Skip to main content

Abstract

Objective:

The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population.

Methods:

This retrospective cohort study included patients ages 0–21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics.

Results:

Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60–0.62; ARR=0.29, 95% CI=0.28–0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients.

Conclusions:

Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.

HIGHLIGHTS

In this population-based cohort study of pediatric patients enrolled in North Carolina Medicaid during a 1-year period, Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription compared with White and non-Hispanic patients.
Future research should focus on identifying and addressing the patient-, provider-, and system-level factors that contribute to racial and ethnic differences in the receipt of filled psychotropic prescriptions among the pediatric population.
In the United States, 16.5% of children and adolescents have at least one behavioral health condition (1); in addition, approximately 9% receive psychotropic medications for treatment of behavioral health conditions (2). Psychotropic medications can benefit those with behavioral health concerns by decreasing symptoms and improving overall functioning (3). Racial and ethnic differences have been observed among those receiving prescriptions of psychotropic medications, including medications that are considered first-line treatments for various behavioral health conditions. Specifically, national data indicate that White and non-Hispanic pediatric patients are more likely to receive psychotropic medications compared with Black and Hispanic pediatric patients (48). To address these differences, state-level data are needed to guide local initiatives to increase access to care for underserved populations and to improve clinician or prescriber understanding of behavioral health and approaches to psychotropic prescribing.
The North Carolina Medicaid system, which provides insurance coverage for 40% of the pediatric population in North Carolina (9), is undergoing a significant transformation that may affect access to behavioral health care. In this study, we aimed to examine receipt of filled psychotropic prescriptions among pediatric patients enrolled in North Carolina Medicaid before this systemic Medicaid transformation. Data were examined for pediatric patients enrolled in North Carolina Medicaid during a 1-year period to identify any racial-ethnic differences.

Methods

We analyzed North Carolina Medicaid 2017–2018 institutional, professional, and prescription claims; enrollment data; and provider data obtained from the North Carolina Department of Health and Human Services (DHHS). Briefly, the enrollment file contains beneficiary information, including date of birth, sex, self- or caregiver-reported race and ethnicity, county of residence, Medicaid eligibility category, and enrollment dates. The prescription claims file contains fill date and prescriber and pharmacy data for filled prescription drugs that were prescribed by providers in outpatient settings. The institutional and professional files contain claims for inpatient and outpatient services. We used the provider file to identify the taxonomy associated with each provider. The Duke University Health System Institutional Review Board and the North Carolina DHHS approved this study.
We used North Carolina Medicaid claims and enrollment data to identify pediatric patients ages 0–21 who were enrolled in Medicaid on October 1, 2017. We included patients ages 0–21 because of the North Carolina foster care program, which includes individuals up to age 21. To be included in the analyses, patients had to have at least one professional or institutional claim with a provider type of interest (child or adult psychiatric provider, pediatric provider, family medicine provider, primary care physician assistant, or primary care nurse practitioner; a table showing provider taxonomies is available in the online supplement to this report) between October 1, 2017, and September 30, 2018.
We then identified patients who filled at least one prescription in the most common psychotropic medication classes (i.e., antidepressant, stimulant, alpha agonist, or antipsychotic) during the study period by using the generic name on the prescription claim (see the online supplement). Notably, Medicaid pharmacy claims include only filled prescriptions.
We categorized age in years as follows: 0–5, 6–11, 12–17, and 18–21. Counties were classified as either urban or rural in accordance with North Carolina Office of State Budget and Management guidelines. We used the race (White, Black, Asian, Native American, Hawaiian or Pacific Islander, or unreported) and ethnicity (non-Hispanic, Hispanic [Cuban, Mexican, Puerto Rican, or Hispanic other], or unreported) listed in the member enrollment file. The Medicaid eligibility categories were grouped into children from low-income families (N=905,995); foster care or adoption assistance (N=20,334); blind, disabled, or medically needy (N=49,499); pregnant women (N=712); and other programs (e.g., documented and undocumented immigrants, family planning waiver, and refugee medical assistance) (N=7,346).
We fit unadjusted and adjusted multivariable modified Poisson regression models (10) to examine factors associated with the likelihood of filling any psychotropic prescription and filling a prescription in each of the four included drug classes among the entire pediatric Medicaid population. The modified Poisson model was used because the traditional logistic model does not reliably estimate risk ratios for dependent-variable prevalence rates of the outcome (e.g., prescription rates) >10%. In the multivariable model, we included covariates for age, sex, race, ethnicity, county of residence (rural vs. urban), and Medicaid eligibility category. We conducted a sensitivity analysis restricted to those who were continuously enrolled during the 1-year period (93%, N=916,986) to determine whether there were differences from the primary models. We used a two-tailed alpha of 0.05 to establish statistical significance and reported 95% confidence intervals (CIs).

Results

Of the 983,886 pediatric patients enrolled in North Carolina Medicaid who met eligibility criteria, 10.6% (N=103,817) received at least one filled psychotropic prescription. When examining the proportions of patients who received a filled prescription in each of the four included drug classes by race and ethnicity, a higher percentage of White patients (4.2%, N=24,742 of 590,536) received an antidepressant than Black patients (2.1%, N=7,346 of 345,946) (see the online supplement). However, a similar proportion of White and Black patients received a filled antipsychotic prescription (2.0% [N=11,709 of 590,536] and 1.9% [N=6,407 of 345,946], respectively). Compared with Hispanic patients, a higher percentage of non-Hispanic patients received a filled antidepressant (3.9% [N=29,345 of 751,843] vs. 1.3% [N=2,793 of 215,348]) or antipsychotic (2.2% [N=16,731 of 751,843] vs. 0.5% [N=1,144 of 215,348]) prescription.
After multivariable adjustment, we found racial and ethnic differences in the receipt of any filled prescription (Table 1). Compared with White patients, patients of all other races had a significantly lower likelihood of receiving any filled psychotropic prescription, with Asian patients being the least likely to receive a filled prescription (adjusted risk ratio [ARR]=0.20, 95% CI=0.18–0.22). When examining ethnicity in the adjusted model, we found that Hispanic patients and those with unreported ethnicity had a lower likelihood of receiving any filled psychotropic prescription than non-Hispanic patients.
TABLE 1. Adjusted risk ratios (ARRs) for receiving filled psychotropic medication prescriptions among pediatric patients enrolled in North Carolina Medicaid during 2017–2018a
PredictorNAny psychotropic prescriptionAntidepressantAlpha agonistStimulantAntipsychotic
ARR95% CIARR95% CIARR95% CIARR95% CIARR95% CI
Race (reference: White)590,536          
 Black345,946.61***.60–.62.40***.39–.41.61***.60–.63.67***.65–.68.63***.61–.66
 Asian19,048.20***.18–.22.25***.22–.29.14***.11–.17.16***.14–.19.29***.24–.36
 Native American18,551.73***.69–.77.62***.56–.69.74***.68–.81.75***.70–.80.65***.57–.73
 Hawaiian or Pacific Islander1,743.64***.53–.77.65**.47–.90.69*.51–.94.56***.44–.73.50**.31–.82
 Unreported8,062.56***.51–.61.44***.38–.52.51***.44–.60.55***.48–.62.51***.42–.61
Ethnicity (reference: non-Hispanic)751,843          
 Hispanic215,348.29***.28–.29.30***.29–.32.22***.21–.23.26***.25–.27.29***.27–.30
 Unreported16,695.83***.79–.86.80***.74–.86.83***.78–.88.84***.80–.89.86***.80–.92
a
N represents the total number of pediatric beneficiaries included in the sample, by race and ethnicity. All models are adjusted for age, sex, rural or urban county of residence, and Medicaid eligibility program, and the models include a random intercept for the enrollee’s county of residence.
*p<0.05, **p<0.01, ***p<0.001.
When examining the multivariable adjusted likelihood of patients receiving a filled prescription in each drug class, we found similar results. Compared with White patients, Black patients were significantly less likely to receive a filled antidepressant (ARR=0.40, 95% CI=0.39–0.41), alpha agonist (ARR=0.61, 95% CI=0.60–0.63), stimulant (ARR=0.67, 95% CI=0.65–0.68), or antipsychotic (ARR=0.63, 95% CI=0.61–0.66) prescription. Hispanic patients were 70%–78% (ARRs=0.22–0.30) less likely to receive a filled prescription in each of the given drug classes compared with non-Hispanic patients. Comparable estimates were found with the unadjusted model as well as with the sensitivity analysis that examined only those with continuous enrollment. The full multivariable model, adjusted for other covariates (e.g., age, sex, county of residence, Medicaid eligibility category), can be found in the online supplement.

Discussion

In this study, we examined filled psychotropic prescription claims for pediatric patients enrolled in North Carolina Medicaid. We found that 10.6% of all enrolled patients received at least one filled psychotropic prescription and that prescription rates varied by race and ethnicity among the four included drug classes. Similar to prior research that used national samples (48), these findings demonstrate that, compared with White and non-Hispanic patients, Black and Hispanic pediatric patients in North Carolina were significantly less likely to receive any filled psychotropic prescription or a filled psychotropic prescription in any of the four major classes of psychotropic medications reported in our study, after adjusting for relevant demographic characteristics. Understanding these patterns within a specific state and determining avenues to address these differences require further research on provider-, patient-, and system-level factors.
Our findings raise questions about whether racial and ethnic differences are due to the lack of access to pharmacological treatment for Black and Hispanic patients, the overuse of psychotropic medications among White and non-Hispanic patients, or the combination of both. Previous research has shown that Black and Hispanic patients have significantly lower rates of outpatient behavioral health service utilization compared with White and non-Hispanic patients, even though no racial or ethnic differences exist in prevalence rates of behavioral health conditions after controlling for provider behavior (1113). Furthermore, there are widespread sociopolitical and systemic inequalities, such as racism and discrimination, that disproportionately affect Black and Hispanic populations; as a result, these inequalities may affect their access to behavioral health treatment (14). Gaining insight into patients’ perspectives of lived experience with seeking and receiving behavioral health care may also help to address racial and ethnic differences in treatment.
Although we found significant racial and ethnic differences in receipt of filled psychotropic prescriptions, we did not have access to sufficient data to ascertain whether these differences constitute health disparities. Specifically, the Institute of Medicine has defined “disparities” as differences not due to clinical needs, appropriateness, or patient preferences (15). Unfortunately, Medicaid claims data do not include information on clinical need for, appropriateness of, or patient preference for psychotropic prescriptions; thus, this limitation precludes characterizing the differences we found as disparities. Other provider- and system-level factors, such as provider bias, stereotypes and clinical uncertainty, institutional and structural racism, and cultural barriers, may be potential explanations for the differences in receipt of filled psychotropic prescriptions found in our study; therefore, these factors should be investigated in future studies.
This study had several limitations. The time frame was opportunistic and limited to a 1-year period in order to inform and support a statewide initiative being implemented in North Carolina. Although we did not restrict our sample to patients with continuous Medicaid enrollment, our sensitivity analysis indicated that this covariate did not affect our results. Our sample included only pediatric patients enrolled in North Carolina Medicaid; thus, results may not be generalizable to other states or patient populations.
We did not include patients’ clinical diagnoses or symptoms; therefore, we are unable to determine whether patients’ prescriptions were indicated. We also recognize that there may be racial and ethnic biases associated with a behavioral health diagnosis, which is typically required when prescribing a psychotropic medication. Additionally, our analyses do not account for off-label prescribing, polypharmacy, the use of psychotherapy and other behavioral health treatments, patient or parent-guardian preference, or treatment response, all of which may influence receipt of a filled psychotropic prescription and are important factors to investigate in future research.

Conclusions

In this study, we examined receipt of filled psychotropic prescriptions among Medicaid-insured pediatric patients in North Carolina. Our results are consistent with those from prior studies, demonstrating that Black and Hispanic patients are significantly less likely to receive filled psychotropic prescriptions compared with White and non-Hispanic patients. Our results can be used by policy makers to inform community outreach and investment, to better understand racial and ethnic differences in prescription receipt, and to promote access to care for underserved populations. In future studies, researchers should seek to understand and address the reasons for these racial and ethnic differences in treatment and investigate patient-, provider-, and system-level factors.

Supplementary Material

File (appi.ps.202100473.ds001.pdf)

References

1.
Whitney DG, Peterson MD: US national and state-level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Pediatr 2019; 173:389–391
2.
Lopez-Leon S, Lopez-Gomez MI, Warner B, et al: Psychotropic medication in children and adolescents in the United States in the year 2004 vs 2014. Daru 2018; 26:5–10
3.
A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents. Washington, DC, American Academy of Child and Adolescent Psychiatry, 2012. www.aacap.org/App_Themes/AACAP/docs/press/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and_adolescents_2012.pdf
4.
Rodgers CRR, Flores MW, Bassey O, et al: Racial/ethnic disparity trends in children’s mental health care access and expenditures from 2010 to 2017: disparities remain despite sweeping policy reform. J Am Acad Child Adolesc Psychiatry 2022; 61:915–925
5.
Cataife G, Weinberg DA: Racial and ethnic differences in antipsychotic medication use among children enrolled in Medicaid. Psychiatr Serv 2015; 66:946–951
6.
Zhang S, Cain DS, Liao M: Racial/ethnic disparities in the decision points of mental health service use and psychotropic medication receipt among depressed youth. Youth Soc 2021; 53:610–635
7.
Coker TR, Elliott MN, Toomey SL, et al: Racial and ethnic disparities in ADHD diagnosis and treatment. Pediatrics 2016; 138:e20160407
8.
Cook BL, Carson NJ, Kafali EN, et al: Examining psychotropic medication use among youth in the US by race/ethnicity and psychological impairment. Gen Hosp Psychiatry 2017; 45:32–39
9.
Ten Things to Know About Medicaid’s Role for Children With Behavioral Needs. San Francisco, Kaiser Family Foundation, 2017. files.kff.org/attachment/Fact-Sheet-10-Things-to-Know-About-Medicaids-Role-for-Children-with-Behavioral-Health-Needs. Accessed Mar 4, 2020
10.
Zou GY, Donner A: Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res 2013; 22:661–670
11.
Costello EJ, He JP, Sampson NA, et al: Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent. Psychiatr Serv 2014; 65:359–366
12.
Cook BL, Barry CL, Busch SH: Racial/ethnic disparity trends in children’s mental health care access and expenditures from 2002 to 2007. Health Serv Res 2013; 48:129–149
13.
Marrast L, Himmelstein DU, Woolhandler S: Racial and ethnic disparities in mental health care for children and young adults: a national study. Int J Health Serv 2016; 46:810–824
14.
Alegria M, Vallas M, Pumariega AJ: Racial and ethnic disparities in pediatric mental health. Child Adolesc Psychiatr Clin N Am 2010; 19:759–774
15.
Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Edited by Smedley BD, Stith AY, Nelson AR. Washington, DC, National Academies Press, 2003. doi: 10.17226/12875

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 1401 - 1404
PubMed: 36039550

History

Received: 9 August 2021
Revision received: 8 February 2022
Revision received: 28 March 2022
Accepted: 8 April 2022
Published online: 30 August 2022
Published in print: December 01, 2022

Keywords

  1. Child psychiatry/general
  2. Community psychiatry
  3. Primary care
  4. Research/service delivery

Authors

Details

Alexis French, Ph.D. [email protected]
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Kelley A. Jones, Ph.D.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Christopher Bush, M.P.H.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Melissa A. Greiner, M.S.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
J. Nathan Copeland, M.D., M.P.H.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Naomi O. Davis, Ph.D.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Michelle S. Franklin, Ph.D.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Nicole Heilbron, Ph.D.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).
Gary R. Maslow, M.D., M.P.H.
Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin).

Notes

Send correspondence to Dr. French ([email protected]).

Competing Interests

Dr. Davis has received research support from Akili Interactive Labs. Dr. Maslow has received research funding from Pfizer and the National Institutes of Health; program funding from the U.S. Department of Health and Human Services (DHHS), HRSA, and The Arc of North Carolina; and program support from the North Carolina DHHS. The other authors report no financial relationships with commercial interests.

Funding Information

This study was supported by Health Resources and Services Administration (HRSA) grant U4C-MC-32315. These views represent the opinions of the authors and not necessarily those of HRSA; HRSA had no role in the design and conduct of this study.

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.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Get Access

Login 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 login
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

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.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share