Robert J. Constantine

Changing Trends in Pediatric Antipsychotic Use in Florida's Medicaid Program

OBJECTIVE This study describes the changing trends in antipsychotic use among youths aged 18 years and younger and in age subgroups (zero to five, six to 12, and 13 to 18 years) in the Florida Medicaid program. METHODS The study used Florida Medicaid claims data associated with approximately 1.2 million children and adolescent enrollees per year to describe monthly antipsychotic use from July 2002 to December 2005. A preliminary examination of trends indicated that antipsychotic use might be different for the periods before May 2004 and after April 2004. For this reason, piecewise regression was used to compare the trends for these two periods. RESULTS This study found significant increases in the use of antipsychotic medications for all three age groups from July 2002 to April 2004. The greatest rate of growth was for the 13- to 18-year age group, and the least rate of growth was for the zero- to five-year age group. From May 2004 to December 2005 antipsychotic utilization trends were flat for youths age 18 years and younger and for the six- to 12-year and the 13- to 18-year age groups. For preschool-age children (the zero- to five-year age group), there was a slight but significant decline in antipsychotic use. Significant changes were also observed in the specific second-generation antipsychotic agents prescribed. Although risperidone remained the most frequently prescribed antipsychotic, its use declined significantly from May 2004 to December 2005. Olanzapine use also declined during this period. On the other hand, aripiprazole use increased significantly throughout the study period, with usage among the 13- to 18-year age group almost equaling that of risperidone by December 2005. CONCLUSIONS The lack of growth in antipsychotic prescribing after the spring of 2004 represents a significant departure from historical trends. Although some in-state policies may have affected these trends, it appears that the timing and extent of the changes occurred shortly after the Food and Drug Administration required warnings on second-generation antipsychotic medications related to weight gain, glucose levels, and diabetes. They appeared immediately after the black box warning for pediatric antidepressant medications, and they appeared shortly after the Joint American Diabetes and American Psychiatric Association Consensus Statement. These factors suggest the existence of a prescribing community that is responsive to evidence and to professional and regulatory actions based on it.

Early Diagnoses and Psychotherapeutic Medication Treatment Experiences of a Cohort of Children Under 6 Years Old Who Received Antipsychotic Treatment in Florida's Medicaid Program

OBJECTIVE To describe the diagnostic characteristics and psychotherapeutic medication experiences of a cohort of children who received antipsychotic treatment before their sixth birthday. METHODS Children enrolled in Floridas Medicaid program were identified as having initiated an index episode of antipsychotic treatment before their sixth birthday. The characteristics of these children were compared to nonrecipients who were less than 6 years old on January 1, 2004. An index episode is described as the filling of at least two consecutive antipsychotic prescriptions with a gap no greater than 15 days between the last day supplied of the first prescription and the fill date of the second prescription. We describe the diagnoses and psychotherapeutic medication experiences of these children during the 365 days before the start of their index episodes (preindex periods) and during the 365 days immediately after the start of their index episodes (index periods). RESULTS Five hundred twenty-eight recipients were identified. Recipients were more likely than nonrecipients to be male, to be older, and to have a supplemental security income enrollment status. Recipients were exposed to psychotherapeutic medications at very early ages. Four hundred thirty-nine (83%) had already been treated with some psychotherapeutic medication during their preindex periods. Of these children, 303 (69%) filled at least one prescription for an antipsychotic medication. Index antipsychotic episodes were often lengthy. Mean ± standard deviation and median episode lengths were 266.9 ± 286.8 and 174 days, respectively. During the index periods half of the children were found to have attention-deficit/hyperactivity disorder and 18% had disruptive behavior disorders. Treatment during these periods included other classes of psychotherapeutic medications for 73% of children. Nearly 30% (29.6%) received two or more classes of medications in addition to antipsychotics. CONCLUSIONS We found a large group of very young children who were persistently treated with antipsychotic medications. This early and extensive exposure is a cause for concern.

Gender Differences and Risk of Arrest Among Offenders with Serious Mental Illness

Despite the increasing number of men and women with serious mental illness (SMI) incarcerated in Americas jails, little research exists on the role gender may play in arrest among persons with SMI. This study examined correlates of arrests among offenders with SMI, specifically the role of gender. County criminal justice records, as well as county and statewide social service archival databases, were used to identify jail inmates with SMI in a large urban county in Florida. Of the 3,769 inmates identified, 41% were female. This study identified three distinct classes of male and female offenders within which persons had similar trajectories of arrests over the 4-year study period representing those with minimal, low, and high arrest rates. Findings suggest some important differences between women and men in risk factors for re-arrests. Attention to these factors may improve the ability to prevent future recidivism among men and women with SMI.

Optimizing pharmacotherapy of schizophrenia: Tools for the psychiatrist

The pharmacologic treatment of schizophrenia presents several challenges: 1) available treatments are incompletely and variably effective; 2) treatments take time to show their full effects; and 3) different benefits and adverse effects of treatment appear over different time frames. To aid in treatment decisions, clinicians are inundated with information that can be difficult to digest and integrate. Treatment often is provided within systems of care that limit the range of available treatment options. To preserve broad treatment options and facilitate optimal care, the State of Florida has developed a comprehensive program to provide several tools to the treating physician, and systems of care to promote optimally effective and efficient pharmacotherapy for each individual with schizophrenia. Although a formal evaluation of its effectiveness is underway, the program has been uniformly well received and considered to be very useful in helping clinicians and treatment systems efficiently provide schizophrenia patients with the best currently available pharmacologic treatment. Elements of the program and its evolution and operation are described.

Exposure to antipsychotic medications over a 4-year period among children who initiated antipsychotic treatment before their sixth birthday†

This study aims the following: (i) to describe the exposure to antipsychotic medications over a 4‐year period experienced by a cohort of children who initiated antipsychotic treatment before their sixth birthday; and (ii) to identify variables associated with the risk of antipsychotic exposure.

Factors related to criminal justice expenditure trajectories for adults with serious mental illness

BACKGROUND Criminal careers have been extensively studied in general population sample, but less is known about such patterns among people with major mental illness, and where so, criminal justice expenditure has not been taken into account. AIMS Our aim was to examine criminal justice system expenditure over time in one Florida county. Our main research question was whether treatment for mental disorders was related to a change in criminal offending and expenditure trajectory. METHODS We used the Pinellas County (Florida) Criminal Justice Information System to identify individuals under age 65 arrested between July 2003 and June 2004. Archival medical service, social and homeless services data were used to identify individuals with a serious mental illness. A two-step analysis was used to examine the data: first, we identified groups of people with similar patterns of criminal justice expenditures over 4 years (July 2002 to June 2006); second, we evaluated their demographic characteristics, diagnosis and treatment as potential predictors of group membership. RESULTS Three thousand seven hundred sixty-nine people with serious mental illness were identified in the Pinellas County jail population. Their average length of stay in jail was 151 days and in prison was 48 days. The trajectory analysis identified three groups of individuals with distinct trajectories of criminal justice expenditures: those with low stable, those with initially high but decreasing and those with initially high and sustained or increasing. Mental health treatment, whether acute or sustained, voluntary or mandatory, was associated with membership of the low stable group. CONCLUSION Review of criminal justice expenditure over time on individuals with major mental disorder may provide important indicators of unmet need for mental health services. Furthermore, it seems probable that improved provision of such services for them could reduce recidivism as well as improving health. Interventions may also be better focused if criminal justice expenditure trajectories are examined; programmes targeting re-offending as well as specific mental health problems may be most effective.

The risks and benefits of switching patients with schizophrenia or schizoaffective disorder from two to one antipsychotic medication: a randomized controlled trial.

BACKGROUND Despite little evidence to support its use and practice guidelines discouraging the practice, antipsychotic polypharmacy is widely prevalent in schizophrenia. This randomized controlled trial studied the effects of switching patients stable on two antipsychotic medications to one antipsychotic medication. METHOD 104 adult outpatients with schizophrenia from 7 community mental health centers clinically stable on concurrent treatment with 2 antipsychotics were randomly assigned to stay on polypharmacy or to switch to antipsychotic monotherapy. Participants were followed for 1-year with assessments of symptoms and side effects occurring every 60days (7 total assessments). We examined differences in time trajectories in symptoms (PANSS, CGI) and side effects (EPS, metabolic, other) as a function of group assignment (switch vs. stay) and time, using intention-to-treat analysis. RESULTS Participants who switched to antipsychotic monotherapy experienced greater increases in symptoms than stay patients. These differences emerged in the second 6months of the trial. All-cause discontinuation rates over the 1-year trial were higher in the switch-to-monotherapy group than in the stay-on-polypharmacy group (42% vs. 13%; p<0.01). There were no differences in change over time in any of the side effect measures, except that stay patients experienced a greater decrease in Simpson Angus total scores than switch patients. CONCLUSION Clinicians should be cautious in switching patients with chronic schizophrenia who are stable on 2 antipsychotics to one antipsychotic. Given the challenges in discontinuing antipsychotic polypharmacy, adequate trials of evidence-based treatments such as clozapine and long-acting injectable antipsychotics should be undertaken in inadequately responsive schizophrenia patients before moving to antipsychotic polypharmacy.

Impact of the Florida Medicaid Prior-Authorization Program on Use of Antipsychotics by Children Under Age Six

OBJECTIVE This study assessed the impact of a prior-authorization process on the use of antipsychotic medications by children under six years old in Floridas fee-for-service Medicaid program. METHODS Child psychiatrists reviewed requests for antipsychotic treatment (N=1,424) using forms and criteria created by a panel of Florida-based experts. Data on the characteristics of the children and clinicians involved were organized into 11 consecutive quarters beginning in July 2008. Multivariate generalized estimating equations were used to examine the association between each study variable and changes in the odds of submission of a new request over time. RESULTS Prior-authorization requests declined from 124 in the first quarter to 81 in the last quarter. Compared with applications from child psychiatrists, the odds of applications being submitted by adult psychiatrists, neurologists, and pediatricians increased over time. CONCLUSIONS Although applications declined, the diminished role of child psychiatry specialists raises questions about the impact of the program on the quality of care provided.

Risperidone Long-Acting Therapy Prescribing Patterns and Their Impact on Early Discontinuation of Treatment in a Large Medicaid Population

OBJECTIVE Medicaid claims were examined to determine whether utilization of risperidone long-acting therapy (LAT) was consistent with manufacturers prescribing information recommendations and what factors were associated with early discontinuation. METHOD Florida Medicaid claims between July 1, 2003, and June 30, 2007, were used. Recipient demographics and diagnoses, provision of oral antipsychotic supplementation during the first 21 days, number of injections received, medication possession ratio, and augmentation/polypharmacy after the first 21 days were assessed. Logistic regression was used to identify factors associated with early discontinuation of risperidone LAT. RESULTS There were 3,364 individuals who received 4,546 episodes of risperidone LAT. Most recipients were between 18 and 64 years and had schizophrenia or schizoaffective disorder. Median episode length was 106 days. Median number of injections was 5. Supplementation with oral antipsychotic during the first 21 days was provided in 48% of episodes. Mean dosages were 25 mg or less for 28% of episodes and greater than 75 mg for 7% of episodes. Augmentation/polypharmacy after the first 21 days occurred in 43% of episodes. Early risperidone LAT discontinuation was associated with absence of oral supplementation during the first 21 days (P < .001), low (P = .045) or high (P < .001) initial doses of risperidone LAT, prior inpatient treatment (P < .001), having a substance use disorder (P = .001), and being male (P = .036). CONCLUSIONS Prescribing practices for risperidone LAT were compared with the recommended protocol. Risperidone LAT was typically used with recommended age and diagnostic groups. However, important discrepancies were identified that could have reduced perceived effectiveness and tolerability of risperidone LAT. Early discontinuation was less likely when the recommendations in the manufacturers prescribing information regarding dosage and supplementation with oral antipsychotics were followed.

Short-Term Impact of Preferred Drug List Changes on Health Care Use and Medicaid Costs: Injectable Risperidone

OBJECTIVE This study assessed short-term effects of the removal of injectable risperidone long-acting therapy from the Florida Medicaid preferred drug list (PDL) in April 2006. METHODS A difference-in-difference approach was used to contrast changes (60 days pre and post) in health care utilization and costs of Medicaid recipients who were receiving risperidone long-acting therapy when the policy was changed (N=247) and of a matched sample who received risperidone long-acting therapy in April 2005 (non-PDL, N=247). RESULTS The policy change was associated with increased acute care events. Whereas acute care events declined for the non-PDL group, involuntary commitments and total acute care events increased for the PDL group, as did expenditures for crisis-related events. Medicaid pharmacy costs fell for both groups, but total expenditures did not decline significantly for the PDL group. CONCLUSIONS The PDL restriction was associated with increased acute care events and did not reduce short-term Medicaid program expenditures.