[Show abstract][Hide abstract] ABSTRACT: This study examined associations between stimulant use and risk of cardiovascular events and symptoms in youth with attention-deficit/hyperactivity disorder and compared the risks associated with methylphenidate and amphetamines.
Claims were reviewed of privately insured young people 6 to 21 years old without known cardiovascular risk factors (n = 171,126). A day-level cohort analysis evaluated the risk of cardiovascular events after a diagnosis of attention-deficit/hyperactivity disorder in relation to stimulant exposures. Based on filled stimulant prescriptions, follow-up days were classified as current, past, and no stimulant use. Endpoints included an emergency department or inpatient diagnosis of angina pectoris, cardiac dysrhythmia, or transient cerebral ischemia (cardiac events) or tachycardia, palpitations, or syncope (cardiac symptoms).
There were 0.92 new cardiac events and 3.08 new cardiac symptoms per 1,000,000 days of current stimulant use. Compared with no stimulant use (reference group), the adjusted odds ratios of cardiac events were 0.69 (95% confidence interval 0.42-1.12) during current stimulant use and 1.18 (95% CI 0.83-1.66) during past stimulant use. The corresponding adjusted odds ratios for cardiac symptoms were 1.18 (95% CI 0.89-1.59) for current and 0.93 (95% CI 0.71-1.21) for past stimulant use. No significant differences were observed in risks of cardiovascular events (2.14, 95% CI 0.82-5.63) or symptoms (1.08, 95% CI 0.66-1.79) for current methylphenidate use compared with amphetamine use (reference group).
Clinical diagnoses of cardiovascular events and symptoms were rare and not associated with stimulant use. The results help to allay concerns over the cardiovascular safety of stimulant treatment for attention-deficit/hyperactivity disorder in young people without known pre-existing risk factors.
Journal of the American Academy of Child and Adolescent Psychiatry 02/2012; 51(2):147-56. · 6.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In order to examine relationships between depression treatments (antidepressant and/or psychotherapy utilization) and adherence to antiretroviral therapy (ART), we conducted a retrospective analysis of medical and pharmacy insurance claims for privately insured persons living with HIV/AIDS (PLWHA) diagnosed with depression (n = 1,150). Participants were enrolled in 80 insurance plans from all 50 states. Adherence was suboptimal. Depression treatment initiators were significantly more likely to be adherent to ART than the untreated. We did not observe an association between psychotherapy utilization and ART adherence, yet given the limitations of the data (e.g., there is no information on types of psychological treatment and its targets), the lack of association should not be interpreted as lack of efficacy.
AIDS and Behavior 04/2011; 15(8):1819-28. · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined the prevalence and demographic and clinical correlates of children diagnosed with Tourette disorder, chronic motor or vocal tic disorder, and other tic disorders in public and private insurance plans over the course of a 1-year period.
Claims were reviewed of Medicaid (n = 10,247,827) and privately (n = 16,128,828) insured youth (4-18 years old) focusing on tic disorder diagnoses during a 1-year period. Rates are presented for children with each tic disorder diagnosis overall and stratified by demographic characteristics and co-identified mental disorders. Mental health service use, including medications prescribed, and co-existing psychiatric disorders were also examined.
In Medicaid-insured children, rates of diagnosis per 1,000 were 0.53 (95% confidence interval [CI] 0.51-0.55) for Tourette disorder, 0.08 (95% CI 0.07-0.08) for chronic motor or vocal tic disorder, and 0.43 (95% CI 0.41-0.44) for other tic disorders. In privately insured children, comparable rates were 0.50 (95% CI 0.49-0.52), 0.10 (95% CI 0.10-0.11), and 0.59 (95% CI 0.58-0.61). In 1 year, children diagnosed with tic disorders also frequently received other psychiatric disorder diagnoses. Compared with privately insured youth, children under Medicaid diagnosed with Tourette disorder had higher rates of attention-deficit/hyperactivity disorder (50.2% versus 25.9%), other disruptive behavior (20.6% versus 5.6%), and depression (14.6% versus 9.8%) diagnoses and higher rates of antipsychotic medication use (53.6% versus 33.2%).
Despite similarities in annual rates of tic disorder diagnoses in publicly and privately insured children, important differences exist in patient characteristics and service use of publicly and privately insured youth who are diagnosed with tic disorders.
Journal of the American Academy of Child and Adolescent Psychiatry 02/2011; 50(2):119-31. · 6.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Scant information exists to guide pharmacological treatment of early-onset schizophrenia. We examine variation across commonly prescribed second-generation antipsychotic medications in medication discontinuation and psychiatric hospital admission among children and adolescents clinically diagnosed with schizophrenia. A 45-state Medicaid claims file (2001-2005) was analyzed focusing on outpatients, aged 6-17 years, diagnosed with schizophrenia or a related disorder prior to starting a new episode of antipsychotic monotherapy with risperidone (n = 805), olanzapine (n = 382), quetiapine (n = 260), aripiprazole (n = 173), or ziprasidone (n = 125). Cox proportional hazard regressions estimated adjusted hazard ratios of 180-day antipsychotic medication discontinuation and 180-day psychiatric hospitalization for patients treated with each medication. During the first 180 days following antipsychotic initiation, most youth treated with quetiapine (70.7%), ziprasidone (73.3%), olanzapine (73.7%), risperidone (74.7%), and aripirazole (76.5%) discontinued their medication (χ(2) = 1.69, df = 4, P = .79). Compared with risperidone, the adjusted hazards of antipsychotic discontinuation did not significantly differ for any of the 4-comparator medications. The percentages of youth receiving inpatient psychiatric treatment while receiving their initial antipsychotic medication ranged from 7.19% (aripiprazole) to 9.89% (quetiapine) (χ(2) = 0.79, df = 4, P = .94). As compared with risperidone, the adjusted hazard ratio of psychiatric hospital admission was 0.96 (95% CI: 0.57-1.61) for olanzapine, 1.03 (95% CI: 0.59-1.81) for quetiapine, 0.85 (95% CI: 0.43-1.70) for aripiprazole, and 1.22 (95% CI: 0.60-2.51) for ziprasidone. The results suggest that rapid antipsychotic medication discontinuation and psychiatric hospital admission are common in the community treatment of early-onset schizophrenia. No significant differences were detected in risk of either adverse outcome across 5 commonly prescribed second-generation antipsychotic medications.
[Show abstract][Hide abstract] ABSTRACT: Stimulants and atomoxetine should generally not be used or used only with caution in adults with pre-existing cardiovascular conditions. The extent to which pre-existing cardiovascular conditions influence initiation of these ADHD medications in adults is not known.
We performed a retrospective cohort study of privately insured adults with new ADHD treatment episodes. Pre-existing cardiovascular conditions were assessed by the presence of ICD-9-CM codes for congenital abnormalities, atherosclerosis, cardiac disease, and cerebrovascular disease in the 12 months before the index ADHD diagnosis. The primary outcome was new initiation of a stimulant or atomoxetine in the 3 months after the index date. Multivariate logistic regression was used to predict the likelihood of treatment initiation with stimulants or atomoxetine based on pre-existing cardiovascular conditions, patient demographic characteristics, clinical mental disorder comorbidities, other psychotropic drug use, and provider type.
Of 8752 patients with a new ADHD treatment episode, 917 (10.5%) had evidence of >or=1 pre-existing cardiovascular condition. Stimulants were started by 40.8% of patients with and 53.0% of patients without pre-existing cardiovascular conditions (Adjusted Odds Ratio, AOR 0.71; 95%CI 0.61-0.82). Pre-existing cardiovascular conditions reduced the likelihood of initiating stimulant treatment in younger but not in older patients (p-value for age x cardiovascular condition interaction = 0.0002). Initiation of atomoxetine treatment was not affected by pre-existing cardiovascular conditions (AOR 1.19, 95%CI 0.94-1.50).
Pre-existing cardiovascular conditions reduce the likelihood of stimulant therapy but not atomoxetine treatment in adult ADHD patients. However, many adult ADHD patients with pre-existing cardiovascular conditions initiate stimulant therapy.
Pharmacoepidemiology and Drug Safety 03/2010; 19(5):457-64. · 2.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study describes recent trends and patterns in antipsychotic treatment of privately insured children aged 2 through 5 years.
A trend analysis is presented of antipsychotic medication use (1999-2001 versus 2007) stratified by patient characteristics. Data are analyzed from a large administrative database of privately insured individuals. Participants were privately insured children, aged 2 through 5 years, with 12 months of continuous service enrollment in 1999-2001 (N = 400,196) or 2007 (N = 755,793). The main outcomes are annualized rates of antipsychotic use and adjusted rate ratios (ARR) of year effect on rate of antipsychotic use adjusted for age, sex, and treated mental disorder.
The annualized rate of any antipsychotic use per 1,000 children increased from 0.78 (95% confidence interval [CI] 0.69-0.88) (1999-2001) to 1.59 (95% CI 1.50-1.68) (2007) (ARR 1.76, 95% CI 1.56-2.00). Significant increases in antipsychotic drug use were evident for boys (ARR 1.66, 95% CI 1.44-1.90) and girls (ARR 2.26, 95% CI 1.70-3.01) and for children diagnosed with several different psychiatric disorders. Among antipsychotic-treated children in the 2007 sample, pervasive developmental disorder or mental retardation (28.2%), attention deficit/hyperactivity disorder (ADHD) (23.7%), and disruptive behavior disorder (12.9%) were the most common clinical diagnoses. Fewer than one-half of antipsychotic-treated young children received a mental health assessment (40.8%), a psychotherapy visit (41.4%), or a visit with a psychiatrist (42.6%) during the year of antipsychotic use.
Despite increasing rates of antipsychotic use by very young children, provision of formal mental health services remains sparse. These service patterns highlight a critical need to improve the availability of specialized and well integrated mental health care for very young children with serious mental health problems.
Journal of the American Academy of Child and Adolescent Psychiatry 01/2010; 49(1):13-23. · 6.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.
Health Affairs 08/2009; 28(5):w770-81. · 4.64 Impact Factor