Use of Atypical Antipsychotics In Pediatric Patients William Golden, MD MACP Professor of Medicine and Public Health Med. Dir. Health Policy, DHS/Medicaid.

Use of Atypical Use of Atypical Antipsychotics Antipsychotics

In Pediatric PatientsIn Pediatric PatientsWilliam Golden, MD MACPWilliam Golden, MD MACPProfessor of Medicine and Public Professor of Medicine and Public

HealthHealth

Med. Dir. Health Policy, Med. Dir. Health Policy, DHS/MedicaidDHS/Medicaid

1

Pediatric Mood DisordersPediatric Mood Disorders

Reliable Diagnosis in Very Young Reliable Diagnosis in Very Young ChildrenChildren ADHD, Oppositional Defiant Disorder, ADHD, Oppositional Defiant Disorder,

AutismAutism Schizophrenia, DepressionSchizophrenia, Depression Sequelae of Dysfunctional Family Sequelae of Dysfunctional Family

SettingsSettings

2

Atypical AntipsychoticsAtypical Antipsychotics

Limited FDA Approval Only in Older Limited FDA Approval Only in Older ChildrenChildren Risperidone Approved for Autism (>Age 5)Risperidone Approved for Autism (>Age 5)

Limited Data in Younger ChildrenLimited Data in Younger Children No Safety DataNo Safety Data Long Term Neurologic EffectsLong Term Neurologic Effects Weight Gain, DiabetesWeight Gain, Diabetes Extrapyramidal Side Effects Extrapyramidal Side Effects Literature Suggests Role for Aggressive Literature Suggests Role for Aggressive

BehaviorBehavior

3

National ConcernNational Concern

SafetySafety PolypharmacyPolypharmacy DiagnosisDiagnosis Growth in PrescribingGrowth in Prescribing Foster Children At Particular RiskFoster Children At Particular Risk

Less Parental Oversight, PolypharmacyLess Parental Oversight, Polypharmacy

4

Steven Domon, M.D.Steven Domon, M.D.Section Chief, Adolescent ServicesSection Chief, Adolescent Services

Arkansas State HospitalArkansas State Hospital

Clinical Assistant ProfessorClinical Assistant ProfessorUAMS College of MedicineUAMS College of MedicineDepartment of Psychiatry,Department of Psychiatry,

Division of Child and Adolescent Division of Child and Adolescent PsychiatryPsychiatry

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““For Foster kids, oversight of prescriptions is For Foster kids, oversight of prescriptions is scarce”scarce”

USA TODAY, May 2, 2006USA TODAY, May 2, 2006

““In California, Med-Cal prescription claims for atypicals for In California, Med-Cal prescription claims for atypicals for kids in foster care increased 77% between 2001 and kids in foster care increased 77% between 2001 and 2005.”2005.”

““In Illinois, the number of children covered under the state’s In Illinois, the number of children covered under the state’s public health care program—not just foster children—who public health care program—not just foster children—who had an atypical prescription went up 39% between fiscal had an atypical prescription went up 39% between fiscal years 2003 and 2005, to 17,746.”years 2003 and 2005, to 17,746.”

““In February [2006], Florida’s health care agency ordered an In February [2006], Florida’s health care agency ordered an independent investigation into why the number of independent investigation into why the number of Medicaid children taking antipsychotics nearly doubled in Medicaid children taking antipsychotics nearly doubled in the past five years. The numbers jumped from 9,500 to the past five years. The numbers jumped from 9,500 to 17,900 [from 2000 to 2005].” 17,900 [from 2000 to 2005].”

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““Concern About Psychotropic Drugs and Concern About Psychotropic Drugs and Foster Kids”Foster Kids”

Psychiatric Times, July 1, 2008Psychiatric Times, July 1, 2008

““Concern is on the rise about psychotropic medications—Concern is on the rise about psychotropic medications—especially atypical antipsychotics—given to foster children especially atypical antipsychotics—given to foster children covered under Medicaid”covered under Medicaid”

““Rep. Jim McDermott, M.D. (D, Washington), the only Rep. Jim McDermott, M.D. (D, Washington), the only psychiatrist in Congress, has introduced legislation that psychiatrist in Congress, has introduced legislation that requires states to improve care coordination for foster requires states to improve care coordination for foster children.” [The American Academy of Pediatrics has endorsed children.” [The American Academy of Pediatrics has endorsed this section of McDermott’s bill.]this section of McDermott’s bill.]

Based on a review of data from Texas, Dr. Julie M. Zito “found Based on a review of data from Texas, Dr. Julie M. Zito “found that in 2004, 38% of the more than 32,000 foster care youth in that in 2004, 38% of the more than 32,000 foster care youth in Texas younger than 19 years received a psychotropic drug.” Texas younger than 19 years received a psychotropic drug.”

[12.4% 0-5 years, 55% 6-12 years, and 66.5% 13-17 years][12.4% 0-5 years, 55% 6-12 years, and 66.5% 13-17 years]

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Rebecca RileyRebecca Riley

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Rebecca Riley (cont.)Rebecca Riley (cont.)

Diagnosed with ADHD and Bipolar Diagnosed with ADHD and Bipolar Disorder at age 28 monthsDisorder at age 28 months

Medications at age 4:Medications at age 4: SeroquelSeroquel DepakoteDepakote ClonidineClonidine

Source:Source:Patricia Wen, Boston Globe, February 19, 2007Patricia Wen, Boston Globe, February 19, 2007Scott Allen, Boston Globe October 7, 2007Scott Allen, Boston Globe October 7, 2007

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Rebecca Riley (cont.)Rebecca Riley (cont.) During the summer of 2006 her in-home During the summer of 2006 her in-home

therapist expressed concerns about therapist expressed concerns about Rebecca’s medications to her psychiatrist Rebecca’s medications to her psychiatrist and to her motherand to her mother

The Massachusetts Dept. of Social Services The Massachusetts Dept. of Social Services investigated at least two reports of neglect investigated at least two reports of neglect and abuse made by Rebecca’s therapistand abuse made by Rebecca’s therapist

In October her school nurse and gym In October her school nurse and gym teacher described her as lethargic every teacher described her as lethargic every dayday

On December 9, 2006 her parents refused On December 9, 2006 her parents refused to allow a concerned family member to to allow a concerned family member to take her to the hospitaltake her to the hospital

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Rebecca Riley (cont.)Rebecca Riley (cont.) On December 13, 2006 she was found dead On December 13, 2006 she was found dead

beside her parents bedbeside her parents bed The state medical examiner determined that she The state medical examiner determined that she

died due to the combined effects of her died due to the combined effects of her prescribed medications and over-the-counter prescribed medications and over-the-counter cold medicationscold medications

She apparently died after deteriorating slowly, She apparently died after deteriorating slowly, over the course of several daysover the course of several days

Her parents were charged with murder and her Her parents were charged with murder and her physician surrendered her license while the state physician surrendered her license while the state investigated the deathinvestigated the death

Soure:Dennis Tatz and Sue Reinert, The Patriot Ledger, Feb 6, 2007Soure:Dennis Tatz and Sue Reinert, The Patriot Ledger, Feb 6, 2007

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Massachusetts’ ResponseMassachusetts’ Response State officials set up an “early warning State officials set up an “early warning

system” to identify preschoolers who may system” to identify preschoolers who may be getting excessive medication (35 were be getting excessive medication (35 were identified in the first 3 months)identified in the first 3 months)

The State Medicaid program began The State Medicaid program began reviewing the records of all children reviewing the records of all children under age 5 for those who were on at under age 5 for those who were on at least three psychiatric medications or on least three psychiatric medications or on an antipsychotican antipsychotic

The Massachusetts oversight system The Massachusetts oversight system continues to evolvecontinues to evolve

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Indications for Indications for AntipsychoticsAntipsychotics

Psychotic DisordersPsychotic Disorders Bipolar DisorderBipolar Disorder Autism and other developmental Autism and other developmental

disordersdisorders Tourette’s Syndrome and tic disordersTourette’s Syndrome and tic disorders AggressionAggression Augmentation in other disorders such Augmentation in other disorders such

as severe OCD, PTSDas severe OCD, PTSD

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FDA-approved pediatric FDA-approved pediatric indications for indications for antipsychoticsantipsychotics

Risperidone (Risperdal)Risperidone (Risperdal) age 5-16 irritability associated with age 5-16 irritability associated with

autismautism age 10-17 bipolar disorderage 10-17 bipolar disorder age 13-17 schizophreniaage 13-17 schizophrenia

Aripiprazole (Abilify)Aripiprazole (Abilify) age 10-17 acute mania or mixed episodesage 10-17 acute mania or mixed episodes age 13-17 schizophreniaage 13-17 schizophrenia

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FDA-approved pediatric FDA-approved pediatric indications for indications for

antipsychotics (cont.)antipsychotics (cont.) Quetiapine (Seroquel) noneQuetiapine (Seroquel) none Ziprasidone (Geodon) noneZiprasidone (Geodon) none Olanzapine (Zyprexa) noneOlanzapine (Zyprexa) none

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““Off label” use of Off label” use of antipsychoticsantipsychotics

When antipsychotics are used in children, When antipsychotics are used in children, more often than not, that use is not FDA-more often than not, that use is not FDA-approved (this is true of most psychiatric approved (this is true of most psychiatric medications)medications)

Off label use is often consistent with the Off label use is often consistent with the standard of carestandard of care

There may be evidence supporting the use There may be evidence supporting the use of a medication even absent FDA approvalof a medication even absent FDA approval

Off label use of many other medications is Off label use of many other medications is not uncommon in pediatric populationsnot uncommon in pediatric populations

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Potential side effects of Potential side effects of antipsychoticsantipsychotics

Weight gainWeight gain SedationSedation Dry mouth and problems urinatingDry mouth and problems urinating ““Nervousness” or restlessnessNervousness” or restlessness InsomniaInsomnia Tremors and muscle stiffnessTremors and muscle stiffness Movement disordersMovement disorders DiabetesDiabetes Elevations in cholesterol and triglyceridesElevations in cholesterol and triglycerides Menstrual changes and excessive breast milk productionMenstrual changes and excessive breast milk production Cardiac conduction effects and ECG changesCardiac conduction effects and ECG changes Neuroleptic Malignant Syndrome (fever, stiffness—Neuroleptic Malignant Syndrome (fever, stiffness—

potentially fatal)potentially fatal) Rare reports of fatalities in children treated with Rare reports of fatalities in children treated with

antipsychotics—causality not necessarily provenantipsychotics—causality not necessarily proven

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Examples of potential Examples of potential problems with problems with antipsychoticsantipsychotics

1.1. Olanzapine-induced diabetes. Olanzapine-induced diabetes. 2.2. Quetiapine-associated diabetes. Quetiapine-associated diabetes. 3.3. Olanzapine-induced weight gainOlanzapine-induced weight gain4.4. Risperidone-induced Risperidone-induced

galactorrhea (breast milk galactorrhea (breast milk production)production)

5.5. Ziprasidone-induced tardive Ziprasidone-induced tardive dyskinesiadyskinesia

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Example of a troubling case Example of a troubling case involving a preschooler on an involving a preschooler on an

antipsychoticantipsychotic 3 year-old male outpatient diagnosed with 3 year-old male outpatient diagnosed with

Intermittent Explosive Disorder and AutismIntermittent Explosive Disorder and Autism Records indicated he had a history of Records indicated he had a history of

severe ear infections and only responded to severe ear infections and only responded to conversation if he looked at the speaker’s conversation if he looked at the speaker’s faceface

No hearing evaluation was referred to or No hearing evaluation was referred to or present in the recordspresent in the records

Treated with trazadone, clonidine, lexapro, Treated with trazadone, clonidine, lexapro, and olanzapineand olanzapine

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Preschool Psychopharmacology Preschool Psychopharmacology Working GroupWorking Group

Gleason, et al., Gleason, et al., JAACAPJAACAP, 46:12, December , 46:12, December 20072007

Reviewed available literature and made recommendations Reviewed available literature and made recommendations regarding the psychopharmacologic treatment of preschool regarding the psychopharmacologic treatment of preschool childrenchildren

Acknowledged the very limited literature in this age groupAcknowledged the very limited literature in this age group

Developed algorithms for ADHD, Major Depressive Disorder, Developed algorithms for ADHD, Major Depressive Disorder, Anxiety Disorders, Posttraumatic Stress Disorder, Obsessive-Anxiety Disorders, Posttraumatic Stress Disorder, Obsessive-Compulsive Disorder, Primary Sleep Disorders, Compulsive Disorder, Primary Sleep Disorders, Disruptive Disruptive Behavior Disorders, Bipolar Disorder, and Pervasive Behavior Disorders, Bipolar Disorder, and Pervasive Developmental DisordersDevelopmental Disorders

Emphasized the importance of Emphasized the importance of psychosocial interventions psychosocial interventions before medications are utilizedbefore medications are utilized in part to better support in part to better support the development of emotional and behavioral self-regulationthe development of emotional and behavioral self-regulation

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Preschool Psychopharmacology Preschool Psychopharmacology Working Group (cont.)Working Group (cont.)

Disruptive Behavior Disorders Algorithm-Disruptive Behavior Disorders Algorithm-- psychotherapy first (involving parents) - psychotherapy first (involving parents) --risperidonerisperidone only if aggression is severe and psychotherapeutic only if aggression is severe and psychotherapeutic interventions fail interventions fail -psychopharmacological interventions without psychotherapy is -psychopharmacological interventions without psychotherapy is notnot recommendedrecommended-chemical restraints and “prn” medications are -chemical restraints and “prn” medications are notnot recommended recommended

PDD Algorithm- PDD Algorithm- risperidone has an FDA indication age 5 and uprisperidone has an FDA indication age 5 and up

Bipolar Disorder Algorithm- Bipolar Disorder Algorithm- -psychotherapeutic interventions first -psychotherapeutic interventions first --risperidonerisperidone should be the first medication choice should be the first medication choice-mood stabilizers (lithium, Depakote) only if parents are highly reliable-mood stabilizers (lithium, Depakote) only if parents are highly reliable- psychopharmacological interventions without psychotherapy is - psychopharmacological interventions without psychotherapy is notnot recommendedrecommended-polypharmacy (using multiple medications) should be used with -polypharmacy (using multiple medications) should be used with extreme cautionextreme caution

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Arkansas Medicaid DataArkansas Medicaid Data

New processNew process Other states are Other states are beginningbeginning to do this to do this

but only a very few have published but only a very few have published any findings (Texas and Florida)any findings (Texas and Florida)

States are beginning to band States are beginning to band together with respect to how they together with respect to how they examine data so that comparisons examine data so that comparisons can be madecan be made

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The number of Medicaid-The number of Medicaid-covered Arkansas children covered Arkansas children

aged 0-18 who were aged 0-18 who were prescribed antipsychotic prescribed antipsychotic medications* in FY 2007:medications* in FY 2007:

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12,41812,418

* All Arkansas data for antipsychotic use excludes those with fewer than 2 * All Arkansas data for antipsychotic use excludes those with fewer than 2 claimsclaims

Comparison of the number of Medicaid-Comparison of the number of Medicaid-covered childrencovered children

Number of Medicaid Covered Children on Number of Medicaid Covered Children on Antipsychotics Antipsychotics

Arkansas (2008):Arkansas (2008):12,41812,418

Illinois (2005):Illinois (2005): 17,746*17,746*

Florida (2006):Florida (2006): 18,137**18,137**

*USA TODAY, May 2, 2006*USA TODAY, May 2, 2006

**Daytona Beach News-Journal, May 30, 2008**Daytona Beach News-Journal, May 30, 2008

Population under age 18 (2006, Population under age 18 (2006, estimated)estimated)

691,475691,475

3,220,8243,220,824

4,015,9554,015,955

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Medicaid-covered children who Medicaid-covered children who received antipsychoticsreceived antipsychotics

FY 2007FY 2007

0-4 years: 4720-4 years: 472

5-12 years: 6,3355-12 years: 6,335

13-18 years: 5,61113-18 years: 5,611

0-18 years: 12,4180-18 years: 12,418

FY 2008FY 2008

0-5 years:0-5 years: 893 893

6-12 years:6-12 years: 5,602 5,602

13-18 years:13-18 years: 4,909 4,909

0-18 years:0-18 years: 11,40411,404 (an 8% decrease in total numbers)(an 8% decrease in total numbers)

*Includes foster *Includes foster childrenchildren

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Medicaid-covered children who Medicaid-covered children who received antipsychotics received antipsychotics

(prescription rates)(prescription rates)FY 2007FY 2007

0-4 yrs: 0-4 yrs: 3.4/10003.4/1000

5-12 yrs: 5-12 yrs: 34.3/100034.3/1000

13-18 yrs: 13-18 yrs: 45.8/100045.8/1000

0-18 yrs: 0-18 yrs: 27.8/100027.8/1000

FY 2008FY 2008 Florida Florida 20052005**

0-5 yrs: 5.3/10000-5 yrs: 5.3/10000.9/10000.9/1000

6-12 yrs: 34.4/10006-12 yrs: 34.4/100016/100016/1000

13-18 yrs: 40.0/100013-18 yrs: 40.0/100025/100025/1000

0-18 yrs: 25.2/10000-18 yrs: 25.2/100012/100012/1000

*approximate, from graphs in Constantine and Larsen (2007)*approximate, from graphs in Constantine and Larsen (2007)

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The number of Arkansas The number of Arkansas foster children aged 0-18 foster children aged 0-18

who were prescribed who were prescribed antipsychotic medications antipsychotic medications

in FY 2007 and 2008in FY 2007 and 2008

2007:2007: 1,1041,104 of 6,078 of 6,078

20082008 :: 982 of 982 of 6,9576,957

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The rates of antipsychotic use The rates of antipsychotic use in Arkansas foster children in Arkansas foster children

aged 0-18aged 0-18FY 2007FY 2007

0-4 years:0-4 years: 23.6/1000 23.6/1000 3.4/1000*3.4/1000*

5-12 years:5-12 years: 225.4/1000225.4/1000 34.3/1000*34.3/1000*

13-18 years:13-18 years: 261.6/1000261.6/1000 45.8/1000*45.8/1000*

0-18 years:0-18 years: 181.6/1000181.6/1000 27.8/1000*27.8/1000*

-Medicaid rates-Medicaid rates

FY 2008FY 2008

0-5 years: 27.1/1000 0-5 years: 27.1/1000

5.3/1000*5.3/1000* (2-5 years: 43.5/1000)(2-5 years: 43.5/1000)

6-18 years: 216.5/10006-18 years: 216.5/100036.8/1000*36.8/1000*

0-18 years: 141.2/10000-18 years: 141.2/100025.9/1000*25.9/1000*

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Comparison of rates of Comparison of rates of antipsychotic use in foster antipsychotic use in foster

childrenchildren Texas (0-17 years) Texas (0-17 years)

FY 2005:FY 2005: 203.0/1000203.0/1000 children children (approximately)*(approximately)*

*from a report by the Texas Health and Human Services Commission, Department of *from a report by the Texas Health and Human Services Commission, Department of State Health Services, and Department of Family and Protective ServicesState Health Services, and Department of Family and Protective Services

ArkansasArkansas (0-18 years) (0-18 years)

FY 2007:FY 2007: 181.6/1000181.6/1000 children children

FY 2008:FY 2008: 141.2/1000141.2/1000 children children

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In which counties do children 0-4 In which counties do children 0-4 years who receive antipsychotics years who receive antipsychotics

live? live? (FY 2007)(FY 2007)1.1. PulaskiPulaski 6464

2.2. CraigheadCraighead 3232

3.3. GarlandGarland 2828

4.4. Green Green 2626

5.5. SalineSaline 2222

6.6. JeffersonJefferson 2020

7.7. LonokeLonoke 1919

8.8. MillerMiller 1818

8.8. MississippiMississippi 1818

10.10. UnionUnion 1414

11.11. RandolphRandolph 1313

12.12. WhiteWhite 1212

13.13. ClarkClark 1111

13.13. PoinsettPoinsett 1111

15.15. CrittendenCrittenden 9 9

15.15. SebastianSebastian 9 9

17.17. WashingtonWashington 8 8

18.18. BaxterBaxter 6 6

18.18. BentonBenton 6 6

18.18. ClayClay 6 6

18. 18. CrawfordCrawford 6 6

18.18. DeshaDesha 6 6

18.18. IndependenceIndependence 6 6

18.18. JohnsonJohnson 6 6

25.25. ChicotChicot 5 5

25.25. CrossCross 5 5

25.25. Hot SpringHot Spring 5 5

25.25. LawrenceLawrence 5 5

25.25. PolkPolk 5 5

25.25. YellYell 5 5

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In which counties do children 0-4 In which counties do children 0-4 years who receive antipsychotics years who receive antipsychotics

live? live? (FY 2007)(FY 2007)

31

Where do atypical antipsychotic prescriptions Where do atypical antipsychotic prescriptions

for preschoolers in Arkansas originate?for preschoolers in Arkansas originate? (FY (FY

2007)2007)1.1. Pulaski CountyPulaski County 1971972.2. UnknownUnknown 1291293.3. Craighead CountyCraighead County 1011014.4. Sebastian CountySebastian County 25 255.5. Garland CountyGarland County 20 206.6. Union CountyUnion County 18 187.7. Jefferson CountyJefferson County 16 168.8. Miller CountyMiller County 16 169.9. TexasTexas 16 1610.10. TennesseeTennessee 12 12

11.11. Lee CountyLee County 111112.12. White CountyWhite County 111113.13. Benton CountyBenton County 101014.14. Independence CountyIndependence County 8 815.15. Johnson CountyJohnson County 8 816.16. Saline CountySaline County 6 617.17. Faulkner CountyFaulkner County 5 518.18. Mississippi CountyMississippi County 5 519.19. St. Francis CountySt. Francis County 5 520.20. MissouriMissouri 5 5

Note: some children received Note: some children received prescriptions from more prescriptions from more than one countythan one county

32

Where do atypical antipsychotic prescriptions Where do atypical antipsychotic prescriptions

for preschoolers in Arkansas originate?for preschoolers in Arkansas originate? (FY (FY

2007)2007)

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Children’s Home CountyChildren’s Home County Prescription County of OriginPrescription County of Origin

34

Facts about those who prescribed Facts about those who prescribed atypical antipsychotics for preschoolers atypical antipsychotics for preschoolers

in FY 2007in FY 2007 243 providers wrote atypical antipsychotic 243 providers wrote atypical antipsychotic

prescriptions for 472 preschoolers in FY 2007.prescriptions for 472 preschoolers in FY 2007.

Most prescriptions were written by psychiatrists.Most prescriptions were written by psychiatrists.

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Psychiatric Diagnoses of Medicaid-Psychiatric Diagnoses of Medicaid-covered 0-5 year-olds receiving covered 0-5 year-olds receiving

Risperidone (Risperdal)Risperidone (Risperdal)1.1. ADHDADHD 2352352.2. Unspecified Disturbance of ConductUnspecified Disturbance of Conduct 1461463.3. Speech/Language DisorderSpeech/Language Disorder 1131134.4. Developmental DelayDevelopmental Delay 1121125.5. Parent-Child Relational ProblemParent-Child Relational Problem 59 596.6. Oppositional Defiant DisorderOppositional Defiant Disorder 53 537.7. Autism Autism 44 448.8. Adjustment DisorderAdjustment Disorder 43 439.9. Other Emotional DisturbanceOther Emotional Disturbance 33 3310.10. PsychosisPsychosis 29 2911.11. Bipolar DisorderBipolar Disorder 25 2512.12. PTSD/AnxietyPTSD/Anxiety 17 1713.13. Int. Explosive disorder/Impulse D/O NOSInt. Explosive disorder/Impulse D/O NOS 16 1614.14. Mental RetardationMental Retardation 15 1515.15. Conduct Disorder/Childhood Antisocial BehaviorConduct Disorder/Childhood Antisocial Behavior 14 1416.16. Depressive Disorder NOSDepressive Disorder NOS 9 9

Diagnoses do not necessarily represent the primary diagnosisDiagnoses do not necessarily represent the primary diagnosisFY2007FY2007

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Psychiatric Diagnoses of Medicaid-Psychiatric Diagnoses of Medicaid-covered 0-5 year-olds receiving covered 0-5 year-olds receiving

Aripiprazole (Abilify)Aripiprazole (Abilify)1.1. ADHDADHD 86862.2. Unspecified Disturbance of ConductUnspecified Disturbance of Conduct 59593.3. Speech/Language DisordersSpeech/Language Disorders 40404.4. Oppositional Defiant DisorderOppositional Defiant Disorder 34345.5. Parent-Child Relational ProblemParent-Child Relational Problem 28286.6. Bipolar DisorderBipolar Disorder 24247.7. Developmental DelayDevelopmental Delay 26268.8. PsychosisPsychosis 17179.9. Adjustment DisorderAdjustment Disorder 121210.10. AutismAutism 8 811.11. PTSD/AnxietyPTSD/Anxiety 7 712.12. Depressive Disorder NOSDepressive Disorder NOS 7 713.13. Mental RetardationMental Retardation 5 514.14. Conduct DisorderConduct Disorder 4 4

Diagnoses do not necessarily represent the primary diagnosisDiagnoses do not necessarily represent the primary diagnosis FY FY 20072007

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Why the increase in Why the increase in antipsychotic usage?antipsychotic usage?

There is currently no continuum of services in There is currently no continuum of services in most areas of the state.most areas of the state.

““Provider-rich” areas have limited openings.Provider-rich” areas have limited openings. Family’s need help “now.”Family’s need help “now.” Physician’s may attempt to do something to help Physician’s may attempt to do something to help

without proper attention to or access to without proper attention to or access to psychotherapeutic services.psychotherapeutic services.

There have been recent changes in diagnostic There have been recent changes in diagnostic patterns (Bipolar Disorder).patterns (Bipolar Disorder).

Sometimes they are used in a manner Sometimes they are used in a manner inconsistent with best practices.inconsistent with best practices.

Insufficient knowledge of psychopharmacologic Insufficient knowledge of psychopharmacologic issues by parents and guardians (including issues by parents and guardians (including risk/benefit ratios and treatment options, etc.).risk/benefit ratios and treatment options, etc.).

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What is currently being What is currently being done?done?

DHS will continue to examine data from DHS will continue to examine data from Medicaid and other sources to evaluate Medicaid and other sources to evaluate prescription practices and patterns for all prescription practices and patterns for all Medicaid eligible children and compare them Medicaid eligible children and compare them to data from other states’ data.to data from other states’ data.

DHS is currently reviewing the profiles of DHS is currently reviewing the profiles of preschoolers in DCFS custody who are preschoolers in DCFS custody who are receiving antipsychotics. Once that review is receiving antipsychotics. Once that review is complete, profiles of 6-12 and 13-18 year-olds complete, profiles of 6-12 and 13-18 year-olds may be examined.may be examined.

39

What is currently being What is currently being done? done? (cont.)(cont.)

DYS is currently working with UAMS DYS is currently working with UAMS to evaluate the medications of youth to evaluate the medications of youth in their custody.in their custody.

As of August 18, 2008:As of August 18, 2008: 93 youth had been evaluated93 youth had been evaluated 10 had medications decreased10 had medications decreased 9 had medications discontinued 9 had medications discontinued

altogetheraltogether

40

Where do we go from Where do we go from here?here?

Explore the use of a “call in” system Explore the use of a “call in” system whereby physicians may speak to a whereby physicians may speak to a child and adolescent psychiatrist for child and adolescent psychiatrist for guidance with younger and/or guidance with younger and/or difficult to treat patients.difficult to treat patients.

Explore the use of Telemedicine as a Explore the use of Telemedicine as a means of providing consultation to means of providing consultation to providers in underserved areas.providers in underserved areas.

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Where do we go from Where do we go from here? here? (cont.)(cont.)

Begin training programs for DHS Begin training programs for DHS staff who have consent authoritystaff who have consent authority

Consider implementation of DHS Consider implementation of DHS Psychotropic Medications and Psychotropic Medications and Children Team RecommendationsChildren Team Recommendations

42

House Committee on Ways and MeansHouse Committee on Ways and MeansJuly 19, 2007July 19, 2007

Dr. Michael W. Naylor, M.D., University of Illinois-Dr. Michael W. Naylor, M.D., University of Illinois-ChicagoChicago

Discussed Illinois DCFS’ “Centralized Psychotropic Discussed Illinois DCFS’ “Centralized Psychotropic Medication Consent Unit”:Medication Consent Unit”:DCFS contracted with U of Illinois at Chicago Dept. of DCFS contracted with U of Illinois at Chicago Dept. of Psychiatry to Psychiatry to

-provide independent medication reviews for psychotropic consents-provide independent medication reviews for psychotropic consents

-special consultation on difficult or complex cases-special consultation on difficult or complex cases

-notify DCFS when prescription patterns are suspect-notify DCFS when prescription patterns are suspect

-provide training for DCFS staff regarding psychotropic medication -provide training for DCFS staff regarding psychotropic medication managementmanagement

-disseminate information on new psychotropics and developments -disseminate information on new psychotropics and developments and/or alerts to physicians who treat DCFS wardsand/or alerts to physicians who treat DCFS wards

43

DHS Psychotropic Medications and DHS Psychotropic Medications and Children Team: Recommendations for Children Team: Recommendations for

Youth in State CustodyYouth in State Custody

1.1. Establish policies and procedures to guide the Establish policies and procedures to guide the psychotropic medication management of youth psychotropic medication management of youth in state custody including:in state custody including:

a. identify parties empowered to provide a. identify parties empowered to provide consent in a timely mannerconsent in a timely manner

b. develop training for child welfare, juvenile b. develop training for child welfare, juvenile justice justice providers, and court personnel in providers, and court personnel in addition to foster addition to foster parents to help them parents to help them become more effective become more effective advocates for advocates for children and youth in their custodychildren and youth in their custody

c. monitor the use of psychotropic medications c. monitor the use of psychotropic medications for both for both safety and effectivenesssafety and effectiveness

44

DHS Recommendations for DHS Recommendations for Youth in State Custody Youth in State Custody

(cont.)(cont.)2.2. Design and implement oversight Design and implement oversight

procedures to:procedures to:

a. examine the utilization of medications a. examine the utilization of medications for for youth in state custodyyouth in state custody

b. review DHS medication formulary on b. review DHS medication formulary on a a continual basis continual basis

c. provide medication monitoring c. provide medication monitoring guidelines to guidelines to practitioners who treat practitioners who treat children and youth in children and youth in the child welfare system the child welfare system

45

DHS Recommendations for DHS Recommendations for Youth in State Custody Youth in State Custody

(cont.)(cont.)3.3. Create a program to provide Create a program to provide

consultation to the persons and consultation to the persons and agencies responsible for agencies responsible for consenting for treatment with consenting for treatment with psychotropic medications in psychotropic medications in addition to or at the request of addition to or at the request of physicians treating children and physicians treating children and youth who are in state custody.youth who are in state custody.

46

DHS Recommendations for DHS Recommendations for Youth in State Custody Youth in State Custody

(cont.)(cont.)4.4. Develop a website, under the proposed DMS Develop a website, under the proposed DMS

Monitoring Unit, to provide ready access for Monitoring Unit, to provide ready access for clinicians, foster parents, and other caregivers clinicians, foster parents, and other caregivers to pertinent policies and procedures governing to pertinent policies and procedures governing psychotropic medications management, psychotropic medications management, psychoeducational materials, consent forma, psychoeducational materials, consent forma, adverse side effect information, reports on adverse side effect information, reports on prescription patterns, and links to helpful, prescription patterns, and links to helpful, accurate, and ethical websites about child and accurate, and ethical websites about child and adolescent psychiatric diagnoses and adolescent psychiatric diagnoses and psychotropic medications.psychotropic medications.

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SourcesSources

Constantine, R, Larsen B (2007). The Use of Constantine, R, Larsen B (2007). The Use of Antipsychotic Medications in Children: A Antipsychotic Medications in Children: A Comprehensive and Current View. Tampa, FL: Comprehensive and Current View. Tampa, FL: Louis de la Parte Florida Mental Health Institute. Louis de la Parte Florida Mental Health Institute. University of South Florida.University of South Florida.

““Use of Psychoactive Medication in Texas Foster Use of Psychoactive Medication in Texas Foster Children State Fiscal Year 2005,” prepared by Children State Fiscal Year 2005,” prepared by the Texas Health and Human Services the Texas Health and Human Services Commission, Department of State Health Commission, Department of State Health Services, and Department of Family and Services, and Department of Family and Protective Services. June 2006.Protective Services. June 2006.

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