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Hulvershorn L, Parkhurst S, Jones S, Dauss K, Adams C. Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility. J Child Adolesc Psychopharmacol 2017; 27:897-907. [PMID: 28880609 DOI: 10.1089/cap.2017.0040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital. METHODS The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge. RESULTS Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores. CONCLUSION Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.
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Affiliation(s)
- Leslie Hulvershorn
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Samantha Parkhurst
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Shannon Jones
- 2 Evansville Psychiatric Children's Center , Indiana Family and Social Services Agency, Evansville, Indiana
| | - Kristin Dauss
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Caitlin Adams
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
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Mann A, Li A, Radwan K, Karnik NS, Keenan K. Factors Associated with Management of Teen Aggression: Child Psychiatric Clinical Decision Making. J Child Adolesc Psychopharmacol 2017; 27:445-450. [PMID: 26784955 DOI: 10.1089/cap.2015.0059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study explores whether patient-specific and clinician-specific factors are associated with child psychiatrists' use of second generation antipsychotics (SGAs) in the management of aggression in children with attention-deficit/hyperactivity disorder (ADHD). The patient-specific factors included patient's race, caregiver status, and patient engagement in psychotherapy. METHODS Child psychiatrists attending an annual conference (n = 156) were asked to complete an anonymous questionnaire on clinical decision making. Each participant was randomized to one of eight vignettes on a physically aggressive male teenager with methylphenidate-responsive ADHD. Patient race, caregiving status, and patient engagement in psychotherapy were systematically varied. Respondents rated how likely they were to prescribe an SGA and whether they would adjust the patient's current medication. RESULTS Seventy-five percent of participants (n = 117) were uncomfortable with adding an SGA, and 61% (n = 95) were likely to make medication adjustments to the current stimulant. None of the patient-specific factors were related to management recommendations. However, inpatient psychiatrists compared with non-inpatient psychiatrists reported a higher likelihood of using antipsychotics (OR = 2.40, 95% CI [1.181, 4.879], p = 0.016). Midwestern psychiatrists compared with those from other regions also reported a higher likelihood of using antipsychotics (OR = 3.07, 95% CI [1.376, 6.857], p = 0.005). Academic psychiatrists compared with nonacademics were less likely to endorse making adjustments to the current medication regimen (OR = 0.49, 95% CI [0.860, 0.274], p = 0.013). CONCLUSIONS When presented with a hypothetical case, the vast majority of child psychiatrists surveyed advised that additional information was needed before adding an SGA. Many felt the need for more psychosocial information and greater clarity of possible comorbid diagnoses.
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Affiliation(s)
- Andrea Mann
- 1 Department of Psychiatry, Stanford University School of Medicine , Stanford, California
| | - Ang Li
- 2 Department of Statistics, The University of Chicago , Chicago, Illinois
| | - Karam Radwan
- 3 Department of Psychiatry and Behavioral Neuroscience, The University of Chicago , Chicago, Illinois
| | - Niranjan S Karnik
- 4 Department of Psychiatry, Rush University Medical Center , Chicago, Illinois
| | - Kate Keenan
- 3 Department of Psychiatry and Behavioral Neuroscience, The University of Chicago , Chicago, Illinois
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Huskamp HA, Horvitz-Lennon M, Berndt ER, Normand SLT, Donohue JM. Patterns of Antipsychotic Prescribing by Physicians to Young Children. Psychiatr Serv 2016; 67:1307-1314. [PMID: 27417891 PMCID: PMC5133161 DOI: 10.1176/appi.ps.201500224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Antipsychotic use among young children has grown rapidly despite a lack of approval by the U.S. Food and Drug Administration (FDA) for broad use in this age group. Characteristics of physicians who prescribed antipsychotics to young children were identified, and prescribing patterns involving young children and adults were compared. METHODS Physician-level prescribing data from IMS Health's Xponent database were linked with American Medical Association Masterfile data and analyzed. The sample included all U.S. psychiatrists and a random sample of 5% of family medicine physicians who wrote at least ten antipsychotic prescriptions per year from 2008 to 2011 (N=31,713). Logistic and hierarchical binomial regression models were estimated to examine physician prescribing for children ages zero to nine, and the types and numbers of ingredients used for children versus adults ages 20 to 64 were compared. RESULTS Among antipsychotic prescribers, 42.2% had written at least one antipsychotic prescription for young children. Such prescribing was more likely among physicians age ≤39 versus ≥60 (odds ratio [OR]=1.70) and physicians in rural versus nonrural areas (OR=1.11) and was less likely among males (OR=.93) and graduates of a top-25 versus a lower-ranked U.S. medical school (OR=.87). Among physicians who prescribed antipsychotics to young children and adults, 75.0% of prescriptions for children and 35.7% of those for adults were for drugs with an FDA-approved indication for that age. Fewer antipsychotic agents were prescribed for young children (median=2) versus adults (median=7). CONCLUSIONS Prescribing antipsychotics for young children was relatively common, but prescribing patterns differed between young children and adults.
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Affiliation(s)
- Haiden A Huskamp
- Dr. Huskamp and Dr. Normand are with the Department of Health Care Policy, Harvard Medical School, Boston (e-mail: ). Dr. Horvitz-Lennon is with the RAND Corporation, Boston. Dr. Berndt is with the MIT Sloan School of Management, Cambridge, Massachusetts. Dr. Donohue is with the Health Policy and Management Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
| | - Marcela Horvitz-Lennon
- Dr. Huskamp and Dr. Normand are with the Department of Health Care Policy, Harvard Medical School, Boston (e-mail: ). Dr. Horvitz-Lennon is with the RAND Corporation, Boston. Dr. Berndt is with the MIT Sloan School of Management, Cambridge, Massachusetts. Dr. Donohue is with the Health Policy and Management Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
| | - Ernst R Berndt
- Dr. Huskamp and Dr. Normand are with the Department of Health Care Policy, Harvard Medical School, Boston (e-mail: ). Dr. Horvitz-Lennon is with the RAND Corporation, Boston. Dr. Berndt is with the MIT Sloan School of Management, Cambridge, Massachusetts. Dr. Donohue is with the Health Policy and Management Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
| | - Sharon-Lise T Normand
- Dr. Huskamp and Dr. Normand are with the Department of Health Care Policy, Harvard Medical School, Boston (e-mail: ). Dr. Horvitz-Lennon is with the RAND Corporation, Boston. Dr. Berndt is with the MIT Sloan School of Management, Cambridge, Massachusetts. Dr. Donohue is with the Health Policy and Management Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
| | - Julie M Donohue
- Dr. Huskamp and Dr. Normand are with the Department of Health Care Policy, Harvard Medical School, Boston (e-mail: ). Dr. Horvitz-Lennon is with the RAND Corporation, Boston. Dr. Berndt is with the MIT Sloan School of Management, Cambridge, Massachusetts. Dr. Donohue is with the Health Policy and Management Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
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Saloner B, Matone M, Kreider AR, Budeir MS, Miller D, Huang YS, Raghavan R, French B, Rubin D. Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health. Psychiatr Serv 2014; 65:1458-64. [PMID: 25179737 PMCID: PMC4757898 DOI: 10.1176/appi.ps.201300574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures. METHODS Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates. RESULTS With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics. CONCLUSIONS Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.
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Affiliation(s)
- Brendan Saloner
- Dr. Saloner is with the Department of Health Care Policy, Johns Hopkins University, Baltimore (e-mail: ). Ms. Matone, Ms. Kreider, Mr. Budeir, Ms. Miller, and Dr. Rubin are with PolicyLab, Children's Hospital of Philadelphia, Philadelphia. Dr. Rubin is also with the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Ms. Huang is with Division of General Pediatrics and Healthcare Analytics Unit, Children's Hospital of Philadelphia. Dr. Raghavan is with the George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri. Dr. French is with the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
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Domino ME, Beadles CA. State Investments in Psychiatric Innovation: Investigating Unmeasured State Factors. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2014; 14:34-53. [PMID: 25395878 PMCID: PMC4226516 DOI: 10.1007/s10742-014-0116-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We apply three separate panel data estimation methods to examine the diffusion of technologies at the state-level. These methods include the Hausman-Taylor random effects model, the fixed effects vector decomposition (FEVD), and generalized estimating equations (GEE). We discuss the assumptions required of each and assess the stability of our policy results across the three models for a longitudinal study of the diffusion of newer psychotropic technologies. We find a reasonable level of consistency among marginal effects for time varying independent variables between our three estimation methods but some discrepancy in the estimated measure of precision in our empirical application. We find a number of policy conclusions are quite stable across estimation methods and may be of interest to state-level mental health policy decision makers.
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Affiliation(s)
- Marisa Elena Domino
- Department of Health Policy and Management, UNC Gillings School of
Global Public Health
- Cecil G. Sheps Center for Health Services Research, University of
North Carolina at Chapel Hill
| | - Christopher Alan Beadles
- Department of Health Policy and Management, UNC Gillings School of
Global Public Health
- Center for Health Services Research in Primary Care, Department of
Veterans Affairs
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Miller L, Riddle MA, Pruitt D, Zachik A, dosReis S. Antipsychotic treatment patterns and aggressive behavior among adolescents in residential facilities. J Behav Health Serv Res 2013; 40:97-110. [PMID: 23319375 PMCID: PMC3637837 DOI: 10.1007/s11414-012-9314-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study examined the association between acute aggressive behavior patterns of 145 adolescents in residential treatment facilities with use of and changes in antipsychotic medication for the chronic management of aggression. Seclusion/restraint (S/R) frequency over 12 months was used to categorize youth into none, low, moderate, and high S/R groups. Data were analyzed using longitudinal mixed effects logistic regression models that allowed for intra-subject variability over time. The high and moderate S/R groups were significantly more likely to receive antipsychotics, get higher doses, and have changes in medication compared with the none S/R group. Increases in antipsychotic dose were associated with a lower likelihood of changes in antipsychotic medication over time. Despite persistent antipsychotic use at higher doses, youth in the high and moderate S/R groups continued to be secluded/restrained frequently. The findings question the adequacy of these medications in managing aggressive behavior.
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Affiliation(s)
- Leslie Miller
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry, Baltimore, MD, USA. Phone: +1-410-5509014; Fax: +1-410-5501302;
| | - Mark A. Riddle
- Johns Hopkins University School of Medicine, Division of Child and Adolescent Psychiatry, Baltimore, MD, USA. Phone: +1-410-9552321; Fax: +1-410-9558691;
| | - David Pruitt
- Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA. Phone: +1-410-3283522; Fax: +1-410-3280202;
| | - Al Zachik
- Maryl and Mental Hygiene Administration Spring Grove Hospital Center, Catonsville, MD, USA. Phone: +1-410-402848; Fax: +1-410-4028306;
| | - Susan dosReis
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, Room 01-220, Baltimore, MD 21201, USA. Phone: +1-410-7060807; Fax: +1-410-7065394;
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Handwerk ML, Smith GL, Thompson RW, Spellman DF, Daly DL. Psychotropic medication utilization at a group-home residential facility for children and adolescents. J Child Adolesc Psychopharmacol 2008; 18:517-25. [PMID: 18928416 DOI: 10.1089/cap.2008.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to examine psychotropic medication utilization over the course of treatment for children and adolescents admitted to a large residential group-home facility for youth with emotional and behavioral disorders. METHOD Retrospective analyses of psychotropic medication utilization at admission, during treatment, and at departure were examined for 1,010 children and adolescents consecutively admitted to the facility during 2001-2004. The relationship between psychotropic medication utilization and demographic variables, psychiatric diagnoses, objective measures of behavioral and emotional problems, in-program behavior, and ratings of program success were examined. RESULTS The overall utilization rate was 49%, and there was a significant reduction in utilization from admission (40%) to departure (26%). Reductions were evident across all medication classes (e.g., stimulants, antipsychotics, etc.). At admission, medication utilization was related to several psychosocial variables, higher scores on measures of behavioral and emotional problems, and psychiatric diagnoses (attention-deficit/hyperactivity disorder (ADHD) and mood disorders). A small percentage (16%) of youth was prescribed novel medication during stay. Being placed on medication during treatment was related to internalizing problems on the Child Behavior Checklist (CBCL) at admission, psychiatric diagnoses, higher rates of in-program behavior problems, and poorer outcomes at departure. Youth departing on medication were more likely to be male, younger, and rated as doing more poorly in the program. They also were more likely to be placed in more restrictive settings at follow-up. CONCLUSIONS There was a high rate of psychotropic medication utilization among this population, though utilization rates dropped significantly over the course of treatment.
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Affiliation(s)
- Michael L Handwerk
- Harrisburg Medical Center, Behavioral Health, Harrisburg, Illinois, USA.
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Haroun N, Dunn L, Haroun A, Cadenhead KS. Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. Schizophr Bull 2006; 32:166-78. [PMID: 16207892 PMCID: PMC2632176 DOI: 10.1093/schbul/sbj007] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Over the last decade schizophrenia researchers have turned their attention to earlier identification in the prodromal period of illness. A greater understanding of both risk and protective factors can lead to improved prevention and treatment strategies in this vulnerable population. This research, however, has far-reaching ethical implications. One year follow-up data from 50 individuals who met established criteria for a prodromal state is used to illustrate ethical issues that directly affect clinicians and future research strategies. At 1-year follow-up, the psychotic transition rate was 13%, but it increased in subsequent years with smaller sample sizes. One-half developed an affective psychosis. The converted sample was older (p > 0.05) than the nonconverted sample and more likely to have a premorbid history of substance abuse, as well as higher clinical ratings on "subsyndromal" psychotic items (delusional thinking, suspiciousness, and thought disorder). Despite a lack of conversion, the nonconverted sample remained symptomatic and had a high rate of affective and anxiety disorders with evidence of functional disability. This conversion rate is relatively low compared to similar studies at 1 year. Specific risk factors were identified, but these findings need to be replicated in a larger cohort. By examining the rate of conversion and nonconversion in this sample as an example, we hope to contribute to the discussion of implications for clinical practice and the direction of future research in the schizophrenia prodrome. Finally, our data strengthen the evidence base available to inform the discussion of ethical issues relevant to this important research area.
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Affiliation(s)
| | | | | | - Kristin S Cadenhead
- To whom correspondence should be addressed; Department of Psychiatry, 0810, University of California, San Diego, 9500 Gilman Drive, La Jolla CA 92093-0810; tel: 619-725-3537, fax: 619-260-8437, e-mail:
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