In a recently released issue of Pediatrics(10.1542/peds.2019-2705), Dr. Susan dosReis and colleagues examine a pressing clinical question and come to a concerning conclusion. The authors aimed to identify clusters of family adversity, including parental disability, mental health disorder and socioeconomic status, that are associated with risk of youth psychotropic polypharmacy. The authors used the 2009-2015 Medical Expenditure Panel Survey (MEPS) data to describe the family characteristics of 5,136 index youth who were diagnosed with mental health and behavioral disorders. The MEPS database is built from a national household survey that utilizes 5 rounds of interviews over the course of 2 years to collect a broad range of family information including health status and expenditures, demographics and economic level. Polypharmacy for the index youth was defined as treatment with 3 or more psychotropic medication classes (e.g. antipsychotics, antidepressants, stimulants, mood stabilizers) at any one interview round within one year. The authors used an interesting statistical method called “K-means cluster analysis” to categorize mutually exclusive groups of families with similar adversity profiles: 4 groups were ultimately identified among the families of the index youth.
Most youth (69.6%) had a disruptive behavior disorder: this category included attention deficit disorder, anxiety, oppositional defiant disorder, conduct disorders and adjustment disorders. The next most prevalent condition among the index youth was mood disorder (14.3%), which included depression and bipolar disorders. The 4 family clusters ranged from an advantaged group with 2 well-educated parents and a high income to a meaningfully disadvantaged group with predominantly 2 parent households but low income and high school or less education. In this disadvantaged family cluster, 67.0% of parents had a serious disability, 74.8% had a mental illness and 94.1% had at least one parent with some disability and mental illness. Psychotropic polypharmacy was experienced by 4.2% of youth in this heavily disadvantaged family cluster, and the odds of polypharmacy were 2.7 greater (95% CI 1.1-6.4) for these youth than those in the most advantaged group.
There just isn’t a way to see these results in a positive light. Parents who are struggling the most themselves are tasked with supervising medical treatments that put their children at risk for worrisome side effects including suicidality and metabolic syndrome, as well as undertreatment of the underlying condition. The authors point out that psychological treatments may not be prescribed when parents cannot make appointments regularly, do not have access to such care, or are not coached to support the therapist’s work. Hence medication treatment reigns, and there is no reason to believe youth benefit. Parents of children on psychotropic polypharmacy may not believe “talking treatments” work, and case managers, social workers and physicians erroneously accept this unacceptable state of affairs as “reasonable” given the extraordinary mental health burden the youth bears. We have no excuse to tolerate psychotropic polypharmacy, and must engage with other professionals and with parents to find a different path forward. This won’t be easy, but the bare facts that Dr. dosReis and colleagues reveal to us are a call to action for all of us serving youth from highly disadvantaged homes who have emotional and behavioral disorders.
