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Minjon L, van den Ban E, Bazelier MT, Lalmohamed A, Egberts TC, Heerdink ER. Monitoring of Adverse Drug Reaction-Related Parameters in Children, Youth, and Young Adults Prescribed Antipsychotic Drugs by General Practitioners. J Child Adolesc Psychopharmacol 2022; 32:36-44. [PMID: 34619039 PMCID: PMC8884168 DOI: 10.1089/cap.2021.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: The aim of the study was to assess monitoring of adverse drug reaction (ADR)-related parameters in children, youth, and young adults treated with second-generation antipsychotic drugs (SGAs) prescribed by general practitioners (GPs). Methods: This retrospective follow-up study included children, youth, and young adults aged 0 - 24 years, who had an initial prescription of an SGA recorded in the Clinical Practice Research Datalink between 2000 and 2017, and who were prescribed an SGA more than once for a duration of at least 6 months. It included an assessment of which ADR-related physical parameters (weight, height, body-mass index, waist circumference, pulse, blood pressure, and heart examination) and laboratory parameters (glucose, HbA1c, lipids, and prolactin) were monitored in children, youth, and young adults at least once every 6-month period, stratified by sex, age categories, and calendar years. Results: In total, 7006 patients were included and the mean duration of follow-up was 1.6 years. Monitoring frequencies of all parameters were below 25%. Blood pressure and weight were monitored in 23.6% and 23.4%, respectively, of all children, youth, and young adults during the first half year; waist circumference was monitored in 0.2%. Females were monitored more often than males, some differences between age categories were observed, and monitoring frequencies increased after 2000, but did not exceed 35% in any year. Conclusion: Monitoring frequencies of ADR-related parameters in children, youth, and young adults treated with SGAs prescribed by a GP were low. Monitoring in primary care should be improved to enable a better evaluation of the benefit-risk balance during antipsychotic drug therapy.
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Affiliation(s)
- Lenneke Minjon
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Els van den Ban
- Karakter Child and Adolescent Psychiatry, Zwolle, The Netherlands
| | - Marloes T. Bazelier
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Arief Lalmohamed
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Toine C.G. Egberts
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eibert R. Heerdink
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Research Group Innovation of Pharmaceutical Care, University of Applied Sciences, Utrecht, The Netherlands.,Address correspondence to: Eibert R. Heerdink, PhD, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, Utrecht 3508 TB, The Netherlands
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Jazi S, Ben-Amor L, Abadie P, Menard ML, Choquette R, Berthiaume C, Mottron L, Ilies D. Long-Term Metabolic Monitoring of Youths Treated with Second-Generation Antipsychotics 5 Years after Publication of the CAMESA Guidelines Are We Making Progress? Surveillance Métabolique à Long Terme des Jeunes Traités par Antipsychotiques de Deuxième Génération, Cinq ans Après la publication des Lignes Directrices Camesa: Faisons-Nous des Progrès? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:645-656. [PMID: 33243011 PMCID: PMC8243171 DOI: 10.1177/0706743720974847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The potential metabolic adverse effects of second-generation antipsychotics (SGA) need to be monitored. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics (CAMESA) offers guidelines for this purpose. We aimed to evaluate the long-term rates of youths receiving monitoring in mental health clinics and document the factors that may influence them. METHOD The charts of 180 patients (13.3 ± 3.1 years, 54.4% males) receiving SGA treatment for the first time between January 2016 and June 2018 were reviewed. Monitoring was divided into baseline and 1- to 6-month and 9- to 24-month periods. Population under study was stratified into children (4 to 12 years) and adolescents (13 to 18 years). Sociodemographic characteristics, psychiatric diagnosis and comorbidities, prescribed SGAs and comedications, anthropometric measures (AM), blood pressure (BP), blood tests (BT), electrocardiogram, and the psychiatrist's years of practice were collected. Cross tables were used to present the monitoring rates. Categories were compared by covariate analysis. Rates of patients monitored across categories were compared using Fisher exact test. RESULTS Monitoring rates for AM, BT, and BP were 55%, 47.8%, and 46.7% at baseline; 50%, 41.7%, and 45.2% at 1 to 6 months; and 47.2%, 41.5%, and 40.6% at 9 to 24 months, respectively. Higher monitoring rates were significantly associated with adolescent status (baseline, 1 to 6 months), a diagnosis of psychotic and/or affective disorder (baseline, 1 to 6 months, 9 to 24 months), having ≤1 psychiatric comorbidities (1 to 6 months), high SGA dose (baseline, 1 to 6 months), and clinician's experience (baseline, 9 to 24 months). Significantly lower monitoring rates were associated with the psychostimulant/atomoxetine comedication (baseline, 1 to 6 months, 9 to 24 months). CONCLUSION Five years after publication of the CAMESA guidelines, metabolic monitoring is conducted for less than half of patients. In our sample, age, diagnostic category, psychiatric comorbidities, SGA dose, clinician's experience, and comedications influenced the monitoring rates. Major progress still needs to be made before reaching a satisfactory level of monitoring.
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Affiliation(s)
- Sarra Jazi
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada
| | - Leila Ben-Amor
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada.,Department of Child and Adolescents Psychiatry, CHU Sainte-Justine Research Center, Montreal, Quebec, Canada
| | - Pascale Abadie
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada.,Child and Adolescents Psychiatry Division, Department of Psychiatry, Rivière-des-Prairies Mental Health Hospital, CIUSSS-NIM, Montreal, Quebec, Canada.,CIUSSS-NIM Research Center, Montreal, Quebec, Canada
| | - Marie-Line Menard
- Children's Hospital of Nice, University Department of Child and Adolescent Psychiatry, Côte d'Azur University, Nice, France
| | - Rachel Choquette
- Faculty of Pharmacy, 5622University of Montreal, Montreal, Quebec, Canada
| | - Claude Berthiaume
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada.,CIUSSS-NIM Research Center, Montreal, Quebec, Canada
| | - Laurent Mottron
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada.,Child and Adolescents Psychiatry Division, Department of Psychiatry, Rivière-des-Prairies Mental Health Hospital, CIUSSS-NIM, Montreal, Quebec, Canada.,CIUSSS-NIM Research Center, Montreal, Quebec, Canada
| | - Drigissa Ilies
- Department of Psychiatry and Addictology, 5622University of Montreal, Montreal, Quebec, Canada.,Child and Adolescents Psychiatry Division, Department of Psychiatry, Rivière-des-Prairies Mental Health Hospital, CIUSSS-NIM, Montreal, Quebec, Canada.,CIUSSS-NIM Research Center, Montreal, Quebec, Canada
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3
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Soda T, Richards J, Gaynes BN, Cueva M, Laux J, McClain C, Frische R, Lindquist LK, Cuddeback GS, Jarskog LF. Systematic Quality Improvement and Metabolic Monitoring for Individuals Taking Antipsychotic Drugs. Psychiatr Serv 2021; 72:647-653. [PMID: 33887956 PMCID: PMC8192348 DOI: 10.1176/appi.ps.202000155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors sought to increase the rate of cardiometabolic monitoring for patients receiving antipsychotic drugs in an academic outpatient psychiatric clinic serving people with serious mental illness. METHODS Using a prospective quasi-experimental, interrupted time-series design with data from the electronic health record (EHR), the authors determined metabolic monitoring rates before, during, and after implementation of prespecified quality improvement (QI) measures between August 2016 and July 2017. QI measures included a combination of provider, patient, and staff education; systematic barrier reduction; and an EHR-based reminder system. RESULTS After 1 year of QI implementation, the rate of metabolic monitoring had increased from 33% to 49% (p<0.01) for the primary outcome measure (hemoglobin A1C and lipid panel). This increased monitoring rate was sustained for 27 months beyond the end of the QI intervention. More than 75% of providers did not find the QI reminders burdensome. CONCLUSIONS Significant improvement in the rate of metabolic monitoring for people taking antipsychotic drugs can be achieved with little added burden on providers. Future research needs to assess the full range of patient, provider, and system barriers that prevent cardiometabolic monitoring for all individuals receiving antipsychotic drugs.
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Affiliation(s)
- Takahiro Soda
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Jennifer Richards
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Bradley N Gaynes
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Michelle Cueva
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Jeffrey Laux
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Christine McClain
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Rachel Frische
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Lisa K Lindquist
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - Gary S Cuddeback
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
| | - L Fredrik Jarskog
- Department of Psychiatry (Soda, Gaynes, Cueva, Frische, Cuddeback, Jarskog), North Carolina Translational and Clinical Sciences Institute (Laux), and School of Social Work (Cuddeback), University of North Carolina at Chapel Hill, Chapel Hill; Cherry Hospital, North Carolina Department of Health and Human Services, Goldsboro (Richards); Northwest Human Services, Salem, Inc., Salem, Oregon (McClain); Department of Psychiatry, Providence Alaska Medical Center, Anchorage (Lindquist)
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Melamed OC, LaChance LR, O'Neill BG, Rodak T, Taylor VH. Interventions to Improve Metabolic Risk Screening Among Children and Adolescents on Antipsychotic Medication: A Systematic Review. J Child Adolesc Psychopharmacol 2021; 31:63-72. [PMID: 33512274 DOI: 10.1089/cap.2020.0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: Antipsychotic use among youth is common and is associated with metabolic side effects such as weight gain. Guidelines recommend periodic screening of metabolic measures in youth prescribed antipsychotics; however, a guideline-to-practice gap exists. We systematically reviewed the literature to synthesize the knowledge from interventions that aim to improve antipsychotic metabolic screening. We described the interventions' effect on screening rates, the strategies used for improvement, and study quality. Methods: We conducted a systematic review of studies that attempted to improve antipsychotic metabolic risk screening practices among pediatric populations published between 2004 and August 2019. We included studies with an improvement intervention that compared screening rates before and after the intervention. We extracted data about study characteristics, screening rates in pre- and postintervention groups, strategies used to influence screening practices, and assessed studies' risk of bias. This review was prospectively registered with PROSPERO #CRD42018088241. Results: We identified six studies that demonstrated modest improvements in median metabolic screening rates for waist circumference (0%-16%), glucose (9%-39%), and lipids (11%-37%). Median postintervention screening rates were higher for weight and blood pressure (84% and 72.5%) compared with glucose and lipids (39% and 37%). Interventions used a variety of improvement strategies to address patient-, provider-, and organization-level barriers for screening, including increasing patient and provider knowledge regarding antipsychotic side effects, fostering social clinical environments that promote screening, and organizational commitment for screening antipsychotic-treated youth. All interventions were deemed at high risk of bias due to uncontrolled design and lack of adjustment for confounders. Conclusions: Included studies reported partial success in improving antipsychotic screening rates but were of poor methodological quality. Common improvement strategies may affect provider behavior to conduct metabolic screening, but these need to be tailored to local resources and organization structure. Future studies need to use rigorous methodology and theory-informed improvement strategies aligned with organizational actions to prioritize safe and judicious practice of antipsychotics among pediatric populations.
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Affiliation(s)
- Osnat C Melamed
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura R LaChance
- St. Mary's Hospital, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Braden G O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada
| | - Terri Rodak
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
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5
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Hayden JD, Horter L, Parsons T, Ruble M, Townsend S, Klein CC, Duran RP, Welge JA, Crystal S, Patel NC, Correll CU, DelBello MP. Metabolic Monitoring Rates of Youth Treated with Second-Generation Antipsychotics in Usual Care: Results of a Large US National Commercial Health Plan. J Child Adolesc Psychopharmacol 2020; 30:119-122. [PMID: 31851522 DOI: 10.1089/cap.2019.0087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: To examine metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. Methods: In this retrospective study, data were collected from a large national commercial health plan for the period covering January 1, 2016 to December 31, 2017. Commercially insured children and adolescents, aged 8-19 years with ≥2 SGA prescription claims during the CY, were identified for the CY2016 and CY2017 cohorts. The primary outcome of interest was the percentage of subjects with any glucose or lipid metabolism parameter monitoring. Other calculated metabolic testing rates included glucose, hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), other cholesterol (including triglycerides), and combined glucose and lipid metabolism testing (≥1 test for blood glucose or HbA1c and ≥1 test for LDL-C or other cholesterol). Results: In CY2016 and CY2017, 1502 and 1239 subjects, respectively, were identified for this study. The most common psychiatric diagnoses in CY2016 and CY2017 were major depressive disorder (57.1%, 56.5%, respectively), anxiety disorders (42.9%, 47.5%), attention-deficit/hyperactivity disorder (41.6%, 45.8%), and bipolar disorder (24.1%, 25.9%). The rate of any metabolic testing was 53.5% in CY2016 and 51.3% in CY2017. Glucose testing (50.3%, 46.9%, respectively) was most common in both CYs, followed by LDL-C testing (31.2%, 28.5%). Rates of combined glucose and lipid metabolism testing were 30.7% in CY2016 and 26.9% in CY2017. Conclusions: Given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. There is a critical need for understanding barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring.
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Affiliation(s)
| | - Libby Horter
- Humana Healthcare Research, Inc., Louisville, Kentucky
| | | | | | | | - Christina C Klein
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Rodrigo Patino Duran
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey A Welge
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, New Jersey
| | - Nick C Patel
- Humana Healthcare Research, Inc., Louisville, Kentucky
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York.,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,The Feinstein Institute for Medical Research, Manhasset, New York.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Prescribing antipsychotics in child and adolescent psychiatry: guideline adherence. Eur Child Adolesc Psychiatry 2020; 29:1717-1727. [PMID: 32052173 PMCID: PMC7641940 DOI: 10.1007/s00787-020-01488-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 02/01/2020] [Indexed: 12/23/2022]
Abstract
Antipsychotics are often prescribed to children and adolescents, mostly off-label. We aimed to assess adherence to recommendations of guidelines for antipsychotic prescription. We reviewed 436 medical records from 155 clinicians from 26 clinics within three Dutch child and adolescent psychiatry organizations (n = 398 outpatient, n = 38 inpatient care). We assessed target symptoms, diagnostic process, prior and concomitant treatment, and consideration of contra-indications. Multiple logistic regression assessed the role of age, sex, and psychiatric diagnosis on adherence to three main recommendations: to (1) prescribe antipsychotics only after other treatments proved insufficient, (2) always combine antipsychotics with psychosocial interventions, and (3) not prescribe multiple antipsychotics simultaneously. Most patients received off-label antipsychotics. Main target symptoms were inattention/hyperactivity (25%), aggression (24%), and other disruptive behaviors (41%). Most patients underwent diagnostic evaluation before the first prescription; however, screening of contra-indications was low (0.2-19%). About 84% had previously received psychosocial treatment and 48% other psychoactive medication, but 9% had not received any treatment. Notably, only 37% continuously received concomitant psychosocial treatment. Simultaneous use of multiple antipsychotics occurred in 3.2%. Younger children were at higher risk of non-adherence to guideline recommendations regarding prior and concomitant treatment, children with autism spectrum disorder or attention-deficit/hyperactivity disorder more likely not to receive concomitant psychosocial treatment. Sex did not significantly affect adherence. Our findings implicate insufficient adherence to important recommendations regarding antipsychotic use in children and adolescents. Especially younger children are at higher risk of receiving suboptimal care. There is an urgency to consistently offer psychosocial interventions during antipsychotic treatment.
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7
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Leckman-Westin E, Finnerty M, Scholle SH, Pritam R, Layman D, Kealey E, Byron S, Morden E, Bilder S, Neese-Todd S, Horwitz S, Hoagwood K, Crystal S. Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid. J Manag Care Spec Pharm 2018; 24:238-246. [PMID: 29485947 PMCID: PMC10397713 DOI: 10.18553/jmcp.2018.24.3.238] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
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Affiliation(s)
- Emily Leckman-Westin
- 1 New York State Office of Mental Health, Albany, New York, and State University of New York at Albany, School of Public Health, Rensselaer, New York
| | - Molly Finnerty
- 2 New York State Office of Mental Health, and New York University Langone Health, New York, New York
| | | | - Riti Pritam
- 4 New York State Office of Mental Health, Albany, New York
| | - Deborah Layman
- 4 New York State Office of Mental Health, Albany, New York
| | - Edith Kealey
- 4 New York State Office of Mental Health, Albany, New York
| | - Sepheen Byron
- 3 National Committee for Quality Assurance, Washington, DC
| | - Emily Morden
- 3 National Committee for Quality Assurance, Washington, DC
| | | | | | - Sarah Horwitz
- 6 New York University Langone Health, New York, New York
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8
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Bozymski KM, Whitten JA, Blair ME, Overley AM, Ott CA. Monitoring and Treating Metabolic Abnormalities in Patients with Early Psychosis Initiated on Antipsychotic Medications. Community Ment Health J 2018; 54:717-724. [PMID: 29127566 DOI: 10.1007/s10597-017-0203-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
Antipsychotic medications carry an established lifetime risk of metabolic syndrome. This retrospective chart review evaluated feasibility of a metabolic monitoring clinical decision support tool (CDST) for weight, lipid, blood glucose, and blood pressure management of 163 clients in an early psychosis outpatient clinic over 2 years. Each parameter had at least 98 (60.1%) clients with a recorded value, the most being documented for weight with 112 (68.7%) clients. CDST adherence ranged from at least 54.3-100% for non-pharmacologic interventions (e.g. clinic counseling, referral to health program or primary care) and at least 33.3-100% for pharmacologic interventions (e.g. metformin). Though no baseline cardiometabolic abnormalities were identified, dyslipidemia and obesity were later found in 37 (22.7%) and 35 (21.5%) clients, respectively. Only 14 (8.6%) clients were prescribed medications for cardiometabolic abnormalities by psychiatrists in the clinic. Increasing focus on physical health is needed to better this population's long-term prognosis.
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Affiliation(s)
- Kevin M Bozymski
- Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Jessica A Whitten
- Department of Pharmacy, Eskenazi Health, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
| | - Mary E Blair
- Department of Pharmacy, Eskenazi Health, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA
| | - Ashley M Overley
- Eskenazi Health Midtown Community Mental Health, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA.,Department of Psychiatry, Indiana University School of Medicine, 355 West 16th Street, Suite 4800, Indianapolis, IN, 46202, USA
| | - Carol A Ott
- Department of Pharmacy, Eskenazi Health, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA.,Eskenazi Health Midtown Community Mental Health, 720 Eskenazi Avenue, Indianapolis, IN, 46202, USA.,Department of Psychiatry, Indiana University School of Medicine, 355 West 16th Street, Suite 4800, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 Stadium Mall Drive, West Lafayette, IN, 47907, USA
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9
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Le L, Bostwick JR, Andreasen A, Malas N. Neuroleptic Prescribing and Monitoring Practices in Pediatric Inpatient Medical and Psychiatric Settings. Hosp Pediatr 2018; 8:410-418. [PMID: 29895596 DOI: 10.1542/hpeds.2017-0129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric use of second-generation antipsychotics, or neuroleptics, has increased over the past decade. Neuroleptic use can have significant and lasting adverse neurologic, metabolic, and cardiovascular effects. In the current literature, neuroleptic prescribing and monitoring is described in outpatient settings, with little description of inpatient pediatric practice. In this study, we are the first to explore prescribing and monitoring in inpatient pediatrics, highlighting similarities and differences in practice between pediatric medicine and psychiatry. METHODS This retrospective study included patients <18 years of age who received a neuroleptic during inpatient hospitalization between September 2014 and March 2015, within either the pediatric inpatient medical or psychiatric setting. Data collected included sex, age, race, height, weight, length of stay, service providing care, details involving the neuroleptic(s) administered, comorbidities, lipid and glycemic monitoring, and results, monitoring for extrapyramidal symptoms, and mental health consultation. RESULTS Factors associated with improved neuroleptic monitoring included longer length of stay and evidence of an adverse drug effect. Clearly specified indication for use was associated with improved neuroleptic monitoring. Although neuroleptic initiation during admission had improved indication documentation and monitoring practices compared with initiation before admission, a significant gap exists between inpatient psychiatry and medical settings in adverse drug effect monitoring, particularly extrapyramidal symptom monitoring and lipid collection. CONCLUSIONS In our study, we describe current practice in the use and monitoring of neuroleptics in inpatient pediatric medical and psychiatric settings. In this study, we suggest that the use of neuroleptics in inpatient pediatrics, particularly inpatient medical settings, is conducted with suboptimal monitoring and, at times, without clear documented indication.
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Affiliation(s)
- Lan Le
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, Ann Arbor, Michigan
| | - Jolene R Bostwick
- University of Michigan College of Pharmacy, Department of Clinical Pharmacy, Ann Arbor, Michigan; .,Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan; and
| | - Arnold Andreasen
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan; and
| | - Nasuh Malas
- Department of Psychiatry, and.,Department of Pediatrics and Communicable Disease, University of Michigan Medical School, Ann Arbor, Michigan
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10
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Cotes RO, Fernandes NK, McLaren JL, McHugo GJ, Bartels SJ, Brunette MF. Improving Cardiometabolic Monitoring of Children on Antipsychotics. J Child Adolesc Psychopharmacol 2017; 27:916-919. [PMID: 28581341 PMCID: PMC5725629 DOI: 10.1089/cap.2017.0034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study evaluated changes in cardiometabolic monitoring for children and adolescents who were prescribed an antipsychotic medication in a state mental health system before and after a quality improvement intervention. METHODS The intervention included education for prescribers, auditing on metabolic monitoring, and feedback to mental health center leaders regarding their monitoring. Research staff extracted yearly data on cardiometabolic monitoring from randomly selected community mental health center records before and after the intervention. Pre- and postintervention changes in monitoring were assessed with chi-squared tests. RESULTS Evidence of past year monitoring increased: for glucose 18.9%-42.1% (χ2 = 6.75, p < 0.001), for triglycerides 13.5%-31.0% (χ2 = 4.54, p = 0.033), for cholesterol 13.5%-33.1% (χ2 = 5.48, p = 0.019), and for weight 67.6%-84.1% (χ2 = 5.21, p = 0.022). Rates of monitoring for blood pressure and waist circumference increased but not significantly. In both years studied, weight was obtained most frequently and waist circumference was obtained least frequently. CONCLUSIONS Monitoring rates significantly improved for four out of six parameters evaluated, but overall monitoring rates remained low at the end of the study period. Prescriber education with audit and feedback may improve cardiometabolic monitoring rates, but research is needed to evaluate barriers to monitoring in children.
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Affiliation(s)
- Robert O. Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | | | - Jennifer L. McLaren
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Gregory J. McHugo
- The Dartmouth Insitute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Stephen J. Bartels
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Bureau of Mental Health Services, Department of Health and Human Services, Concord, New Hampshire
| | - Mary F. Brunette
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Bureau of Mental Health Services, Department of Health and Human Services, Concord, New Hampshire
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11
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Chee GL, Wynaden D, Heslop K. Improving metabolic monitoring rate for young people aged 35 and younger taking antipsychotic medications to treat a psychosis: A literature review. Arch Psychiatr Nurs 2017; 31:624-633. [PMID: 29179831 DOI: 10.1016/j.apnu.2017.09.002] [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] [Received: 03/25/2017] [Revised: 08/14/2017] [Accepted: 09/03/2017] [Indexed: 01/08/2023]
Abstract
Young people aged 35 and younger who are taking antipsychotic medications to treat a psychosis are a high risk for developing metabolic syndrome due to the adverse effects of the medications. This paper reports the finding of a review of literature to identify interventions to improve metabolic monitoring rates in this group. A review of 478 studies identified 15 articles which met the inclusion criteria. Five articles reported single-intervention studies and the remaining integrated two or more interventions to improve uptake level of metabolic monitoring. As metabolic syndrome can be detected early through metabolic monitoring in young people taking antipsychotics, early intervention is important to improve their physical health trajectory.
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Affiliation(s)
- Gin-Liang Chee
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.
| | - Dianne Wynaden
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Karen Heslop
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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12
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Uzal NE, Chavez B, Kosirog ER, Billups SJ, Saseen JJ. Monitoring of Recommended Metabolic Laboratory Parameters Among Medicaid Recipients on Second-Generation Antipsychotics in Federally Qualified Health Centers. Ann Pharmacother 2017; 52:160-165. [DOI: 10.1177/1060028017731421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Natalia E. Uzal
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Benjamin Chavez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Emily R. Kosirog
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Sarah J. Billups
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
- CU Medicine, Office of Value Based Performance, Aurora, CO, USA
| | - Joseph J. Saseen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
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