Collaborative Effort Allows Oversight of Antipsychotic Medications in Medicaid Children Interview with:

Julie M. Zito, PhD Professor of Pharmacy and Psychiatry University of Maryland, Baltimore Pharmaceutical Health Services Department Baltimore, MD 21201

Dr. Zito

Julie M. Zito, PhD
Professor of Pharmacy and Psychiatry
University of Maryland, Baltimore
Pharmaceutical Health Services Department
Baltimore, MD 21201 What is the background for this study? What are the main findings?

Response: The growth of antipsychotic use in children, mainly for the treatment of behavior, has been of increasing concern in recent years. Clinical safety issues (Burcu et al. 2017) and government reports on overuse in the treatment of poor and foster care children (GAO, 2017; 2012) motivated our assessment of peer review programs. These programs are a relatively new approach to Medicaid oversight intended to monitor and assure clinical appropriateness of second generation antipsychotics in children. Critically important is the fact that most antipsychotic use is for child behavioral problems which are off-label conditions, i.e. without sufficient evidence of effectiveness or safety. What should clinicians and patients take away from your report?

Response: Two points: First, oversight by state Medicaid programs using a peer review approach is generally an improvement over previous less clinically-focused procedures.

Second, peer review is likely to  work best when there is a concerted effort to engage prescribers by sharing information sources that establish the reasons for efficacy, safety and policy concerns. This was the case in state D where a major educational initiative preceded the implementation of peer review. The advantage of this approach is that it gives relevant information to prescribers so that they can make clinical decisions consistent with the latest information on marketed medications. This model recognizes that medication practices change as more information accrues after use in large populations and enables prescribers to be better prepared to carry major responsibility for the well-being of their child patients. What recommendations do you have for future research as a result of this study?

Response: It is imperative that state data on all prior authorization programs be published in the clinical literature to assure their value in protecting our children’s health. In addition, little is known of antipsychotic use among privately-insured youth.

Finally, long-term outcomes research in community-treated populations, particularly very young children, is urgent. The range of outcomes should include clinical and public health related outcomes, e.g. use of emergency departments and psychiatric hospitalizations. Is there anything else you would like to add?

Response: This government-academic collaboration made it possible to bring to a wide national readership information on the value of peer review prior authorization to help balance the growing use of powerful medications for the treatment of off-label indications such as behavioral disorders Thank you for your contribution to the community.


Julie M. Zito, Mehmet Burcu, Stephen McKean, Rob Warnock, Jeffrey Kelman. Pediatric Use of Antipsychotic Medications Before and After Medicaid Peer Review Implementation. JAMA Psychiatry. Published online November 15, 2017. doi:10.1001/jamapsychiatry.2017.3493

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.


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Last Updated on November 21, 2017 by Marie Benz MD FAAD