Morbid Obesity and Use of Second Generation Antipsychotics among Adolescents in Foster Care: Evidence from Medicaid

Pediatric Psychotropic Polypharmacy: An Evaluation of the Correlates and Prevalence Across Assessment Cycles in the National Health and Nutrition Examination Survey

Background: Pediatric psychotropic polypharmacy (PPP) is the prescription of more than one medication targeting psychiatric disorders among people younger than 18 years. Recent data suggested that PPP rates may be plateauing. Few studies have evaluated this question in large, nationally recruited samples. Objective: The National Health and Nutrition Examination Survey was used to examine the correlates and prevalence of PPP across assessment cycles. Independent assessments were obtained biannually between 2013 and 2018. Methods: Eleven thousand four hundred thirty-nine participants (4-17 years; Mage = 8.69 years; standard deviation = 5.16) were included in analyses. The Anatomic Therapeutic Chemical coding scheme was employed to classify medications, and participants were characterized as taking psychotropic medication if the medication was associated with a psychiatric diagnosis code. Participants self-reported past month medication use. Logistic regressions were used to examine correlates of pediatric psychotropic monotherapy compared with psychotropic polypharmacy. Results: Across assessments, 1.2% of respondents reported using two or more psychotropic medications. This estimate is lower than has been observed in specialized samples, but higher than other work using national samples. There was a small, significant difference in PPP across assessment cycles, such that rates of PPP were higher at the latter assessments. Correlates of PPP accorded with prior work, including male gender, increasing age, and markers of low socioeconomic status. The most robust predictor was having seen a mental health professional in the past year. Conclusions: This study documents that ∼1% of U.S. participants from a nationally recruited sample endorsed PPP. Findings are situated in the broader literature and the need for additional, prospective data to better characterize those trends in the United States and around the world. Key Takeaway Points It is known that many children and adolescents in the United States take more than one psychotropic medication, although few studies have examined trends in large, nationally recruited datasets. This study adds to this literature by documenting the prevalence of pediatric psychotropic polypharmacy in a large, unselected sample (i.e., 1.2%) and shows that rates were slightly higher at subsequent assessment intervals. Plain Language Summary Many kids take more than one medication for psychological problems. We analyzed data from ∼11,000 children and adolescents from across the United States, evaluated between 2013 and 2018. The number of kids taking multiple medications for psychological problems was different (higher) when measured later in time. Being a boy, being older, living in poverty, and having seen a mental health professional in the past year were associated with taking multiple medications for psychological problems. Implications for Managed Care Pharmacy These findings suggest rates of pediatric psychotropic polypharmacy (PPP) remain high in the United States, and correlate with male gender, poverty, and having recently seen a mental health professional. Relative to White children and adolescents, Black participants were less likely and Hispanic participants more likely to endorse PPP. Policy considerations include fully educating families and practitioners about the benefits as well as potential downsides of PPP and additional intervention options for mental health problems.

Antipsychotics in the California Foster Care System: A 10-Year Analysis

Background: In response to concerns regarding psychotropic medication prescribing, California's foster care system implemented oversight strategies to improve prescribing and monitoring practice, particularly for antipsychotics. The impact of these policies has not been evaluated. Objectives: To examine foster youth psychotropic use data in California and their relationship to national and state policy initiatives. Methods: This study analyzed 2011-2020 data curated by the California Child Welfare Indicators Project. The platform matches Medicaid medication and laboratory claims with individual-level foster youth data to report rates of dispensed psychotropic medications, authorization status, and metabolic screening. Results: In 2011, there were 78,231 California youth in foster care, of which 10,435 (13.3%) received psychotropics and 5570 (7.1%) antipsychotics. In 2020, of 68,386 foster children, 7172 (12.2%) received psychotropics and 2068 (3.0%) antipsychotics. Proper authorizations for psychotropics were obtained for 5581 (77.8%) foster youth in 2020. Of those receiving antipsychotics, 904 (43.7%) underwent metabolic screening. The greatest declines in antipsychotic use occurred between 2013 (6.7%) and 2018 (3.1%). Overall 2011 to 2020 declines were similar for males (8.5% → 3.6%, 58% reduction, p < 0.001) and females (5.5% → 2.4%, 57% reduction, p < 0.001). Regarding age and race, greater declines occurred for children <10 years (2.33% → 0.84%, 64% reduction, p < 0.001) and Latino youth (5.4% → 2.2%, 59% reduction, p < 0.001). Conclusions: Temporal patterns in antipsychotic use suggest an impact of policies and guidelines. While 12.2% of foster youth continue to receive psychotropics, there were reductions in racial/ethnic disparities and declines in antipsychotic use. Lack of adherence to authorization and metabolic screening requirements continue to be concerning.

Long-Term Metabolic Monitoring of Youths Treated with Second-Generation Antipsychotics 5 Years after Publication of the CAMESA Guidelines Are We Making Progress? Surveillance Métabolique à Long Terme des Jeunes Traités par Antipsychotiques de Deuxième Génération, Cinq ans Après la publication des Lignes Directrices Camesa: Faisons-Nous des Progrès?

OBJECTIVE

The potential metabolic adverse effects of second-generation antipsychotics (SGA) need to be monitored. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics (CAMESA) offers guidelines for this purpose. We aimed to evaluate the long-term rates of youths receiving monitoring in mental health clinics and document the factors that may influence them.

METHOD

The charts of 180 patients (13.3 ± 3.1 years, 54.4% males) receiving SGA treatment for the first time between January 2016 and June 2018 were reviewed. Monitoring was divided into baseline and 1- to 6-month and 9- to 24-month periods. Population under study was stratified into children (4 to 12 years) and adolescents (13 to 18 years). Sociodemographic characteristics, psychiatric diagnosis and comorbidities, prescribed SGAs and comedications, anthropometric measures (AM), blood pressure (BP), blood tests (BT), electrocardiogram, and the psychiatrist's years of practice were collected. Cross tables were used to present the monitoring rates. Categories were compared by covariate analysis. Rates of patients monitored across categories were compared using Fisher exact test.

RESULTS

Monitoring rates for AM, BT, and BP were 55%, 47.8%, and 46.7% at baseline; 50%, 41.7%, and 45.2% at 1 to 6 months; and 47.2%, 41.5%, and 40.6% at 9 to 24 months, respectively. Higher monitoring rates were significantly associated with adolescent status (baseline, 1 to 6 months), a diagnosis of psychotic and/or affective disorder (baseline, 1 to 6 months, 9 to 24 months), having ≤1 psychiatric comorbidities (1 to 6 months), high SGA dose (baseline, 1 to 6 months), and clinician's experience (baseline, 9 to 24 months). Significantly lower monitoring rates were associated with the psychostimulant/atomoxetine comedication (baseline, 1 to 6 months, 9 to 24 months).

CONCLUSION

Five years after publication of the CAMESA guidelines, metabolic monitoring is conducted for less than half of patients. In our sample, age, diagnostic category, psychiatric comorbidities, SGA dose, clinician's experience, and comedications influenced the monitoring rates. Major progress still needs to be made before reaching a satisfactory level of monitoring.

Characterization of Chronic Multiclass Psychotropic Polypharmacy and Psychotherapy in Foster Care Youth in a State Medicaid Population

BACKGROUND

Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy.

METHODS

This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy.

RESULTS

Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64).

CONCLUSIONS

Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes.

DISCLOSURES

This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.

Foster homes for neglected children with severe obesity-Debated but rarely studied

AIM

To explore current research and theoretical articles on foster home placement of children with severe obesity.

METHODS

An integrative literature review. Literature searches in six electronic databases included theoretical, quantitative and qualitative articles and case reports published in English (2008-2018) on the topic of severe childhood obesity and foster home placement.

RESULTS

Seventeen selected papers included six theoretical articles, nine quantitative studies, one qualitative study and one case report. Eight of the nine quantitative studies did not specify the grading of obesity in children in foster care. The case report and the qualitative study showed distinct and sustainable body mass index (BMI) reductions after a child had been placed in foster care. Five theoretical articles justified foster care placement when chronic parental neglect led to severe obesity in the child, while one article emphasised the opposite.

CONCLUSION

Parental and societal neglect of children with severe obesity placed in a foster home is rarely studied or the exclusive aim of research. The views of the children themselves are lacking in research articles, as well as the child's right to health obligations concerning children with severe obesity.

High-risk psychotropic medications for US children with trauma sequelae

Children exposed to trauma are predisposed to develop a number of mental health syndromes. They are prone to under-treatment with effective psychosocial interventions and over-treatment with high-risk psychotropic medications, especially polypharmacy and the use of antipsychotics for unapproved conditions. We review the evidence for psychosocial and pharmacological treatments for mental health problems associated with high exposure to childhood trauma - identifying those in foster care as an index group - and the frequency of high-risk pharmacological practices. We describe current efforts to reduce over-treatment of children with high-risk psychotropic medications and propose further recommendations to protect and provide effective care for these vulnerable children.

Variation of the prevalence of pediatric polypharmacy: A scoping review

PURPOSE

To examine the range of prevalence of pediatric polypharmacy in literature through a scoping review, focusing on factors that contribute to its heterogeneity in order to improve the design and reporting of quality improvement, pharmacovigilance, and research studies.

METHODS

We searched Ovid Medline, PubMed, EMBASE, CINAHL, Ovid PsycINFO, Cochrane CENTRAL, and Web of Science Core Collection databases for studies with concepts of children and polypharmacy, along with a hand search of the bibliographies of six reviews and 30 included studies. We extracted information regarding study design, disease conditions, and prevalence of polypharmacy.

RESULTS

Two hundred eighty-four studies reported prevalence of polypharmacy. They were more likely to be conducted in North America (37.7%), published after 2010 (44.4%), cross-sectional (67.3%), in outpatient settings (59.5%). Prevalence ranged from 0.9% to 98.4%, median 39.7% (interquartile range [IQR] 22.0%-54.0%). Studies from Asia reported the highest median prevalence of 45.4% (IQR 27.3%-61.0%) while studies from North America reported the lowest median prevalence of 30.4% (IQR 14.7%-50.2%). Prevalence decreased over time: median 45.6% before 2001, 38.1% during 2001 to 2010, and 34% during 2011 to 2017. Studies involving children under 12 years had a higher median prevalence (46.9%) than adolescent studies (33.7%). Inpatient setting studies had a higher median prevalence (50.3%) than studies in outpatient settings (38.8%). Community level samples, higher number and duration of medications defining polypharmacy, and psychotropic medications were associated with lower prevalence.

CONCLUSIONS

The prevalence of pediatric polypharmacy is high and variable. Studies reporting pediatric polypharmacy should account for context, design, polypharmacy definition, and medications evaluated.

Defining pediatric polypharmacy: A scoping review

OBJECTIVES

Lack of consensus regarding the semantics and definitions of pediatric polypharmacy challenges researchers and clinicians alike. We conducted a scoping review to describe definitions and terminology of pediatric polypharmacy.

METHODS

Medline, PubMed, EMBASE, CINAHL, PsycINFO, Cochrane CENTRAL, and the Web of Science Core Collection databases were searched for English language articles with the concepts of "polypharmacy" and "children". Data were extracted about study characteristics, polypharmacy terms and definitions from qualifying studies, and were synthesized by disease conditions.

RESULTS

Out of 4,398 titles, we included 363 studies: 324 (89%) provided numeric definitions, 131 (36%) specified duration of polypharmacy, and 162 (45%) explicitly defined it. Over 81% (n = 295) of the studies defined polypharmacy as two or more medications or therapeutic classes. The most common comprehensive definitions of pediatric polypharmacy included: two or more concurrent medications for ≥1 day (n = 41), two or more concurrent medications for ≥31 days (n = 15), and two or more sequential medications over one year (n = 12). Commonly used terms included polypharmacy, polytherapy, combination pharmacotherapy, average number, and concomitant medications. The term polypharmacy was more common in psychiatry literature while epilepsy literature favored the term polytherapy.

CONCLUSIONS

Two or more concurrent medications, without duration, for ≥1 day, ≥31 days, or sequentially for one year were the most common definitions of pediatric polypharmacy. We recommend that pediatric polypharmacy studies specify the number of medications or therapeutic classes, if they are concurrent or sequential, and the duration of medications. We propose defining pediatric polypharmacy as "the prescription or consumption of two or more distinct medications for at least one day". The term "polypharmacy" should be included among key words and definitions in manuscripts.