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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on December 8, 2009, at 21:21:02
Seems managed care has forced docs to be more aggressive in their treatment of adolescents with suicidal ideation main reason for admission. Time and Cost factor not good. Phillipa
Medscape Medical News from the:
American Academy of Child & Adolescent Psychiatry (AACAP) 56th Annual MeetingThis coverage is not sanctioned by, nor a part of, the American Academy of Child & Adolescent Psychiatry.
From Medscape Medical News
Polypharmacy Linked to Higher Hospital Readmission Rates in Suicidal Adolescents
Caroline Cassels
November 5, 2009 (Honolulu, Hawaii) Polypharmacy with psychotropic medications in suicidal adolescent inpatients has been linked to a significantly increased risk for early readmission, new research shows.Presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, investigators at the Ohio State University and Nationwide Children's Hospital, Columbus, found that suicidal adolescent inpatients receiving 3 or more different classes of psychotropic medications had a 2.6-fold increased risk of being readmitted within 30 days of discharge.
In addition, the researchers found that prescribing an antidepressant was associated with an 85% decreased risk for early readmission.
"We found antidepressants were associated with a lower risk of readmission, which is an indicator of quality of care. Conversely, though, we also found that when kids are prescribed 3 or more medications from different drug classes, the risk of early readmission increased by almost 3-fold," principal investigator Cynthia A. Fontanella, PhD, told Medscape Psychiatry.
According to Dr. Fontanella, although psychotropic medications are commonly used in this patient population, little is known about whether these interventions are effective in the inpatient setting or whether they reduce early readmission rates. Furthermore, she said, readmission rates in this patient population are on the rise.
"We don't really know a lot about inpatient care for kids and whether it is effective or not. We do know that readmission rates are increasing, and there is some evidence that these increases are associated with reductions in length of stays.
"We also know that the mainstay of treatment is psychopharmacological, yet we don't know much about the types of medications being prescribed, the frequency of medication changes, or what types of aftercare adolescents receive. This study was really an attempt to get inside the 'black box' of inpatient treatment and find out what's happening in terms of medication use," said Dr. Fontanella.
Antidepressants Mitigate Readmission Risk
The observational study included 318 Medicaid-covered adolescents aged 11 to 17 years admitted to 3 Maryland hospitals for suicidal behaviors. Using medical records and Medicaid claims data, the researchers gathered extensive data on subjects' clinical characteristics, as well as polypharmacy (defined as 3 or more medications) and medication changes.
"Suicidal patients account for 55% of all adolescent admissions to psychiatric hospitals," said Dr. Fontanella.
The study's main outcome measure was the effects of psychotropic medication changes and polypharmacy on 30-day readmission rates.
The researchers found that at least 1 medication change was made in 78% of study subjects, typically the addition of an antidepressant, mood stabilizer, or antipsychotic. At discharge, 23% of adolescents were prescribed 3 or more medications from different drug classes.
"Our finding that antidepressant therapy mitigates the risk of early readmission is good news and should reassure psychiatrists about the possible benefits of these medications. However, the relationship between antidepressants and suicidal risk remain unclear and these types of studies have inherent limitations.
"More research, particularly randomized clinical trials, [is] needed to examine the effectiveness of antidepressants and other pharmacological treatment in stabilizing suicidal youth in inpatient settings," said Dr. Fontanella.
"Our finding that polypharmacy was associated with an increased risk of readmission is concerning, although not surprising," she added.
However, she added, it is not possible to determine from these findings the appropriateness or inappropriateness of polypharmacy in this patient population. Nevertheless, she said, this research does highlight the need for clinicians to carefully weigh the risks and benefits of prescribing multiple psychotropic medications, particularly in such a vulnerable population.
Under Pressure
Dr. Fontanella pointed out that under managed care, national psychiatric hospital readmission rates have gone up, whereas hospital length of stays have gone down. Managed care, she said, has put psychiatrists under a great deal of pressure to demonstrate symptom reduction in a very short period of time and may partially account for the high rate of medication changes and for the fact that medication (vs psychotherapy) is now the mainstay of inpatient treatment.
"Back in the 1980s, we used to keep kids in the hospital for several months to monitor treatment effects and progress, but this is no longer the case," said Dr. Fontanella.
Depending on the medication, it can take up to 6 weeks before a drug takes effect, so it is possible that, because psychiatrists do not have the luxury of time to titrate and accurately gauge medication efficacy, this is contributing to the high rate of medication change observed in the study, said Dr. Fontanella.
Ultimately, she added, if early readmission rates continue to rise, reduced hospital stays mandated by managed care may prove to be a false economy.
She added that there is an urgent need for standardized decision-making tools that cover the entire spectrum of in-hospital treatment, follow-up, and aftercare for suicidal adolescents.
The investigators' next research steps include taking a more detailed look at polypharmacy and developing a better understanding of this phenomenon.
"We need more studies looking at the effectiveness of inpatient care and the effectiveness in reductions in lengths of stays and how that ultimately affects quality of care," said Dr. Fontanella.
The authors have disclosed no relevant financial relationships.
American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract: 3.34. Presented October 29, 2009.
Posted by floatingbridge on December 8, 2009, at 22:21:26
In reply to Adolescent Readmission Rate Linked To Polypharmacy, posted by Phillipa on December 8, 2009, at 21:21:02
Interesting read, Phillipa--thanks! Children's and young adult brains are sooooo different--and under-studied.
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Posted by bleauberry on December 9, 2009, at 17:21:52
In reply to Adolescent Readmission Rate Linked To Polypharmacy, posted by Phillipa on December 8, 2009, at 21:21:02
Well, not popular or even thought of by many, but I happen to believe the adolescent brain is not all that different than the adult brain. Different yes, but not that different. Not enough different to have a black box warning only for adolescents but not for adults.
It's a pharmaceutical industry political thing that has spun the story the way it is. Reality is, it happens across all age groups. It's not as if the brain magically changes stature at age 18 or whatever. For some, it might be age 8, for others, age 12, for others, age 21, for others age 35, and so on. To try to say that all people's brains follow a definable pattern on a reliable timeframe is ludicracy as I see it.
Just thinking back on the people in the worst condition here at pbabble over the last 12 or 15 years I've been hanging out here, they all had pretty much one thing in common...out-of-control polypharmacy of at least 3 drugs but sometimes more, sometimes up to 7. The ones that seemed to get people in deep water that was hard to get out of were the mood stabilizers, antipsychotics, and designer off-label drugs. That said, an antipsychotic was pretty good to me for a number of years...though I regret it now. Generally speaking of course.
Likewise, the longterm sufferers who ended up with happy endings did so usually with 1 to 3 med combos, usually just 2. The STAR*D program also achieved high remission rates with just 2 meds.
When I see people pile one new med on top of several that already are not working, if you could see my face, you would see a grimace and a worry.
My realistic logic says polypharmacy for anyone should be approached with respect, and a continual weeding process that removes the underperformers or the ones that cause deterioration before the situation gets bad enough for a so-called readmission.
The readmission in my opinion is not the patient's fault, not the disease's fault, and not the medicine's fault. It is the fault of poor medication choice and poor medication management combined for a knockout punch. It was the doctor's fault. They were the ones in charge of the whole mess, from beginning to readmission.
Posted by linkadge on December 9, 2009, at 17:48:12
In reply to Re: Adolescent Readmission Rate Linked To Polypharmacy, posted by bleauberry on December 9, 2009, at 17:21:52
Well more meds clearly are not necessarily any better. I remember leaving the hospital on like 5 meds. I started to feel better as I came off the meds.
Linkadge
Posted by Phillipa on December 9, 2009, at 18:23:23
In reply to Re: Adolescent Readmission Rate Linked To Polypharmacy, posted by linkadge on December 9, 2009, at 17:48:12
Less is better but cringe when think of when the doc tried an ad on my Grandson and he was knocking boxes over in a store when he walked. Taken off the med and never needed another one. I just don't believe in meds for kids with exception of ADD meds. My personal opinion. Theraphy first as so many factors come into play with hormones and the adolescent period. Till fully developed. Even height and weight are not complete until at least 18. Phillipa
Posted by floatingbridge on December 12, 2009, at 4:42:17
In reply to Re: Adolescent Readmission Rate Linked To Polypharmacy, posted by Phillipa on December 9, 2009, at 18:23:23
> Less is better but cringe when think of when the doc tried an ad on my Grandson and he was knocking boxes over in a store when he walked. Taken off the med and never needed another one. I just don't believe in meds for kids with exception of ADD meds. My personal opinion. Theraphy first as so many factors come into play with hormones and the adolescent period. Till fully developed. Even height and weight are not complete until at least 18. Phillipa
Well, I could have used one in my early teens. Sigh. Glad for your grandson though!
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