b.sahasranaman,md medical director henderson behavioral health · one in five children has a...
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B.Sahasranaman,MD
Medical Director
Henderson Behavioral Health
No conflicts of interest
No disclosures
Florida Medicaid Drug Therapy Management Program for Behavioral Health – administered by FMHI at USF
Psychotropic medication guidelines
Monitoring physical health in the context of psychopharmacology in children/adolescents: integrated care
Improve the quality of care and behavioral health drug prescribing practices, monitoring for safety and quality
Collaborative development of evidence and consensus-based psychotherapeutic medication guidelines
Collaborative development of edits to review practices through analysis of pharmacy claims
Provide educational and technological tools
to promote high quality prescribing
One in five children has a diagnosable behavioral health condition
Nearly 2/3rds get little help or treatment
Help is difficult to access
Nationwide, serious shortage of Child Psychiatrists especially in rural areas
2012 survey of 69 US children’s hospitals indicate families wait about 7.5 weeks on average to be seen by a child psychiatrist
Demand for child psychiatric services is projected to double between 1995 and 2020
PCPs are being asked more and more to manage behavioral health needs of children
There are reports that about 50% of Pediatric office visits involve behavioral, emotional, developmental, psychosocial, educational concerns
There are reports that 75% of children with psychiatric disorders are being brought to see pediatric PCPs
There are reports that between 1979 and 1996, psychosocial problems treated by Pediatric PCPs increased by 275%
Families typically have long term treatment relationships with their PCPs
Families may experience less stigma in coming to PCPs than to child psychiatrists
Primary care providers find lack of time as a challenge: At least twice as much if not more time is needed to address behavioral health needs during a PCP visit
Pediatric PCPs report lack of adequate knowledge as a challenge, only 5% of training time in pediatric residency is on Beh Health
Behavioral health issues are a leading cause of disability in children
Timely treatment and provision of Behavioral Health services is of paramount importance
Consequences of children not getting such care could be serious such as school failure, involvement with the criminal justice system, suicide etc.
Goal is to provide a guide to clinicians in the use of Psychotherapeutic medications in certain behavioral health conditions
Intended as a starting point, provide rational approaches to treatment
Cover a range of behavioral health conditions
Based on current Scientific knowledge/ thorough review of scientific literature and clinical consensus
Use of the guidelines is totally up to the clinician
The guidelines should be adapted and tailored to the individual’s treatment needs
The clinician and patient’s collaborative decision prevails in choice of treatment
◦ Convened “Expert panel”
◦ National and Florida experts
◦ Academic psychiatrists, CMHC psychiatrists, private practice
◦ Others: pediatricians, developmental pediatricians, clinical pharmacists
◦ Updated every 2 years
◦ First child guideline developed: 2008
◦ Most recent update: Sept 2014
Electronic copy –
◦ Available at http://medicaidmentalhealth.org
Paper copy –
◦ Stop by The Florida Medicaid Drug Therapy
Management booth.
OR
◦ Contact [email protected] to have copies mailed to you.
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ADHD
Aggression (Severe and Chronic, impulsive)
Anxiety Disorders
Bipolar Disorder (Acute or Mixed Mania)
Insomnia Disorder
Major Depression
OCD
PTSD
Schizophrenia
Tic Disorders
Principles of practice regarding the use of psychotropic medications under age 6
Dosing recommendations regarding use of antipsychotic medications under age 6
ADHD medications guidelines for children under age 6
Aggression (severe) under age 6
Anxiety Disorders in children under age 6
Major Depression in children under age 6
PTSD in children under age 6
ADHD
Aggression (Chronic, Impulsive)
Anxiety Disorders
Bipolar Disorder-(Acute Mania or Mixed Episodes)
Major Depression
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Tic Disorders
Guidelines are organized by “levels” of treatment recommendations
Level 0: is comprised of a thorough clinical assessment
Subsequent Levels 1,2,3,etc are based on the strength of scientific evidence and expert consensus regarding a particular agent or treatment option
The expert panel considered both safety and efficacy when assigning a treatment option to a level
Psychotropic medications are only one component of a comprehensive treatment plan
Bio-Psycho-Social model Social: Environmental factors/family
circumstances and relationships/trauma/disrupted attachments
Do medication benefits outweigh risks? Are there alternate interventions with
possibility of a good outcome?
What is the risk-benefit relationship between psychosocial interventions alone versus adding any psychotropic medication?
Is another agent with fewer side effects a better choice in managing the child’s symptoms?
Have parents/guardians consented to the medication knowing the risks versus benefits? Has the child assented?
Treatment needs to be individualized
Treatment targets need to be precisely defined-target a clear symptom
Do no harm, manage benefit: risk
Maximize response to one medication before adding another
If possible, change one medication at a time
Monitor progression towards treatment goals
Monitor for safety, side effects and effects of medication on physical health
Form a partnership with the parent and child
Acute Phase: Initiation of treatment, dose adjustments to maximize response and to minimize side effects
Maintenance Phase: Monitor for maintenance of treatment response, monitor side effects and effects on physical health
Discontinuation Phase: Medication is successfully tapered with minimal risk for relapse/recurrence
Thorough assessment
Must incorporate information from various sources – school, previous treatment records, therapist, case manager
Pay attention to psychosocial factors
Use of appropriate rating scales: eg Vanderbilt, PHQ9, BPRS
Prevalence of childhood obesity is reaching epidemic proportions
Serious public health problem
No sign of reduced prevalence
Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years
The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012
The percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period
In 2012, more than one third of children and adolescents were overweight or obese
Increased rates of metabolic syndrome, cardiovascular conditions
Increased rates of type 2 diabetes Diabetes was once a disease almost
exclusively in adults Increased rates of pediatric use of
antihypertensive, antidiabetic and antidyslipidemic medications
Childhood obesity goes into adulthood Individuals with mental illness have an
excess mortality, 2 to 3 X that of gen pop. 13 to 30 years shortened life expectancy
Pediatric obesity has been correlated with deficits in orbito-frontal cortical gray matter and cognitive functioning
Type 2 diabetes has been associated with additional structural white matter brain impairments
Obesity related to body image/low self esteem issues
Baseline medical assessment (thorough medical history, physical, baseline labs, height/wt, vitals)
Screen regularly for medication side effects
Monitor: use rating scales such as AIMS
Intervene: Lower dose, discontinue, treat side effects
Rapid increase in recent decades
Atypical antipsychotic prescriptions doubled among privately insured youth between 1997 and 2000 from 2.4 percent of all psychotropic prescriptions to 5.1 percent
National study of Medicaid-enrolled children found 62% increase of atypical antipsychotic prescribing from 2002 to 2007
The use of antipsychotic drugs for very young
children with behavior problems doubled between 1999-2001 and 2007.
Antipsychotic medication has tripled in last 10 to 15 years in children
Increase seems to be disproportionately higher among children with low family income and minority children
Evidence for efficacy and tolerability of AP medication in children is inadequate
Significant concern about weight gain and metabolic side effects
Greater tendency for cardiovascular changes in children than adults
Name of Atypical
Antipsychotic
Schizophrenia
Bipolar I
Disorder:Manic or Mixed
Irritability with
Autistic Disorder
Risperidone
√ (age 13-18) √ (age 10-18) √ (age 5-17)
Aripiprazole
√ (age 13-18) √ (age 10-18) √ (age 6-18)
Quetiapine
√ (age 13-18) √ (age 10-18) NO
Olanzapine
√ (age 13-18) √ (age 13-18) NO
Paliperidone
√ (age 12-18) NO NO
There is evidence supporting efficacy of single antipsychotics in youth for certain conditions
There is very limited or no evidence supporting the efficacy of using higher doses of antipsychotics or multiple antipsychotics
Severe aggression (impulsive)
Self-injurious Behaviors
Extreme Irritability
Extreme Impulsivity
Mood instability
Psychosis (positive symptoms)
Repetitive movements, Tics
Autism/Pervasive Developmental Disorders
ADHD alone and comorbid
Mood Disorders
Conduct Disorder
Oppositional Defiant Disorder
Obsessive-Compulsive Disorder
Tourette’s Syndrome
Schizophrenia and other psychotic disorders
An initiative of the ABIM Foundation
Launched in 2012
www.choosingwisely.org
Designed to Spur conversations about what medical treatments are appropriate and necessary
American Psychiatric Association joined the campaign in 2013
APA chose to address the prescription practices of anti-psychotic medication and issues 5 cautionary principles
1. Do not prescribe AP meds to patients for any indication without appropriate initial evaluation and ongoing monitoring
2. Do not routinely prescribe 2 or more AP medications concurrently
3. Do not use APs as the first choice to treat behavioral and psychological Sx of dementia
4. Do not routinely prescribe AP meds as first line intervention for insomnia in adults
5. Don’t routinely prescribe an antipsychotic medication to treat behavioral and emotional symptoms of childhood mental disorders in the absence of approved or evidence supported indications
www.choosingwisely.org
Drug (High Dose) Average Number of Patients Per Quarter – 2013
Risperidone 6-11 y/o >4mg/day 12-17y/o >6mg/day
242
Aripiprazole 6-11 y/o>15mg/day 12-17y/o>30mg/day
103
Quetiapine 6-11 y/o >400mg/day 12-17y/o>800mg/day
27
Olanzapine 6-11y/o >10mg/day 12-17y/o>20mg/day
23
Ziprasidone 6-11y/o>80 mg/day 12-17y/o>160mg/day
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Children and adolescents are more at risk for serious side effects including weight gain, extrapyramidal side effects, hyperprolactinemia, metabolic changes
These side effects may lead to increased rates of cardiovascular disease
Minimize side effects: start low/go slow, stop slowly, mono-therapy
Dystonia: A sustained muscle contraction Akathisia: A subjective feeling of motor
restlessness Parkinsonism: Tremor, rigidity, akinesia Tardive Dyskinesia: Irregular stereotypical
movements of mouth, face, jaw, tongue, choreoathetoid movements of fingers, arms, legs and trunk
Many antipsychotics increase prolactin level
Persistent prolactin elevation for up to two years has been documented in maintenance treatment with risperidone
Gynecomastia
Galactorrhea
Irregular menses, amenorrhea
Low bone density, osteoporosis
Sexual dysfunction
Some reports of associated increased risk of pituitary tumors
All antipsychotics have increased weight risk
Multiple antipsychotics further increase weight risk
Kids more susceptible to rapid and large weight gain
Some antipsychotics have weight independent direct metabolic effects
In 2003, FDA required a warning on diabetes risk for second-generation antipsychotic drugs
The American Diabetes Association and the American Psychiatric Association recommend glucose and lipid testing for all patients starting these medications
Despite this, there is documented low screening and monitoring rates in youth which is highly concerning
Initiating and continuing use of antipsychotics should be considered very carefully
Proactive cardiometabolic screening as part of routine clinical treatment
Integrated care with primary care
Ht/Wt/BMI –Every visit
BMI for age percentile in children
Pulse/BP—Every visit
Waist circumference
Labs: Fasting glucose/lipids at baseline, 3 mos, 6 mos, 6 mos thereafter
Hgb A1C
Consider more frequent monitoring if there is considerable weight gain
Reevaluate medication, risk-benefit ratio Consider alternative treatment strategies Health promotion and life style
intervention strategies: -Dietary counseling -Exercise -Lifestyle choices -Limiting electronics -Education
Younger kids are more sensitive to medication side effects than older youth
Limited evidence on efficacy of psychotropic meds in preschool children
Antipsychotic meds should be used extremely conservatively and carefully due to the potential for serious side effects
Developmental interventions e.g. speech therapy, occupational therapy; psychosocial interventions should be prioritized
Children with developmental disorders and
comorbid behavioral disorders – more sensitive to medication side effects
Many of these children are medically complex – Multiple diagnoses, multiple medications, multiple
prescribers (at increased risk)
– Psychotherapeutic medication management is
challenging
– Prescribers could include non-specialists that may
lack specialized training/experience
Psychotropic Medication Recommendations for Target Symptoms in Youth with Neurodevelopmental Disorders
Program Website:
http://medicaidmentalhealth.org
Edits to identify patterns of unusual prescribing
High Dose Indicators
Polypharmacy: >2 antipsychotics/3 or more antipsychotics (for >90 days concurrently), 5 or more different classes of psychotropic medications concurrently
Intervention include communication with prescriber, psychiatrist consultant-peer to peer visits etc
Initiated in April 2008: WHY?
Once started antipsychotic treatment tends to persist for multiple years
Diagnostic information on claims often do not support antipsychotic treatment
Concerns about the long term health of recipients
Child psychiatrists: 76
General Psychiatrists: 56
Pediatric Neurologists: 67
Neurologists: 59
Pediatricians: 34
Developmental Pediatricians: 16
ARNPs: 23
Q2 2008
Q3 2008
Q4 2012
Q1 2013
Q2 2013
# Applications 500 320 146 143 128
Severe Aggression
61% 69% 88% 78% 83%
Self Injurious Behavior
27% 29% 45% 35% 31%
Severe Impulsivity
41% 64% 59% 63% 64%
Severe Irritability
0% 0% 67% 64% 59%
More than 50% reduction in the number of requests
Use of more than one antipsychotic has stopped
Reduction in the proposed doses
Better monitoring rates:
-BMI from 11% in 2008 to 94% in 2013
-Labs from 11% (2010) to 41% (2013)
-TD screen from 6% (2010) to 54% (2013)
Florida Best Practice Guidelines
Thorough evaluation, identifying target symptoms, assessing degree of functional impairment
Comprehensive treatment plan incorporating non-pharmacological interventions
Adherence to evidence-based practices for prescribing psychotherapeutic medications
Careful monitoring of medication side effects and physical health, minimize side effects
Ongoing evaluation of medication benefits versus risks
Electronic copy –
◦ Available at http://medicaidmentalhealth.org
Paper copy –
◦ Stop by The Florida Medicaid Drug Therapy
Management booth.
OR
◦ Contact [email protected] to have copies mailed to you.
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