Saturday, 15 January 2005 - 4:00 PM

This presentation is part of: Assessing the Context of Mental Health Service Delivery for Youth: Opportunities for Targeted Intervention

Clinical and Organizational Influences on Psychotropic Medication Use among Youth in Outpatient Mental Health Services in the U.S

Purpose. Psychotropic medication use among youth with serious emotional disturbances is increasing, due in part to scientific advances in diagnostic assessment and psychopharmacology. At the same time, managed care controls on reimbursement for interpersonal therapy or organizational pressures on profit making may also exert influences on medication use. The purpose of this study is to analyze the extent to which the use of psychotropic medications for youth is guided by clinical need and organizational level characteristics.

Methods. Two data sets managed by the U.S. Department of Health and Human Services, Center for Mental Health Services were merged for this study: the 1994 Inventory of Mental Health Organizations and General Hospital Mental Health Services (IMHO) is the universe of specialty inpatient, outpatient, and residential mental health programs in the U.S., and the 1997 Client/Patient Sample Survey (CPSS), the most recently available data on persons receiving specialty mental health care throughout the nation. The IMHO served as the sampling frame for the CPSS, which used a two-stage cluster design survey. After 1,599 facilities were randomly selected from the IMHO, clients within facilities were randomly selected, with youth under age 18 years oversampled. This study was based on 2,749 youth (weighted N=514,000) from 690 outpatient settings.

The IMHO was the source of organizational measures hypothesized to be associated with use of medication (facility ownership, facility part of managed care network, organization affiliated with college or university, and hours worked by psychiatrists and other physicians). Individual level information from the CPSS was extracted from medical records by administrative staff blind to the purposes of this study and includes sociodemographic (age, gender, race-ethnicity, living arrangement and source of payment), and clinical (primary psychiatric diagnosis, number of psychiatric diagnoses, and Global Assessment of Functioning score) information. Receipt of psychotropic medication is a dichotomous measure from a multiple checklist of services received by each youth. Multivariate logistic regression equations were used to analyze the effect of clinical and organizational characteristics, controlling on sociodemographic characteristics. SAS-callable SUDAAN was used to account for multiple level effects.

Results. 29.7% of youth in outpatient settings received medication. Compared to youth with adjustment disorders, medication receipt was significantly more likely for youth with anxiety (adjusted odds ratio (OR) 1.92, p<.05) and mood, psychotic and attention deficit disorders (ORs of 2.71, 3.96, and 4.95, respectively, p< .01), and for youth with the most severe functional limitations (OR 1.85, p<.01). Controlling on sociodemographic and clinical characteristics, youth who received care from non-profit providers were one third less likely to receive medication than youth who received care in public and for-profit organizations (OR=0.67, p<.05).

Implications. Direct care providers may need to be prepared to address inequities in children's mental health service delivery that are generated at the organizational level, and policy makers may need to examine organizational incentives that jeopardize best practices.

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