PolicyLab

PolicyLab has and continues to examine the national problem of over-prescription of psychotropic medication, particularly among publicly insured children and adolescents and those involved with the child welfare system. Our most recent report, Psychotropic Medication Use by Pennsylvania Children in Foster Care and Enrolled in Medicaid, highlighted some concerning statistics.

As with many studies that provide us with unsettling results, we are left thinking, “Why?” Devoid of context, one might assume that the problem lies with physicians as the prescribers of these medications. However, as PolicyLab co-Director Kathleen Noonan pointed out in a recent interview with Medscape, “This is not a story about bad doctors; it’s about limited resources…We need pediatricians at the table when these policy and resource decisions are made. Their experiences with families and children must shape the policy about the appropriate use of medications.” As PolicyLab authors have noted in a previous blog post, the over-prescription of psychotropic medication to youth is a complex issue and rooted, we believe, in a lack of availability, access, and reimbursement for alternative mental and behavioral health therapies. The downstream effect of this resource limitation is felt by physicians treating youth presenting with real behavior-related crises that may jeopardize family stability, school stability, foster care placements, and most importantly, the child’s well-being.

With this in mind, PolicyLab has begun the initial phase of our next project – a qualitative exploration of physician attitudes on psychotropic prescribing practices among children and adolescents. This is a vital step in understanding the current context – the systems, resources, barriers to care, and human interactions and reactions – in which youth in foster care are prescribed psychotropic medications at significantly higher rates than other youth.

Exploring the issue qualitatively

You may ask: are these differences in prescribing rates justified by the disproportionate need among children in foster care who are experiencing more trauma? Or, is the system failing to properly treat children in foster care, and instead relying too heavily on powerful drugs that abate difficult behaviors, but may cause some significant side effects? We don’t know yet. Most likely, the answer is somewhere in the middle of these two extremes, and there are a number of other complex factors shaping systems and individual behaviors.

To find the answer, our team is interviewing providers from all over the state of Pennsylvania to ask them how they make decisions about prescribing psychotropic medications. Anticipating that certain factors will impact an individual’s practices, we are making sure to speak with psychiatrists, pediatricians, and family medicine doctors in both urban and rural settings about the types of behavioral problems they see in their communities, how they assess and treat behavioral problems, and the resources they depend on (whether present or absent) to provide the best care. While we have only just begun interviewing providers, there is already a great deal of variation between provider responses. We are hearing about the difficult circumstances physicians wrestle with, ranging from pressure from the family or school system for an immediate solution for behavioral health issues to month-long waiting lists for an appointment with a behavioral health specialist.

Implementing change

Unlike many others, this study does not stop with a description of the problem. This brings me to one of the reasons I am so excited about this study; it truly mixes qualitative methods and implementation science with a randomized control trial. After gaining a better understanding of this issue from our qualitative interviews, we will use this knowledge to create meaningful guidelines for psychotropic prescribing that respond to physician-defined needs. These guidelines will then be disseminated to physicians, and we will measure their impact using Medicaid claims data. And here is where this study turns into a randomized control trial: providers will be randomized to receive either the standard guidelines or guidelines paired with narratives created from real physician experiences gleaned during interviews. Previous work by our collaborator, Dr. Zachary Meisel, suggests that the use of narratives improves provider recall of guidelines, likely increasing the impact of guidelines disseminated in the medical community. Our current project aims to test this premise: while narratives increase recall, can they change clinical practice?

In the end, we will know whether or not our hypothesis – that stories will help physicians retain and apply the guidelines – is true. And more broadly, we will learn something about how to communicate research findings in a way that actually shapes behaviors – no small feat, if you ask me.