Have Efforts to Slow the Rapid Increase in Antipsychotic Use in Children on Medicaid Worked?

A new study in Health Affairs suggests antipsychotic use among Medicaid children peaked in 2008 and has slowed since that time, but this remains a policy challenge.

A study suggests that rising use of antipsychotic medications among Medicaid-insured children peaked in 2008 and has since started to decline. Additionally, children in foster care who are treated with antipsychotics are more likely than other Medicaid-insured children to receive psychosocial interventions and important physiological monitoring for medication side effects. The study, by Stephen Crystal, director of the Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes at Rutgers University, New Brunswick, NJ, and colleagues, appeared in the June 2016 issue of Health Affairs.

During the early and mid-2000s, use of antipsychotic medications increased sharply among Medicaid-insured US children. One study found that use of these medications increased by 51% among Medicaid-insured youth between 2001 and 2004. It is estimated that use among children and youth in foster care also increased during this period, from 8.9% in 2002 to 11.8% in 2007. State and federal agencies addressed this troubling trend by taking steps to improve oversight of prescriptions to Medicaid-insured children, such as prior authorization and the use of special telephone numbers to connect primary care providers with child psychiatrists for consults when antipsychotics were considered.

Investigators examined changes in prescribing patterns that occurred during the period of rapid policy and programmatic change since the mid 2000s, using administrative claims data to study whether the previously reported trend of increased use of antipsychotic medications has continued among foster children and other Medicaid-insured children.

Their analysis found that use of antipsychotics among all Medicaid-insured children peaked in 2008 at 1.86% and declined slightly to 1.73% by 2010. Within the Medicaid-insured population, antipsychotic use remained much higher among foster children, in whom prescription rates for antipsychotics increased from 8.73% in 2005 to 9.26% in 2008, before dropping to 8.92% in 2010. Use of antipsychotics among Medicaid-insured children remained much higher than among privately insured children, where use rates increased from 0.62% in 2009 and remained at a relatively steady level through 2013, when the rate was 0.75%. A trend toward more judicious use of these medications among children with weaker indications for their use (such as children with attention deficit hyperactivity disorder) has been seen in recent years.

The investigators also found that the 3% of Medicaid-insured children who were in foster care accounted for 15.3% of Medicaid-insured children treated with antipsychotics in 2010. In 2010, antipsychotic use was higher among non-Hispanic white than African American or Hispanic children, both among children in foster care and other Medicaid-insured children.

The “new normal” levels of antipsychotic prescribing represent a much higher rate than was seen prior to the growth in the early 2000s, the researchers note. Given safety concerns about glucose and lipid metabolism side effects associated with antipsychotics, and the gaps in actually monitoring them, as well as uncertainties about long-term effects on brain development, more judicious prescribing of antipsychotic medications for children remains a policy challenge, the investigators conclude. Problems also remain with respect to timely access to psychosocial interventions as the first line of treatment, with more than a third of children in foster care not receiving these services. The authors recommend greater use of emerging managed care models, such as special needs plans for foster children, and quality metrics to hold Medicaid managed care plans accountable.