Let Them Eat Anti-Psychotics

I couldn't resist that title, but I must admit it isn't mine; the
author's post is href="http://pasadenasubrosa.typepad.com/pasadena_sub_rosa/2009/12/let-them-eat-antipsychotics.html">here. 




This is about the NYT article about the finding that children on
Medicaid are more likely to be prescribed antipsychotic medication,
compared to those with private insurance.  The obvious correlation
is that children with Medicaid are from poor families, whereas those
with private insurance are from families that have more
resources. 



It is one of those studies that documents an evocative finding, without
really telling you what it means.  It is up to everyone else to
decide what it means. 

href="http://www.nytimes.com/2009/12/12/health/12medicaid.html?_r=3&em=&pagewanted=all">Poor
Children Likelier to Get Antipsychotics

By DUFF WILSON

Published: December 11, 2009

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 href="http://content.healthaffairs.org/cgi/content/abstract/28/5/w770">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. ( href="http://pediatrics.aappublications.org/cgi/content/full/121/1/e157">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.