Factors That Predict the Use of Psychotropics Among Children and Adolescents With PTSD: Evidence From Private Insurance Claims
Abstract
Objective:
This study aimed to determine which characteristics of youths with posttraumatic stress disorder (PTSD) were associated with receiving prescriptions for antidepressants, antipsychotics, or benzodiazepines.
Methods:
A 2011–2012 retrospective cohort of children and adolescents with a new episode of PTSD was extracted from medical and pharmacy claims from a nationally representative sample of privately insured persons. Multivariate logistic regression assessed attributes (demographic characteristics, mental and general medical comorbidities, insurance arrangements, specialty type, and geographic location) associated with utilization of antidepressants, antipsychotics, and benzodiazepines.
Results:
Among 7,726 youths with a new episode of PTSD in 2012, just less than 60% received psychotherapy alone, about 6% received pharmacotherapy, and about 35% received neither psychotherapy nor pharmacotherapy. Among utilizers of medications, 71.3% used antidepressants and 21.6% used antipsychotics. Youths prescribed medication tended to be older and have more general medical and mental comorbidities. Provider specialty, capitated insurance arrangements, and more comorbidities predicted being prescribed antidepressants. History of hospitalization, noncapitated insurance arrangements, nonuse of psychotherapy, and more comorbidities predicted being prescribed antipsychotics. Antidepressants and antipsychotics were more likely to be used in the South.
Conclusions:
Only three-fifths of youths with PTSD received first-line treatment (psychotherapy). More than one in 20 received pharmacotherapy, which appeared to be associated with the most severe and complex presentations. More than one-third of youths with PTSD received neither therapy nor medication, signaling compromised quality of care. Future research should confirm the factors associated with pharmacotherapy prescription and explore ways to increase the use of psychotherapy in primary care.
Exposure to one or more major traumatic events, such as physical or sexual assault, accidents, emotional abuse, and natural disasters, may trigger the development of posttraumatic stress disorder (PTSD) among children and adolescents (1). According to DSM-5, PTSD symptoms include intrusive memories or re-experiencing of the traumatic event (nightmares and flashbacks), avoidance of reminders of the traumatic event, negative thoughts and feelings (memory problems and a distorted sense of blame), and hyperarousal (irritability, reckless behavior, difficulty concentrating, and sleep disturbance). Such broad symptomatology may adversely affect a child's age-appropriate development (2). According to point-prevalence estimates, PTSD affects between 3% and 15% of girls and between 1% and 6% of boys. The lifetime prevalence estimate is 8% for girls and 2.3% for boys (3). The latest estimates reported an overall pediatric PTSD prevalence of 15.9% (4,5).
Even though PTSD is becoming a more common pediatric diagnosis, most of the treatment evidence comes from adult trials. Indeed, the bulk of research exploring PTSD treatment options relies almost entirely on war veterans and adult disaster victims (6). This evidence suggests that psychotherapy has superior clinical effectiveness in treating PTSD compared with pharmacotherapy (7–9). For severe cases, the combination of psychotherapy and pharmacotherapy may work best (10,11). Pediatric PTSD treatment guidelines (including those from the American Academy of Child and Adolescent Psychiatry) agree on the appropriateness of psychotherapy, particularly trauma-focused cognitive-behavioral therapy (TF-CBT) as the first-line treatment (12). This recommendation was based upon multiple systematic reviews and meta-analyses that demonstrated large effect sizes (.8–.9) for psychotherapy (13–15). The favorable effects of psychotherapy for youths pertained across a wide range of traumatic exposures, including sexual and physical abuse, war, accidents, sickness, and natural disasters, and were shown to be durable for up to one year (8,13). Yet psychotherapy remains underused in primary care settings (14,15), where expertise in this treatment modality may be limited.
In contrast to psychotherapy, pharmacotherapy for pediatric PTSD lacks rigorous empirical support (16–18), and—as such—the Food and Drug Administration (FDA) has not granted approval for use of any medication among children and adolescents for this indication. The only randomized trials of a psychotropic medication (sertraline, an antidepressant) for the treatment of pediatric PTSD failed to demonstrate significant beneficial effects, either as monotherapy or as an adjunctive treatment to psychotherapy (19,20). Medications from other classes have only low-quality evidence of effectiveness for PTSD (8,13). Although these medications, including alpha-agonists (guanfacine [16,21] and clonidine [17,18]), antipsychotics (risperidone [22] and quetiapine [23]), mood stabilizers (carbamazepine [24] and divalproex [25]), an alpha-antagonist (prazosin [26]), and a beta blocker (propranolol [27,28]), have shown potential efficacy in case reports and uncontrolled trials, stronger evidence is needed to support a first-line treatment recommendation (29,30).
To date, little is known about the prevalence of psychotropic prescribing for PTSD among children and adolescents in the United States. If common, this practice would be concerning, given that it is associated with significant side effects and limited efficacy, hardly a favorable risk-benefit ratio (31,32). Similarly, little is known about the factors associated with the use of pharmacotherapy for PTSD among youths, including characteristics of patients and of practice settings, such as primary versus specialty care and geographic location (33).
For pharmaceuticals, evidence from adult veterans enrolled in Veterans Affairs clinics suggest that most (80%) veterans who receive pharmacotherapy for PTSD are treated in specialty mental health clinics, and only 13% are treated exclusively in primary care (34). Also, ruling out random noise, geographic variation in pharmacotherapy for PTSD among adults is substantial, pervasive, and persistent (35). Yet this important research agenda, identified more than 20 years ago, remains underexplored (31).
This study is one of the first that aims to determine the utilization of three classes of commonly prescribed psychotropic medications—antidepressants, benzodiazepines, and antipsychotics—in a national sample of children and adolescents with diagnosed PTSD and to identify the patient and setting factors that significantly predict the use of these medications by these youths.
Methods
Study Design
We conducted a retrospective cohort analysis with data from the MarketScan Commercial Claims and Encounter database for children and adolescents (ages six to 18) who received a new diagnosis of PTSD between January 1 and December 31, 2012. The Boston Medical Center Institutional Review Board considered this data source as de-identified, and the study was exempted from review.
Data Source
The Truven MarketScan claims database offers information on more than 200 million unique patients (including employees, spouses, and dependents) since 1995. It allows the creation of a nationally representative data sample of Americans with employer-provided health insurance. The commercial claims are collected from small and large employers and health plans. Data comprise service-level claims for inpatient and outpatient services and outpatient prescription drugs. All claims have been paid and adjudicated.
Study Population
The index date was defined as the date of the first PTSD-related outpatient medication claim during the index period (January 1, 2012, to December 31, 2012). The preindex period included the six months prior to the index date.
The inclusion criteria included age between six and 18 years at the index date; a new diagnosis of PTSD (ICD-9 code 309.81) at the index date, with no PTSD claims during the preindex period (36); at least two PTSD-related outpatient claims or one PTSD-related outpatient claim and one PTSD-related medication claim during the index period; and insurance coverage for at least 12 months after the index date and during the preindex period (18 months total). Individuals were excluded if they had a comorbidity that would legitimize the use of antidepressants, benzodiazepines, or antipsychotics (bipolar disorder [296.0x, 296.4x], schizophrenia [295.6x], depressive disorders [296.2x or 296.3x and 300.4 or 311], and mixed psychotic disorders [e.g., depressive-type psychosis]) or a PTSD diagnosis or a PTSD-related medication claim during the preindex period. This approach allowed us to capture new PTSD episodes.
Measurement and Outcomes
Patient characteristics such as sex, age, region, insurance arrangement, provider specialty, hospitalization history, patient complexity, and history of psychotherapy were included. Patients were divided into two groups by age: children ages six to 11 and adolescents ages 12 to 17. Four geographic regions of the Unites States were analyzed (Northeast, Midwest, South, and West). Insurance arrangements were categorized as follows: health maintenance organization (HMO) and point-of-service (POS) with capitation, noncapitated POS, high-deductible plan, noncapitated preferred provider organization (PPO), and comprehensive plan.
Provider specialties were divided in two groups: mental health providers (MHPs) (psychiatrists, psychiatric nurses, and psychologists) and primary care providers (PCPs) (internists, pediatricians, family physicians, general practitioners, and medical nurses). History of hospitalization was defined as having an inpatient claim during the 12 months prior to the index date. PTSD-related psychotherapy was identified as receiving psychotherapy within 30 days of the index date. We used this approach to capture the most common clinical practice (psychotherapy is provided after the hospitalization [32]) rather than searching for the evidence-based recommendation (psychotherapy is the first line of treatment). Having multiple mental conditions has been associated with poorer outcomes and higher mortality and morbidity rates (37,38). Hence, to assess complexity, we constructed a complexity index grouping four psychiatric comorbidities common with PTSD (anxiety, disruptive behavior, dissociative conditions, and suicidal ideation). To account for general medical comorbidities, we utilized the Elixhauser Index, developed for use with large administrative databases (39). The general medical index identifies 31 unweighted comorbidity indicators by scanning diagnosis-related groups and secondary ICD-9 codes (40). Medication data were extracted from the outpatient pharmacy claims by using the National Drug Code. Medication was categorized in three mutually exclusive groups (antidepressants, benzodiazepines, and antipsychotics).
Data Analysis
We calculated frequency of prescriptions in the three medication classes for all individuals with at least one prescription. For univariate analysis, we compared continuous data by using t tests and categorical variables by using chi-square tests. Logistic regression models were developed to predict two dependent variables: odds of receiving an antidepressant (versus no medication) and odds of receiving an antipsychotic (versus no medication). Each dependent variable was regressed on sex, age, region, insurance arrangement, provider specialty, hospitalization history, patient complexity, and history of psychotherapy. The weighted estimates were calculated based on a probabilistic nationally representative sample. All analyses were performed with person-level national weights constructed with the Medical Expenditure Panel Survey (MEPS), which provides estimates of the number of people with employer-sponsored private health insurance in the United States.
The person-level weights reflect the ratio of MEPS-based estimates in four categories: sex, age, region, and insurance arrangement. We used the SAS raking macro, developed by Izrael et al. (41), to adjust the Truven database marginal totals. Hence our results are representative of the privately insured population in the United States in terms of sex, age, region, and insurance arrangement. We inspected collinearity by the variance inflation factor criteria (<10). The models were evaluated by using c statistics for discrimination, Akaike information criterion and the Hosmer-Lemeshow test for goodness of fit, and bootstrapping to assess the internal validity of the coefficients. All statistical analysis was performed with SAS, version 9.3.
Results
A total of 13,818 pediatric patients with PTSD were identified. Among them, 7,726 met our inclusion and exclusion criteria. Overall, 5.9% of youths received pharmacotherapy, 59.0% received psychotherapy alone, 2.7% received combination treatment (psychotherapy and pharmacotherapy), and 35.2% received neither psychotherapy nor pharmacotherapy. Of those receiving pharmacotherapy, 71.3% received antidepressants, 21.6% received antipsychotics, and 7.1% received benzodiazepines (Table 1).
| Treatment | N | % |
|---|---|---|
| Psychotherapy only | 4,556 | 59.0 |
| Psychotherapy and pharmacotherapy | 209 | 2.7 |
| Pharmacotherapy only | 244 | 3.2 |
| No psychotherapy or pharmacotherapy | 2,717 | 35.2 |
| Any pharmacotherapy | 453 | 5.9 |
| Antidepressants | 323 | 71.3 |
| Antipsychotics | 98 | 21.6 |
| Benzodiazepines | 32 | 7.1 |
The baseline characteristics of youths who received pharmacotherapy were significantly different from those who did not. Youths in the pharmacotherapy group tended to be older, to be female, to live in the South, to reside in rural areas, to be insured under capitated arrangements, and to be treated by MHPs. They also tended to have been previously hospitalized and, on average, had a larger number of comorbidities (data available upon request).
Table 2 summarizes the demographic characteristics of youths who received a medication and the results of univariate assessment comparing patient characteristics by medication class. The mean±SD age of medication recipients was 14.0±2.8. Those who received benzodiazepines were older (mean age=15.2±1.8) than those who received antipsychotics (13.1±3.0) and antidepressants (14.1±2.7). Children received antipsychotics more often (27.6%) than antidepressants or benzodiazepines (17.7% and 6.3% respectively). Almost all use of benzodiazepines was by adolescents (93.8%). In terms of gender, females accounted for about three-fourths of benzodiazepine and antidepressant users, compared with 59.2% of users of antipsychotics. For insurance type, use of antidepressants was highest among individuals with PPO coverage (54.6%), whereas use of benzodiazepines was highest among people covered by an HMO (31.3%). Other predictors such as area of residence, region, use of psychotherapy, and provider type were evenly distributed across medication types.
| Total (N=453) | Benzodiazepines (N=32) | Antipsychotics (N=98) | Antidepressants (N=323) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | N | % | N | % | N | % | N | % | p |
| Age (M±SD) | 14.0±2.8 | 15.2±1.8 | 13.1±3.0 | 14.1±2.7 | <.001 | ||||
| Age group | .011 | ||||||||
| 6–11 (children) | 86 | 19 | 2 | 6.3 | 27 | 27.6 | 57 | 17.7 | |
| 14–17 (adolescents) | 367 | 81 | 30 | 93.8 | 71 | 72.5 | 266 | 82.4 | |
| Sex | .030 | ||||||||
| Male | 136 | 30 | 8 | 25 | 40 | 40.8 | 88 | 27.2 | |
| Female | 317 | 70 | 24 | 75 | 58 | 59.2 | 235 | 72.8 | |
| Region | .573 | ||||||||
| Northeast | 58 | 13.2 | 6 | 18.8 | 11 | 12 | 41 | 12.9 | |
| Midwest | 132 | 29.9 | 8 | 25 | 30 | 32.6 | 94 | 29.7 | |
| South | 134 | 30.4 | 7 | 21.9 | 32 | 34.9 | 95 | 30 | |
| West | 117 | 26.5 | 11 | 34.8 | 19 | 20.7 | 87 | 27.4 | |
| Urban | .313 | ||||||||
| Yes | 384 | 85.3 | 28 | 87.5 | 88 | 89.9 | 268 | 83.8 | |
| No | 66 | 14.7 | 4 | 12.5 | 10 | 10.2 | 52 | 16.3 | |
| Insurance arrangement | .010 | ||||||||
| Fee for service | 16 | 3.6 | 1 | 3.1 | 3 | 3.1 | 12 | 3.8 | |
| HMO and POS with capitation | 115 | 25.8 | 10 | 31.3 | 19 | 19.8 | 86 | 27.1 | |
| Noncapitated POS | 39 | 8.8 | 5 | 15.6 | 17 | 17.7 | 17 | 5.4 | |
| PPO | 230 | 51.7 | 13 | 40.6 | 44 | 45.8 | 173 | 54.6 | |
| High-deductible plan | 45 | 10.1 | 3 | 9.4 | 13 | 13.5 | 29 | 9.2 | |
| Provider type | .780 | ||||||||
| MHP | 155 | 83.8 | 9 | 81.8 | 33 | 80.5 | 113 | 85 | |
| PCP | 30 | 16.2 | 2 | 18.2 | 8 | 19.5 | 20 | 15 | |
| Hospitalization history | .025 | ||||||||
| Yes | 81 | 18.9 | 7 | 21.9 | 26 | 26.5 | 48 | 14.9 | |
| No | 372 | 82.1 | 25 | 78.1 | 72 | 73.5 | 275 | 85.1 | |
| Psychotherapy | .387 | ||||||||
| Yes | 287 | 63.4 | 19 | 59.4 | 57 | 58.2 | 211 | 65.3 | |
| No | 166 | 36.6 | 13 | 40.6 | 41 | 41.8 | 112 | 34.7 | |
a
Means were compared by analysis of variance, and proportions were compared by chi-square tests. HMO, health maintenance organization; POS, point of service; PPO, preferred provider organization; MHP, mental health provider; PCP, primary care provider
Table 3 reports the adjusted independent predictors of receiving a prescription for antidepressants. First, provider specialty had the strongest association with antidepressant use (OR=3.13). For age, children under age 12 were less likely than adolescents to receive antidepressants (OR=.49). Geographically, providers in Northeastern and Western regions were less likely than those located in the South to prescribe antidepressants. For insurance arrangements, persons at PPOs and high-deductible plans were less likely to receive antidepressants compared with those under capitated HMO/POS plans. Last, the number of medical comorbidities, as measured by the Elixhauser severity index, was significantly higher for youths receiving antidepressants (OR=2.34).
| Predictor | OR | 95% CI |
|---|---|---|
| Sex (reference: male) | 1.23 | .78–1.93 |
| Age group (reference: 12–17) | ||
| 6–11 | .49 | .29–.82* |
| Region (reference: south) | ||
| Midwest | 1.05 | .63–1.78 |
| Northeast | .29 | .15–.58** |
| West | .50 | .29–.87** |
| Insurance arrangement (reference: HMO) | ||
| Fee for service | 2.91 | .83–10.19 |
| High-deductible plan | .36 | .15–.85** |
| Noncapitated POS | .56 | .21–1.48 |
| PPO | .40 | .24–.67** |
| History of hospitalization (reference: no) | 1.10 | .60–2.02 |
| Mental health provider (reference: primary care provider) | 3.13 | 1.80–5.43** |
| Elixhauser Index of medical comorbidities | 2.34 | 1.82–3.01** |
| Psychiatric comorbidities | 1.45 | .87–2.42 |
| Psychotherapy (reference: no) | .77 | .50–1.19 |
a
Multivariate model (reference=no medication); c statistic=.811. MHP, mental health provider; PCP, primary care provider; HMO, health maintenance organization; POS, point of service; PPO, preferred provider organization
*
p=.05, **p=.001
Table 4 reports the adjusted independent predictors of receiving a prescription for antipsychotics. A history of hospitalization was the strongest predictor of antipsychotic use (OR=2.99). As was the case with antidepressants, the Northeast and West regions were less likely to use antipsychotics compared with the South. The Elixhauser severity index (more medical comorbidities) and the complexity index (more psychiatric comorbidities) were significantly higher among youths receiving antipsychotics. Last, the odds of receiving psychotherapy were lower for those receiving antipsychotics (OR=.49).
| Predictor | OR | 95% CI |
|---|---|---|
| Sex (reference: male) | .68 | .42–1.10 |
| Age group (reference: 12–17) | ||
| 6–11 | .74 | .42–1.30 |
| Region (reference: south) | ||
| Midwest | .77 | .43–1.39 |
| Northeast | .30 | .14–.64* |
| West | .51 | .27–.96* |
| Insurance arrangement (reference: HMO) | ||
| Fee for service | 2.49 | .66–9.49 |
| High-deductible plan | 1.89 | .80–4.42 |
| Noncapitated POS | 3.70 | 1.75–7.73* |
| PPO | .44 | .24– 83* |
| History of hospitalization | 2.99 | 1.67–5.35* |
| Elixhauser Index of medical comorbidities | 1.76 | 1.26–2.45* |
| Psychiatric comorbidities | 2.27 | 1.29–3.98* |
| Psychotherapy | .49 | .28–.84* |
a
Multivariate model (reference=no medication); c statistic= .805. MHP, mental health provider; PCP, primary care provider; HMO, health maintenance organization; POS, point of service; PPO, preferred provider organization
*
p=.05
The discrimination and goodness of fit were good for both models. After 100 bootstrapping iterations, the direction and magnitude of the estimates did not vary significantly, which suggested good internal validity for both models (data available upon request).
Discussion
To our knowledge, this may be the first large population-based study to identify frequency and predictors of various treatments for children and adolescents with PTSD. We noted several important findings. First, less than 10% of youths were treated with pharmacotherapy. Second, two-fifths of youths with PTSD did not receive psychotherapy, and more than one-third did not receive any treatment, which highlights an important treatment gap. As mentioned earlier, there is strong and consistent empirical support for the safety and effectiveness of psychotherapy, particularly TF-CBT, for PTSD (9,12–15,19). As such, psychotherapy is considered the first-line treatment for PTSD. On average, clinicians followed guidelines for treating PTSD among youths, given that few patients with PTSD were treated with off-label medications and over 60% received some sort of psychotherapy.
Second, more than one of every 20 youths with PTSD received pharmacotherapy, predominantly antidepressants (three-quarters of the medicated youths) and antipsychotics (one-fifth). Even though the FDA has not approved the use of any medication for pediatric PTSD (9,16–19,22–35), PTSD experts suggest that pharmacotherapy might be considered for more severe or complex presentations (12), a recommendation predominantly based upon experience with adults. The tendency to prescribe medication for more complex cases was confirmed in our findings. Youths receiving pharmacotherapy had, on average, more medical and psychiatric comorbidities. The main predictor of antidepressant use was MHP specialty type and for antipsychotics, the second strongest factor was a previous hospitalization history. These findings support a relationship between PTSD severity and complexity and psychotropic medication use.
Most providers who prescribed psychotropic medications chose antidepressants, which may reflect the symptom overlap between clinical depression and PTSD (e.g., for both disorders, negative mood and loss of pleasure or interest in usual activities are included in the diagnostic criteria). Hence, to opt for an antidepressant may reflect symptom-guided medication selection (42). Another reason for this decision may derive from the lack of alternative medications with a similar record of safety and effectiveness among youths. This is particularly relevant for antipsychotics and benzodiazepines, both of which are associated with significant side effects (19,28,29) and, for benzodiazepines, a risk of dependency (43).
In terms of provider specialty, more than 83% of youths who received medication were seen by an MHP. This finding matches adult use patterns (34). Interestingly, this finding contravenes patterns of use for other mental disorders, such as depression, given that most youths who are prescribed antidepressant medication receive the prescription from a PCP (44). Consequently, PCPs may be more empowered to deal with certain mental illnesses compared with others. With the migration of mental health care to primary care settings and the escalating shortages of MHPs around the country (45), this finding stands out. It suggests that there is a need to promote training and support to deal with PTSD more frequently in primary care settings.
Although the role of PCPs has evolved to include recognizing and addressing trauma exposure in families, there has been only a modest shift in practice to proactively identify and treat trauma exposure (46). The American Academy of Pediatrics suggests that PCPs can play several key roles in this regard (43). First, PCPs can familiarize themselves with screening instruments designed to facilitate the identification of PTSD. Several of these instruments assess the psychological response to traumatic exposure (47–49), whereas others identify risk factors for the development of PTSD (50,51). Early identification is important, given that studies suggest that early psychological intervention may avert the development of full-blown PTSD (52).
Second, PCPs can provide self-management tools to patients and families to enhance their ability to adaptively cope with stressful or traumatic circumstances. Even very brief educational interventions that are feasible to deliver in the primary care setting have been demonstrated to reduce the development of PTSD among youths (53). Third, PCPs can become knowledgeable about trauma-focused resources in their community and track referrals of youths with clinically significant symptoms of PTSD to ensure completion. These and other simple primary care interventions have been shown to favorably affect both clinical practices and patient outcomes (54,55).
Finally, PCPs considering the use of psychotropic medications to treat PTSD among children and adolescents would be well advised to seek specialist consultation. Payer-blind child and adolescent psychiatry (CAP) consultation programs have been launched in 27 states and the District of Columbia to facilitate on-demand PCP access to telephone and in-person CAP consultation, with emerging evidence of the ability of these programs to foster safe and effective psychotropic prescribing practices by PCPs (www.nncpap.org).
Finally, geographic variation in use of pharmacotherapy for PTSD remained significant after multivariable adjustment. The southern region utilized antipsychotics and antidepressants more often than northeast and western regions of the country. This effect may be explained by the large rural and urban poverty rate gap. In the South, historically, this gap has been the largest, averaging 5.1 percentage points over the past two decades (56). Also, rural poverty is deepest in certain parts of the south. This resource constraint acts as a disincentive to practice in these settings, greatly limiting the number of specialized mental health providers capable of offering effective psychosocial services.
Several limitations should be noted. First, our findings may not generalize to other types of insurance coverage. Second, we used billing records that may have underidentified patients with PTSD by excluding those who had an outpatient visit in which a PTSD diagnosis was not recorded. In other words, our estimates may be biased toward the null hypothesis and are more likely conservative. Third, we may have overestimated the use of psychotropics by not excluding youths with anxiety and disruptive behavior disorders. Even though previous research showed these comorbidities are likely to coexist, in our sample less than 7% of individuals reported them (data available per request). Therefore, we included these two disorders and other psychiatric comorbidities from the complexity index and accounted for their effects in the multivariable analysis. Fourth, the database captures only the formal version of psychotherapy. Hence, we may underreport other less intensive versions (e.g., brief supportive therapy) not captured in the data.
Fifth, a fraction of our sample may not represent a new episode of PTSD, given that some youths may have had a previous diagnosis prior to our six-month clean period. However, given routine care practices, a six-month period should be adequate to uncover new episodes. Sixth, although we tried to control for case mix by using a severity and complexity index, the effects of unmeasured confounders on treatment decisions may be unknown. Also, because of the cross-sectional design, we could not identify temporal changes in medication use (such as switching or augmenting drugs) that are clinically relevant. For benzodiazepines, the small sample size did not permit the calculation of stable coefficients. Finally, we did not have information to assess whether providers monitored metabolic profiles when prescribing antipsychotics.
Conclusions
Psychotherapy was the treatment option used most often among children for a new episode of PTSD. Two-fifths of youths with a formal PTSD diagnosis did not receive psychotherapy. Even though less than 10% of youths used off-label pharmaceuticals, quality-of-care concerns remain valid. Further research is needed to understand the rationale behind the prescription of pharmacotherapy for PTSD among children and develop initiatives to expand psychotherapy access, especially in the primary care setting.
References
1.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association, 2013
2.
Ipser JC, Stein DJ, Hawkridge S, et al: Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 3:CD005170, 2009
3.
Merikangas KR, He JP, Burstein M, et al: Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry 49:980–989, 2010
4.
Trivedi H, Chang K (eds): Pediatric Psychopharmacology (special issue). Child and Adolescent Psychiatric Clinics of North America 21:1056–4993, 2012
5.
Alisic E, Zalta AK, van Wesel F, et al: Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. British Journal of Psychiatry 204:335–340, 2014
6.
Breslau N: The epidemiology of posttraumatic stress disorder: what is the extent of the problem? Journal of Clinical Psychiatry 62(suppl 17):16–22, 2001
7.
Florida Psychotherapeutic Medication Guidelines for Children and Adolescents, 2015. Tampa, University of South Florida, Florida Medicaid Drug Therapy Management Program for Behavioral Health, 2015. http://medicaidmentalhealth.org/_assets/file/Guidelines/2015%20Florida%20Best%20Practice%20Medication%20Child-Adolescent%20Guidelines_online2.pdf
8.
Keeshin BR, Strawn JR: Psychological and pharmacologic treatment of youth with posttraumatic stress disorder: an evidence-based review. Child and Adolescent Psychiatric Clinics of North America 23:399–411, 2014
9.
Bisson JI, Ehlers A, Matthews R, et al: Psychological treatments for chronic post-traumatic stress disorder: systematic review and meta-analysis. British Journal of Psychiatry 190:97–104, 2007
10.
Hetrick SE, McKenzie JE, Merry SN: The use of SSRIs in children and adolescents. Current Opinion in Psychiatry 23:53–57, 2010
11.
Cox GR, Callahan P, Churchill R, et al: Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database of Systematic Reviews 11:CD008324, 2012
12.
Cohen JA, Bukstein O, Walter H, et al: Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry 49:414–430, 2010
13.
Wilkinson JM, Carrion VG: Pharmacotherapy in pediatric PTSD: a developmentally-focused review of the evidence. Current Psychopharmacology 1:252–270, 2012
14.
Nieuwsma JA, Trivedi RB, McDuffie J, et al: Brief Psychotherapy for Depression in Primary Care: A Systematic Review of the Evidence. Washington DC, US Department of Veterans Affairs, 2011
15.
Thomas KC, Ellis AR, Konrad TR, et al: County-level estimates of mental health professional shortage in the United States. Psychiatric Services 60:1323–1328, 2009
16.
Connor DF, Grasso DJ, Slivinsky MD, et al: An open-label study of guanfacine extended release for traumatic stress related symptoms in children and adolescents. Journal of Child and Adolescent Psychopharmacology 23:244–251, 2013
17.
Harmon RJ, Riggs PD: Clonidine for posttraumatic stress disorder in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry 35:1247–1249, 1996
18.
Porter DM, Bell CC: The use of clonidine in post-traumatic stress disorder. Journal of the National Medical Association 91:475–477, 1999
19.
Cohen JA, Mannarino AP, Perel JM, et al: A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry 46:811–819, 2007
20.
Robb AS, Cueva JE, Sporn J, et al: Sertraline treatment of children and adolescents with posttraumatic stress disorder: a double-blind, placebo-controlled trial. Journal of Child and Adolescent Psychopharmacology 20:463–471, 2010
21.
Kaminer D, Seedat S, Stein DJ: Post-traumatic stress disorder in children. World Psychiatry 4:121–125, 2005
22.
Keeshin BR, Strawn JR: Risperidone treatment of an adolescent with severe posttraumatic stress disorder. Annals of Pharmacotherapy 43:1374, 2009
23.
Stathis S, Martin G, McKenna JG: A preliminary case series on the use of quetiapine for posttraumatic stress disorder in juveniles within a youth detention center. Journal of Clinical Psychopharmacology 25:539–544, 2005
24.
Looff D, Grimley P, Kuller F, et al: Carbamazepine for PTSD. Journal of the American Academy of Child and Adolescent Psychiatry 34:703–704, 1995
25.
Steiner H, Saxena KS, Carrion V, et al: Divalproex sodium for the treatment of PTSD and conduct disordered youth: a pilot randomized controlled clinical trial. Child Psychiatry and Human Development 38:183–193, 2007
26.
Lorenz RA, Hayes JW, Saitz M: Prazosin treatment of nightmares related to post-traumatic stress disorder. Mental Health Clinician 2:202–203, 2013
27.
Famularo R, Kinscherff R, Fenton T: Propranolol treatment for childhood posttraumatic stress disorder, acute type: a pilot study. American Journal of Diseases of Children 142:1244–1247, 1988
28.
Nugent NR, Christopher NC, Crow JP, et al: The efficacy of early propranolol administration at reducing PTSD symptoms in pediatric injury patients: a pilot study. Journal of Traumatic Stress 23:282–287, 2010
29.
Lakhan SE, Hagger-Johnson GE: The impact of prescribed psychotropics on youth. Clinical Practice and Epidemiology in Mental Health 3:21, 2007
30.
Fisher S, Greenberg RP: From Placebo to Panacea: Putting Psychiatric Drugs to the Test. Hoboken, NJ, Wiley, 1997
31.
Dubois RW, Batchlor E, Wade S: Geographic variation in the use of medications: is uniformity good news or bad? Health Affairs 21:240–250, 2002
32.
Olfson M, Marcus SC, Druss B, et al: National trends in the use of outpatient psychotherapy. American Journal of Psychiatry 159:1914–1920, 2002
33.
Anis AH, Carruthers SG, Carter AO, et al: Variability in prescription drug utilization: issues for research. Canadian Medical Association Journal 154:635–640, 1996
34.
Vojvoda D, Stefanovics E, Rosenheck RA: Treatment of veterans with PTSD at a VA medical center: primary care versus mental health specialty care. Psychiatric Services 65:1238–1243, 2014
35.
Zhang Y, Baicker K, Newhouse JP: Geographic variation in the quality of prescribing. New England Journal of Medicine 363:1985–1988, 2010
36.
Kessler RC, Avenevoli S, Costello EJ, et al: Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry 69:372–380, 2012
37.
Newacheck PW, Stoddard JJ: Prevalence and impact of multiple childhood chronic illnesses. Journal of Pediatrics 124:40–48, 1994
38.
Rezaee ME, Pollock M: Multiple chronic conditions among outpatient pediatric patients, southeastern Michigan, 2008–2013. Preventing Chronic Disease 12:E18, 2015 http://www.cdc.gov/pcd/issues/2015/14_0397.htm
39.
Elixhauser A, Steiner C, Harris DR, et al: Comorbidity measures for use with administrative data. Medical Care 36:8–27, 1998
40.
Elixhauser Comorbidity Software, Version 3.7. Rockville, MD, Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp
41.
Izrael D, Hoaglin D, Battaglia M: A SAS Macro for Balancing a Weighted Sample. Cambridge, Abt Associates, 1999
42.
Jain S, Greenbaum MA, Rosen C: Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines. Psychiatric Services 63:154–160, 2012
43.
Developmental issues for young children in foster care. Pediatrics 106:1145–1150, 2000
44.
Soria-Saucedo R, Walter HJ, Cabral H, et al: Receipt of evidence-based pharmacotherapy and psychotherapy among children and adolescents with new diagnoses of depression. Psychiatric Services 67:316–323, 2016
45.
Soria-Saucedo R, Eisen SV, Cabral HJ, et al: Receipt of pharmacotherapy and psychotherapy among a nationally representative US sample of privately insured adults with depression: associations with insurance plan arrangements and provider specialty. Journal of Pharmaceutical Health Services Research 7:53–62, 2016
46.
Horwitz SM, Kelleher KJ, Stein REK, et al: Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics 119:e208–e218, 2007
47.
Verlinden E, Opmeer BC, Van Meijel EPM, et al: Enhanced screening for posttraumatic stress disorder and comorbid diagnoses in children and adolescents. European Journal of Psychotraumatology 6:26661, 2015
48.
Kassam-Adams N: The Acute Stress Checklist for Children (ASC-Kids): development of a child self-report measure. Journal of Traumatic Stress 19:129–139, 2006
49.
Steinberg AM, Brymer MJ, Decker KB, et al: The University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index. Current Psychiatry Reports 6:96–100, 2004
50.
van Meijel EP, Gigengack MR, Verlinden E, et al: Predicting posttraumatic stress disorder in children and parents following accidental child injury: evaluation of the Screening Tool for Early Predictors of Posttraumatic Stress Disorder (STEPP). BMC Psychiatry 15:113, 2015
51.
Garg A, Butz AM, Dworkin PH, et al: Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project. Pediatrics 120:547–558, 2007
52.
Gillies D, Taylor F, Gray C, et al: Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Evidence-Based Child Health: 8:1004–1116, 2013
53.
Berkowitz SJ, Stover CS, Marans SR: The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry, and Allied Disciplines 52:676–685, 2011
54.
Salloum A, Wang W, Robst J, et al: Stepped care versus standard trauma-focused cognitive behavioral therapy for young children. Journal of Child Psychology and Psychiatry, and Allied Disciplines 57:614–622, 2016
55.
Flynn AB, Fothergill KE, Wilcox HC, et al: Primary care interventions to prevent or treat traumatic stress in childhood: a systematic review. Academic Pediatrics 15:480–492, 2015
56.
Cooper CA, Knotts HG: Declining Dixie: regional identification in the modern American south. Social Forces 88:1083–1101, 2010
Information & Authors
Information
Published In
Cover: Landscape at L’Estaque, by Georges Braque, 1906. Oil on canvas. Restricted gift of Friends of the Art Institute of Chicago in honor of Mary Block; Walter Aitken, Martha Leverone, and Major Acquisitions Centennial endowments, 1981.65. Art Resource, New York City.
History
Received: 7 April 2017
Revision received: 9 August 2017
Revision received: 26 March 2018
Accepted: 27 April 2018
Published online: 2 July 2018
Published in print: September 01, 2018
Keywords
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Center of Assessment of Pharmaceutical Practices, Boston University School of Public Health
The Center for the Assessment of Pharmaceutical Practices, Department of Health Policy and Management, Boston University School of Public Health provided support for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and review of the manuscript.Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).