Health-care costs of pediatric clients developing adverse events during treatment with antipsychotics

Variation of the prevalence of pediatric polypharmacy: A scoping review

PURPOSE

To examine the range of prevalence of pediatric polypharmacy in literature through a scoping review, focusing on factors that contribute to its heterogeneity in order to improve the design and reporting of quality improvement, pharmacovigilance, and research studies.

METHODS

We searched Ovid Medline, PubMed, EMBASE, CINAHL, Ovid PsycINFO, Cochrane CENTRAL, and Web of Science Core Collection databases for studies with concepts of children and polypharmacy, along with a hand search of the bibliographies of six reviews and 30 included studies. We extracted information regarding study design, disease conditions, and prevalence of polypharmacy.

RESULTS

Two hundred eighty-four studies reported prevalence of polypharmacy. They were more likely to be conducted in North America (37.7%), published after 2010 (44.4%), cross-sectional (67.3%), in outpatient settings (59.5%). Prevalence ranged from 0.9% to 98.4%, median 39.7% (interquartile range [IQR] 22.0%-54.0%). Studies from Asia reported the highest median prevalence of 45.4% (IQR 27.3%-61.0%) while studies from North America reported the lowest median prevalence of 30.4% (IQR 14.7%-50.2%). Prevalence decreased over time: median 45.6% before 2001, 38.1% during 2001 to 2010, and 34% during 2011 to 2017. Studies involving children under 12 years had a higher median prevalence (46.9%) than adolescent studies (33.7%). Inpatient setting studies had a higher median prevalence (50.3%) than studies in outpatient settings (38.8%). Community level samples, higher number and duration of medications defining polypharmacy, and psychotropic medications were associated with lower prevalence.

CONCLUSIONS

The prevalence of pediatric polypharmacy is high and variable. Studies reporting pediatric polypharmacy should account for context, design, polypharmacy definition, and medications evaluated.

Access to Psychosocial Services Prior to Starting Antipsychotic Treatment Among Medicaid-Insured Youth

OBJECTIVE

To examine rates and predictors of receiving a psychosocial service before initiating antipsychotic treatment among young people in the Medicaid program.

METHOD

A retrospective new-user cohort study of 8 state Medicaid programs focused on children and adolescents 0 to 20 years, initiating antipsychotic treatment (N = 24,372). The proportion receiving a psychosocial service in the 3 months before initiating antipsychotic treatment was calculated and stratified by socio-demographic and diagnostic characteristics arranged in 9 hierarchical groups, as follows: developmental, psychotic/bipolar, disruptive, attention-deficit/hyperactivity, obsessive-compulsive, stress, major depressive, anxiety, and other disorders.

RESULTS

Less than one-half of youth received a psychosocial service before initiating antipsychotic treatment (48.8%). Compared to younger adolescents (12-17 years) initiating antipsychotic treatment (51.5%), corresponding younger children (0-5 years; 39.2%) and older adolescents (18-20 years; 40.1%), but not older children (6-11 years; 51.5%), were significantly less likely to have received a psychosocial service. In relation to youth diagnosed with psychotic or bipolar disorder (52.7%), those diagnosed with attention-deficit/hyperactivity (43.3%), developmental (41.4%), depressive (46.5%), or anxiety (35.6%) disorder were significantly less likely to have received a psychosocial service during the 3 months before antipsychotic initiation. By contrast, youth diagnosed with stress disorders (61.2%) were significantly more likely than those diagnosed with psychotic or bipolar disorders (52.7%) to have received a psychosocial service before starting an antipsychotic.

CONCLUSION

A majority of Medicaid-insured youth initiating antipsychotic treatment have not received a psychosocial service in the preceding 3 months. This service pattern highlights a critical gap in access to psychosocial services.

[Simulation and data mining model for identifying and prediction budget changes in the care of patients with hypertension]

Objective To present a simulation model that establishes the economic impact to the health care system produced by the diagnostic evolution of patients suffering from arterial hypertension. Methodology The information used corresponds to that available in Individual Health Records (RIPs, in Spanish). A statistical characterization was carried out and a model for matrix storage in MATLAB was proposed. Data mining was used to create predictors. Finally, a simulation environment was built to determine the economic cost of diagnostic evolution. Results 5.7 % of the population progresses from the diagnosis, and the cost overrun associated with it is 43.2 %. Conclusions Results shows the applicability and possibility of focussing research on establishing diagnosis relationships using all the information reported in the RIPS in order to create econometric indicators that can determine which diagnostic evolutions are most relevant to budget allocation.

Are non-serious adverse reactions to psychiatric drugs really non-serious?

OBJECTIVE

The EudraVigilance Pharmacovigilance system classifies the seriousness of adverse drug reactions (ADRs) based on the requirement of hospital care. To date, no systematic study has been conducted on the impact of non-serious ADRs, in terms of therapy continuation and course of the underlying disease. We analyzed a pediatric population receiving psychiatric care and subjected to drug treatment, to assess whether non-serious ADRs do or do not have a relevant clinical impact.

METHODS

Data from a 1 year period were collected, which included: Administered drugs, choices made to manage the ADRs, the long-term (6 month) effect of these interventions on the course of the reaction, and their impact on the drug treatment for the underlying pathology.

RESULTS

Observed ADRs were concordant with those previously described for the same drug classes, and mainly comprised alterations of behavior, mood, and sleep (53%) and excessive variations of appetite and body weight (39%). The type of drug influenced the management decision, as we found that drug discontinuation was the most frequent strategy employed to resolve ADRs, especially with drugs employed in the treatment of attention-deficit/hyperactivity disorders (63%, p<0.05), whereas management of antipsychotics mainly relied upon drug substitution (21%, p<0.01). Also, the type of ADR influenced the management decision, as alterations of behavior, mood, and sleep were seldom managed by maintaining the drug unchanged (10%, p<0.05), at variance with appetite/weight alteration ADRs (unchanged in 41%, p<0.01). Follow-up information revealed that drug discontinuation was most efficient at treating ADRs (no persistent ADRs, p<0.01), but had a severe impact on the course of the underlying psychiatric disease. Conversely, management of ADRs by maintaining the original drug even if at different dosage did not lead to an amelioration of the reactions; however, as it caused a significant clinical improvement (83%, p<0.04) that superseded the ADR in terms of clinical benefit.

CONCLUSIONS

These data suggest that the best strategy to improve both ADR management and the clinical course of patients is to limit, whenever possible, changes to the original therapy. Optimization of the actual therapeutic regimes also might benefit from development of specific pharmacokinetic and pharmacodynamic monitoring programs.

Treatment of early-onset schizophrenia

PURPOSE OF REVIEW

Treatment of children who develop schizophrenia in childhood and early adolescence presents unique considerations. There has been increasing attention to the importance of early intervention and whether treatment effects may be affected by brain development.

RECENT FINDINGS

Several recent trials support the use of antipsychotics for treatment of schizophrenia in children and adolescents. Clozapine shows greater efficacy in children and adolescents than it has in adults. A large-scale trial comparing a first-generation antipsychotic (molindone) with newer agents did not find significant differences in treatment response, although the newer antipsychotics were associated with more severe weight gain. Data regarding effects of antipsychotics on brain development in children and young adolescents with schizophrenia are sparse, although one report found no difference between effects of clozapine and olanzapine on cortical thickness.

SUMMARY

Although psychosocial interventions are an important adjunctive treatment, antipsychotic medications continue to be the mainstay of treatment. Careful monitoring of metabolic side effects and age-appropriate intervention is particularly important, as children and adolescents appear to be more likely to develop metabolic abnormalities such as pronounced weight gain, which may significantly impact adherence as well as lead to other health issues.