Date of Award

2018

Degree Type

Dissertation

Degree Name

Doctor of Philosophy in Pharmaceutical Sciences

Department

Biomedical and Pharmaceutical Sciences

First Advisor

Ashley L. Buchanan

Abstract

The pediatric mental health burden in the United States (US) is substantial, with more than 4 million children meeting diagnostic criteria for a mental health disorder. As of 2014, this number represented 20% of US children and adolescents. In 2010, mental health disorders are estimated to cost children and their families $247 billion dollars annually and severely impact quality of life for children and their families. From 2007 to 2010, inpatient admissions for mental health disorders in pediatric patients increased 24% and mood disorder admissions in pediatric patients increased 80% from 1997-2010. An estimated $11.6 billion was spent on pediatric mental health hospitalizations from 2006 through 2011, with public sources such as Medicaid and Medicare responsible for approximately 50% of the payments, leaving 50% to private payers. This economic and clinical concern has led pediatric medical associations and health quality agencies to increase support and funding for pediatric mental health research and treatment.

Medication therapy is a common intervention in mental health treatment and atypical antipsychotics are increasing in utilization, often becoming first-line therapy. Despite available data describing the need to treat pediatric mental health conditions, the available evidence for clinical effectiveness and economic impact of atypical antipsychotics (AAPs) has many shortfalls. Most available research is derived from patients utilizing publicly-funded medical care, such as Medicaid or Medicare resources, with little data available about patients with privately-funded care. To help address this gap in the literature, we used a large, privately-insured, US population for our analysis. We examined if the increased trend in AAP utilization from previous research is also present in this pediatric population. Considering the payer perspective, we evaluated the cost of AAP medication therapy based on most recent utilization.

Available studies lack information about the direct costs of pediatric mental health treatment and efficacy of psychiatric medications in the pediatric population. Most efficacy studies are based on clinical trials necessary for pediatric indication approval from regulatory agencies such as the Food and Drug Administration (FDA). Many of the AAP medications do not have pediatric clinical trial evidence available and are frequently utilized without pediatric indications. The available data suggests that off-label prescribing is not an uncommon practice in the pediatric patient population.3,4

Approximately half of atypical antipsychotics do not have pediatric indications but are increasingly used, particularly in treating behavior disorders, due to such factors as improved patient compliance and improved side effect profiles. Limited formal studies examining atypical antipsychotic use compared to other agents in the class have been conducted. Studies with direct comparisons have yet to be conducted in the pediatric population with mental health disorders.

The manuscripts that comprise this dissertation aim to provide new insights into available trend and utilization patterns of atypical antipsychotic medication use in children. This research characterized the prevalence of atypical antipsychotic use in pediatric patient with mental health conditions in a large, privately insured US population, evaluating the diagnoses associated with treatment and estimate the cost of AAP medication therapy in this population. This research determined if the trends observed in publicly-insured children persist in the privately-insured, pediatric patient. The analysis evaluated annual trends in prevalent use of atypical antipsychotic medication over 6-year period in this pediatric population and evaluated the appropriate use of AAPs for mental health diagnoses. Lastly, an evaluation determined if specific antipsychotic therapy delayed time to readmission among privately-insured children following a psychiatric hospital admission. The results of this dissertation will provide new insights regarding the trends and direct medication costs of atypical antipsychotic agents when utilized in pediatric patients with mental health disorders.

Manuscript 1: This analysis focused on characterizing the most recent (2015) AAP use in the pediatric population with mental health disorders, using a large, US population of privately- insured children. The study evaluated if the prevalence data observed among publicly insured children persists. Characterization of the prescribing trends for atypical antipsychotics and the medication costs of the use in this population were examined. Patterns of use across demographics and associated mental health diagnoses were characterized by the class of medication. This study focused on the prevalent use of AAPs in pediatric patients with a mental health diagnosis, evaluated the mental health diagnoses associated with AAPs and the direct cost burden of medication therapy associated with this use of AAP in the pediatric population to the private payer.

Manuscript 2: This research evaluated the trends in the prescribing of atypical antipsychotic medications from 2010 through 2015 in this privately-insured pediatric population. The trends of AAP use in the pediatric population over six years were examined. The associated mental health diagnoses corresponding with AAP prescribing were described to examine the off-label diagnoses treatment prevalence in this population. This study hypothesizes that the prevalent use of AAPs is increasing in the privately-insured patients and off-label prescribing accounts for most clinical use in pediatric patients.

Manuscript 3: This analysis examined pediatric patients who utilized oral atypical antipsychotic therapy after an inpatient admission for mental health treatment. Readmission for mental health treatment was evaluated to determine the efficacy of using oral AAP medications in pediatric mental health patients. Some oral AAP agents have shown benefit in pediatric patients compared to placebo and have an official FDA indication for pediatric use. Many clinical providers believe that this entire class of medications can demonstrate benefit in pediatric patients, regardless of FDA indication. This study hypothesized that certain oral AAP medications are associated with delayed readmission in pediatric patients with an index admission for mental health treatment.

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