Abstract
Background
Methods
Results
Conclusions
Keywords
Rutgers University Institute for Health, Health Care Policy, and Aging. Accelerating utilization of comparative effectiveness findings in Medicaid mental health: Medicaid Network for Evidence-based Treatment (MEDNET). Available at: http://www.academyhealth.org/files/FileDownloads/MEDNET.pdf. Accessed April 3, 2014.
Center for Health Care Strategies Inc. Improving the use of psychotropic medication among children and youth in foster care: a quality improvement collaborative. Available at: http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326. Accessed April 3, 2014.
Methods
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013.
Abbreviated Name | Sponsoring Organization and Guideline Title | Year | Population | Brief Description |
---|---|---|---|---|
AACAP-AAA | AACAP—Practice parameter for the use of atypical antipsychotic medications in children and adolescents 23 American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012. | 2011 Web | 5–18 y | 19 recommendations on the use of atypical antipsychotics in children, rated using AACAP rating system. |
AACAP-PsyMed | AACAP—Practice parameter on the use of psychotropic medication in children and adolescents 24 | 2009 | ≤18 y | 13 best practice principles that underlie psychotropic medication prescribing for children (unrated). |
AACAP-BP | AACAP—Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 17 | 2007 | ≤18 y, bipolar disorder | 11 recommendations on the treatment of bipolar disorder in children, rated using AACAP rating system. |
AACAP-ODD | AACAP—Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder 18 | 2007 | ≤18 y, oppositional defiant disorder | 11 recommendations on the treatment of oppositional defiant disorder, rated using AACAP rating system. |
AACAP-SZ | AACAP—Practice parameter for the assessment and treatment of children and adolescents with schizophrenia 25 | 2001 | ≤18 y, schizophrenia | Recommendations are embedded within a summary of the literature on treatment of schizophrenia in children, with some recommendations rated using AACAP system. |
CAMESA | CAMESA—Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children—Evidence-based recommendations for monitoring safety of second generation antipsychotics in children and youth 19 | 2011 | ≤18 y, on antipsychotic | Monitoring tests for children on antipsychotics are rated for SOR and SOE for 10 laboratory and 6 physical examination tests for each of 6 atypical antipsychotics, at 4 time points (baseline, 3, 6, and 12 mo) using the GRADE 29 , 33 system (total of 384 rated recommendations). |
PPWG | AACAP-sponsored Preschool Psychopharmacology Working Group—Psychopharmacological treatment for very young children: Contexts and guidelines 21 | 2007 | <6 y | 9 treatment algorithms for the treatment of 9 diagnoses in preschool aged children with rated recommendations for each stage of the algorithm using an adaptation of the AACAP rating system. |
TRAAY | Center for the Advancement of Children's Mental Health—Treatment recommendations for the use of antipsychotics for aggressive youth 22 | 2003 | ≤18 y, aggression | 14 recommendations on the use of antipsychotics in the treatment of aggression in youth. Formal consensus methods are used and recommendations are unrated. |
T-MAY | Center for Education and Research on Mental Health Therapeutics—Treatment of maladaptive aggression in youth 20 | 2012 | ≤18 y, aggression | 20 recommendations on the treatment of aggression in children, with ratings of SOE using Oxford Centre for EBM grading of evidence system 34 and separate SOR ratings.OCEBM Levels of Evidence Working Group. The Oxford 2011 levels of evidence. Available at: http://www.cebm.net/index.aspx?o=5653. Accessed October 12, 2013. |
TX | Texas Department of Family and Protective Services—Psychotropic medication utilization parameters for foster children 26 Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013. | 2013 | Foster care | 9 psychotropic prescribing practices that trigger a clinical review for children in foster care in Texas (unrated). |
APA-CW | American Psychiatric Association—Choosing Wisely 27 American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013. | 2013 | Children and adults | 5 questionable antipsychotic prescribing practices for children and adults, based on formal consensus methods (modified Delphi, >70% agreement). |
Guidelines | Rating System | Rating Definition | |||
---|---|---|---|---|---|
Strong/Highest Rating | Moderate Rating | Weak Rating | Not Endorsed | ||
AACAP-AAA, AACAP-BP AACAP-ODD, AACAP-SZ | AACAP rating system | Minimal standard/clinical standard: Rigorous/substantial empirical evidence (meta-analyses, systematic reviews, RCTs) and/or overwhelming clinical consensus; expected to apply more than 95% percent of the time | Clinical guideline: Strong empirical evidence (nonrandomized controlled trials, cohort or case-control studies), and/or strong clinical consensus; expected to apply in most cases (75% of the time) | Options: Acceptable but not required; there may be insufficient evidence to support higher recommendation (uncontrolled trials, case/series reports) | Not endorsed: Ineffective or contraindicated |
CAMESA | GRADE 29 system (includes SOR and SOE ratings) | SOR strong: 1A, 1B, 1C | SOR weak: 2A, 2B, 3 | ||
SOE high: 1A, 2A | SOE moderate: 2A | SOE low: 1C, 2B, 3 | |||
PPWG | Adaptation of AACAP rating system | A: Well-controlled RCTs, large meta-analyses, or overwhelming clinical consensus | B: Empirical evidence (open trials, case series) or strong clinical consensus | C: Single case reports or no published reports, recommendation developed by expert consensus (informal) | |
T-MAY | Oxford Centre for EBM grading of evidence (A-D) system 34 for SOE and separate SOR ratingsOCEBM Levels of Evidence Working Group. The Oxford 2011 levels of evidence. Available at: http://www.cebm.net/index.aspx?o=5653. Accessed October 12, 2013. | SOR very strong: ≥90% agreement | SOR strong: 70–89% agreement | SOR fair: 50–69% agreement | SOR weak: <50% agreement |
SOE A: Consistent level 1 studies (eg, RCT) | SOE B: Consistent level 2 or 3 studies (eg, cohort or case control studies) or extrapolations from level 1 studies, B | SOE C: Level 4 studies (eg, case studies) or extrapolations from level 2 or 3 studies | SOE D: Level 5 evidence (eg, expert opinion without explicit critical appraisal) or troublingly inconsistent or inconclusive studies of any level |
Results
Guideline | Strength of Recommendation and Evidence Ratings by Antipsychotic Measure Concept | ||||||
---|---|---|---|---|---|---|---|
Use in Very Young Children | Multiple Concurrent Antipsychotics | Higher Than Recommended Doses | Use Without a Primary Indication | Access to Psychosocial Interventions | Metabolic Screening | Follow-up Visit With Prescriber | |
AACAP-AAA | Strong | Strong | Moderate | Strong | Strong | Strong | Strong |
AACAP-PsyMed | Unrated | Unrated | |||||
AACAP-BP | Strong | Strong | Strong | ||||
AACAP-ODD | Moderate | Strong | |||||
AACAP-SZ | Strong | Strong | Strong | Strong | |||
CAMESA | Strong (SOR) ‡ , high (SOE)CPG ratings were categorized as strong/high, moderate, or weak to facilitate comparisons across guidelines (see Table 2). Most guideline rating systems did not rate strength of recommendation and evidence separately. To be conservative, we consider all ratings as SOR unless it is specified that the rating is for SOE. ‡ CPG ratings were categorized as strong/high, moderate, or weak to facilitate comparisons across guidelines (see Table 2). Most guideline rating systems did not rate strength of recommendation and evidence separately. To be conservative, we consider all ratings as SOR unless it is specified that the rating is for SOE. | ||||||
PPWG | Strong–weak | Strong–weak | Strong–weak | Unrated | Unrated | ||
TRAAY | Unrated | Unrated | Unrated | Unrated | |||
T-MAY | Strong (SOR), weak (SOE) | Unrated | Unrated | Strong (SOR), high (SOE) | Strong (SOR), high (SOE) | ||
TX | Unrated | Unrated | Unrated | Unrated | Unrated | Unrated | |
APA-CW | Unrated | ||||||
Totals | |||||||
CPG with recommendation | 3 | 4 | 5 | 7 | 7 | 8 | 6 |
CPG with rated recommendation | 2 | 2 | 2 | 3 | 6 | 5 | 3 |
CPGs with SOR = strong | 2 | 2 | 1 | 2 | 6 | 5 | 3 |
CPGs with SOE = strong | 0 | 0 | 0 | 0 | 1 | 2 | 0 |
Use of Antipsychotics in Very Young Children
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
Use of 2 or More Concurrent Antipsychotics
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
High Doses of Antipsychotics
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
Use of Antipsychotics without a Primary Indication
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Psychiatric Association. Choosing Wisely. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/. Accessed October 21, 2013.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Psychosocial Services
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Metabolic Screening
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Follow-up Visits
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Texas Department of Family and Protective Services and University of Texas at Austin College of Pharmacy. Psychotropic medication utilization parameters for foster children. Available at: http://www.dfps.state.tx.us/documents/Child_Protection/pdf/TxFosterCareParameters-September2013.pdf. Accessed October 22, 2013.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of atypical antipsychotic medications in children and adolescents. Available at: http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed July 12, 2012.
Discussion
Rutgers University Institute for Health, Health Care Policy, and Aging. Accelerating utilization of comparative effectiveness findings in Medicaid mental health: Medicaid Network for Evidence-based Treatment (MEDNET). Available at: http://www.academyhealth.org/files/FileDownloads/MEDNET.pdf. Accessed April 3, 2014.
Center for Health Care Strategies Inc. Improving the use of psychotropic medication among children and youth in foster care: a quality improvement collaborative. Available at: http://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326. Accessed April 3, 2014.
National Quality Forum. Review and update of guidance for evaluating evidence and measure testing: draft technical report. NQF Technical Report. October 2, 2013. Available at: http://www.qualityforum.org/Publications/2013/10/Review_and_Update_of_Guidance_for_Evaluating_Evidence_and_Measure_Testing_-_Technical_Report.aspx. Accessed February 10, 2014.
National Quality Forum. Review and update of guidance for evaluating evidence and measure testing: draft technical report. NQF Technical Report. October 2, 2013. Available at: http://www.qualityforum.org/Publications/2013/10/Review_and_Update_of_Guidance_for_Evaluating_Evidence_and_Measure_Testing_-_Technical_Report.aspx. Accessed February 10, 2014.
Acknowledgments
Supplementary Data
- Online Supplement A
- Online Supplement B
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Article Info
Publication History
Footnotes
Dr Hoagwood, Dr Kelleher, Dr Kealey, and Dr Leckman-Westin report no conflicts of interest. Dr Finnerty has been the PI on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is in kind. Dr Scholle and Ms Byron work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures.
Publication of this article was supported by the US Department of Health and Human Services and the Agency for Healthcare Research and Quality.
The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services or the Agency for Healthcare Research and Quality.