Another State Wants To Limit Antipsychotics

progressive

(Tue, 13 May 2008 23:28:20 -0500 (CDT)) --- From recent reports, more than 60% of antipsychotics are purchased with
taxpayers dollars. In Florida and Texas investigators found that more
than 50% of the foster children getting these drugs had no psychiatric
problems at all.

www.pharmalot.com

Another State Wants To Limit Antipsychotics

May 13th, 2008 7:00 am
By Ed Silverman

Concerned about how antipsychotics are being used in
children, Washington state officials are working on a plan
due by early fall to ensure the meds are properly prescribed
for kids on Medicaid, The Tacoma News-Tribune reports. bThe
data is concerning,b Jeff Thompson, chief medical officer for
the state Medicaid program, tells the paper.

State data, in fact, show the use of atypical antipsychotics
in children enrolled in Washingtonbs Medicaid program for
low-income people increased about 25 percent between 2004 and
2007. Last year, 4,978 Medicaid participants 18 or younger
were taking the drugs, and 187 were 5 or younger. Some were
on two or more drugs at the same time.

The most recent data available show that the state Medicaid
program spent about $9 million last year on the drugs for
children 18 or younger, up from $4.96 million in 2004. Stats
on use of the drugs in Washington children not taking part in
Medicaid are unavailable, the paper adds.

There are indications, Thompson tells the paper, that the
drugs are sometimes being used when not needed, in doses
sometimes too high, and in children who are too young for
them. Thompson, by the way, is leading a work group in the
state Department of Social and Health Services to ensure the
drugs are prescribed to Medicaid children in Washington only
when truly needed and at proper doses.

The plan requires expert second opinion if the drugs are
prescribed outside of certain parameters: such as to very
young kids, or in combination, or in very high doses. Some
kids are on bdoses that are far beyond any reasonable maximum
dose,b Chris Varley, a University of Washington professor of
child and adolescent psychiatry and member of the DSHS work
group, tells the paper.

Among those who question the widespread use of atypical
anti-psychotics in children and the popularity of bipolar
diagnosis of kids is John Holttum, a Tacoma child
psychiatrist who treats 300 to 400 children a year, almost
all referred by family doc and general psychiatrists for
additional help.

bAt times, yes, (atypical anti-psychotics) help,b Holttum
tells the paper. bKids do get psychotic, and they do have
mania, but both are very rare.b

What he sees more in his practice, he continues, are violent
or aggressive children who are labeled as bipolar, but who do
not show the traditional signs of mania, depression and
delusions of grandeur that are hallmarks of the traditional
definition of bipolar disorder in adults, the News-Tribune
writes.

He and others say the definition of bipolar disorder is
expanding and now captures children who 10 or 15 years ago
might have been seen as troubled or irritable, and more
likely treated with counseling, parenting training for their
caregivers or other social interventions.

bWe absolutely need some oversightb of atypical
anti-psychotic use in children, Holttum tells the paper.
bSome of the kids who walk into my office have been grossly
mismanaged.b Atypical anti-psychotics bare aggressive
medications,b he adds, and their potential long-term side
effects on developing brains worry experts.

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www.thenewstribune.com

Should kids get these drugs? Plan likely to increase scrutiny
of anti-psychotics in children
Doctors focus on new anti-psychotics

M. ALEXANDER OTTO;
alex.otto@thenewstribune.com

May 11th, 2008

Concerned about how anti-psychotic drugs are being used in
children, state officials are working on a plan due out by
early fall to make sure the medications are properly
prescribed for Washington kids on Medicaid.

bThe data is concerning,b said Dr. Jeffrey Thompson, chief
medical officer for the state Medicaid program and an expert
in pharmaceutical trends in the statebs Medicaid population.

The long term safety and effectiveness of the drugs in
children are not known, he and others say.

bWe are at risk of treating kids before we know if these
drugs are safe in the long-term,b said Dr. Christopher
Varley, a University of Washington professor of child and
adolescent psychiatry.

The drugs are used to treat such conditions as bipolar
disorder or schizophrenia. Theybre sold under the names
Zyprexa, Geodon, Risperdal, Abilify, Seroquel, Clozaril and
Invega.

The drugs belong to a relatively new class of anti-psychotics
called batypical.b The older class of anti-psychotics has
been on the market for decades.

So far, the federal Food and Drug Administration has approved
only Risperdal and Abilify for use in children, and only for
the short term. All have been approved for adults. Doctors
are free to prescribe drugs to anyone and in any way they see
fit once they have been approved for some purpose.

In the past, anti-psychotic drugs were used mostly in adults,
and mostly to treat schizophrenia. Long-term use of the
batypicalb drugs in adults has been linked to serious side
effects, including significant weight gain, diabetes,
permanent involuntary movement disorders and even early
death.

TROUBLING STATISTICS

State data show that the use of atypical anti-psychotics in
children enrolled in Washingtonbs Medicaid program for
low-income people increased about 25 percent between 2004 and
2007.

In 2007, 4,978 Medicaid participants 18 or younger were
taking the drugs, and 187 were 5 or younger. Some children
were on two or more drugs at the same time.

The most recent data available show that the state Medicaid
program spent about $9.08 million last year on the drugs for
children 18 or younger, up from $4.96 million in 2004.

Statistics on use of the drugs in Washington children not
taking part in Medicaid are unavailable. Their use in
children nationally has increased more than six-fold in the
past 15 years, Varley said.

There are indications, Thompson said, that the drugs are
sometimes being used when not needed, in doses sometimes too
high, and in children who are too young for them.

USE THE ADHD MODEL, DOCTOR SAYS

Thompson is leading a work group in the state Department of
Social and Health Services that seeks to ensure the drugs are
prescribed to Medicaid children in Washington only when truly
needed and at proper dosages.

The linchpin of the plan is the requirement of an expert
second opinion if the drugs are prescribed outside of certain
parameters: for instance, to very young children, or in
combination, or in very high doses.

Some kids are on bdoses that are far beyond any reasonable
maximum dose,b said Varley, who is a member of the DSHS work
group.

Such a plan already is in place for drugs to treat attention
deficit hyperactivity disorder, or ADHD. The plan has helped
standardize the use of stimulants such as Ritalan since 2005,
when similar concerns were raised about ADHD drugs being used
inappropriately in Medicaid children.

Among the chief drivers behind the use of atypical
anti-psychotics in children, experts say, is the increasing
popularity of bipolar disorder diagnoses. Bipolar disorder
was previously known as manic depression.

Between 1994 and 2003, the number of children treated for
bipolar disorder in the United States increased to more than
800,000 from 20,000, according to researchers.

The treatment trend is defended by some, questioned by
others.

bBipolar disorder is a very debilitating disease,b said
Jamaison Schuler, a spokesman for Eli Lilly, which makes
Zyprexa. bThe earlier you can capture it, the better off you
are.b

DOCTOR QUESTIONS DIAGNOSES

Zyprexa, like most of the atypical anti-psychotics, is not
approved for children. Schuler said the company has produced
data to support that use and has submitted them to the FDA.

For now, though, bto the extent doctors might be prescribing
it (for children),b they are doing so without the data,
Schuler said.

Among those who question the widespread use of atypical
anti-psychotics in children and the popularity of bipolar
diagnosis of kids is Dr. John Holttum. The Tacoma child
psychiatrist treats 300 to 400 children a year, almost all
referred to him by family doctors and general psychiatrists
for additional help.

bAt times, yes, (atypical anti-psychotics) help,b Holttum
said. bKids do get psychotic, and they do have mania, but
both are very rare.b

What he sees more in his practice, he said, are violent or
aggressive children who are labeled as bipolar, but who do
not show the traditional signs of mania, depression and
delusions of grandeur that are hallmarks of the traditional
definition of bipolar disorder in adults.

He and others say the definition of bipolar disorder is
expanding and now captures children who 10 or 15 years ago
might have been seen as troubled or irritable, and more
likely treated with counseling, parenting training for their
caregivers or other social interventions.

Furthering the trend is extensive marketing of atypical
anti-psychotics by the companies that make them, and media
coverage of bipolar disorder as a childhood disease.

bAlmost everybody in the field would agree therebs been a
relative underrecognition of bipolar in children and
adolescents over the past two decades,b Varley said. bBut Ibm
skeptical of the way bipolar disorder is being used in terms
of this new conceptualization.b

Holttum has seen the effects in his office on Division Avenue
in Tacoma. He said he used to struggle to persuade parents to
put their children on an anti-psychotic drug in the rare
cases he thought one was needed.

But now, he said, bpeople come in and tell me (their child)
is bipolar. I spend a lot of time convincing parents to
remove that diagnosis, and explaining they have a child that
is just angry.b

He also spends a lot of time taking children off atypical
anti-psychotics, sometimes replacing them with
antidepressants or ADHD drugs that have fewer side effects.

bWe absolutely need some oversightb of atypical
anti-psychotic use in children, Holttum said. bSome of the
kids who walk into my office have been grossly mismanaged.b

Atypical anti-psychotics bare aggressive medications,b he
said, and their potential long-term side effects on
developing brains worry experts.

Holttum said atypical anti-psychotics are useful in the
short-term to calm violent children before switching them to
other drugs or looking for other solutions. Overall, though,
bnot a lot of children with unstable moods are bipolar,b
Holttum said.

M. Alexander Otto: 253-597-8616

By early fall, the state Department of Social and Health
Services will issue guidelines for the appropriate age and
dose of anti-psychotic drugs for children whose medical bills
are covered by the statebs Medicaid program.

Use of the drugs outside the parameters b using more than one
of the batypical anti-psychoticsb at high doses in a child
under 5, for instance b will trigger a review by an expert.

Either the pharmacy dispensing the drug or the prescriber
will be required to alert the state and get a second opinion
before the drug can be dispensed.

Dr. Jeffrey Thompson, head of the statebs Medicaid
pharmaceutical program, is working on the plan with
psychiatrists and others in the mental health community.

The hope, he said, is to make the system as user-friendly as
possible for doctors and patients, so therebs no delay in
care.

Over the past three years, a similar approach to curb
inappropriate use of stimulants in children with attention
deficit hyperactive disorder found that required second
opinions resulted in a change in drug dosage or the treatment
plan 56 percent of the time.

For ADHD drugs, Thompson said, the program resulted in fewer
young children being prescribed stimulants, fewer given
multiple ADHD drugs at a time, and lower doses.

bNow we are working with the mental health community for the
same thing with anti-psychotics,b he said.

The plan was triggered in part by a wide-ranging law to
improve mental health care for children, signed by Gov. Chris
Gregoire in May 2007.

The law required DSHS to bset standards for reducing the
number of children that are prescribed anti-psychotic drugs
and receive no outpatient mental health services with their
medication.b

To meet the second goal, on July 1 the department will bump
up the number of mental health visits the agency covers for
participants 12 to 20, so that stress factors, family
situations and other problems can be more thoroughly
addressed before they lead to psychiatric symptoms.

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IT IS ADVISABLE TO REDUCE DOSES GRADUALLY WITH EXTREME CAUTION, as it is
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getting as much information and support as you can, and involving your
doctor wherever possible. You will find withdrawal information here:

www.mind.org.uk

FOR MORE INFORMATION ON WITHDRAWAL:: Get Peter Lehmann's book, Coming off
Psychiatric Drugs: Successful Withdrawal from Neuroleptics,
Antidepressants, Lithium, Carbamazepine and Tranquilizers. This valuable
resource comes in US, UK, and German editions.

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