Antipsychotic Use Skyrockets in America's Poorest Children

Fran Lowry

March 12, 2013

Antipsychotic use among Medicaid-insured children from low- or very-low-income families skyrocketed in just under a decade, new research shows.

Investigators from the University of Maryland in Baltimore found that from 1997 to 2006, use of antipsychotic medications in this population increased 7- to 12-fold, with most of the increased use associated with treatment for behavioral problems.

"Awareness of the expanding use of antipsychotic medications in the emotional and behavioral treatment of children has been noted in several studies of community-based pediatric populations," lead author Julie Magno Zito, PhD, from the University of Maryland, told Medscape Medical News.

"But," she added, "additional information is needed on trends in our neediest youth, namely according to how antipsychotic users differ in terms of their eligibility for Medicaid insurance coverage and the reasons for use. Such information would help to characterize the 'who' and 'why' of expanded antipsychotic use."

The study is published in the March issue of Psychiatric Services.

Call to Action

In the current observational, cross-sectional study, Dr. Zito and colleagues analyzed claims data for 456,315 youths aged 2 to 17 years who were continuously enrolled in Medicaid in a mid-Atlantic state from 1997 to 2006.

They focused on the use of antipsychotic drugs in the following Medicaid-eligibility categories: foster care; State Children's Health Insurance Program (SCHIP), currently known as the Children's Health Insurance Program; Temporary Assistance for Needy Families (TANF), for children whose family income was at or below the federal poverty level; and Supplemental Security Income (SSI).

The researchers found that the prevalence of use of antipsychotic medications almost tripled, from 1.2% in 1997 to 3.2% in 2006.

This growth was greatest in youth enrolled in SCHIP (adjusted odds ratio [AOR], 5.9), followed by those in foster care (AOR, 4.1) and TANF (AOR, 3.6), and least among children with SSI (AOR, 2.8).

"The children on SSI are the ones we would presume to be the sickest," Dr. Zito noted. "This 6-fold increase for near-poor or SCHIP children and the 3.6-fold increase among poor or TANF children in a decade means that there was increasing use among the vast majority of enrollees and not, as one would expect, among the small minority, approximately 10%, on SSI, who qualify as the most vulnerable."

During this decade, 9320 children received a prescription for an antipsychotic. The growth in prescribing was most pronounced for pediatric bipolar disorder (AOR, 3.77) and behavioral conditions such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (AOR, 3.48).

The researchers also found that the proportion of children using antipsychotics from 1997 to 2006 increased significantly more among African Americans and Hispanics than among whites.

"These data support a call to action for outcomes research to better establish clinical appropriateness and to encourage system-wide oversight for quality assurance," Dr. Zito said.

Postmarketing surveillance studies are also needed to assess the outcomes of community-based psychiatric treatment, she added.

"This is particularly true when medications are used for off-label conditions that have minimal or no evidence of benefit relative to medications with FDA labeling for a particular diagnosis," she said.

Psychotherapy Undervalued

"This is a continuation of the important work by Dr. Zito and her group," R. Scott Benson, MD, a child and adolescent psychiatrist in private practice in Pensacola, Florida, told Medscape Medical News.

In this article, the researchers acknowledge that there are many factors involved in the increased rate of prescriptions for antipsychotics in children, Dr. Benson pointed out.

"There is always the suggestion that these children are given a diagnosis without the benefit of the comprehensive assessment that these psychiatric conditions demand. And there is the suggestion that the reimbursement system undervalues effective psychotherapy interventions and overvalues prescribing medication," he said.

He added that the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have developed guidelines for the evaluation of children and the use of evidence-based treatment.

"Florida and other states have developed consultation services for physicians who are providing care to these children, and we have seen a reduction in the prescription of these medications. Also, when they are prescribed, there is closer monitoring for safety and effectiveness," Dr. Benson said.

Dr. Zito and Dr. Benson report no relevant financial relationships.

Psychiatr Serv. 2013;64:223-229. Abstract