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Articles   |    
Prescription of Psychiatric Medications and Polypharmacy in the LAMS Cohort
Robert A. Kowatch, M.D., Ph.D.; Eric A. Youngstrom, Ph.D.; Sarah Horwitz, Ph.D.; Christine Demeter, M.A.; Mary A. Fristad, Ph.D., A.B.P.P.; Boris Birmaher, M.D.; David Axelson, M.D.; Neal Ryan, M.D.; Thomas W. Frazier, Ph.D.; L. Eugene Arnold, M.D.; Andrea S. Young, Ph.D.; MaryKay Gill, R.N., M.S.N.; Robert L. Findling, M.D., M.B.A.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200507
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Dr. Kowatch is affiliated with the Department of Psychiatry, Ohio State Wexner Medical Center and Nationwide Children’s Hospital, Department of Psychiatry, 700 Children's Dr., Columbus, OH 43205 (e-mail: robert.kowatch@nationwidechildrens.org). Dr. Youngstrom is with the Department of Psychology, University of North Carolina, Chapel Hill. Dr. Horwitz is with the Department of Child Psychiatry, New York University School of Medicine, New York City. Ms. Demeter is with the Department of Psychiatry, Division of Child and Adolescent Psychiatry, Case Western Reserve University, Cleveland, Ohio. Dr. Fristad is with the Department of Psychiatry, Division of Child and Adolescent Psychiatry, and Dr. Arnold is with the Department of Psychiatry, both at Ohio State University, Columbus. Dr. Birmaher is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Dr. Axelson and Ms. Gill are with the Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh. They are also with Western Psychiatric Institute and Clinic, Pittsburgh, where Dr. Ryan is affiliated. Dr. Frazier and Dr. Young are with the Center for Pediatric Behavioral Health, Cleveland Clinic, Cleveland. Dr. Findling is with the Division of Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  This study evaluated demographic and clinical correlates and predictors of polypharmacy at baseline assessment in the Longitudinal Assessment of Manic Symptoms (LAMS) sample, a cohort of children age six to 12 years at their first outpatient mental health visit at university-affiliated clinics.

Methods  Use of medications in four classes (mood stabilizers, antidepressants, antipsychotics, and stimulants) was assessed, and the Service Assessment for Children and Adolescents classified lifetime and current use of various services. Analyses examined correlates of the number of medications prescribed and odds of polypharmacy, defined as use of two or more concurrent medications.

Results  In the total sample, 201 of 698 participants (29%) were prescribed two or more medications. These participants had lower Children’s Global Assessment Scale scores, more comorbid disorders, and higher baseline parent-reported mood symptoms than those prescribed no or one medication. White youths were three times as likely as nonwhite youths to be receiving two or more psychotropics, even after adjustment for other demographic and clinical characteristics. Of 262 participants (38% of sample) not being treated with medications, 252 (96%) had a diagnosis of at least one psychiatric disorder (74% had two or more).

Conclusions  Findings suggest that patients with greater severity and comorbidity were more likely to receive two or more medications. However, 38% of these children with serious disorders were not receiving psychotropic medication at the time of this assessment. Results counter findings suggesting overtreatment with medications of children with psychiatric disorders in the community.

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Figure 1 Number of medications prescribed to white and nonwhite youths in the Longitudinal Assessment of Manic Symptoms samplea

aThe analysis controlled for other demographic and clinical characteristics. The mean predicted value for each youth was based on Poisson regression predicting the number of medications with use of the fully augmented model. The dot indicates the median, the bar indicates the middle 50% of the distribution (interquartile range), and the shading shows the density of the score distribution.

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Table 1Characteristics of 698 participants in the Longitudinal Assessment of Manic Symptoms, by number of medications prescribed at baseline
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a Test statistics compared all four medication groups (df=3 in numerator).

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b In each row, values marked with a superscript are significantly different from one another. Difference in group means based on Games-Howell post hoc analyses for analyses of variance (p<.05) or difference in cell count from expected value based on Pearson’s adjusted standardized residual for chi square analyses

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c CGAS, Children's Global Assessment Scale. Possible scores range from 1 to 100, with higher scores indicating better functioning.

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d Parent-Completed General Behavior Inventory Mania Form. Possible scores range from 0 to 30, with higher scores indicating more manic and mixed symptoms.

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e Young Mania Rating Scale. Possible scores range from 0 to 60, with higher scores indicating more manic symptoms.

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f Children’s Depression Rating Scale–Revised. Possible scores range from 17 to 113, with higher scores indicating more severe depressive symptoms.

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Table 2Predictors of polypharmacy among 698 participants in the Longitudinal Assessment of Manic Symptomsa
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a Based on logistic regressions predicting use of two or more medications concurrently. Sensitivity analyses using Poisson regression to predict the count of the total number of medications found the same predictors and patterns, with slightly smaller p values for several due to the greater variance in the dependent measure. Final model: Total R2=25, Nagelkerke R2 change=.30, p<.001

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Table 3Incremental predictors of polypharmacy in the Longitudinal Assessment of Manic Symptomsa
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a df=1 for all predictors. Based on logistic regressions (final model) predicting use of two or more medications concurrently. Sensitivity analyses using Poisson regression to predict the count of the total number of medications found the same predictors and patterns, with slightly smaller p values for several due to the greater variance in the dependent measure.

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Table 4Variance in prescription of medication class explained by demographic, clinical, and provider factors among 698 participants in the Longitudinal Assessment of Manic Symptomsa
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a Based on logistic regressions predicting use of respective medication class. White youths were significantly more likely to receive antipsychotics, mood stabilizers, and antidepressants, and this difference remained significant at every subsequent block of the model. Final model total R2 (p<.001 for all): antipsychotics, .40; mood stabilizers, .33; antidepressants, .26; and stimulants, .23. Change in odds of polypharmacy for white youths in the final model: antipsychotics, 2.4 (95% confidence interval [CI]=1.3–4.2), p<.005; mood stabilizers, 2.5 (CI=1.0–6.2), p<.05; antidepressants, 2.5 (CI=1.1–5.0), p<.05; and stimulants, 1.2 (CI=.8–1.9), ns

Table Footer Note

*p<.05, **p<.005, ***p<.001

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