The relationship between mental health diagnosis and treatment with second-generation antipsychotics over time: a national study of U.S. Medicaid-enrolled children

Abstract

Objective: To describe the relationship between mental health diagnosis and treatment with antipsychotics among U.S. Medicaid-enrolled children over time.

Data sources/study setting: Medicaid Analytic Extract (MAX) files for 50 states and the District of Columbia from 2002 to 2007.

Study design: Repeated cross-sectional design. Using logistic regression, outcomes of mental health diagnosis and filled prescriptions for antipsychotics were standardized across demographic and service use characteristics and reported as probabilities across age groups over time.

Data collection: Center for Medicaid Services data extracted by means of age, ICD-9 codes, service use intensity, and National Drug Classification codes.

Principal findings: Antipsychotic use increased by 62 percent, reaching 354,000 youth by 2007 (2.4 percent). Although youth with bipolar disorder, schizophrenia, and autism proportionally were more likely to receive antipsychotics, youth with attention deficit hyperactivity disorder (ADHD) and those with three or more mental health diagnoses were the largest consumers of antipsychotics over time; by 2007, youth with ADHD accounted for 50 percent of total antipsychotic use; 1 in 7 antipsychotic users were youth with ADHD as their only diagnosis.

Conclusions: In the context of safety concerns, disproportionate antipsychotic use among youth with nonapproved indications illustrates the need for more generalized efficacy data in pediatric populations.

Figure 1

Leading Diagnostic Profiles Ranked by SGA Use, 2002 and 2007 Notes. Diagnostic profile variables were derived from primary diagnostic categories (ADHD; autism; anxiety; bipolar disorder; conduct disorder; depression; intellectual disability; schizophrenia; developmental delay or learning disability) to encode for single, two-diagnosis, and three or more diagnosis combinations for a given child. An “other” category was created as a composite variable of two-diagnosis combinations in which there were <5,000 children over the 6-year period. The diagnostic profiles were ranked by proportion of total SGA use in each year; the leading 10 diagnoses in 2002 and 2007 are shown. The remaining diagnostic profiles were aggregated.

Figure 2

Adjusted Trends in Mental Health Diagnosis and SGA Treatment among U.S. Medicaid-Enrolled Children: 3- to 5-Year Olds Note. Schizophrenia not shown due to low prevalence in this age group. Plots are ordered in rows by proportion of SGA use by diagnosis, with the top row having the lower proportions (y scale, right axis, 0–0.08) and the bottom row having the higher proportions (y scale, right axis, 0–0.8). Each graph plots three values from 2002 to 2007 (x axis). For example, for the 3- to 5-year olds with a diagnosis of ADHD (middle row), the probability of diagnosis increased from 0.01 to 0.02 over these 6 years (y axis, left scale), the probability of treatment increased from 0 to 0.001 (y axis, left scale), and the proportion of SGA use among those with a diagnosis of ADHD increased from 0.10 to 0.13 (y axis, right scale).

Figure 3

Adjusted Trends in Mental Health Diagnosis and SGA Treatment among U.S. Medicaid-Enrolled Children: Six- to Eleven-Year Olds Note. Plots are ordered in rows by proportion of SGA use by diagnosis, with the top row having the lower proportions (y scale, right axis, 0–0.2) and the bottom row having the higher proportions (y scale, right axis, 0–0.8). Each graph plots three values from 2002 to 2007 (x axis). For example, for the 6- to 11-year olds with a diagnosis of ADHD (middle row), the probability of diagnosis increased from 0.06 to 0.08 over these 6 years (y axis, left scale), the probability of treatment increased from 0.010 to 0.014 (y axis, left scale), and the proportion of SGA use among those with a diagnosis of ADHD increased from 0.14 to 0.17 (y axis, right scale).

Figure 4

Adjusted Trends in Mental Health Diagnosis and SGA Treatment among U.S. Medicaid-Enrolled Children: Twelve- to Eighteen-Year Olds Note. Plots are ordered in rows by proportion of SGA use by diagnosis, with the top row having the lower proportions (y scale, right axis, 0–0.2) and the bottom row having the higher proportions (y scale, right axis, 0–0.8). Each graph plots three values from 2002 to 2007 (x axis). For example, for the 12- to 18-year olds with a diagnosis of ADHD (middle row), the probability of diagnosis increased from 0.05 to 0.07 over these 6 years (y axis, left scale), the probability of treatment increased from 0.010 to 0.016 (y axis, left scale), and the proportion of SGA use among those with a diagnosis of ADHD increased from 0.20 to 0.25 (y axis, right scale).