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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)