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By Athena Mandros

A couple of weeks ago, we took a look at how state Medicaid programs restrict access to antipsychotic drugs for adults (see How Many Health Plans Have “Fail First” Policies For Mental Health Prescriptions?). We talked about how restricting adult access to antipsychotic drugs or requiring them to fail first on a preferred drug is considered ineffectual and sometimes dangerous policy in the mental health field (see also It’s Fail First Again). Following that piece, another reader asked, “Are there specific policies about prescribing antipsychotic medications to children?”

The issues associated with appropriately prescribing antipsychotic medications to children are much more complicated. Antipsychotic medications were originally developed to treat psychiatric disorders in adults. In fact, there are only five atypical antipsychotics approved by the FDA to treat three specific conditions in children – schizophrenia, bipolar disorder, and irritability associated with autism (see Atypical Antipsychotic Medications: Use in Pediatric Patients). And there are adverse side effects associated with atypical antipsychotic medications, including possible weight gain, increased lipid and prolactin levels, development of type 2 diabetes, and cardiovascular issues (see Comparative Effectiveness Review Number 39: First & Second Generation Antipsychotics For Children & Young Adults).

Approximately 75% of antipsychotic prescriptions for children are written off-label, usually for ADHD, even though the American Academy of Child and Adolescent Psychiatry (AACAP) does not recommend this line of treatment (Atypical Antipsychotic Medications: Use in Pediatric Patients). Further, the practices around the use of these medication in children are problematic. A recent Office of the Inspector General report on five state’s Medicaid fee-for-service (FFS) claims found that in 2011, 53% of children were poorly monitored for side effects, health problems, and drug effectiveness (see 92% Of Second-Generation Antipsychotic Drug Prescriptions For Medicaid-Enrolled Children Was Off-Label).

Additionally, there are concerns about the differential use of these medications. Children in Medicaid are twice as likely as children with privately held insurance to be prescribed an antipsychotic medication – and children in foster care are more than three times more likely to be prescribed an antipsychotic, than children in the general Medicaid population (see Children’s Mental Health: Concerns Remain About Appropriate Services For Children In Medicaid And Foster Care, GAO-13-15). There is also new evidence to support racial disparity in the prescription of antipsychotics (see Racial and Ethnic Differences in Antipsychotic Medication Use Among Children Enrolled in Medicaid).

The complexities of managing this problem were highlighted by OPEN MINDS Senior Associate Howard Shiffman – “This topic produces a lot of anxiety in professionals that are involved in delivering services to children. Despite the side effects and unknown effects, we see some major improvement in children’s behavior and ability to reside in the community as a result of antipsychotic medications. There are so many questions that need to be answered. Do these children in foster care and Medicaid really have greater behavioral needs? Or is administering medication just a quick way to control the behavior of troubled youth and stop their disruption of society?”

As a result of these concerns, there have been a number of state policies to assure appropriate use of these medications in children. In fact, more than 33 states have these policies. The types of policies include:

  1. Prior authorization – The pre-approval process that a prescriber must use in order for a beneficiary’s payer to cover the prescribed drugs. The PA process varies between payers and even between different prescribed drugs under one payer. Some states limit approval of atypical antipsychotics to children with specific diagnoses. There are 31 states that use prior authorization for at least some children enrolled in Medicaid, although the age requirement varies by state.
  2. Denial – Some states will deny the use of atypical antipsychotics for individuals under a certain age. The drug is not covered by the payer, with no exceptions. There are three states that deny antipsychotic coverage for children under a certain age, with no exceptions.
  3. Informed Consent – The process by which health care providers explain the consequences and benefits of a certain treatment or prescription drug in terms that can be easily understood by the patient. There are five states that use written informed consent for the general Medicaid population and at least nine states that require the use of written informed consent for the foster care population specifically.
  4. Psychiatric Consultation Hotlines – Some states focus on provider education and awareness before a drug is prescribed by offering free psychiatric consultation hotlines. The hotlines allow a physician or prescriber to consult on a child’s behavioral health issue and the best course of treatment. There are ten states that fund psychiatric consultation hotlines for children.

As Howard noted, “As this issue has gained more attention, states as are putting forth rules and regulations for the monitoring of children taking these medications. This is a good thing, and it is my hope that researchers will eventually be able to give us more guidance on the longer term effects of medication on youth.”

For more information on how states monitor antipsychotic prescriptions for children – and a complete state-by-state guide of medication policies – check out our latest market intelligence report: How Do States Monitor Atypical Antipsychotics Prescribed To Children?: An OPEN MINDS Market Intelligence Report. The report answers a number of questions including:

  1. Why Are There Concerns About Prescribing Antipsychotics To Children?
  2. How Many Children Are Prescribed Antipsychotics?
  3. What Are The FDA-Approved Ages For Atypical Antipsychotics?
  4. What States Have Guidelines On Prescribing Antipsychotics To Children?
  5. What States Have Initiatives To Monitor Antipsychotics Prescribed To Children In Foster Care?
  6. OPEN MINDS Resources On Use of Antipsychotic Drugs For Children

This report is free to all OPEN MINDS Circle premium members, and can be purchased in the OPEN MINDS e-Store for $495.


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