Trends in Subthreshold Psychiatric Diagnoses for Youth in Community Treatment | Adolescent Medicine | JAMA Psychiatry | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Rosen  DS.  Eating disorders in children and young adolescents: etiology, classification, clinical features, and treatment.  Adolesc Med. 2003;14(1):49-59.PubMedGoogle Scholar
National Institute of Drug Abuse.  Drug facts: nationwide trends. December 2012. Accessed December 30, 2013.
Costello  EJ, Erkanli  A, Angold  A.  Is there an epidemic of child or adolescent depression?  J Child Psychol Psychiatry. 2006;47(12):1263-1271.PubMedGoogle Scholar
Eaton  WW, Kalaydjian  A, Scharfstein  DO, Mezuk  B, Ding  Y.  Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981-2004.  Acta Psychiatr Scand. 2007;116(3):182-188.PubMedGoogle ScholarCrossref
Kessler  RC, Demler  O, Frank  RG,  et al.  Prevalence and treatment of mental disorders, 1990 to 2003.  N Engl J Med. 2005;352(24):2515-2523.PubMedGoogle ScholarCrossref
Murphy  JM, Horton  NJ, Laird  NM, Monson  RR, Sobol  AM, Leighton  AH.  Anxiety and depression: a 40-year perspective on relationships regarding prevalence, distribution, and comorbidity.  Acta Psychiatr Scand. 2004;109(5):355-375.PubMedGoogle ScholarCrossref
Polanczyk  GV, Willcutt  EG, Salum  GA, Kieling  C, Rohde  LA.  ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis.  Int J Epidemiol. 2014;43(2):434-442.PubMedGoogle ScholarCrossref
Simpson  KR, Meadows  GN, Frances  AJ, Patten  SB.  Is mental health in the Canadian population changing over time?  Can J Psychiatry. 2012;57(5):324-331.PubMedGoogle Scholar
de Graaf  R, ten Have  M, van Gool  C, van Dorsselaer  S.  Prevalence of mental disorders and trends from 1996 to 2009: results from the Netherlands Mental Health Survey and Incidence Study-2.  Soc Psychiatry Psychiatr Epidemiol. 2012;47(2):203-213.PubMedGoogle ScholarCrossref
Spiers  N, Bebbington  P, McManus  S, Brugha  TS, Jenkins  R, Meltzer  H.  Age and birth cohort differences in the prevalence of common mental disorder in England: National Psychiatric Morbidity Surveys 1993-2007.  Br J Psychiatry. 2011;198(6):479-484.PubMedGoogle ScholarCrossref
Marcus  SC, Olfson  M.  National trends in the treatment for depression from 1998 to 2007.  Arch Gen Psychiatry. 2010;67(12):1265-1273.PubMedGoogle ScholarCrossref
Zito  JM, Safer  DJ, dosReis  S,  et al.  Psychotropic practice patterns for youth: a 10-year perspective.  Arch Pediatr Adolesc Med. 2003;157(1):17-25.PubMedGoogle ScholarCrossref
Moreno  C, Laje  G, Blanco  C, Jiang  H, Schmidt  AB, Olfson  M.  National trends in the outpatient diagnosis and treatment of bipolar disorder in youth.  Arch Gen Psychiatry. 2007;64(9):1032-1039.PubMedGoogle ScholarCrossref
Blader  JC, Carlson  GA.  Increased rates of bipolar disorder diagnoses among US child, adolescent, and adult inpatients, 1996-2004.  Biol Psychiatry. 2007;62(2):107-114.PubMedGoogle ScholarCrossref
Visser  SN, Danielson  ML, Bitsko  RH,  et al.  Trends in the parent-report of health care provider–diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011.  J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.e2. doi:10.1016/j.jaac.2013.09.001.PubMedGoogle ScholarCrossref
Kessler  RC, Merikangas  KR, Berglund  P, Eaton  WW, Koretz  DS, Walters  EE.  Mild disorders should not be eliminated from the DSM-V Arch Gen Psychiatry. 2003;60(11):1117-1122.PubMedGoogle ScholarCrossref
Raven  M, Parry  P.  Psychotropic marketing practices and problems: implications for DSM-5 J Nerv Ment Dis. 2012;200(6):512-516.PubMedGoogle ScholarCrossref
Dziegielewski  SF.  DSM-IV-TR in Action.2nd ed. Hoboken, NJ: John Wiley; 2010:51.
First  MB.  Clinical utility in the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM).  Prof Psychol Res Pract. 2010;41(6):465-473.Google ScholarCrossref
Munson  CE.  The Mental Health Diagnostic Desk Reference.2nd ed. New York, NY: Hawthorn Press; 2001:50.
Reichenberg  LW.  DSM-5 Essentials: The Savvy Clinician’s Guide to Changes in Criteria. Hoboken, NJ: Wiley; 2014:4.
National Center for Health Statistics.  National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Accessed December 10, 2013.
National Center for Health Statistics.  National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey estimation procedures. Accessed December 10, 2013.
Axelson  DA, Birmaher  B, Strober  MA,  et al.  Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified.  J Am Acad Child Adolesc Psychiatry. 2011;50(10):1001-1016.e3. doi:10.1016/j.jaac.2011.07.005.PubMedGoogle ScholarCrossref
Bertha  EA, Balázs  J.  Subthreshold depression in adolescence: a systematic review.  Eur Child Adolesc Psychiatry. 2013;22(10):589-603.PubMedGoogle ScholarCrossref
Comer  JS, Gallo  KP, Korathu-Larson  P, Pincus  DB, Brown  TA.  Specifying child anxiety disorders not otherwise specified in the DSM-IV Depress Anxiety. 2012;29(12):1004-1013.PubMedGoogle ScholarCrossref
Wesselhoeft  R, Sørensen  MJ, Heiervang  ER, Bilenberg  N.  Subthreshold depression in children and adolescents: a systematic review.  J Affect Disord. 2013;151(1):7-22.PubMedGoogle ScholarCrossref
Angold  A, Erkanli  A, Egger  HL, Costello  EJ.  Stimulant treatment for children: a community perspective.  J Am Acad Child Adolesc Psychiatry. 2000;39(8):975-994.PubMedGoogle ScholarCrossref
Balázs  J, Keresztény  A.  Subthreshold attention deficit hyperactivity in children and adolescents: a systematic review.  Eur Child Adolesc Psychiatry. 2014;23(6):393-408.PubMedGoogle ScholarCrossref
Döpfner  M, Breuer  D, Wille  N, Erhart  M, Ravens-Sieberer  U; BELLA Study Group.  How often do children meet ICD-10/DSM-IV criteria of attention deficit/hyperactivity disorder and hyperkinetic disorder? parent-based prevalence rates in a national sample: results of the BELLA study.  Eur Child Adolesc Psychiatry. 2008;17(1)(suppl 1):59-70.PubMedGoogle ScholarCrossref
Whitely  M, Raven  M.  The risk that DSM-5 will result in a misallocation of scarce resources.  Curr Psychiatry Rev. 2012;8(4):281-286.Google ScholarCrossref
Rosenberg  RE, Daniels  AM, Law  JK, Law  PA, Kaufmann  WE.  Trends in autism spectrum disorder diagnoses: 1994-2007.  J Autism Dev Disord. 2009;39(8):1099-1111.PubMedGoogle ScholarCrossref
Reiff  MI, Feldman  HM.  Diagnostic and Statistical Manual of Mental Disorders: the solution or the problem?  J Dev Behav Pediatr. 2014;35(1):68-70.PubMedGoogle ScholarCrossref
Charman  T.  The highs and lows of counting autism.  Am J Psychiatry. 2011;168(9):873-875.PubMedGoogle ScholarCrossref
Lauritsen  MB, Pedersen  CB, Mortensen  PB.  The incidence and prevalence of pervasive developmental disorders: a Danish population-based study.  Psychol Med. 2004;34(7):1339-1346.PubMedGoogle ScholarCrossref
Lecavalier  L, Gadow  KD, DeVincent  CJ, Houts  C, Edwards  MC.  Deconstructing the PDD clinical phenotype: internal validity of the DSM-IV J Child Psychol Psychiatry. 2009;50(10):1246-1254.PubMedGoogle ScholarCrossref
Costello  EJ, Shugart  MA.  Above and below the threshold: severity of psychiatric symptoms and functional impairment in a pediatric sample.  Pediatrics. 1992;90(3):359-368.PubMedGoogle Scholar
Maser  JD, Patterson  T.  Spectrum and nosology: implications for DSM-V Psychiatr Clin North Am. 2002;25(4):855-885, viii-ix.PubMedGoogle ScholarCrossref
Pincus  HA, Davis  WW, McQueen  LE.  “Subthreshold” mental disorders: a review and synthesis of studies on minor depression and other “brand names.”  Br J Psychiatry. 1999;174(4):288-296.PubMedGoogle ScholarCrossref
Olfson  M, Broadhead  WE, Weissman  MM,  et al.  Subthreshold psychiatric symptoms in a primary care group practice.  Arch Gen Psychiatry. 1996;53(10):880-886.PubMedGoogle ScholarCrossref
Frances  A.  Essentials of Psychiatric Diagnosis.Rev ed. New York, NY: Guilford Press; 2013.
Maser  JD, Norman  SB, Zisook  S,  et al.  Psychiatric nosology is ready for a paradigm shift in DSM-V Clin Psychol Sci Pract. 2009;16(1):24-40. doi:10.1111/j.1468-2850.2009.01140.x.Google ScholarCrossref
Shankman  SA, Lewinsohn  PM, Klein  DN, Small  JW, Seeley  JR, Altman  SE.  Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes.  J Child Psychol Psychiatry. 2009;50(12):1485-1494.PubMedGoogle ScholarCrossref
Rutter  M, Uher  R.  Classification issues and challenges in child and adolescent psychopathology.  Int Rev Psychiatry. 2012;24(6):514-529.PubMedGoogle ScholarCrossref
Paris  J.  The Intelligent Clinician’s Guide to the DSM-5. New York, NY: Oxford University Press; 2013.
Ferris  TG, Saglam  D, Stafford  RS,  et al.  Changes in the daily practice of primary care for children.  Arch Pediatr Adolesc Med. 1998;152(3):227-233.PubMedGoogle ScholarCrossref
Goldberg  D, Simms  LJ, Gater  R, Krueger  PF. Integration of dimensional spectra for depression and anxiety into categorical diagnoses for general medical practice. In: Regier  DA, Narrow  WE, Kuhl  EA, Kupfer  DJ, eds.  The Conceptual Evolution of DSM-5. Alexandria, VA: American Psychiatric Publishing Inc; 2011:19-31.
Jablensky  A, Kendell  RE. Criteria for assessing a classification in psychiatry. In: Maj  M, Gaebel  W, Lopez-Ibor  JJ, Sartorious  N, eds.  Psychiatric Diagnosis and Classification. New York, NY: Wiley; 2002:1-25.
Jampala  VC, Sierles  FS, Taylor  MA.  The use of DSM-III in the United States: a case of not going by the book.  Compr Psychiatry. 1988;29(1):39-47.PubMedGoogle ScholarCrossref
Westen  D, Heim  AK, Morrison  K, Patterson  M, Campbell  L. Simplifying diagnosis using a prototype matching approach. In: Beutler  LE, Malik  MC, eds.  Rethinking the DSM. Washington, DC: American Psychological Association; 2002:224.
Zimmerman  M, Mattia  JI.  Psychiatric diagnosis in clinical practice: is comorbidity being missed?  Compr Psychiatry. 1999;40(3):182-191.PubMedGoogle ScholarCrossref
Zimmerman  M, Galione  J.  Psychiatrists’ and nonpsychiatrist physicians’ reported use of the DSM-IV criteria for major depressive disorder.  J Clin Psychiatry. 2010;71(3):235-238.PubMedGoogle ScholarCrossref
Mojtabai  R.  Clinician-identified depression in community settings: concordance with structured-interview diagnoses.  Psychother Psychosom. 2013;82(3):161-169.PubMedGoogle ScholarCrossref
Lewinsohn  PM, Shankman  SA, Gau  JM, Klein  DN.  The prevalence and co-morbidity of subthreshold psychiatric conditions.  Psychol Med. 2004;34(4):613-622.PubMedGoogle ScholarCrossref
McClellan  J.  Clinically relevant phenomenology: the nature of psychosis.  J Am Acad Child Adolesc Psychiatry. 2011;50(7):642-644.PubMedGoogle ScholarCrossref
Valluri  S, Zito  JM, Safer  DJ, Zuckerman  IH, Mullins  CD, Korelitz  JJ.  Impact of the 2004 Food and Drug Administration pediatric suicidality warning on antidepressant and psychotherapy treatment for new-onset depression.  Med Care. 2010;48(11):947-954.PubMedGoogle ScholarCrossref
Frances  A.  The DSM-5 subthreshold disorders: not ready for prime time. April 15, 2010. Accessed December 21, 2013.
Dell’osso  L, Pini  S.  What did we learn from research on comorbidity in psychiatry? advantages and limitations in the forthcoming DSM-V era.  Clin Pract Epidemiol Ment Health. 2012;8(2):180-184.PubMedGoogle ScholarCrossref
Cwikel  J, Zilber  N, Feinson  M, Lerner  Y.  Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care.  Soc Psychiatry Psychiatr Epidemiol. 2008;43(3):184-191.PubMedGoogle ScholarCrossref
Axelson  D, Birmaher  B, Strober  M,  et al.  Phenomenology of children and adolescents with bipolar spectrum disorders.  Arch Gen Psychiatry. 2006;63(10):1139-1148.PubMedGoogle ScholarCrossref
Birmaher  B, Axelson  D, Goldstein  B,  et al.  Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study.  Am J Psychiatry. 2009;166(7):795-804.PubMedGoogle ScholarCrossref
Chang  KD.  The bipolar spectrum in children and adolescents: developmental issues.  J Clin Psychiatry. 2008;69(3):e9.PubMedGoogle ScholarCrossref
Hafeman  D, Axelson  D, Demeter  C,  et al.  Phenomenology of bipolar disorder not otherwise specified in youth: a comparison of clinical characteristics across the spectrum of manic symptoms.  Bipolar Disord. 2013;15(3):240-252.PubMedGoogle ScholarCrossref
Stringaris  A, Santosh  P, Leibenluft  E, Goodman  R.  Youth meeting symptom and impairment criteria for mania-like episodes lasting less than four days: an epidemiological enquiry.  J Child Psychol Psychiatry. 2010;51(1):31-38.PubMedGoogle ScholarCrossref
Menard  TV, Galanter  CA, Jensen  PS,  et al. Strategies for improved classification of pediatric bipolar biobank participants. Poster presented at: Annual Meeting of the American Academy of Child and Adolescent Psychiatry; October 2013; Orlando, FL.
Bakker  IM, Terluin  B, van Marwijk  HW, van Mechelen  W, Stalman  WA.  Test-retest reliability of the PRIME-MD: limitations in diagnosing mental disorders in primary care.  Eur J Public Health. 2009;19(3):303-307.PubMedGoogle ScholarCrossref
Galanter  CA, Pagar  DL, Oberg  PP, Wong  C, Davies  M, Jensen  PS.  Symptoms leading to a bipolar diagnosis: a phone survey of child and adolescent psychiatrists.  J Child Adolesc Psychopharmacol. 2009;19(6):641-647.PubMedGoogle ScholarCrossref
Galanter  CA, Hundt  SR, Goyal  P, Le  J, Fisher  PW.  Variability among research diagnostic interview instruments in the application of DSM-IV-TR criteria for pediatric bipolar disorder.  J Am Acad Child Adolesc Psychiatry. 2012;51(6):605-621.PubMedGoogle ScholarCrossref
Nemeroff  CB, Weinberger  D, Rutter  M,  et al.  DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions.  BMC Med. 2013;11(9):202. doi:10.1186/1741-7015-11-202.PubMedGoogle ScholarCrossref
Kupfer  DJ.  Dimensional models for research and diagnosis: a current dilemma.  J Abnorm Psychol. 2005;114(4):557-559.PubMedGoogle ScholarCrossref
Zimmerman  M, Rothschild  L, Chelminski  I.  The prevalence of DSM-IV personality disorders in psychiatric outpatients.  Am J Psychiatry. 2005;162(10):1911-1918.PubMedGoogle ScholarCrossref
Angst  J.  Psychiatry NOS (not otherwise specified).  Salud Mental. 2009;32(1):1-2.Google Scholar
Rucci  P, Gherardi  S, Tansella  M,  et al.  Subthreshold psychiatric disorders in primary care: prevalence and associated characteristics.  J Affect Disord. 2003;76(1-3):171-181.PubMedGoogle ScholarCrossref
Miller  PR, Dasher  R, Collins  R, Griffiths  P, Brown  F.  Inpatient diagnostic assessments, I: accuracy of structured vs unstructured interviews.  Psychiatry Res. 2001;105(3):255-264.PubMedGoogle ScholarCrossref
Polanczyk  GV.  Dimensionality of childhood psychopathology and the challenge of integration into clinical practice.  Eur Child Adolesc Psychiatry. 2014;23(3):183-185.PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    Benefits of Subthreshold BP-NOS Diagnoses
    Robert M. Post | Head, Bipolar Collaborative Network; Professor of Psychiatry, George Washington University
    Safer et al (1) point out the marked increases in the incidence of psychiatric visits for subthreshold diagnoses and conclude that they “lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medications”. The findings of increases in bipolar not otherwise specified (BP-NOS) were particularly noteworthy for the 18 fold increases from 1999-2002 to 2007-2010. Visits increased most markedly in younger individuals and BP-NOS is most highly prevalent in the youngest children. The NIMH Roundtable Conference reached consensus in 2000 that BP-NOS should be considered a “working diagnosis”. Therefore increases in the diagnosis would make sense after such agreement was reached. Birmaher et al (2) followed up children with BP-NOS, BP II, and BP I and found that those with BP-NOS were highly impaired in a range not dissimilar from that of the BP II and I children. Moreover, they found that while it took about 9 months to stabilize those with BP I and II, it took more than a year and a half to achieve this result in those with BP-NOS. Thus, one would anticipate that once diagnosed, those with BP-NOS would have increasingly more visits for monitoring and treatment. BP-NOS is often a precursor to BP I and II, and if there is a positive family history of bipolar disorder, the conversion rate is 53% after 5 years of follow up (3). Furthermore in high-risk offspring because of a positive family history of bipolar disorder, more children had BP-NOS (10.2%) than BP I and II combined (8.4%). Even in the comparison control offspring BP-NOS was more common (1.2%) than BP I and II (0.8%). Epidemiological studies that include BP-NOS also show more childhood bipolar disorder in the US (4). Safer et al (1) imply that off label treatment is ill advised. However, there are no FDA approved medications for any children with bipolar disorder under the age of 10, so pharmacological treatment would of necessity be off label. Compared to adult onsets, childhood onset bipolar disorder carries a poorer prognosis and is associated with longer delays to first treatment, and treatment delay itself is independently associated with a more difficult outcome in adulthood (5). Therefore it would appear that treating these children with high degrees of dysfunction with off-label medications would a most appropriate course of action and might yield the desired benefits of acute and long-term illness amelioration.

    1. Safer DJ, Rajakannan T, Burcu M, Zito JM. Trends in subthreshold psychiatric diagnoses for youth in community treatment. JAMA psychiatry. Jan 2015;72(1):75-83.

    2. Birmaher B, Axelson D, Goldstein B, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. The American journal of psychiatry. Jul 2009;166(7):795-804.

    3. Axelson D, Goldstein B, Goldstein T, et al. Diagnostic Precursors to Bipolar Disorder in Offspring of Parents With Bipolar Disorder: A Longitudinal Study. The American journal of psychiatry. Mar 3 2015:appiajp201414010035.

    4. Van Meter AR, Moreira AL, Youngstrom EA. Meta-analysis of epidemiologic studies of pediatric bipolar disorder. The Journal of clinical psychiatry. Sep 2011;72(9):1250-1256.

    5. Post RM, Leverich GS, Kupka RW, et al. Early-onset bipolar disorder and treatment delay are risk factors for poor outcome in adulthood. The Journal of clinical psychiatry. Jul 2010;71(7):864-872.

    CONFLICT OF INTEREST: Dr. Robert Post has consulted and participated in lecture bureaus for AstraZeneca, Sunovion, and Validus Pharmaceuticals.
    Original Investigation
    January 2015

    Trends in Subthreshold Psychiatric Diagnoses for Youth in Community Treatment

    Author Affiliations
    • 1Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 3Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
    JAMA Psychiatry. 2015;72(1):75-83. doi:10.1001/jamapsychiatry.2014.1746

    Importance  Patterns and trends of subthreshold DSM-IV mental health diagnoses for youth within US community treatment settings merit systematic research.

    Objective  To quantify and assess temporal patterns of DSM-IV diagnoses not otherwise specified (NOS) among youth during physician office visits.

    Design, Setting, and Participants  We conducted a retrospective study using psychiatric diagnostic data from the US National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (n = 16 295) from 1999 through 2010, combined in 4-year intervals. Using diagnoses from visits to physicians, we compared trends of the proportional distribution of the major psychiatric diagnoses with subthreshold criteria (coded as NOS) with proportions of diagnoses reaching full criteria.

    Main Outcomes and Measures  Specific common psychiatric diagnoses NOS compared with full-criteria psychiatric diagnoses.

    Results  Between the 1999-2002 and 2007-2010 periods, the proportion of US medical visits reporting DSM-IV NOS psychiatric diagnoses compared with the proportion reporting full psychiatric diagnostic criteria for youth aged 2 to 19 years rose prominently for major mood diagnostic subtypes. Among all visits for mood disorders, NOS visits grew proportionally 1.5-fold from 45.3% in the 1999-2002 period to 68.8% in the 2007-2010 period (P < .001). Among visits for bipolar disorder, NOS visits increased more than 18-fold, from 3.6% in the 1999-2002 period to 72.6% in the 2007-2010 period (P < .001). In addition, anxiety disorder NOS increased from 44.6% in the 1999-2002 period to 58.1% in the 2007-2010 period. Overall, NOS visits constituted 35.0% of the total psychiatric visits in 2007-2010 but represented 55.9% when attention-deficit/hyperactivity disorder codes were excluded.

    Conclusions and Relevance  The expansion of subthreshold (NOS) DSM-IV diagnoses of mood disorder, bipolar disorder, and anxiety disorder in youth that has occurred since 1999 in all likelihood will continue in the DSM-5 era unless administrative efforts are made to alter this practice. Unspecified diagnoses lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medication.