Antipsychotic Drugs in Kids

Editor's Note:
A recent study^[1] by investigators in the PolicyLab at The Children's Hospital of Philadelphia (CHOP) that was conducted at the request of the Pennsylvania Department of Human Services found startling rates of use of antipsychotics and polypharmacy in Medicaid-enrolled children aged 3-18 years. The analysis was conducted amid growing concerns about the safety and efficacy of psychotropic medications in children. Some key findings of the report include:

For youth aged 6-18 years in 2012, the use of psychotropic medications was nearly three times higher among youth in foster care than youth in Medicaid overall (prescribed in 43% vs 16%).
The use of antipsychotics was four times higher among youth in foster care than youth in Medicaid overall (22% vs 5%). More than one half of youth in Medicaid who used antipsychotics had a diagnosis of attention-deficit/hyperactivity disorder. This is concerning, because most of these youth did not have another diagnosis that clinically indicated the use of antipsychotics, a medication class with significant side effects.
Polypharmacy, the use of multiple classes of medications in combination, occurred at a rate four times higher among youth in foster care than all youth in Medicaid (12% vs 3%).
Youth in foster care were more likely to have not received any visits within a year of seeing a provider for their behavioral health concerns while on psychotropic medications.

The investigators used state Medicaid data from 2007-2010 and 2012 and the results are specific to Pennsylvania children, although the study raises questions about use of these agents in children living in similar circumstances nationwide.

Medscape spoke with three of the investigators about the implications of the study. Meredith Matone, MHS, is a research scientist who addressed the public health implications. Kathleen Noonan, JD, founding codirector of PolicyLab, provided insights on the legal and policy implications of the study. David Rubin, MD, MSCE, founding codirector of PolicyLab and professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania, offered a perspective on the key clinical messages for pediatric healthcare professionals.

Is Drug Overuse a Problem in All Kids, or Just Poor Kids?

Medscape: This very important study from PolicyLab looked at the use of psychotropic agents in Medicaid-eligible children (as a proxy marker for children living in poverty). Are there comparable data for children in other socioeconomic groups—privately insured or underinsured children—or is this a problem unique to the population of children that they studied?

Dr Rubin: The rates of use of psychotropic drugs have been going up for all kids, but the rates among those who are publicly insured are clearly higher than for privately insured children. There are probably many reasons for that, but first and foremost, the privately insured kids often have much greater access to other therapies, including counseling and other therapy services that are not widely available to publicly insured children. Those types of therapies act as a competitive buffer to reduce the rate of antipsychotic use. When antipsychotics are the only tool in the toolbox, you end up seeing disproportionately much higher rates of use of those medications, particularly when children are presenting with disruptive or aggressive behaviors.

Ms Noonan: From a policy/legal perspective, we were particularly interested in the Medicaid population, because what we wanted to understand is the unique medication issues among youth in foster care, most of whom are publicly insured in the Medicaid program. Although it is true that rates of use of psychotropic medications have increased for all children, the rates in foster care are dramatically elevated—which is a concern from a legal perspective, because these children do not always have the benefit of a parent or guardian's involvement when these decisions are made.

As part of our portfolio of work on psychotropic medication at PolicyLab, we conducted a policy analysis to determine whether law or policy contributes to higher rates of psychotropic medication use among children in foster care, and more specifically, whether there are insufficient legal and policy protections for these youth. Our analyses of policies and laws in this area found that few states had put in place rules related to the use of psychotropic mediations in children; the use of multiple medications; the use of medications in very young children; or the identification of prescribing red flags, such as the use of antipsychotics for a nonindicated condition.

Ms Matone: Research demonstrates that prescription of antipsychotic medications is more frequent among publicly insured youth than among privately insured youth. Although medication use among uninsured and underinsured youth is difficult to study, it is likely that access to needed behavioral healthcare is a challenge for these youth.