Antipsychotic prescription rates for children in foster care and other Medicaid-insured children have finally leveled off after a sharp increase in the early 2000s that reached a disturbing peak in 2008, according to a new study at Rutgers University in New Jersey.
Another encouraging finding is that foster kids are more likely to be receiving psychosocial interventions as well as metabolic monitoring while on antipsychotic drugs. But there is still much more work to do, note the researchers, as there are other highly recommended practices that are not being followed by many clinicians.
“While these findings do suggest more careful monitoring of children in foster care who are prescribed antipsychotic medication, challenges remain in increasing safety monitoring and access to psychosocial treatment,” said lead author Dr. Stephen Crystal, board of governors professor and associate director for health services research at Rutgers’ Institute for Health, Health Care Policy and Aging Research.
Some of the highly recommended practices that doctors should be adhering to more frequently include the following: using nonpharmacological mental health services as first-line treatments, monitoring the blood sugar and cholesterol levels of children on antipsychotics due to the metabolic side effects of the drugs, and not prescribing antipsychotics for disorders not approved by the Food and Drug Administration.
Off-label use of antipsychotic drugs is particularly problematic among children in foster care. For example, in 2010, 34 percent of antipsychotic prescriptions among foster care children were for attention-deficit/hyperactivity disorder (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,” said Crystal. He adds that children in foster care continue to receive antipsychotic treatment at much higher rates than other Medicaid-insured children (8.92 percent vs 1.51 percent among zero to 17-year-olds in 2010).
Furthermore, more than one-third of foster children prescribed an antipsychotic did not receive psychosocial mental health interventions during the three months preceding and the month following the start of antipsychotic treatment. This figure is even worse for non-foster kids on Medicaid, as more than two-thirds of these children on antipsychotics did not receive such care.
“Only 28 percent of foster children, and 18 percent of other children, received metabolic monitoring for both blood glucose and serum cholesterol,” said Crystal.
The researchers found that antipsychotic medication use peaked in 2008 among Medicaid children and 2009 among privately insured children, but levels have still 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 said. “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.”
“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 said.
On a positive note, the study identified several promising developments that may improve prescribing quality for antipsychotics and other psychotropic drugs for children. These include the development of specialized managed care plans for children in foster care and new national quality measures ensuring the safe and sensible prescribing of antipsychotic medication.
“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,” Crystal concluded.
The study is published in the journal Health Affairs.
Source: Rutgers University