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West LM, Mooney SJ, Chavez L, Beck A, Clarke GN, Pabiniak CJ, Renz AD, Penfold RB. Evaluation of the Safer Use of Antipsychotics in Youth Study on Population Level Antipsychotic Initiation: An Interrupted Time Series Analysis. J Child Adolesc Psychopharmacol 2024. [PMID: 38743639 DOI: 10.1089/cap.2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background: Antipsychotics carry a higher-risk profile than other psychotropic medications and may be prescribed for youth with conditions in which other first-line treatments are more appropriate. This study aimed to evaluate the population-level effect of the Safer Use of Antipsychotics in Youth (SUAY) trial, which aimed to reduce person-days of antipsychotic use among participants. Methods: We conducted an interrupted time series analysis using segmented regression to measure changes in prescribing trends of antipsychotic initiation rates pre-SUAY and post-SUAY trial at four U.S. health systems between 2013 and 2020. Results: In our overall model, adjusted for age and insurance type, antipsychotic initiation rates decreased by 0.73 (95% confidence interval [CI]: 0.30, 1.16, p = 0.002) prescriptions per 10,000 person-months before the SUAY trial. In the first quarter following the start of the trial, there was an immediate decrease in the rate of antipsychotic initiations of 6.57 (95% CI: 0.99, 12.15) prescriptions per 10,000 person-months. When comparing the posttrial period to the pretrial period, there was an increase of 1.09 (95% CI: 0.32, 1.85) prescriptions per 10,000 person-months, but the increasing rate in the posttrial period alone was not statistically significant (0.36 prescriptions per 10,000 person-months, 95% CI: -0.27, 0.99). Conclusion: The declining trend of antipsychotic initiation seen between 2013 and 2018 (pre-SUAY trial) may have naturally reached a level at which prescribing was clinically warranted and appropriate, resulting in a floor effect. The COVID-19 pandemic, which began in the final three quarters of the posttrial period, may also be related to increased antipsychotic medication initiation.
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Affiliation(s)
- Laura M West
- Department of Epidemiology, University of Washington Seattle, Seattle, Washington, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Stephen J Mooney
- Department of Epidemiology, University of Washington Seattle, Seattle, Washington, USA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington, USA
| | - Laura Chavez
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Arne Beck
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Gregory N Clarke
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Chester J Pabiniak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Anne D Renz
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
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Candon M, Shen S, Rothbard A, Reed A, Everett M, Demp N, Weingartner M, Fadeyibi O. Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia. BMC Health Serv Res 2024; 24:574. [PMID: 38702737 PMCID: PMC11067128 DOI: 10.1186/s12913-024-11029-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target. METHODS In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card. RESULTS Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card. CONCLUSIONS A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.
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Affiliation(s)
- Molly Candon
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Siyuan Shen
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
| | - Aileen Rothbard
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail Reed
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mia Everett
- Community Behavioral Health, Philadelphia, PA, USA
| | - Neal Demp
- Community Behavioral Health, Philadelphia, PA, USA
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Klau J, Gonzalez‐Chica D, Raven M, Jureidini J. Antipsychotic prescribing patterns in children and adolescents attending Australian general practice in 2011 and 2017. JCPP ADVANCES 2024; 4:e12208. [PMID: 38486961 PMCID: PMC10933664 DOI: 10.1002/jcv2.12208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/12/2023] [Indexed: 03/17/2024] Open
Abstract
Background Antipsychotics are increasingly prescribed to children and adolescents worldwide, but little is known about reasons for prescribing. We aimed to examine patterns of paediatric antipsychotic prescribing in Australian primary care services in 2011 and 2017, including diagnoses, sociodemographic characteristics, off-label prescribing, and psychotropic co-prescribing. Methods Retrospective analysis of electronic health records (EHRs) using a large Australian general practice database (MedicineInsight). Diagnoses of mental disorders were extracted from EHRs and associated with antipsychotic prescriptions within the same calendar year for three age-groups: 0-9, 10-14, and 15-18-year-olds. Results In 2017, children/adolescents with mental health diagnoses were more likely to be prescribed antipsychotics (2.9% of 27,412 patients) than in 2011 (2.0% of 8418 patients; absolute difference +0.9, 95% CI + 0.5, +1.4). The likelihood was greater for patients with bipolar disorders (21.6% vs. 41.5%), eating disorders (1.1% vs. 7.2%), and autism without behavioural problems (3.7% vs. 6.1%). Depression/anxiety (adjusted 26.8% of patients 2011; 30.8% 2017) was the most common diagnosis associated with antipsychotics in both years. Most antipsychotics were prescribed off-label (69.8% 2011; 79.7% 2017; absolute difference +9.8, 95% CI + 1.54, +18.4). Off-label prescribing increased most among those aged 15-18-years, females, and patients living in outer regional/remote/very remote communities and the most disadvantaged areas. The three most frequently prescribed antipsychotics in both years were risperidone, quetiapine, and olanzapine. Psychotropic co-prescribing among patients receiving antipsychotic prescriptions was approximately 69% in both years. Conclusions Prescribing antipsychotics for mental health diagnoses to children/adolescents attending Australian general practices was more frequent in 2017 than 2011, and most commonly associated with depression/anxiety diagnoses. In both years, most prescribing was off-label. The majority of patients were co-prescribed other classes of psychotropics along with antipsychotics.
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Affiliation(s)
- Julie Klau
- Robinson Research InstituteCritical and Ethical Mental Health Research GroupUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - David Gonzalez‐Chica
- Discipline of General PracticeUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Melissa Raven
- Robinson Research InstituteCritical and Ethical Mental Health Research GroupUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Jon Jureidini
- Robinson Research InstituteCritical and Ethical Mental Health Research GroupUniversity of AdelaideAdelaideSouth AustraliaAustralia
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Ray WA, Fuchs DC, Olfson M, Patrick SW, Stein CM, Murray KT, Daugherty J, Cooper WO. Antipsychotic Medications and Mortality in Children and Young Adults. JAMA Psychiatry 2024; 81:260-269. [PMID: 38019523 PMCID: PMC10687711 DOI: 10.1001/jamapsychiatry.2023.4573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/05/2023] [Indexed: 11/30/2023]
Abstract
Importance Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. Results The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - D. Catherine Fuchs
- Department of Psychiatry and Behavioral Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mark Olfson
- Columbia University Irving Medical Center, New York, New York
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Division of Rheumatology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Cardiovascular Medicine, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William O. Cooper
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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Chen H, Lyu N, Chan W, De La Cruz A, Calarge C. Utilization and Predictors of Adjuvant Metformin for Children and Adolescents on Mixed Receptor Antagonists (Second-Generation Antipsychotics). J Am Acad Child Adolesc Psychiatry 2023; 62:1245-1255. [PMID: 37245706 PMCID: PMC10750998 DOI: 10.1016/j.jaac.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/30/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To examine utilization and predictors of adjuvant metformin among pediatric recipients of second-generation antipsychotics (SGAs) (mixed receptor antagonist). METHOD This study used 2016-2021 data of a national electronic medical record database. Eligible participants were children aged 6 to 17 with a new SGA prescription for at least 90 days. Predictors of prescribing adjuvant metformin in general and to nonobese pediatric SGA recipients in particular were assessed using conditional logistic regression and logistic regression analyses, respectively. RESULTS Of 30,009 pediatric SGA recipients identified, 2.3% (n = 785) received adjuvant metformin. Among 597 participants with a body mass index z score documented during the 6-month period before metformin initiation, 83% were obese, and 34% had either hyperglycemia or diabetes. Significant predictors for metformin prescribing were high baseline body mass index z score (odds ratio [OR] 3.5, 95% CI 2.8-4.5, p < .0001), having hyperglycemia or diabetes (OR 5.3, 95% CI 3.4-8.3, p < .0001), and undergoing a switch from a higher metabolic risk SGA to a lower risk one (OR 9.9, 95% CI 3.5-27.5, p = .0025) or a switch in the opposite direction (OR 4.1, 95% CI 2.1-7.9, p = .0051) compared with no switch. Nonobese metformin users were more likely to have a positive body mass index z score velocity before metformin initiation than their obese counterparts. Receiving the index SGA prescribed by a mental health specialist was associated with higher likelihood of receiving adjuvant metformin and receiving metformin before the development of obesity. CONCLUSION Utilization of adjuvant metformin among pediatric SGA recipients is uncommon, and early introduction of the medication among nonobese children is rare.
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Affiliation(s)
- Hua Chen
- University of Houston, College of Pharmacy, Houston, Texas.
| | - Ning Lyu
- University of Houston, College of Pharmacy, Houston, Texas
| | - Wenyaw Chan
- University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas
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Chavez LJ, Richards JE, Fishman P, Yeung K, Renz A, Quintana LM, Massimino S, Penfold RB. Cost of Implementing an Evidence-Based Intervention to Support Safer Use of Antipsychotics in Youth. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:725-733. [PMID: 37261566 DOI: 10.1007/s10488-023-01273-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/02/2023]
Abstract
To estimate the cost of implementing a clinical program designed to support safer use of antipsychotics in children and adolescents (youth) age 3-17 years at the time of initiating an antipsychotic medication. We calculate the costs of implementing a psychiatric consultation and navigation program for youth prescribed antipsychotic medications across 4 health systems, which included an electronic health record (EHR) decision support tool, consultation with a child and adolescent psychiatrist, and up to 6 months of behavioral health care navigation, as well as telemental health for patients (n = 348). Cost data were collected for both start-up and ongoing intervention phases and are estimated over a 1-year period. Data sources included study records and time-in-motion reports, analyzed from a health system perspective. Costs included both labor and nonlabor costs (2019 US dollars). The average total start-up and ongoing costs per health system were $34,007 and $185,174, respectively. The average total cost per patient was $2,128. The highest average ongoing labor cost components were telemental health ($901 per patient), followed by child and adolescent psychiatrist consultation ($659), and the lowest cost component was primary care/behavioral health provider time to review/respond to the EHR decision support tool and case consultation ($24). For health systems considering programs to promote safer and targeted use of antipsychotics among youth, this study provides estimates of the full start-up and ongoing costs of an EHR decision support tool, psychiatric consultation service, and psychotherapeutic services for patients and families.Trial registration: Clinicaltrials.gov, NCT03448575.
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Affiliation(s)
- Laura J Chavez
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Julie E Richards
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Paul Fishman
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Anne Renz
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - LeeAnn M Quintana
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
| | | | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Herschell AD, Schuster JM, Keyser DJ, Wasilchak DS, Neimark GB, Shaffer SL, Hurford MO. Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care. Psychiatr Serv 2023; 74:996-1001. [PMID: 36935623 DOI: 10.1176/appi.ps.20220478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.
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Affiliation(s)
- Amy D Herschell
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - James M Schuster
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - Donna J Keyser
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - Deborah S Wasilchak
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - Geoffrey B Neimark
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - Sherry L Shaffer
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
| | - Matthew O Hurford
- Community Care Behavioral Health Organization (Herschell, Schuster, Wasilchak, Neimark, Shaffer, Hurford) and Center for High-Value Health Care (Keyser), UPMC Insurance Services Division, Pittsburgh
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Bushnell G, Lloyd J, Olfson M, Cook S, Das H, Crystal S. Antipsychotic Medication Use In Medicaid-Insured Children Decreased Substantially Between 2008 And 2016. Health Aff (Millwood) 2023; 42:973-980. [PMID: 37406239 PMCID: PMC10845053 DOI: 10.1377/hlthaff.2022.01625] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
After the rapid growth of pediatric antipsychotic prescribing in the early 2000s, especially in the Medicaid population, concerns regarding the safety and appropriateness of such prescribing increased. Many states implemented policy and educational initiatives aimed at safer and more judicious antipsychotic use. Antipsychotic use leveled off in the late 2000s, but there have been no recent national estimates of trends in antipsychotic use in children enrolled in Medicaid, and it is unclear how use varied by race and ethnicity. This study observed a sizable decline in antipsychotic use among children ages 2-17 between 2008 and 2016. Although the magnitude of change varied, declines were observed across foster care status, age, sex, and racial and ethnic groups studied. The proportion of children with an antipsychotic prescription who received any diagnosis associated with a pediatric indication that was approved by the Food and Drug Administration increased from 38 percent in 2008 to 45 percent in 2016, which may indicate a trend toward more judicious prescribing.
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Affiliation(s)
- Greta Bushnell
- Greta Bushnell , Rutgers University, New Brunswick, New Jersey
| | | | - Mark Olfson
- Mark Olfson, Columbia University and New York State Psychiatric Institute, New York, New York
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9
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Lohr WD, Jawad K, Feygin Y, Le J, Creel L, Pasquenza N, Williams PG, Jones VF, Myers J, Davis DW. Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy. Psychiatr Serv 2022; 73:510-517. [PMID: 34470507 DOI: 10.1176/appi.ps.202000673] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.
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Affiliation(s)
- W David Lohr
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Kahir Jawad
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Yana Feygin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Jennifer Le
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Liza Creel
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Natalie Pasquenza
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - P Gail Williams
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - V Faye Jones
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - John Myers
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
| | - Deborah Winders Davis
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky (Lohr, Jawad, Feygin, Le, Pasquenza, Williams, Jones, Myers, Davis); Department of Health Management and System Sciences, University of Louisville School of Public Health and Information Science, Louisville, Kentucky (Creel)
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Guber KM, Cortes ND, Duan L. Risk of Obesity Among Children Prescribed Atypical Antipsychotics for Six Months or More. J Child Adolesc Psychopharmacol 2022; 32:52-60. [PMID: 34283934 DOI: 10.1089/cap.2021.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: The study investigates the risk of obesity for young children prescribed an atypical antipsychotic (AAP) for 6 months or more. AAPs are associated with risk of obesity. They are used in children for a variety of psychiatric conditions and are often prescribed off-label. Long-term risk of obesity in this age group is unknown as most studies are short-term investigations and generally combine younger children with adolescents and adults. Methods: A retrospective cohort of children, 10 years old or younger, prescribed either an AAP or selective serotonin reuptake inhibitor (SSRI) for 6 months or more were followed for up to 9.5 years. The primary endpoint was the body-mass index (BMI) reaching the 95th percentile. Results: One thousand six hundred fifty-five patients met inclusion criteria. One thousand one hundred eighteen patients were prescribed an AAP and 537 were prescribed an SSRI: 1152 (74.5%) patients were male and mean (standard deviation) age was 7.9 [1.90] years at study entry. Median follow-up was 3.58 years for the AAP cohort and 3.28 years for the SSRI cohort (p = 0.02). After adjusting for baseline demographic variables, BMI, and other concomitantly prescribed medications, children prescribed AAPs for 6 months or longer were twice as likely to become obese compared with children prescribed SSRIs (adjusted hazard ratio [HR] 2.06 [95% confidence interval; CI 1.60-2.66], p < 0.0001). Further stratification by AAP revealed that the obesity risk for patients prescribed aripiprazole was 34% greater than for those prescribed risperidone (adjusted HR 1.34 [95% CI 1.01-1.78], p = 0.0033). Conclusions: The risk of obesity for young children prescribed an AAP for 6 months or more is approximately double that of children prescribed an SSRI. The risk of obesity is greater with aripiprazole than risperidone in the first year. Prescribers should consider the risk of obesity when prescribing AAPs and consider alternative treatment modalities in this vulnerable patient population.
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Affiliation(s)
- Kevin Meis Guber
- San Bernardino County Department of Psychiatry, Southern California Permanente Medical Group, Kaiser Permanente Southern California, Fontana, California, USA
| | - Natasha Dasig Cortes
- San Bernardino County Department of Psychiatry, Southern California Permanente Medical Group, Kaiser Permanente Southern California, Fontana, California, USA
| | - Lewei Duan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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11
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Vuori M, Sourander A, Aronen ET, Kronström K, Saastamoinen LK. Relative Age and the Use of Second-Generation Antipsychotics from 7 to 17 Years of Age: A Population-Based Register Study. J Child Adolesc Psychopharmacol 2022; 32:45-51. [PMID: 34619034 DOI: 10.1089/cap.2021.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: The youngest children in a classroom have a higher risk of attention-deficit/hyperactivity disorders (ADHDs) and depression than their relatively older peers. However, there has been a lack of research on how relative age is related to second-generation antipsychotic (SGA) medication use. Methods: This study used the Finnish National Prescription Register data and comprised all 669,726 Finnish children and adolescents aged 7-17 in 2018. We extracted data for those who were dispensed SGAs (risperidone, quetiapine, aripiprazole, and olanzapine) and ADHD medication (methylphenidate, atomoxetine, dexamphetamine, and lisdexamfetamine). Odds ratios (OR) and 95% confidence intervals (CI) were calculated for medication dispensed to schoolchildren born from January to April (the relatively oldest), May to August, and September to December (the relatively youngest). Dispensed prescriptions were a proxy for medication use. Results: SGAs were dispensed to 9146 (1.4%) individuals in 2018. Their use was lower among girls aged 12-17 years born from September to December than January to April (OR 0.89; 95% CI 0.83-0.97), with no association between SGA use and birth month among boys. However, younger relative age was associated with combined SGA and ADHD medication, which was used by 2556 (0.4%) of the cohort: 2074 (0.6%) boys and 482 (0.1%) girls. The OR was 1.27 for boys aged 12-17 born from September to December (95% CI 1.10-1.46), compared with January to April. The OR for girls born from May to August was 1.35 (95% CI 1.04-1.76) and from September to December it was 1.33 (95% CI 1.02-1.74), compared with January to April. Conclusions: A novel discovery of this study was that using both SGA and ADHD medication at the age of 12-17 years was more common among the youngest subjects in a school year than their relatively older peers.
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Affiliation(s)
- Miika Vuori
- Department of Teacher Education, Turku Institute of Advanced Studies, University of Turku, Turku, Finland.,Department of Child Psychiatry, University of Turku, Turku University Hospital, Turku, Finland
| | - Andre Sourander
- Department of Child Psychiatry, University of Turku, Turku University Hospital, Turku, Finland.,Invest Flagship, University of Turku, Turku, Finland
| | - Eeva T Aronen
- Child Psychiatry, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Laboratory of Developmental Psychopathology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Kim Kronström
- Department of Child Psychiatry, University of Turku, Turku University Hospital, Turku, Finland.,Department of Adolescent Psychiatry, Turku University Hospital, Hospital District of Southwest Finland, Turku, Finland
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12
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Penfold RB, Thompson EE, Hilt RJ, Schwartz N, Robb AS, Correll CU, Newton D, Rogalski K, Earls MF, Kowatch RA, Beck A, Yarborough BJH, Crystal S, Vitiello B, Kelleher KJ, Simon GE. Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial. J Am Acad Child Adolesc Psychiatry 2022; 61:93-102. [PMID: 34256967 PMCID: PMC8566327 DOI: 10.1016/j.jaac.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. METHOD A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations. RESULTS The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments. CONCLUSION Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths. CLINICAL TRIAL REGISTRATION INFORMATION Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.
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13
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Stutzman DL. Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. Ment Health Clin 2021; 11:320-333. [PMID: 34824957 PMCID: PMC8582767 DOI: 10.9740/mhc.2021.11.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.
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14
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Candon M, Shen S, Fadeyibi O, Smith JL, Rothbard A. Trends in antipsychotic prescribing for approved and unapproved indications to Medicaid-enrolled youth in Philadelphia, Pennsylvania between 2014 and 2018. BMC Psychiatry 2021; 21:524. [PMID: 34686159 PMCID: PMC8540198 DOI: 10.1186/s12888-021-03533-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear. METHODS Using 2014-2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication. RESULTS Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications. CONCLUSIONS Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate.
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Affiliation(s)
- Molly Candon
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Siyuan Shen
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
| | | | - Joseph L Smith
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- HealthCore, Inc., Wilmington, DE, USA
| | - Aileen Rothbard
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
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15
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Bushnell GA, Crystal S, Olfson M. Trends in Antipsychotic Medication Use in Young Privately Insured Children. J Am Acad Child Adolesc Psychiatry 2021; 60:877-886. [PMID: 33091567 PMCID: PMC8055725 DOI: 10.1016/j.jaac.2020.09.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/16/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To estimate trends of annual antipsychotic medication use by privately insured young children (aged 2-7 years) in the United States, and to describe the clinical and treatment characteristics of these children. METHOD The study population included young children from a nationwide commercial claims database (2007-2017). We estimated annual antipsychotic use by age and sex, defined as the number of children dispensed an antipsychotic per year divided by the number enrolled. We described clinical diagnoses and mental health service use in those with prescription antipsychotic use in 2009 and 2017. RESULTS Annual antipsychotic use in young children was 0.27% in 2007, peaked at 0.29% in 2009, and statistically significantly declined to 0.17% by 2017 (linear trend: -0.017% per year, 95% CI: -0.018 to -0.016). Antipsychotic use was higher in boys than in girls. A greater proportion of antipsychotic users received a mental disorder diagnosis in 2017 (89%) than in 2009 (86%, p < .01). The most common clinical diagnoses in antipsychotic users, under a hierarchical classification, were pervasive developmental disorder (2009 = 27%, 2017 = 38%, p < .01), conduct or disruptive behavior disorder (2009 = 15%, 2017 = 21%, p < .01), and attention-deficit/hyperactivity disorder (2009 = 24%, 2017 = 18%, p < .01). Among 2017 antipsychotic users, 32% had 4+ psychotherapy claims, 43% had a psychiatrist visit, and the majority used another psychotropic medication, most commonly a stimulant (boys = 57%, girls = 50%). CONCLUSION In privately insured young children, antipsychotic use declined from 2009 to 2017, with shifts toward indications with some supporting evidence. Nevertheless, a majority of use remains off label and for conditions lacking effectiveness and safety data. Improving antipsychotic prescribing in young children remains a challenge.
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Affiliation(s)
- Greta A Bushnell
- Rutgers School of Public Health, Piscataway, and the Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, New Jersey.
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research at Rutgers University in New Brunswick, New Jersey
| | - Mark Olfson
- Columbia University Vagelos College of Physicians and Surgeons, Columbia University Mailman School of Public Health, and the New York State Psychiatric Institute in New York
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16
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Davis DW, Lohr WD, Feygin Y, Creel L, Jawad K, Jones VF, Williams PG, Le J, Trace M, Pasquenza N. High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid. BMC Psychiatry 2021; 21:303. [PMID: 34112146 PMCID: PMC8194140 DOI: 10.1186/s12888-021-03309-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.
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Affiliation(s)
- Deborah Winders Davis
- Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY, 40202, Louisville, USA.
| | - W. David Lohr
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Yana Feygin
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Liza Creel
- grid.266623.50000 0001 2113 1622Department of Health Management & System Sciences, University of Louisville School of Public Health and Information Science, 485 E. Gray Street, Louisville, KY 40202 USA
| | - Kahir Jawad
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - V. Faye Jones
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - P. Gail Williams
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Jennifer Le
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Marie Trace
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Natalie Pasquenza
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
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17
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Houghton R, van den Bergh J, Law K, Liu Y, de Vries F. Risperidone versus aripiprazole fracture risk in children and adolescents with autism spectrum disorders. Autism Res 2021; 14:1800-1814. [PMID: 34080319 DOI: 10.1002/aur.2541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Risperidone and aripiprazole, commonly used antipsychotics in children with autism spectrum disorder (ASD), have previously been associated with elevated fracture risk in other populations. The aim of this study was to evaluate and compare the risk of fracture among children with ASD using risperidone or aripiprazole. This was a retrospective, propensity-score matched cohort study, set between January 2013 and December 2018. We used the MarketScan Medicaid insurance data, which covers multiple states of the United States. We included ASD children aged 2-18 years, who were new users of aripiprazole or risperidone and with no prior history of antipsychotic use or fractures. The main exposure was the continued use of aripiprazole or risperidone. The incidence rates of any fracture during follow-up were evaluated, and the risk between aripiprazole and risperidone was compared via Cox-proportional hazard models. Results were stratified by age, sex, duration of exposure and fracture site. In total, 3312 patients (78% male; mean [SD] age 11.0 [3.7] years) were identified for each cohort. Over the full duration of follow-up, fracture incidence rates per 1000 patient-years were 23.2 for risperidone and 38.4 for aripiprazole (hazard ratio and 95% confidence interval: 0.60 [0.44-0.83]). Risks were similar between cohorts throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. Extremity fractures drove most of the increased risk, with the biggest differences in lower leg and ankle fractures. Differences widened for children aged 10 years or younger (HR [95% CI]: 0.47 [0.30-0.74]). In conclusion, compared to aripiprazole, risperidone was associated with 40% lower risk of fracture. Further analysis on the mechanism and long-term bone health of antipsychotic-treated children with ASD is warranted. LAY SUMMARY: We compared the risk of bone fractures among 6624 children with autism spectrum disorder (ASD), half of whom used risperidone and half of whom used aripiprazole. Taking other factors into account, risks were similar between the two groups throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. The biggest differences were in lower leg and ankle fractures. Overall, compared with aripiprazole, risperidone was associated with 40% lower risk of fracture.
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Affiliation(s)
- Richard Houghton
- Personalized Health Care Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland.,Department of Clinical Pharmacy and Toxicology, Maastricht UMC+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Joop van den Bergh
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht UMC+, Maastricht, the Netherlands.,Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands.,Faculty of medicine, Hasselt University, Hasselt, Belgium
| | - Kiely Law
- Kennedy Krieger Institute, Interactive Autism Network, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yutong Liu
- Genesis Research, Real World Evidence Solutions, Hoboken, New Jersey, USA
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht UMC+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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18
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Chavez LJ, Kelleher KJ, Beck A, Clarke GN, Penfold RB. Trends Over Time in Antipsychotic Initiation at a Large Children's Health Care System. J Child Adolesc Psychopharmacol 2021; 31:381-386. [PMID: 34143677 PMCID: PMC8233217 DOI: 10.1089/cap.2020.0190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Antipsychotic prescribing in children and adolescents increased sharply beginning in the 1990s, but recent reports among Medicaid enrollees suggest declining trends. However, few studies have included both commercially and publicly insured patients or focused on trends in new antipsychotic medications in children without documented psychotic disorders or other indicated conditions. The objective of the study was to report trends in new antipsychotic prescribing for pediatric patients (age 3-17 years) in a large children's health care system. Methods: Data were abstracted from electronic medical records (January 1, 2013 to December 31, 2017). New antipsychotic medication orders were defined as antipsychotic orders for patients without an order in the 180 days prior. Patients were excluded if the order was initiated in an emergency department or inpatient setting; they were diagnosed with psychotic disorder, mania, autism spectrum disorder, or intellectual disability; or the order was for prochlorperazine. The crude rate of new antipsychotic prescribing is reported quarterly with Poisson 95% confidence intervals in the total sample and by demographic subgroups (child vs. adolescent, female vs. male, public vs. private insurance, and white vs. nonwhite). Results: Antipsychotic orders decreased from 54.9 prescriptions per 10,000 person months in the first quarter of 2013 to 34.1 per 10,000 person months in the last quarter of 2017. Rates of antipsychotic prescribing were significantly higher for adolescents compared with children, patients who were commercially insured compared with Medicaid insured, and at most time points for white compared with non-white patients. However, prescribing rates did not differ significantly based on gender. Conclusions: Antipsychotic prescribing declined for both commercially and Medicaid-insured children in a pediatric hospital-based system, although white and commercially insured patients were more likely to be prescribed antipsychotics. More attention may be needed for reducing potentially avoidable prescribing of antipsychotics in previously understudied subgroups, such as commercially insured patients. Clinical Trial Registration Number: NCT03448575.
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Affiliation(s)
- Laura J. Chavez
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Address correspondence to: Laura J. Chavez, PhD, MPH, Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kelly J. Kelleher
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Arne Beck
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Gregory N. Clarke
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Robert B. Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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19
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Brown JT, Campo-Soria C, Bishop JR. Current strategies for predicting side effects from second generation antipsychotics in youth. Expert Opin Drug Metab Toxicol 2021; 17:655-664. [PMID: 33896324 DOI: 10.1080/17425255.2021.1922668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Antipsychotic medications are used to treat a number of conditions in children and adolescents. While side effect profiles from second generation antipsychotics (SGAs) may differ from older antipsychotics, they do not come without risk. Knowing which children may be at higher risk for specific outcomes is important clinical information for prescribers. Common side effects and toxicities of SGAs in children include movement disorders, weight gain, and hormonal changes. There are also rare, but potentially dangerous adverse events including neuroleptic malignant syndrome, hypersensitivity and suicidal ideation.Areas covered: This review will summarize and comment on clinical, pharmacological, and genetic factors having evidence as predictors of SGA-associated side effects and toxicities in children.Expert opinion: Observations across studies note that older children and those that do not respond early in treatment may be more at risk for movement disorders, while younger, antipsychotic naive children are at increased risk for weight gain. Relatively fewer studies have looked at pharmacogenetic relationships, although variations in pharmacokinetic and pharmacodynamic genes hold promise to advance drug dosing or selection strategies. Future efforts to assimilate multiple clinical, pharmacological, and genetic factors to facilitate predictive analytics and clinical decision support for prescribers will advance precision care to patients.
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Affiliation(s)
- Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Duluth, MN, USA
| | - Claudia Campo-Soria
- Department of Psychiatry, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA.,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Minnesota, Minneapolis, MN, USA
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20
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Blader JC, Pliszka SR, Kafantaris V, Foley CA, Carlson GA, Crowell JA, Bailey BY, Sauder C, Daviss WB, Sinha C, Matthews TL, Margulies DM. Stepped Treatment for Attention-Deficit/Hyperactivity Disorder and Aggressive Behavior: A Randomized, Controlled Trial of Adjunctive Risperidone, Divalproex Sodium, or Placebo After Stimulant Medication Optimization. J Am Acad Child Adolesc Psychiatry 2021; 60:236-251. [PMID: 32007604 PMCID: PMC7390668 DOI: 10.1016/j.jaac.2019.12.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/29/2019] [Accepted: 01/23/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Stimulant medications are the most prevalent first-line pharmacotherapy for attention-deficit/hyperactivity disorder, but children with aggressive behavior often receive multiagent treatment. There is sparse evidence for the benefits of adjunctive medications when stimulant monotherapy provides inadequate benefit for aggressive behavior, yet the adverse effects of common adjuncts are well established. This study compared the efficacy in reducing aggressive behavior of risperidone (RISP), divalproex sodium (DVPX), and placebo (PBO) added to stimulant medication among childrenwhose symptoms persisted after individually optimized stimulant treatment. METHOD This trial enrolled 6- to 12-year-old with attention-deficit/hyperactivity disorder, a disruptive disorder, significant aggressive behavior, and prior stimulant treatment. Open, systematically titrated stimulant treatment identified patients with inadequate reductions in aggressive behavior, who were then randomly assigned to receive adjunctive RISP, DVPX, or PBO under double-blinded conditions for 8 weeks. Family-based behavioral treatment was offered throughout the trial. The primary outcome was the parent-completed Retrospective Modified Overt Aggression Scale. RESULTS Participants included 175 children (mean [SD] age 9.48 [2.04] years, 19% female). Of participants, 151 completed the stimulant optimization phase, with aggression remitting among 96 (63%), and 45 were randomly assigned to adjunctive treatment groups. The adjunctive RISP group showed greater reductions in aggression ratings than the PBO group (least squares means difference [ΔLSM], -2.33; 95% CI, -3.83 to -0.82; effect size [ES], -1.32), as did the DVPX group (ΔLSM, -1.60; 95% CI, -3.18 to -0.03; ES, -0.91). Mean standardized body mass index scores increased more among RISP-treated participants than participants receiving PBO (ΔLSM, 1.54; 95% CI, 0.68 to 2.40; ES, 0.58). CONCLUSION High response rate during the trial's open stimulant optimization phase suggests that rigorous titration of stimulant medication and concurrent behavioral therapy may avert the need for additional medications. Among nonremitters, RISP and DVPX were efficacious adjunctive treatments, although RISP was associated with weight gain. CLINICAL TRIAL REGISTRATION INFORMATION Effectiveness of Combined Medication Treatment for Aggression in Children With Attention Deficit With Hyperactivity Disorder (The SPICY Study); https://www.clinicaltrials.gov; NCT00794625.
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Affiliation(s)
| | | | - Vivian Kafantaris
- Zucker Hillside Hospital and the Feinstein Institute for Medical Research, Divisions of Northwell Health, Manhasset, NY
| | - Carmel A. Foley
- Cohen Children’s Medical Center of New York and Zucker Hillside Hospital, Divisions of Northwell Health, Manhasset, NY
| | | | | | | | | | | | - Christa Sinha
- Renaissance School of Medicine, Stony Brook University, NY
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Çakır B, Yalın Sapmaz Ş, Kandemir H. Use of Antipsychotics: The Experiences, Views, and Monitoring Practices of Child and Adolescent Psychiatrists in Turkey. J Child Adolesc Psychopharmacol 2021; 31:73-78. [PMID: 32614261 DOI: 10.1089/cap.2020.0078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: The aim of this study is to evaluate the antipsychotics prescribed by child psychiatrists and their applications on the follow-up of these drugs. Methods: The universe of this research included consultant physicians and child psychiatry residents working in the field. A questionnaire has been created that assesses the use of antipsychotics and follow-up processes of physicians. The survey involved 19 questions. Contents of the survey were sociodemographic data, short-term and long-term follow-up of antipsychotic drugs, side-effect intervention strategies, and diagnoses of the most commonly preferred antipsychotic medications. The survey was delivered via e-mail and sent as a message to the child and adolescent psychiatrists in Turkey. Results: One hundred sixty-one physicians working in the field of child and adolescent psychiatry participated in the study. Aripiprazole (32.2%), risperidone (30.4%), and quetiapine (14.9%) were three most commonly prescribed antipsychotics. Disruptive behavior-related disorders (28.9%), behavior problems related to autism spectrum disorder (20.7%), behavior problems related to intellectual disability (14.5%), and attention-deficit/hyperactivity disorder (12.4%) were the most common diagnoses requiring antipsychotics medications. Before starting antipsychotic treatment, the most commonly evaluated parameters were body mass index (BMI) (47.2%), waist circumference (10.5%), blood pressure (28.5%), lipid profile (37%), and blood glucose level (41.6%). When the evaluations made at least in a year after starting antipsychotic drug therapy were examined, 80.2% of physicians reported blood glucose, 79.6% lipid profile, 65.7% BMI, 59.1% blood pressure, and 26.6% waist circumference measurement almost always done. Conclusions: The results showed that the adherence to recommendations in guidelines for the screening of antipsychotic-related side effects was low. This study suggests that interventions should be made about antipsychotic monitoring training to physicians.
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Affiliation(s)
- Burak Çakır
- Department of Child and Adolescent Psychiatry, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Şermin Yalın Sapmaz
- Department of Child and Adolescent Psychiatry, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Hasan Kandemir
- Department of Child and Adolescent Psychiatry, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
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22
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Besch V, Greiner C, Magnin C, Néris MD, Ambrosetti J, Perroud N, Poulet E, Debbané M, Prada P. Clinical Characteristics of Suicidal Youths and Adults: A One-Year Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8733. [PMID: 33255439 PMCID: PMC7727828 DOI: 10.3390/ijerph17238733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 01/07/2023]
Abstract
Suicide is a major mental health problem, particularly during youth, when it is the second leading cause of death. Since young people at risk of suicide are often cared for by the adult health system, we sought to identify the specificities and similarities between suicidal youths and adults in order to further inform the potential need for adaptations in taking care of suicidal youths. For this study, we used the following data: mental disorders, treatments, previous hospitalization, and reasons for current hospitalization, that were collected from November 2016 to October 2017 among people hospitalized for a suicidal crisis in a specialized psychiatric unit. First, we compared the data from the youth group with those from the adult group, and then we tried to determine if there were any associations between variables. Analyses showed that youths were more similar to adults than expected. In particular, we found comparable rates of personality disorders (especially borderline) and relapse, and similar profiles of reasons for hospitalization in suicidal crisis. Remarkably, among youth, neuroleptics appeared to be associated with fewer hospitalizations for behavioral than ideational reasons, but with more relapses. Results of this study suggest that young people could benefit from brief psychotherapeutic interventions implemented for adults.
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Affiliation(s)
- Vincent Besch
- Clinical Developmental Psychology Unit, Faculty of Psychology and Educational Sciences, University of Geneva, 1205 Geneva, Switzerland;
| | - Christian Greiner
- Unit for Investigation and Brief Treatment, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.G.); (M.D.N.); (J.A.); (P.P.)
| | - Charline Magnin
- Emergency Psychiatry Department, Edouard Herriot Hospital, 69003 Lyon, France; (C.M.); (E.P.)
| | - Mélanie De Néris
- Unit for Investigation and Brief Treatment, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.G.); (M.D.N.); (J.A.); (P.P.)
| | - Julia Ambrosetti
- Unit for Investigation and Brief Treatment, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.G.); (M.D.N.); (J.A.); (P.P.)
| | - Nader Perroud
- Department of Psychiatric Specialties for Emotional Regulation Disorders, Geneva University Hospitals, 1201 Geneva, Switzerland;
| | - Emmanuel Poulet
- Emergency Psychiatry Department, Edouard Herriot Hospital, 69003 Lyon, France; (C.M.); (E.P.)
| | - Martin Debbané
- Clinical Developmental Psychology Unit, Faculty of Psychology and Educational Sciences, University of Geneva, 1205 Geneva, Switzerland;
| | - Paco Prada
- Unit for Investigation and Brief Treatment, Geneva University Hospitals, 1205 Geneva, Switzerland; (C.G.); (M.D.N.); (J.A.); (P.P.)
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23
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Pharmacotherapy of attention-deficit hyperactivity disorder: common quandaries, dilemmas and challenges. Int Clin Psychopharmacol 2020; 35:300-304. [PMID: 32694317 DOI: 10.1097/yic.0000000000000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Multiple studies have shown that pharmacologic treatments for attention-deficit hyperactivity disorder (ADHD), especially stimulants, are generally effective. There is yet a paucity of empirical data, however, for some common clinical conditions overlooked in the ADHD treatment guidelines. Some examples include: in cases of first line treatment failure, it is unclear whether switching from one type of stimulant to another is beneficial. In cases of comorbid ADHD and severe aggressive/disruptive behavior in children, it is unclear whether the best first-line treatment is stimulants or atypical antipsychotics like risperidone. In cases of ADHD with comorbid anxiety disorders, there is no clear evidence regarding optimal treatment. The objectives of this article are to review these issues and propose possible answers for such clinical dilemmas.
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24
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Peled O, Lavan O, Stein J, Vinograd I, Yahel A, Valevski A, Weizman A, Kimmel-Tamir E, Apter A, Fennig S, Yaniv I, Bernfeld Y, Benaroya-Milshtein N. Psychopharmacology in the Pediatric Oncology and Bone Marrow Transplant Units: Antipsychotic Medications Palliate Symptoms in Children with Cancer. J Child Adolesc Psychopharmacol 2020; 30:486-494. [PMID: 32845729 DOI: 10.1089/cap.2019.0164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives: The present study characterized the psychiatric diagnoses and symptoms that led to the administration of antipsychotic medications in children and adolescents with cancer, and to evaluate the benefits and tolerability of these drugs in a large hospital-based pediatric hematology-oncology practice. Methods: Efficacy and adverse effects of two second-generation antipsychotics were retrospectively analyzed in 43 patients 2.9-19.6 (mean 12.1) years of age. The Clinical Global Impression-Severity (CGI-S) Scale and Improvement (CGI-I) Scale were used to evaluate psychiatric symptom severity before and following treatment, while the incidence of side effects and drug-drug interactions were collected from medical records. Results: Olanzapine was administered to 58% of patients and risperidone to 42%; the choice of drug was at the discretion of the treating psychiatrist. The common psychiatric diagnoses among these patients included adjustment disorder (37%) and medication-induced psychiatric disorders (23%). The most common psychiatric-medical symptoms included irritability/agitation (79%) and depressed mood (74%). CGI-S improved significantly (p < 0.001) between assessments, with no statistically significant difference between olanzapine- and risperidone-treated patients. CGI-I scores at reassessment indicated superiority of olanzapine as compared with risperidone. Adverse effects of treatment were mild. Conclusions: Olanzapine and risperidone can be well tolerated and ameliorate severe psychiatric-medical symptoms in children and adolescents with cancer. The potential palliative benefits of these second-generation antipsychotics (e.g., rapid onset of action, antiemesis, sedation, and appetite stimulation) increase the utility of their use in children treated in oncology and bone marrow transplant units.
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Affiliation(s)
- Orit Peled
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Lavan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Jerry Stein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Inbal Vinograd
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Yahel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Avi Valevski
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Research Unit, Geha Mental Health Center, and Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Abraham Weizman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Research Unit, Geha Mental Health Center, and Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Ella Kimmel-Tamir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Alan Apter
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Silvana Fennig
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Isaac Yaniv
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yael Bernfeld
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Benaroya-Milshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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25
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Kim HJ, Wilson C, Van Deusen T, Millard H, Qayyum Z, Parke S. Metabolic Syndrome in Child and Adolescent Psychiatry. Psychiatr Ann 2020. [DOI: 10.3928/00485713-20200630-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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26
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Rafaniello C, Sullo MG, Carnovale C, Pozzi M, Stelitano B, Radice S, Bernardini R, Rossi F, Clementi E, Capuano A. We Really Need Clear Guidelines and Recommendations for Safer and Proper Use of Aripiprazole and Risperidone in a Pediatric Population: Real-World Analysis of EudraVigilance Database. Front Psychiatry 2020; 11:550201. [PMID: 33343407 PMCID: PMC7738432 DOI: 10.3389/fpsyt.2020.550201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Although aripiprazole and risperidone are used widespread in pediatrics, there are still limited pieces of evidence on their actual safety profile. By using the EudraVigilance database, we carried out an analysis to perform a comprehensive overview of reported adverse events among children and adolescents treated with aripiprazole and risperidone. Methods: Descriptive analysis was performed of all individual case safety reports (ISCRs) submitted to EudraVigilance associated with aripiprazole and risperidone and related to the pediatric population from 2016 to 2018. Results: A total of 855 and 2,242 ISCRs for aripiprazole and risperidone, respectively, were recorded for a total of 11,042 suspected adverse drug reactions (2,993 for aripiprazole and 8,049 for risperidone). Most ISCRs were related to male patients (65.0 and 86.3% for aripiprazole and risperidone, respectively) and were serious (81.0 and 94.1% for aripiprazole and risperidone, respectively). Schizophrenia spectrum and other psychotic disorders, such as disruptive, impulse-control, and conduct disorders, and autism spectrum disorder were the top three clinical indications for aripiprazole (19.0, 16.1, and 11.6%, respectively). For risperidone, attention-deficit/hyperactivity disorder (25.4%), disruptive, impulse-control, and conduct disorders (17.1%), and bipolar and related disorders (14.2%) were more commonly reported as clinical indications. Data also showed a high proportion of use for clinical conditions not authorized in children. Psychiatric disorders were the main related adverse events for aripiprazole (20.2%), and among these, suicidal behavior was one of the most reported (14.9%). Reproductive system and breast disorders were the main related adverse events for risperidone (19.8%), and gynecomastia was the most reported event; metabolism and nutrition disorders, mainly reported as weight gain disorders, were more reported in children (3-11 years) than in adolescents (12-17 years). Conclusions: Our results demonstrate that spontaneously reported adverse events associated with aripiprazole and risperidone reflect what is already known in terms of safety profile, although with about 90% of them being serious. This analysis stresses the need for further studies and effective training and information activities to better define the actual benefit/risk ratio of these drugs in pediatric patients.
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Affiliation(s)
- Concetta Rafaniello
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Giuseppa Sullo
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute Istituto di Ricovero e Cura a Carattere Scientifico-IRCCS E. Medea, Bosisio Parini, Italy
| | - Barbara Stelitano
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Renato Bernardini
- Unit of Clinical Toxicology, Department of Biomedical and Biotechnological Sciences, University Hospital, Catania, Italy
| | - Francesco Rossi
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy.,Scientific Institute Istituto di Ricovero e Cura a Carattere Scientifico-IRCCS E. Medea, Bosisio Parini, Italy
| | - Annalisa Capuano
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, University of Campania "Luigi Vanvitelli", Naples, Italy
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27
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Kang-Yi CD, Chao B, Teng S, Locke J, Mandell DS, Wong YLI, Epperson CN. Psychiatric Diagnoses and Treatment Preceding Schizophrenia in Adolescents Aged 9-17 Years. Front Psychiatry 2020; 11:487. [PMID: 32581869 PMCID: PMC7289314 DOI: 10.3389/fpsyt.2020.00487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Our study aimed to examine psychiatric diagnoses and treatment preceding a schizophrenia diagnosis in adolescents, stratified by sex and race/ethnicity. METHODS Using Medicaid physical and behavioral health and pharmacy claims data, we identified 1,459 adolescents who were aged 9-17 years and diagnosed with schizophrenia between January 2006 through June 2009. Psychiatric diagnosis, mental health service use including psychiatric hospitalization, residential treatment and outpatient therapy and psychotropic medication use preceding schizophrenia were identified. RESULTS Forty-five percent of the adolescents were diagnosed with one or more psychiatric conditions. More than 40% of the adolescents were hospitalized or placed in a residential treatment facility for other psychiatric conditions preceding schizophrenia. Overall, 72% of the adolescents were prescribed with one or more psychotropic medications and 22% were prescribed with three or more psychotropic medications in the year prior to their first schizophrenia diagnosis. We found that sex and race/ethnicity influence preceding psychiatric conditions and psychiatric treatment use. CONCLUSIONS Careful screening and evaluation to validate diagnoses is important as the presence of certain psychiatric morbidity is common among adolescents with schizophrenia during the prodromal period. Developing acceptable and accessible interventions that will reduce psychiatric hospitalization and residential treatment care and improve care connection for schizophrenia treatment is important to mitigate complexity in treatment for adolescents and reduce cost burden for families and the society. Integrating health claims data in the development of schizophrenia risk conversion models can be useful in effectively predicting ideal timing of tailored interventions for adolescents with preceding psychiatric conditions.
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Affiliation(s)
- Christina D Kang-Yi
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Brian Chao
- Department of Education, Loyola Marymount University, Los Angeles, CA, United States
| | - Shelly Teng
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jill Locke
- Speech and Hearing Sciences, University of Washington, Seattle, WA, United States
| | - David S Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Yin-Ling Irene Wong
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, United States
| | - C Neill Epperson
- Department of Psychiatry, School of Medicine, University of Colorado, Denver, CO, United States
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Incidence of adverse events in antipsychotic-naïve children and adolescents treated with antipsychotic drugs: Results of a multicenter naturalistic study (ETAPE). Eur Neuropsychopharmacol 2019; 29:1397-1407. [PMID: 31699516 DOI: 10.1016/j.euroneuro.2019.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 01/07/2023]
Abstract
The main objective of ETAPE study was to determine the incidence of adverse events (AEs) potentially related to antipsychotic (AP) during a 12-months observational study of naturalistic treatment. ETAPE is a naturalistic prospective multicenter study conducted between April 2013 and May 2016. 200 patients were included. The mean age was 12 ± 3 years, with 73.6% being males. Patients presented a significant clinical improvement over time. At baseline, 92% of patients received a second generation AP, 74% AP monotherapy and 79.5% off-label AP prescriptions. Clinical diagnoses were heterogeneous including psychosis, anxiety, mood and neurodevelopmental disorders. The overall AE incidence rate was 11.52 AEs per person-years. Among AEs potentially attributable to AP, 15.4% were neuromotor, 14.8% gastroenterological, 12.2% metabolic and 11.8% general symptoms. Weight and body mass index increased significantly. More than half of AE appeared during the first 3 months, but onset of AE was noted all over follow-up. The presence of AEs was stable over time. ETAPE study highlights a high incidence rate of AE in children treated with AP. A careful and continuous clinical and biological monitoring is required to adapt treatment decisions based on benefice-risk-analysis. Moreover, additional research is warranted, also in regard of high proportion of off-label prescriptions.
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Piovani D, Clavenna A, Bonati M. Prescription prevalence of psychotropic drugs in children and adolescents: an analysis of international data. Eur J Clin Pharmacol 2019; 75:1333-1346. [DOI: 10.1007/s00228-019-02711-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/25/2019] [Indexed: 12/14/2022]
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Minjon L, van den Ban E, de Jong E, Souverein PC, Egberts TCG, Heerdink ER. Reported Adverse Drug Reactions in Children and Adolescents Treated with Antipsychotics. J Child Adolesc Psychopharmacol 2019; 29:124-132. [PMID: 30676073 DOI: 10.1089/cap.2018.0139] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To characterize reported adverse drug reactions (ADRs) in children and adolescents treated with antipsychotics and determine differences in relative reporting frequency between genders, age classes, and reporter types. METHODS Individual case safety reports of children ages 1 - 17 years in whom an antipsychotic drug was the suspected or interacting drug from the worldwide database, VigiBase, from 1968 until March 2017, were included. Reported ADRs were categorized based on the Standardized Medical Dictionary for Regulatory Activities (MedDRA) Queries and clinical reasoning. Proportional reporting ratios (PRRs) and 95% confidence intervals (95% CIs) were calculated for genders, age classes, and reporter types. RESULTS In total, 45,201 reported ADRs were included. The most frequently reported were ADRs related to extrapyramidal syndrome (14.7%), breast disorders or blood prolactin level changes (4.7%), and cardiac arrhythmias (4.6%). Differences in relative reporting frequencies were observed between age classes and reporter types, and less prominent between genders. For example, ADRs related to hyperglycemia/new-onset diabetes mellitus were less frequently reported in children ages 1 - 5 than in children ages 12 - 17 (PRR: 0.4, 95% CI: 0.2 - 0.5). ADRs related to cardiac arrhythmias were less frequently reported by consumers compared with health care professionals (PRR: 0.5, 95% CI: 0.5 - 0.6), whereas ADRs related to a change in weight/body mass index were more frequently reported by consumers (PRR: 3.2, 95% CI: 2.9 - 3.5). CONCLUSION A wide spectrum of ADRs were reported in children treated with antipsychotics. The relative differences in reporting frequency between age classes and reporter types can be of help to tailor information about possible ADRs and to monitor for ADRs.
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Affiliation(s)
- Lenneke Minjon
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Els van den Ban
- 2 Karakter Child and Adolescent Psychiatry, Zwolle, the Netherlands
| | - Emma de Jong
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Patrick C Souverein
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Toine C G Egberts
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.,3 Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Eibert R Heerdink
- 1 Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.,3 Department of Clinical Pharmacy, Utrecht University Medical Center, Utrecht, the Netherlands.,4 Research Group Innovation of Pharmaceutical Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands
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Ray WA, Stein CM, Murray KT, Fuchs DC, Patrick SW, Daugherty J, Hall K, Cooper WO. Association of Antipsychotic Treatment With Risk of Unexpected Death Among Children and Youths. JAMA Psychiatry 2019; 76:162-171. [PMID: 30540347 PMCID: PMC6440238 DOI: 10.1001/jamapsychiatry.2018.3421] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Children and youths who are prescribed antipsychotic medications have multiple, potentially fatal, dose-related cardiovascular, metabolic, and other adverse events, but whether or not these medications are associated with an increased risk of death is unknown. OBJECTIVE To compare the risk of unexpected death among children and youths who are beginning treatment with antipsychotic or control medications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted from 1999 through 2014 and included Medicaid enrollees aged 5 to 24 years in Tennessee who had no diagnosis of severe somatic illness, schizophrenia or related psychoses, or Tourette syndrome or chronic tic disorder. Data analysis was performed from January 1, 2017, to August 15, 2018. EXPOSURES Current, new antipsychotic medication use at doses higher than 50 mg (higher-dose group) or 50 mg or lower chlorpromazine equivalents (lower-dose group) as well as control medications (ie, attention-deficit/hyperactivity disorder medications, antidepressants, or mood stabilizers) (control group). MAIN OUTCOMES AND MEASURES Deaths during study follow-up while out of hospital or within 7 days after hospital admission, classified as either deaths due to injury or suicide or unexpected deaths. Secondary outcomes were unexpected deaths not due to overdose and death due to cardiovascular or metabolic causes. RESULTS This study included 189 361 children and youths in the control group (mean [SD] age, 12.0 [5.1] years; 43.4% female), 28 377 in the lower-dose group (mean [SD] age, 11.7 [4.4] years; 32.3% female), and 30 120 in the higher-dose group (mean [SD] age, 14.5 [4.8] years; 39.2% female). The unadjusted incidence of death in the higher-dose group was 146.2 per 100 000 person-years (40 deaths per 27 354 person-years), which was significantly greater than that in the control group (54.5 per 100 000 population; 67 deaths per 123 005 person-years) (P < .001). The difference was primarily attributable to the increased incidence of unexpected deaths in the higher-dose group (21 deaths; 76.8 per 100 000 population) compared with the control group (22 deaths; 17.9 per 100 000 population). The propensity score-adjusted hazard ratios were as follows: all deaths (1.80; 95% CI, 1.06-3.07), deaths due to unintentional injury or suicide (1.03; 95% CI, 0.53-2.01), and unexpected deaths (3.51; 95% CI, 1.54-7.96). The hazard ratio was 3.50 (95% CI, 1.35-9.11) for unexpected deaths not due to overdose and 4.29 (95% CI, 1.33-13.89) for deaths due to cardiovascular or metabolic causes. Neither the unadjusted nor adjusted incidence of death in the lower-dose group differed significantly from that in the control group. CONCLUSIONS AND RELEVANCE The findings suggest that antipsychotic use is associated with increased risk of unexpected death and appear to reinforce recommendations for careful prescribing and monitoring of antipsychotic treatment for children and youths and to underscore the need for larger antipsychotic treatment safety studies in this population.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Division of Rheumatology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee,Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee,Division of Cardiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - D. Catherine Fuchs
- Department of Psychiatry and Behavioral Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee,Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee,Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kathi Hall
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William O. Cooper
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee,Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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Monitoring of Metabolic, Cardiac, and Endocrine Indicators in Youth Treated With Antipsychotics as Reported by Health Care Professionals. J Clin Psychopharmacol 2018; 38:489-493. [PMID: 30113929 DOI: 10.1097/jcp.0000000000000936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear how youth treated with antipsychotics are monitored. The purpose of this study was to assess monitoring of metabolic, cardiac, and endocrine indicators in youth (<18 years old) treated with antipsychotics as reported by health care professionals in the Netherlands. METHODS A questionnaire was designed to collect information from health care professionals regarding the monitoring of youth treated with antipsychotics. Data were collected at a national conference. FINDINGS AND RESULTS Fifty-nine health care professionals completed the questionnaire, of which 53 (89.8%) were child and adolescent psychiatrists (approximately 20% of all child and adolescent psychiatrists in the Netherlands). More than 80% of respondents reported monitoring physical indicators-weight, height, body mass index, heart rate, and blood pressure-and over 50% reported monitoring laboratory indicators-lipid profile, blood glucose, and prolactin level. Most of the respondents reported monitoring physical indicators more than twice per year and laboratory indicators once per year. Almost all respondents (56/59, 94.9%) reported monitoring according to a clinical guideline or protocol. Only 1 respondent reported monitoring the indicators completely according to the clinical guideline. Respondents mentioned that facilitating factors for monitoring, such as access to electrocardiogram facilities, were insufficiently available. CONCLUSIONS Although all health care professionals reported monitoring metabolic, cardiac, and endocrine indicators in youth treated with antipsychotics, great variability exists in reported monitoring practices. Factors contributing to this variability must be assessed to optimize the benefit-risk ratio for the individual patient.
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Leckman-Westin E, Finnerty M, Scholle SH, Pritam R, Layman D, Kealey E, Byron S, Morden E, Bilder S, Neese-Todd S, Horwitz S, Hoagwood K, Crystal S. Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid. J Manag Care Spec Pharm 2018; 24:238-246. [PMID: 29485947 PMCID: PMC10397713 DOI: 10.18553/jmcp.2018.24.3.238] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
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Affiliation(s)
- Emily Leckman-Westin
- 1 New York State Office of Mental Health, Albany, New York, and State University of New York at Albany, School of Public Health, Rensselaer, New York
| | - Molly Finnerty
- 2 New York State Office of Mental Health, and New York University Langone Health, New York, New York
| | | | - Riti Pritam
- 4 New York State Office of Mental Health, Albany, New York
| | - Deborah Layman
- 4 New York State Office of Mental Health, Albany, New York
| | - Edith Kealey
- 4 New York State Office of Mental Health, Albany, New York
| | - Sepheen Byron
- 3 National Committee for Quality Assurance, Washington, DC
| | - Emily Morden
- 3 National Committee for Quality Assurance, Washington, DC
| | | | | | - Sarah Horwitz
- 6 New York University Langone Health, New York, New York
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Çeri V, Aykutlu HC, Görker I, Akça ÖF, Tarakçıoğlu MC, Aksoy UM, Kaya H, Sertdemir M, İnce E, Kadak MT, Yalçın GY, Guliyev C, Bilgiç A, Çiftçi E, Tekin K, Tuna ZO, Oğuzdoğan B, Duman NS, Semerci B, Üneri ÖŞ, Karabekiroglu K, Mutluer T, Nebioglu M, Başgül ŞS, Naharcı Mİ, Maden Ö, Hocaoğlu Ç, Durmaz O, Usta H, Boşgelmez Ş, Puşuroğlu M, Eser HY, Kaçar M, Çakır M, Karatepe HT, Işık Ü, Kara H, Yeloğlu ÇH, Yazıcı E, Gündüz A, Karataş KS, Yavlal F, Uzun N, Yazici AB, Bodur Ş, Aslan EA, Batmaz S, Çelik F, Açıkel SB, Topal Z, Altunsoy N, Tulacı ÖD, Demirel ÖF, Çıtak S, Çak HT, Artık AB, Özçetin A, Özdemir I, Çelik FGH, Kültür SEÇ, Çipil A, Ay R, Arman AR, Yazıcı KU, Yuce AE, Yazıcı İP, Kurt E, Kaçar AŞ, Erbil N, Poyraz CA, Altın GE, Şahin B, Kılıç Ö, Turan Ş, Aydın M, Kuru E, Bozkurt A, Güleç H, İnan MY, Şevik AE, Baykal S, Karaer Y, Yanartaş O, Aksu H, Ergün S, Görmez A, Yıldız M, Bag S, Özkanoğlu FK, Caliskan M, Yaşar AB, Konuk E, Altın M, Bulut S, Bulut GÇ, Tulacı RG, Küpeli NY, Enver N, Tasci İ, Kani AS, Bahçeci B, Oğuz G, Şenyuva G, Ünal GT, Yektaş Ç, Örüm MH, Göka E, Gıca Ş, Şahmelikoğlu Ö, Dinç GŞ, Erşan S, Erşan E, Ceylan MF, Hesapçıoğlu ST, Solmaz M, Balcioglu YH, Cetin M, Tosun M, Yurteri N, Ulusoy S, Karadere ME, Kivrak Y, Görmez V. Symposium Oral Presentations. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1464274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Veysi Çeri
- Marmara University Pendik Research and Training Hospital, Child and Adolescent Psychiatry Clinic, Istanbul, Turkey
| | - Hasan Cem Aykutlu
- Department of Child and Adolescent Psychiatry, Trakya University School of Medicine, Edirne, Turkey
| | - Işık Görker
- Department of Child and Adolescent Psychiatry, Trakya University School of Medicine, Edirne, Turkey
| | - Ömer Faruk Akça
- Department of Child and Adolescent Psychiatry, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Mahmut Cem Tarakçıoğlu
- Health Sciences University Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Umut Mert Aksoy
- Health Sciences University Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Heysem Kaya
- Department of Computer Engineering, Çorlu Faculty of Engineering, Namık Kemal University, Çorlu, Tekirdağ, Turkey
| | - Merve Sertdemir
- Department of Child and Adolescent Psychiatry, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Ezgi İnce
- Department of Psychiatry, Istanbul University Istanbul School of Medicine, Istanbul, Turkey
| | - Muhammed Tayyib Kadak
- Department of Child and Adolescent Psychiatry, Istanbul University Cerrahpaşa School of Medicine, Istanbul, Turkey
| | | | | | - Ayhan Bilgiç
- Department of Child and Adolescent Psychiatry, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Elvan Çiftçi
- Department of Psychiatry, Erenkoy Research and Training Hospital, Istanbul, Turkey
| | | | | | | | | | - Bengi Semerci
- Department of Psychology, Hasan Kalyoncu University, Gaziantep, Turkey
| | - Özden Şükran Üneri
- Department of Child and Adolescent Psychiatry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | | | - Tuba Mutluer
- Koç University Hospital, Department of Child and Adolescent Psychiatry, Istanbul, Turkey
| | - Melike Nebioglu
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
| | | | - Mehmet İlkin Naharcı
- Division of Geriatrics, Department of Internal Medicine, Health Sciences University, Ankara, Turkey
| | - Özgür Maden
- SBÜ Sultan Abdülhamid Han Education and Training Hospital, Department of Psychiatry, Istanbul, Turkey
| | - Çiçek Hocaoğlu
- Department of Psychiatry, Recep Tayyip Erdogan University School of Medicine, Rize, Turkey
| | - Onur Durmaz
- Erenköy Mental Health and Neurology Research and Training Hospital, Department of Psychiatry, Istanbul, Turkey
| | - Haluk Usta
- Erenköy Mental Health and Neurology Research and Training Hospital, Department of Psychiatry, Istanbul, Turkey
| | - Şükriye Boşgelmez
- Kocaeli Derince Research and Training Hospital, Psychiatry Clinic, Kocaeli, Turkey
| | | | - Hale Yapıcı Eser
- KOÇ University School of Medicine, Istanbul, Turkey
- KOÇ University Research Center FOR Translational Medicine (Kuttam), Istanbul, Turkey
- Koç University School of Medicine Department of Psychiatry, Istanbul, Turkey
- Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Murat Kaçar
- Department of Child and Adolescent Psychiatry, Recep Tayyip Erdogan University School of Medicine, Rize, Turkey
| | - Mahmut Çakır
- Child Psychiatry Clinic, Health Sciences University, Amasya Research and Training Hospital, Amasya, Turkey
| | - Hasan Turan Karatepe
- Department of Psychiatry, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey
| | - Ümit Işık
- Department of Child and Adolescent Psychiatry, Yozgat State Hospital, Yozgat, Turkey
| | - Halil Kara
- Department of Child and Adolescent Psychiatry, Aksaray University Research and Training Hospital, Aksaray, Turkey
| | | | - Esra Yazıcı
- Department of Psychiatry, Sakarya University School of Medicine, Sakarya, Turkey
| | - Anıl Gündüz
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
| | - Kader Semra Karataş
- Recep Tayyip Erdogan University School of Medicine Psychiatry Department, Rize, Turkey
| | - Figen Yavlal
- Department of Neurology, School of Medicine, Bahcesehir University, Istanbul, Turkey
- Department of Neurology, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Necati Uzun
- Department of Child and Adolescent Psychiatry, Elazığ Psychiatry Hospital, Elazığ, Turkey
| | - Ahmet Bulent Yazici
- Department of Psychiatry, Sakarya University School of Medicine, Sakarya, Turkey
| | - Şahin Bodur
- Health Sciences University, Gulhane Research and Training Hospital, Child and Adolescent Psychiatry Clinic, Ankara, Turkey
| | - Esma Akpınar Aslan
- Department of Psychiatry, Gaziosmanpaşa University School of Medicine, Tokat, Turkey
| | - Sedat Batmaz
- Department of Psychiatry, Gaziosmanpasa University School of Medicine, Tokat, Turkey
| | - Feyza Çelik
- Department of Psychiatry, Dumlupınar University School of Medicine, Evliya Çelebi Research and Training Hospital, Kütahya, Turkey
| | - Sadettin Burak Açıkel
- Dr. Sami Ulus Research and Training Hospital, Child and Adolescent Psychiatry Department, Ankara, Turkey
| | | | | | | | - Ömer Faruk Demirel
- Department of Psychiatry, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Serhat Çıtak
- Department of Psychiatry, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey
| | - Halime Tuna Çak
- Department of Child and Adolescent Psychiatry, Hacettepe University School of Medicine, Ankara, Turkey
| | - Abdül Baki Artık
- Department of Child and Adolescent Psychiatry, Hacettepe University School of Medicine, Ankara, Turkey
| | - Adnan Özçetin
- Department of Psychiatry, Duzce University School of Medicine, Duzce, Turkey
| | - Ilker Özdemir
- Giresun University Prof. Dr. A. İlhan Özdemir Research and Training Hospital, Giresun, Turkey
| | | | | | - Arif Çipil
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
| | - Rukiye Ay
- Malatya Research and Training Hospital, Malatya, Turkey
| | - Ayşe Rodopman Arman
- Department of Child and Adolescent Psychiatry, Marmara University School of Medicine, Istanbul
| | - Kemal Utku Yazıcı
- Department of Child and Adolescent Psychiatry, Firat University School of Medicine, Elazig, Turkey
| | | | - İpek Perçinel Yazıcı
- Department of Child and Adolescent Psychiatry, Firat University School of Medicine, Elazig, Turkey
| | - Emel Kurt
- Psychiatry Clinic, Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Anıl Şafak Kaçar
- Koc University, Research Center for Translational Medicine, Istanbul, Turkey
| | - Nurhan Erbil
- Department of Biophysics, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cana Aksoy Poyraz
- Department of Psychiatry, Istanbul University Cerrahpaşa School of Medicine, Istanbul, Turkey
| | | | - Berkan Şahin
- Iğdır State Hospital, Child and Adolescent Psychiatry Clinic, Iğdır, Turkey
| | - Özge Kılıç
- Department of Psychiatry, Koç University Hospital, Istanbul, Turkey
| | - Şenol Turan
- Department of Psychiatry, Istanbul University Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Memduha Aydın
- Department of Psychiatry, Selçuk University School of Medicine, Konya, Turkey
| | - Erkan Kuru
- Özel Boylam Psychiatry Hospital, Ankara, Turkey
| | - Abdullah Bozkurt
- Department of Child and Adolescent Psychiatry, Konya Research and Training Hospital, Konya, Turkey
| | - Hüseyin Güleç
- Erenköy Mental Health and Neurology Research and Training Hospital, Department of Psychiatry, Istanbul, Turkey
| | | | - Ali Emre Şevik
- Department of Psychiatry, Çanakkale 18 Mart University School of Medicine, Çanakkale, Türkiye
| | - Saliha Baykal
- Department of Child and Adolescent Psychiatry, Namık Kemal University School of Medicine, Tekirdağ, Turkey
| | - Yusuf Karaer
- Department of Child and Adolescent Psychiatry, Hacettepe University School of Medicine, Ankara, Turkey
| | - Omer Yanartaş
- Department of Psychiatry, Marmara Medical School, Istanbul, Turkiye
| | - Hatice Aksu
- Department of Child and Adolescent Psychiatry, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - Serhat Ergün
- Department of Psychiatry, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Aynur Görmez
- Department of Child and Adolescent Psychiatry, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey
| | - Mesut Yıldız
- Department of Psychiatry, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sevda Bag
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | | | - Mecit Caliskan
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
| | - Alişan Burak Yaşar
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
- Behavioral Sciences Institute, Istanbul, Turkey
| | - Emre Konuk
- Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey
- Behavioral Sciences Institute, Istanbul, Turkey
| | - Murat Altın
- Istinye University Hospital, Psychiatry Clinic, Istanbul, Turkey
| | - Serkut Bulut
- Psychiatry Clinic, Health Sciences University Sakarya Research and Training Hospital, Sakarya, Turkey
| | | | - Rıza Gökçer Tulacı
- Uşak University School of Medicine Research and Training Hospital, Uşak, Turkey
| | - Neşe Yorguner Küpeli
- Department of Psychiatry, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Necati Enver
- Department of Otolaryngology, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - İlker Tasci
- Health Sciences University, Gulhane School of Medicine, Department of Internal Medicine, Ankara, Turkey
| | - Ayşe Sakallı Kani
- Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Bülent Bahçeci
- Department of Psychiatry, Recep Tayyip Erdogan University, Rize, Turkey
| | | | | | - Gülşen Teksin Ünal
- Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey
| | - Çiğdem Yektaş
- Duzce University School of Medicine, Department of Child and Adolescent Psychiatry, Duzce, Turkey
| | - Mehmet Hamdi Örüm
- Department of Psychiatry, Adiyaman University School of Medicine, Adiyaman, Turkey
| | - Erol Göka
- SBÜ Ankara Numune Eğitim ve Araştırma Hastanesi
| | - Şakir Gıca
- Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey
| | - Özge Şahmelikoğlu
- Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey
| | - Gülser Şenses Dinç
- Department of Child and Adolescent Psychiatry, Ankara Children’s Hematology Oncology Research and Training Hospital, Ankara Turkey
| | - Serpil Erşan
- Cumhuriyet University Advanced Technology Research and Application Center, Sivas, Turkey
| | - Erdal Erşan
- Sivas Numune Hospital, Community Mental Health Center, Sivas, Turkey
| | - Mehmet Fatih Ceylan
- Department of Child and Adolescent Psychiatry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Selma Tural Hesapçıoğlu
- Department of Child and Adolescent Psychiatry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Mustafa Solmaz
- Health Sciences University Bagcilar Research and Training Hospital, Department of Psychiatry, Istanbul, Turkey
- Bakirkoy Prof. Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, Forensic Psychiatry Unit, Istanbul, Turkey
| | - Yasin Hasan Balcioglu
- Health Sciences University Bagcilar Research and Training Hospital, Department of Psychiatry, Istanbul, Turkey
- Bakirkoy Prof. Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, Forensic Psychiatry Unit, Istanbul, Turkey
| | | | - Musa Tosun
- Istanbul University Cerrahpaşa School of Medicine, Department of Child and Adolescent Psychiatry, Istanbul, Turkey
| | - Nihal Yurteri
- Duzce University School of Medicine, Department of Child and Adolescent Psychiatry, Duzce, Turkey
| | - Sevinc Ulusoy
- Bakirkoy Prof. Dr. Mazhar Osman Research and Training Hospital for Psychiatry and Neurology, Istanbul, Turkey
| | | | - Yüksel Kivrak
- Department of Psychiatry, Kafkas University School of Medicine, Kars, Turkey
| | - Vahdet Görmez
- Bezmialem Vakif University, Department of Child and Adolescent Psychiatry, Istanbul, Turkey
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Coughlin M, Goldie CL, Tranmer J, Khalid-Khan S, Tregunno D. Patient, Treatment, and Health Care Utilization Variables Associated with Adherence to Metabolic Monitoring Practices in Children and Adolescents Taking Second-Generation Antipsychotics. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63. [PMID: 29528720 PMCID: PMC5894916 DOI: 10.1177/0706743717751693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Children and adolescents with a range of psychiatric disorders are increasingly being prescribed atypical or second-generation antipsychotics (SGAs). While SGAs are effective at treating conduct and behavioural symptoms, they infer significant cardiometabolic risk. This study aims to explore what patient, treatment, and health care utilization variables are associated with adherence to Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) metabolic monitoring guidelines. METHOD A retrospective chart review of 294 children and adolescents accessing a large outpatient psychiatry setting within a 2-year study period (2014-2016) was conducted. Baseline and follow-up metabolic monitoring, demographic, treatment, and health care utilization variables were then assessed over a 1-year period of interest. RESULTS Metabolic monitoring practices did not adhere to CAMESA guidelines and were very poor over the 1-year observation period. There were significant differences between children (ages 4-12 years, n = 99) and adolescents (ages 13-18 years, n = 195). In adolescents, factors associated with any baseline metabolic monitoring were a higher number of psychiatry visits (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.10 to 1.41), longer duration of contact (OR, 14; 95% CI, 2.31 to 82.4), and use of other non-SGA medications (OR, 3.2; 95% CI, 1.17 to 8.94). Among children, having an emergency room visit (OR, 3.4; 95% CI, 1.01 to 11.71) and taking aripiprazole (OR, 7.4; 95% CI, 2.02 to 27.45) increased the odds of receiving baseline metabolic monitoring. CONCLUSION Findings from this study highlight the need for better metabolic monitoring for children and adolescents taking SGAs. Enhanced focus on opportunities for multidisciplinary collaboration is needed to improve the quality of care offered to this population.
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Affiliation(s)
- Mary Coughlin
- 1 Department of Health Sciences, School of Nursing, Queen's University, Kingston, Ontario
| | | | - Joan Tranmer
- 1 Department of Health Sciences, School of Nursing, Queen's University, Kingston, Ontario
| | | | - Deborah Tregunno
- 1 Department of Health Sciences, School of Nursing, Queen's University, Kingston, Ontario
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Kloosterboer SM, Schuiling-Veninga CCM, Bos JHJ, Kalverdijk LJ, Koch BCP, Dieleman GC, Hillegers MHJ, Dierckx B. Antipsychotics in Dutch Youth: Prevalence, Dosages, and Duration of Use from 2005 to 2015. J Child Adolesc Psychopharmacol 2018; 28:173-179. [PMID: 29641239 DOI: 10.1089/cap.2017.0155] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objectives: The use of antipsychotic drugs by youth is associated with serious side effects, especially when prescribed in higher dosages and for a longer period. Despite this, little is known about recent trends in the dosages and duration of use of antipsychotic drugs in children and adolescents. The aim of this study was to describe trends in prevalence, incidence, dosages, duration of use, and preceding psychotropic medication in Dutch youth who had been prescribed antipsychotic drugs from 2005 to 2015. Methods: We analyzed 84,828 antipsychotic prescriptions of youths aged 0-19 years between 2005 and 2015, derived from a large Dutch community pharmacy-based prescription database (IADB.nl). Results: Since a peak of 9.8 users per 1000 youths in 2009, prevalence rates stabilized. Dosages in milligram per kilogram declined for the most frequently prescribed antipsychotic drugs during the study period. The median duration of use was 6.0 (95% CI 5.4-6.6) months. Boys used antipsychotic drugs significantly longer than girls, with a median of 6.9 (95% CI 6.1-7.7) versus 4.6 (95% CI 3.9-5.3) months (p < 0.01). Of the youths prescribed antipsychotics, 12.4% used them for at least 48 months. The majority of youths had used other psychotropic agents in the year before the start of an antipsychotic drug (62.4% in 2005 and 64.7% in 2015). Conclusions: Despite a stabilization of usage rates and decline in dosages and duration of use, one in eight youths still used antipsychotic drugs for 4 years or longer. A substantial share of youths may, therefore, be at high risk for serious side effects.
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Affiliation(s)
- Sanne M Kloosterboer
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Jens H J Bos
- Department of Pharmacotherapy, -Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
| | - Luuk J Kalverdijk
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Manon H J Hillegers
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre, Rotterdam, The Netherlands
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Prescribing Trends of Atypical Antipsychotic Drugs in an Outpatient Unit of a Child and Adolescent Clinic in Turkey. Clin Neuropharmacol 2018; 41:23-27. [DOI: 10.1097/wnf.0000000000000263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cohen E, Hall M, Lopert R, Bruen B, Chamberlain LJ, Bardach N, Gedney J, Zima BT, Berry JG. High-Expenditure Pharmaceutical Use Among Children in Medicaid. Pediatrics 2017; 140:peds.2017-1095. [PMID: 28765380 DOI: 10.1542/peds.2017-1095] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications. METHODS Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013. RESULTS Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes. CONCLUSIONS Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.
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Affiliation(s)
- Eyal Cohen
- Department of Pediatrics and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario; .,Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ruth Lopert
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | - Brian Bruen
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | - Lisa J Chamberlain
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, and Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Naomi Bardach
- Division of General Pediatrics, Philip R. Lee Institute for Health Policy Studies, Department of Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Bonnie T Zima
- UCLA-Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California; and
| | - Jay G Berry
- Division of General Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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