National Study of U.S. Youth Shows Uptick in Prescribing of Antipsychotics in Combination with Other Psychotropic Medications

Medicaid data provide picture of changing antipsychotic prescribing practice

Released: 25-Jun-2014 2:30 PM EDT
Source Newsroom: Children's Hospital of Philadelphia
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Citations Journal of the American Academy of Child and Adolescent Psychiatry

Newswise — Philadelphia ⎯ A national study conducted by researchers at The Children’s Hospital of Philadelphia’s PolicyLab shows an increase in the concurrent prescribing of second-generation antipsychotics (SGA) – one type of medication used for the treatment of severe mental disorders such as schizophrenia and mania – with other psychotropic medications among Medicaid-enrolled youth. The study, published online on June 23rd in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), found that while overall SGA use increased by 22 percent from 2004 to 2008, the majority (85 percent) of youth using SGA were prescribed this medication concurrently with another psychotropic medication class.

This large-scale, population-based study, using a data set estimating medication use for 10.6 million children annually, is a rich resource for providing a picture of clinical practice trends on a national scale and can be valuable in informing policies and practice around SGA use.

The researchers used national Medicaid data from the Centers for Medicare and Medicaid Services, for years 2004, 2006, and 2008, to calculate the number of youth who received SGA concurrently with each of the four most commonly prescribed psychotropic medication classes (stimulants, antidepressants, mood stabilizers, and alpha agonists). They also calculated the average annual number of days each psychotropic medication class was prescribed and the days of concurrent SGA use.

Concurrent SGA use increased over time. Notably, by 2008, 1 in 5 stimulant users also received SGA, as well as 1 in 3 antidepressant users. The researchers note that for youth prescribed SGA alongside other psychotropic medications, the concurrent use was present for an average of four to five months in a given year, suggesting the addition of SGA was intended for long-term use rather than as a short-term strategy for behavioral health crisis situations.

“We knew that antipsychotic use was increasing among youth, but we were surprised to learn just how often youth on common psychotropic medications like stimulants or antidepressants also receive an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time," said David M. Rubin, MD, MSCE, a senior author of the study, attending pediatrician, and co-director of CHOP’s PolicyLab.

While the rates of concurrent SGA use were 30-60 percent higher among youth in foster care and youth with disability-related Medicaid eligibility, the growth in concurrent SGA use over time was largest among income-eligible youth, who represent the majority of youth served by the Medicaid program. Additionally, youth with ADHD experienced disproportionate increases in concurrent SGA prescribing over time, including youth with a sole diagnosis of ADHD, who experienced a 15 percent increase over the time period.

"The numbers tell a story of emerging clinical practice, where concurrent antipsychotic use by youth is no longer on the margins; rather, we are seeing a shift in use toward less-impaired groups of youth, including among those with ADHD and no other behavioral health diagnosis and among those who were never hospitalized,” explained Rubin.

“It is also noteworthy that the largest growth within the Medicaid program has not been among populations with high clinical need in the foster care and disability programs, but rather among those with income eligibility for Medicaid. This article foretells the spread of this therapy into general psychiatric practice," said Rubin.

Growing evidence of serious metabolic side effects of SGAs in youth, including weight gain and diabetes, heightens concern for the use of concurrent SGA.

“The reality is that there is very little safety and efficacy data for SGA in most youth, and we must also consider potential drug-drug interactions when SGAs are used concurrently with other medications,” explained Amanda Kreider, the study’s lead author and a researcher at PolicyLab. “As clinical practice moves toward the prescribing of these medication combinations in youth with less severe psychiatric impairments, consideration of alternative, non-pharmacologic interventions and, at minimum, monitoring of potential side effects will be critical.”

For more information about the study and on PolicyLab’s portfolio of work on antipsychotic medications, visit http://www.research.chop.edu/PolicyLab.

Blog post: The numbers of youth on antipsychotics: What does it all mean?

About PolicyLab at The Children’s Hospital of Philadelphia
PolicyLab develops evidence-based solutions for the most challenging health-related issues affecting children. PolicyLab engages in research that is both responsive to community needs and relevant to policy priorities, partnering with practitioners, policymakers, and families throughout the research process. Through its work, PolicyLab identifies the programs, practices, and policies that support the best outcomes for children and their families, disseminating its findings beyond research and academic communities as part of its commitment to transform evidence to action. www.research.chop.edu/PolicyLab

About The Children’s Hospital of Philadelphia
The Children’s Hospital of Philadelphia was founded in 1855 as the nation’s first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children’s Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program receives the highest amount of National Institutes of Health funding among all U.S. children’s hospitals. In addition, its unique family-centered care and public service programs have brought the 535-bed hospital recognition as a leading advocate for children and adolescents. For more information, visit http://www.chop.edu.
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