Meredith Matone

The Relationship between Mental Health Diagnosis and Treatment with Second-Generation Antipsychotics over Time: A National Study of U.S. Medicaid-Enrolled Children

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.

Risk for Incident Diabetes Mellitus Following Initiation of Second-Generation Antipsychotics Among Medicaid-Enrolled Youths

IMPORTANCE Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children, either singly or in a medication combination. Although metabolic adverse effects have been linked to SGA use in youths, estimating the risk for type 2 diabetes mellitus, a rarer outcome, has been challenging. OBJECTIVE To determine whether SGA initiation was associated with an increased risk for incident type 2 diabetes mellitus. Secondary analyses examined the risk associated with multiple-drug regimens, including stimulants and antidepressants, as well as individual SGAs. DESIGN, SETTING, AND PARTICIPANTS Retrospective national cohort study of Medicaid-enrolled youths between January 2003 and December 2007. In this observational study using national Medicaid Analytic eXtract data files, initiators and noninitiators of SGAs were identified in each month. Included in this study were US youths aged 10 to 18 years with a mental health diagnosis and enrolled in a Medicaid fee-for-service arrangement during the study. Those with chronic steroid exposure, a diagnosis of diabetes mellitus, or SGA use during a 1-year look-back period were ineligible. The mean follow-up time for all participants was 17.2 months. Youths were followed up until diagnosis of diabetes mellitus or end of follow-up owing to censoring caused by the transition into a Medicaid managed care arrangement or Medicaid ineligibility (the end of available data). Propensity weights were developed to balance observed demographic and clinical characteristics between exposure groups. Discrete failure time models were fitted using weighted logistic regression to estimate the risk for incident diabetes mellitus between initiators and noninitiators. EXPOSURE A filled SGA prescription. MAIN OUTCOMES AND MEASURES Incident type 2 diabetes mellitus identified through visit and pharmacy claims during the observation period. RESULTS Among 107,551 SGA initiators and 1,221,434 noninitiators, the risk for incident diabetes mellitus was increased among initiators (odds ratio [OR], 1.51; 95% CI, 1.35-1.69; P < .001). Compared with youths initiating only SGAs, the risk was higher among SGA initiators who used antidepressants concomitantly at the time of SGA initiation (OR, 1.54; 95% CI, 1.17-2.03; P = .002) but was not significantly different for SGA initiators who were concomitantly using stimulants. As compared with a reference group of risperidone initiators, the risk was higher among those initiating ziprasidone (OR, 1.61; 95% CI, 0.99-2.64; P = .06) and aripiprazole (OR, 1.58; 95% CI, 1.21-2.07; P = .001) but not quetiapine fumarate or olanzapine. CONCLUSIONS AND RELEVANCE The risk for incident type 2 diabetes mellitus was increased among youths initiating SGAs and was highest in those concomitantly using antidepressants. Compared with risperidone, newer antipsychotics were not associated with decreased risk.

Growth in the Concurrent Use of Antipsychotics With Other Psychotropic Medications in Medicaid-Enrolled Children

OBJECTIVE Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008. METHOD Repeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics. RESULTS While SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%-89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%). CONCLUSION Concurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug-drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.

Home visitation program effectiveness and the influence of community behavioral norms: a propensity score matched analysis of prenatal smoking cessation

BackgroundThe influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.MethodsRetrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.ResultsThe association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, p < 0.001) than in an earlier implementation period (28.4% vs. 25.8%, p = 0.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (OR = 0.84 per 5 percentage point change in county smoking rate, p = 0.002).ConclusionsFollowing a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.

Child abuse prevention and child home visitation: Making sure we get it right

Home visitation to at-risk families is an important strategy for improving early-childhood outcomes. On the heels of numerous trials demonstrating many positive and sustained outcomes for mothers and children, the Affordable Care Act in 2010 allocated

Mental Health, Behavioral and Developmental Issues for Youth in Foster Care

1.5 billion to this initiative and recently, the White House proposed an appropriation of

Behavioral and Health Outcomes for HIV+ Young Transgender Women Linked To and Engaged in Medical Care

15 billion over 10 years to strengthen and expand programs across the United States. This substantial public investment in home visiting is a tremendous achievement for researchers who have focused on early childhood as a crucial time period to pursue strategies that alter lifetime trajectories of at-risk children. As these programs rapidly disseminate across the country, researchers must address issues and challenges that may arise and strengthen programs as needed. To this point, child abuse prevention strikes a cautionary note. Prevention of child maltreatment has been a significant position of advocacy for home-visiting programs. This outcome is frequently cited as one of the service’s strengths and moreover, has been included in estimates of program cost-effectiveness.1,2 However, a deeper review of the trial evidence is inconclusive. First, the lack of standard outcomes has made comparison of outcomes between program models difficult. Studies vary from more proximal outcomes of harsh parenting practice to health care encounters for injury or official child protective service reports. When comparisons have been made, the results are mixed. The most recent 2013 US Preventive Services Task Force systematic review of homevisitation programs found that when compared with earlier trials, 2 programs (Child First and the Nurse Family Partnership) either reduced reports of abuse or of death due to all causes over a long follow-up. The review also included 4 other high-quality randomized controlled trials that did not find effects on reported child maltreatment.1 An earlier review by Reynolds et al3 characterized the overall evidence base as relatively weak because of a lack of shared benefit across program models. Second, interpreting trial data has also been challenging due to limitations in study design and risk of bias. Many trials lacked power to detect the rare outcome of abuse over reasonable follow-up durations. Furthermore, many investigators suggest that surveillance bias among visited families might explain the lack of effect observed in some studies. Yet research on the effect of surveillance on child abuse reporting by parent support programs found small influence during the period families were actively enrolled, no excess bias attributed to home visitation, and no evidence that homevisited families were reported for less-severe maltreatment.4 Additionally, many home-visitation programs struggle to retain families once the child is born, weakening this argument. Researchers must therefore be careful to write off inconclusive data as solely the product of a surveillance bias, masking the program’s true benefit—such is a tenuous position. Uncertainty around the benefit of home-visiting services on child maltreatment reduction is a strong argument for the continued investment in postimplementation evaluation. This is also a time of great opportunity because the implementation environment will expose much larger groups of families to home-visiting services, allowing for robust analysis on a rare outcome such as child maltreatment, and obviating the concerns about power from the original trials. At this time, evaluators should understand that the challenges of expanding programs will be great because implementation across diverse social service agencies and into geographic areas and populations not well-studied in smaller trials may be problematic. Many programs will operate without the resources of clinical trials and face local barriers to implementation and program fidelity.5 Such concerns make it even more important for programs to sustain their commitment to successful implementation and continuing robust evaluations. Although postimplementation data are beginning to emerge, 2 recent studies suggest home-visitation programs may be encountering some challenges. The first, a quasi-experimental evaluation of Nurse Family Partnership in Pennsylvania following the program’s statewide dissemination, found that over a 6-year period, 5016 nurse-visited families were no less likely than 16 704 matched nonvisited families to have serious head injuries or other injuries suspicious for abuse.6 After statewide implementation of Healthy Families Massachusetts (a program using the Healthy Families America curriculum with paraprofessional home visitors), a randomized controlled trial conducted among 840 women at 18 sites found mothers in the home-visiting group were equally, if not more likely, to have a substantiated report of child maltreatment than those in the nonvisited group.7 Certainly researchers should be cautious about the limitations of these postimplementation studies, but should not completely discount them. Although one study was a randomized trial,7 the other was an observational study.6 The observational design might introduce selection bias in the absence of randomization, and even the best attempts at controlling for confounding can be incomplete. However, observational studies include much larger samples and report real-world outcomes and distribution of resources. Generalizability is also a concern because the programs studied in both evaluations represented 1 model in a single state and therefore might not be representative of the performance of other program models or even the same program models implemented VIEWPOINT

Effect of Maternal–Child Home Visitation on Pregnancy Spacing for First-Time Latina Mothers

Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Second-Generation Antipsychotic Use Among Stimulant-Using Children, by Organization of Medicaid Mental Health

We describe health and psychosocial outcomes of HIV+ young transgender women (YTW) engaged in care across the United States. When compared to other behaviorally infected youth (BIY), YTW reported higher rates of unemployment (25% vs. 19%), limited educational achievement (42% vs 13%), and suboptimal ART adherence (51% vs. 30%). There was no difference in likelihood of having a detectable viral load (38% vs. 39%) between groups. However, particular isolating psychosocial factors (unstable housing, depression, and lack of social support for attending appointments) increased predicted probability of viral detection to a greater extent among YTW that may have important health implications for this marginalized youth population.

Variation in Practice of Expedited Partner Therapy for Adolescents by State Policy Environment

OBJECTIVES We examined the impact of a maternal-child home visitation program on birth spacing for first-time Latina mothers, focusing on adolescents and women who identified as Mexican or Puerto Rican. METHODS This was a retrospective cohort study. One thousand Latina women enrolled in the Pennsylvania Nurse-Family Partnership between January 1, 2003, and December 31, 2007, were matched to nonenrolled Latina women using propensity scores. The primary outcome was the time to second pregnancy that resulted in a live birth (interpregnancy interval). Proportional hazards models and bootstrap methods compared the time to event. RESULTS Home visitation was associated with a small decrease in the risk of a short interpregnancy interval (≤ 18 months) among Latina women (hazards ratio [HR] = 0.86; 95% confidence interval [CI] = 0.75, 0.99). This effect was driven by outcomes among younger adolescent women (HR = 0.80; 95% CI = 0.65, 0.96). There was also a trend toward significance for women of Mexican heritage (HR = 0.74; 95% CI = 0.49, 1.07), although this effect might be attributed to individual agency performance. CONCLUSIONS Home visitation using the Nurse-Family Partnership model had measurable effects on birth spacing in Latina women.