As a practicing psychiatrist and a state mental health administrator, Dr. Joseph Parks sees both sides of the debate over the use of antipsychotic medication to treat high-energy children who hallucinate, can't sit still or keep their thoughts together.

Under Missouri law, any physician is allowed to prescribe psychiatric medications to treat such Medicaid-eligible children. But Dr. Parks (right), the chief clinical officer for the Department of Mental Health, says Missouri needs to amend that policy for several reasons.

One concern, he says, is that some well-meaning doctors may be overprescribing antipsychotics. Soon-to-be released data from the federal Agency for Healthcare Research and Quality would seem to bear out that concern. The study is expected to show that Missouri ranks highest among the 16 states surveyed in the use of antipsychotics for kids under age 18 and also for those under age 6.

To address this issue, Missouri is putting together a panel of representatives from the Mental Health Department, along with psychiatrists, doctors, pharmacists and mental-health advocates to guide the Missouri Legislature. The goal is to impose restraints on the extent to which these drugs are prescribed to children under Medicaid. The guidelines would apply only to children under Medicaid with newly diagnosed mental-health problems, and wouldn't affect those already on medications.

legal change required

Only the Legislature can mandate this change because Missouri law, unlike some other states, bans agencies from imposing mandatory requirements and limitations on the use of these drugs among Medicaid-eligible children.

“There's protective language (in Missouri) that says if a doctor writes this type of prescription for (Medicaid-eligible) children, they're going to get it, whether it's needed or not,” Dr. Parks says.

Therapy might be a better alternative for some children, says Dr. Parks. He sees a few patients in private practice a few hours a week. There, he has encountered parents who say schools tell them that “the child can't be managed in class,” and that parents need “to get a psychiatrist to see him.”

Dr. Parks says, “Medication isn't the answer to everything. There are children who need smaller classrooms. There are children who need additional tutoring or behavioral intervention. There needs to be plans in the way we interact with them when they act up rather than relying solely on medication.”

A third concern, he says, involves side effects from antipsychotics.

“People put on a lot of weight with these drugs,” he says. “When they use them, their blood pressure goes up, and people develop diabetes. They also get high cholesterol, which can lead to heart disease.”

Of the 13,000 Missouri children taking antipsychotics during one three-month period last year, 351 of them took two different drugs, and 944 took five or more antipsychotics. Dr. Parks says, “when people take two of these drugs together, they are 2 ½ times more likely to die, primarily from heart disease, than somebody who takes just one.”

He stresses that the drugs are very useful, “but they are very powerful and must be used very carefully and not in a cavalier manner.”

More than 31 percent, or over $220 million, of the $702 million the department spends for medications is for antipsychotics. More than $11 million of that amount is spent on antipsychotics for children.

Ideally, he says a legislative mandate that amends the extent to which antipsychotics are prescribed and under what conditions could save Missouri as much as $10 million the first year. He adds, however, that “savings is a secondary issue here” and that most doctors adhere to the agency's voluntary education program in the way they prescribe these drugs. But he says about 4 percent to 5 percent of doctors “just don't seem to read the information and change, don't seem to get it.”

That group, he says, has led the department to decide that “we need to take some careful, selected mandatory approaches” that could lead to better prescribing practices and “make sure people get the best treatment, both kids and adults.”

money matters

Rep. David Sater, R-Cassville, differs with Dr. Parks on one point: Saving money is a primary reason the law governing these drugs needs to be amended. Sater chairs the House appropriations panel for mental health and social services.

“Missouri has not done a very good job in controlling the number of psychotropic drugs,” Sater says. “We're finding that a lot of kids are on two to three drugs. This is just ridiculous for the normal patient. This is out of bounds.”

The agency and state lawmakers must do no harm to mentally challenged children, he says, “but the goal also is to be efficient with the money. We have a lot of developmentally disabled people who are not getting services because we don't have the money. We need to find ways to treat people effectively and spend the money we save” to serve others with mental illnesses.

Sater says the Legislature didn't succeed in approving a related bill last year. He says the new bill might meet with more success because patients already taking the drugs would be grandfathered into the proposed legislation, which would apply only to new patients.

“We would like to have a little bit more control over what medications they (new patients) take and the cost.”