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Monitoring For Vermont Kids On Antipsychotics Is Lacking, UVM Study Shows

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Vermont doctors who prescribe antipsychotic meds to children are failing to follow best practices - including lab testing and continual monitoring - about 50 percent of the time, according to a new UVM study.

A new study from the University of Vermont found that Vermont doctors are failing to follow best practices about half the time when prescribing antipsychotic medicine to children.

The use of antipsychotics has become increasingly common in recent years, said the study’s lead author Dr. David Rettew.

“But there’s actually very little data that speaks to whether this is an appropriate increase or whether this reflects an overuse of this class of medications,” he said.

In an effort to get more data about when and how these drugs are used, Rettew and nine coauthors on the study pored over data from Medicaid claims for four months in 2012, then sent a mandatory survey to each doctor who’d prescribed an antipsychotic to a patient under 18 years old. The study was published in the journal Pediatrics.

“It was pretty clear from our data that antipsychotic medicines were only being used once other things didn’t work, or other types of treatments or other types of medications failed,” he said. “And I think that’s really good news because it reflects the idea that doctors are not prescribing these medicines casually or in a knee-jerk way.”

Despite finding positive results with regard to overuse -- the study found that “almost 92 percent of doctors prescribed the drugs under the proper circumstances” -- researchers found a troubling trend.

“The bad news is I don’t think we in the medical community can be too excited about a best practice rate of 50 percent,” Rettew said. "And we should be working on ways to improve that number.”

"The bad news is I don't think we in the medical community can be too excited about a best practice rate of 50 percent." - Dr. David Rettew

Best practices when it comes to antipsychotic prescriptions, Rettew said, include exhausting other available options before prescribing the drugs, and doing appropriate follow-up after a child is on the drug.

“For instance, if a child presents with something like schizophrenia, then a medicine like this might be first-line,” he said. “But if a child is presenting with something like physical aggression, the guidelines state that you’re supposed to be trying other things before you get to antipsychotic medications.”

Other guidelines, Rettew said, include not prescribing the medications to children under 5 and not using more than one of the drugs at a time.

Rettew said one key guideline that was problematic for many of the doctors out of compliance with best practices was blood testing.

“The number one reason why a prescription did not follow best practice guidelines was not because it was being used inappropriately, it was because the doctors were not getting the recommended lab work that’s supposed to go along with these prescriptions,” he said.

That lab work can help doctors detect some of the serious side effects that can result from antipsychotic medicines, Rettew said, such as “weight gain, sometimes massive weight gain, new onset of diabetes, movement disorders that are sometimes irreversible, as well as sometimes profound levels of sedation.”

"The number one reason why a prescription did not follow best practice guidelines ... was because the doctors were not getting the recommended lab work that's supposed to go along with these prescriptions." - Dr. David Rettew

The lab work often isn’t done, but not because of a lack of lab infrastructure.

“Sometimes children are terrified of having the lab work done, and it becomes almost a traumatic experience to do it,” Rettew said. "And so people will overlook it. And I also think that sometimes doctors just aren’t aware that these are the recommended guidelines. That you’re supposed to be checking things like glucose and cholesterol before you start the medicine and then sequentially after it.”

There was a bright spot with regard to best practices, Rettew said: 57.7 percent of psychiatrists prescribing antipsychotics followed guidelines. Other doctors, mostly primary care physicians, had a rate of 35.1 percent.

The study’s authors came up with a set of recommendations for doctors to address some of these issues, including the use of electronic medical records, which use software that could alert doctors that tests should be done when a patient is prescribed one of these drugs.

Other recommendations included better training for doctors that may work with children on these drugs, even if they weren’t the prescribing doctor. The study also calls for providing Vermont children with better access to therapy.

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