New federal and state policies may have helped drive down the rate at which powerful psychiatric medications are prescribed to children, including those in foster care, a recent study finds.
The study finds that while prescription rates for antipsychotic drugs are slightly trending down, appropriate mental health interventions to accompany the drugs are frequently absent from the treatment plans.
In a recently released article from Health Affairs, “Rapid Growth Of Antipsychotic Prescriptions for Children Who Are Publicly Insured Has Ceased, But Concerns Remain,” researchers from Rutgers, Columbia and New York State Psychiatric Institute look at trends and efforts in the field since 2008, when the prescriptions peaked.
Researchers set out to determine how the post-2008 trends around antipsychotic drug prescriptions affected Medicaid-insured children, and foster children as a specific subset.
Antipsychotics are a class of psychotropic drug used to treat the most serious of mental health diagnoses. According to a 2014 GAO report, “the risks these drugs pose specifically to children are not well understood.” A few of the documented side effects include lethargy, increased risk for type II diabetes, and in some cases, involuntary tics.
The Food and Drug administration advises that antipsychotics only be prescribed to children for treatment of schizophrenia, Tourette’s Syndrome, bipolar disorder, and “irritability associated with autism,” not symptoms associated with attention deficit hyperactivity disorder (ADHD), which they are also often used for, according to researchers.
As the article’s title suggests, rates of prescribing antipsychotic drugs have been reduced, but still remain higher than before 2000, and recent implementation of best practices around monitoring children on these medications leaves room for improvement.
They surveyed earlier studies and found that “medication use increased by 51 percent among Medicaid-insured youth (ages 7-17) between 2001 and 2004. Use among children in foster care also increased in this decade – from 8.9 percent in 2002 to 11.8 percent in 2007 (ages 3-18).”
The increase prompted policy-makers to initiate new oversight efforts, such as boosted use of the prior authorization process within Medicaid, which requires doctors to fill out additional request forms for certain drugs to be covered by insurance. In some foster care systems, antipsychotic medication prescriptions now must be reviewed by a mental health specialist who is not the prescriber of the drug.
Researchers outlined best practices that have emerged since 2008, which were streamlined by the National Collaborative for Innovation in Quality Measurement through the Pediatric Quality Measures Program.
The first of these is the need to pair psychosocial mental health treatments, such as anger management sessions for children, family counseling, or cognitive behavioral therapy, with the use of antipsychotics.
Additionally, since antipsychotics can have harmful metabolic effects in children and increase the risk of type II diabetes, blood glucose and lipid levels must be monitored. Also, the use of only one antipsychotic medication at a time is increasingly viewed as a best practice.
Finally, they note the importance of making sure that the treatment matches the diagnosis, and implementing monitoring to make sure they are not prescribed for treating disorders outside of the FDA’s recommendations, such as ADHD.
Initiatives vary by state, but specifically concerning children in foster care, by 2013 44 states and Washington D.C. had implemented psychotropic drug monitoring programs or protocols.
It is unsurprising that the experiences of children and youth in foster care were a focal point of the conversation when psychotropic prescriptions spiked in the early-2000s. According to researchers, children in foster care “often experience trauma associated with abuse, neglect and family separation.” Additionally, “foster children account for 3 percent of all Medicaid-insured children but 29 percent of behavioral health expenditures.”
In light of knowledge of initiatives and newly codified best practices after the surge, researchers set out to see how much the trends slowed for youth in foster care, and if states had improved ability to monitor programs.
They assessed trends based on Medicaid administrative data for twenty states that had been previously identified as having the most complete “encounter data for treatment, services and diagnoses” for children in care, and data for privately insured children from 2005-2013. Three states also directly submitted their Medicaid data from 2009-2011.
They studied data for children ages 0-17, and broke them down by age, sex, race/ethnicity, whether or not they were in foster care, and diagnostic groups (which individuals had been divided into since many users received more than one diagnosis in “multiple healthcare encounters”).
Trends they identified in combing through this data show that the 2008 peak of antipsychotic use among all Medicaid-insured children was 1.86 percent. By 2010, the rate was down to 1.73 percent. However, rates for children in foster care within that data set are more dramatic, though followed the same trend: use of antipsychotics in 2008 was 9.26 percent, and declined to 8.92 percent in 2010. All of these rates are much higher than privately insured children, who faced a .62 percent rate of use of antipsychotics in 2005 to .77 percent in 2009 and then .75 percent in 2013.
They found that “3 percent of Medicaid-insured children who were in foster care accounted for 15.3 percent of Medicaid-insured children treated with antipsychotics in 2010,” and that use was “higher among non-Hispanic white than African American or Hispanic children, both in foster care and other Medicaid-insured children.”
Between 2005 and 2010, they did not see an increase in use in antipsychotics for diagnoses of “ADHD, anxiety or depression, or adjustment-related disorders.”
Beyond trends in actual prescribing, researchers considered the way best practices were being implemented along with these prescriptions — findings which suggest that there is still work to be done.
In 2011, 65.47 percent of children in foster care received mental health interventions accompanying antipsychotic drug treatment, compared with 29.01 percent of other Medicaid-insured children.
The number of children receiving mental health interventions leaves “considerable room for improvement,” according to the research team, given that slightly more than one third of foster children still do not receive the services that policy makers focus on.
Additionally, only a respective 18.o1 and 28.09 percent of Medicaid-insured and foster children received metabolic monitoring.
In looking at multiple states efforts to continue to improve these numbers, the article highlights Texas’ STAR Health managed care plan, which provides more clinical services and care monitoring and coordination for children in foster care, and has reportedly significantly reduced psychotropic drug use in a number of ways.
The article reports that by 2014, an estimated 54 percent of foster children were in managed care plans. This structural shift brings both “opportunities and challenges for efforts to better address [foster children’s] often-complex behavioral needs,” which will be tended to by states to ensure that foster youth receive appropriate provision of evidence-based therapy and pharmacological management.
For more discussion about the study, states’ efforts, tensions facing clinicians and researchers discussion about the implication of their findings, click here.