Antipsychotic Polypharmacy in the Treatment of Children and Adolescents in the Fee-for-Service Component of a Large State Medicaid Program
ABSTRACT The aims of this study were to quantify and describe antipsychotic polypharmacy use among patients aged 6 to 12 years (children) and 13 to 17 years (adolescents) and to identify the characteristics of polypharmacy recipients.
Data from patients enrolled in Florida's Medicaid fee-for-service program and receiving treatment with an antipsychotic were included. Antipsychotic polypharmacy was defined as the receipt of > or = 2 antipsychotic medications concurrently for >60 days, with no gaps >15 days in polypharmacy treatment. The prevalence of antipsychotic polypharmacy, durations of treatment episodes, times to antipsychotic polypharmacy after initiation of antipsychotic monotherapy, and rates of antipsychotic combination use were calculated for the period between July 2002 and June 2007.
During the 5-year period, 12,764 children and 10,419 adolescents received antipsychotic treatment. The proportions of patients who were male (73% and 63%) and whose race was indicated as "other" (31% and 14%) were significantly greater in children than in adolescents, respectively (both, P < 0.001). Seven percent of the children and 8% of the adolescents were prescribed antipsychotic polypharmacy (P = 0.001). Mean (SD) durations of polypharmacy episodes were 170.0 (139.0) days in children and 185.5 (175.9) days in adolescents (P = 0.010). Times to initiation of polypharmacy were 505.8 (440.5) days in children and 384.9 (424.3) days in adolescents (P < 0.001). Adolescents (odds ratio [OR] = 1.16; 95% CI, 1.04-1.29) were more likely than children to be polypharmacy recipients, as were those with psychotic disorders (OR = 1.47; 95% CI, 1.20-1.81) compared with those with bipolar I disorder. Patients whose race was indicated as "other" were more likely than patients of white race to receive polypharmacy (OR = 1.18; 95% CI, 1.04-1.34; P < 0.001); other ethnic/racial groups did not differ significantly. The most common specific antipsychotic combinations prescribed in children and adolescents were aripiprazole/quetiapine (23% and 17%, respectively), risperidone/quetiapine (18% and 15%), aripiprazole/risperidone (17% and 11%), risperidone/olanzapine (5% and 6%), and quetiapine/olanzapine (4% and 7%).
The prevalence and duration of Antipsychotic polypharmacy among antipsychotic recipients in this Medicaid fee-for-service population were noteworthy. Research on the risks and benefits of the practice in the pediatric population is needed.
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ABSTRACT: Objective: This study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income). Methods: Serial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes). Results: Both types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]= 1.12, 99% confidence interval [CI]=1.10-1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09-1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07-1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants. Conclusions: Polypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.Psychiatric services (Washington, D.C.) 07/2014; 65(11). DOI:10.1176/appi.ps.201300410 · 1.99 Impact Factor
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ABSTRACT: Objective: The objective of this study was to analyze the initial treatment with antipsychotics (APs) and its changes during the first year of treatment in patients visited in specialized child and adolescent psychiatry departments. Methods: Participants were 265 patients, aged 4 to 17 years, who attended consecutively at 4 different centers and were naive of AP or quasi-naive (less than 30 days since the beginning of AP treatment). Type of AP, dosage, and concomitant medication were registered at baseline, 1, 3, 6, and 12 months after beginning the treatment with AP. Results: At baseline, the patients' mean age was 14.4 (2.9) years, and 145 (54.7%) patients were males. Antipsychotics were more prescribed in the following: schizophrenia spectrum disorders (30.2%), disruptive behavior disorders (DBDs) (18.9%), bipolar disorders (14.3%), depressive disorders (12.8%), and eating disorders (11.7%). A total of 93.2% of the patients were on an off-label indication of AP. Risperidone was the AP most prescribed in all the assessments, but differences were observed in the type of AP according to diagnosis. Thus, risperidone was significantly most prescribed in patients with DBD and olanzapine was most prescribed in patients with eating disorders. Olanzapine and quetiapine were the second-generation APs (SGAs) most prescribed after risperidone, and haloperidol was the most prescribed first-generation AP. Up to 8.3% of patients during the follow-up were on AP polypharmacy. Almost 16% patients had a change in its AP treatment during the follow-up, and the main switch was from one SGA to another. Conclusions: Second-generation APs were the APs most prescribed in our sample and approximately 93% of the patients used AP off-label. Risperidone was the most common AP used above all in patients with DBD, whereas olanzapine was most prescribed in patients with eating disorders. Antipsychotic polypharmacy and switch rates were low during the follow-up.Journal of Clinical Psychopharmacology 08/2014; 34(5). DOI:10.1097/JCP.0000000000000190 · 3.76 Impact Factor
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ABSTRACT: Antipsychotic polypharmacy-the use of more than one antipsychotic concomitantly-has increased in children and adolescents and may be associated with increased adverse effects, nonadherence, and greater costs. Thus, we sought to examine the demographic and clinical characteristics of psychiatrically hospitalized children and adolescents who were prescribed antipsychotic polypharmacy and to identify predictors of this prescribing pattern.Pharmacotherapy 08/2014; 34(8). DOI:10.1002/phar.1453 · 2.20 Impact Factor