Receipt of Guideline-Concordant Pharmacotherapy Among Children With New Diagnoses of Bipolar Disorder

Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
Psychiatric services (Washington, D.C.) (Impact Factor: 2.41). 12/2011; 62(12):1443-9. DOI: 10.1176/
Source: PubMed


This study examined the extent to which children with bipolar I disorder received recommended treatment of mood-stabilizer or second-generation antipsychotic monotherapy and factors associated with its receipt.
Administrative claims data collected from January 1, 2005, to December 31, 2007, were used to construct a cohort of 412 privately insured children with bipolar I disorder. The primary outcome measure was the receipt of mood-stabilizer or second-generation antipsychotic monotherapy within 90 days of an index diagnosis of bipolar disorder.
Only 82 (20%) children received recommended first-line treatment for bipolar I disorder within 90 days of the index diagnosis, and 130 (32%) received no psychotropic medications. Of children receiving any medications, 200 (71%) received nonrecommended pharmacotherapy, most commonly antidepressant monotherapy (N=67, 24%) and combination pharmacotherapy (N=51, 18%). Youths who had been treated by a psychiatrist on the day of or 180 days before the fill date of medication were more likely to receive guideline-recommended care (risk ratio [RR]=1.64, 95% confidence interval [CI]=1.10-2.45) and to receive any psychotropic medications (RR=1.13, CI=1.02-1.24). Nevertheless, only 51 of the 209 (24%) children who visited a psychiatrist and 31 of the 203 (15%) who visited a nonpsychiatrist received recommended pharmacotherapy.
This study highlights significant gaps in the treatment of pediatric bipolar disorder. Most children in this sample received either no medications or nonrecommended pharmacotherapies. Additional research is needed to further assess factors related to the nonuse of recommended psychotropic medications and to the persistent use of nonrecommended pharmacotherapies for children with bipolar disorder.

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    • "It is difficult to escape the conclusion that overall quality of care was poor in the assessed sample, with rates of conformance hovering at or below 25 % for all but one quality measure, suggesting the need for thoughtful and directed quality improvement initiatives. We found that over three-quarters of youths received guideline congruent pharmacotherapy with a mood stabilizer or atypical antipsychotic within 12 weeks of bipolar diagnosis, an ostensibly encouraging finding in comparison to those of previous studies which found much lower conformance rates of 20–26 % (Dusetzina et al. 2011; Evans-Lacko et al. 2011). This may be related to differences in study populations in that prior studies focused on the privately insured who have different socioeconomic and demographic characteristics which may predispose them to greater skepticism about medications (Evans-Lacko et al. 2011). "
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    ABSTRACT: This study examined conformance to clinical practice guidelines for children and adolescents with bipolar disorders and identified patient and provider factors associated with guideline concordant care. Administrative records were examined for 4,047 Medicaid covered youth aged 5-18 years with new episodes of bipolar disorder during 2006-2010. Main outcome measures included 5 claims-based quality of care measures reflecting national treatment guidelines. Measures addressed appropriate pharmacotherapy, therapeutic drug monitoring, and psychosocial treatment. The results indicated that current treatment practices for youth diagnosed with bipolar disorder typically fall short of recommended practice guidelines. Although the majority of affected youth are treated with recommended first-line pharmacotherapy, only a minority receive therapeutic drug monitoring and/or psychotherapy of recommended duration, underscoring the need for quality improvement initiatives.
    Administration and Policy in Mental Health and Mental Health Services Research 04/2014; 42(2). DOI:10.1007/s10488-014-0553-5 · 3.44 Impact Factor
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    ABSTRACT: IMPORTANCE Despite evidence of the increasing use of psychotropic medications, little is known about the broader changes in the delivery of outpatient mental health treatment to children, adolescents, and adults. OBJECTIVE To assess national trends and patterns in the mental health care of children, adolescents, and adults in office-based medical practice. DESIGN, SETTING, AND PARTICIPANTS Outpatient visits to physicians in office-based practice from the 1995-2010 National Ambulatory Medical Care Surveys (N = 446 542). Trends (1995-2010) in visits with mental health care indicators are first compared between youths (<21 years) and adults (≥21 years) and then between children (0-13 years) and adolescents (14-20 years). Background and clinical characteristics of recent visits (2007-2010) resulting in a mental disorder diagnosis are also compared among children, adolescents, and adults. MAIN OUTCOMES AND MEASURES Visits resulting in mental disorder diagnoses, prescription of psychotropic medications, provision of psychotherapy, or psychiatrist care. RESULTS Between 1995-1998 and 2007-2010, visits resulting in mental disorder diagnoses per 100 population increased significantly faster for youths (from 7.78 to 15.30 visits) than for adults (from 23.23 to 28.48 visits) (interaction: P < .001). Psychiatrist visits also increased significantly faster for youths (from 2.86 to 5.71 visits) than for adults (from 10.22 to 10.87 visits) (interaction: P < .001). Psychotropic medication visits increased at comparable rates for youths (from 8.35 to 17.12 visits) and adults (from 30.76 to 65.90 visits) (interaction: P = .13). While psychotherapy visits increased from 2.25 to 3.17 per 100 population for youths, they decreased from 8.37 to 6.36 for adults (interaction: P < .001). In 2007-2010, 27.4% of child visits, 47.9% of adolescent visits, and 36.6% of adult visits resulting in a mental disorder diagnosis were to a psychiatrist. CONCLUSIONS AND RELEVANCE Compared with adult mental health care, the mental health care of young people has increased more rapidly and has coincided with increased psychotropic medication use. A great majority of mental health care in office-based medical practice to children, adolescents, and adults is provided by nonpsychiatrist physicians calling for increased consultation and communication between specialties.
    JAMA Psychiatry 11/2013; 71(1). DOI:10.1001/jamapsychiatry.2013.3074 · 12.01 Impact Factor
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    Revista de Psiquiatría Biológica y Salud Mental 11/2014; DOI:10.1016/j.rpsmen.2014.11.001 · 1.62 Impact Factor


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