In the early 2000s, concerns emerged regarding increases in prescribing psychotropic medication, specifically antipsychotic prescribing, to children, mainly due to the frequent use of antipsychotics to respond to disruptive behavior in children. Additionally, rates of psychotropic polypharmacy—use of multiple classes of medications simultaneously—were disproportionately high among Medicaid-enrolled children, particularly youth in foster care. This was a concerning finding given the documented long-term health impacts of these medications for children.
To develop plans for safe prescribing in Pennsylvania, the Pennsylvania Department of Human Services (PA DHS) partnered with PolicyLab to conduct an analysis of psychotropic prescribing among children enrolled in Medicaid. PolicyLab found that between 2002-2007, the number of Medicaid-enrolled children prescribed antipsychotics increased by 62%, many of whom had a diagnosis of attention deficit hyperactivity disorder (ADHD) and no other mental or behavioral health diagnosis. An additional 2014 PolicyLab study found that along with rising antipsychotic prescribing alone, rates of antipsychotic prescribing concurrently with other psychotropic medication classes had increased, despite limited knowledge of drug interactions and long-term impacts for children.
Following the release of this report in 2015, PA DHS introduced several policies aimed at reducing psychotropic prescribing to Medicaid-enrolled children with a specific focus on youth in foster care. Initial assessments identified declines in pediatric psychotropic prescribing, but little is known about how these changes may have differentially affected subsets of the state’s pediatric Medicaid population and whether the changes led to shifts in mental health diagnoses.
The COVID-19 pandemic has also disrupted access to mental/behavioral health services during a time when children have faced sustained psychological stress. Therefore, there is an urgent need to understand population-level psychotropic prescribing trends and any influence the pandemic may have had on declines in prescribing, particularly if the pandemic worsened preexisting disparities in off-label prescribing to youth by race and foster care status.
Following changes to prescribing guidelines in 2015, our team will examine longitudinal trends in psychotropic prescribing rates among Medicaid-enrolled children in Pennsylvania from 2016 to 2021. The analysis will pay particular attention to differences in rates of prescription by medication class and will identify possible differences in prescribing by race, age, foster care status and Medicaid payor region. Finally, we will examine changes in the number of children who were prescribed an antipsychotic medication and at least one other psychotropic medication class.
Our study will also assess changes in antipsychotic prescribing related to the COVID-19 pandemic when many health care practices and organizations implemented new workflows for conducting visits via telehealth. Given existing workforce limitations that have impacted access to child mental/behavioral health care, telehealth may be one long-term solution to provide access to care in areas of the state impacted by these limitations. However, concerns have also been raised about technology and cost barriers, or the digital divide, to accessing telehealth visits. This pilot study will allow us to examine potential changes in psychotropic prescribing occurring concurrently with these documented trends in child mental/behavioral health visit access, including telehealth, and identify potential opportunities for future analyses and policy intervention.
Findings from this pilot study will be the first to report on population-level trends across Pennsylvania about mental/behavioral health care utilization and prescribing since the implementation of the 2016 PA DHS policies and following the COVID-19 pandemic. Our findings will also help PA DHS understand not only the impact of their policies targeting psychotropic prescribing, but also the differential trends across Pennsylvania’s diverse population in access and psychotropic prescribing during a time of increasing child mental/behavioral health need.
The team will begin work on analysis in late 2022. Findings will be shared with PA DHS and then with a wider audience.
Children's Hospital of Philadelphia, PolicyLab. Analyzing Trends in Psychotropic Prescribing Among Pennsylvania Children Enrolled in Medicaid [Online]. Available at: http://www.policylab.chop.edu [Accessed: plug in date accessed here].