Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (M_age = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Exploring Heterogeneity of Stepped Collaborative Care Treatment Response Trajectories after Adolescent Sports Injury Concussion

Objective: Few clinical trials of posttraumatic interventions have utilized symptom trajectory modeling to explore heterogeneity of treatment responses. The goal of this investigation was to conduct a secondary analysis of a randomized clinical trial of stepped collaborative care for adolescents with sports and recreational related concussion and persistent symptoms of >1 month.Method: Trajectory modeling was used to examine the impact of randomization to the intervention as well as demographic, clinical, and injury characteristics on adolescent post-concussive symptom trajectories. Two hundred male and female adolescents were assessed >1 month after a concussion, and then 3-, 6- and 12-months later with a standardized measure of concussive symptoms, the Health and Behavior Inventory (HBI). Multinomial logistic regression was used to compare the association between intervention, demographic, clinical and injury characteristics with trajectory group membership.Results: Four post-concussive symptom trajectories emerged: recovery, remitting, low-persistent, and high-persistent. In adjusted analyses randomization to the intervention condition was associated with significantly greater odds of HBI recovery trajectory group membership (OR 3.29 95% CI 1.06-10.28). Female gender and prior concussion history were associated with significantly greater odds of high-persistent trajectory group membership relative to all other trajectories. Greater odds of high-persistent versus recovery group trajectory membership was observed for adolescents with a pre-injury history of anxiety and/or depressive disorders.Conclusions: Stepped collaborative care was associated with an increased odds of recovery versus high-persistent post-concussive symptom trajectories, while readily identifiable baseline characteristics were associated high-persistent symptoms. Future post-concussive clinical trials and practice improvement efforts could incorporate these observations.

Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial

OBJECTIVE

To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths.

METHOD

A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations.

RESULTS

The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments.

CONCLUSION

Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths.

CLINICAL TRIAL REGISTRATION INFORMATION

Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS)

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

A Second-Opinion Program for the Care of Youths Prescribed Five or More Psychotropics in Washington State

This retrospective study describes a second-opinion review program for the care of children in Washington State who received Medicaid coverage and who were prescribed five or more psychotropic medications, primarily by mental health specialists. In total, 136 second-opinion reviews from 2013 and 169 from 2018 were included in this study. Attention-deficit hyperactivity disorder (ADHD), behavioral difficulties, anxiety, and trauma were prevalent among these children, and participants were commonly prescribed ADHD medications, selective serotonin reuptake inhibitors, and second-generation antipsychotics. The incidence of reviews remained stable over the two periods, but psychosocial treatment increased significantly over this time. This study sheds light on the initiation, maintenance, and identification of polypharmacy psychotropic regimens and highlights psychosocial treatment as an intervention that increases best practice care for at-risk patients.

Editorial: Best Practices in Child Antipsychotic Use Monitoring

One major change in our field over the past 20 years has been the rapid increase and acceptance of antipsychotic use for children. Pediatric use of antipsychotics was quite rare as recently as the early 1990s, though this was followed by a roughly 6-fold increase in antipsychotic prescribing from 1996 to 2004 with continued higher use rates.¹ There is, of course, nothing inherently wrong with rapidly increasing use of a drug class, particularly when it yields significant clinical results. However, alarm was raised for several reasons, such as use variations (eg, children in foster care having much higher rates of use), a majority of antipsychotic use for off-label indications, and significant cardio/metabolic medical complications from their use.^2,3 Cost was another concern before generics were available; for instance, all-ages antipsychotic use at one time accounted for nearly one-third of my state's entire Medicaid pharmacy budget. These factors together drove health systems to devise and implement strategies to ensure that youth receiving antipsychotic medications were receiving them appropriately.

Safer use of antipsychotics in youth (SUAY) pragmatic trial protocol

BACKGROUND

Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants.

METHODS

Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3-17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services).

DISCUSSION

The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03448575.

Effectiveness of mandatory peer review to reduce antipsychotic prescriptions for Medicaid-insured children

BACKGROUND

Prior authorization of prescription medications is a policy tool that can potentially impact care quality and patient safety.

OBJECTIVE

To examine the effectiveness of a mandatory peer-review program in reducing antipsychotic prescriptions among Medicaid-insured children, accounting for secular trends that affected antipsychotic prescribing nationally.

DATA SOURCE

Medicaid Analytical eXtracts (MAX) with administrative claims for health services provided between January 2006 and December 2011.

STUDY DESIGN

This retrospective, observational study examined prescription claims records from Washington State (Washington) and compared them to a synthetic control drawing from 20 potential donor states that had not implemented any antipsychotic prior authorization program or mandatory peer review for Medicaid-insured children during the study period. This method provided a means to control for secular trends by simulating the antipsychotic use trajectory that the program state would have been expected to experience in the absence of the policy implementation.

PRINCIPAL FINDINGS

Before the policy implementation, antipsychotic use prevalence closely tracked those of the synthetic control (6.17 per 1000 in Washington vs. 6.21 in the synthetic control group). Within two years after the policy was implemented, prevalence decreased to 4.04 in Washington and remained stable in the synthetic control group (6.47), corresponding to an approximately 38% decline.

CONCLUSION

Prior authorization program designs and implementations vary widely. This mandatory peer-review program, with an authorization window and two-stage rollout, was effective in moving population level statistics toward safe and judicious use of antipsychotic medications in children.

Telemedicine for Child Collaborative or Integrated Care

Telemedicine with child psychiatry specialists is a useful tool for collaborative and integrated care systems. This article reviews the workforce and care process rationale for using child psychiatric telemedicine for collaborative care, and discusses practical ways to address the technical challenges that arise when using telemedicine. Different systems of using telemedicine discussed include child psychiatry access programs, collaborative and integrated care use of telephone consultations, televideo consultations, and televideo care delivery. Telemedicine can also be used for collaboratively conducted but care review requested by third-party consultations with treatment providers or care teams.

Evaluating Integrated Mental Health Care Programs for Children and Youth

Evaluations of integrated care programs share many characteristics of evaluations of other complex health system interventions. However, evaluating integrated care for child and adolescent mental health poses special challenges that stem from the broad range of social, emotional, and developmental problems that need to be addressed; the need to integrate care for other family members; and the lack of evidence-based interventions already adapted for primary care settings. Integrated care programs for children's mental health need to adapt and learn on the fly, so that evaluations may best be viewed through the lens of continuous quality improvement rather than evaluations of fixed programs.

Implementing Integrated Care in Pediatric Mental Health: Principles, Current Models, and Future Directions

Traditional models of health care delivery are inadequate for addressing all the needs of the child and adolescent population that has mental illness. The integrated care model seeks to partner pediatric mental health specialists with primary providers to better meet these needs. The authors outline the core principles guiding integrated care for youths and describe key characteristics of the team members involved. Three models of integrated care have emerged and have proven effective. Several representative programs are described, and the advantages and disadvantages of each are reviewed. The review concludes by identifying the challenges that have prevented wider dissemination of the integrated care model and by exploring potential future directions for the field.

Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services

OBJECTIVE

To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization.

DATA SOURCES/STUDY SETTING

Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013.

STUDY DESIGN

Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization.

DATA COLLECTION/EXTRACTION METHODS

All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization.

PRINCIPAL FINDINGS

Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens.

CONCLUSIONS

Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service.

Integrated Care for Pediatric Substance Abuse

Integrated care is a way to improve the prevention, identification, and treatment of mental health difficulties, including substance abuse, in pediatric care. The pediatrician's access, expertise in typical development, focus on prevention, and alignment with patients and families can allow successful screening, early intervention, and referral to treatment. Successful integrated substance abuse care for youth is challenged by current reimbursement systems, information exchange, and provider role adjustment issues, but these are being addressed as comfort with this care form and resources to support its development grow.

Side effects from use of one or more psychiatric medications in a population-based sample of children and adolescents

OBJECTIVE

The purpose of this study was to investigate the side effect risks from using one or more psychiatric medications (including antipsychotics, antidepressants, α-2 agonists, benzodiazepines, mood stabilizers, and stimulants) among a national cohort of children and adolescents.

METHODS

A questionnaire survey was administered to parents who filled a prescription for a psychiatric medication for their child at a large national retail pharmacy chain. Primary outcome variables were the total count of side effects from a list of 12 problem areas, as well as parent-reported side effect intensity (mild/moderate/severe). Modifiers investigated included specific medication and number of medications utilized, demographics, and difficulties with access to care.

RESULTS

A total of 1347 parents of study subjects ages 3-17 years from 30 U.S. states who were taking psychiatric medications for any indication purchased at one retail pharmacy chain enrolled following a single mail invitation (7.5% response). Of the study subjects, 80% were white/non-Hispanic, 64% were male, 63% had private health insurance, and 67% had used a current medication for >1year. Most (84%) had one or more parent-reported side effect. After adjusting for covariates, subjects with two medications reported 17% (p<0.001) and with three or more medications reported 38% (p=0.002) increases in their average number of side effects than did children taking one medication. Parental reporting of difficulties in accessing care also predicted a 42% (p<0.001) greater number of side effects than for those who had no access difficulties. Side effects were particularly more common in medication combinations including either selective serotonin reuptake inhibitors (SSRIs) (77% higher odds, p<0.001) or antipsychotics (99% higher odds, p<0.001).

CONCLUSIONS

Side effects from psychiatric medications appear to be both more common and more severe overall with increasing numbers of medications utilized, and with perceived difficulty in accessing care. Polypharmacy regimens including either SSRIs or antipsychotics were especially associated with experiencing side effects, within this study sample.

The Partnership Access Line: evaluating a child psychiatry consult program in Washington State

OBJECTIVE

To evaluate a telephone-based child mental health consult service for primary care providers (PCPs).

DESIGN

Record review, provider surveys, and Medicaid database analysis.

SETTING

Washington State Partnership Access Line (PAL) program.

PARTICIPANTS

A total of 2285 PAL consultations by 592 PCPs between April 1, 2008, and April 30, 2011.

INTERVENTIONS

Primary care provider-initiated consultations with PAL service.

MAIN OUTCOME MEASURES

The PAL call characteristics, PCP feedback surveys, and Medicaid claims between April 2007 and December 2009 for fee-for-service Medicaid children before and after a PAL call.

RESULTS

Sixty-nine percent of calls were about children with serious emotional disturbances, and 66% of calls were about children taking psychiatric medications. Primary care providers nearly always received new psychosocial treatment advice (87% of calls) and were more likely to receive advice to start rather than stop a medication (46% vs 24% of calls). Primary care provider feedback surveys reported uniformly positive satisfaction with the program. Among Medicaid children, there was significant increases in attention-deficit/hyperactivity disorder and antidepressant medication use after the PAL call but no significant change in reimbursements for mental health medications (P < .05). Children with a history of foster care experienced a 132% increase in outpatient mental health visits after the PAL call (P < .05).

CONCLUSIONS

Primary care providers used PAL for psychosocial and medication treatment assistance for particularly high-needs children and were satisfied with the service. Furthermore, PAL was associated with increased use of outpatient mental health care for some children.