Antipsychotic Medication Prescribing in Children Enrolled in Medicaid

Abstract

BACKGROUND: Although the increase in treatment of children and adolescents with antipsychotic medications has been well documented, much less is known about the factors related to the use of these agents and how closely the treatment follows best practice recommendations.METHODS: Prescribers of each antipsychotic medication prescription issued for a Medicaidinsured child in Vermont aged ,18 years were sent a prior authorization survey that assessed several domains including the clinical indication, other treatments, metabolic monitoring, prescriber specialty, and prescription origin. These variables were combined to categorize prescriptions as following indications approved by the US Food and Drug Administration (FDA) and best practice guidelines. RESULTS:The response rate of the survey was 80%, with 677 surveys from 147 prescribers available for analysis; more than one-half of the respondents were primary care clinicians. Overall, the clinical indication for an antipsychotic prescription followed best practice guidelines 91.7% of the time, with overall best practice guidelines followed at a rate of 50.1%. An FDA indication was followed in 27.2% of cases. Psychiatrists were significantly more likely to follow best practice guidelines than nonpsychiatrists. Antipsychotic medications were typically used only after other pharmacologic and nonpharmacologic treatments were ineffective, although previous treatment with cognitive-behavioral therapy was uncommon (15.5%). Metabolic monitoring that included serial laboratory tests was reported in 57.2% of cases.CONCLUSIONS: Current prescribing patterns of antipsychotic medications for children and adolescents follow best practice guidelines approximately one-half of the time, with nonadherence often related to lack of metabolic monitoring. WHAT'S KNOWN ON THIS SUBJECT:Although the rates of antipsychotic medication treatment are rising for children and adolescents, little is known about the factors associated with this practice. WHAT THIS STUDY ADDS:This study provides some of the first data regarding when and why clinicians decide to use antipsychotic medications. It reveals clues as to how prescribing might better follow best practice guidelines.

Decline in Medicaid-Funded One-to-One Behavioral Support Use in School as Children Age

“…Most published studies examine medication use among children with psychiatric disorders (e.g., Kamble, Chen, Johnson, Bhatara, & Aparasu, 2015; Rettew, et al, 2015; Visser et al, 2015), acute psychiatric treatment use such as psychiatric hospitalization (e.g., Fantanella et al, 2015), and Medicaid expenditures (e.g., Cidav, Lawer, Marcus, & Mandell, 2013). Even less research has examined school-based behavioral health service use by disorder.…”

A National Survey of State Medicaid Psychotropic-Monitoring Programs Targeting Youths

“…Some initial outcomes include a 64% decrease in polypharmacy over a six-year period (8). A recent report on Vermont's experience noted that only 50% of antipsychotic prescribing followed best practice as defined by the American Academy of Child and Adolescent Psychiatry practice parameters (9). The lack of metabolic monitoring was the main reason that prescribing did not meet best-practice standards (9).…”

Evaluating long-term consequences of adolescent antipsychotic exposure

“…Despite the US Food and Drug Administration's (FDA) approval of selected atypical APDs such as risperidone, olanzapine and aripiprazole for a limited number of disorders, for example, autism, bipolar disorder and schizophrenia (Ronsley et al 2015), the majority of APD prescriptions in adolescents and children are for symptom-targeted treatment of behaviour such as aggression, mood instability, violent behaviour or irritability associated with non-psychotic neuropsychiatric disorders (Cooper et al 2006;Olfson et al 2006;Olfson et al 2012;Rettew et al 2015). Consequently, offlabel prescribing constitutes a greater proportion of increased use of APDs in these two populations.…”

“…Alterations in these regions may provide insight into reported sub-cortical neurochemical alterations or mechanisms related to cognitive performance influenced by adolescent exposure to APDs. Given the symptom-targeted approach of clinicians, polypharmacy (APD plus other psychotropic drugs such as antidepressants or methylphenidate) is common in children and adolescents (Rettew et al 2015). The outcomes with APD polypharmacy have still to be examined in preclinical studies.…”

“…The clinical reports are now revealing that APD prescription is increasing not only in adolescents but also in children (Olfson et al 2006;Olfson et al 2012;Rettew et al 2015;Ronsley et al 2013).…”