Declining Statewide Prescribing of Antipsychotic Medications in Foster Youth and Social Work Implications

Background:  Each State has responsibility for safeguarding the mental and physical health and overall well-being of children.  This responbility is even more significant for children/youth placed into foster care because of abuse and/or neglect.  Psychotropic medications (pharmaceuticals affecting the brain) are more commonly prescribed to foster youth compared to other youth.  This has prompted concern about these drugs’ benefits versus risks and whether they always serve the best interests of foster youth.  Antipsychotic medications, often used for behavioral symptoms not approved by the FDA, are a special concern. Increasing interdisciplinary consensus among stakeholders suggests that psychotropic medications, particularly antipsychotics, are over-used.  Since mid-2013, California’s Department of Social Services and the State’s Medicaid program have co-sponsored a quality improvement project (QIP) aimed at encouraging evidence-based prescribing to foster youth.  The QIP has spawned new legislation, additional drug prior authorization requirements, modified procedures for court-approved prescribing, and new data reporting.

Methods:  This study examines recent statewide trends in psychotropic medication prescribing.  It utilizes publicly reported data that links Medicaid medication claims with individual level foster care data to examine the proportion of youth prescribed psychotropic medications from Quarter 1(2011) through Quarter 2 (2016). We used data on all foster youth in California (N=78,194 for Q2 2016).  Annual data (rolling 12 months) are available quarterly. All comparisons reported attained statistical significance (p<0.01).

 Results:  There was a 38% decline in the proportion of foster youth receiving antipsychotic medications between Q4 2011 (7.1%) and Q2 2016 (4.4%) with a greater change after Q1 2014 (0.96% absolute decline per year) than before (0.16%).  The relative decline in antipsychotic use was more prominent for ages 0-5 years (0.26%→0.11%) and 6-10 (6.7%→3.4%) compared to 11-15 (13.3%→9.6%) and 16-17 (15.0→12.7%).  Relative changes were similar in boys (8.5%→5.5%) and girls (5.5%→3.5%).  While declines were similar for Whites (8.8%→5.6%), Latino (5.4%→3.3%), and Blacks (9.4%→5.9%), negligible change was observed for Asians/Pacific Islanders (4.3%→4.2%).  Greater declines were seen in Los Angeles County (7.0%→3.9%) compared to the rest of California (7.1%→4.7%).  Foster youth in County welfare had larger relative reductions (6.4%→4.0%) compared to those in County probation programs (14.0%→11.2%). Relative declines in antipsychotic prescribing did not vary by length of time in foster care. A divergent trend was found for psychotropic medications other than antipsychotics, which increased from 6.1% (2011) to 6.5% (2013) to 8.6% (2016). Aggregate prescribing for all psychotropic medications in foster youth did not change over time (13.2% in 2011→13.0% in 2016). 

Implications:  The temporal correlation between QIP activities and reduced use of antipsychotics in foster youth suggests a QIP impact.  Larger relative declines were seen in younger children, a QIP focus.  As prescribing of antipsychotics declined, use of other psychotropic medications increased, suggesting that prescribers may be substituting other drugs in place of antipsychotics. Whenever psychotropic medications are considered for foster youth, the involved social workers need to engage in an interdisciplinary dialogue to assess and intervene to promote and advocate for these youths’ mental and physical health and well-being.