Foster Kids More Likely to Receive 2 or More Antipsychotics

Expert Says Findings Raise a Red Flag

Deborah Brauser

November 30, 2011 Children in the foster care system are prescribed concurrent antipsychotic medications at concerning rates, new research suggests. In a sample study of almost 17,000 children and adolescents younger than 20 years, those in foster care were more likely to receive 2 or more overlapping antipsychotics than those who qualified for Medicaid because of a disability or low income. They were also more likely to receive these medications for a longer duration. "I did not expect to find that children would be receiving 2 medications for an extended period of time. And this pattern of treatment occurred despite a lack of evidence to support such regimens," lead author Susan dosReis, PhD, associate professor at the University of Maryland School of Pharmacy in Baltimore, told Medscape Medical News. She added that there is also a lack of data on child developmental risks from this concurrent use, even though "there are clear indications of metabolic adverse effects from these agents." The investigators note that although previous research has shown that youth in foster care have high rates of psychotropic medication use, this is the first time concomitant antipsychotic use has been assessed in this population. "The present findings would be of interest to state child welfare and Medicaid agencies and could be used to guide antipsychotic monitoring programs and policies," they write, noting that treatment with 2 or more concurrent antipsychotics should trigger a full clinical review. "It is without question...that routine monitoring should be enforced." The study was published online November 21 in Pediatrics. Adult Polypharmacy Increasing "Antipsychotic polypharmacy has increased among adults, so it is possible this is also occurring in youths," write the researchers.

The investigators compared overlapping antipsychotic treatments between those in foster care; those who met Medicaid eligibility for physical, psychological, or development impairment; and those who met eligibility for financial need. "The foster care population has been a concern for a while. We wanted to look at the complexity of their treatment use because it's been an issue of national debate for some time now," said Dr. dosReis. The investigators evaluated data on 16,969 children and adolescents aged 19 years or younger (70% boys; 67.3% white, 20.8% black, 3.6% Hispanic) who were continuously enrolled in a Mid-Atlantic state Medicaid program. All participants had at least 1 psychiatric diagnosis claim and at least 1 antipsychotic claim in 2003. Concomitant use was defined as use of at least 2 overlapping antipsychotics for more than 30 days. Medicaid program categories were split into foster care, disabled (Supplemental Security Income [SSI]), and Temporary Assistance for Needy Families (TANF). For those in foster care, multicategory classifications were also assessed, including foster care/adoption. The category distributions for the participants were as follows:

SSI, 52%; TANF, 21%; foster care only, 14%; foster care/SSI, 5%; foster care/TANF, 4%; and foster care/adoption, 4%.

Significant Concurrent Use Results showed that those children in foster care had longer average antipsychotic use duration than those in the TANF group (mean days, 222.3 vs 134.9; P < .001), as well as longer duration than for the SSI group (mean days, 190.3). In addition, concomitant use of antipsychotics for at least 180 days was greatest in the foster care/adoption group (24%), followed by in the foster careonly group (19%). The rate was less than 15% in all other groups examined. Attention-deficit/hyperactivity disorder was the most common diagnosis in the participants who used at least 1 antipsychotic medication (53.3%), followed by depression (33.8%), oppositional defiant disorder (26.8%), conduct disorder (26.3%), and bipolar disorder (20.8%). Schizophrenia was diagnosed in 5.2% of the participants.

A diagnosis of conduct disorder, psychosis, or schizophrenia, as well as antidepressant or moodstabilizer use, was significantly associated with a higher likelihood of concomitant antipsychotic use (P < .0001 for all). White youth were found to be 27% less likely to use antipsychotics concomitantly than black youth, and those between the ages of 5 and 9 years were 28% less likely to do so than those children between the ages of 15 and 19 years. "After controlling for psychiatric diagnoses, other psychotropic use and demographic factors, youth who entered foster care were as likely to receive antipsychotics concomitantly for over 30 days as were disabled youth who typically have conditions for which antipsychotics are indicated," write the investigators. "Additional study is needed to assess the clinical rationale, safety, and outcomes of [this] use," they add. Better Monitoring Needed Dr. dosReis noted that because the study did not include data on the reasons for prescribing concurrent medications or on the participants' symptom severity, it is hard to know why this practice was occurring. "It could be that issues were not resolved with 1 medication, or that 1 of the medications was prescribed for sleep with another scheduled to be taken on a more regular basis, or it could be that side effects from 1 were so intolerable that a new lower dose of medication was prescribed. But that's all speculation," she said. "I think this is something that isn't happening exclusively in foster care, but these kids do often have more complex social situations that can impact their emotional development. And we currently don't have services and treatments that seem to fully meet their needs. Plus, there's definitely a need for some sort of oversight." Dr. dosReis reported that she is now working on a study that will examine these issues in data from all 50 states over the course of 5 years. "This will not only give a national perspective but also cover a time period when some of the states have put together programs to begin monitoring utilization." Red Flag "Overall, I think this is an important study," Robert L. Findling, MD, MBA, professor of psychiatry and pediatrics at Case Western Reserve University and director of child and adolescent psychiatry at University Hospitals Case Medical Center in Cleveland, Ohio, told Medscape Medical News.

"You need to be very careful about overinterpreting these data, but I think a paper like this provides a warning signal that this may be a practice that's going on that is potentially worrisome." Dr. Findling, who was not involved with this study, noted that there have been concerns about using this class of medicine in the young because of safety considerations, including adverse effects, some of which can be serious. "I think the first take-home message is that there is no rigorous scientific evidence to suggest the benefit of doing this. That doesn't mean that there isn't any situation where this approach might be considered, based on clinical inference alone. But there's no evidence that has demonstrated that this is a good practice." In addition, he said, this is a particularly vulnerable population. "Youngsters in foster care are oftentimes significantly troubled and often highly symptomatic. So they may be at higher risk for treatment or exposure to powerful medicines. In fact, the evidence suggests that the more symptomatic or greater psychosocial dysfunction a youngster has, the greater the likelihood they are for receiving this class of medicine." However, he also pointed out that the authors "were very wise" to note that the determinants of these issues may not be clear based on their data. For example, it is not known whether these medications were given in high doses or were being cross-titrated, or whether there was some overlap between stopping a prescription and starting a new one. "I think there are some inherent limitations with these kinds of claims data. But that doesn't mean this isn't an important study, because what it does is raise a warning flag for clinicians," said Dr. Findling. "Further research can help clarify what's truly going on in more detail, and why this phenomenon was observed based on the claims data." He added that he would like to see an external validation study conducted with a large group of youth that identifies what treatments they have received, and at what times. "This study suggests that this should be a topic of future studies, so that we can be clear about what indeed is going on, and if something bad is going on, how to prevent it. Ultimately, these are youngsters who deserve to be protected." The study was supported by a grant from the National Institute of Mental Health. All but one study author disclosed no relevant financial relationships. Coinvestigator Mark A. Riddle, MD, from Johns Hopkins University School of Medicine in Baltimore, Maryland, reported being an expert witness in a legal matter involving Teva Pharmaceuticals. Dr. Findling, who is a member of the editorial advisory board for Medscape Medical News, has received research support from, acted as a consultant to, and/or served on a speakers' bureau for Abbott, Addrenex, AstraZeneca, Biovail, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson & Johnson, Eli

Lilly, KemPharm, Lundbeck, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, sanofiaventis, Sepracore, Schering-Plough, Shire, Solvay, Sunovion, Supernus Pharmaceuticals, Validus, and Wyeth. Pediatrics. Published online November 21, 2011. Abstract

Suicide Risks for Pregnant and Postpartum Women Identified

Megan Brooks

December 7, 2011 Increased efforts to screen pregnant women and new mothers for depression, substance abuse, and conflicts with their partners may help identify those at risk for suicide, a study suggests. "The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population," study investigators write in a report published online November 4 in General Hospital Psychiatry. Importantly, they note, the study shows that in addition to a higher incidence of problems with intimate partners, pregnant and postpartum women have risk factors for suicide similar to those of their nonpregnant peers, a finding that should aid screening efforts. "This tells us that we know what to look for; we just need to make sure we ask and follow up," lead author Katherine J. Gold, MD, MSW, assistant professor of family medicine from the University of Michigan Medical School, Ann Arbor, told Medscape Medical News. "We need to ask about depressed mood, substance abuse, prior attempt at suicide, and conflicts with intimate partners," she said. "Although suicide is less common in pregnancy, it is still a major public health problem and potentially a preventable cause of death." Preexisting Mood Disorders Dr. Gold and colleagues used data from 17 states reporting to the US National Violent Death Reporting System (NVDRS) from 2003 to 2007 to evaluate suicide patterns among women who were pregnant, postpartum, or neither pregnant nor postpartum. They compared demographic factors, mental health status, substance use, precipitating circumstances, problems with intimate partners, and suicide methods among the groups. The researchers identified 2083 reproductive-age women who died by suicide. Of these, 48 (2%) were pregnant at the time of death, 65 (3%) were within 1 year postpartum, and 1970 (95%) were neither pregnant nor postpartum.

Overall, more than half of the women who died by suicide (1169/2083; 56%) had known mental disorders, most commonly mood disorders (95%), followed by anxiety disorders (9%) and schizophrenia (5%). The prevalence of depressed mood was not significantly different between pregnant and nonpregnant women. However, postpartum women were more likely to have been identified as having depressed mood in the 2 weeks before suicide than other women. Overall, nearly a third of the women (32%) had a history of prior suicide attempt, and 28% had a known alcohol or substance abuse issue at the time of death; these factors did not differ by pregnancy status. Although education level and marital status were very similar for pregnant, postpartum, and nonpregnant women who committed suicide, Hispanic women were far more likely to die by suicide while pregnant (10% of suicides among pregnant women) or within 1 year of pregnancy (9% of postpartum suicides) than when not pregnant (4% of non-pregnancy-associated suicides). Clinical Implications Clear The implications for healthcare providers, Dr. Gold said, are clear. "Obstetricians, family physicians, midwives, and pediatricians see these families many times during pregnancy and after delivery and should be alert to these risk factors," she advised. In addition, she said friends and family members should be encouraged to watch for these risk factors. "If a pregnant woman or new mom is depressed, dont just dismiss it as 'hormones' or lack of sleep. It could be something more serious," she said. "Suicide in pregnancy and postpartum is devastating for both the patient and the family she leaves behind." "As a society, we tend to avoid talking about suicide," Dr. Gold said. "But its important to try to understand and talk about risk factors if we are going to address suicide from a public health perspective." Current expert opinion from the American College of Obstetricians and Gynecologists (ACOG) holds that there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum depression screening, but ACOG does strongly encourage screening, Dr. Gold and colleagues note in their report. ACOG also recommends that women with current depression or a history of major depression undergo close monitoring and evaluation during pregnancy and postpartum. The researchers acknowledge some inherent limitations to their study. They note that the study sample included only 2083 suicides among women of plausible child-bearing age (15 - 54 years) and was drawn only from the 17 states for which data were available.

Obviously, the suicide victim cannot be interviewed after death, so it is impossible to get a complete picture of mental health conditions, thoughts about intent, or precipitating factors, the researchers point out. They also note that toxicology data do not provide quantity of ingestion of substances or whether a specific substance caused the death. Also, the NVDRS assumes that victims with a mental health diagnosis are receiving treatment, so this variable is not useful in evaluating whether treatment offers any protection against self-harm. Dr. Gold reports receiving salary support from the National Institute of Mental Health. One coauthor reports receiving salary support from the Robert Wood Johnson Clinical Scholars Program. The other coauthors have disclosed no relevant financial relationships. Gen Hosp Psychiatry. Published online November 4, 2011. Abstract

Postpartum Psychiatric Episode Predicts Bipolar Disorder

Fran Lowry December 9, 2011 Women who experience a psychiatric episode in the immediate postpartum period appear to have an increased risk of developing bipolar affective disorder, according to the results of a new study. In a large Danish cohort study, women who experienced the onset of psychiatric symptoms within 14 days after delivery had a more than 4-fold increased risk of converting to bipolar disorder than women who did not experience such symptoms, Trine Munk-Olsen, PhD, from Aarhus University, Aarhus, Denmark, and colleagues reported. Dr. Munk-Olsen told Medscape Medical News that there is a well-established link between childbirth and bipolar affective disorders and that she and others have documented this link in several studies. She and her team conducted the present study because, despite this knowledge, many women who experience a psychiatric disorder in the immediate postpartum period do not receive a specific diagnosis of bipolar disorder. "For this reason, we were interested in following women with non-bipolar postpartum psychiatric episodes over time to study if they, at a later stage, convert to a bipolar diagnosis," Dr. Munk-Olsen said. The findings were published online on December 5 in the Archives of General Psychiatry. Implications for DSM-5?

Dr. Munk-Olsen and her team conducted a cohort study drawing information from the entire Danish population using different registries as data sources covering a study period from 1973 to 2007. They identified all women (n = 120,378) who had a first-time psychiatric episode with any type of diagnosis, excluding bipolar affective disorder, and followed them over time. "By doing this, we identified how many women were readmitted at a later stage in their lives and diagnosed specifically with bipolar affective disorder diagnoses," she explained. Of these women, a total of 3062 were readmitted or had an outpatient contact with bipolar affective disorder diagnoses. The study found that a postpartum onset of symptoms 0 to 14 days after giving birth predicted subsequent conversion to bipolar disorder, with a relative risk (RR) of 4.26 (95% confidence interval [CI], 3.11 - 5.85). Fifteen years after the initial psychiatric contact, approximately 14% of the women who had their first treatment at a psychiatric facility within the first month after delivery converted to a bipolar affective diagnosis. In comparison, after 15 years, approximately 5% of women with later postpartum onset of psychiatric symptoms (31 - 365 days postpartum) and 4% of women who experienced their first psychiatric episode at a time not related to childbirth had converted to bipolar disorder. The study also showed that postpartum inpatient admissions were associated with a 2-fold increased risk for conversion to bipolar disorder than did outpatient visits (RR = 2.16; 95% CI, 1.27 - 3.66). "We hope that our study will be considered in the current debate regarding revisions of both the DSM [Diagnostic and Statistical Manual of Mental Disorders] and ICD [International Classification of Diseases] classification systems," Dr. Munk-Olsen said. "We also believe our results provide evidence that a postpartum psychiatric episode is a marker which raises the possibility of both a current and a subsequent bipolar diagnosis, which most importantly has both diagnostic and prognostic implications," she added. Need for Careful Evaluation Shari I. Lusskin, MD, director of reproductive psychiatry at New York University Langone Medical Center and Mt Sinai Medical Center, New York City, told Medscape Medical News that this association has long been known, but that this study adds scientific "proof" to what clinicians know clinically. "Women who develop their first episode of psychiatric illness in the first month after having a baby have an elevated risk of developing bipolar disorder. The relative risk is highest for those

who require inpatient treatment and for those who become symptomatic in the first 2 weeks postpartum," Dr. Lusskin said. For her, the take-home message is that women with postpartum mental illness, including postpartum depression, "should be carefully evaluated for personal and family risk factors for bipolar disorder before they are given an antidepressant." "The big problem is people dont appreciate that whenever you put a person on an antidepressant, there is a risk of converting them into a manic or hypermanic state if they have an underlying bipolar disorder, and by putting somebody on an antidepressant, you may unmask their bipolar disorder faster. "So you really want to screen for bipolar disorder whenever you see a patient for depression. Clinicians tend not to do this, or they dont do it enough," Dr. Lusskin said. Dr. Munk-Olsen and Dr. Lusskin have disclosed no relevant financial relationships. Arch Gen Psychiatry. Published online December 5, 2011. Abstract

Good News, Bad News Scenario for US Teen Drug, Alcohol Use
Caroline Cassels December 15, 2011 Cigarette and alcohol use by teens is at its lowest point in more than 3 decades, according to the latest results of an annual survey conducted by the National Institute on Drug Abuse (NIDA). However, this good news is counterbalanced by a slowing rate of decline in teen smoking as well as continued high rates of abuse of other tobacco products, including hookahs, small cigars, smokeless tobacco, marijuana, and prescription drugs. "The use of cigarettes by adolescents increases the risk of addiction to nicotine, but also there is increasing evidence that it may be priming them for the rewarding effects of other drugs of abuse, including the illicit substances," NIDA director Nora Volkow, MD, told reporters attending a press briefing. "So the decline in cigarette smoking is likely to have [positive] downstream consequences both in medical health as well as substance use disorders. In fact, [the prevalence] of cigarette smoking is at its lowest since the inception of the survey in 1975," she added. Dr. Volkow also noted that the survey revealed "dramatic decreases" in the prevalence of daily smoking as well as past-month smoking. For daily smoking, the rates have gone down 60%

during a 15-year period, a finding that indicates that smoking prevention messages and interventions are effective. On the other hand, she said, despite these dramatic decreases, smoking rates among teens remain high. There is also good news on the alcohol front, with survey results indicating rates of use are the lowest level since 1996. Rates for daily drinking are 46% lower, and rates for binge drinking are 30% lower findings that Dr. Volkow said "exemplify the concept that prevention interventions work and can have a big impact." Shift in Perception of Harm Overall, the annual NIDA survey, Monitoring the Future (MTF), which polled 46,773 8th, 10th, and 12th graders in the United States, showed that more teens continue to abuse marijuana than cigarettes and that alcohol remains the drug of choice. Although marijuana use declined in the late 1990s and early 2000s, 5-year trends indicate significant increases among 10th and 12th graders for current- and past- year use. In 2011, 12.5% of 8th graders, 28. 8% of 10th graders, and 36.4% of 12th graders reported past-year marijuana use. Dr. Volkow pointed out that although there was no increase in marijuana use between 2010 and 2011, it continues to exceed cigarette use among teens. In 2011, the rate of 30-day past use of marijuana vs cigarette smoking among high school seniors was 22.6% vs 18.7%, respectively. "We have seen trending towards increases in marijuana utilization, particularly among 10th and 12th graders," she said, adding that 6.6% of 12th graders smoke marijuana daily. The survey also showed a decline in teens' perceived risk of harm associated with marijuana use. "This is not a good indicator because throughout the inception of MTF, we have learned to recognize that perception of risk predicts whether kids are going to be smoking marijuana or not," Dr. Volkow said. First Data on Synthetic Cannabis Use This year's MTF survey captured the use of synthetic marijuana, also known as K2 or Spice, for the first time. It revealed that almost 1 in 9, or 11.4%, of high school seniors reported having used these substances in the past year. Synthetic cannabis, explained Dr. Volkow, is mixed with plant materials to give the impression that it is a herbal product when, in fact, it is a chemical substance. A recent study presented at the American Academy of Addiction Psychiatry and reported by Medscape Medical News suggests that Spice is more potent than natural cannabis and may confer an even greater risk for psychosis than the natural product in individuals with no psychiatric history.

Gil Kerlikowske, director of the White House Office of National Drug Control Policy, told reporters that synthetic marijuana is dangerous. "These drugs are dangerous, and you can see from calls to poison control centers and you can certainly see from the data about visits to emergency departments that these drugs can cause serious harm," he said. Mr. Kerlikowske noted that US Drug Enforcement Agency scheduled them as an illegal substance in February. Whether this move has had an impact on the use of Spice and K2 will be revealed in next year's MTF survey. He noted that Spice, or synthetic marijuana, is now the second most widely used illegal drug among high school seniors, second only to marijuana. Prescription, OTC Drug Abuse Finally, after marijuana, the illicit use of prescription and over-the-counter medications account for the majority of drug abuse by 12th graders in the past year. These include hydrocodone (Vicodin, Abbott Laboratories), racemic amphetamine (Adderall, Shire Pharmaceuticals), tranquilizers, cough medicine, sedatives, oxycodone (OxyContin, Purdue Pharma), and methylphenidate (Ritalin, Novartis). "The use of psychotherapeutics, which we have come to recognize in the past 10 years of the survey, has become increasingly prevalent among teenagers. The pattern has shifted towards favoring this type of drug for abuse because of the misperception that they are safer than illicit substances," said Dr. Volkow. The survey showed that 8.2% of high school seniors reported using stimulant medications such as racemic amphetamine "not just to get high but to improve cognitive performance." To help educate teens about the dangers of prescription drug abuse, NIDA is launching an updated prescription drug section of its teen Web site, PEERx. Dr. Volkow and Mr. Kerlikowske have disclosed no relevant financial relationships.