Complexity and Continuity of Treatments Among Privately Insured Youth Diagnosed with Bipolar Disorder

Objectives: To examine longitudinal patterns of complexity, continuity, and initiation of treatment for youth diagnosed with bipolar disorder. Additionally, we explore bipolar diagnosis stability and its relationship to observed treatment patterns. Methods: A cohort of 426 privately insured youth (ages 6–18) diagnosed with bipolar disorder was identified from the 2000–2001 Thomson/Medstat-MarketScan® database. Medication complexity was defined as number of different psychotropic medication classes dispensed during a 6-month period following a new treatment episode of bipolar disorder. Treatment continuity was examined over a 6-month follow-up period, specifically focusing on mood stabilizing medications and antidepressant monotherapy. Predictors of complexity and continuity were investigated. Results: Fifty-five percent of youth received more than one and 25% received three or more different types of psychotropic medication classes during follow-up. This was contrasted with several youth having no prescription fills (21%) and 31% discontinuing mood stabilizing medication. Youth with a stable bipolar diagnosis were more likely to have continuity of mood stabilizing prescriptions (OR: 4.05), but also greater psychotropic medication complexity. Age, health status/comorbidity, and being in a managed care plan were also related to complexity and continuity of psychotropic medication class regimens. Conclusions: More evidence is needed on the causal patterns leading to increased psychotropic medication complexity and continuity and how diagnosis of bipolar disorder may drive treatment patterns

Exploring stimulant treatment in ADHD: narratives of young adolescents and their parents

BACKGROUND: Young adolescents’ and their parents’ experiences with Attention-Deficit/Hyperactivity Disorder (ADHD) and its treatment were explored to investigate beliefs and attitudes regarding use of stimulant medication, and their influence on treatment decisions. METHODS: Using in-depth qualitative interviews, 12 adolescents with ADHD aged 12 – 15 years, and their parents described their experiences of ADHD and its treatment. Twenty four interviews, 12 with adolescents and 12 with their parents elicited detailed descriptions of beliefs about ADHD, attitudes about stimulant use and the circumstances surrounding treatment decisions. Verbatim transcripts were iteratively analyzed by a team of researchers following an interpretive interactionist framework. RESULTS: Young people offered three themes describing ADHD: 1) personality trait, 2) physical condition or disorder, and 3) minor issue or concern. Regarding medication use, youth described 1) benefits, 2) changes in sense of self, 3) adverse effects, and 4) desire to discontinue use. Parents’ beliefs were more homogeneous than youth beliefs, describing ADHD as a disorder requiring treatment. Most parents noted benefits from stimulant use. Themes were 1) medication as a last resort, 2) allowing the child to reach his or her potential; and 3) concerns about adverse and long-term effects. Families described how responsibility for treatment decisions is transferred from parent to adolescent over time. CONCLUSIONS: Young adolescents can have different beliefs about ADHD and attitudes about medication use from their parents. These beliefs and attitudes influence treatment adherence. Incorporating input from young adolescents when making clinical decisions could potentially improve continuity of treatment for youth with ADHD

Impact of different interventions on preventing suicide and suicide attempt among children and adolescents in the United States: a microsimulation model study

IntroductionDespite considerable investment in suicide prevention since 2001, there is limited evidence for the effect of suicide prevention interventions among children and adolescents. This study aimed to estimate the potential population impact of different interventions in preventing suicide-related behaviors in children and adolescents.MethodsA microsimulation model study used data from national surveys and clinical trials to emulate the dynamic processes of developing depression and care-seeking behaviors among a US sample of children and adolescents. The simulation model examined the effect of four hypothetical suicide prevention interventions on preventing suicide and suicide attempt in children and adolescents as follows: (1) reduce untreated depression by 20, 50, and 80% through depression screening; (2) increase the proportion of acute-phase treatment completion to 90% (i.e., reduce treatment attrition); (3) suicide screening and treatment among the depressed individuals; and (4) suicide screening and treatment to 20, 50, and 80% of individuals in medical care settings. The model without any intervention simulated was the baseline. We estimated the difference in the suicide rate and risk of suicide attempts in children and adolescents between baseline and different interventions.ResultsNo significant reduction in the suicide rate was observed for any of the interventions. A significant decrease in the risk of suicide attempt was observed for reducing untreated depression by 80%, and for suicide screening to individuals in medical settings as follows: 20% screened: −0.68% (95% credible interval (CI): −1.05%, −0.56%), 50% screened: −1.47% (95% CI: −2.00%, −1.34%), and 80% screened: −2.14% (95% CI: −2.48%, −2.08%). Combined with 90% completion of acute-phase treatment, the risk of suicide attempt changed by −0.33% (95% CI: −0.92%, 0.04%), −0.56% (95% CI: −1.06%, −0.17%), and −0.78% (95% CI: −1.29%, −0.40%) for reducing untreated depression by 20, 50, and 80%, respectively. Combined with suicide screening and treatment among the depressed, the risk of suicide attempt changed by −0.27% (95% CI: −0.dd%, −0.16%), −0.66% (95% CI: −0.90%, −0.46%), and −0.90% (95% CI: −1.10%, −0.69%) for reducing untreated depression by 20, 50, and 80%, respectively.ConclusionReducing undertreatment (the untreated and dropout) of depression and suicide screening and treatment in medical care settings may be effective in preventing suicide-related behaviors in children and adolescents

Exploring stimulant treatment in ADHD: narratives of young adolescents and their parents

Abstract Background Young adolescents’ and their parents’ experiences with Attention-Deficit/Hyperactivity Disorder (ADHD) and its treatment were explored to investigate beliefs and attitudes regarding use of stimulant medication, and their influence on treatment decisions. Methods Using in-depth qualitative interviews, 12 adolescents with ADHD aged 12 – 15 years, and their parents described their experiences of ADHD and its treatment. Twenty four interviews, 12 with adolescents and 12 with their parents elicited detailed descriptions of beliefs about ADHD, attitudes about stimulant use and the circumstances surrounding treatment decisions. Verbatim transcripts were iteratively analyzed by a team of researchers following an interpretive interactionist framework. Results Young people offered three themes describing ADHD: 1) personality trait, 2) physical condition or disorder, and 3) minor issue or concern. Regarding medication use, youth described 1) benefits, 2) changes in sense of self, 3) adverse effects, and 4) desire to discontinue use. Parents’ beliefs were more homogeneous than youth beliefs, describing ADHD as a disorder requiring treatment. Most parents noted benefits from stimulant use. Themes were 1) medication as a last resort, 2) allowing the child to reach his or her potential; and 3) concerns about adverse and long-term effects. Families described how responsibility for treatment decisions is transferred from parent to adolescent over time. Conclusions Young adolescents can have different beliefs about ADHD and attitudes about medication use from their parents. These beliefs and attitudes influence treatment adherence. Incorporating input from young adolescents when making clinical decisions could potentially improve continuity of treatment for youth with ADHD

Evaluation of guideline-concordant care for bipolar disorder among privately insured youth

OBJECTIVE: To describe and quantify the prevalence of treatments and services for youth with bipolar disorder and to assess whether concordance with treatment guidelines is associated with inpatient hospitalization and emergency department visits. METHOD: Insurance claims of 423 privately insured youth (ages 6-18) having prescription drug coverage and diagnosed with bipolar disorder were examined from the 2000-2001 Thomson Medstat MarketScan database, a national (US) dataset. Treatments and services were examined for the 6 months following the index bipolar disorder diagnosis, defined as the first diagnosis after a diagnosis-free period of 6 months. RESULTS: The majority of youth did not receive guideline-concordant care. Only 26% (n = 109) received a mood stabilizer or antipsychotic, as recommended, within 1 month of a bipolar diagnosis. Antidepressant monotherapy, which is contraindicated in therapeutic guidelines, was observed for 33% (n = 140) of youth. Less than 40% of youth received adjunctive psychotherapy. Guideline concordance was statistically significantly related to a lower likelihood of an inpatient hospitalization or an emergency department visit. CONCLUSIONS: Although deviation from guidelines may be warranted in some cases due to individual variation and patient complexity or patient and/or family preferences, these findings suggest that evidence-based guidelines are not followed in clinical practice. Incorporation of guideline-concordant care may increase the likelihood of overall better quality of care and presage better long-term outcomes for youths diagnosed with bipolar disorder

The meaning of attention-deficit/hyperactivity disorder medication and parents' initiation and continuity of treatment for their child

OBJECTIVE: The aim of this study was to examine parents' early understanding of medication for attention-deficit/hyperactivity disorder (ADHD) in relation to decisions to initiate and continue treatment for their child. METHODS: Qualitative, semistructured telephone interviews were conducted with 48 parents of children newly diagnosed with ADHD. Parents were recruited from inner city, outpatient primary care, and mental health clinics affiliated with a large university hospital. Data were analyzed using grounded theory. RESULTS: Parents' initial perspectives of the appropriateness, anticipated effects, and symbolic meaning of medication were classified by four typologies (illness oriented, problem oriented, generally acceptable, unacceptable). In this sample, 29% of parents believed medication was required to treat the illness and 20% believed medication was unacceptable. Except for the unacceptable group, nearly all of the parents in the other groups initiated medication shortly after diagnosis. More than 80% of the illness- and problem-oriented groups used medication at 6 months; this fell to 64% and 78%, respectively, at 12 months. Only half of the unacceptable group ever used medication for their child. CONCLUSIONS: Parents' views of ADHD medication may be predictive of continuity of treatment. Increasing physician awareness of parent preferences for managing their child's ADHD problems may lead to care management plans that maximize continuity