Getting It Right: Improving Access to Behavioral Health Services and the Appropriate Use of Psychotropic Medication for Children and Youth Kamala D. Allen, MHS, Center for Health Care Strategies Christopher Bellonci, MD, Tufts University School of Medicine and Judge Baker Children's Center John H. Straus, MD, Massachusetts Behavioral Health Partnership
Agenda • Introductions and Context Setting Kamala Allen, MHS • Trends in the Use of Psychotropic Medications for Children and Youth with Behavioral Health Challenges Christopher Bellonci, MD • Children in Foster Care and Psychotropic Medications: A Special Needs Population Kamala Allen, MHS • Building a Psychiatric Consultation Program: Lessons from Massachusetts and Beyond John Straus, MD • Implications for Practice Christopher Bellonci, MD • Question and Answer
Le Learning Objectives 1. Understand the nature of behavioral health service use and expense for children and youth. 2. Understand trends in the use of psychotropic medications. 3. Understand the concern regarding psychotropic medication use, and populations at highest risk. 4. Understand the role of effective oversight and monitoring of psychotropic medications use. 5. Become familiar with the key characteristics of Child Psychiatry Access Programs through the Massachusetts model. 6. Become aware of the potential impacts of Child Psychiatry Access Programs on psychotropic prescribing.
What’s the Problem?
Behavioral l Healt lth Car are for Child ildren, Youth, an and You oung Adult lts: Federal Gu Guid idance • An estimated 1 in 5 children in Medicaid have a behavioral health diagnosis, 1 but only 1 in 10 receive services. 2 • States must meet obligations under the Americans with Disabilities Act and Medicaid’s EPSDT. • Home- and community-based services are efficacious and cost-effective. Sources: 1. MACPAC, June 2015. 2. Pires, McLean, Allen. Faces of Medicaid: Children’s Behavioral Health Care Utilization and Expenditures, Center for Health Care Strategies, 2018.
Chan anges in in th the Nu Number of of Child ildren Receiv iving Psychotropic Medications 20 2005 05 – 20 2011 11 2,157,045 1,843,734 1,686,387 Approximately 28% more children receiving psych meds 17% increase from 2008-2011 9% increase from 2005-2008 2011 2005 2008 2005 2008 2011 Source: Pires, et al. Faces of Medicaid: Children’s Behavioral Health Care Utilization and Expenditures, Center for Health Care Strategies, 2018. 6
Chan anges in in Psychotropic Medication Expendit itures, 20 2005 05 – 20 2011 11 $2,726,520,045 $2,202,732,411 $1,602,793,310 70% Increase from 2005 to 2011 24% increase from 2008-2011 37% increase from 2005-2008 2011 2008 2005 2005 2008 2011 Source: Pires, McLean, Allen. Faces of Medicaid: Children’s Behavioral Health Care Utilization and Expenditures, Center for Health Care Strategies, 2018. 7
Chan anges in in th the Receip ipt of of Psychotropic Medications with ith an and with ithout BH Se Services 2005 2011 2008 w/ 51% 49% 53% 857,376 900,220 1,134,722 Psych meds with services 49% 51% 47% 4% 829,011 943,514 1,022,323 Psych meds only Total children receiving psych 1,686,387 1,843,734 2,157,045 meds Source: Pires, McLean, Allen. Faces of Medicaid: Children’s Behavioral Health Care Utilization and Expenditures, Center for Health Care Strategies, 2018. 8
Key Medicaid Fin Findin ings regardin ing Psychotropic Medications fr from 20 2005 05-2011 2011 • The number of children receiving psychotropic medications increased • Particularly among young children (0 – 5 years) • Concurrent use of psychotropic medication decreased but remains an area of concern • Children in foster care remain a vulnerable population • Higher rates of concurrent use of psychotropic medication and use of antipsychotics • Expenditures for psychotropic medications increased • Driven by ADHD medications and antipsychotics • Remains one of the biggest drivers of behavioral health expenses Source: Pires, McLean, Allen. Faces of Medicaid: Children’s Behavioral Health Care Utilization and Expenditures, Center for Health Care Strategies, 2018. 9
A Com omplex Iss Issue • Medications used to control difficult behaviors • Financial incentives drive prescribing • Aggressive/effective pharmaceutical marketing • Need for “quick fixes” • Insufficient access to… • Psychosocial interventions • Behavioral health specialists • Need for better… • Knowledge re: appropriate psychotropic use • Coordination across providers and among child-serving systems 10
Trends in in th the Use se of of Psychia iatric Medications for Child ildren an and You outh: : Im Implications for or Practice Christopher Bellonci, M.D. Adjunct Associate Professor, Tufts University School of Medicine Vice President of Policy and Practice, Chief Medical Officer, Judge Baker Children’s Center cbellonci@jbcc.harvard.edu The University of Maryland Training Institutes Washington, DC July 27, 2018
Disclosures • No Pharma conflicts of interest • Medical Director of the National Technical Assistance Center for Children’s Behavioral Health (funded by SAMHSA) • Sub-PI on Grant from ACF to Develop Best Practices to support LGBT Youth in Foster Care
Introduction • Over the last decade there has been an exponential increase in the use of psychotropic medications prescribed for emotional and behavioral disorders in children, particularly preschoolers. • Research into the effects of these medications lags behind prescribing trends. • These trends and the lack of research to support current practice have important implications for our work with children.
Antipsychotic medications • Use of antipsychotic medications is amongst the fastest growing class of psychiatric medications. • Use in Medicaid-enrolled Children age 3-18 grew 62% between 2002 and 2007; • 354,000 children in 2007 were taking a second- generation antipsychotic (SGA). • Evidence to support this increase for most conditions remains limited. • ADHD is the most common diagnosis (39%, Bipolar 11%, ADHD and Bipolar 12%). • (Meredith Matone, David Rubin, Policy Lab at CHOP, 2012)
Polypharmacy • Between 2004-2008, for youth age 6-18: • SGA use increased 22%; • 85% of the use was concurrent with another psychiatric medication; • Polypharmacy occurred for long periods (69-89% of annual medication days) • Most significant increases over time occurred in youth who had not been hospitalized, were not in foster care or on disability or had intellectual disability. • Meaning concurrent use of SGAs with other psych meds is increasing disproportionately among youth with less perceived comorbidity and impairment and an overall growth in off-label prescribing for whom evidence of benefit is lacking . (J. Am. Acad. Child Adolesc. Psychiatry 2014:53:9: 960-70 )
Variability in Prescribing Practices • There is every indication these rates have continued or accelerated since this data was reported. • Children in the Child Welfare system are being prescribed psychiatric medications at an even higher rate. • Rates of antipsychotic use increased from 8.9% in 2002 to 11.8% in 2007 (range from 2.8% in HI to 21.7% in TX). (Rubin, et. al. Children and Youth Services Review , 34(6), 2012)
Trends in Prescribing Practices- Child Welfare The few research studies available show rates of psychotropic medication use ranging from 13%-50% among children in foster care (J Child Adolesc Psychopharmacol. 1999:9:3: 135-47 and 2006:16:4: 474-481; Peds 2008:121:1; e157-e163)
Lack of Safety and Efficacy Studies of Psychotropic medications for children • Brain continues to develop through adolescence • Impact of adding psychoactive medications to a developing brain is unknown • Medications that were safe for use in adults that had unanticipated side-effects for children: • Tetracycline > dental discoloration • Second-generation antipsychotics > wt gain • Aspirin > Reye’s syndrome • FDA guidelines do not limit prescribing practice. • Medications are developed privately by Pharmaceutical companies. • FDA requires safety and efficacy studies for target population and target purpose only.
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