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Concurrent antipsychotic, psychotropic use common among Medicaid-enrolled children

New data suggest an increase in concurrent, or combination, prescribing of second-generation antipsychotics with other psychotropic medications among Medicaid-enrolled youth.

“We knew that antipsychotic use was increasing among youth, but we were surprised to learn just how often youth on common psychotropic medications like stimulants or antidepressants also receive an antipsychotic as part of their treatment, and when they do, it is for sustained periods of time,” David M. Rubin, MD, MSCE, attending pediatrician and co-director of the Children’s Hospital of Philadelphia’s PolicyLab, said in a press release.

David M. Rubin

Rubin and colleagues conducted a national study of children (aged 6-18 years) continuously enrolled in Medicaid from 2004 to 2008 to determine the rate of concurrent use of second-generation antipsychotics (SGAs) with four psychotropic classes, including stimulants, antidepressants, mood stabilizers and alpha agonists.

Stimulants were the most common psychotropic medication class by 2008 (8.3%), followed by antidepressants (3.7%), SGAs (3.3%), alpha agonists (1.8%) and mood stabilizers (1.6%). Compared with participants who were income-eligible for  Medicaid, those with foster care- or Supplemental Security Income-based eligibility were 3.5 to 10 times more likely to receive psychotropic medications.

In 2004, SGA use was 2.7% and increased to 3.3% in 2008. Eighty-five percent of the participants on SGAs were also using the SGA in combination with another psychotropic medication. By 2008, 52% of participants using mood stabilizers were also using an SGA, along with 37% alpha agonist users, 32% of antidepressant users and 22% of stimulant users. There was a 30% to 60% higher concurrent SGA rate among foster care- and Supplemental Security Income-eligible participants.

Concurrent use also occured for long periods of time, on average, accounting for 35% to 40% of annual calendar days.

Large increases in concurrent SGA use were specifically seen among participants with attention-deficit/hyperactivity disorder, more than 16% of the total sample.

“The numbers tell a story of emerging clinical practice, where concurrent antipsychotic use by youth is no longer on the margins; rather, we are seeing a shift in use toward less-impaired groups of youth, including among those with ADHD and no other behavioral health diagnosis and among those who were never hospitalized,” Rubin said. “It is also noteworthy that the largest growth within the Medicaid program has not been among populations with high clinical need in the foster care and disability programs, but rather among those with income eligibility for Medicaid. This article foretells the spread of this therapy into general psychiatric practice.”

David M. Rubin, MD, MSCE,  can be reached at rubin@email.chop.edu.

Disclosure: See the study for a full list of the researchers’ financial disclosures.