High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid

Davis, Deborah Winders; Lohr, William David; Feygin, Yana; Creel, Liza; Jawad, Kahir; Jones, V. Faye; Williams, P. Gail; Le, Jennifer; Trace, Marie; Pasquenza, Natalie

doi:10.1186/s12888-021-03309-9

Cited by 12 publications

(4 citation statements)

References 58 publications

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“…However, it is still notable that youth identified as male were significantly more likely to be in both the AP (58% male) and persistent AP (62% male) categories. This is consistent with various other reports (9,46) and likely reflects that the reasons for AP use are not homogenous across genders. Therefore, efforts to limit AP use among different populations may benefit from including gender or other associated factors that may drive AP prescribing practices.…”

Section: Limitationssupporting

confidence: 92%

The Utah psychotropic oversight program: collaboratively addressing antipsychotic use within youth in foster care without prior authorization

Monson,

Shastri,

Chen

et al. 2023

Front. Psychiatry

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ObjectivesFostered youth have increased risk of exposure to trauma. Antipsychotic medications are often utilized within the foster care system, potentially to address problematic behaviors that may be associated with trauma. The Utah Psychotropic Oversight Program (UPOP) was formed to support prescribers and encourage evidence-based treatment approaches for fostered youth. However, it is unclear what impact an oversight program can have on a high turnover population and without tools such as prior authorization. This study evaluates 4 years of collected data from the UPOP program for efficacy and to identify future intervention targets.MethodsDeidentified data were collected as a routine function of the oversight program over 4 years (01/2019-12/2022), from individuals aged 0–18 years old (total N = 8,523, 48.3% female). UPOP oversight criteria: ≤6yo + any psychotropic medication, ≥7yo + 2 or more psychotropic medications. For this analysis, youth were divided by UPOP individuals ever receiving an antipsychotic (AP) prescription (UPOP_AP; N = 755, 42.3% female) or not (UPOP_NAP, N = 1,006, 48.3% female) and non-UPOP fostered (N = 6,762, 48.9% female). Comparisons were made across demographic and clinical variables via ANOVA, Chi-square, unpaired t-test, and logistic regression.ResultsUPOP_AP more likely to be older males with behavioral diagnoses, increased polypharmacy, longer duration of fostering, and higher care level. AP prescription rates dropped from 52.8 to 39.1% for males and 43.3 to 38.2% in females with unchanged number of psychotropic prescriptions and care level across 2019-2022. UPOP_AP that discontinued AP treatment had fewer average psychotropic medications, but increased antidepressant and sleep prescriptions, as compared with individuals that remained on AP.ConclusionYouth within the foster care system receive antipsychotics at high rates and in an uneven distribution. Prescribing practices can change in the context of supportive oversight programs without components such as prior authorization, and without increasing the need for higher levels of care. Specific emphasis on the treatment of mood, anxiety, and sleep issues may also lead to greater success in discontinuing AP treatment. Oversight may support treatment providers while reducing exposure to medications with considerable side effect burden that could cause future comorbidity.

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Section: Limitationssupporting

confidence: 92%

The Utah psychotropic oversight program: collaboratively addressing antipsychotic use within youth in foster care without prior authorization

Monson,

Shastri,

Chen

et al. 2023

Front. Psychiatry

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“…Many studies have shown that youth in foster care are more likely to be prescribed multiple psychotropic medications as part of their care ( 12 , 21 , 34 , 35 ). However, the definition of concomitant medication use in literature has been heterogeneous and ranged from concurrent use of 1 day to 60 days.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have also shown that children experiencing concomitant medication use often have inadequate management to monitor side effects of their medications ( 34 ). Altogether, this highlights the need to elucidate the benefits and harms, as well as find optimal management for the use of concurrent interclass psychotropics in pediatric populations, especially those in foster care.…”

Section: Discussionmentioning

confidence: 99%

Prescribed psychotropic medication patterns among treated Foster Care enrollees: a single institution study

Cosme,

Rudig,

Borsellino

et al. 2024

Front. Psychiatry

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BackgroundWhile several state-based studies have shown that children in foster care are more likely to be prescribed psychotropic medications and experience concomitant medication use both within and among medication class, these patterns have not been explored in the state of Nevada, which lacks state mandated oversight of psychotropic prescribing for foster care enrolled youth.MethodsData from an electronic medical record system from a single institution were analyzed to examine the prevalence of psychotropic prescribing and concomitant medication use in children ages 2 to 19 who were enrolled and received psychotropic prescriptions between July 2019 to June 2022.ResultsOut of 569 distinct psychotropic medication treatment episodes within this cohort, the most frequent psychotropic classes prescribed were non-stimulant ADHD medications (alpha-agonists and atomoxetine, 31.5%), atypical antipsychotics (22.1%), antidepressants (20.6%), and stimulants (16.0%). The use of stimulants and non-stimulant ADHD medications decreased in older age groups while the use of antidepressants and antipsychotics increased in older age groups. During the three-year period studied, 24.0% of psychotropic medications prescriptions increased in dosage. Treatments were prescribed for only one month in 43.8% of youth. In children prescribed psychotropic medications, concomitant medication use for at least 60 days occurred in 28.0% of children who had any psychotropic medication prescribed.ConclusionWithin the cohort of 273 foster care enrolled subjects aged 2 to 19 years old who received psychotropic medication prescriptions, non-stimulant ADHD medications (both alpha-agonists and atomoxetine) and atypical antipsychotics were more commonly co-prescribed additional psychotropic medication compared to other co-prescribed medication categories. This study illustrates prescribing patterns in a community mental health clinic focused on judicious prescribing of psychotropic medications in foster care enrolled youth. Despite this, 41% of the youth treated in this clinic received at least one prescription for psychotropic medication, and of those, 27.8% were prescribed more than one psychotropic medication at the same time. More studies are necessary to understand the underlying causes of high prevalence of concomitant medication use and prescribing practices of psychotropic medications use in foster care involved pediatric populations.

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“…Such medication use may still be rational and evidence-based (for example, use of risperidone and aripiprazole for treatment of irritability in autism) ( 29 ). However, while polypharmacy may be necessary in a patient with a MHNDD and comorbidities ( 30 ), the fact that patients required a referral to sleep medicine despite the medications trials, raises the concern to what degree sleep, as a complex neurophysiologic function, had been integrated in previous assessments and choice of treatment strategies. The youngest patient taking sleep medication (melatonin) was 3 years of age, an age for which the use of behavioural strategies to manage difficulties with sleep initiation and maintenance are highly effective ( 31 ).…”

Section: Discussionmentioning

confidence: 99%

Understanding patient characteristics and medication prescriptions in children with mental health and neurodevelopmental disorders referred to a sleep clinic—A quality improvement/quality assurance analysis

et al. 2022

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IntroductionMotivated by challenges faced in outpatient sleep services for mental health and neurodevelopmental disorders (MHNDD) during the COVID-19 clinical shutdown, a pan-Canadian/international working group of clinicians and social scientists developed a concept for capturing challenging sleep and wake behaviours already at the referral stage in the community setting.MethodsIn a quality improvement/quality assurance (QIQA) project, a visual logic model was the framework for identifying the multiple causes and possible interventions for sleep disturbances. Intake forms informed clinicians about situational experiences, goals/concerns, in addition to the questions from the Sleep Disturbances Scale for Children (SDSC), the ADHD Rating Scale-IV and medication history. Descriptive statistics were used to describe the sample.Results66% of the pilot study patients (n = 41) scored in the SDSC red domains (highest scoring) with highest sub-scores for insomnia (falling asleep 73%; staying asleep: 51%) and daytime somnolence (27%). A total of 90% of patients were taking at least one medication; 59% sleep initiation/sleep medications, 41% in combination with further non-stimulant medications, 9% with stimulants, 27% with antidepressants and 18% with antipsychotics. Polypharmacy was observed in 62% of all patients and in 73% of the ones medicated for sleep disturbances. Qualitative information supported individualisation of assessments.ConclusionOur intake process enabled a comprehensive understanding of patients’ sleep and wake profiles prior to assessment, at the referral stage. The high prevalence of insomnia in patients, combined with polypharmacy, requires special attention in the triaging process at the community level.

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High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid

Cited by 12 publications

References 58 publications

The Utah psychotropic oversight program: collaboratively addressing antipsychotic use within youth in foster care without prior authorization

The Utah psychotropic oversight program: collaboratively addressing antipsychotic use within youth in foster care without prior authorization

Prescribed psychotropic medication patterns among treated Foster Care enrollees: a single institution study

Understanding patient characteristics and medication prescriptions in children with mental health and neurodevelopmental disorders referred to a sleep clinic—A quality improvement/quality assurance analysis

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