1 Behavioral Health Pharmacy Children’s Issues Hoosier Healthwise presentations

The Best Care. Because We Care.

1

Behavioral Health PharmacyChildren’s Issues

Hoosier Healthwise presentations

The Best Care. Because We Care.

2

MHQAC

• April 2007 meeting first requested– Pediatric data pull for determination of

prevalence for Indiana and other States– Literature Search– Other State Programs

• April 2008 meeting scheduled for presentation

Mental Health Medication Utilization in Children:

Anthem BCBS

Jeannine Murray

Mental Health Data Collection

Date Range: January 2007- June 2007

Age: 0-18 yrs

Identified Therapeutic Classes:

• Antidepressants (GPI 58)

• Antipsychotics (GPI 59)*

• Anticonvulsants (GPI 72)

• Anxiolytics/ benzodiazepines (GPI 57)

• Stimulants, Misc ADHD (GPI 61)

• Sedative/ hypnotics (GPI 60)

Anthem Medicaid States: OH, IN, KS, NV, CA

*Injectables are not included

State differences

State Membership

June 2007

Status of Mental Health Drugs TANF SCHIP ABD

California1,243,128

(65% 18 & under)Restrictions; Antipsychotics carved

out for Medi-Cal (772,000

members)

X X X

Indiana99,404

(78% 18 & under)No Restrictions; level 1 edits X X

Kansas49,373

(77% 18 & under)No Restrictions X X

Nevada44,823

(74% 18 & under)Restrictions X X

Ohio 155,143

(67% 18 & under)

Restrictions; no restrictions on

atypicals for ABD (4122 members)

X X X

Total Unique Members with a Mental Health Medication Pharmacy Claim

Anxiolytics/ benzodiazepines (GPI 57) Antidepressants (GPI 58) Antipsychotics (GPI 59) Sedative/ hypnotics (GPI 60) Stimulants, Misc ADHD (GPI 61) Anticonvulsants (GPI 72)

Unique Members with Any Claims for GPI 57, 58, 59, 60, 61 or 72Total = 51,007 Members across IN,CA,KS, NV, OH

4.8% of pediatric recipients

0

500

1000

1500

2000

2500

3000

3500

4000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age

Un

iqu

e M

em

ber

s

Total Unique Members with an Antipsychotic, Antidepressant, ADHD Pharmacy Claim

Unique Members w ith Any Claims for GPI 58, 59, 61Total = 34,743 Members across IN, CA, KS, NV, OH

3.3% pediatric recipients

0

1000

2000

3000

4000

5000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age

Un

iqu

e M

em

be

rs

GPI 58,59,61 GPI 57,58,59,60,61,72

Antidepressants (GPI 58) Antipsychotics (GPI 59) Stimulants, Misc ADHD (GPI 61) Anxiolytics/ benzodiazepines (GPI 57) Sedative/ hypnotics (GPI 60) Anticonvulsants (GPI 72)

Mental Health Medication Utilization in Children by State

Anxiolytics/ benzodiazepines (GPI 57) Antidepressants (GPI 58) Antipsychotics (GPI 59) Sedative/ hypnotics (GPI 60) Stimulants, Misc ADHD (GPI 61) Anticonvulsants (GPI 72)

RXs PMPM = total prescriptions per member, age 18 and under, per month

RXs PMPM

0

0.02

0.04

0.06

0.08

0.1

0.12

CA SSP Indiana Kansas Nevada Ohio Total

Mental Health Medication Utilization in Children by State

RXs PUPM

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

CA SSP Indiana Kansas Nevada Ohio Total

Anxiolytics/ benzodiazepines (GPI 57) Antidepressants (GPI 58) Antipsychotics (GPI 59) Sedative/ hypnotics (GPI 60) Stimulants, Misc ADHD (GPI 61) Anticonvulsants (GPI 72)

RXs PUPM = total prescriptions per utilizing member, age 18 and under, per month

Member Utilization of an Antipsychotic, Antidepressant, ADHD Medication by State

Rxs/K - GPI 59, 58 and 61

-

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

CA SSP Indiana Kansas Nevada Ohio

Antipsychotics GPI 59 Antidepressants GPI 58 Psychostimulants GPI 61

RXs/K= total prescriptions per 1000 members, age 18 and under, per month

Children with Atypical Antipsychotic Medications Concurrently receiving Medication for Diabetes

AGE ATYPICAL ANTIPSYCHOTIC DIABETES MEDICATION

12 Abilify Insulin

12 Risperdal Insulin

13 Risperdal Metformin

16 Abilify Metformin

16 Abilify + Zyprexa Metformin

June 2007 data only, members 18 and under1167 unique members receiving atypical antipsychotics5 unique members (0.43%) receiving treatment for diabetes

Behavioral Health PharmacyChildren’s Issues

Indiana State Mental Health Quality Advisory

Committee

The Best Care. Because We Care. 14

Overview

Review of DataPrevalence

Literature Search Results Precedent Government Programs Considerations

The Best Care. Because We Care. 15

Prevalence Data

Eligible Members Ages 0-18 years By year of age Ages grouped

Timeframe claims with Date of Service from: Jan. 1, 2007 to June 30, 2007 Member months calculated as an average for 6 month

period AAAX list on file with OMPP (see handout for current

full listing of antianxiety, antidepressnt, antipsychotic, or cross-indicated drug)

Therapy class focus Antipsychotics

TypicalsAtypicals

Antidepressants Psychostimulants

The Best Care. Because We Care. 16

Total Recipients 227,607

0

5000

10000

15000

20000

25000

0 1 2 3 4 5 6 7 8 9101112131415161718

age in years

Number of Recipients by year of age

The Best Care. Because We Care. 17

Unique Members with AAAX claim (23,932): 10.5% of pediatric recipients

0

500

1000

1500

2000

2500

0 1 2 3 4 5 6 7 8 9101112131415161718Age in years

The Best Care. Because We Care. 18

2003 Arch Ped Adolesc Med

Study of 2 U.S. Prescription Databases reported youth psychotropic medication utilization nearly at adult utilization rates

Reported that in 1996, 6% of 900,000 youth under 20 years of age received psychotropic medicationMost prescribed were stimulants, then

antidepressants

The Best Care. Because We Care. 19

21,095 Unique Members: Antipsychotics, Antidepressants, Psychostimulants

88% of AAAX drugs prescribed; 9.3% of all pediatric recipients

0200400600800

100012001400160018002000

0 1 2 3 4 5 6 7 8 9 101112131415161718

unique members with claims in one or more of these therapy classes

The Best Care. Because We Care. 20

Total Medication Cost for 6 month period =$14,536,191

$0

$1

$2

$3

$4

$5

$6

$7

Millions

Antipsychotics ($4.8million)

Antidepressants($753,000)

Psychostimulants/ NRI($6.8 million)

Other ($2 million)

note: Does not include cost related to adverse event profiles

The Best Care. Because We Care. 21

Prevalence by Category

Antipsychotics = 2.3%Antidepressants= 3.7%Psychostimulants = 8.1%

The Best Care. Because We Care. 22

Antipsychotics

Prevalence Data per 1,000 recipientsPatel et al 2001

(MM- Midwestern Medicaid; SM= Southern Medicaid; WM= western Medicaid; MCO= Managed Care Organization)

Cooper et al 2001TennCare

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005;44(6)

Cooper Wo, Hickson GB, Fuchs C, et al. Arch Pediatr Adolesc Med. 2004;158(8)

The Best Care. Because We Care. 23

Patel et al.

All antipsychotics per 1,000 recipients by region

MM=14.3 SM=15.5 MDwise=23.4

(2.3%)

WM=6.9 MCO= 3.4

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005; 44(6)

The Best Care. Because We Care. 24

Cooper et al.

All antipsychotics per 1,000 recipients

TennCare=4.5

Cooper Wo, Hickson GB, Fuchs C, et al. Arch Pediatr Adolesc Med. 2004;158(8)

The Best Care. Because We Care. 25

Patel et al

Atypical antipsychotics MM=13.1 SM=14.9 MDwise=23.2 (2.3%)WM=6.2 MCO= 2.7

Typical antipsychoticsMM=2.0 SM=1.5 MDwise= 0.4 (0%)WM=1.3 MCO=0.9

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005; 44(6)

The Best Care. Because We Care. 26

Prevalence by Age

All antipsychotics2-4 years

MM=2.2SM=5.5 MDwise=3.7 (0.4%)WM=0.8MCO=0.9

5-9 yearsMM=14.4SM=20.7 MDwise=27.1 (2.7%)WM=5.7MCO=3.1

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005;44(6)

The Best Care. Because We Care. 27

Prevalence by Age

All antipsychotics10-14 years

MM=27.2SM=35.4 MDwise=49.3 (4.9%)WM=11.4MCO=4.9

15-19 yearsMM=28.1SM=26.3 MDwise= 41.0 (15-18 yrs)WM=14.2 =(4.1%)MCO=4.9

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005;44(6)

The Best Care. Because We Care. 28

Prevalence By Age

Atypical Antipsychotics2-4 years

MM=1.9SM=5.3 MDwise=3.7 (0.4%)WM=0.6MC0=0.5

5-9 yearsMM=13.7SM=20.0 MDwise=27.0 (2.7%)WM=5.3MCO=2.6

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005; 44(6)

The Best Care. Because We Care. 29

Prevalence by Age

Atypical Antipsychotics10-14 years

MM=25.6SM=34.0 MDwise=48.8 (4.9%)WM=10.5MCO=4.1

15-19 yearsMM=24.2SM=24.8 MDwise=40.3 (15-18 yrs)WM=12.2 =(4.0%)MCO=3.4

Patel N, Crismon M, Hoagwood K, et al. J Am Acad Child Adolesc Psychiatry. 2005; 44(6)

The Best Care. Because We Care. 30

Trends in Antipsychotic Prescribing

Cooper WO, et alStatistical analysis of data taken from National

Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS)

Methodology: sample of physicians that recorded sampling of office visits for randomly chosen 1-week period

From 1995-2002, frequency of antipsychotic prescribing to children aged 2-18 yo increased fivefold

Coincided with introduction of atypical antipsychoticsOver 30% of Rx associated with visit to non-mental health

providerOver 50% of associated diagnoses were non-FDA approved

indicationsCooper WO, Arbogast PG, Ding H, et al. Ambul Pediatr. 2006; 6(2)

The Best Care. Because We Care. 31

Trends in Antipsychotic Prescribing

Cooper WO, Arbogast PG, Ding H, et al. Ambul Pediatr. 2006;6(2)

The Best Care. Because We Care. 32

Sutcliffe et al.

“This rapid increase in antipsychotic prescribing is of concern because there is little robust evidence of a corresponding increased prevalence of psychotic illness in young people.”

Sutcliffe AG, Wong ICK. BMJ. 2006;332 (7556)

Rani F, Murray M, Byrne P. PEDIATRICS. 2008;121(5)

The Best Care. Because We Care. 33

Atypical Antipsychotics (unique recipients by year of age)

Unique Number of Members Per Drugs By Age From 01/01/07 - 06/30/07

Brand_Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18ABILIFY 4 17 28 40 73 103 118 118 123 130 150 151 129 114 59 47ABILIFY DISCMELT 1 1 1 1 1 1CLOZAPINE 1GEODON 1 5 4 11 22 25 25 38 36 27 36 41 34 26 15INVEGA 1 2 2 4 7 6 4 5 4 2 2 2RISPERDAL 2 10 34 81 142 164 249 238 236 240 227 183 162 169 139 84 72 42RISPERDAL CONSTA 1 1 1SEROQUEL 1 15 25 39 54 58 88 113 103 93 96 105 106 98 77 61ZYPREXA 1 3 2 12 21 21 16 21 19 23 24 21 18 15 19 16ZYPREXA ZYDIS 1 3 1 1 2 2 4 3 1 1 1

The Best Care. Because We Care. 34

Unique Recipients (0-18 years) by Antidepressant Class

0

100

200

300

400

500

600

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

SSRIs TCAs a-2 antagonists SSNRIs bupropion serotonin-2 antagonist/ reup

The Best Care. Because We Care. 35

Antidepressants

Prevalence per 1,000 recipientsMDwise=36.74

3.7% of pediatric recipientsPrevalence of depression reported in the

general US pediatric population3%

Preschoolers-0.3%Elementary school age-2%Adolescents-5-8%

Harold S. Koplewicz, MD child psychiatrist and director of the New York University Child Study Center

Dopheide, JA. Psychiatric Issues in Pediatrics. The American Society of Health-System Pharmacists, Inc. 2006

The Best Care. Because We Care. 36

Antidepressant Utilization

October 2003- FDA warning issued Libby AM, et al.

Analyzed effect of FDA warning on “patterns of care” in pediatric depression

Large cohort (N = 65,349) of pediatric managed care enrolleesOctober 1998- September 2005Diagnosis of pediatric depression and AD prescribing

increased from 1999-2004Trends observed after FDA warning

Rate of new diagnoses declined to 1999 levelsProportion of patients receiving ADs declined

Libby AM, Brent DA, Morrato EH, et al. Am J Psychiatry. 2007;164(6)

The Best Care. Because We Care. 37

Unique member counts Psychostimulants/NRI-typeby year of age

0

500

1000

1500

2000

2500

0 1 2 3 4 5 6 7 8 9101112131415161718

The Best Care. Because We Care. 38

Psychostimulants/NRI-type

Prevalence per 1,000 recipients80.9

8.1% of pediatric recipients

Prevalence of ADHD reported in the general US pediatric population3-5% NIMH 19994-12% AAP 2001

Office of the Surgeon General, and National Institute of Mental Health, 1999

American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attenetion-Deficit/Hyperativity Disorder. Pediatrics. 2000;105:1158-1170.

The Best Care. Because We Care. 39

Trends in Psychostimulant Utilization

Zuvekas SH, et al.Utilization of stimulants increased four

times from 1987-1996No statistical difference in utilization from

1997-2002

Zuvekas, SH, Vitiello B, Norquist GS. Am J Psychiatry. 2006;163

The Best Care. Because We Care. 40

Literature Review

Key Studies/GuidelinesAntipsychoticsAntidepressantsPsychostimulants

Note: TMAP publications specifically excluded based on prior MHQAC feedback. Information available upon request.

The Best Care. Because We Care. 41

Treatment of Pediatric Aggression Treatment Recommendations for the use of

Antipsychotics for Aggressive Youth (TRAAY)Based on evidence in literature and panel

consensus14 recommendations intended to provide

systematic approach to treating aggressive behaviors (eg, ODD, CD, ADHD) in youth

Considered a guide to treating aggressive behavior because controlled trials are scarce

Schur SB, Sikich L, Findling RL, et al. J Am Acad Child Adolesc Psychiatry. 2003;42(2)

Pappadopulos E, Macintyre Ii JC, Crismon M , et al. J Am Acad Child Adolesc Psychiatry. 2003;42(2)

The Best Care. Because We Care. 42

TRAAY

Established atypical antipsychotics as the treatment of choice in aggressive behavior

Stressed importance of behavioral interventions Currently, atypicals considered treatment of choice

Risperidone 0.25 mg qd for children, 0.5 mg qd for adolescents

Schur SB, Sikich L, Findling RL, et al. J Am Acad Child Adolesc Psychiatry. 2003;42(2)

Pappadopulos E, Macintyre Ii JC, Crismon M , et al. J Am Acad Child Adolesc Psychiatry. 2003;42(2)

The Best Care. Because We Care. 43

Treatment Guidelines for Children and Adolescents with Bipolar Disorder

These treatment guidelines arose out of a need first voiced by members of the Child and Adolescent Bipolar Foundation (CABF), who noted that clinicians who treat children and adolescents with bipolar disorders (BPDs) are in desperate need of guidelines regarding how to best treat these patients.

Established treatment guidelines for pediatric patients with bipolar disorder

Combination of evidence in literature and expert opinion Intended as guidance, not absolute standard of practice

Differentiates childhood-onset manic symptoms from “normal” childhood behavior and other diagnosis

Recommends starting with mood stabilizer monotherapy and augmenting for partial response.

Higher response rates when mood stablilizer combined with second generation antipsychotic.

Kowatch, RA, Fristad M, Birmaher B, et al. J Am Acad Child Adolesc Psychiatry. 2005;44(3)

The Best Care. Because We Care. 44

Treatment Guidelines for Children and Adolescents with Bipolar Disorder

Disorder Monotherapy Augmentation Last-line therapy

Acute BPD, mixed or manic,

w/o psychosis

Mood stabilizer1 or atypical

antipsychotic2

Add second agent (regimen must contain mood

stabilizer)

[Two mood stabilizers + atypical] or alternate

monotherapy3

Acute BPD, mixed or manic, with psychosis

Mood stabilizer1 + any atypical

antipsychotic

Add second mood stabilizer (regiment

must contain Lithium

Alternate monotherapy3 +

atypical

Acute BPD with depression

Mood stabilizer (preferably Lithium)

Add SSRI or bupropion

ECT (adolescents only)

1Lithium, valproic acid, carbamazepine 2Olanzapine, quetiapine, risperidone

3Alternate monotherapy with oxcarbazepine, ziprasidone, or abilify; if this fails, clonidine or ECT (adolescents only)

Kowatch, RA, Fristad M, Birmaher B, et al. J Am Acad Child Adolesc Psychiatry. 2005;44(3)

The Best Care. Because We Care. 45

Treatment of Pediatric Depression

TADS studyTreatment for Adolescents with Depression

StudyMulticenter RCT, N=439Treatment groups

Fluoxetine alone and placebo alone (double-blind)

CBT alone and CBT + fluoxetine (unblinded)

ResultsCBT + fluoxetine group exhibited most

significant improvementMarch J, Silva S, Petrycki S, et al. JAMA. 2004;292(7)

The Best Care. Because We Care. 46

Treatment of Pediatric Depression Current evidence

Limited literature for < 11 yo Non-pharmacologic therapy is 1st line for non-psychotic

depression in youth given high efficacy rates and avoidance of drug side effects;need motivated patient and family

70% of adolescents with MDD achieved a significant reduction in symptoms with CBT during controlled clinical trial

Drug therapy1st line = SSRIsMost literature with fluoxetine

FDA approved for children > 8 yo with major depressionShould avoid paroxetine use (high suicidality risk suggested)Consider Zoloft® or Celexa® 2nd line

Dopheide, JA. Psychiatric Issues in Pediatrics. The American Society of Health-System Pharmacists, Inc. 2006

The Best Care. Because We Care. 47

Psychostimulant Use

2001 Clinical Practice Guidelines for ADHD from the American Academy of Pediatrics (AAP) Extensive Evidence-based Review including Multimodal

treatment study of children with ADHD (MTA) Treatment algorithm Guideline provides 5 major recommendations

ADHD is a chronic condition: 60-80% of children will have symptoms into adolescence.

Information from multiple informant crucial for clear diagnosis and target outcomes should be established by caregivers and clinician

Psychostimulants are the most effective treatment for ADHD and behavioral interventions are adjunctive

Diagnosis should be reassesssed when target symptoms not responsive to treatment

Systematic follow-up essential for postive outcome Medication guides dispensed with every Rx All pediatric pts should receive thorough CV assessment prior to

initiation of txAmerican Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder.PEDIATRICS. 2000;105

MTA Cooperative Group. Arch Gen Psychiatry. 1999;56

The Best Care. Because We Care. 48

Preschool Age Guidelines/Recommendations

Gleason MM, et al. Founded Preschool Psychopharmacology Working Group

(PPWG)Group formed to develop treatment recommendations for

psychiatric drug treatment in “very young children” Based on evidence in literature, panel consensus Encouraged NPT as initial treatment Aimed to reduce drug utilization, polypharmacy

Provide treatment algorithms for numerous disease states

Gleason MM, Egger HL, Emslie GJ, et al. J Am Acad Child Adolesc Psychiatry. 2007;46(12)

The Best Care. Because We Care. 49

Preschool Age Guidelines/Recommendations

Disease states addressed: ADHD Disruptive Behavior

Disorder Major Depressive

Disorder Bipolar Disorder Anxiety disorders

PTSD OCD Pervasive Development

Disorder Primary sleep disorders

Gleason MM, Egger HL, Emslie GJ, et al. J Am Acad Child Adolesc Psychiatry. 2007;46(12)

The Best Care. Because We Care. 50

Guidelines

The Best Care. Because We Care. 51

“SafeGuards”

IC 12-15-35.5-7 clinical quality and patient safety; accepted clinical practice for the

diagnosis and treatment of mental illness

implement a disease management program;

The Best Care. Because We Care. 52

Precedent Program Examples

Texas Department of State Health Services (please see handout)

Federation of Texas PsychiatryTexas Pediatric SocietyTexas Academy of Family PhysiciansTexas Osteopathic Medical AssociationTexas Medical Association

Center for Health Care Strategies (please see handout)

The Best Care. Because We Care. 53

Previously Addressed by MHQAC(but not implemented)

2 or more stimulants (different active ingredients)

3 or more mood stabilizer medications

The Best Care. Because We Care. 54

MDwise Data 0-18 years

5 or more psychotropics2 or more antidepressants2 or more antipsychotic medications

The Best Care. Because We Care. 55

5 or more any psychotropics

644 unique members with this occurring one or more times in a six month period

The Best Care. Because We Care. 56

2 or more antidepressants

3230 unique members with this occurring one or more times in a six month period

The Best Care. Because We Care. 57

2 or more antipsychotic med

770 unique members with this occurring one or more times in a six month period

The Best Care. Because We Care. 58

Atypical antipsychotic + hypoglycemic

18 unique members with this occurring one or more times in a six month period

The Best Care. Because We Care. 59

Recent Case #1

Pre-K child with diagnosis of bipolar ADHD Medication claims history (one prescriber for all)

RISPERDAL 2mg qhs and RISPERDAL 0.5mg qam and qpm (concurrently) followed by

INVEGA 3mg qam, RISPERDAL 0.5mg qam and qpm, plus DAYTRANA, clonidine, SEROQUEL (concurrently)

The Best Care. Because We Care. 60

Recent Case #2

Toddler (diagnosis under review)Medication claims history (3 prescribers)

Risperdal 1mg (1.5 tablet/day)Strattera 40mg (1 tablet/day)Rozerem 8mg (0.5 tablet/day)Dextroamphetamine 5mg (1.5 tab/day)

Case manager contacted parent who reports that there are several other prescriptions from other doctors that hadn’t been filled because they were afraid to give all of the medications to the toddler.

Questions

P0079 (9/06)