A national study conducted by researchers at The Children's Hospital of Philadelphia's PolicyLab shows an increase in the concurrent prescribing of second-generation antipsychotics (SGA) -- one type of medication used for the treatment of severe mental disorders such as schizophrenia and mania -- with other psychotropic medications among Medicaid-enrolled youth. The study, published online on June 23rd in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), found that while overall SGA use increased by 22 percent from 2004 to 2008, the majority (85 percent) of youth using SGA were prescribed this medication concurrently with another psychotropic medication class.
This large-scale, population-based study, using a data set estimating medication use for 10.6 million children annually, is a rich resource for providing a picture of clinical practice trends on a national scale and can be valuable in informing policies and practice around SGA use.
The researchers used national Medicaid data from the Centers for Medicare and Medicaid Services, for years 2004, 2006, and 2008, to calculate the number of youth who received SGA concurrently with each of the four most commonly prescribed psychotropic medication classes (stimulants, antidepressants, mood stabilizers, and alpha agonists). They also calculated the average annual number of days each psychotropic medication class was prescribed and the days of concurrent SGA use.
Concurrent SGA use increased over time. Notably, by 2008, 1 in 5 stimulant users also received SGA, as well as 1 in 3 antidepressant users. The researchers note that for youth prescribed SGA alongside other psychotropic medications, the concurrent use was present for an average of four to five months in a given year, suggesting the addition of SGA was intended for long-term use rather than as a short-term strategy for behavioral health crisis situations.
"We knew that antipsychotic use was increasing among youth, but we were surprised to learn just how often youth on common psychotropic medications like stimulants or antidepressants also receive an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time," said David M. Rubin, MD, MSCE, a senior author of the study, attending pediatrician, and co-director of CHOP's PolicyLab.
While the rates of concurrent SGA use were 30-60 percent higher among youth in foster care and youth with disability-related Medicaid eligibility, the growth in concurrent SGA use over time was largest among income-eligible youth, who represent the majority of youth served by the Medicaid program. Additionally, youth with ADHD experienced disproportionate increases in concurrent SGA prescribing over time, including youth with a sole diagnosis of ADHD, who experienced a 15 percent increase over the time period.
"The numbers tell a story of emerging clinical practice, where concurrent antipsychotic use by youth is no longer on the margins; rather, we are seeing a shift in use toward less-impaired groups of youth, including among those with ADHD and no other behavioral health diagnosis and among those who were never hospitalized," explained Rubin.
"It is also noteworthy that the largest growth within the Medicaid program has not been among populations with high clinical need in the foster care and disability programs, but rather among those with income eligibility for Medicaid. This article foretells the spread of this therapy into general psychiatric practice," said Rubin.
Growing evidence of serious metabolic side effects of SGAs in youth, including weight gain and diabetes, heightens concern for the use of concurrent SGA.
"The reality is that there is very little safety and efficacy data for SGA in most youth, and we must also consider potential drug-drug interactions when SGAs are used concurrently with other medications," explained Amanda Kreider, the study's lead author and a researcher at PolicyLab. "As clinical practice moves toward the prescribing of these medication combinations in youth with less severe psychiatric impairments, consideration of alternative, non-pharmacologic interventions and, at minimum, monitoring of potential side effects will be critical."
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