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8/13/2015 12:00 AM

While concerns continue to be raised about the safety of antipsychotic treatment for young children, a new study examining antipsychotic prescription patterns among young people in the United States has found that most office visits by children and adolescents that involve antipsychotic treatment do not include a clinical mental health diagnosis. The research, first published online in JAMA Psychiatry in July, will appear in print in September.

While concerns continue to be raised about the safety of antipsychotic treatment for young children, a new study examining antipsychotic prescription patterns among young people in the United States has found that most office visits by children and adolescents that involve antipsychotic treatment do not include a clinical mental health diagnosis. The research, first published online in JAMA Psychiatry in July, will appear in print in September.

Clinical trials support the efficacy of several antipsychotics for child and adolescent bipolar mania, adolescent schizophrenia and irritability associated with autism in adolescents and children as young as 5 (risperidone) and 6 (aripiprazole), according to the study, “Treatment of Young People With Antipsychotic Medications in the United States.”

In this setting, the clinical diagnoses associated with antipsychotic treatment vary with patient age. For example, a larger percentage of child (63 percent) than adolescent (33.7 percent) visits with antipsychotic treatment include disruptive behavior disorder diagnoses, while the reverse is true of bipolar disorder diagnoses (12.2 percent for child vs. 28 percent for adolescent).

Concern, noted researchers, has particularly focused on the safety of antipsychotic treatment of young children. In preschool-aged children, a paucity of research on psychiatric diagnoses complicates patient selection, the known efficacy of antipsychotics is limited largely to irritability associated with developmental disorders, and adverse metabolic and endocrine effects are pronounced.

The national prevalence of antipsychotic use by young people is not known, say researchers. In the Medicaid program and some private insurance plans, antipsychotic use increased among young people during the late 1990s and early 2000s. A growing awareness of increasing use and safety concerns may have tempered antipsychotic treatment of young people, said researchers.

“This study represents the first national estimate of the trends in antipsychotic use among young people in the U.S.,” Mark Olfson, M.D., M.P.H., professor of clinical psychiatry and research psychiatrist at Columbia University and the New York State Psychiatric Institute, and lead researcher, told MHW. “There’s a lot of concern about the extent to which children are treated for conditions outside FDA-approved indicators.”

Olfson added, “We were particularly interested in which groups are most likely being treated and what they are being treated for.”

Study method

Researchers performed a retrospective descriptive analysis of antipsychotic prescriptions among patients ages 1 to 24 with data from calendar years 2006 (765,829), 2008 (858,216) and 2010 (851,874), including a subset from calendar year 2009 with service claims data (53,896). They retrieved data from the IMS LifeLink LRx Longitudinal Prescription database, which includes approximately 60 percent of all retail pharmacies in the United States. Denominators were adjusted to generalize estimates to the U.S. population.

Results

In contrast with earlier reports of increasing antipsychotic treatment of U.S. children through the early 2000s, the percentage of children treated with antipsychotics was lower in 2010 than in 2006. Among adolescents and young adults, however, antipsychotic use increased during this period.

The research noted that boys ages 11–17 diagnosed with attention-deficit hyperactivity disorder (ADHD) represented the highest use of antipsychotic treatments, said Olfson. Antipsychotics are used to manage aggression and other symptoms in ADHD, especially in boys that age, Olfson said. Risperidone (Risperdal) has been used with stimulants to reduce the severity of the ADHD conduct disorder, he said. Antipsychotics are not approved by the Food and Drug Administration (FDA) to treat ADHD, Olfson said.

Olfson noted that if the antipsychotic medications have to be used for children with disruptive or aggressive behaviors that they are being used very sparingly and only for short periods of time.

Of all antipsychotics, risperidone is the most widely used in the young, said Olfson. There has been research that shows that it is effective in treating autism-related symptoms like irritability, he said.

Researchers found that the percentages of young people using antipsychotics in 2006 and 2010 were, respectively, 0.14 percent and 0.11 percent for younger children, 0.85 percent and 0.80 percent for older children, 1.10 percent and 1.19 percent for adolescents, and 0.69 percent and 0.84 percent for young adults.

In 2010, males were more likely than females to use antipsychotics, especially during childhood and adolescence: 0.16 percent vs. 0.06 percent for younger children, 1.20 percent vs. 0.44 percent for older children, 1.42 percent vs. 0.95 percent for adolescents and 0.88 percent vs. 0.81 percent for young adults.

Approximately 29.3 percent of younger children treated with antipsychotics in 2010 received one or more antipsychotic prescriptions from a child and adolescent psychiatrist. Among young people with claims for mental disorders in 2009 who were treated with antipsychotics, the most common diagnoses were ADHD in younger children (52.5 percent), older children (60.1 percent), and adolescents (34.9 percent), and depression in young adults (34.5 percent).

Researchers noted that in the merged 2009 medical claims and LRx sample, most of the younger children (60 percent), older children (56.7 percent), adolescents (62 percent) and young adults (67.1 percent) treated with antipsychotics had no outpatient or inpatient claim that included a mental health diagnosis.

The study found that among antipsychotic-treated children and adolescents with mental disorder claims, the most common diagnosis was ADHD (younger children, 52.5 percent; older children, 60.1 percent; adolescents, 34.9 percent). Depression was the most common diagnosis among young adults (34.5 percent), followed by bipolar (26.6 percent) and anxiety disorder (22.9 percent).

Psychological interventions lacking

Researchers also found a low rate of psychological intervention and counseling among young children receiving antipsychotic medication, said Olfson. “We were surprised that more prescriptions weren’t [prescribed] by child and adolescent psychiatrists, especially for younger children,” said Olfson.

Olfson added, “Most of the younger children were getting their medication from other kinds of physicians.” The research found that three of 10 children ages 1 through 6 treated with antipsychotics were being treated by a child psychologist, he said.

Another concern is that not enough children are going to see a specialist, said Olfson. “There are not enough child psychiatrists in the area where the child exists,” he said. “It’s a workforce issue.”

Despite the efforts of state education campaigns and others like the American Psychiatric Association’s “Choosing Wisely” campaign — which aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence and free from harm — it’s surprising to continue to see increases in antipsychotic medication use, said Olfson.

 “We need to learn more about the sequences, about the children who are receiving the dosing and for how long and whether the medications are safe and effective,” said Olfson. “There’s a lot we need to learn.”

Preschool-aged children presenting for mental health care should receive a comprehensive psychiatric assessment and a trial of psychosocial intervention before considering psychopharmacologic treatment, study authors recommend.

Clinical policymakers have opportunities to promote improved quality and safety of antipsychotic medication use in young people through expanded use of quality measures, physician education, telephone- and Internet-based child and adolescent psychiatry consultation models, and improved access to alternative, evidence-based psychosocial treatments, researchers concluded.

Bottom Line…

It is recommended that preschool-aged children presenting for mental health care should receive a comprehensive psychiatric assessment and psychosocial intervention before considering psychopharmacologic treatment.

8/6/2015 12:00 AM

The quest for mental health reform is gaining even greater traction in Congress following the introduction August 5 of Senate legislation to reform the country’s mental health system. The Mental Health Reform Act of 2015 represents months of collaboration among mental health professionals, policy experts, consumers and family members.

The quest for mental health reform is gaining even greater traction in Congress following the introduction August 5 of Senate legislation to reform the country’s mental health system. The Mental Health Reform Act of 2015 represents months of collaboration among mental health professionals, policy experts, consumers and family members.

Senators Chris Murphy (D-Conn.) and Bill Cassidy (R-La.) introduced S. 1945, which calls for strengthening transparency and enforcement of mental health parity, establishes new grant programs for early intervention and a new Serious Mental Illness (SMI) Coordinating Committee that will document and promote research and treatment related to SMI.

Among its provisions, the bill designates an assistant secretary for mental health and substance use disorders within the U.S. Department of Health and Human Services (HHS) who will be responsible for overseeing grants and promoting best practices in early diagnosis, treatment and rehabilitation.

Additionally, the secretary will work with other federal agencies and key stakeholders to coordinate mental health services across the federal system and help them to identify and implement effective and promising models of care, according to a joint release from Cassidy and Murphy.

The legislation repeals the current Medicaid exclusion on inpatient care for individuals between the ages of 22 and 64 if the Centers for Medicare & Medicaid Services (CMS) actuary certifies that it would not lead to a net increase of federal spending.

Critical reforms

The bill would also make critical reforms to allow for patients to use mental health services and primary care services at the same location, on the same day. “We’re pleased to see in the Murphy/Cassidy bill a clarification on Medicaid same-day billing,” Rebecca Farley, director of policy and advocacy for the National Council for Behavioral Health, told MHW. Currently, there’s a lot of confusion and variability around whether clinics can bill for both mental health and physical health services on the same day, she noted.

The legislation provides an important clarification for integrated care around the country, she said. The bill requires states to identify barriers to integration. According to the legislation, states would be eligible for grants of up to $2 million for five years, prioritizing those states that have already taken action. States taking part are eligible with additional federal funds to treat low-income individuals who have chronic conditions or serious and persistent mental illness.

Farley said the National Council is pleased that Murphy and Cassidy’s bill includes important modifications to the Health Insurance Portability and Accountability Act (HIPAA), such as funding support for training health care providers, patients and families on their rights and responsibilities under HIPAA. “There’s so much confusion around HIPAA; it’s important that families understand what their rights are,” she said.

“We appreciate that the bill codifies the 5 percent set-aside for the Mental Health Block Grant,” Farley said. The funds can be used for innovations based on the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode (RAISE) program.

The bill strengthens parity compliance as well as enforcement of parity, she said. “We’re also pleased that there is a strong focus on integrated care,” Farley said.

Farley pointed out one of the differences between S. 1945 and H.R. 2646 (the Helping Families in Mental Health Crisis Act), Rep. Tim Murphy’s (R-Pa.) reform legislation. Although both bills would appoint an assistant secretary for mental health and substance use disorders, Murphy and Cassidy would keep the authority within SAMHSA, while the congressman’s bill proposes to transfer all SAMHSA authority to the new secretary, said Farley.

Another provision included in Rep. Murphy’s bill but lacking in the Senate bill is the two-year extension of the Excellence in Mental Health demonstration program, said Farley.

Overall, the reform legislation elevates the conversation around mental health reform. Both bills aim to take different approaches to strengthen this country’s mental health system, Farley said. “We are thrilled to see this level of attention on mental health,” she said.

Early intervention

Paul Gionfriddo, the president and CEO of Mental Health America (MHA), said that advocates were very pleased to see the emphasis of screening and early intervention and integration in the Mental Health Reform Act of 2015. “In our minds those are the most important pieces to reform a mental health system,” Gionfriddo told MHW. “We need to stop waiting for a crisis to occur. We need to act before stage four.”

Gionfriddo noted that many of the provisions of S. 1945 mirror closely those of H.R. 2646. “There is an emerging consensus that screening and early intervention are important to people in both chambers and that they’re making those the centerpieces of mental health reform,” he said. “We’re very pleased to see that.”

On whether or not Congress can work together to pass comprehensive mental health reform, Gionfriddo said it should occur this year. “The bills are similar enough that members should be able to compromise and work it out," he said. 

Although some organizations have endorsed both bills, MHA has not officially endorsed either one, said Gionfriddo. “We’re working with both chambers to persuade them to amend the legislation in a better way,” he said. There should, for example, be some enhancement around the peer workforce, he noted.

The language in the Senate bill currently references peer specialists who work in clinical settings, he noted. “We don’t want to undermine the entirety of the peer community. Peers are working in all states and in nonclinical settings,” he said. “If you’re working in a peer drop-in center or you’ve been hired by a family member to work as a companion to someone with the same lived-in experience, that’s a direction that makes sense. We want to protect that.”

Gionfriddo added, “We don’t think that the sponsor of the bill intended to go in that direction. We just need clarification.”

The House bill has provisions that put limitations on what protection and advocacy legal services can do, said Gionfriddo. “We’d like to see less limitations,” he said. “We want to hold some judgment to see how these [issues] will iron out.”

More field support

Andrew Sperling, director of federal legislative activity for the National Alliance on Mental Illness (NAMI), told MHW that NAMI is very pleased about a number of provisions, including the repeal of the current Medicaid exclusion on inpatient care for individuals between the ages of 22 and 64, and the reauthorization of key programs like the community mental health block grants.

“We need reform on behalf of our patients who live with serious mental illness,” Renée Binder, M.D., president of the American Psychiatric Association (APA), told MHW. “We’re very pleased that everyone recognizes that reform is needed. Our mental health system needs resources.” The APA supports the House and Senate bills, she said.

“We’re looking forward to working with Congress to pass mental health reform this year,” said Binder. “We want to engage in a national dialogue on this issue so that reform can happen.”

Bottom Line…

Field advocates and leaders intend to work with both parties to ensure mental health reform legislation is passed in 2015.

7/30/2015 12:00 AM

In a move that is carried out rarely because of hospitals’ opportunity at numerous intervals to correct detected deficiencies, the federal Centers for Medicare & Medicaid Services has moved to decertify a large North Texas psychiatric health system from the Medicare and Medicaid programs.

In a move that is carried out rarely because of hospitals’ opportunity at numerous intervals to correct detected deficiencies, the federal Centers for Medicare & Medicaid Services (CMS) has moved to decertify a large North Texas psychiatric health system from the Medicare and Medicaid programs.

Timberlawn Mental Health System, a facility of nearly 150 beds that as of 2013 was receiving about one-third of its overall revenue from Medicare and Medicaid, has been the target of regulatory scrutiny since late last year when a female patient hanged herself from a type of doorknob that presents a known safety risk. After several months passed without the hospital completing a number of requested improvements, the facility failed a final inspection in late June, triggering the move to cease Medicare and Medicaid payments to the hospital as of this month.

A CMS regional administrator confirmed last month to The Dallas Morning News that the hospital, which is part of the national Universal Health Systems family of facilities, will not have additional opportunities in the immediate term to show compliance for the purposes of seeing federal funding restored. It essentially would have to reapply from scratch for Medicare and Medicaid certification, in a process that likely would take many months to unfold.

State officials also may take their own action against the hospital, where problems have included long wait times for nursing care as well as suicidal patients’ exposure to unsafe objects that could be used in a suicide attempt.

“The issues have been egregious and incredibly disheartening,” Texas Department of State Health Services spokesperson Christine Mann told MHW. “We are looking at the full range of penalties, including license revocation.”

Rare steps

Mark Covall, CEO of the National Association of Psychiatric Health Systems (NAPHS), confirms it is rare for a facility to reach the stage that Timberlawn Mental Health System now faces at the federal and state levels.

“Reviews are not uncommon, but in most cases a corrective action plan is developed by the hospital, and that would then get reviewed,” Covall told MHW. “The idea of having a hospital lose its Medicare certification, not a lot of that goes on. There are a lot of opportunities to make changes.”

Timberlawn is a member of NAPHS. Covall said the actions being taken against it do not affect the facility’s membership status in the organization; that is also true with some other professional associations in the behavioral health industry. “Our view is that there are oversight organizations that are responsible for enforcing health and safety,” Covall said.

The challenge of remaining in compliance with Medicare conditions of participation and other regulatory requirements likely is intensifying, Covall believes, based on the tenor of conversations he has had with NAPHS members. “The acuity of patients today is much higher,” he said. “The standard for medical necessity for inpatient care has been tightened based on the actions of payers. It’s an acutely ill population.”

Much of this, Covall says, reflects the decline in state-run psychiatric hospitals’ treatment of short-term acute-care patients, as the focus of state facilities has moved to a longer-term forensic population. That has in turn functioned to change the patient mix at private psychiatric facilities, he said.

Covall said that beyond the periodic surveys hospitals undergo, any complaints against facilities generally trigger a review by The Joint Commission and CMS. For a number of years now, he said, reviews have been trending in a more intensive direction. That means that, in general, facilities that in the aggregate offer millions of days of care per year are doing a good job of correcting problems that are uncovered and avoiding major sanctions, he said.

State’s perspective

“Our inspectors have been in and out of the facility since February, citing issues and not seeing progress,” the Department of State Health Services’ Mann said in regard to Timberlawn. “It has turned into a critical situation.”

CMS surveys of Timberlawn began at the same time, finding numerous compliance problems as well as instances where safety issues remained even after the hospital had stated that all were corrected. According to local media reports, CMS had been told at one point that all patient rooms were free of ligature risks, but the agency found that faucets in the youth wing of the facility posed a suicide risk (that section housed patients deemed at risk of harming themselves). A recent inspection found that a staff member had falsified notes after an incident involving a patient.

It is uncertain when the state itself may take any action against the facility, such as possible license revocation. “We can’t really offer a timeline for any enforcement actions, but we are moving quickly to evaluate our options,” Mann said.

The Texas chapter of Mental Health America did not return a phone request from MHW to address whether the federal action taken against Timberlawn will have a pronounced effect on mental health service capacity in the North Texas region.

From the Field
9/26/2013 12:00 AM
FromtheField
8/7/2013 12:00 AM
In Case
7/11/2013 12:00 AM
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    Valarie Canady
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    Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.
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