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: 2.73).
05/2010; 32(5):949-59. DOI: 10.1016/j.clinthera.2010.04.021
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.
Available from: Pieter Joost van Wattum
- "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. "
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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.
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.
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.
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.
Available from: Mohammad Reza Khodaie
- "During the past decade, prescriptions of antipsychotic polypharmacy medications have increased, especially for adult patients with PDs. In addition, fees for the services are enormous, especially for individuals with severe PDs. "
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ABSTRACT: Antipsychotic monotherapy or polypharmacy (concurrent use of two or more antipsychotics) are used for treating patients with psychiatric disorders (PDs). Usually, antipsychotic monotherapy has a lower cost than polypharmacy. This study aimed to predict the cost of antipsychotic medications (AM) of psychiatric patients in Iran.
For this purpose, 790 patients with PDs who were discharged between June and September 2010 were selected from Razi Psychiatric Hospital, Tehran, Iran. For cost prediction of AM of PD, neural network (NN) and multiple linear regression (MLR) models were used. Analysis of data was performed with R 2.15.1 software.
Mean ± standard deviation (SD) of the duration of hospitalization (days) in patients who were on monotherapy and polypharmacy was 31.19 ± 15.55 and 36.69 ± 15.93, respectively (P < 0.001). Mean and median costs of medication for monotherapy (n = 507) were $8.25 and $6.23 and for polypharmacy (n =192) were $13.30 and $9.48, respectively (P = 0.001). The important variables for cost prediction of AM were duration of hospitalization, type of treatment, and type of psychiatric ward in the MLR model, and duration of hospitalization, type of diagnosed disorder, type of treatment, age, Chlorpromazine dosage, and duration of disorder in the NN model.
Our findings showed that the artificial NN (ANN) model can be used as a flexible model for cost prediction of AM.
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