On Wednesday, June 19, Substance Abuse and Mental Health Services Administration hosted a webinar on “Implementation of Models to Support Best Practice Prescribing Antipsychotics: SAMHSA Initiatives”. Justine Larson, MD, MPH, MHS for the Substance Abuse and Mental Health Services Administration and Gloria Reeves, MD, University of Maryland School of Medicine both presented on the current state of antipsychotic use in the United States and ways to prescribe medications to children in safer and more informed ways.
Dr. Larson cited that, in the 21st century the United States had a dramatic increase of antipsychotics prescribed to children and adolescents, and vulnerable groups such as children and youth in foster care. These children are prescribed at higher rates and are not prescribed in the safest and most effective ways. She said that these issues became apparent and that as a response the Child and Family Services Improvement and Innovation Act of 2011, created new mandates through Title IV-E. State child welfare agencies are to develop a plan for psychotropic medication oversight and are directed to increase the availability of therapies to address the trauma experienced by foster youth. By 2015, 45 states and the District of Columbia had employed at least one strategy to provide psychotropic medication oversight in foster youth. However, these programs varied and it was clear there needed to be a better approach to addressing the oversight issue.
In May 2018, SAMHSA held an Expert Meeting entitled “Strategies to Support Best Practice Prescribing of Antipsychotics in Children and Adolescents” to create a guidance document of strategies for Best Practice included Monitoring Programs for Antipsychotic Oversight, Supports for Best Practice Prescribing, and Delivery System Investments that focused on prior authorization of drug prescription. It also includes mandatory peer review and drug utilization reviews, such as looking closer at prescriptions for young children.
Best practice looks at sharing decision making tools for youth and family, to allow them to feel more empowered in making decisions about prescriptions, elective psychiatric consultation for the youth, and quality improvement for both of these practices so they enable the family and child to learn as much about treatment as possible. Delivery system investments include having trauma informed and evidence based system of care, public reporting and quality indicators of treatment, and care coordination between providers. Together, all of these practices create a comprehensive approach to keeping prescriptions of antipsychotics to a minimum and as safe as possible.
Dr. Reeves followed by proposing five ways prescribers should think about prescribing youth antipsychotic medication.
1. First, she advises that prescribers think about whether a medication is being used to treat a clinical diagnosis, such as anxiety or ADHD, or if it is being used to treat a target symptom, such as severe aggression. In both cases, there needs to be an ongoing assessment of the symptoms, which is different if there is only one symptom to be tracking.
2. Second, the importance of tracking both visible and invisible side effects of medication, along with short and long term side effects. Planning how to monitor invisible side effects can help and having a communication plan with both the prescriber and pharmacy about side effects and drug interaction issues are both important factors.
3. Third, assessing the benefits of the medication is important and includes having the child rate symptoms, tracking their functioning in multiple settings, and getting “observer” input from teachers, coaches, or anyone else who is in close contact with the child.
4. Fourth, tracking adherence to medication is important because not taking the medication can cause problems in tracking benefits and side effects. She says that adherence is a problem for almost all children at some point, whether they stop taking the medication because they don’t like the side effects, the stigma that comes with taking medication, they thing they feel better, or are worried about addiction. Dr. Reeves talks about reinforcing accurate reporting over “compliance”, using reminders, anticipating challenges, such as the child living in multiple homes, and considering if it is best to dose the medication while the child is at school.
5. Last, she discussed what she calls “missed opportunities”, problems that need an intervention other than medication, but contribute to the continuance of high dosages of medication. This could include trauma, learning disabilities, illness of a family member or friend, or substance abuse. These issues might not be discussed initially because of trust issues or because they are associated with stigma.
Dr. Reeves recommends avoiding “missed opportunities” by re-assessing the youth’s problems periodically over the treatment time, seeking input from those close to the child, considering formal evaluation of the child, obtaining history regarding safety concerns, and using strengths and coping strategies to assess underlying concerns.