Antipsychotic Polypharmacy in the Treatment of Children and Adolescents in the Fee-for-Service Component of a Large State Medicaid Program

Florida Mental Health Institute, University of South Florida, Tampa, Florida 33612, USA.
Clinical Therapeutics (Impact Factor: 2.59). 05/2010; 32(5):949-59. DOI: 10.1016/j.clinthera.2010.04.021
Source: PubMed

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.

  • Source
    • "uring the past two decades, the prevalence of psychotropic prescribing for children and adolescents with behavioral problems has significantly increased (Gadow 1997; Olfson et al. 2002; Safer et al. 2003; Zito et al. 2003; Cooper et al. 2004, 2006; Schubert et al. 2010; Pringsheim et al. 2011), more so in the United States and Canada than in other countries (Schirm et al. 2001; Zito et al. 2006, 2008a), with polypharmacy, the use of multiple psychotropic medications for one patient, becoming more the rule than the exception (Connor et al. 1997; Olfson et al. 2002; Safer et al. 2003; Zito et al. 2003; DosReis, et al. 2005; Cooper et al. 2006; Comer, et al. 2010). Co-prescription of second generation antipsychotic (SGA) medications in youth has become more commonplace , despite a lack of data supporting the safety and efficacy of polypharmacy (Greenhill et al. 2003; Safer et al. 2003; Correll et al. 2006, 2007; Henin et al. 2009; Roke et al. 2009; Constantine et al. 2010). A longitudinal study of 1958 inpatients with bipolar disorder (Brooks et al. 2011) found that 10% of patients ‡15 years of age who were taking at least 1 SGA were prescribed more than one SGA. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Objective: The purpose of this study was to assess whether polypharmacy regimens can be safely and effectively reduced for youth placed in a residential treatment center, and to assess the cost savings achieved from medication reductions. Methods: Data were collected for 131 youth ages 11-18, who were admitted to and discharged from a residential treatment center between 2007 and 2011. Six month postdischarge data were available for 51 youth. Data include demographics, admission and discharge medications, place of discharge, and postdischarge stability level. Results: Upon admission, 30 youth were not on medication, at discharge 48 were not; a 60% increase. Mean number of admission medications was 2.16 (SD=0.97) versus 1.55 (SD=0.70) upon discharge. Upon admission, one youth was on five and nine were on four medications. At end-point, only one youth was on four medications. The number of youth needing two or more medications declined by 55%, and the number of those needing three or more declined by 69%. The largest reduction was seen in the number of antipsychotics and antidepressants. Mood stabilizer and antipsychotic combinations declined by 65%. Youth with medication reduction were more likely to be discharged to a less restrictive setting than were youth without medication reduction (72.6% vs. 53.8%), p=0.03. At 6 months postdischarge, of the 51 out of 131 youth with available follow-up data, 71% were doing well. Cost analysis based on discontinued medication by class showed monthly savings of $21,365, or $256,368 yearly. The largest contributor was the reduction in the use of antipsychotics, accounting for $205,332 of the total savings. Conclusions: Our study indicates that comprehensive treatment can lead to significant reductions in polypharmacy, and positive short- and longer-term treatment outcomes. Judicial prescribing also resulted in significant cost reduction in an already costly healthcare system.
    Journal of child and adolescent psychopharmacology 11/2013; 23(9):620-627. DOI:10.1089/cap.2013.0014 · 3.07 Impact Factor
  • Clinical Therapeutics 05/2010; 32(5):922-3. DOI:10.1016/j.clinthera.2010.05.010 · 2.59 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The onset of severe, chronic or recurrent psychiatric illnesses, such as schizophrenia-spectrum and bipolar disorders, is a dramatic clinical event often detectable during adolescence and even in childhood. At any age, pharmacotherapy, along with enhancement of social skills and family support, is the mainstay for the management of such disorders. The aim of this review is to critically analyze findings from randomized controlled trials (RCTs) that have investigated the clinical utility of second-generation antipsychotics (SGAs) for the treatment of early-onset schizophrenia and bipolar disorders. Eighteen studies were considered, all of which were unfortunately impaired by methodologic limitations, such as the paucity of long-term data and lack of a three-arm comparison (SGA vs SGA vs placebo). Nevertheless, the results of this review allow us to suggest the effectiveness of three SGAs (aripiprazole, olanzapine, and risperidone) in the short-term treatment of both early-onset schizophrenia and bipolar mania, although such agents show different safety profiles. The use of clozapine should be strictly limited to patients with non-affective, psychotic symptoms who do not respond to any of these three SGAs. In contrast, the use of quetiapine and ziprasidone in young patients with either affective or non-affective psychosis is not yet supported by evidence-based information. Given our findings, further studies are urgently required to identify the best treatment option(s) for pediatric bipolar disorder (especially the depressive phase) and the long-term management of early-onset schizophrenia.
    Paediatric Drugs 10/2011; 13(5):291-302. DOI:10.2165/11591250-000000000-00000 · 1.72 Impact Factor
Show more