Psychotropic Drug Prescription and Youths in Psychiatric Residential Treatment: Examining Patterns over Time
Monitoring medication in psychiatric residential treatment facilities (PRTFs) that serve youths is critical because the settings often house highly vulnerable, child welfare-involved youths. Psychotropic drugs introduce both risks and promise; long-term effects on youth are unclear, but may be more efficacious than non-pharmacological treatments alone. Youths in PRTFs have higher rates of medication use than children in other out of home care (48% v. 12-14%) and substantially higher use than non-foster children in the United States (5-10%). Among child welfare-involved youths, differences in prescription patterns emerge by gender and race. Despite discrepancies, empirical evidence regarding disparate conditions is limited. The purposes of the current study are to examine trends in 1) time from PRTF admission until prescription, 2) the prescription patterns of youth prior to and after admission, and 3) the number of different types of drugs prescribed over time, and the associations of these three trends with youth demographics and diagnosis histories.
Methods
Child welfare, TANF, and Medicaid data were linked to identify youth (n= 2,730) from child welfare and TANF populations in PRTFs from 2007 to 2012. Longitudinal data were modeled as follows: First, survival curves demonstrated the length of time from PRTF admission to initial prescription of psychotropic drugs; demographics and drug classes were used to stratify survival curves. Second, longitudinal models of the prescription histories prior to and after admission to PRTFs were analyzed with demographic and ICD-9 diagnostic predictors (e.g., psychoactive substance addiction). Third, negative binomial fixed effects models were used to examine the number of different types of psychotropic drugs prescribed over time.
Results
During or after their PRTF stays, 34% of youth were prescribed antipsychotics, 36% mood stabilizers, 30% were prescribed antidepressants, anxiolytics or stimulants. Prescriptions for antipsychotics were given earlier, girls were prescribed earlier than boys, and African Americans were prescribed earlier than Whites. Changes over time in the odds of being prescribed any type of drug were modest but significant, with antipsychotics and non-SSRI antidepressants increasing; certain classes of psychostimulants and SSRI antidepressants decreased after PRTF admission. Younger youth, boys, whites, youth in a lower-intensity facility prior to PRTF admission, and youth with foster care or TANF histories were more likely to be prescribed psychotropic drugs; youth with a maltreatment history were less likely. Fixed effects models show that after admission, youth were prescribed more types of medications, African American youth, boys, and youth from foster care were prescribed more types; youth with TANF and foster care histories were prescribed fewer types.
Conclusions
This study advances knowledge about youths in PRTFs because it compares youths from different demographics having different child welfare and TANF histories on the timing of treatment with psychotropic drugs. There is clear evidence of difference in prescription history based on drug class, gender, race and involvement in child welfare. With respect to policy, reducing disparity will involve careful monitoring of PRTFs medication management. In practice, fidelity in assessment and prescription are critical. Future research should closely monitor psychotropic prescriptions in this population.