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<div class="figure-label">Figure. Prevalence of Psychotropic Polypharmacy Among Youth Enrolled in Medicaid With Any Psychotropic Use by Eligibility Group, 2015 to 2020</div><a id="zld230271f1" class="figure-table-anchor"> </a>
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<p class="para">In calculating the annual polypharmacy prevalence, the numerator was the number of youths who had at least 1 polypharmacy episode of 90 or more consecutive days in the study year. The denominator was the number of
youths who had at least 1 pharmacy claim for a psychotropic medication and 90 days or more of continuous Medicaid enrollment during the same study year.</p>
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<div class="table-label">Table. Characteristics Associated With Psychotropic Polypharmacy Among Youths Enrolled in Medicaid With Any Psychotropic Use</div><a class="figure-table-anchor" id="zld230271t1"> </a>
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<div class="supplement-title"><span class="title-label">Supplement 1.</span><p class="para"><strong>eMethods.</strong></p></div>
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<div class="supplement-title"><span class="title-label">Supplement 2.</span><p class="para"><strong>Data Sharing Statement</strong></p></div>
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<h1 class="meta-article-title ">Psychotropic Polypharmacy Among Youths Enrolled in Medicaid</h1>
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<span class="meta-authors--limited"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Yueh-Yi+Chiang&q=Yueh-Yi+Chiang" rel="nofollow" target="_blank">Yueh-Yi Chiang, BS<sup>1</sup></a></span><span
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class="wi-fullname brand-fg"><a href="/searchresults?author=Alejandro+Amill-Rosario&q=Alejandro+Amill-Rosario" rel="nofollow" target="_blank">Alejandro Amill-Rosario, MPH, PhD<sup>1</sup></a></span><span
class="al-author-delim">; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Phuong+Tran&q=Phuong+Tran" rel="nofollow" target="_blank">Phuong Tran, MPH<sup>1</sup></a></span>;
<a class="meta-authors--etal td-u stats-meta-authors--etal">et al</a></span>
<span class="meta-authors--remaining"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Susan+dosReis&q=Susan+dosReis" rel="nofollow" target="_blank">Susan dosReis, PhD<sup>1</sup></a></span></span>
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<div class="meta-author-name"><sup>1</sup>Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore</div>
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<span class="meta-citation-journal-name">JAMA Netw Open. </span><span class="meta-citation"> 2024;7(2):e2356404. doi:10.1001/jamanetworkopen.2023.56404</span>
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<p class="para">Concomitant use of medications for attention-deficit/hyperactivity disorder (ADHD), antipsychotics, mood-stabilizing anticonvulsants, and antidepressants is referred to as psychotropic
polypharmacy.<sup><a href="#zld230271r1" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">1</a></sup> Over the past 2 decades, psychotropic polypharmacy in youths increased, raising safety
concerns.<sup><a href="#zld230271r2" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">2</a></sup><sup>-<a href="#zld230271r2" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">4</a></sup>
Our goal was to examine trends from 2015 to 2020 in psychotropic polypharmacy among youths aged 17 years or younger who were enrolled in Medicaid to identify temporal changes and characteristics associated with psychotropic
polypharmacy.</p> <a class="article-section-id-anchor" id="249494420"></a>
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<div class="h3 cb section-type-section ">
<div class="heading-text thm-col sb-sc"> Methods </div>
</div>
<a class="article-section-id-anchor" id="249494421"></a>
<p class="para">The cross-sectional study was approved by the University of Maryland institutional review board and followed the Strengthening the Reporting of Observational Studies in Epidemiology
(<a href="http://www.equator-network.org/reporting-guidelines/strobe/">STROBE</a>) reporting guideline. Informed consent was waived because data were deidentified.</p> <a class="article-section-id-anchor" id="249494422"></a>
<p class="para">This is a sequential, annual, cross-sectional study using Medicaid eligibility files and fee-for-service and managed care medical encounter claims from 2015 to 2020 from a single US state. For each annual cohort, we
included youths who were 17 years or younger, had received at least 1 pharmacy claim for psychotropic medication, and had 90 days or more of continuous Medicaid enrollment. We created 4 mutually exclusive Medicaid eligibility groups
in each annual cohort: (1) youths with low income, (2) youths enrolled in Children’s Health Program (CHP), (3) youths in foster care, and (4) youths with disabilities. Additional information regarding the methods can be found in the
eMethods in <a class="supplement-link section-jump-link" data-tab-toggle=".tab-nav-supplemental" href="#note-ZLD230271-1">Supplement 1</a>. Using the American Hospital Formulary Service Pharmacologic Therapeutic Classification
System, we classified psychotropic medications into 6 therapeutic classes: antipsychotics, ADHD medications, mood-stabilizing anticonvulsants, antidepressants, anxiolytics, and sedatives. Use of 3 or more different psychotropic
classes that overlapped for 90 consecutive days or longer in each study year defined psychotropic polypharmacy.<sup><a href="#zld230271r1" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">1</a></sup> We
allowed no more than a 15-day gap between prescription fills within the 90-day period. Annual psychotropic polypharmacy prevalence was defined as the proportion of youths who had at least 1 polypharmacy episode per 100 youths with
any psychotropic use. A multivariable logistic regression model, using all study years, estimated the odds of psychotropic polypharmacy (dependent variable) among psychotropic users. Independent variables included study year
(continuous), age, sex, race, region, Medicaid eligibility group, COVID-19, and mental health disorders. The race and ethnicity categories included in this study were American Indian, Asian, Black, Hispanic, Native Hawaiian, White,
and all other races not listed in one of the predefined categories. Information regarding race and ethnicity was extracted from the Medicaid demographic summary file. We used generalized estimating equations for robust variance
estimators to account for nonindependence of observations given that a youth may be in multiple study years. A supplemental analysis modeled categorical year (reference year, 2015) to identify which years contributed to significant
psychotropic polypharmacy changes. Significance levels were set at <i>P</i> < .05 for 2-tailed tests. All analyses were performed using SAS Studio version 9.4 (SAS Institute). Data were analyzed from January to December 2023.</p>
<a class="article-section-id-anchor" id="249494423"></a>
<div class="h3 cb section-type-section ">
<div class="heading-text thm-col sb-sc"> Results </div>
</div>
<a class="article-section-id-anchor" id="249494424"></a>
<p class="para">Across all years, 126 972 unique youths met the inclusion criteria. Psychotropic polypharmacy prevalence among youths who used psychotropics increased from 2259 of 53 569 youths (4.2%) in 2015 to 2334 of 50 806 youths
(4.6%) in 2020. The 2015 to 2020 increase in psychotropic polypharmacy prevalence was observed for those with Medicaid eligibility from foster care (414 of 3824 [10.8%] and 387 of 3420 [11.3%]), CHP (225 of 10 354 [2.2%] and 222 of
7974 [2.8%]), and being from a low-income household (648 of 30 222 [2.1%] and 883 of 31 172 [2.8%]) (<a href="#zld230271f1" class="figure-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Figure</a>). The adjusted odds
ratios (AORs) of psychotropic polypharmacy for the year was 1.04 (95% CI, 1.02-1.06), a 4% increase in the odds of psychotropic polypharmacy per year. The supplemental analysis revealed a significant increase in 2019 and 2020
relative to 2015. Psychotropic polypharmacy was significantly more likely among youths who were disabled (AOR, 3.68; 95% CI, 3.34-4.05) or in foster care (AOR, 3.31; 95% CI, 2.93-3.74) relative to youths in the low-income group.
Individuals aged 10 to 14 years (AOR, 1.94; 95% CI, 1.80-2.10) and 15 to 17 years (AOR, 2.41; 95% CI, 2.22-2.61) had significantly higher odds of psychotropic polypharmacy than those who were younger than 10 years. Black individuals
(AOR, 0.47; 95% CI, 0.43-0.51) or individuals who identified as other races (including individuals identifying as American Indian, Asian, Hispanic, or Pacific Islander, or other races) (AOR, 0.54; 95% CI, 0.50-0.59) had
significantly lower odds of psychotropic polypharmacy than White individuals (<a href="#zld230271t1" class="table-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Table</a>).</p>
<a class="article-section-id-anchor" id="249494427"></a>
<div class="h3 cb section-type-section ">
<div class="heading-text thm-col sb-sc"> Discussion </div>
</div>
<a class="article-section-id-anchor" id="249494428"></a>
<p class="para">In this cross-sectional study, we observed a 4% increased odds of psychotropic polypharmacy per year from 2015 to 2020, indicating growing concomitant use of multiple psychotropic classes. Among youths enrolled in
Medicaid with any psychotropic use, individuals who were disabled or in foster care were significantly more likely than individuals with low income to receive 3 or more psychotropic classes overlapping for 90 days or more. Factors
such as complex medical conditions, early-life trauma, and fragmented care may have contributed to these findings.<sup><a href="#zld230271r5" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">5</a></sup> This
study was limited by the focus on youths enrolled in Medicaid in a single US state, which limits the generalizability of our findings to other states, populations, or health care systems. The findings emphasize the importance of
monitoring the use of psychotropic combinations, particularly among vulnerable populations, such as youths enrolled in Medicaid who have a disability or are in foster care.</p>
<a class="article-section-id-anchor" id="249494429"></a>
<div class="h3 cb section-type-acknowledgements has-back-to-top">
<a href="#top" class="section-jump-link back-to-top" data-tab-toggle=".tab-nav-full-text">Back to top</a>
<div class="heading-text thm-col sb-sc"> Article Information </div>
</div>
<p class="para"><strong>Accepted for Publication:</strong> December 22, 2023.</p>
<p class="parapublished-online"><strong>Published:</strong> February 16, 2024. doi:10.1001/jamanetworkopen.2023.56404</p>
<p class="paraopen-access-note"><strong>Open Access:</strong> This is an open access article distributed under the terms of the <a href="https://jamanetwork.com/pages/cc-by-license-permissions">CC-BY License</a>. © 2024 Chiang YY et
al. <i>JAMA Network Open</i>.</p>
<p class="authorInfoSection"><strong>Corresponding Author:</strong> Yueh-Yi Chiang, BS, Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, 220 Arch St, 12th Floor, Baltimore, MD
21201 (<a href="mailto:yueh-yichiang@umaryland.edu" target="_blank">yueh-yichiang@umaryland.edu</a>).</p>
<p class="paraauthor-contributions"><strong>Author Contributions:</strong> Dr dosReis and Ms Chiang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data
analysis.</p>
<p class="para"><i>Concept and design:</i> Amill-Rosario, Chiang, dosReis.</p>
<p class="para"><i>Acquisition, analysis, or interpretation of data:</i> Amill-Rosario, Chiang, Tran.</p>
<p class="para"><i>Drafting of the manuscript:</i> Amill-Rosario, Chiang, Tran.</p>
<p class="para"><i>Critical review of the manuscript for important intellectual content:</i> Amill-Rosario, Chiang, dosReis.</p>
<p class="para"><i>Statistical analysis:</i> All authors. Amill-Rosario, Chiang, dosReis, Tran.</p>
<p class="para"><i>Administrative, technical, or material support:</i> Chiang, dosReis, Tran.</p>
<p class="para"><i>Supervision:</i> dosReis.</p>
<p class="parafinancial-disclosure"><strong>Conflict of Interest Disclosures:</strong> None reported.</p>
<p class="paradata-sharing-statement"><strong>Data Sharing Statement:</strong> See <a class="supplement-link section-jump-link" data-tab-toggle=".tab-nav-supplemental" href="#note-ZLD230271-1">Supplement 2</a>.</p>
<a class="article-section-id-anchor" id="249494430"></a>
<div class="h3 cb section-type-references ">
<div class="heading-text thm-col sb-sc"> References </div>
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Top of Article
* Introduction
* Methods
* Results
* Discussion
* Article Information
* References
Figure. Prevalence of Psychotropic Polypharmacy Among Youth Enrolled in
Medicaid With Any Psychotropic Use by Eligibility Group, 2015 to 2020
View LargeDownload
In calculating the annual polypharmacy prevalence, the numerator was the number
of youths who had at least 1 polypharmacy episode of 90 or more consecutive days
in the study year. The denominator was the number of youths who had at least 1
pharmacy claim for a psychotropic medication and 90 days or more of continuous
Medicaid enrollment during the same study year.
Table. Characteristics Associated With Psychotropic Polypharmacy Among Youths
Enrolled in Medicaid With Any Psychotropic Use
View LargeDownload
Supplement 1.
eMethods.
Supplement 2.
Data Sharing Statement
1.
Zito JM, Zhu Y, Safer DJ. Psychotropic polypharmacy in the US pediatric
population: a methodologic critique and commentary. Front Psychiatry.
2021;12:644741. doi:10.3389/fpsyt.2021.644741PubMedGoogle ScholarCrossref
2.
Fontanella CA, Warner LA, Phillips GS, Bridge JA, Campo JV. Trends in
psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002-2008.
Psychiatr Serv. 2014;65(11):1332-1340.
doi:10.1176/appi.ps.201300410PubMedGoogle ScholarCrossref
3.
Soria Saucedo R, Liu X, Hincapie-Castillo JM, Zambrano D, Bussing R,
Winterstein AG. Prevalence, time trends, and utilization patterns of
psychotropic polypharmacy among pediatric Medicaid beneficiaries, 1999-2010.
Psychiatr Serv. 2018;69(8):919-926. doi:10.1176/appi.ps.201700260PubMedGoogle
ScholarCrossref
4.
Keefe RJ, Cummings ADL, Smith AE, Greeley CS, Van Horne BS.
Psychotropic medication prescribing: youth in foster care compared with other
Medicaid enrollees. J Child Adolesc Psychopharmacol. 2023;33(4):149-155.
doi:10.1089/cap.2022.0092PubMedGoogle ScholarCrossref
5.
Baker M, Bellonci C, Huefner JC, Hilt RJ, Carlson GA. Polypharmacy
and the pursuit of appropriate prescribing for children and adolescents.
Child Adolesc Psychopharmacol News. 2017;22(1):1-7, 12.
doi:10.1521/capn.2017.22.1.1Google ScholarCrossref
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Chiang Y, Amill-Rosario A, Tran P, dosReis S. Psychotropic Polypharmacy Among
Youths Enrolled in Medicaid. JAMA Netw Open. 2024;7(2):e2356404.
doi:10.1001/jamanetworkopen.2023.56404
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Research Letter
Pediatrics
February 16, 2024
PSYCHOTROPIC POLYPHARMACY AMONG YOUTHS ENROLLED IN MEDICAID
Yueh-Yi Chiang, BS1; Alejandro Amill-Rosario, MPH, PhD1; Phuong Tran, MPH1; et
al Susan dosReis, PhD1
Author Affiliations Article Information
* 1Department of Practice, Sciences, and Health Outcomes Research, University
of Maryland School of Pharmacy, Baltimore
JAMA Netw Open. 2024;7(2):e2356404. doi:10.1001/jamanetworkopen.2023.56404
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Introduction
Concomitant use of medications for attention-deficit/hyperactivity disorder
(ADHD), antipsychotics, mood-stabilizing anticonvulsants, and antidepressants is
referred to as psychotropic polypharmacy.1 Over the past 2 decades, psychotropic
polypharmacy in youths increased, raising safety concerns.2-4 Our goal was to
examine trends from 2015 to 2020 in psychotropic polypharmacy among youths aged
17 years or younger who were enrolled in Medicaid to identify temporal changes
and characteristics associated with psychotropic polypharmacy.
Methods
The cross-sectional study was approved by the University of Maryland
institutional review board and followed the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) reporting guideline. Informed
consent was waived because data were deidentified.
This is a sequential, annual, cross-sectional study using Medicaid eligibility
files and fee-for-service and managed care medical encounter claims from 2015 to
2020 from a single US state. For each annual cohort, we included youths who were
17 years or younger, had received at least 1 pharmacy claim for psychotropic
medication, and had 90 days or more of continuous Medicaid enrollment. We
created 4 mutually exclusive Medicaid eligibility groups in each annual cohort:
(1) youths with low income, (2) youths enrolled in Children’s Health Program
(CHP), (3) youths in foster care, and (4) youths with disabilities. Additional
information regarding the methods can be found in the eMethods in Supplement 1.
Using the American Hospital Formulary Service Pharmacologic Therapeutic
Classification System, we classified psychotropic medications into 6 therapeutic
classes: antipsychotics, ADHD medications, mood-stabilizing anticonvulsants,
antidepressants, anxiolytics, and sedatives. Use of 3 or more different
psychotropic classes that overlapped for 90 consecutive days or longer in each
study year defined psychotropic polypharmacy.1 We allowed no more than a 15-day
gap between prescription fills within the 90-day period. Annual psychotropic
polypharmacy prevalence was defined as the proportion of youths who had at least
1 polypharmacy episode per 100 youths with any psychotropic use. A multivariable
logistic regression model, using all study years, estimated the odds of
psychotropic polypharmacy (dependent variable) among psychotropic users.
Independent variables included study year (continuous), age, sex, race, region,
Medicaid eligibility group, COVID-19, and mental health disorders. The race and
ethnicity categories included in this study were American Indian, Asian, Black,
Hispanic, Native Hawaiian, White, and all other races not listed in one of the
predefined categories. Information regarding race and ethnicity was extracted
from the Medicaid demographic summary file. We used generalized estimating
equations for robust variance estimators to account for nonindependence of
observations given that a youth may be in multiple study years. A supplemental
analysis modeled categorical year (reference year, 2015) to identify which years
contributed to significant psychotropic polypharmacy changes. Significance
levels were set at P < .05 for 2-tailed tests. All analyses were performed using
SAS Studio version 9.4 (SAS Institute). Data were analyzed from January to
December 2023.
Results
Across all years, 126 972 unique youths met the inclusion criteria. Psychotropic
polypharmacy prevalence among youths who used psychotropics increased from 2259
of 53 569 youths (4.2%) in 2015 to 2334 of 50 806 youths (4.6%) in 2020. The
2015 to 2020 increase in psychotropic polypharmacy prevalence was observed for
those with Medicaid eligibility from foster care (414 of 3824 [10.8%] and 387 of
3420 [11.3%]), CHP (225 of 10 354 [2.2%] and 222 of 7974 [2.8%]), and being from
a low-income household (648 of 30 222 [2.1%] and 883 of 31 172 [2.8%]) (Figure).
The adjusted odds ratios (AORs) of psychotropic polypharmacy for the year was
1.04 (95% CI, 1.02-1.06), a 4% increase in the odds of psychotropic polypharmacy
per year. The supplemental analysis revealed a significant increase in 2019 and
2020 relative to 2015. Psychotropic polypharmacy was significantly more likely
among youths who were disabled (AOR, 3.68; 95% CI, 3.34-4.05) or in foster care
(AOR, 3.31; 95% CI, 2.93-3.74) relative to youths in the low-income group.
Individuals aged 10 to 14 years (AOR, 1.94; 95% CI, 1.80-2.10) and 15 to 17
years (AOR, 2.41; 95% CI, 2.22-2.61) had significantly higher odds of
psychotropic polypharmacy than those who were younger than 10 years. Black
individuals (AOR, 0.47; 95% CI, 0.43-0.51) or individuals who identified as
other races (including individuals identifying as American Indian, Asian,
Hispanic, or Pacific Islander, or other races) (AOR, 0.54; 95% CI, 0.50-0.59)
had significantly lower odds of psychotropic polypharmacy than White individuals
(Table).
Discussion
In this cross-sectional study, we observed a 4% increased odds of psychotropic
polypharmacy per year from 2015 to 2020, indicating growing concomitant use of
multiple psychotropic classes. Among youths enrolled in Medicaid with any
psychotropic use, individuals who were disabled or in foster care were
significantly more likely than individuals with low income to receive 3 or more
psychotropic classes overlapping for 90 days or more. Factors such as complex
medical conditions, early-life trauma, and fragmented care may have contributed
to these findings.5 This study was limited by the focus on youths enrolled in
Medicaid in a single US state, which limits the generalizability of our findings
to other states, populations, or health care systems. The findings emphasize the
importance of monitoring the use of psychotropic combinations, particularly
among vulnerable populations, such as youths enrolled in Medicaid who have a
disability or are in foster care.
Back to top
Article Information
Accepted for Publication: December 22, 2023.
Published: February 16, 2024. doi:10.1001/jamanetworkopen.2023.56404
Open Access: This is an open access article distributed under the terms of the
CC-BY License. © 2024 Chiang YY et al. JAMA Network Open.
Corresponding Author: Yueh-Yi Chiang, BS, Department of Practice, Sciences, and
Health Outcomes Research, University of Maryland School of Pharmacy, 220 Arch
St, 12th Floor, Baltimore, MD 21201 (yueh-yichiang@umaryland.edu).
Author Contributions: Dr dosReis and Ms Chiang had full access to all of the
data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Amill-Rosario, Chiang, dosReis.
Acquisition, analysis, or interpretation of data: Amill-Rosario, Chiang, Tran.
Drafting of the manuscript: Amill-Rosario, Chiang, Tran.
Critical review of the manuscript for important intellectual content:
Amill-Rosario, Chiang, dosReis.
Statistical analysis: All authors. Amill-Rosario, Chiang, dosReis, Tran.
Administrative, technical, or material support: Chiang, dosReis, Tran.
Supervision: dosReis.
Conflict of Interest Disclosures: None reported.
Data Sharing Statement: See Supplement 2.
References
1.
Zito JM, Zhu Y, Safer DJ. Psychotropic polypharmacy in the US pediatric
population: a methodologic critique and commentary. Front Psychiatry.
2021;12:644741. doi:10.3389/fpsyt.2021.644741PubMedGoogle ScholarCrossref
2.
Fontanella CA, Warner LA, Phillips GS, Bridge JA, Campo JV. Trends in
psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002-2008.
Psychiatr Serv. 2014;65(11):1332-1340.
doi:10.1176/appi.ps.201300410PubMedGoogle ScholarCrossref
3.
Soria Saucedo R, Liu X, Hincapie-Castillo JM, Zambrano D, Bussing R,
Winterstein AG. Prevalence, time trends, and utilization patterns of
psychotropic polypharmacy among pediatric Medicaid beneficiaries, 1999-2010.
Psychiatr Serv. 2018;69(8):919-926. doi:10.1176/appi.ps.201700260PubMedGoogle
ScholarCrossref
4.
Keefe RJ, Cummings ADL, Smith AE, Greeley CS, Van Horne BS.
Psychotropic medication prescribing: youth in foster care compared with other
Medicaid enrollees. J Child Adolesc Psychopharmacol. 2023;33(4):149-155.
doi:10.1089/cap.2022.0092PubMedGoogle ScholarCrossref
5.
Baker M, Bellonci C, Huefner JC, Hilt RJ, Carlson GA. Polypharmacy
and the pursuit of appropriate prescribing for children and adolescents.
Child Adolesc Psychopharmacol News. 2017;22(1):1-7, 12.
doi:10.1521/capn.2017.22.1.1Google ScholarCrossref
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