Foster Kids More Likely to Receive 2 or More Antipsychotics

Expert Says Findings Raise a Red Flag

Deborah Brauser

November 30, 2011

November 30, 2011 — Children in the foster care system are prescribed concurrent antipsychotic medications at concerning rates, new research suggests.

In a sample study of almost 17,000 children and adolescents younger than 20 years, those in foster care were more likely to receive 2 or more overlapping antipsychotics than those who qualified for Medicaid because of a disability or low income. They were also more likely to receive these medications for a longer duration.

"I did not expect to find that children would be receiving 2 medications for an extended period of time. And this pattern of treatment occurred despite a lack of evidence to support such regimens," lead author Susan dosReis, PhD, associate professor at the University of Maryland School of Pharmacy in Baltimore, told Medscape Medical News.

She added that there is also a lack of data on child developmental risks from this concurrent use, even though "there are clear indications of metabolic adverse effects from these agents."

The investigators note that although previous research has shown that youth in foster care have high rates of psychotropic medication use, this is the first time concomitant antipsychotic use has been assessed in this population.

"The present findings would be of interest to state child welfare and Medicaid agencies and could be used to guide antipsychotic monitoring programs and policies," they write, noting that treatment with 2 or more concurrent antipsychotics should trigger a full clinical review.

"It is without question...that routine monitoring should be enforced."

The study was published online November 21 in Pediatrics.

Adult Polypharmacy Increasing

"Antipsychotic polypharmacy has increased among adults, so it is possible this is also occurring in youths," write the researchers.

The investigators compared overlapping antipsychotic treatments between those in foster care; those who met Medicaid eligibility for physical, psychological, or development impairment; and those who met eligibility for financial need.

"The foster care population has been a concern for a while. We wanted to look at the complexity of their treatment use because it's been an issue of national debate for some time now," said Dr. dosReis.

The investigators evaluated data on 16,969 children and adolescents aged 19 years or younger (70% boys; 67.3% white, 20.8% black, 3.6% Hispanic) who were continuously enrolled in a Mid-Atlantic state Medicaid program.

All participants had at least 1 psychiatric diagnosis claim and at least 1 antipsychotic claim in 2003. Concomitant use was defined as use of at least 2 overlapping antipsychotics for more than 30 days.

Medicaid program categories were split into foster care, disabled (Supplemental Security Income [SSI]), and Temporary Assistance for Needy Families (TANF). For those in foster care, multicategory classifications were also assessed, including foster care/adoption.

The category distributions for the participants were as follows:

  • SSI, 52%;

  • TANF, 21%;

  • foster care only, 14%;

  • foster care/SSI, 5%;

  • foster care/TANF, 4%; and

  • foster care/adoption, 4%.

Significant Concurrent Use

Results showed that those children in foster care had longer average antipsychotic use duration than those in the TANF group (mean days, 222.3 vs 134.9; P < .001), as well as longer duration than for the SSI group (mean days, 190.3).

In addition, concomitant use of antipsychotics for at least 180 days was greatest in the foster care/adoption group (24%), followed by in the foster care–only group (19%). The rate was less than 15% in all other groups examined.

Attention-deficit/hyperactivity disorder was the most common diagnosis in the participants who used at least 1 antipsychotic medication (53.3%), followed by depression (33.8%), oppositional defiant disorder (26.8%), conduct disorder (26.3%), and bipolar disorder (20.8%). Schizophrenia was diagnosed in 5.2% of the participants.

A diagnosis of conduct disorder, psychosis, or schizophrenia, as well as antidepressant or mood-stabilizer use, was significantly associated with a higher likelihood of concomitant antipsychotic use (P < .0001 for all).

White youth were found to be 27% less likely to use antipsychotics concomitantly than black youth, and those between the ages of 5 and 9 years were 28% less likely to do so than those children between the ages of 15 and 19 years.

"After controlling for psychiatric diagnoses, other psychotropic use and demographic factors, youth who entered foster care were as likely to receive antipsychotics concomitantly for over 30 days as were disabled youth who typically have conditions for which antipsychotics are indicated," write the investigators.

"Additional study is needed to assess the clinical rationale, safety, and outcomes of [this] use," they add.

Better Monitoring Needed

Dr. dosReis noted that because the study did not include data on the reasons for prescribing concurrent medications or on the participants' symptom severity, it is hard to know why this practice was occurring.

"It could be that issues were not resolved with 1 medication, or that 1 of the medications was prescribed for sleep with another scheduled to be taken on a more regular basis, or it could be that side effects from 1 were so intolerable that a new lower dose of medication was prescribed. But that's all speculation," she said.

"I think this is something that isn't happening exclusively in foster care, but these kids do often have more complex social situations that can impact their emotional development. And we currently don't have services and treatments that seem to fully meet their needs. Plus, there's definitely a need for some sort of oversight."

Dr. dosReis reported that she is now working on a study that will examine these issues in data from all 50 states over the course of 5 years.

"This will not only give a national perspective but also cover a time period when some of the states have put together programs to begin monitoring utilization."

Red Flag

"Overall, I think this is an important study," Robert L. Findling, MD, MBA, professor of psychiatry and pediatrics at Case Western Reserve University and director of child and adolescent psychiatry at University Hospitals Case Medical Center in Cleveland, Ohio, told Medscape Medical News.

"You need to be very careful about overinterpreting these data, but I think a paper like this provides a warning signal that this may be a practice that's going on that is potentially worrisome."

Dr. Findling, who was not involved with this study, noted that there have been concerns about using this class of medicine in the young because of safety considerations, including adverse effects, some of which can be serious.

"I think the first take-home message is that there is no rigorous scientific evidence to suggest the benefit of doing this. That doesn't mean that there isn't any situation where this approach might be considered, based on clinical inference alone. But there's no evidence that has demonstrated that this is a good practice."

In addition, he said, this is a particularly vulnerable population.

"Youngsters in foster care are oftentimes significantly troubled and often highly symptomatic. So they may be at higher risk for treatment or exposure to powerful medicines. In fact, the evidence suggests that the more symptomatic or greater psychosocial dysfunction a youngster has, the greater the likelihood they are for receiving this class of medicine."

However, he also pointed out that the authors "were very wise" to note that the determinants of these issues may not be clear based on their data. For example, it is not known whether these medications were given in high doses or were being cross-titrated, or whether there was some overlap between stopping a prescription and starting a new one.

"I think there are some inherent limitations with these kinds of claims data. But that doesn't mean this isn't an important study, because what it does is raise a warning flag for clinicians," said Dr. Findling.

"Further research can help clarify what's truly going on in more detail, and why this phenomenon was observed based on the claims data."

He added that he would like to see an external validation study conducted with a large group of youth that identifies what treatments they have received, and at what times.

"This study suggests that this should be a topic of future studies, so that we can be clear about what indeed is going on, and if something bad is going on, how to prevent it. Ultimately, these are youngsters who deserve to be protected."

The study was supported by a grant from the National Institute of Mental Health. All but one study author disclosed no relevant financial relationships. Coinvestigator Mark A. Riddle, MD, from Johns Hopkins University School of Medicine in Baltimore, Maryland, reported being an expert witness in a legal matter involving Teva Pharmaceuticals. Dr. Findling, who is a member of the editorial advisory board for Medscape Medical News, has received research support from, acted as a consultant to, and/or served on a speakers' bureau for Abbott, Addrenex, AstraZeneca, Biovail, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson & Johnson, Eli Lilly, KemPharm, Lundbeck, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, sanofi-aventis, Sepracore, Schering-Plough, Shire, Solvay, Sunovion, Supernus Pharmaceuticals, Validus, and Wyeth.

Pediatrics. Published online November 21, 2011. Abstract

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