The New York Times recently reported some disturbing differences in the psychiatric care received by poor children on Medicaid and children from families with physicians in private practice. Part of the story is the surging use of adult antipsychotics to treat American children from all economic backgrounds.
A December 2009 story in the Times, “Poor Children Likelier to Get Antipsychotics,” reported that these adult medications are prescribed four times more frequently for Medicaid children, as well as more often for children in foster care. Then an article just last month, “Child's Ordeal Shows Risks of Psychosis Drugs for Very Young,” told how a boy from an impoverished Louisiana family, misdiagnosed at 18 months, ended up being given half a dozen powerful drugs every day by the time he was 3. The drugs included adult medications such as Prozac, as well as the antipsychotic Risperdal, commonly prescribed in cases of full-blown schizophrenia.
Professionals commenting in the Times on the disparities in care said that a poor child or a foster child is unlikely to receive a full mental health assessment before a course of treatment begins, and that drugs are cheaper (in the short term, at least) than individual psychotherapy and family counseling.
Washington now leads several states in curbing the disproportionate use of antipsychotic drugs for poor children, according to a study that began as a collaborative project called Too Many, Too Much, Too Young. In June, Rutgers University's Center for Education and Research on Mental Health Therapeutics and the Medicaid Medical Directors Learning Network published the 16-state report, “Antipsychotic Medication Use in Medicaid Children and Adolescents.” The Rutgers report described Washington strategies that have driven a 40 percent reduction this year in the use of antipsychotics to treat children on Medicaid — and that have begun influencing approaches in other states.
One innovation is a Partnership Access Line (PAL) funded by the Washington legislature, which lets pediatricians anywhere in the state telephone child psychiatry specialists affiliated with the UW and Children's Hospital for consultations about a child with apparent mental health issues. Another is Washington's law requiring a second opinion from a psychiatrist if ADHD medications are going to be prescribed in combination with other drugs, in dosages exceeding pre-defined safety thresholds, or to children under 5.
Dr. Jeffery Thompson, chief medical officer for Washington state's Medicaid program, pointed to a study published last year that demonstrated the positive impact of the state's second-opinion mandate on reducing inappropriate prescriptions for ADHD drugs. “Now we're working on (a similar goal for) antipsychotics,” he said.
Prescriptions of adult antipsychotics for children rose fivefold in America between 1993 and 2002, according to the Rutgers study. “The community has been looking for easy solutions to very difficult problems,” Thompson said.
But solutions are complicated. “First we need to use better diagnostic tools,” he said, referring to a recent spike in the number of moody, mercurial children diagnosed as bipolar. According to a report by the National Institutes of Mental Health, diagnoses of pediatric bipolar disorder rose 40 percent in the decade leading up to 2007. A 2009 New York Times article suggested that this nationwide increase was largely fomented by an influential Harvard psychiatrist who was paid huge fees by pharmaceutical companies to consult, lecture, and write about their newest bipolar disorder drugs.
Said Thompson, “We called it a disease, and we had drugs, but it's not that simple. We learned a lesson (about) categorizing something and just throwing a drug at it. We need to offer mental health therapies that are not (all) prescription-based.” Some people believe in the exclusive effectiveness of either medications or psychotherapy, he said, but there is “magic” in both, and a combination can be more effective than either one alone.
“We need a more comprehensive approach,” agreed Dr. Eric Trupin, director of the Evidence Based Practice Institute, in the UW medical school's department of psychiatry and behavioral sciences. Yet, he said, “fewer than half of the children on psychotropic medications being paid out of Medicaid are getting psychosocial treatment” such as therapy or family counseling.
“In terms of best practices, we want to see that the family is getting good psychosocial support,” Trupin said. If children have “hyperactivity, are inattentive, meet the criteria for ADD (Attention Deficit Disorder), they can get some meds that may help them slow down."
"But typically the problem is that their social relationships, academic skills, and responses to parental inputs are not developing well. The parents need help, need guidance” of a kind that is too rarely provided, said Trupin. “If you have medications for diabetes but bad nutrition, you’ll continue getting bad results.” Similarly, a child with a psychiatric disorder whose parents don't know how to work with him needs more from doctors than doses of chemicals.
Drugs have taken precedence in treating mental illness, Trupin said, because “comprehensive evidence-based treatment is more expensive. But only in the short term. In the long run it saves money.” (It's common knowledge now that people with inadequately treated psychiatric disorders get worse over time and draw heavily on expensive public resources such as ERs and prisons. Less well known are the millions of dollars that the poorly treated mental illnesses of employees cost businesses every year, and the extraordinary amounts of teacher time and attention that some students lacking skillful mental health care require in public schools including Seattle's.)
Trupin added that pediatric consultations with the Partnership Access Line, along with the state's second-opinion law restricting ADHD prescriptions, are helping to spread throughout the state some best practices for children who need mental health care. “But there is a real need to advocate for providing psychosocial interventions as well as medications.”
He emphasized that “the effects of adult medications on the developing mind and body of a child are not fully known.” About the disproportionate prescribing of antipsychotics to children on Medicaid he wryly commented, “We're doing experiments on poor children.” It is “incumbent on us,” said Trupin, to give effective psychiatric assessments and appropriate psychosocial treatment to all children with mental health care needs.
Reducing the medications taken by children with mental illnesses is an important part of the work of Dr. Jack McClellan, medical director of the Child Study and Treatment Center. The Center is Washington's only state hospital for children suffering from mental illnesses and is run by DSHS. McClellan told me in a phone interview that his young patients arrive at the hospital “quite ill, unresponsive to other interventions, and medicated” with perhaps four different prescriptions.
Antipsychotics help children in some circumstances, according to McClellan. “There's no doubt that they reduce aggressive behavior. In a situation where kids are being aggressive and families are frustrated, and behavioral therapy isn’t available,” it can make some sense to prescribe them alone. But through psychotherapy and related practices at the Child Study and Treatment Center “the goal is by the time they leave to get them down to one or two, or sometimes none.” The children, who range in age from 5-17, eventually go home to families or group residences, but “these are complex kids,” said McClellan. “They'll need more than medications, including wraparound services and behavioral treatment.”
Thirteen percent of children between the ages of 8 and 15 have a psychiatric disorder, according to the National Institutes of Mental Health. Asked why so many youngsters are diagnosed with serious mental illnesses today, McClellan replied that there's no certain answer, but the “tendency in the last decade has been to take what have been adult diagnoses and apply them downwards. It doesn’t necessarily reflect what’s happening with youth.”
He affirmed that “a significant number of kids are struggling” today, but what can happen is that some adults have “a classic real old-fashioned disorder that needs medication, and we apply the same name to those kids. Studies show that the rise in bipolar diagnosis in the pediatric population completely parallels the rise in the medications” used to treat bipolar disorder in adults.
The statistical increases in childhood mental illness can also be seen positively, as reflecting stronger efforts on the part of concerned adults to get treatment for kids who are struggling, added McClellan. “And like it or not, it’s easier to get qualified help if you have a name for the problem.” However, “once you start calling an illness by a name,” it takes on a reality of its own. If the illness is considered “a thing,” he said, people think “there must be a thing to treat it with.”
More effective therapies for children need to be made widely available, said McClellan. “There are psychosocial treatments that help, but it's hard to find people who know how to do them. And even those are not perfect, not panaceas.” For Trupin, too, “Children should not be getting treatments that the data do not show to be effective.” This goes for any medicine prescribed alone, Trupin said, but it also goes for medications “in combination with the wrong kind of psychosocial treatment.”
What Trupin called America's quick-fix mentality hinders progress in treating mental illness. “We’re a nation of people who like outcomes, people who get annoyed when the U.S. economy isn't fixed right away, people acculturated to be successful,” he told me. “It’s an irritant to many Americans if you respond to a problem by saying, 'It’s more complicated than that.' They get annoyed if you say, 'Medicine is one component. Here’s what else we have to do.' It's easier to prescribe the medicine.”