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Psychopharmacology
Central Planning and U.S Child Psychopharmacology
Back to the USSR?
Posted May 26, 2016
The Soviet Union had a centrally planned economy. Belief in central planning for economic development was a tenet of Soviet communism. Every facet of production was managed and monitored by the government through five year plans. Once every five years, managers had to complete reports for the planning committees and the central committee to demonstrate the progress that had been made toward their goals. Survival of the managers depended on reports that supported the efficacy of the system. Although the method had its successes, in general, it is regarded as having failed. Its failure contributed greatly to the fall of the Soviet Union (1).
Similar central planning efforts seemed to have seized the imaginations of some U.S. federal and state mental health administrators and have led to efforts to control the prescription of antipsychotic medications to psychiatrically disturbed children and adolescents. Antipsychotic medications are often used to control aggression in violent children. Although these medications can be effective, they are associated with undesirable side effects. With the support of the federal government, many states have begun to make efforts to reduce the amount of antipsychotic medications prescribed for children and adolescents (2, 3). In Pennsylvania, for example, the Department of Human Services has recognized an increase in the use of antipsychotic medications in foster care children and other children on Medicaid (4). Pennsylvania has implemented several initiatives to limit the amount of antipsychotic medications given to children and adolescents including the use of prior authorization by managed care pharmacy managers.
Prior authorization is a technique of for-profit managed care organizations that provide (manage) pharmaceutical benefits for their patients. The practitioner prescribes the medications, but the prescriptions are reviewed by the pharmacy benefit managers who make the final decision about whether the medications will be provided. They review the prescription to learn if the cost of the medication is justified. Originally such reviews were mainly an effort to shift costs from an expensive prescribed medication to a less expensive prescribed medication that worked as well as the prescribed medicine but with less cost. If the pharmacy benefit managers refuse to provide the prescribed medication, the prescriber is asked to complete a “prior authorization” form in which the rationale for the prescribed medication is argued.
Although the use of pharmacy benefit managers to contain cost is well established, a new role has emerged: containing perceived risk.
The use of pharmacy benefit managers as risk/benefit arbiters judging the adequacy prescribed pharmacological treatments for psychiatric disorders is new and inappropriate.
Correctly prescribing antipsychotics for children and adolescents is a nuanced undertaking and one that cannot easily be second guessed by bureaucrats with limited expertise in behavioral health. Counting specific objects such as tractors produced in a given year, as was done in Soviet Russia in an effort to control tractor production, is very different from evaluating the risk benefit decision made between a parent and psychiatrist. The number of patients receiving a medication does not convey information about the need for the medication, patient response to the medication, or the severity of side effects of the medication.
The Pennsylvania Department of Human Services takes a critical view of the prescription of antipsychotics for children who are not psychotic. But these agents are often critically needed and highly useful components in the care of disturbed young children and adolescents (5). For example a full 50% of children with ADHD who are violent and assaultive will require an antipsychotic along with stimulant medication to improve (6). The lowest possible dose of antipsychotic should be used and the practitioner must be sophisticated and able to monitor potential side effects and complications such as changes in lipids, body weight, and hormone levels.
Requiring a prior authorization for antipsychotic medications for every child and adolescent psychiatric Medicaid patient below the age of 19 years as is the current policy in Pennsylvania is becoming a major obstacle to the effective delivery of care to seriously mentally ill, impoverished children 18 years and younger.
The prior authorization necessitates the practitioner writing a justification for the need for the medication as well as demonstrating compliance with other clinical requirements associated with giving the medication. Prescribers are already strained to provide care within the limited amount of time provided by managed care for medication visits. Time is not provided to write rationales for prescribing a specific medication to a pharmacy benefit manager.
Pharmacy benefit prior authorization systems permit the use of antipsychotics for conditions for which the drugs are FDA approved, for example, schizophrenia and bipolar disorder. The managed care organizations are reluctant to approve antipsychotics for non FDA approved conditions such as the treatment of dangerous violent behavior. This creates considerable pressure for practitioners to misdiagnose their patients to enable them to get the needed medications.
Pharmacy benefit managers in Pennsylvania periodically demand prior authorizations for agents other than antipsychotics that could be used as initial attempts to control aggressive behavior. There has not been any detectable decrease in the demand for prior authorizations for alternative FDA approved medications that offer some promise of reducing children’s aggressive behavior such as stimulant medications.
Violent children denied stimulants and antipsychotics quickly revert to their aggressive behavior. Parents become frantic and schools threaten disciplinary action including expulsion of the children. I work several days per week in Medicaid clinics for psychiatrically disturbed children and have seen firsthand the confusion, anger, and despair that the refusal to fill these prescriptions have created in children and their families. In the bureaucratically created chaos it can seem to parents and practitioners as if war has been declared on mentally ill children.
Pharmacy benefit managers are not trained to understand the value, necessity, and use of these medications to treat the serious problems of some children. The patients and their families are pawns in a well meant, but poorly implemented, clinical administrative mandate to reduce indiscriminately the prescription of antipsychotic medications to children under 19 years of age.
1. Wikipedia.org/wiki/Economy_of_the_soviet_union
2. dosReis, S. et al. Psychiatric ServicesPublished online May 02, 2016 http://dxdoi.org/10.1176.ps.2015080270
3. Schmid,I et al Medicaid Prior Authorization Policies for Pediatric Use of Antipsychotic Medications. JAMA 2015; 313(9): 966 DOI: 10 1001/jama.2015.0763
4. Malone, M. et al (2015) Psychotropic Medication Use by Pennsylvania Children in Foster Care and Enrolled in Medicaid. Philadelphia PolicyLab at The Children’s Hospital of Philadelphia
5. Aman MG, et al. What does risperidone add to parent training and stimulant medication for severe aggression in child attention-deficit/hyperactivity disorder J Am Acad Child Adolesc Psychiatry. 2014:53:47-60.
6. Blader, J.C. Callous-unemotional traits, proactive aggression, and treatment outcomes of aggressive children with attention-deficit/hyperactivity disorder J Am Acad Child Adolesc Psychiatry. 2013:52:1281- 1293.
Copyright: Stuart L. Kaplan, M.D., 2016.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com
