Polypharmacy Linked to Higher Hospital Readmission Rates in Suicidal Adolescents

Caroline Cassels

November 05, 2009

November 5, 2009 (Honolulu, Hawaii) — Polypharmacy with psychotropic medications in suicidal adolescent inpatients has been linked to a significantly increased risk for early readmission, new research shows.

Presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, investigators at the Ohio State University and Nationwide Children's Hospital, Columbus, found that suicidal adolescent inpatients receiving 3 or more different classes of psychotropic medications had a 2.6-fold increased risk of being readmitted within 30 days of discharge.

In addition, the researchers found that prescribing an antidepressant was associated with an 85% decreased risk for early readmission.

"We found antidepressants were associated with a lower risk of readmission, which is an indicator of quality of care. Conversely, though, we also found that when kids are prescribed 3 or more medications from different drug classes, the risk of early readmission increased by almost 3-fold," principal investigator Cynthia A. Fontanella, PhD, told Medscape Psychiatry.

According to Dr. Fontanella, although psychotropic medications are commonly used in this patient population, little is known about whether these interventions are effective in the inpatient setting or whether they reduce early readmission rates. Furthermore, she said, readmission rates in this patient population are on the rise.

"We don't really know a lot about inpatient care for kids and whether it is effective or not. We do know that readmission rates are increasing, and there is some evidence that these increases are associated with reductions in length of stays.

"We also know that the mainstay of treatment is psychopharmacological, yet we don't know much about the types of medications being prescribed, the frequency of medication changes, or what types of aftercare adolescents receive. This study was really an attempt to get inside the 'black box' of inpatient treatment and find out what's happening in terms of medication use," said Dr. Fontanella.

Antidepressants Mitigate Readmission Risk

The observational study included 318 Medicaid-covered adolescents aged 11 to 17 years admitted to 3 Maryland hospitals for suicidal behaviors. Using medical records and Medicaid claims data, the researchers gathered extensive data on subjects' clinical characteristics, as well as polypharmacy (defined as 3 or more medications) and medication changes.

"Suicidal patients account for 55% of all adolescent admissions to psychiatric hospitals," said Dr. Fontanella.

The study's main outcome measure was the effects of psychotropic medication changes and polypharmacy on 30-day readmission rates.

The researchers found that at least 1 medication change was made in 78% of study subjects, typically the addition of an antidepressant, mood stabilizer, or antipsychotic. At discharge, 23% of adolescents were prescribed 3 or more medications from different drug classes.

"Our finding that antidepressant therapy mitigates the risk of early readmission is good news and should reassure psychiatrists about the possible benefits of these medications. However, the relationship between antidepressants and suicidal risk remain unclear and these types of studies have inherent limitations.

"More research, particularly randomized clinical trials, [is] needed to examine the effectiveness of antidepressants and other pharmacological treatment in stabilizing suicidal youth in inpatient settings," said Dr. Fontanella.

"Our finding that polypharmacy was associated with an increased risk of readmission is concerning, although not surprising," she added.

However, she added, it is not possible to determine from these findings the appropriateness or inappropriateness of polypharmacy in this patient population. Nevertheless, she said, this research does highlight the need for clinicians to carefully weigh the risks and benefits of prescribing multiple psychotropic medications, particularly in such a vulnerable population.

Under Pressure

Dr. Fontanella pointed out that under managed care, national psychiatric hospital readmission rates have gone up, whereas hospital length of stays have gone down. Managed care, she said, has put psychiatrists under a great deal of pressure to demonstrate symptom reduction in a very short period of time and may partially account for the high rate of medication changes and for the fact that medication (vs psychotherapy) is now the mainstay of inpatient treatment.

"Back in the 1980s, we used to keep kids in the hospital for several months to monitor treatment effects and progress, but this is no longer the case," said Dr. Fontanella.

Depending on the medication, it can take up to 6 weeks before a drug takes effect, so it is possible that, because psychiatrists do not have the luxury of time to titrate and accurately gauge medication efficacy, this is contributing to the high rate of medication change observed in the study, said Dr. Fontanella.

Ultimately, she added, if early readmission rates continue to rise, reduced hospital stays mandated by managed care may prove to be a false economy.

She added that there is an urgent need for standardized decision-making tools that cover the entire spectrum of in-hospital treatment, follow-up, and aftercare for suicidal adolescents.

The investigators' next research steps include taking a more detailed look at polypharmacy and developing a better understanding of this phenomenon.

"We need more studies looking at the effectiveness of inpatient care and the effectiveness in reductions in lengths of stays and how that ultimately affects quality of care," said Dr. Fontanella.

The authors have disclosed no relevant financial relationships.

American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract: 3.34. Presented October 29, 2009.

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