The Corpus Callosum

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them -- but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children? ...

Note that the original research is not openly accessible, although the abstract can be viewed here.

The finding is not entirely new, although the treatment in prominent mainstream media is a new development.  In 2008, a similar study found a similar disparity in youth in foster care.  That study included only children on Medicaid, and found that those in foster care were more than three times as likely to be prescribed an antipsychotic medication. (Psychotropic Medication Patterns Among Youth in Foster Care).  Medicaid youth in foster care are not only poor, but in general, they come from highly distressed families. 

The report highlights a number of questions that have been percolating for years, if not decades.  It is reminiscent of debates over the use of methylphenidate (Ritalin) and other stimulants in children.  Those debates are decades old, and haven't really been settled. 

Antipsychotic medication does have legitimate uses in children.  Some of these uses are established pretty well; others have a fairly thin base of evidence.  Some kids do have psychosis as a result of schizophrenia or bipolar disorder.  Sometimes antipsychotic medication can be used to prevent major mood episodes in persons, including children, who have bipolar disorder.  This is true even if the patient is not actively psychotic.  These uses are not very controversial, although I am sure that some persons will argue with them. 

The problem is that the frequency of schizophrenia and bipolar disorder does not vary with socioeconomic status.  So it might be tempting to assume that if the medications are being prescribed solely to control symptoms of such illnesses, then the frequency of the prescriptions would not vary with socioeconomic status. 

This assumption is not entirely valid, for a couple of reasons.  It could be true, that persons predisposed to such illnesses will have an earlier age of onset, or a more abrupt onset of acute symptoms, in the face of psychosocial stressors.  That could account for the greater use of the medication in persons who have more severe stressors. 

However, without a careful accounting to show that the variation in prescribing can be attributed to these factors, it is important to examine the possibility that the disparities could indicate that some inappropriate prescribing is taking place.

The NYT article mentions a possibility:

Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do. Part of it may have to do with the challenges that families in poverty may have in consistently attending counseling or therapy sessions, even when such help is available.

"It's easier for patients, and it's easier for docs," said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases include children and adolescents covered by Medicaid and who sometimes prescribes antipsychotics...Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need.

I'll step in for a second with a personal observation: I have seen many cases in which I thought that antipsychotic medication was being used when it was not necessary.  More commonly, I can see a rationale, but I see kids who are taking does that are higher than necessary, or who are taking multiple medications when there is no apparent rationale for polypharmacy. 

On the other hand, I also should point out that I have seen kids on very high doses of antipsychotic medication, and have reduced the dose, only to find that the kids really do need those high doses.  That is not common, but it does happen.  This illustrates a very important point: each person is different; it is hazardous to draw general conclusions and then apply those conclusions to each individual.

The article does provide a balancing counterpoint:

Some experts even say Medicaid may provide better care for children than many covered by private insurance because the drugs -- which can cost $400 a month -- are provided free to patients, and families do not have to worry about the co-payments and other insurance restrictions.

"Maybe Medicaid kids are getting better treatment," said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. "If it helps keep them in school, maybe it's not so bad."

This is a valid point.  It does not ease my concern very much, but it does help some.  It is important to recognize the fact that the problems that these kids have are serious.  The problems can have serious consequences, such as fragmentation of the family, educational failure, and incarceration.  These consequences can affect a person for a very long time.  So in some cases it is worth taking some risk, in order to lower a different risk.

There are additional issues with the prescribing patterns that the article does not address.  What is the role of the drug manufacturers in the prescribing patterns?  Are there problems with the prescribers not being educated properly?  Are patients and/or families (and caregivers, educators, etc,) pressuring providers to get these prescriptions?  How valid are the diagnoses being given?

I often see written evaluations of children, in which it is reported that the kids said they were hearing voices or seeing things.  But the kid shows no other indication of psychosis: no behavioral changes, no loose associations, no negative symptoms.  And they never again say they are having hallucinations.  So why did they say it when they first came in for treatment?  It happens all the time.  An unseasoned practitioner could easily take that as evidence for a major mental illness, and prescribe an antipsychotic medication that is not needed. 

There are some problems in the article that I would like to point out.  One of these happens to be a pet peeve of mine:

...children covered by Medicaid are given powerful antipsychotic medicines...

Get that?  Not only are these medicines antipsychotic, but they are powerful antipsychotic medications.  Just what does the adjective powerful contribute to the story?  There is no scientific distinction between drugs based on power.  The adjective does not denote to anything about the drug.  Rather, it denotes the journalist's emotional response to the subject matter.  Readers do not need to know how strongly the journalist feels about the subject.  And if they do, then the journalist should state that directly.  He or she should not slant the story in a way that conveys this emotional impression.

The other flaws are more serious:

...The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders -- especially when the children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these "off label" uses, there have been no long-term studies of their effects when used for such conditions...

Two problems here.  one is the use of the phrase "so-called conduct disorders."  That is a value judgment.  It has no valid place in the story.  I would invite the author to try to raise a couple of kids with conduct disorder.  This is a very serious matter.  It is not helpful harmful for him to trivialize it.  Kids with conduct disorder beat people up, shoot people, steal cars...get drunk...and crash the cars, and so forth.  We can debate the question of whether it makes sense to give them antipsychotic medication, but I cannot tolerate an implied trivialization of the problems. 

 The other problem is this: "there have been no long-term studies of their effects when used for such conditions."  This is not necessarily true.  The absence of an FDA indication for a drug does not mean that there have not been studies.  It means that the company that makes the drug has not gone through the process of getting approval for that indication.  Studies -- long-term or otherwise -- may very well have been done. 

It is very expensive for a company to submit an application for a new indication.  If the patent(s) on the drug has/have expired, it is very unlikely that anyone is going to go through the expense of obtaining FDA approval for a new indication.  Clozapine and risperidone (two atypical antipsychotic medications) are already past their patent life. 

It is not only expensive to get approval for a new use, but it takes a long time.  The patent for Seroquel expires in 2012.  If AstraZeneca (makers of Seroquel) started working on a new indication now, it is possible that it would not be complete before the expiration of the patent.  From a financial point of view, it would be a waste of money.  It would benefit the makers of the generics more than it would benefit AstraZeneca.

The bottom line is that this is a complex issue, it is easy to make snap judgments, but hard to figure out exactly what the study means.  I suspect that follow-up research will demonstrate that there are a lot of unnecessary prescriptions being given, that the doses often are too high, and that our overall care system does overemphasize medication while underemphasizing psychosocial treatments.  It also may show that doctors and other providers are not spending enough time with the patients and their families, not getting enough collateral information, and not providing sufficiently close follow-up.  Itr may turn out to be true, that the care system is trying to treat poverty with prescriptions.  But we need to be thoughtful about these things, not draw hasty conclusions, and not apply the conclusions too broadly.  We need to consider how this care is being funded, and we need to appreciate the consequences of not providing sufficient funding to address these problems optimally.