Geographic variation and sociodemographic correlates of prescription psychotropic drug use among children and youth in Ontario, Canada: a population-based study

Association between a publicly funded universal drug program and antipsychotic and antidepressant medication dispensing to children

BACKGROUND

The prescribing of antidepressants and antipsychotics to children has increased worldwide, but little is known about how changes in drug funding policy influence the practice. In 2018, Ontario introduced a universal pharmacare program (OHIP+) for children and youth, amending it in April 2019 to cover only those without private insurance. We examined the association of these policy changes with antipsychotic and antidepressant medication prescribing.

METHODS

We conducted a population-based study of antidepressant and antipsychotic medication dispensing to children ≤ 18 years old between September 1, 2014, and February 29, 2020. We obtained dispensing data from the IQVIA Geographic Prescription Monitor database, and used interventional autoregressive integrated moving average models to examine whether the implementation of OHIP + and its subsequent revision were associated with changes in dispensing.

RESULTS

The implementation of OHIP + was not associated with changes in the rate of antidepressants (-19.3 units per 1,000 population; 95% confidence interval [CI]: -41.7 to 3.1) or antipsychotics (+ 1.0 unit per 1,000 population; 95% CI: -5.4 to 7.5) dispensed. Similarly, subsequent changes to the program restricting coverage to children without private insurance were not associated with antidepressant (0.3 units per 1,000; 95% CI: -7.4 to 7.9) or antipsychotic (1.0 units per 1,000; 95% CI: -0.9 to 2.9) dispensing trends.

CONCLUSION

Implementation of a publicly-funded pharmacare program did not influence trends in antidepressant or antipsychotic medication dispensing among children.

Temporal trends of the utilization patterns of sedative-hypnotic medications in children, adolescents and young adults: a 21-year population-based study with joinpoint regression analysis

BACKGROUND

There is limited research on real-world utilization patterns of benzodiazepines and Z-drugs (collectively-termed benzodiazepine-receptor agonists [BZRAs]) in children and adolescents, particularly in non-western countries. We aimed to examine temporal trends of BZRA prescribing-practice among children, adolescents and young adults in Hong Kong over a 21-year period.

METHODS

This population-based study identified 60,660 individuals aged 4-24 years who had redeemed ≥ 1 BZRA prescription within 2000-2020, using data from medical-record database of Hong Kong public-healthcare-services. We calculated annual prescription prevalence (per 1,000 persons per year) for any BZRA, BZRA-subtypes (short- and long-acting benzodiazepines, Z-drugs) and individual BZRAs. Joinpoint-regression analyses were performed to assess temporal BZRA prescription trends, quantified by average annual-percent-change (AAPC), with 95% confidence-intervals (CIs).

RESULTS

Overall BZRA prescription prevalence significantly increased (AAPC: 5.70% [95%CI: 5.31-6.54%]), from 1.88 in 2000 to 5.69 in 2020, uniformly across both sexes. Young adults (18-24 years-old) displayed the highest prescription prevalence, followed by adolescents (12-17 years-old) and children (4-11 years-old). Young adults and adolescents exhibited more pronounced increased BZRA use than children. Use of all BZRA subtypes consistently increased over time for all age-groups, except decline in Z-drug prescriptions in children. Lorazepam and diazepam represented the two most frequently-prescribed individual BZRAs, whereas alprazolam use showed the steepest increase. Anxiety and depression emerged as the most commonly-assigned diagnoses for BZRA-users.

CONCLUSION

This first Asian population-based study indicates a significant rising trend of BZRA prescriptions, especially among adolescents and young adults. Judicious prescribing-practices and further investigation clarifying factors contributing to increased BZRA use are warranted.

Childhood Opportunity Index and Low-Value Care in Children's Hospitals

BACKGROUND AND OBJECTIVE

Few studies have explored the relationship between social drivers of health and pediatric low-value care (LVC). We assessed the relationship between Childhood Opportunity Index (COI) 2.0 and LVC in children's hospitals.

METHODS

We applied the Pediatric Health Information System LVC Calculator to emergency and inpatient encounters from July 2021 through June 2022. Proportions with LVC in highest (greatest opportunity) and lowest COI quintiles were compared. Generalized estimating equation logistic regression models were used to analyze LVC trends across COI quintiles.

RESULTS

842 463 encounters were eligible for 20 LVC measures. Across all measures, odds of LVC increased across increasing COI quintiles (adjusted odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03-1.08). For 12 measures, LVC was proportionally more common in highest versus lowest COI quintile, whereas the reverse was true for 4. Regression modeling revealed increasing LVC as COI increased across all quintiles for 10 measures; gastric acid suppression for infants had the strongest association (OR 1.22, 95% CI 1.17-1.27). Three measures revealed decreasing LVC across increasing COI quintiles; Group A streptococcal testing among children <3 years revealed the lowest OR (0.85, 95% CI 0.73-0.99). The absolute volume of LVC delivered was greatest among low COI quintiles for most measures.

CONCLUSIONS

Likelihood of LVC increased across COI quintiles for 10 of 20 measures, whereas 3 measures revealed reverse trends. High volumes of LVC across quintiles support a need for broad de-implementation efforts; measures with greater impact on children with lower opportunity warrant prioritized efforts.

Impact of the COVID-19 pandemic on antidepressant and antipsychotic use among children and adolescents: a population-based study

Background

The COVID-19 pandemic was associated with increases in the prevalence of depression, anxiety and behavioural problems among children and youth. Less well understood is the influence of the pandemic on antidepressant and antipsychotic use among children. This is important, as it is possible that antidepressants and antipsychotics were used as a "stop-gap" measure to treat mental health symptoms when in-person access to outpatient care and school-based supportive services was disrupted. Furthermore, antipsychotics and antidepressants have been associated with harm in children and youth. We examined trends in dispensing of these medications two years following the pandemic among children 18 years of age and under in Ontario, Canada.

Methods

We conducted a population-based time-series study of antidepressant and antipsychotic medication dispensing to children and adolescents ≤18 years old between September 1, 2014, and March 31, 2022. We measured monthly population-adjusted rates of antidepressant and antipsychotics obtained from the IQVIA Geographic Prescription Monitor (GPM) database. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of antidepressants and antipsychotics occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected use of these drugs.

Results

Overall, we found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. Specifically, we observed an immediate step decrease in antidepressant dispensing associated with a structural break in April 2020 (-55.8 units per 1,000 individuals; 95% confidence intervals [CI] CI: -117.4 to 5.8), followed by an increased monthly trend in the rate of antidepressant dispensing of 13.0 units per 1,000 individuals (95% CI: 10.2-15.9). Antidepressant dispensing was consistently greater than predicted from September 2020 onward. Antipsychotic dispensing increased immediately following a June 2020 structural break (26.4 units per 1,000 individuals; 95% CI: 15.8-36.9) and did not change appreciably thereafter. Antipsychotic dispensing was higher than predicted at all time points from June 2020 onward.

Conclusion

We found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. These increases were sustained through nearly two years of observation and are especially concerning in light of the potential for harm with the long-term use of antipsychotics in children. Further research is required to understand the clinical implications of these findings.