Wish I could say I found this surprising

From the Times:
New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.
This is entirely consistent with my experience. I nodded in bemused resignation as I read the whole article.
Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?
Hmmmm. How to answer this question? I'd go with "yes."

There are numerous reasons for this disparity, from what I see here in rural Maine. Impoverished families lack both awareness of alternatives to medication and resources to access them. Children raised in these homes often have very disordered, stressed lives, and lack the structure necessary to foster good mental health. Their parents often have little wherewithal, financial and otherwise, to cope with their behavioral problems. In addition, schools seem to have diminishing patience for unruly children, and numerous children have been directed to my office because the teacher has begun issuing imperatives about getting their behavior under control by whatever means necessary. Conversely, more affluent children often have parents who are educated enough about powerful psychotropic medication to be very resistant to management by prescription. They can drive their kids to appointments and explore other resources in the community.

I hasten to add that I am loath to prescribe anti-psychotic medication to children. I can think of very few instances in the past five years when I have done so, excluding situations when I merely prescribed refills for medications already started by a mental health provider. Having seen the marked weight gain many patients have sustained following initiation of an anti-psychotic regimen, I remain gravely concerned about the long-term ill-effects of inappropriately cavalier use of very powerful drugs. I also object stridently to how aggressively some of these medications are marketed.

Bad medicine is, of course, part of the problem.
Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need. Recently, for example, he met with a 15-year-old girl. She had stopped taking the antipsychotic medication that had been prescribed for her after a single examination, paid for by Medicaid, at a clinic where she received a diagnosis of bipolar disorder.


The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.
While my characterization of contemporary mental health culture that "bipolar is the new black" may be a wee bit on the glib side, this diagnosis is being given with dubious frequency. It seems that the diagnosis is being given to suit the treatment desired, and not the other way around. Add in the predilection of some providers to throw medication at something until something works (the "thrown spaghetti" approach to medical management), and the result is an ill-advised liberality with potent anti-psychotics. It is incumbent on physicians to use their prescription pads judiciously, and it is all too easy to just write out a script for Seroquel and hustle the challenging cases out the door. Nobody is well-served by this approach, least of all the children who come from poor homes.

Perhaps awareness of this disparity will lead to greater scrutiny for how these medications are prescribed, for whom and for what reasons. These are children who need more care, not necessarily more medication. The last anecdote in the article offers a cautionary example.
“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of her son’s use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental and physical conditions manageable. “They’re helping with everything,” she said.
Perhaps they are. But one wonders how valid a diagnosis of bipolar disorder is for a three-year-old, and what other options were closed off to Ms. Torres and her son by her poverty.


  1. Well, then, I am certainly convinced. Government healthcare for everyone!

  2. Wow. That is some seriously deep analysis there, John. Because it's obviously the Medicaid that's leading to the over-prescription of anti-psychotics, and not the poverty that led to the Medicaid enrollment in the first place, with all the associated ills. Correlation is clearly the same thing as causation, and I think we can all agree that the solution to this particular problem is simply to do away with Medicaid.

  3. Dr. Dan, Medicare is supposed to *help* alleviate the ills of poverty, not finance cures that are worse than the disease. The point of the article is that kids on Medicare are, for whatever reason, far more likely to be prescribed powerful drugs that you believe to be problematic. My take is that, regardless of the reason the kids are having behavioral issues, Medicare is part of the problem, not part of the solution. Do you disagree?

    Why not have Congress and the Administration fix the serious problems with Medicare and Medicaid (budget bloat, Drugs R Us for kids, etc. etc. etc.) before they attempt this all-singing, all-dancing CongressCare program? Seriously.

  4. "Do you disagree?"

    Yes, John. Medicaid isn't the problem. The poverty that puts kids on Medicaid in the first place (with all of the attendant ills) is the problem, in combination with parents who have little access to alternatives and providers who are too heavy-handed with the prescriptions. (And I think you've gotten your talking points garbled. This doesn't have anything to do with Medicare.)

    Medicaid pays for the medications because the medications are sometimes appropriate. Should there be tighter regulation of which medications are readily approved? Sure. That would likely be part of a multi-faceted solution. But blaming Medicaid for this problem is like blaming corn farmers for obesity.

  5. My claim isn't garbled. The article doesn't clear Medicare, in fact, it suggests that physicians who study the issue are finding Medicare is partly to blame.

    Consider what the article said...

    Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do.

    Hummmm. Sounds like Medicaid isn't doing as much as the private insurers. Is there more evidence?

    Because there can be long waits to see the psychiatrists accepting Medicaid, it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.

    Long waits for government care. Now where have I heard that before? In any case, it certainly sounds like a Medicaid problem to me. But wait, can't it simply all be explained due to the fact that it sucks to be poor? Well, it would appear that isn't the whole story.

    As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.

    What I'm taking away from the NYT is that Medicaid doesn't pay much for non-drug care that takes a long time to get. In the meantime, Medicare hands out drugs for free to poor families. And people are puzzled over the fact that children are far more likely to be prescribed these free drugs than they are to suffer from the suckage of poverty. Hummmm. How could I ever suspect that government medical care -- Medicare -- and its policies have anything whatsoever to do with this problem.

  6. You appear to be conflating two different programs, first of all. Medicare and Medicaid are different, and you are referring to them interchangeably.

    And just because providers don't accept the government-sponsored insurance for the poor does not mean that the program is to blame. Maybe if Medicaid were to be better funded, therapies like counseling would receive better coverage. Again, you're blaming a cash-strapped insurance program for being unable to pay out at rates commensurate with private coverage, but I can't imagine you actually would support increased funding for Medicaid to provide better mental health services for the poor.

  7. Sorry, I did mistype MedicAID in my second and final sentences. My bad. Fortunately, nothing in the discussion is affected by this error.

    Hey, I agree, if MedicAID were better funded, it might be better for poor kids. If it didn't give out free meds to poor parents who can't get appointments for non-drug care, it might be better. But MedicAID is what Congress passed, and the very same people will be designing and funding CongressCare. As I said at the start, I'm convinced, government healthcare for everyone!

    And you might be amazed at what I would support to help children, especially poor children.