Inter-class Concomitant Pharmacotherapy in Medicaid-Insured Youth Receiving Psychiatric Residential Treatment

Abstract

Background: Concomitant pharmacotherapy has become increasingly common in the treatment of youth, including in psychiatric residential treatment facilities (PRTF) despite limited efficacy and safety data. Research is reported on the prevalence of any class and interclass concomitant pharmacotherapy, specific class combinations of psychotropics, and changes in number of medications from admission to discharge for Medicaid insured youth treated in PRTFs in one mid—Atlantic state.Methods: Medicaid administrative claims data were examined for youth under age 18 years who were discharged from one of 21 PRTFs during calendar year 2019. Descriptive statistics were calculated to examine patterns of service utilization 90 days prior to admission. The rates of concomitant psychotropic use at admission were compared to the rates at discharge. Logistic regression models were used to examine covariates associated with discharging on 4 or more medications.Results: Fifty-four % of youth were admitted on either two or three psychotropics, while 25% were admitted on four or more psychotropics. The proportion of youth admitting and discharging on 2 or 3 medications was stable. There was a 27% increase in number of youth discharging on 4 medications with a 24% decrease in those on a 5- drug regimen. Only the number of medications prescribed at admission was found to be significant (p < 0.001), with more medications at admission contributing to probability of discharging on 4 or more medications.Conclusions: Concomitant pharmacotherapy is common in PRTFs. These findings support the practice of deprescribing and underscore the need for further research.

Antipsychotic medications and admission to psychiatric residential treatment facilities among youth in foster care diagnosed with disruptive behavior disorders.

“…Youth with aggression and DBD are frequently institutionalized in PRTFs (Edelsohn et al, 2021; Yampolskaya et al, 2014; Huefner et al, 2017). The objective of preventing or reducing the risk of admission to PRTFs among youth in this population by identifying treatments that keep youth in the community is worthwhile.…”

“…These diagnoses, which lead to a high risk for both AP prescribing and PRTF admission, are indicated for APs (Centers for Medicare and Medicaid Services, 2015). About 15%-28% of institutionalized youth have one of these indicated disorders, a much higher rate than the 1%-3% typically seen in the noninstitutionalized population (Birmaher, 2013;Edelsohn et al, 2021;Yampolskaya et al, 2014). We then compared the relative hazard ratios, of those youth prescribed APs to those youth not prescribed APs, within groups defined by having a DBD diagnosis, with these confounding effects assumed to be removed.…”

“…Recent studies suggest that PRTFs continue to serve children with DBD. In a study of youth admitted to PRTFs in Pennsylvania almost 18% of youth were admitted for disruptive, impulse, and conduct disorders (Edelsohn et al, 2021). In Florida’s State Inpatient Psychiatric Program, 12% of youth admitted between 2004 and 2008 were admitted for conduct disorders (Yampolskaya et al, 2014).…”

Debate: Involuntary treatment – not whether, but when and what else is needed

“…Investigative reports have documented abuses of foster youth placed in long‐term hospital or residential settings, including inappropriate use of seclusion, physical/mechanical and chemical restraint, punitive programming, overt maltreatment and a lack of oversight (Lurie, 2023). In a survey of youth admitted to residential centres in the United States in 2019 (based on Medicaid claims data, n = 548), polypharmacy was the norm (80% of youth), with 25% on four or more psychotropic medications (Edelsohn, Eren, Parthasarathy, Ryan, & Herschell, 2021). In Washington State, historically dependent youth requiring residential care were often sent out of state, but this practice was curtailed due to concerns that some of the programs provided inadequate supervision and staffing, and inappropriate use of restraint (Washington State Department of Children, Youth and Families, 2020).…”