Rapid Growth Of Antipsychotic Prescriptions For Children Who Are Publicly Insured Has Ceased, But Concerns Remain

Abstract

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.

Clinical use of second-generation antipsychotics in children

“…However, the content and schedule of the physical evaluations and follow-up practices of SGA medications have been diverse in child psychiatric clinical work (7,39,(44)(45)(46), as was also observed in this study. Only about one-third of the study patients had undergone a physical evaluation at SGA initiation.…”

“…When looking at the socio-demographic background factors of paediatric patients using SGAs in the USA, studies show that the increase in SGA use has occurred disproportionately more often among publicly than privately insured patients (1,7). Those in foster care seem to be especially prone to antipsychotic prescriptions among publicly insured children (7).…”

“…Those in foster care seem to be especially prone to antipsychotic prescriptions among publicly insured children (7). Children in foster care have often experienced traumatic life events, which are, among other individual and environmental factors, known risk factors for several mental health disturbances (15)(16)(17).…”

“…The detected increase in SGA use has induced attempts to monitor and improve SGA prescription practices around the world (7,39,40). All monitoring recommendations emphasize on the appropriate use of psychosocial interventions and the regular monitoring of metabolic and other adverse effects (41).…”

“…Psychotropic medications are however, recommended to be initiated for children in specialist-level health care services (5), with the exception of attention deficit hyperactivity disorder medication (methylphenidate). Recommendations and follow-up protocols seem to be helpful in clinical work and appear to increase monitoring and possibly have an effect on prescribing practices (7,43,44). Despite the already existing recommendations, there has been a lag in the translation of research evidence into clinical practice (39,45).…”