• Antidepressant Use in Medicaid-Insured Youth: Trends, Covariates, and Future Research Needs

      Zito, J.M.; Pennap, D.; Safer, D.J. (Frontiers Media S.A., 2020)
      Background: Detailed research on long-term antidepressant (AD) trends within a single large US Medicaid population of youth has not heretofore been reported. Methods: Administrative claims data for eight annual timepoints across 28 years (1987–2014) were organized for youth (<20 years old) who were continuously enrolled during each study year in a mid-Atlantic state Medicaid program. Total annual AD prevalence and age-, gender-, race-, eligibility group-, and diagnosis-specific prevalence were formed from bivariate analyses; logistic regression assessed the change in use (2007–2014) adjusted for covariates. AD-polypharmacy data were assessed in 2014. Results: The major findings are: 1) AD use in state Medicaid enrollees grew 14-fold between 1987 and 2014. Data from 2014 revealed significantly increased odds of youth with SSRI/SNRI dispensings compared to 2007 (AOR=1.15 95% CI 1.11–1.19), representing 78% of total AD users. 2) Recent AD increases were greatest for 15–19-year olds. 3) AD use in girls passed up AD use in boys for the first time in 2014. 4) In 2014, ADs for foster care (12.7%) were 6 times greater than for their income-eligible Medicaid-counterparts. 5) In 2014, a quarter of AD-medicated youth were diagnosed with a behavior disorder. 6) More than 40 percent of AD medicated youth had >=1 other concomitant psychotropic classes for 60 or more days. Conclusions: Second-generation antidepressant use in Medicaid-insured youth has increased despite growing questions that pediatric AD benefits may not outweigh harms. These patterns support the call for publicly funded, independent investigator-conducted post-marketing outcomes research. Copyright 2020 Zito, Pennap and Safer.
    • Hispanic residential isolation, ADHD diagnosis and stimulant treatment among Medicaid-insured youth

      Pennap, D.; Burcu, M.; Safer, D.J. (ISHIB, 2017)
      Objective: This study aimed to evaluate a conceptual framework that assessed the effect of Hispanic residential isolation on Attention Deficit Hyperactivity Disorder (ADHD) health service utilization among 2.2 million publicly insured youth. Design: Cross-sectional. Setting: Medicaid administrative claims data for ambulatory care services from a US Pacific state linked with US census data. Participants: Youth, aged 2-17 years, continuously enrolled in 2009. Main Outcome Measures: The percent annual prevalence and odds of ADHD diagnosis and stimulant use according to two measures of racial/ethnic residential isolation: 1) the county-level Hispanic isolation index (HI) defined as the population density of Hispanic residents in relation to other racial/ethnic groups in a county (<.5; .5-.64; ?.65); and 2) the proportion of Hispanic residents in a ZIP code tabulation area (<25%; 25%-50%; >50%). Results: Among the 47,364 youth with a clinician-reported ADHD diagnosis, 60% received a stimulant treatment (N = 28,334). As the county level HI increased, Hispanic residents of ethnically isolated locales were significantly less likely to receive an ADHD diagnosis (adjusted odds ratio [AOR]=.92 [95% CI=.88-.96]) and stimulant use (AOR=.61 [95% CI=.59-.64]) compared with Hispanic youth in less isolated areas. At the ZIP code level, a similar pattern of reduced ADHD diagnosis (AOR=.81 [95% CI=.77-.86]) and reduced stimulant use (AOR=.65 [95% CI=.61-.69]) was observed as Hispanic residential isolation increased from the least isolated to the most isolated ZIP code areas. Conclusions: These findings highlight the opportunity for Big Data to advance mental health research on strategies to reduce racial/ethnic health disparities, particularly for poor and vulnerable youth. Further exploration of racial/ethnic residential isolation in other large data sources is needed to guide future policy development and to target culturally sensitive interventions. Copyright 2017, ISHIB. All rights reserved.
    • Patterns of early mental health diagnosis and medication treatment in a medicaid-insured birth cohort

      Pennap, D.; Zito, J.M.; Santosh, P.J. (American Medical Association, 2018)
      IMPORTANCE The increased use of psychiatric services in the US pediatric population raises concerns about the appropriate use of psychotropic medications for very young children. OBJECTIVE To assess the longitudinal patterns of psychotropic medication use in association with diagnosis and duration of use in a Medicaid-insured birth cohort. DESIGN, SETTING, AND PARTICIPANTS A cohort designwas applied to computerized Medicaid administrative claims data for 35 244 children born in a mid-Atlantic state in 2007 and followed up for up to 96 months through December 31, 2014. Children were included in the birth cohort if they had an enrollment record at birth or within 3 months of birth and at least 6 months of continuous enrollment from birth. The cohort represents 92.2%of 38 225 Medicaid-insured newborns in 2007. EXPOSURES Mental health treatments from birth through age 7 years. MAIN OUTCOMES AND MEASURES Cumulative incidence of first psychiatric diagnosis and psychotropic medication use (monotherapy or concomitant use of psychotropic medications) from birth through age 7 years, total and by sex, and the cumulative incidence of the use of psychosocial services (age, 0-7 years) as well as the annual duration of medication use (ie, number of days of psychotropic medication use among children 3-7 years of age). RESULTS Of the 35 244 children in the cohort, 17 267 were girls and 17 977 were boys. By age 8 years, 4550 children in the birth cohort (19.7%[percentage adjusted for right censoring]) had received a psychiatric diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 290-319); 2624 of these diagnoses (57.7%) were behavioral (codes 312, 313, or 314). Girls were more likely than boys to receive an incident psychiatric diagnosis of adjustment disorder (355 of 1598 [22.2%] vs 427 of 2952 [14.5%]; P < .001) or anxiety disorder (114 of 1598 [7.1%] vs 120 of 2952 [4.1%]; P < .001). By age 8 years, 2196 children in the cohort (10.2%[percentage adjusted for right censoring]) had received a psychotropic medication. Among medication users, 1763 of 2196 (80.5%[percentage adjusted for right censoring]) received monotherapy, 343 of 2196 (16.4%[percentage adjusted for right censoring]) received 2 medication classes concomitantly, and 90 of 2196 (4.3%[percentage adjusted for right censoring]) received 3 or more medication classes concomitantly for 60 days or more (range, 78-180 days). The annual median number of days of psychotropic medication use among medicated children increased with age, reaching 210 of 365 days for children 7 years of age. Among children 7 years of age, the median number of days of use of an antipsychotic (193 days [interquartile range, 60-266 days]), stimulant (183 days [interquartile range, 86-295 days]), or ?-agonist (199 days [interquartile range, 85-305 days]) exceeded half of the year. CONCLUSIONS AND RELEVANCE Medicaid-insured children received substantial mental health services and had prolonged exposure to psychotropic medications in the early years of life. These findings highlight the need for outcomes research in pediatric populations. Copyright 2018 American Medical Association. All rights reserved.