Trends & Patterns of Psychotropic Medication Use among Medicaid-insured Youth
Open Access DepositedStudy 1
56.2% and 57.1% patients stayed with 3 NPC or 4 and 5 NPC regimens combined, respectively. For patients with a given NPC, some decreased to a lower NPC. For example, 548 patients (24.7%) dropped from 3 NPC to 2 NPC. The patients who started concomitant use took substantial time to change to the next higher or lower NPC or to stay at the same NPC. For example, 223 days for staying in 2 NPC, and 417 median days for dropping from NPC 5 to NPC 3. Competing risk analysis was applied to investigate the association between patient factors and 2-5 NPCs (event of interest or outcome variable)
2.2% (N=671)
Psychotropic Medication use for mental health conditions in youth has expanded greatly since the mid-1990s. Among them, 50-75% of psychotropic medications are used for indications that lack approval by the US FDA, and are therefore prescribed off-label, i.e. failing to be evaluated in clinical trials to yield evidence that the benefits exceed the risks.Psychotropic polypharmacy or concomitant drug treatment, especially stimulant polypharmacy with antipsychotics (ATP), antidepressants (ATD) and anticonvulsant mood stabilizers (ATC-MS), in youth has been more common due to the increasing prevalence, early identification, and comorbidities of more than one psychiatric disorder. The public health concerns regarding the use of 3 or more class stimulant polypharmacy requires additional research to understand the details of the prevalence, patterns of use, polypharmacy changes, polypharmacy duration, types of polypharmacy regimens and their association with adverse drug events. Most published pediatric studies have focused on the prevalence of 2 or more class stimulant polypharmacy in a cross-sectional, typically one year framework. Higher number of stimulant class polypharmacy, for example, 3, 4, and 5 class stimulant polypharmacy, has not been fully investigated in a long-term follow-up cohort in terms of the prevalence, duration, polypharmacy changes, types of polypharmacy (concomitant) regimens and association with incident type 2 diabetes (T2DM). Method
The data source of the dissertation comprises the 2007-2014 Medicaid administrative claims data of 2–17-year-olds from a mid-Atlantic state which included enrollment files, outpatient and physician claims files and dispensed prescription drug files. The files in the data source were linked together via an encrypted identification number. In study 1, the comparison of patient factors between stimulant treated and treatment date-matched non-stimulant treated patients were conducted via χ2 test. The association between patients’ factors and stimulant polypharmacy were evaluated using logistic regression models. In study 2, the demographic characteristics and clinician-reported psychiatric diagnosis in the stimulant monotherapy group, maximum 2, 3, 4 and 5 number of psychotropic classes (NPCs) between different groups were compared using χ2 analysis. Duration of NPC changes was calculated and presented as median, and interquartile range (IQR). The association between patient factor sand various maximum NPC regimens was assessed by competing-risk analysis using Fine and Gray’s proportional hazards regression model and is reflected by the sub-hazard ratio (SHR). In Study 3, the absolute risk of incident type 2 diabetes (T2DM) per 10,000 person-months was calculated in each category of number of polypharmacy classes and cumulative duration groups. The more than 120 baseline and time-dependent risk factors for pediatric T2DM were summarized as disease risk scores using discrete time failure model. The final discrete failure time model was fitted using logistic regression model, which was adjusted for disease risk score, number of polypharmacy classes and selected demographic factors. The adjusted hazard ratio for each demographic factor was calculated. Results
65.3% of patients stayed with 2 NPC until the end of study
age group 12-17 years, white, patients in foster care or SSI, and with 3-4 years continuous enrollment were significantly related to 2-5 NPCs. Antipsychotics (ATP), antidepressants (ATD), and anticonvulsant mood stabilizers (ATC-MS) were the most frequent psychotropic class combinations used. Study 3： Among 30,112 new stimulant users aged 2-17 years old, with an average 6.4 years of follow-up, 43 patients had incident T2DM diagnosis following initiation with stimulants, 30,069 patients were non-diabetic. Compared to non-diabetic patients, T2DM patients were more frequent among 6–11-year-olds, females, African Americans, 7–8-year continuous enrollees, those with disability or poverty coverage and had disease risk scores greater than 75%. The absolute risk (AR) of incident T2DM increased with the higher class and longer duration of polypharmacy regimens, especially for 3 to 5 class stimulant polypharmacy regimens with antipsychotics (ATP), antidepressants (ATD), and anticonvulsant mood stabilizers (ATC-MS). The relative risk (RR) of patients factors showed stimulant polypharmacy with ATP, ATD or ATC-MS were significantly more likely to develop T2DM for 3 class or 4 and 5 combined class psychotropic polypharmacy [RR=2.58, 95% CI (1.05,6.82) and 5.81, 95% CI (2.29,14.75), respectively] and for longer cumulative duration (120-779 days) in 4 and 5 class combined stimulant polypharmacy [RR=3.78, 95% CI (1.16,12.40)]. Conclusions and Significance
5.4% (N=1,634)
Psychotropic medication concomitant use (polypharmacy) in youth has increased greatly in the past 30 years and the use patterns have grown complex and we are still largely unclear about the effectiveness and safety of these polypharmacy regimens. The findings of this dissertation show stimulant polypharmacy, particularly 3-5 class polypharmacy, has a substantial prevalence, a complex flux of use patterns, long polypharmacy durations, and is significantly associated with incident T2DM. Collectively, the findings from the three studies can guide pediatric psychotropic drug prescription practice monitoring and improve the clinical practice for children and adolescents with emotional and behavioral disorders. The findings provide new information for future studies to investigate the appropriateness, effectiveness and safety of polypharmacy, in other databases, in vulnerable populations, particularly foster care insured youth, and in robust simple trial designs, which can support clinical practice and policy change in the Medicaid use population.
Background
and 0.3% (N=103) had maximum 3, 4 and 5 NPC regimens, respectively. The NPC change pathways are complex
The prevalence of stimulant users (16.5%,) in the entire group of 2–17-year-olds with 3-8 years continuous enrollment was approximately 2 times higher than that reported in studies with 1 year follow-up time using annual datasets. Compared with non-stimulant users, stimulant users (N=43,700) were more frequently male, white, aged 6–11 years, more often in foster care or with Supplemental Security Income (SSI), and with 7-8 years of enrollment and had externalizing disorders reported. The duration of stimulant exposure was substantial (487 median days). After adjusting other factors, the youth who were 6-11 years old, male, white, in foster care or SSI, and had 7-8 years of continuous enrollment were more likely to receive 3-5 class stimulant polypharmacy. In these 3-5 class stimulant polypharmacy users, the most prevalent combinations were stimulants with antipsychotics (ATP), antidepressants (ATD) or anticonvulsant mood stabilizers (ATC-MS). Study 2： Among 30,294 new stimulant users (no stimulant exposure in 180 days prior to first stimulant dispensing), 75.5% (N=22,882) were on stimulant monotherapy, 16.5% (N=5,004) had maximum 2 NPC
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