefore, it can only be hypothesized that the use of antipsychotics in female adolescents corresponds to increased rates of treatment for depression, eating disorders, or other symptoms or disorders such as sleep problems.
Overall, we were able to demonstrate an increase in prescriptions of antidepressants and antipsychotics in adolescents, which was especially pronounced in females. The observed trends are in line with increasing levels of symptoms of depression and anxiety during the COVID-19 pandemic as reported globally [
23,
33] and in Austria [
10,
28].
Data regarding prescription rates of psychopharmacological agents in children and adolescents during the COVID-19 pandemic are scarce, although a report issued by the German health insurance company DAK described a substantial increase in antidepressant prescriptions in adolescent females between 2019 and 2021 (+ 30% in 10–14-year-olds and + 65% in 15–17-year-olds in those diagnosed with a depressive disorder) [
41]
Our findings are consistent with this reported increase in antidepressant prescriptions, but extend further than these datasets in terms of the population covered. For example, while the DAK report includes data from 5.7% of German children and adolescents [
41], our dataset includes approximately 858,000 Austrian adolescents, representing about 99.4% of the Austrian population in this age group. Furthermore, we were able to analyze two different medication groups (antidepressants and antipsychotics).
A study from the US using data from the IQVIA health insurance company (encompassing roughly 8.9 million minors aged between 2 and 17 years) analyzed monthly prescription rates of ADHD medication, antidepressants, antipsychotics, and mood stabilizers between January 2019 and September 2020. The results revealed a spike in overall psychopharmacological prescriptions in April 2020, which subsequently returned to normal, pre-pandemic levels [
2]. This trend is in line with the patterns assessed in our data, although it appears that the upward trend in the US sample is more short-lived than in our study. This might be explained by differences in the availability of mental health practitioners, different COVID-19 restrictions, and also different time frames of the respective analyses. A cohort study of Danish youth also reported an increase in incident prescriptions of psychotropic medication between March 2020 and June 2022, which was most prominent in the 12–24 years age group [
3]. Interestingly, the rise in prescriptions was seen for all groups of psychotropic drugs, including hypnotics and sedatives, psychostimulants, antidepressants, and antipsychotics, but not in the group of anxiolytics. A recent study from Austria [
40], analyzing a shorter time frame of 2020 only, observed no significant changes in defined daily doses of psychopharmacological drugs between 2019 and 2020 in any age group. The differences from our findings are likely due to the different time intervals examined in the two studies: While the present study observed cumulative effects over six quarters, the study by [
40] focused on medication prescriptions during the national lockdowns in 2020. Nevertheless, it should be noted that in the study by [
40], the age group of 10–20-year-olds likewise showed the largest percentage increase in psychopharmacological prescriptions of all age groups.