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Vocapedia > Media > USA > NYT > Illustrations >
2008-2009
Jon Han
Letters
Giving
Psychiatric Drugs to Children
December 16, 2009
The New York Times
To the Editor:
Re “Poor Children
Likelier to Get Antipsychotics” (front page, Dec. 12):
I am the mother of a teenage boy who received a diagnosis of attention deficit
disorder and oppositional defiant disorder eight years ago and was prescribed
antipsychotic medication. Throughout the years, we have visited no fewer than
five psychiatrists and countless other therapists.
I would often question why my son was prescribed medications (at one point three
at a time) that failed to do as they promised. For example, the ones that were
designed to help him sleep at night did the reverse, and the ones to keep him
awake made him lethargic.
I decided that it was in my son’s best interest to take a break from the weekly
therapy and daily medication. Surprisingly, he functioned much better: His
sleeping patterns and appetite improved. He is now back on medication, but with
new therapists and with the parents’ considerations in mind.
Families like ours are often duped into believing that there aren’t options
other than medication, or should we refuse to comply, charges of neglect could
be brought.
Suzanne Joblonski
Ridgewood, N.Y., Dec. 14, 2009
•
To the Editor:
In discussing the “off label” use of antipsychotic medications to treat children
with attention deficit hyperactivity disorder and other disruptive behavior
disorders, the article did not mention that there are well-established,
effective, evidence-based treatment protocols for children with these diagnoses.
These programs use cognitive behavioral interventions with children, and, of at
least equal importance, provide parent training and coordination between family,
school and treatment provider. These treatment models are often used in
conjunction with medication, but may reduce or in some cases obviate the need
for medication.
Effective use of these protocols requires coordination and follow-up with
teachers and parents, much of which is not currently reimbursable either by
private insurance or Medicaid.
Arlene Klingman
New York, Dec. 14, 2009
The writer is director of the Child and Family Clinic-Plus Program of the
Riverdale Mental Health Association.
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To the Editor:
As a practicing child psychiatrist for the last 22 years, I am not surprised
that poorer children on Medicaid are prescribed antipsychotic drugs at four
times the rate of middle-class children. Sadly, it is symptomatic of the general
trend in psychiatry over the last 15 years to “medicalize” complex behavioral
problems and label them with an overly simplistic medical diagnosis, like
bipolar disorder, implying that the right medication will solve the problem.
In a Medicaid population, the temptation for overwhelmed doctors and
understaffed clinics to succumb to a potentially quick fix with a readily
available treatment is often too compellingly expedient. If only the simple act
of writing a prescription could cure the emotional distress of children
subjected to the social ills of poverty.
Richard Levine
Berkeley, Calif., Dec. 12, 2009
•
To the Editor:
We are parents of a 10-year-old son who is on Medicaid as a result of long-term
disability. He has been prescribed antipsychotics for more than five years. We
have tried numerous times to taper off the medication and instead focus on
counseling with various therapists.
After a few sessions with these therapists, we have been told either that his
disorder is not their specialty or that his situation is too complex. We have
always felt — and the study behind this article lends credence to our suspicions
— that the motivation for not offering long-term counseling was tied to the
reimbursement offered by his insurance.
We are fearful that the heavy reliance on medication is leaving our son ill
equipped to live independently when he becomes an adult. He and every other
child deserve to be provided the treatment that offers them the best chance to
be functioning members of society, and a pill is not always the answer.
Duncan Cameron
Aimee Gunn
Eau Claire, Wis., Dec. 12, 2009
•
To the Editor:
One of the reasons for the disparate use of medication has to do with the large
cohort of poor children and adolescents in residential treatment centers, foster
care, group homes and juvenile justice facilities. These institutions often do
not or cannot provide the kind of mental health services that ultimately would
help children face issues like profound rage and deep sadness that fuel
behaviors that are often frightening and violent, but not necessarily psychotic.
Because these institutions focus on controlling behavior instead of the more
time-consuming process of helping children identify and understand their
feelings, they are given drugs that, in the long run, do more harm than good.
This is not only a disservice to children who already face tremendous hurdles,
but will also ultimately increase the costs borne by Medicaid when it becomes
necessary to address the physical and psychological damage done by the use of
these drugs.
Debra Kuppersmith
Dobbs Ferry, N.Y., Dec. 12, 2009
The writer is a psychoanalyst.
•
To the Editor:
Federal funding allocated to help treat and study psychiatric disorders pales in
comparison to that for other medical conditions. Research on cancer, heart
disease and infectious diseases receives three to four times the annual funding
of the National Institute of Mental Health. Within that small pool, childhood
psychiatric disorders are allocated an even smaller portion of funds.
Because of the limited funds, few children with psychiatric disorders are
treated by doctors with advanced training in this area. Rather, they are often
managed by family practitioners and pediatricians.
Can the same be said of children with cancer or heart disease? Doesn’t a child
with a serious psychiatric disorder deserve to be seen by a doctor with
specialized training just as children with cancer are? Sadly, the answer from
our current system of distributing medical funds is a resounding no.
Jonathan E. Posner
New York, Dec. 13, 2009
The writer is a child and adolescent psychiatrist.
Giving Psychiatric Drugs
to Children, NYT, 16.12.2009,
http://www.nytimes.com/2009/12/16/opinion/l16drugs.html
Poor Children Likelier to Get Antipsychotics
December 12, 2009
The New York Times
By DUFF WILSON
New federally financed drug research reveals a stark disparity: children
covered by Medicaid are given powerful antipsychotic medicines at a rate four
times higher than children whose parents have private insurance. And the
Medicaid children are more likely to receive the drugs for less severe
conditions than their middle-class counterparts, the data shows.
Those findings, by a team from Rutgers and Columbia, are almost certain to add
fuel to a long-running debate. Do too many children from poor families receive
powerful psychiatric drugs not because they actually need them — but because it
is deemed the most efficient and cost-effective way to control problems that may
be handled much differently for middle-class children?
The questions go beyond the psychological impact on Medicaid children, serious
as that may be. Antipsychotic drugs can also have severe physical side effects,
causing drastic weight gain and metabolic changes resulting in lifelong physical
problems.
On Tuesday, a pediatric advisory committee to the Food and Drug Administration
met to discuss the health risks for all children who take antipsychotics. The
panel will consider recommending new label warnings for the drugs, which are now
used by an estimated 300,000 people under age 18 in this country, counting both
Medicaid patients and those with private insurance.
Meanwhile, a group of Medicaid medical directors from 16 states, under a project
they call Too Many, Too Much, Too Young, has been experimenting with ways to
reduce prescriptions of antipsychotic drugs among Medicaid children.
They plan to publish a report early next year.
The Rutgers-Columbia study will also be published early next year, in the
peer-reviewed journal Health Affairs. But the findings have already been posted
on the Web, setting off discussion among experts who treat and study troubled
young people.
Some experts say they are stunned by the disparity in prescribing patterns. But
others say it reinforces previous indications, and their own experience, that
children with diagnoses of mental or emotional problems in low-income families
are more likely to be given drugs than receive family counseling or
psychotherapy.
Part of the reason is insurance reimbursements, as Medicaid often pays much less
for counseling and therapy than private insurers do. Part of it may have to do
with the challenges that families in poverty may have in consistently attending
counseling or therapy sessions, even when such help is available.
“It’s easier for patients, and it’s easier for docs,” said Dr. Derek H. Suite, a
psychiatrist in the Bronx whose pediatric cases include children and adolescents
covered by Medicaid and who sometimes prescribes antipsychotics. “But the
question is, ‘What are you prescribing it for?’ That’s where it gets a little
fuzzy.”
Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors
have given antipsychotics that the patients do not seem to need. Recently, for
example, he met with a 15-year-old girl. She had stopped taking the
antipsychotic medication that had been prescribed for her after a single
examination, paid for by Medicaid, at a clinic where she received a diagnosis of
bipolar disorder.
Why did she stop? Dr. Suite asked. “I can control my moods,” the girl said
softly.
After evaluating her, Dr. Suite decided she was right. The girl had arguments
with her mother and stepfather and some insomnia. But she was a good student and
certainly not bipolar, in Dr. Suite’s opinion.
“Normal teenager,” Dr. Suite said, nodding. “No scrips for you.”
Because there can be long waits to see the psychiatrists accepting Medicaid, it
is often a pediatrician or family doctor who prescribes an antipsychotic to a
Medicaid patient — whether because the parent wants it or the doctor believes
there are few other options.
Some experts even say Medicaid may provide better care for children than many
covered by private insurance because the drugs — which can cost $400 a month —
are provided free to patients, and families do not have to worry about the
co-payments and other insurance restrictions.
“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson,
a child psychiatrist and professor at the Stony Brook School of Medicine. “If it
helps keep them in school, maybe it’s not so bad.”
In any case, as Congress works on health care legislation that could expand the
nation’s Medicaid rolls by 15 million people — a 43 percent increase — the scope
of the antipsychotics problem, and the expense, could grow in coming years.
Even though the drugs are typically cheaper than long-term therapy, they are the
single biggest drug expenditure for Medicaid, costing the program $7.9 billion
in 2006, the most recent year for which the data is available.
The Rutgers-Columbia research, based on millions of Medicaid and private
insurance claims, is the most extensive analysis of its type yet on children’s
antipsychotic drug use. It examined records for children in seven big states —
including New York, Texas and California — selected to be representative of the
nation’s Medicaid population, for the years 2001 and 2004.
The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid
fee-for-service programs received antipsychotic drugs, compared with less than 1
percent of privately insured children and adolescents. More recent data through
2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers
professor who led the study. Experts generally agree that some characteristics
of the Medicaid population may contribute to psychological problems or
psychiatric disorders. They include the stresses of poverty, single-parent
homes, poorer schools, lack of access to preventive care and the fact that the
Medicaid rolls include many adults who are themselves mentally ill.
As a result, studies have found that children in low-income families may have a
higher rate of mental health problems — perhaps two to one — compared with
children in better-off families. But that still does not explain the four-to-one
disparity in prescribing antipsychotics.
Professor Crystal, who is the director of the Center for Pharmacotherapy at
Rutgers, says his team’s data also indicates that poorer children are more
likely to receive antipsychotics for less serious conditions than would
typically prompt a prescription for a middle-class child.
But Professor Crystal said he did not have clear evidence to form an opinion on
whether or not children on Medicaid were being overtreated.
“Medicaid kids are subject to a lot of stresses that lead to behavior issues
which can be hard to distinguish from more serious psychiatric conditions,” he
said. “It’s very hard to pin down.”
And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of
the study, said at least one thing was clear: “A lot of these kids are not
getting other mental health services.”
The F.D.A. has approved antipsychotic drugs for children specifically to treat
schizophrenia, autism and bipolar disorder. But they are more frequently
prescribed to children for other, less extreme conditions, including attention
deficit hyperactivity disorder, aggression, persistent defiance or other
so-called conduct disorders — especially when the children are covered by
Medicaid, the new study shows.
Although doctors may legally prescribe the drugs for these “off label” uses,
there have been no long-term studies of their effects when used for such
conditions.
The Rutgers-Columbia study found that Medicaid children were more likely than
those with private insurance to be given the drugs for off-label uses like
A.D.H.D. and conduct disorders. The privately insured children, in turn, were
more likely than their Medicaid counterparts to receive the drugs for
F.D.A.-approved uses like bipolar disorder.
Even if parents enrolled in Medicaid may be reluctant to put their children on
drugs, some come to rely on them as the only thing that helps.
“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of
her son’s use of antipsychotics since he received a diagnosis of bipolar
disorder at age 3. Seven years later, the boy is now also afflicted with weight
and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental
and physical conditions manageable. “They’re helping with everything,” she said.
Poor Children Likelier
to Get Antipsychotics, NYT, 12.12.2009,
http://www.nytimes.com/2009/12/12/health/12medicaid.html
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