Antipsychotic Guidelines for Kids Still Largely Unheeded

Megan Brooks

June 20, 2016

Antipsychotic prescribing rates for children in foster care and for other Medicaid-insured children have leveled off following a period of rapid growth in the early and mid 2000s. However, guideline-recommended practices are frequently still not followed, new research shows.

"To me, the most important take-home from this work is how far we still need to go before we can say we are getting to a best-practices pattern of treatment," lead researcher Stephen Crystal, PhD, of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University, New Brunswick, New Jersey, told Medscape Medical News.

The study was published online June 7 in Health Affairs.

Quality Shortfall Underestimated

Current guidelines and treatment recommendations highlight the importance of care processes, including the use of psychosocial mental health interventions as first-line treatment; the monitoring of antipsychotic-treated children at baseline and after treatment initiation for metabolic side effects, and the avoidance of antipsychotic polypharmacy, among other measures of quality, said Dr Crystal.

The new study, however, found that among children treated with antipsychotics, more than one third of foster children and more than two thirds of other Medicaid children failed to receive psychosocial mental health interventions during the 3 months preceding and the month following the start of antipsychotic treatment.

Only 28% of foster children and 18% of other children received metabolic monitoring of both blood glucose and serum cholesterol levels.

The "shortfall in quality is actually greater than the above figures suggest because they are based on setting the bar very low ― even one psychosocial mental health visit regardless of type or quality of service," Dr Crystal said.

The findings are based on an analysis of national and state-level Medicaid data and data from private health insurance companies for the years 2005-2013.

"The 'good news' aspect, if one wants to call it that," he said, is that the earlier pattern of rapid increase seems to have leveled off.

"However, it has leveled off at rates that are very high. Children in foster care continue to receive antipsychotic treatment at much higher rates than other Medicaid-insured children (8.92% vs 1.51% among 0- to 17-year-olds in 2010)," he said.

Limited Access to Proven Treatments

"The 'new normal' levels of prescribing represent a substantially higher rate than was seen prior to the sharp expansion of the early 2000s. Given safety concerns and uncertainties about long- term effects on brain development, encouraging judicious prescribing of antipsychotic medications for children remains a policy challenge and a priority," Dr Crystal said in a statement.

The study also showed that antipsychotics continue to be prescribed for mental disorders not indicated by the US Food and Drug Administration, particularly among children in foster care.

For example, in 2010, 34% of antipsychotic prescriptions written for children in foster care were for attention-deficit/hyperactivity disorder, anxiety, or depression, compared with 18% written for children not in foster care. "Doctors should consider other first-line treatments for children with these diagnoses," Dr Crystal said.

"Particularly for kids in foster care, what is needed is not just any mental health service but mental health services that are evidence-based and tailored to the needs of children who are often traumatized. There are a number of evidence-based interventions that are out there, as discussed in the paper, but access to them is very limited," he added.

In his view, "We have a long way to go before we can say that kids who are considered troubled enough to receive an antipsychotic are receiving appropriate patterns of care. We need to make major efforts to expand the supply, quality, and accessibility of evidence-based, nonpharmacological mental health services for this population. With more and more kids in general receiving mental health diagnoses and treatments, we need to make sure that care for this subset of kids doesn't get crowded out."

Encouraging Sign

Reached for comment, Meredith Matone, DrPH, MHS, deputy director of PolicyLab at the Children's Hospital of Philadelphia, said, "The decline in prescribing seen in this study is an encouraging sign. It will be important to make sure as we reduce medication use for youth in foster care that we provide appropriate alternative therapies. The goal is child health and safety."

The reason children in foster care are prescribed antipsychotics so often is "complicated," Dr Matone told Medscape Medical News.

"Many children in foster care have behavioral concerns, often as a consequence of trauma exposure, and providers frequently have few alternatives to medications because evidence-based psychotherapies are unavailable or inaccessible within many behavioral health systems. We've also seen expanded use of antipsychotics in children for the treatment of aggressive behaviors, above and beyond their approved use for treatment of psychoses."

What's needed to address this issue? "Provider education and expanded availability of medication alternatives are important," Dr Matone said. "Currently, many state and local Medicaid and child welfare systems are responding to this issue with the use of prescribing guidelines, oversight policies, such as the use of prior authorization, and psychiatric telephonic consultative services for prescribing physicians."

The study was funded in part by the Agency for Healthcare Research and Quality. One author has disclosed a relationship with Sunovion Pharmaceuticals.

Health Aff. Published online June 7, 2016. Abstract

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