Examining Effects of State Policies to Monitor Mental Health Medicines for Children in Foster Care

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What was the research about?

Doctors sometimes give children medicine called antipsychotics that can affect mood and behavior. Antipsychotics can have long-term risks, like heart attack and diabetes, but they help treat serious conditions like schizophrenia. But children may also receive antipsychotics to treat other conditions, like attention deficit hyperactivity disorder. The Food and Drug Administration, or FDA, has not approved antipsychotics for these types of mental health problems. Children in foster care get these medicines more often than children not in foster care.

States are responsible for children in foster care, including what medicines they get. In this study, the research team looked at policies to improve antipsychotic use in four states:

• In some Ohio counties, doctors got prescribing guidance that included reducing the use of multiple antipsychotics at once.
• In some Wisconsin counties, a policy improved coordination of medical and mental health care.
• In Washington, the state required doctors to get approval from psychiatrists to prescribe antipsychotics.
• In Texas, doctors got guidance on prescribing antipsychotics. The guidance also suggested testing for side effects of antipsychotics.

The team looked at how the state policies and programs affected antipsychotic use for children in foster care.

What were the results?

Overall, the policies improved appropriate use of antipsychotics for children in foster care.

Ohio

• There were reductions in use of more than one antipsychotic at the same time. Children in foster care had the largest reductions

Wisconsin

• Rates of recommended blood tests improved for children in foster care

Washington

• Before the state required reviews by psychiatrists, rates of antipsychotic medicines in Washington were similar to other states. Two years after the new policy, rates declined in Washington but stayed the same in the comparison states. Rates went down more among children in foster care than children not in foster care

Texas

• Compared with adopted children, those in foster care with less severe conditions where the FDA does not recommend antipsychotic treatment were less likely to get those prescriptions
• Treatment rates didn’t change for children with more severe problems, where the FDA does recommend treatment.
• Rates of blood tests for safety monitoring increased among children in foster care and adopted children.

What did the research team do?

The team looked at states with policies that affect how children in foster care get antipsychotics. All children had Medicaid. Using health records, the team identified which medicines children in foster care got. The team also looked at whether children in Texas and Wisconsin had blood tests for antipsychotics side effects.

Young adults who were once in foster care, caregivers of children in foster care, social workers, and doctors gave input on the study.

What were the limits of the study?

The study looked at policies in four states. Results may differ for other states and policies. Findings may have differed if the research team used interviews or surveys instead of health records.

Future research could look at policies in other states, or at other kinds of information from children, like quality of life.

How can people use the results?

Policymakers can use these results when considering how to improve antipsychotic prescribing for children in foster care.

Objective

To examine the effects of state antipsychotic prescription strategies for children in foster care (FC)

Study Design

Researchers examined interventions that monitor antipsychotic prescriptions for children in FC implemented in four states:

• Ohio: Minds Matter, a multi-component quality improvement program that included provider education and a guide for providers on antipsychotic prescribing. The program’s quality improvement targets included use of multiple antipsychotics
• Wisconsin: Integration of medical and mental health services for children in FC
• Washington: Prior authorization for antipsychotic prescriptions for children in FC based on review from child psychiatrists
• Texas: A multi-modal specialized managed care program for children in FC, supported by prescribing parameters that included metabolic monitoring requirements

The intervention groups included children in foster care, eligible for Medicaid, treated with antipsychotics; comparisons were with children not in foster care, except in Texas, where comparisons were with adopted children. Researchers examined Medicaid claims data before and after the implementation of state interventions to identify differences in outcomes among children exposed to interventions. Outcomes examined and specific comparison groups varied by state.

Young adults who were once in FC, caregivers of children in FC, social workers, and doctors helped plan and execute the study.

Results

Ohio

• After implementation of Minds Matter, antipsychotic polypharmacy rates fell to lower levels that were sustained over time, with the largest changes observed among children in FC.

Wisconsin

• Metabolic testing rates improved significantly for children in FC on antipsychotics in pilot counties from pre- to post-implementation.
• Rates were stable in non-pilot counties.

Washington

• Within two years of policy implementation, prevalence decreased from 6.17 per 1000 to 4.04 in Washington and remained stable (6.21) in comparison states.
• Initially, compared with children not in FC, antipsychotic use rates declined less for children in FC. However, in year two, rates declined significantly more quickly among children in FC.

Texas

• After program implementation, prescribing for conditions without an FDA-approved indication for use was reduced relative to a comparison population. Antipsychotic use did not significantly change among individuals with diagnoses carrying FDA-approved indications for use.
• Compared with children in FC treated with antipsychotics in Ohio (where the intervention did not focus on metabolic monitoring), children in FC treated with antipsychotics in Texas had significantly greater increases in metabolic monitoring.
• Addition of metabolic monitoring to state prescribing parameters was followed by an increase in both the level and trend of monitoring rates among youth in FC.

Limitations

Researchers examined antipsychotic prescription monitoring strategies in four states. Results may differ in other states and systems. Findings may have differed if researchers measured outcomes using self-reported data instead of administrative data.

Conclusions and Relevance

Overall, the antipsychotic policies studied improved appropriate use of antipsychotics for children in FC. State and local policymakers can use this research when considering antipsychotic prescription strategies for children in FC.

Future Research Needs

Future research could study the effects of antipsychotic prescription strategies in other states. Studies could also use self-reported data and different client-centered outcomes such as quality of life.