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The Maryland Department of Health and Mental Hygiene used materials created by AHRQ's Effective Health Care Program to help set up a new program for appropriate use of antipsychotic medications in children.

The ÂÜÀòÊÓƵmaterials provide guidance on the use of "atypical" antipsychotic medications such as risperidone. These drugs, called atypical because they were developed later than so-called "conventional" antipsychotic medications, have been approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia and bipolar disorder, but are commonly prescribed for off-label uses such as treatment of dementia, depression, and obsessive-compulsive disorder. It is legal for a physician to prescribe drugs to treat conditions other than those approved by the FDA, but it is illegal for the manufacturer to promote such use.

Mary Mussman, MD, MPH, Maryland's Physician Advisor to the Deputy Secretary for Health Care Financing, became aware of AHRQ's work on atypical antipsychotic medications at a meeting of the AHRQ-sponsored Medicaid Medical Directors Learning Network in 2010. She had been concerned by reports that children were being overprescribed certain antipsychotic medications, and saw a need for intervention among her State's pediatric Medicaid population. "We had very young kids who were being prescribed some of these drugs, and about half were prescribed by a mental health professional," Mussman says. "So we were pretty sensitized to that." In fact, an analysis of State data revealed that 178 children younger than age 5 years receiving Medicaid were prescribed 705 atypical antipsychotic medications for off-label use in 2010.

AHRQ's Effective Health Care Program has been studying atypical antipsychotic medications since 2006, when it published "Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics." This report reviewed the scientific evidence on the safety, efficacy, and effectiveness of off-label uses. ÂÜÀòÊÓƵresearchers revisited the topic in 2011 as new evidence emerged, and found that physicians commonly prescribe some psychiatric drugs for uses other than their officially approved purposes, despite thin evidence backing many of these uses.

Mussman worked with staff to establish a program called the "Peer Review Program for Mental Health Drugs" under the Maryland Medicaid Pharmacy Program (MMPP). Its goal is to promote the safe and appropriate use of antipsychotics in children through a peer-review authorization program.

The program developed criteria for use with input from child psychiatrists, psychiatric pharmacists, pediatric health experts, family advocates, and agencies serving children. It posts the criteria and other information on the MMPP Web site (). It also conducts outreach activities to prescriber groups to discuss issues involved in pediatric antipsychotic medication use and to educate them about the program.

MMPP contracts with the University of Maryland School of Pharmacy and the School of Medicine's Division of Child and Adolescent Psychiatry to provide Peer Review Program services. When a prescription is written for a young child for an antipsychotic medication, the prescriber is automatically directed to the Peer Review's call center, where a psychiatric pharmacist evaluates the request. If the information falls outside of the criteria or reveals other therapeutic issues, a child psychiatrist follows up, discussing the issues with the treating psychiatrist. If issues persist, an additional review with a Medicaid child psychiatrist can be requested.

The program was established in October 2011 and expanded in July 2012. Since then, reviewers have screened more than 1,000 prescriptions for children age 9 years and younger, according to Athos Alexandrou, MMPP Director. In some instances, the review leads to a reconsideration of antipsychotic medication use by the prescriber, the addition of psychosocial services, or the use of an alternative form of treatment that might be better suited for the patient. "What we've found is that the prescriber sometimes feels compelled to use a medication to treat a challenging case," Alexandrou says. "When indicated, the review helps prescribers identify additional resources for their patients. In addition, the program supports prescribers in obtaining appropriate safety monitoring while the child is receiving one of these powerful medications."