Concurrent Mental Health Specialty
Care Among Medicaid Enrolled
Children Receiving Antipsychotic
Medications
Emily Nicole Harris, 1 M.D., M.P.H., Mark J. Sorbero,3 M.S.,
Jane N. Kogan,2,3 Ph.D., James Schuster, 3 M.D., M.B.A.,
Bradley D. Stein,2,3 M.D., Ph.D.
Academy Health, June 29, 2009
AcademyHealth 2009
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Increasingly Liberal Use of Antipsychotic
Medication in Children
Substantial increase in use of antipsychotic
medications in children over the last 2 decades
Increasingly used for children with disruptive
behavior disorders such as ADHD, Conduct
Disorder, and Oppositional Defiant Disorder
Despite PCP reported discomfort in prescribing
antipsychotic medications, increasingly
prescribed by pediatricians and family
practitioners
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Are Children Receiving Antipsychotics Getting
Appropriate Non-Pharmacologic Treatment?
 Evidence/consensus for antipsychotic use in
conjunction with non-pharmacologic interventions in
children with schizophrenia, bipolar disorder, autism
 No clear evidence/consensus for antipsychotic use in
child behavioral problems, but effective nonpharmacologic interventions
Behavioral Interventions
Parent Management Training
 Children receiving antipsychotic medication with no
concurrent mental health treatment is clinically
questionable
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Methods
 Used administrative data from largest MBHO in large
Mid-Atlantic State and state provided pharmacy data
 Identified Medicaid-enrolled children receiving
antipsychotic medication during 2007
 Identified children receiving concurrent mental health
care, defined as any specialty mental health care in 30
days preceding or while receiving antipsychotic
medication
 Examined association between concurrent mental
health care and socio-demographic and clinical
variables
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Antipsychotic Medication and
Concurrent Mental Health Care
 6311 children received antipsychotic medications
 Risperidone, Aripiprazole, and Quetiapine accounted
for over 80% of the antipsychotic medication
prescribed
 64% of children on antipsychotic medication
diagnosed with a behavioral disorder
 22% of children on antipsychotic medication
diagnosed with a disorder with an indication/consensus
for antipsychotic medications
 20% of children on antipsychotic medications had no
concurrent mental health care
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Who Receives Concurrent
Mental Health Care?
 Concurrent mental health care significantly lower
among youth age 12-17 (76%; OR 0.74), youth
Medicaid-eligible due to disability (78%; OR 0.65),
youth involved in the child welfare system (76%; OR
0.65), and boys (79%; OR 0.62)
 Concurrent mental health care significantly higher
among those with hospitalization in previous year
(92%; OR 2.5) and Latinos (92%; OR 2.4)
 Median duration of antipsychotic medication trial
significantly longer in those receiving concurrent
mental health care (159 days) than those not receiving
concurrent mental health care (110 days)
AcademyHealth 2009
A Glass Half Full or Half Empty?
 80% of children receiving antipsychotic medication receive
concurrent mental health specialty care, but 20% do not
 Majority of children receiving antipsychotic medications have a
behavioral disorder
 No evidence of antipsychotic effectiveness in such disorders and
effective non-pharmacologic interventions exist
 No information available about what interventions had already been
tried, parental preferences
 No information available about interventions being received by those in
concurrent mental health care
 Some ability to target interventions to populations at higher risk
of not receiving concurrent care
AcademyHealth 2009
Implications and Next Steps
 Children receiving antipsychotic medication with no concurrent
mental health treatment is clinically questionable
 Access and prescriber practice patterns both potential issues
 What is role of family preferences?
 Difficult to make targeted changes to prescribing patterns
 Many psychotropic prescribers are PCPs
 Educational and information campaigns are seldom successful
 Effective interventions are either poorly targeted (prior authorizations,
triplicate prescribing) or labor intensive (academic detailing)
 Potentially easier to increase use of appropriate nonpharmacologic interventions
 Timely identification of children
 Public already concerned about use of medications in children
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