Patterns of treatment for psychiatric disorders among children and adolescents in Mississippi Medicaid

Health-related quality of life, service utilisation and costs for anxiety disorders in children and young people: A systematic review and meta-analysis

BACKGROUND

Anxiety disorders (ADs) are common mental health issues in children and young people (CYP). The literature on its overall economic burden regarding health-related quality of life (HRQoL), service use and costs is limited. This study synthesises the literature on how ADs are associated with these outcomes in CYP (0-24 years) and caregivers.

METHOD

A systematic search was undertaken across six databases from January 2013 to the end of December 2024. Grey literature was also searched. Dual-independent screening and quality assessment were conducted. An adapted version of the Effective Public Health Practice Project tool was used for quality assessment. Narrative synthesis and meta-analysis were conducted.

RESULTS

Of 41,166 studies identified, 24 studies were included. Most were cross-sectional; only four were longitudinal, with 1.5- to 6-year follow-up periods. Studies found poorer HRQoL in CYP with ADs compared to those without ADs or healthy peers. The meta-analysis found a strong effect on the psychological/emotional and social functioning of HRQoL. Comorbid ADs were also associated with poor overall HRQoL, with a particularly very large effect on emotional functioning. Limited studies show that childhood ADs were associated with increased health service use and costs, with mixed findings on caregivers' HRQoL.

CONCLUSION

ADs in CYP were associated with lower HRQoL for CYP and their caregivers, and with increased health service use and costs. This review highlights the need for future research to examine the burden on caregivers and the long-term impact on CYP's HRQoL, service use and costs.

A classification system for youth outpatient behavioral health services billed to medicaid

Rates of youth behavioral health concerns have been steadily rising. Administrative data can be used to study behavioral health service utilization among youth, but current methods that rely on identifying an associated behavioral health diagnosis or provider specialty are limited. We reviewed all procedure codes billed to Medicaid for youth in one U.S. county over a 10-year period. We identified 158 outpatient behavioral health procedure codes and classified them according to service type. This classification system can be used by health services researchers to better characterize youth behavioral health service utilization.

Treatment and Outcomes Among North Carolina Medicaid-Insured Youth With Depression

Objective

Youth depression is increasing and is associated with adverse concurrent and long-term outcomes. Understanding receipt of depression treatment and outcomes is critical for population-level efforts to address youth depression. This study aimed to understand treatment patterns and their association with depression-related outcomes.

Method

North Carolina Medicaid claims were used to conduct a retrospective cohort study of treatment and depression-related outcomes in pediatric Medicaid beneficiaries. The sample included 34,623 youth ages 5 to 21 years with an incident depression diagnosis. Psychotherapy and antidepressant medication were assessed for 6 months following diagnosis. Depression-related outcomes including suicidal or self-harming behaviors, emergency department use, and psychiatric hospitalization were analyzed using Cox proportional hazards models to calculate hazard ratios.

Results

Among youth with depression, 86% received treatment (39% psychotherapy, 16% medication, 31% combined), but few youth received guideline-recommended treatment duration. At 6 and 18 months, youth who received combined treatment had higher risk of adverse outcomes compared with the other groups. The untreated group had lower risk of outcomes other than all-cause emergency department visits. Single-session psychotherapy and inconsistent medication fills were also associated with poor outcomes; however, more psychotherapy sessions were associated with lower risk of all-cause emergency department visits.

Conclusion

These data show that the majority of youth who received depression treatment had suboptimal adherence to recommended guidelines. Youth who received combined treatment (both medication and therapy) had more adverse depression outcomes. As claims records do not include clinical data, the effect of treatment type, dose, depression severity, or a combination of these factors cannot be readily disentangled; therefore, these findings do not support a conclusion that combined treatment leads to poor outcomes. Rather, it is possible that youth with a more severe clinical profile are more likely to be prescribed combined treatment or to have poor adherence and thus worse outcomes. Understanding how to improve adherence in real-world settings is needed. Results suggest that many youth continue to struggle despite receipt of mental health care, indicating a call for enhancing existing treatment strategies. Research should aim to better understand population-level care for depression and to promote receipt of and adherence to recommended treatment duration across modalities.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Rates of genetic testing in patients prescribed drugs with pharmacogenomic information in FDA-approved labeling

This study examined rates of genetic testing in two cohorts of publicly insured individuals who have newly prescribed medication with FDA pharmacogenomic labeling guidance. Genetic testing was rare (4.4% and 10.5% in Medicaid and Medicare cohorts, respectively) despite the fact that all participants selected were taking medications that contained pharmacogenomic labeling information. When testing was conducted it was typically done before the initial use of a target medication. Factors that emerged as predictors of the likelihood of undergoing genetic testing included White ethnicity (vs. Black), female gender, and age. Cost analyses indicated higher expenditures in groups receiving genetic testing vs. matched comparators with no genetic testing, as well as disparities between proactively and reactively tested groups (albeit in opposite directions across cohorts). Results are discussed in terms of the possible reasons for the low base rate of testing, mechanisms of increased cost, and barriers to dissemination and implementation of these tests.

Patterns of mental health service use among Medicaid-insured youths treated by nurse practitioners and physicians: A retrospective cohort study

BACKGROUND

Despite the growing involvement of nurse practitioners in mental health services for children and adolescents, little is known about the patterns of mental health service use among youths treated by nurse practitioners compared to those by physicians.

OBJECTIVES

To identify new users of psychotropic medications initiated by nurse practitioners and physicians among Medicaid-insured youths and to assess if receiving psychosocial services prior to or concurrent with medication initiation differs among youths treated by provider and specialty type.

DESIGN

A retrospective cohort study.

SETTINGS

We used Medicaid-insurance claims data in one mid-Atlantic state in the US.

PARTICIPANTS

A total 12,991 Medicaid-insured youths aged 0-20 years who started psychotropic medications prescribed by nurse practitioners or physicians with primary care or psychiatric specialty during 2013-2014.

METHODS

Providers were grouped into nurse practitioners and physicians and into primary care and psychiatric specialty. Descriptive statistics were performed to compare each class of psychotropic medications initiated and psychiatric diagnoses of enrollees according to provider type within each specialty. Using multinomial logistic regression with psychiatrists as a reference group, we estimated the odds of having a type of prescriber for psychotropic medication initiation for youths who received psychosocial services prior to a new start of the medication and concurrently, compared to that for those who did not, after adjusting for patients' demographic characteristics and diagnosis.

RESULTS

Youths served by nurse practitioners resided in small and non-metropolitan areas significantly more often than those served by their physician counterparts. There was no major difference in a class of psychotropic medications initiated by nurse practitioners and physicians within each specialty type, except a higher proportion of antidepressants (13.5% versus 10.5%) and a lower proportion of attention deficit hyperactivity disorder medications prescribed (68.8% versus 74.0%) by primary care nurse practitioners compared to their physician counterparts. Youths who received psychosocial services prior to medication initiation were less likely to have primary care physicians (Adjusted odds ratio=0.15, 95% confidence interval=0.82, 1.33) or primary care nurse practitioners (Adjusted odds ratio=0.16, 95% confidence interval=0.12, 0.20) as their initiating prescriber than those who did not.

CONCLUSIONS

Youths treated by nurse practitioners and physicians with or without psychiatric specialty showed unique patterns of mental health service use. Our findings can be used to build effective collaborations among provider and specialty type for quality of mental health services delivered to targeted populations in need.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children

OBJECTIVE

We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility.

METHODS

We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner).

RESULTS

We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits.

CONCLUSIONS

Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.