Why Psychiatric Prescribing Data Aren't Always Accurate
Why Psychiatric Prescribing Data Aren't Always Accurate
Hello. I am Dr. Robert Findling, Director of the Division of Child and Adolescent Psychiatry at University Hospitals Case Medical Center, and Professor of Psychiatry and Pediatrics of Case Western Reserve University. In this posting, I will be talking about some findings from an article that I published with several colleagues not too long ago. The topic of that article was the factors that might be associated with the prescription of antipsychotic medication in children. I am the first author on this article, which was published in the Journal of Child and Adolescent Psychopharmacology.
There is substantial evidence that the rate at which children are receiving antipsychotic medications has increased over the past several years. The clinical characteristics of these children are often reported in data sets that come from insurance claims. However, it is possible that the data from these claims-based data sets might not be as precise as we might hope.
For example, there is evidence from earlier work that discrepancies can exist between the clinical diagnosis given by a practitioner and the diagnosis ascertained by a research interviewer. Furthermore, it is possible that in a child with psychiatric comorbidity, not all diagnoses are listed on the billing sheets. So, comorbidity might not be fully documented on insurance claims.
Because we weren't aware of any studies that attempted to confirm the validity of any of the large claims-based data sets pertaining to the use of antipsychotic agents in children, our research group set out to examine the clinical characteristics of children who were being prescribed antipsychotic medications. This work was under the auspices of a National Institutes of Health (NIH)-supported grant called "The Longitudinal Assessment of Manic Symptoms" (LAMS).
The children who participated in LAMS were recruited from outpatient clinical settings that were associated with 4 medical schools in Ohio and Western Pennsylvania. This epidemiologically ascertained cohort recruited children aged 6-12 years who had symptoms that were or could be associated with mania, but didn't necessarily have bipolar illness. In fact, most of these children did not suffer from a bipolar illness. Ultimately, 707 children were the constituents of our LAMS cohort.
What did we find out about the treatment history in these young people? We found that the use of antipsychotic medications was relatively common. Of the almost 450 children who were being prescribed psychotropic medications, almost 1 in 3 were being prescribed an antipsychotic drug. In addition, we found geographic differences in the rates of antipsychotic prescription. We also found that having a previous psychiatric hospitalization was associated with being treated with an antipsychotic medication. Perhaps those 2 findings are not surprising -- they certainly were not surprising to us.
However, we were surprised to find that only 2 psychiatric diagnoses were associated with being prescribed an antipsychotic medication. The first was a psychotic illness, and the other was bipolar I disorder. Of interest, a diagnosis of bipolar spectrum disorder, such as bipolar disorder not otherwise specified (NOS), or disruptive behavior disorder was not related to receiving an antipsychotic.
Previous reports have raised concerns that children with attention-deficit/ hyperactivity disorder (ADHD) are being prescribed antipsychotic agents, despite the evidence that antipsychotics have not been shown to be safe or effective in this patient population.
So, we looked at our LAMS patients in more detail. We found that 361 children in our cohort had a diagnosis of ADHD and were being prescribed a psychotropic agent. A substantial number of these children suffered from psychiatric comorbidities. We found that only 13 of 361 children with ADHD did not have comorbidities and were being prescribed an antipsychotic medicine. Of interest, 12 of the 13 children had previously failed a therapeutic trial with a psychostimulant or were currently being prescribed a psychostimulant.
In short, despite the limitations of this study, these data suggest that more detailed and precise examinations of groups of children can complement the information ascertained from claims-based data sets.
Some important policy decisions are likely to be made on the basis of information derived from these claims data. It's important that other studies be conducted to determine whether the claims data are valid. That can be done easily through external validation studies. Otherwise, policymakers run the risk of making vital decisions about these vulnerable children on the basis of imperfect information.
I'm Dr. Robert Findling. Thank you for watching.
Hello. I am Dr. Robert Findling, Director of the Division of Child and Adolescent Psychiatry at University Hospitals Case Medical Center, and Professor of Psychiatry and Pediatrics of Case Western Reserve University. In this posting, I will be talking about some findings from an article that I published with several colleagues not too long ago. The topic of that article was the factors that might be associated with the prescription of antipsychotic medication in children. I am the first author on this article, which was published in the Journal of Child and Adolescent Psychopharmacology.
There is substantial evidence that the rate at which children are receiving antipsychotic medications has increased over the past several years. The clinical characteristics of these children are often reported in data sets that come from insurance claims. However, it is possible that the data from these claims-based data sets might not be as precise as we might hope.
For example, there is evidence from earlier work that discrepancies can exist between the clinical diagnosis given by a practitioner and the diagnosis ascertained by a research interviewer. Furthermore, it is possible that in a child with psychiatric comorbidity, not all diagnoses are listed on the billing sheets. So, comorbidity might not be fully documented on insurance claims.
Because we weren't aware of any studies that attempted to confirm the validity of any of the large claims-based data sets pertaining to the use of antipsychotic agents in children, our research group set out to examine the clinical characteristics of children who were being prescribed antipsychotic medications. This work was under the auspices of a National Institutes of Health (NIH)-supported grant called "The Longitudinal Assessment of Manic Symptoms" (LAMS).
The children who participated in LAMS were recruited from outpatient clinical settings that were associated with 4 medical schools in Ohio and Western Pennsylvania. This epidemiologically ascertained cohort recruited children aged 6-12 years who had symptoms that were or could be associated with mania, but didn't necessarily have bipolar illness. In fact, most of these children did not suffer from a bipolar illness. Ultimately, 707 children were the constituents of our LAMS cohort.
What did we find out about the treatment history in these young people? We found that the use of antipsychotic medications was relatively common. Of the almost 450 children who were being prescribed psychotropic medications, almost 1 in 3 were being prescribed an antipsychotic drug. In addition, we found geographic differences in the rates of antipsychotic prescription. We also found that having a previous psychiatric hospitalization was associated with being treated with an antipsychotic medication. Perhaps those 2 findings are not surprising -- they certainly were not surprising to us.
However, we were surprised to find that only 2 psychiatric diagnoses were associated with being prescribed an antipsychotic medication. The first was a psychotic illness, and the other was bipolar I disorder. Of interest, a diagnosis of bipolar spectrum disorder, such as bipolar disorder not otherwise specified (NOS), or disruptive behavior disorder was not related to receiving an antipsychotic.
Previous reports have raised concerns that children with attention-deficit/ hyperactivity disorder (ADHD) are being prescribed antipsychotic agents, despite the evidence that antipsychotics have not been shown to be safe or effective in this patient population.
So, we looked at our LAMS patients in more detail. We found that 361 children in our cohort had a diagnosis of ADHD and were being prescribed a psychotropic agent. A substantial number of these children suffered from psychiatric comorbidities. We found that only 13 of 361 children with ADHD did not have comorbidities and were being prescribed an antipsychotic medicine. Of interest, 12 of the 13 children had previously failed a therapeutic trial with a psychostimulant or were currently being prescribed a psychostimulant.
In short, despite the limitations of this study, these data suggest that more detailed and precise examinations of groups of children can complement the information ascertained from claims-based data sets.
Some important policy decisions are likely to be made on the basis of information derived from these claims data. It's important that other studies be conducted to determine whether the claims data are valid. That can be done easily through external validation studies. Otherwise, policymakers run the risk of making vital decisions about these vulnerable children on the basis of imperfect information.
I'm Dr. Robert Findling. Thank you for watching.
