09

Psychotropic Use

Medicaid Child and Adolescent Mentally Ill Population

Andrea Y. Stevens

Auburn University, HADM 4920

Executive Summary

        The child and adolescent mentally ill population is a serious concern that plagues the entire nation. These individuals require special care and special medications. Medicaid has always been at the forefront of providing excellent care to the underserved, and the mentally ill population is not an exception. The Medicaid mental health program was designed to provide comprehensive mental coverage and at most times covering more than private insurers. This has lead to Medicaid being the single highest payer of mental health services.

In Medicaid mental health, medications play a major role. A major problem with the administration of psychotropic medications is the administration of these medications to the child and adolescent populations. These medications have proven to be potentially harmful and in addition, there is not enough empirical evidence to support their use. In order for Medicaid to continue to promise to remain at the forefront in the administration of mental health services, researchers must provide successful and reliable information on the use of psychotropic medications in children and adolescents.

Andrea Stevens

HADM 4920

Jennifer Johnson

July 20, 2009

Psychotropic Medication Use among the Medicaid Child and Adolescent Mentally Ill Population

The mentally ill population is a serious concern in the United States and according to a report entitled a National Action Agenda for Children's Mental Health, by Dr.David Satcher, the Assistant Secretary for Health and Surgeon General, “the nation is facing a public crisis in mental health for children and adolescents” (Satcher 1). The treatment and upkeep of these individuals is extremely critical in order for society to function at an optimal level. As in every arena of health care, CMS, Centers for Medicare and Medicaid Services, provides mental health care coverage to the underserved individuals who are in need of the services. In terms of funding for the program, “Medicaid is the single largest payer for mental health services in the United States, providing services and support for fifty eight million adults and children” (www.cms.hhs.gov/MHS/). Medicaid’s spending towards mental health services accounts for nearly one-sixth of the nation’s health care spending and one-half of the long-term care spending. Together the Federal and State governments work with advocates and have constructed an efficient program administering mental health services in order to fit the needs of each individual state. Each state has a mental health program that is unique to their particular state; however, the way in which each program is formulated and/or administered is subject to Federal regulations and guidelines.

There has been a substantial amount of progress in Medicaid’s mental health program since Medicaid was authorized in 1965 under Title XIX of the Social Security Act. For example, “there are now effective medications, evidence-based practices and other promising practices that can aid many individuals with serious mental illness to live fulfilling, productive lives in the community” (http://www.cms.hhs.gov/MHS/).  In addition to this remarkable progress, the Centers for Medicare and Medicaid services understands the errors in the mental health program. It is believed that in order for transformation to be a complete success “the system must be redirected towards its primary goal – helping adults with serious mental illness and children with serious emotional disturbances achieve recovery to live, work, learn and participate fully in their communities” (http://www.cms.hhs.gov/MHS/).  One of the most prevalent and/or serious issues that must be addressed by Medicaid when treating their child and adolescent mentally ill population, is the use of psychotropic medications. These medications vary in strength and are many in number. They have a substantial effect on child and adolescent development and furthermore have been proven to be potentially harmful to the individual in the short-term as well as in the long-term.

It is estimated that “one in ten children and adolescents in the United States suffer from a mental illness severe enough to cause some level of impairment; Fewer than one in five of these ill children will receive treatment” (http://www.nimh.nih.gov/health/publications/treatment-of-children-with-mental-disorders/index.shtml). In addition to this, a study done by the Massachusetts Department of Mental Health says this is approximately eleven percent of children ages nine through seventeen. Furthermore, “consistent with this estimate, 4 million youths may suffer from a major mental illness and have significant impairments at home, at school, and with peers” (Psychoactive Medication for Children and Adolescents: Orientation for Parents, Guardians, and Others, 2007, p.7). Although there is plenty of treatment and there are ample amounts of medication available to these children, there is also a lot of hesitation involved when it comes to administering the psychotropic medications to them.

There is a huge controversy over the use of psychotropic medications among the Medicaid enrolled child and adolescent population because of many reasons. For example, the long-term side effects that these medications may cause due to the fact that children have not completely developed; or the side effects may be too much for someone very young to endure as well as the issue of adherence to the medications. By definition, a psychoactive drug or a psychotropic substance is a “chemical substance that acts primarily upon the central nervous system where it alters brain function, resulting in temporary changes in perception, mood, consciousness and behavior” (www.wikipedia.org/wiki/Psychoactive-drug). These drugs have been proven to be affective for the management of many mental and emotional disorders. There are six major classes of psychiatric medications which are:  Anti-depressants, Stimulants, Antipsychotics, Mood Stabilizers, Depressants, and Anxiolytics. Under each one of the classes of medication falls specific mental and mood disorders that the medication is used to manage.

 Anti-depressants treat depression and some kinds of anxiety. They had been originally prescribed to adults; however, recently they have been used to treat children. There are several classes of anti-depressants and they are named for their chemical structure or the way they are thought to work in the brain. The four classes of anti-depressants are tricyclic anti-depressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and other anti-depressants. The selective serotonin reuptake inhibitors are the medications that have been more recently introduced into treating childhood and adolescent depression. Specifically those who have been given Fluoxetine combined with cognitive therapy have shown a substantial amount of progress. Although there are high suicide risks of children and adolescents with depression even though they are on medications, and the Food and Drug Administration was lead to require a “black box” warning for antidepressants prescribed to youth, there is a greater risk of suicide if depression goes untreated. The next class of psychoactive medications are stimulants. Stimulants are used to treat children who are hyperactive and inattentive. These medications improve behavioral control and cognitive performance. The effects that these drugs have on children are similar to those of caffeine. Research has proven that stimulants are in fact effective in the long-term; however, children and adolescents vary considerably in their responses to stimulants. For example, many of the children and adolescents who receive stimulants for treatment only receive partial relief for their symptoms. The next form of psychotropic medication is the most controversial when considered for use for children and adolescents; they are antipsychotics. Antipsychotics reduce psychotic symptoms in children and adolescents. They have been used to treat children with “schizophrenia and other psychotic disorders, reduce verbal and motor tics in children and adolescent with Tourette Syndrome, and reduce manic symptoms in adults and children and adolescents” (Psychoactive Medication for Children and Adolescents: Orientation for Parents, Guardians, and Others, 2007, p.27). They could be effective in reducing some abnormal behavior in children and adolescents with autism and mental retardation. There are two classes of antipsychotics, first generation antipsychotics and second generation antipsychotics. With the use of the first generation antipsychotics, there are significant risks of the individual developing movement disorders in the short term as well as in the long term. Second generation antipsychotics are capable of causing movement disorders as well but more than likely less frequently than the first generation antipsychotics. With second generation antipsychotics there has been a growing concern with metabolic risks such as weight gain, development of diabetes mellitus, and abnormal secretion of the hormone protactin. Along with these risks, the most effective drug Cloozapine has a small but definite risk of bone marrow suppression and those who take the drug must have a blood test every other week. All antipsychotics can be sedating and can interfere with optimal functioning. Furthermore, in Massachusetts, the Department of Social Services does not authorize the use of antipsychotics for children and adolescents in their custody because the use of them for treatment is considered to be harsh. Mood Stabilizers are used in the treatment of bipolar disorder, conduct disorder and ADHD, and violent aggression. They have been effective in the treatment of adults; however, their use for mentally ill children and adolescents has been controversial. Furthermore, an article entitled “Mood Stabilizers in Children and Adolescents” was published by the Journal of the American Academy of Child and Adolescent Psychiatry stating that “the efficacy of mood stabilizers in children and adolescents has not been studied adequately” and the article goes on to say that “In the absence of definitive studies in youth, physicians often base their pharmacological treatment decisions on extrapolation of scientific data from studies in adults” (Bhatara, Perel, Ryan, Vinod, 1999, p.1). From this research it can be concluded that much of what is known about these medications is known because of their use on adults.

Much of the controversy and/or problems arise when the child and adolescent population has been given these psychotropic medications proven to be effective for adults however, they have not been proven to be effective for the younger mentally ill population because of the dangers of testing them on children and adolescents. This has been an ongoing concern for those organizations that have long prided themselves in the administration of optimal health care. Medicaid mental health programs throughout the United States have conducted a substantial amount of research concerning the use of psychotropic medications and their effectiveness among the child and adolescent population.

Medicaid serves millions of low income children nationwide and in addition to these low income children, some of these individuals account for the hundreds of thousands of children and adolescents who receive mental health services. The Medicaid Medical Directors Network comprised a project called “A Data Dictionary and Workbook for Benchmarking ATYPICAL ANTI-PSYCHOTICS (AAPs) Use in Children: 2004-2007” and the purpose of the project was to, by State, benchmark AAPs in the Medicaid child and adolescent population, by paying special attention to “State differences in demographics, dosage, age, multiple AAP drug exposure, poly-prescribing, gaps in therapy, and other markers” (Medicaid Medical Directors Network, 2008, p.3). By examining these differences, the MMDN hoped to find correlations between the States on issues and “perhaps ‘best practices’ will emerge to help States discern processes to improve mental health prescribing” (Medicaid Medical Directors Network, 2008, p.3). This was an area of concern for the Medicaid Medical Directors Network because

“Atypical Anti-Psychotics represent the single highest drug class spend for Medicaid states. A significant proportion of the AAP use is ‘off label’ in children. This trend is growing and requires attention, data, and better evidence to address the right drug for the right reason at the right dose for the right age” (Medicaid Medical Directors Network, 2008, p.3).

In order for these problems areas to be addressed, the different States’ Medicaid Mental Health Programs must analyze their administration of these Atypical Anti-Psychotics to their child and adolescent population.

 The state of Connecticut was examined in a study entitled “Multiple Psychotropic Pharmacotherapy among Child and Adolescent Enrollees in Connecticut Medicaid Managed Care.” The objective of their study was “to determine the prevalence, patterns, and demographic correlate of multiple psychotropic pharmacotherapy in a statewide sample of low-income children and adolescents in community-based clinical care” (Martin, Scahill, Sherwin, Stubbe, Vanhoof, 2003, p.72). They wanted to analyze the effectiveness of administering multiple anti-psychotics to children and adolescents. In the study they found that 4.8 percent of the children enrolled in Medicaid received at least one psychotropic medication and of those 13.6 had been prescribed multiple psychotropic medications; this rate “is virtually identical to that reported in 1995 for children enrolled in Kansas Medicaid, the most recent for which comparable data are available” (Martin \’et al.\’, p.74). Furthermore, the majority of the individuals who had been receiving these psychotropic medications had been “in state custody, male, and older than other participants and less likely to be African American or Hispanic” (Martin \’et al.\’, p.72). The types of drugs that had been administered to the children and adolescents varied between the six different categories of psychotropic medications; however, stimulants, antidepressants, and mood stabilizers were the most commonly prescribed and the most common combinations of the drugs were antidepressants plus antipsychotics, stimulants plus antidepressants, and stimulants plus alpha2 agonists.

There is limited evidence that encourages the use of antipsychotics in children and adolescents and in reference to combined medications, the evidence is even more limited. Despite the proof of efficacy, “combined pharmacotherapy is becoming an increasingly accepted practice in pediatric psychopharmacology” furthermore, “in the hands of experienced clinicians, rational use of combined psychotropic medications may result in positive effects for the pediatric patient” (Martin \’et al.\’, p.73). Researchers and physicians have found that the drugs given in combination with other psychotropic medications could actually benefit the individual in their treatments as opposed to harming them. An example used in the Connecticut Medicaid Managed Care study says that “clinicians may resort to combination treatments in order to address a co-morbid condition or to augment the benefits of the medication” (Martin \’et al.\’, 2003, p.73). The concern with the use of multiple anti-psychotics for one patient is the fact that the ways in which drugs interact with one another could be potentially harmful and could lead researchers as well as consumers to believe it to be an unjustified practice and fraught with pitfalls. Furthermore, while there has been more and more empirical evidence to support the use of multiple pharmacotherapy to treat child and adolescent mentally ill populations, there is still “a gap between practice and research” (Martin\’et al.\’, 2003, p.73). This research and practice gap is present because of the lack of evidence due to the fact that children and adolescents are inadequate testing subjects. They are inadequate for testing because of their underdeveloped bodies which causes them to react to the anti-psychotics in ways an adult might not. With them being inadequate for testing leads to abuse of medications and these individuals could suffer from short-term as well as long-term problems.

By analyzing data and research conducted on the administration of psychotropic medication to the Medicaid child and adolescent mentally ill population some suggestions and conclusions can be made as to what will encourage progress in the current system. There are already some remarkable things that Medicaid has accomplished in terms of mental health services. For example, the services that children and adolescents receive through the Medicaid mental health program have proven to be more comprehensive than the majority of those who are privately insured. However, a major problem that has surfaced for Medicaid policy makers is the fact that more and more children qualify to receive mental health benefits than before. This has caused a spike in cost and in terms of medication, the more individuals who qualify for services, the more children there will be who need these medications. Medicaid “must now consider both seriously and less seriously ill children in making policy decisions, and this may dilute the program’s focus on the most seriously ill” with this issue at hand they now face administering more of the more serious psychotropic medications; These are the ones that have the least amount of empirical data to prove their safety (Glied and Cuellar, 2003, p.45). Safety is necessary in order for Medicaid’s mental health program to thrive. With the focus on the health and stability of its mentally ill child and adolescent population steps will be being taken in the right direction. One way that this can be ensured is that the medications that are being administered to children have empirical evidence supporting their efficacy. It must first be understood that a child’s body is different than an adults. In the sense that children undergo development faster than an already developed adult. Secondly, in child and adolescent mental health, the individual’s family is essential to understanding the disease of the child. The family is an important factor when it comes to what the child’s symptoms are and how to treat them. Finally, the way in which a child receives care and services for their disease is far different from that of an adult. Children and adolescents must interact at school and in the classroom their teachers and peers spend time helping to enforce their treatment; where as an adult’s environment is in the workplace.

In conclusion, in order to completely phase out the issues of the use of psychotropic medications among Medicaid’s child and adolescent mentally ill population, they must start at the very beginning. This includes analyzing populations, finding the seriousness of conditions in these populations, finding alternative medications until the child is able to manage the side effects effectively, ceasing to over prescribe, and most importantly researchers must provide enough empirical data to prove that these drugs will in fact be safe as well as effective. To look towards the future, the nation’s most critical asset, its children, must be preserved.

Works Cited

(2004). Treatment of children with mental disorders. National Institute of Mental Health, Retrieved July 2009, from http://www.nimh.nih.gov/publicat/index.cfm

(2007, January 17). Evidence lacking to support many off-label uses of atypical antipsychotics. Retrieved March 17, 2008, from Agency for Healthcare Research and Quality Web site: htt://www.ahrq.gov/news/press/pr2007/antipsypr.htm

(2008, August 8). A data dictionary and workbook for benchmarking atypical anti-psychotics (aaps) use in children: 2004 to 2007. Retrieved July 29, 2009, Web site: http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/

Bhatara, Perel, Ryan, Vinod, (1999, May). Mood stabilizers in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 38, Retrieved July 2009, from http://www.bpkids.org/site/PageServer?pagename=dt_ft_moodstabilizers

Glied and Cuellar, (2003, October). Trends and issues in child and adolescent mental health. Health Affairs, 22, Retrieved July 2009, from http://content.healthaffairs.org/cgi/reprint/22/5/39

Hoagwood, Burns, Kiser, Ringeisen, Schoenwald, (2001, September). Evidence-based practices in child and adolescent mental health services. Psychiatric Services, 52, Retrieved July 2009, from http://psychservices.psychiatryonline.org/cgi/content/full/52/9/1179

Howell, Embry (2004, August). Access to children's mental health services under medicaid and schip. The Urban Institute, B-60, Retrieved July 2009, from http://www.urban.org/UploadedPDF/311053_B-60.pdf

Mandell, Morales, Marcus, Stahmer, Doshi, Polsky, (2008). Psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders. Pediatrics, 121, Retrieved 2009, from http://pediatrics.org/cgi/content/full/121/3/e441

Martin, Scahill, Sherwin, Stubbe, Van Hoof, (2003 January). Multiple psychotropic pharmacotherapy among child and adolescent enrollees in Connecticut Medicaid managed care. Psychiatric Services, 54, Retrieved July 15, 2009, from http://www.psychservices.psychiatryonline.org/cgi/content/abstract/54/1/72

Massachusetts Department of Mental Health Division of Child and Adolescent Services Office of Clinical and Professional Services. (2007). Psychoactive Medication for Children and Adolescents: Orientation for Parents, Guardians, and Others. Massachusetts.

Overview mental health services. Retrieved July 2009, from Centers for Medicare and Medicaid Services Web site: http://www.cms.hhs.gov/MHS/

Park, Carolyne (2008, August, 31). Anti-psychotic drugs for kids get state look. Arkansas Democrat Gazette, Retrieved July 2009, from http://www.nwanews.com/adg/National/235834/print/

Patel, Sanchez, Johnsrud, Crimson, (2002).Trends in antipsychotic use in a Texas Medicaid population of children and adolescents: 1996-2000. Journal of Child and Adolescent Psychopharmacology, 12(3), 221-229.

Psychotropic Drugs. Retrieved July 2009, from wikipedia Web site: http://www.wikipedia.org/wiki/Psychoactive-drug

Satcher, David (2001, January 3). Report of the surgeon general's conference on children's mental health: a national action agenda. Retrieved July 29, 2009, from U.S. Department of Health and Human Services Web site: http://www.surgeongeneral.gov/topics/cmh/

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