Trends in Antipsychotic Prescribing in Medicaid-Eligible Youth.

OBJECTIVE: To examine trends in the use of antipsychotic medication in Medicaid-eligible youth from 2008 to 2013 and the factors associated with this use. METHOD: Youth aged 0 to 17 years with at least one claim indicating antipsychotic medication use were identified from the network of a behavioral health managed care organization (BHMCO). Demographic and clinical variables were derived from state eligibility data and service claims data from the BHMCO. Overall and specific prevalence rates of antipsychotic drug use were calculated over the course of 6 years (2008-2013). The probability of antipsychotic use during 2013 was further explored with logistic regression that included demographic and diagnostic groups. RESULTS: The overall trend in prevalence for antipsychotics for youth decreased from 49.52 per 1,000 members in 2008 to 30.54 in 2013 (p < .0001). Although rates decreased for all age groups, the rate per 1,000 members in 2013 for the youngest children was 3.79, versus 39.23 for 6- to 12-year-olds and 64.33 for 13- to 17-year-olds. Controlling for demographic and clinical variables, children 0 to 5 years old were 79% less likely to be prescribed antipsychotic medications compared to the oldest youth, 13 to 17 years of age (p < .0001). Rates were higher for males versus females regardless of age (odds ratio [95% CI] =1.48 [1.36-1.62], p < .0001). Children with a diagnosis of attention-deficit/hyperactivity disorder were less likely to be prescribed antipsychotics compared to those with diagnoses of autism spectrum disorder, bipolar disorder, psychoses, and depression. CONCLUSION: Prevalence rates decreased significantly over time for all socio-demographic groups. The largest decrease was observed for the youngest children, ages 0 to 5 years, with a rate in 2013 under half the rate for 2008. Clinical, policy, and managed care implications are discussed.

Reducing Problematic Benzodiazepine Use Among Individuals Enrolled in Methadone Treatment Programs.

OBJECTIVE: The purpose of this study was to decrease problematic benzodiazepine (BZD) prescriptions provided to patients enrolled in methadone maintenance treatment (MMT) programs in an urban setting through a quality improvement intervention. METHODS: A prospective, interactive, feedback loop was used with 4 MMT providers over a period of 5 years (2009-2013) to help reduce the number of BZD prescriptions that clients were receiving from other providers. To track individuals who were receiving a BZD prescription from an outside provider, MMT medical teams were provided with patient-level Medicaid pharmacy claims data every month for 5 years. A technical assistance team, comprised of a medical director, pharmacists, data analysts, clinical, and management information staff at a behavioral health managed care organization experienced in MMT, met with each of the 4 MMT providers at several time points to devise methods of reducing problematic BZD prescriptions and engaging community medical providers. RESULTS: A total of 3464 Medicaid eligible adults were included in the quality improvement project over the 5-year period. The overall rate of BZD prescriptions provided to patients decreased significantly, from 37% at the beginning of 2009, to 27% at the end of 2013. Three out of the 4 MMT programs showed a significant decrease in BZD prescriptions among their participants. CONCLUSIONS: The 4 MMT providers involved in the study found the ongoing feedback loops valuable in the process of managing the health risks of their MMT patients.

Psychotropic prescribing for persons with intellectual disabilities and other psychiatric disorders.

OBJECTIVE: Prescribing patterns of psychotropic medication over a five-year period for Medicaid recipients (adults and children) with codiagnoses of an intellectual disability and a mental disorder were compared with patterns for those with sole mental disorder diagnoses. METHODS: Each group was identified through paid behavioral health services claims. Four classes of medications (antidepressants, antipsychotics, benzodiazepines, and mood stabilizers) were examined in paid pharmacy claims. Diagnostic categories, rates of psychotropic prescription, and polypharmacy (three or more medications concurrently for 90 days or more) were compared by age group (child or adult). RESULTS: Adults with mental disorders only (N=793 to 883; the range reflects the five study years) were prescribed antidepressants at a significantly higher rate compared with adults in the codiagnosis group (N=184 to 217). For three of the five study years, antipsychotics were prescribed to the sole-diagnosis group of adults at a significantly higher rate than to those with codiagnoses. Children in the group with codiagnoses (N=108 to 141) were prescribed mood stabilizers at a significantly higher rate than the comparison group (N=638 to 728) in all five study years. Rates of antipsychotics prescribed were not statistically different between the two groups of children. Polypharmacy rates for both adults and children were higher for the codiagnosis group compared with the group with a sole mental disorder, but the difference did not reach statistical significance. CONCLUSIONS: Psychotropic prescribing patterns in the two groups studied varied by class of medication and age. Although evidence exists for using psychotropics to treat psychopathology and challenging behaviors among individuals with intellectual disabilities, consideration of behavioral intervention alternatives and careful monitoring of psychotropic effectiveness and side effects are recommended.