The Impact of a State Medicaid Peer-Review Authorization Program on Pediatric Use of Antipsychotic Medications.

OBJECTIVE: This cross-sectional study assessed the impact of a peer-review program on the prevalence of pediatric antipsychotic use among Medicaid-insured youths in a Mid-Atlantic state. METHODS: Medicaid claims (2010-2014) were assessed among continuously enrolled youths in the 12 months before and after implementation of peer review. The study identified children ages zero to four preimplementation (N=118,815) and postimplementation (N=121,431), ages five to nine preimplementation (N=98,681) and postimplementation (N=107,872), and ages 10 to 17 preimplementation (N=154,696) and postimplementation (N=161,370). (Age ranges are inclusive of the final number). In each age group, multivariable logistic regression models with generalized estimating equations assessed the change in annual prevalence of antipsychotic use pre- to postimplementation. Use of other leading psychotropic classes and antipsychotic prescribing by medical specialty were also examined. RESULTS: The annual pre- to postimplementation prevalence of antipsychotic use decreased significantly, from .07% to .03% (adjusted odds ratio [AOR]=.41) among children ages zero to four, from 1.57% to .86% (AOR=.54) among those ages five to nine, and from 3.28% to 2.40% (AOR=.72) among those ages 10 to 17. With the exception of alpha-agonist use, which increased postimplementation (AOR=1.30) among those ages zero to four, no clinically significant pre-post change was noted in other leading psychotropic classes among children ages zero to four and 10 to 17. By contrast, postimplementation use of other psychotropic medications decreased among those ages five to nine (AOR=.73). CONCLUSIONS: A state Medicaid peer-review program resulted in decreased antipsychotic use across all age groups, particularly among children younger than ten. No notable substitution of other psychotropic classes for antipsychotics was observed.

Atypical antipsychotic use among Medicaid-insured children and adolescents: duration, safety, and monitoring implications.

OBJECTIVE: Over the last two decades, the increased use of atypical antipsychotic medications, often for unlabeled indications including attention-deficit/hyperactivity disorder (ADHD), has been profound. This study aims to characterize duration of atypical antipsychotic use by age group and Medicaid eligibility category, and among youth with noncomorbid ADHD. METHODS: Administrative data on 266,590 youth 2-17 years of age, and continuously enrolled in a mid-Atlantic state Medicaid program in 2006, were assessed in terms of median days of atypical antipsychotic use using bivariate analyses and multivariable quantile regression. Also, in a subanalysis of youth diagnosed with ADHD without any reported psychiatric comorbidities (i.e., noncomorbid ADHD), age-specific adjusted odds and adjusted median days of atypical antipsychotic use by Medicaid eligibility category were assessed. Additionally, patterns of use of single atypical antipsychotic regimens and two concomitant atypical antipsychotic regimens were described. RESULTS: Overall, the median annual duration of atypical antipsychotic use was 180 days (interquartile range: 69-298 days). Children (2-12-year-olds) had longer durations of use than did adolescents (13-17-year-olds) (median 192 vs. 179 days), respectively. In the absence of any comorbid psychiatric diagnosis, ADHD-diagnosed foster care youth had more than threefold greater adjusted odds of atypical antipsychotic use than did youth enrolled in income-eligible Medicaid categories. Nearly one third of such ADHD-diagnosed foster care youth received atypical antipsychotics regardless of age group, with annual duration of use >250 median days in 2-12-year-olds. In concomitant atypical antipsychotic regimens, risperidone, aripiprazole, and quetiapine were the most common. CONCLUSIONS: Exposure to atypical antipsychotics in Medicaid-insured youth, in particular for children in foster care and those diagnosed with ADHD, was substantial, warranting outcomes research for long-term effectiveness, safety, and oversight for appropriate cardiometabolic monitoring.

Antipsychotic use by medicaid-insured youths: impact of eligibility and psychiatric diagnosis across a decade.

OBJECTIVE: This cross-sectional study evaluated the impact of Medicaid-eligibility category on the increased use of antipsychotic medication by Medicaid-insured youths across a decade. METHODS: The authors analyzed computerized administrative claims data for 456,315 youths aged two to 17 years who were continuously enrolled in Medicaid in a mid-Atlantic state in 1997 (N=159,171) and 2006 (N=297,144). Bivariate and multivariable analyses quantified changes in antipsychotic use in relation to the youths' psychiatric diagnosis and eligibility category (Temporary Assistance for Needy Families [TANF], state Children's Health Insurance Program [SCHIP], Supplemental Security Income [SSI], and foster care). A second multivariable regression model examined changes in demographic and clinical characteristics of antipsychotic users with a psychiatric diagnosis. RESULTS: The prevalence of antipsychotic use increased from 1.2% in 1997 to 3.2% in 2006. The increase in odds of antipsychotic use in 2006 was greatest among youths enrolled in SCHIP (adjusted odds ratio [AOR]=5.9), followed by youths enrolled in foster care (AOR=4.1), TANF (AOR=3.6), and SSI (AOR=2.8). Among users of antipsychotics who had a psychiatric diagnosis, youths with externalizing behavior disorders and bipolar disorder had 2.4- to 3.8-fold greater odds of using antipsychotics in 2006 versus 1997 compared with youths with schizophrenia or other psychoses and pervasive developmental disorders. The proportion of youths using antipsychotics between 1997 and 2006 increased significantly more among African Americans and Hispanics than among whites. CONCLUSIONS: The expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP) and reflects increased medication use for behavioral problems.

Anticonvulsant treatment for psychiatric and seizure indications among youths.

OBJECTIVE: This study compared the prevalence of anticonvulsant treatment for youths with a diagnosis of a psychiatric disorder to youths with a diagnosis of a seizure disorder. METHODS: Administrative claims from outpatient visits and prescriptions were organized for a data set of 258,472 youths who were younger than 18 years of age in a mid-Atlantic state Medicaid program and were continuously enrolled in 2000. Youths dispensed an anticonvulsant were grouped into the following ICD-9 diagnostic categories: a diagnosis of a psychiatric disorder without a seizure disorder, a diagnosis of a seizure disorder without a psychiatric disorder, and a diagnosis of both a psychiatric and a seizure disorder. Anticonvulsant use was analyzed for specific diagnostic classes by age, gender, race or ethnicity, and Medicaid eligibility categories. RESULTS: A total of 4,522 youths in the one-year data set received an anticonvulsant (1.75 percent): 3,061 had a psychiatric disorder only, 251 had a seizure disorder only, and 611 had both psychiatric and seizure disorders. Among anticonvulsant-treated youths with diagnosis information in their records (3,923 of 4,522 youths), 81 percent had a psychiatric diagnosis and 19 percent had a seizure disorder; 71 percent of those with a seizure disorder also had a psychiatric disorder. Anticonvulsant use for seizure control was proportionally greater for those younger than five years. By contrast, a vast majority of anticonvulsant users with a psychiatric diagnosis were between five and 17 years. Among anticonvulsant-treated youths with a psychiatric diagnosis, males were approximately twice as common as females. For youths with a seizure disorder, no difference was found for gender. Mood disorders and attention-deficit hyperactivity disorder were the major psychiatric diagnoses associated with anticonvulsant use. Valproic acid products were the most commonly dispensed type of anticonvulsant. CONCLUSIONS: Recent state Medicaid data reveal that youths who use anticonvulsants are far more likely to have a psychiatric diagnosis than a seizure diagnosis. Widespread off-label use of anticonvulsants for psychiatric disorders among youths warrants attention to ensure benefits and minimize risks.

Antidepressant use in children and adolescents in Germany.

OBJECTIVE: The expanded use of antidepressants in youth has been the subject of numerous studies and some concerns in recent years. This study describes prescription patterns of antidepressants (ATD) for youths in Germany for the years 2000-2003 and includes prescription use of St. John's Wort. METHODS: Prescription data from a health insurance organization with 1.4 million members per year across Germany, of whom approximately 280,000 were under 20 years of age, were accessed. Total age- and gender-specific ATD yearly utilization rates were computed. Prevalence was defined as the dispensing of 1 or more prescriptions for an ATD per calendar year per 1000 continuously enrolled youth. RESULTS: ATD prevalence was 3.43 per 1000 (95% Confidence Interval [CI], 3.21-3.65) in 2000 and 3.74 per 1000 (3.25-3.97) in 2003. St John's Wort products, which are approved for antidepressant use by the German drug agency, and tricyclic antidepressants (TCAs), accounted for more than 80% of antidepressant use. Although selective serotonin reuptake inhibitors (SSRIs) represented only 15% of antidepressant use, there was a doubling of its use over the 4-year period. Adolescent girls (age, 15-19 years) had utilization rates ranging from 11.44 to 13.82 per 1000, and accounted for most ATD use. Overall, females were twice as likely as males to get an antidepressant. Among users, there were low rates of multiple medication use (5.6% used more than one class of ATD, and 6.7% more than one drug). CONCLUSIONS: Prescription patterns in Germany reveal predominate use of St. John's Wort and TCAs, which contrasts sharply with U.S. patterns, wherein SSRIs predominate. Also, in the United States, unlike Germany, 5-9- and 10-14 year olds receive sizable proportions of ATDs. Labeling status (only herbal hypericum preparations and TCAs are labeled for the treatment of depression in children and adolescents in Germany) and cost restrictions appear to influence the prescribing pattern of doctors in Germany. Recent treatment recommendations of national and international regulatory agencies need to take into account the different national situations.

Effect of Medicaid eligibility category on racial disparities in the use of psychotropic medications among youths.

OBJECTIVE: This study sought to determine the degree to which Medicaid eligibility categories modify disparities between black and white youths in the prevalence of psychotropic medication. METHODS: Computerized claims for 189,486 youths aged two to 19 years who were continuously enrolled in a mid-Atlantic state Medicaid program for the year 2000 were analyzed to determine population-based annual prevalence of psychotropic medication by race or ethnicity and by whether the youths were eligible for Medicaid for reasons of family income, disability, or foster care placement. Logistic regression was used to assess the interaction of eligibility category and race. RESULTS: The mean annual prevalence of psychotropic medication for the population was 9.9 percent. The prevalence was 2.17 times higher for white youths than for black youths (16.5 percent compared with 7.6 percent). However, within eligibility categories, the white-to-black disparity was 3.8 among youths who were eligible for Medicaid because their family income was below the federal poverty level and 3.2 for youths enrolled in the State Children's Health Insurance Program. CONCLUSIONS: Medicaid eligibility categories had a profound impact on the racial disparity associated with the prevalence of psychotropic medications for youths. Eligibility category should be taken into account when ascertaining the role of access, undertreatment, and culture in disparities in mental health treatment.

Comparative prevalence of psychotropic medications among youths enrolled in the SCHIP and privately insured youths.

The one-year prevalence of use of psychotropic medications among youths enrolled in a Mid-Atlantic State Children's Insurance Program (SCHIP) in 1999 or 2000 was compared with the 1998-2000 prevalence findings for youths enrolled in four large multistate private medical insurance programs. Prevalence was significantly higher among youths enrolled in the SCHIP than among those with private insurance in all eight medication group comparisons. Unlike private insurance, the surveyed state SCHIP program did not require a copayment or have a restrictive formulary. These administrative differences may partly explain the comparatively higher rate of psychotropic use under the SCHIP.

Rising prevalence of antidepressants among US youths.

OBJECTIVE: To examine changes in antidepressant (ATD) prevalence and the sociodemographic and clinical correlates of ATD use among youths who are treated in community practice settings. METHODS: A retrospective study was undertaken using large data sets from 3 US sites. Outpatient prescription and clinical service records of youths who were aged 2 to 19 and enrolled in Midwestern Medicaid (MWM) and mid-Atlantic Medicaid (MAM) state programs and a group-model health maintenance organization (HMO) were organized into seven 1-year cross-sectional data sets from 1988 through 1994 to evaluate ATD utilization patterns. RESULTS: In 1994, ATD prevalence per 1000 youths was 19.10 (MWM), 17.78 (MAM), and 12.85 (HMO), which represented a consistent increase in prevalence from 1988-1994: 2.9-fold (MWM), 4.6-fold (MAM), and 3.6-fold (HMO). Despite the rapidly expanding use of selective serotonin reuptake inhibitors prescribed mainly for depression, more than half of ATD use in 1994 was still attributable to tricyclic antidepressants prescribed mainly for attention-deficit/hyperactivity disorder. ATD prevalence was generally predominant among 10- to 14-year-old boys and among 15- to 19-year-old girls. In the Medicaid populations, 42% (MAM) and 72% (MWM) of ATD-treated youths had primary care services, whereas the bulk of the remainder had psychiatric services. Attention-deficit/hyperactivity disorder followed by depression led the physician-reported primary care diagnoses associated with ATD use, whereas that diagnostic rank order was reversed for youths who received psychiatric services. CONCLUSIONS: ATD treatments among youths substantially increased in the 1990s. This was generated primarily by primary care providers, and thus evaluations of the outcome of ATD treatment need to target primary care in addition to psychiatric providers. Longitudinal study designs are needed to evaluate the use of ATDs in youths in regard to the duration of treatment, combination medications, and the reasons for treatment.

Antipsychotic dosing and concurrent psychotropic treatments for Medicaid-insured individuals with schizophrenia.

Antipsychotic medications have been first line treatment for schizophrenia for half a century, yet few studies have assessed outpatient maintenance treatment in large populations. This article describes oral antipsychotic dosing patterns and psychotropic treatments using computerized Medicaid claims data for individuals who were diagnosed with schizophrenia and received treatment on an outpatient basis during 1991. The findings show that the mean daily oral antipsychotic dose was 729 +/- 586 chlorpromazine equivalents (CPZ-EQ) for high-potency agents and 304 +/- 328 CPZ-EQ for low-potency agents. Males, younger individuals, and African-Americans received larger mean daily doses of high-potency agents, ranging from 747 to 800 CPZ-EQ. Antiparkinsonian agents were prescribed for over 90 percent of the outpatient antipsychotic treatment exposure. In summary, young adults, males, and African-Americans were given high-potency antipsychotic medications at outpatient maintenance doses that exceeded the maximum recommended levels, despite well-established evidence that high-dose treatment offers no additional benefit. Likewise, concurrent antiparkinsonian treatment exceeded the 1990 World Health Organization recommendations.