The stigma associated with mental illness harms the self-esteem of many people who have serious mental illnesses. An important consequence of reducing stigma would be to improve the self-esteem of people who have mental illnesses.

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The rapid growth of antipsychotic medication use among publicly insured children in the early and mid-2000s spurred new state efforts to monitor and improve prescription behavior. A starting point for many oversight initiatives was the foster care system, where most of the children are insured publicly through Medicaid. To understand the context and the effects of these initiatives, we analyzed patterns and trends in antipsychotic treatment of Medicaid-insured children in foster care and those in Medicaid but not in foster care. We found that the trend of rapidly increasing use of antipsychotics appears to have ceased since 2008. Children in foster care treated with antipsychotic medications are now more likely than other Medicaid-insured children to receive psychosocial interventions and metabolic monitoring for the side effects of the medications. However, challenges persist in increasing safety monitoring and access to psychosocial treatment. Development of specialized managed care plans for children in foster care represents a promising policy opportunity. New national quality measures for safe and judicious antipsychotic medication use are also now available to guide improvement. Oversight policies developed for foster care appear to have potential for adaptation to the broader population of Medicaid-covered children.

Objectives The authors investigated the extent to which clinical externalizing disorder diagnoses explain increased rates of antipsychotic use in foster youth. Methods Medicaid claims data from 44 states for 2009 were analyzed to determine antipsychotic use rates among foster youth (n=301,894) and non-foster youth (n=5,092,574), excluding individuals diagnosed with schizophrenia, bipolar, autistic, or major depressive disorder. Logistic regressions assessed the relationship among foster status, externalizing disorder diagnoses, and antipsychotic use. Results Foster youth had higher rates of externalizing disorder diagnoses (ADHD: 17.3% vs. 6.5%; disruptive behavior disorder: 7.2% vs. 2.5%; conduct disorder: 2.3% vs. .5%) and antipsychotic use (7.4% vs. 1.4%) compared to non-foster youth. Foster care remained a significant predictor of antipsychotic use after controlling for demographic and diagnostic covariates, including externalizing disorder diagnoses (adjusted odds ratio [AOR]=2.59; 95% confidence interval [C.I.]=2.54–2.63). Conclusions High rates of externalizing disorder diagnoses only partially explain elevated levels of antipsychotic use in this vulnerable population.

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.