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There appears to be a subgroup of children and adolescents who, despite repeated brief hospitalizations, do not improve, but along the way, these patients accumulate medications. During long-term residential treatment, however, these patients do improve and their medications are reduced.
The Child and Adolescent Service System Program (CASSP) model launched by the National Institute of Mental Health stated that youth with emotional disturbances should be treated in the least restrictive setting (Stroul and Friedman, 1986). However, clinicians often encounter children and adolescents with severe psychiatric illnesses who require 24-hour supervised treatment. At the same time that long-term state hospital beds have been significantly reduced, managed care has led to a sharp reduction in the length of stay of acute admissions (Pottick et al., 2000). As a result, pediatric patients who fail to respond to repeated brief hospitalizations and intensive outpatient programs are referred to residential treatment facilities (RTFs) (Wells, 1991). Patients in RTFs have severe and chronic disorders, have received a variety of treatments in the past and are often taking several psychotropic medications (Connor et al., 1998).
During brief hospital stays, medications are often used to quickly stabilize patients. During repeated admissions, medications often accumulate. New medications are added, while past medications may be continued for no apparent reason. For example, Connor et al. (1997) found polypharmacy in 60.3% of patients admitted to an RTF. One factor associated with polypharmacy was the number of previous psychiatric placements.
Despite the CASSP principles, many youth continue to be in need of residential treatment due to insufficient quality and quantity of outpatient services; overwhelming psychosocial adversity; and significant illness severity. Advantages of RTFs are the ability to treat the patient in a safe and structured environment with a multidisciplinary team (milieu therapy, individual and group psychotherapy, pharmacotherapy, family therapy, special education) over a longer period of time. In this context, a minimum of pharmacotherapy need be instituted. Ideally, treatment in RTFs should lead to a reduction in medications.
This hypothesis was evaluated through a retrospective chart review of 24 male patients (mean age=12.8 plus/minus 2.5 with a range from 9 years to 17 years) consecutively treated in an RTF over an 18-month period. Seventy-five percent of patients were white, 17% were African-American, and 8% were Hispanic. Patients with mental retardation or significant substance use were not admitted.
On admission, all patients were interviewed with the Mini-International Neuropsychiatric Interview for children and adolescents (MINI-KID) (Sheehan et al., 1998). Collateral information was obtained from parents, past records and social agencies. Physical examinations were routinely performed. Diagnoses were made according to DSM-IV along the five axes; these can be found in Table 1. The mean Global Assessment of Functioning (GAF) score on admission was 34.4±4.5.
On entry into the RTF, patients were taking an average of 2.6±1.4 medications (range=0 to 5). The numbers of medication taken can be found in the Figure and the types in Table 2. The number of prior medication trials, not including the admission medications, was 2.1±1.6.
The mean number of hospitalizations before the RTF placement was 3.1±2.4, with a range from 0 to 10. Statistically significant correlations existed between the number of prior hospitalizations and both the number of pre-RTF medication trials (R=0.64; p=0.0008; df 22) and the number of medications on admission (R=0.47; p=0.02; df 22).
Throughout the RTF stay (mean length of stay=279.3 days±163.1 days), progress was measured with the Child Behavior Rating Form-Abbreviated (CBRF) (Van Egeren et al., 1999), filled out twice per day by staff. Diagnosis-specific rating scales, such as attention-deficit/hyperactivity disorder scales in the classroom, were used as well. School and parent reports were reviewed twice per week. Mental status examinations were performed on a weekly basis by a board certified child and adolescent psychiatrist. Based on this information, GAF scale scores on Axis V were adjusted.
During the treatment, 17 patients (71%) had the number of their medications reduced. Five patients remained on the same number and two patients were treated with an increased number of medications. Overall, the total number of medications prescribed decreased from 63 on admission to 38 on discharge, a 40% decrease. Alpha-2 agonists, antipsychotics and antidepressants were stopped most frequently. Patients were taking an average of 1.6±1.3 medications at discharge (range=0 to 4) (Figure). At the same time, the mean GAF score showed a 27% increase from 34.4±4.5 to 43.8±8.9.
Acute Admissions Versus RTF
Conclusions from this project are very preliminary, mainly because of the absence of a control group not admitted to an RTF. It might be argued that these patients would have improved over the same amount of time while receiving treatment in less-restrictive environments, and while decreasing their medications as well. However, considering their pre-RTF records with numerous hospitalizations, intensive outpatient treatments and several medication trials, it appears unlikely that a similar outcome would have occurred. Many of these patients were referred because of serious concern for ongoing suicidal and aggressive behavior, despite repeated hospitalizations and intensive outpatient treatment.
Despite the small number of patients, strong correlations were found between the number of hospitalizations and the number of medications used before and on admission. These findings are a replication of the 1997 Connor et al. study. It appears that severely ill youth accumulate psychiatric medications during repeated acute admissions without much benefit, thus ending up in RTFs. This study continued to follow the patients throughout their RTF treatment. With more time for multidisciplinary psychosocial treatments to take effect, medications were reduced by 40%. Patients left on average with one less medication. Polypharmacy decreased from 79% to 63%. Yet, patients improved, as evidenced by increased GAF scores.
A tentative conclusion appears to point to a subgroup of children and adolescents with severe psychiatric disorders who do not get better with repeated brief hospitalizations and who accumulate medications. These patients do get better with long-term residential treatment at the same time that medications are significantly reduced.
If replicated in more controlled studies, several questions are raised by these findings. How are non-responding patients best identified, when, and after how many hospitalizations? What are the economic implications of these findings? What role do brief hospitalizations play in the treatment of severe and chronic psychiatric illnesses? What is the role of polypharmacy in this treatment? The answers are important in the current climate of managing cost by insurances, of limited resources to provide treatment and of ongoing controversy about the role of medications to treat problems in youth.
Connor DF, Ozbayrak KR, Harrison RJ et al. (1998), Prevalence and patterns of psychotropic and anticonvulsant medication use in children and adolescents referred to residential treatment. J Child Adolesc Psychopharmacol 8(1):27-38.
Connor DF, Ozbayrak KR, Kusiak KA et al. (1997), Combined pharmacotherapy in children and adolescents in a residential treatment center. J Am Acad Child Adolesc Psychiatry 36(2):248-254 [see comment].
Pottick KJ, McAlpine DD, Andelman RB (2000), Changing patterns of psychiatric inpatient care for children and adolescents in general hospitals, 1988-1995. Am J Psychiatry 157(8):1267-1273.
Sheehan DV, Lecrubier Y, Sheehan KH et al. (1998), The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(suppl 20):22-23; quiz 34-57.
Stroul BA, Friedman RM (1986) A system of care for children and youth with severe emotional disturbances. (Revised edition.) Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center.
Van Egeren LA, Frank SJ, Paul JS (1999), Daily behavior ratings among child and adolescent inpatients: the abbreviated Child Behavior Rating Form. J Am Acad Child Adolesc Psychiatry 38(11):1417-1425.
Wells K (1991), Placement of emotionally disturbed children in residential treatment: a review of placement criteria. Am J Orthopsychiatry 61(3):339-347.