Foster kids get antipsychotics at ‘new normal’ rate

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Although fewer children in foster care and on Medicaid are getting prescriptions for antipsychotic medicines than during the early and mid-2000s, challenges remain.

A new study in the journal Health Affairs finds that guidelines about drug-free mental health services as first-line treatment and monitoring of medication side effects are frequently not followed.

“The ‘new normal’ levels of prescribing represent a substantially higher rate than was seen prior to the sharp expansion of the early 2000s.”

Children in foster care, whose treatment receives closer oversight than other Medicaid children, were more likely than others to receive these guideline-recommended practices, says lead author Stephen Crystal, professor and associate director for health services research at Rutgers’ Institute for Health, Health Care Policy and Aging Research.

However, among children treated with antipsychotics, more than one-third of foster children and more than two-thirds of other Medicaid children, failed to receive psychosocial mental health interventions during the three months preceding and the month following the start of antipsychotic treatment, he observes.

“Only 28 percent of foster children, and 18 percent of other children, received metabolic monitoring for both blood glucose and serum cholesterol,” Crystal says, adding that children in foster care continue to receive antipsychotic treatment at much higher rates than other Medicaid-insured children (8.92 percent versus 1.51 percent among 0-17-year-olds in 2010).

Why are preschoolers taking antipsychotic drugs?

In their article, the authors report that antipsychotic medication use peaked in 2008 among Medicaid children and 2009 among privately insured children, but levels have not returned to the pre-2000 rates.

“The ‘new normal’ levels of prescribing represent a substantially higher rate than was seen prior to the sharp expansion of the early 2000s,” Crystal says. “Given safety concerns and uncertainties about long-term effects on brain development, encouraging judicious prescribing of antipsychotic medications for children remains a policy challenge and a priority.”

The study used national and state-level Medicaid data, in addition to data from private health insurance.

One of the study’s key findings is the need to continue to address antipsychotic use among children in foster care, Crystal notes. “Levels of use of antipsychotics among children in foster care were almost six times higher than in nonfoster care children in 2010. The state serves in loco parentis (“in place of the parent”) for these children. Therefore, we have additional responsibility to ensure they are receiving the most appropriate treatment,” he says.

The study finds that antipsychotics continue to be prescribed for mental disorders not indicated by the Food and Drug Administration, particularly among children in foster care. For example, in 2010, 34 percent of antipsychotic prescriptions among foster care children were for ADHD, anxiety, or depression, compared to 18 percent among children not in foster care. “Doctors should consider other first-line treatments for children with these diagnoses,” Crystal says.

Off-label drug use could pose health risks

The study identifies several promising developments that have the potential to be important tools in improving prescribing quality for antipsychotics and other psychotropic drugs for children. These include the development in specialized managed care plans for children in foster care and new national quality measures for safe and judicious prescription of antipsychotic medication.

“Progress in a number of states that have implemented programs for oversight and quality improvement in children’s psychotropic medication use is encouraging,” says Crystal. “However, persistently high rates of antipsychotic treatment, particularly among foster children, alongside gaps in metabolic monitoring, over-reliance on use of multiple concurrent antipsychotic medications, and underuse of psychosocial interventions, underscore enduring behavioral health care challenges.

“State and federal health care policymakers have opportunities to promote meaningful improvements that bear directly on the symptoms, social function, and quality of life of foster children with mental health problems, by seizing opportunities such as emerging managed care models and new treatment guidelines,” he concludes.

Source: Rutgers University