UVM Study Shows Doctors Don't Consistently Prescribe Antipsychotic Medications to Kids

Researchers at the University of Vermont released a study investigating the use of antipsychotic medications on children in the March edition of Pediatrics. While the results concluded that the inappropriate use of the drugs is not a concern, about 50 percent of prescribers failed to meet best practice standards.

Amidst increasing nationwide use of such drugs by minors, lead author Dr. David Rettew and his team wished to gain understanding of what was causing the upward trend and if there is any reason for alarm. Rettew is the director of the Pediatric Psychiatry Clinic at the University of Vermont Medical Center and the Vermont Center for Children, Youth, and Families.

“Part of our concern is that these medicines may be getting pulled out too early in the treatment planning for things like oppositional behavior, ahead of things like behavioral therapy that could be tried first,” Rettew said in an official press release.

To collect information, the researchers examined Medicaid claims for July to October of 2012, extracting the names of Vermont physicians who had prescribed antipsychotic medications to children and sending them mandatory surveys.

In total, 147 doctors responded, accounting for prescriptions to 647 patients. Ultimately, the team decided that the drugs were issued under the proper circumstances in 92 percent of cases.

“It was pretty clear from our data that antipsychotic medicines were only being used once other things didn’t work, or other types of treatments or other types of medications failed,” Rettew said. “And I think that’s really good news because it reflects the idea that doctors are not prescribing these medicines casually or in a knee-jerk way.”
While Rettew seemed comforted by the lack of overuse, he insisted, “I don’t think we in the medical community can be too excited about a best practice rate of 50 percent … and we should be working on ways to improve that number.”

The standards for best practice guidelines were taken from the American Academy of Child and Adolescent Psychiatry. The recommendations include not only prescribing medications as a last resort but also stipulations such as appropriate testing before prescription as well as follow-up, not issuing such medications to children under 5 or using multiple antipsychotic drugs at one time. The greatest violations to best practice were due to a lack of adequate blood testing, both before and after commencement of drug use.

“The number one reason why a prescription did not follow best practice guidelines was not because it was being used inappropriately, it was because the doctors were not getting the recommended lab work that’s supposed to go along with these prescriptions,” Rettew said.

Such testing is important for keeping track of cholesterol and blood-glucose levels, elevations of which are common side effects when using these types of drugs. A leading reason for insufficient blood testing was reportedly children’s aversion to having the lab work done and undergoing the process of blood sampling. However, the researchers also feel that many physicians simply are not aware of the guidelines.

The report includes recommendations for doctors in order to mitigate poor performance on best practices. Namely, the authors tout the incorporation of electronic medical records that use software capable of alerting doctors when tests should be done. Additionally, the team is pushing for the better training of doctors that may work with children taking these drugs, even if the doctors are not the ones to prescribe them. The team is also looking for better access to therapy for children in Vermont and improved information sharing between centers to ensure consideration of patient history.

Interestingly, the rates of pediatric patients on antipsychotic medications in Vermont has fallen in recent years, by 45 percent for children ages 6 to 12 and 27 percent for ages 13-17. This contrasts with national statistics in previous years from the U.S. Department of Health and Human Services, which report that usage increased by 62 percent for children on Medicaid between 2002 and 2007.

The aim of Rettew and his nine coauthors was not to undermine the validity of such drugs. “I’m not anti-antipsychotics; I just want to make sure they’re used very carefully,” Rettew said. “These findings could help us design a game plan for measures to improve best-practice prescribing.” He admited that while “there are risks associated with using these medicines … I think they’ve saved lives.”