Antipsychotic Medication Standards: Our Recommendations to NCQA

Our  recent post introduced the opportunity that the National Committee for Quality Assurance (NCQA) is providing for comments on its proposed standards for “Safe and Judicious Use of Antipsychotics in Children and Adolescents.”

As promised, here are our responses to NCQA’s proposals.

Overall

We applaud the NCQA for establishing standards in an area where, as of now, there are none.  “Antipsychotics[1]” (APs) are powerful drugs that have well established adverse effects, including adverse effects that are common and severe and well as adverse effects that are uncommon but fatal.  It is clear beyond doubt that the AP drugs shorten the lives of frail old people in nursing homes; in fact the FDA requires “Black Box” warnings of that danger.  As for children, David Rubin, MD, co-director of Policy Lab at Children’s Hospital of Philadelphia, has warned of “emerging evidence that there are significant adverse effects that may be worse in youth than in adults.”[2]  Very few classes of drugs are more urgent candidates for the application of treatment standards than are “antipsychotics.

1.    Use of Higher-Than-Recommended Doses of Antipsychotics in Children and Adolescents

The NCQA proposes to measure “the percentage of children and adolescents 0- [through]17 years of age who were on antipsychotic medication and who received two or more antipsychotic medications with higher-than-recommended doses.” We are pleased that NCQA intends to discourage high dosages.

We wish that NCQA were more restrictive in what it considers a “high” dose.  For example, the NCQA would count a prescription of quetiapine fumarate (Risperdal) as a “high” dosage only if it were greater than 600 mg per day for adolescents 13 through 17 years old.  But 600 mg/day is a typical adult dosage.  Adolescents are not adults.  Their bodies and their brains are still growing.  Virtually no data is available concerning long-term effects of “antipsychotic” drugs on children or adolescents.  Do people exposed to AP drugs as children experience better or worse outcomes as adults?  No one knows.

Perhaps most important, children and adolescents often have no opportunity to discontinue psychotropic drugs if they suffer severe adverse effects.  Adults usually do have that alternative, and they very frequently exercise it.  Such data as exists for the long-term effects of AP drugs on adults is almost always based on a fraction of the adults who began to take the drug: the fraction that chose to continue taking the drug long-term.

In addition, we would like to see NCQA count any administration of AP drugs to children younger than 6 years as excessive.

2.    Use of Multiple Concurrent Antipsychotics in Children and Adolescents   

The NCQA proposes to assess polypharmacy—multiple AP drugs at the same time—as a sign of poor performance on the part of the health care providing organization.  We are among the many who will applaud this standard.  If we were in the mood for self-medication, we might order a beer.  We would not recommend supplementing it with whiskey, wine and brandy, nor with other sedative substances such as barbiturates, opiates or “antipsychotics.”  Analogous polypharmaceutical experimentation with multiple AP drugs is not good science or good medical practice.

3.    Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

The NCQA proposes to count it as a positive when the first efforts to deal with problem behavior in children are psychosocial, not pharmaceutical.  We strongly agree.  In fact, virtually everyone strongly agrees—in theory.  Practice is something else altogether.  Measuring this dimension of health care providers’ performance should help to bring theory and practice into closer alignment.

4.    Follow-Up Visit(s) for Children and Adolescents on Antipsychotics.

The NCQA proposes to count it as a positive when a child on AP drugs has at least one follow-up visit with a prescriber.

We agree, but we wish that the NCQA would measure regular follow-ups, not just a single return to the prescriber.  The NCQA seems to be focused on adverse metabolic effects such as major weight gain, neurological damage resulting in uncontrolled movements (tardive dyskinesia, akathisia, etc.), sedation, somnolence, liver toxicity, and cardiac arrhythmias.  We would like to see the NCQA focus also on children’s behavior as assessed at follow-up visits.  If the child’s behavior has improved, “safe and judicious” treatment would mean reducing the dosage or discontinuing the drug entirely.

5.    Metabolic Screening for Children and Adolescents Newly on Antipsychotics

The NCQA plans to grant credit for metabolic screening as a positive measure of quality.  In other words, it wants to see tests for blood glucose and blood cholesterol or LDL-C.  Such tests can warn prescribers that continuation of the drug runs a serious risk of causing diabetes.

We agree.  We regret only that this standard was not implemented years ago.  Many of the “antipsychotics” have outlived their patent protection or are about to do so.  A great many children have been endangered by the years of delay, and many billions of dollars have been spent on AP drugs that would have been discontinued when metabolic screening flashed red—not even counting the billions of dollars that will be spent in efforts to mitigate the effects of diabetes in the former children, now adults, who will suffer with drug-induced Type II diabetes throughout the remainder of their lives and ours.


[1] We use quotation marks here because in current practice the drugs are prescribed mainly for people who are not psychotic, and that is especially true for children.

[2] Quoted in Jacobson, R., Should children take antipsychotic drugs? Scientific American (March 1, 2014).  (http://www.scientificamerican.com/articles/should-children-take-antipsychotic-drugs/?&WT.mc_id=SA_HLTH_20140218)

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