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Original Investigation
June 2018

Patterns of Early Mental Health Diagnosis and Medication Treatment in a Medicaid-Insured Birth Cohort

Author Affiliations
  • 1Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore
  • 2Department of Psychiatry, University of Maryland, Baltimore
  • 3Centre for Interventional Pediatric Psychopharmacology and Rare Diseases, Maudsley Hospital, London, United Kingdom
  • 4Department of Epidemiology and Public Health, University of Maryland, Baltimore
JAMA Pediatr. 2018;172(6):576-584. doi:10.1001/jamapediatrics.2018.0240
Key Points

Question  What is the cumulative incidence of psychiatric diagnosis and use of psychotropic medications in a Medicaid-insured birth cohort by age 8 years?

Findings  In this cohort study of 35 244 newborns, 19.7% received a psychiatric diagnosis and 10.2% received a psychotropic medication by age 8 years; 20% of medication users received 2 or more medication classes concurrently for 60 days or more. At age 7 years, half or more of the medicated children had more than 200 days of drug exposure.

Meaning  Early exposure to psychotropic medications has implications for long-term safety and highlights the need for outcomes research in young children.


Importance  The increased use of psychiatric services in the US pediatric population raises concerns about the appropriate use of psychotropic medications for very young children.

Objective  To assess the longitudinal patterns of psychotropic medication use in association with diagnosis and duration of use in a Medicaid-insured birth cohort.

Design, Setting, and Participants  A cohort design was applied to computerized Medicaid administrative claims data for 35 244 children born in a mid-Atlantic state in 2007 and followed up for up to 96 months through December 31, 2014. Children were included in the birth cohort if they had an enrollment record at birth or within 3 months of birth and at least 6 months of continuous enrollment from birth. The cohort represents 92.2% of 38 225 Medicaid-insured newborns in 2007.

Exposures  Mental health treatments from birth through age 7 years.

Main Outcomes and Measures  Cumulative incidence of first psychiatric diagnosis and psychotropic medication use (monotherapy or concomitant use of psychotropic medications) from birth through age 7 years, total and by sex, and the cumulative incidence of the use of psychosocial services (age, 0-7 years) as well as the annual duration of medication use (ie, number of days of psychotropic medication use among children 3-7 years of age).

Results  Of the 35 244 children in the cohort, 17 267 were girls and 17 977 were boys. By age 8 years, 4550 children in the birth cohort (19.7% [percentage adjusted for right censoring]) had received a psychiatric diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 290-319); 2624 of these diagnoses (57.7%) were behavioral (codes 312, 313, or 314). Girls were more likely than boys to receive an incident psychiatric diagnosis of adjustment disorder (355 of 1598 [22.2%] vs 427 of 2952 [14.5%]; P < .001) or anxiety disorder (114 of 1598 [7.1%] vs 120 of 2952 [4.1%]; P < .001). By age 8 years, 2196 children in the cohort (10.2% [percentage adjusted for right censoring]) had received a psychotropic medication. Among medication users, 1763 of 2196 (80.5% [percentage adjusted for right censoring]) received monotherapy, 343 of 2196 (16.4% [percentage adjusted for right censoring]) received 2 medication classes concomitantly, and 90 of 2196 (4.3% [percentage adjusted for right censoring]) received 3 or more medication classes concomitantly for 60 days or more (range, 78-180 days). The annual median number of days of psychotropic medication use among medicated children increased with age, reaching 210 of 365 days for children 7 years of age. Among children 7 years of age, the median number of days of use of an antipsychotic (193 days [interquartile range, 60-266 days]), stimulant (183 days [interquartile range, 86-295 days]), or α-agonist (199 days [interquartile range, 85-305 days]) exceeded half of the year.

Conclusions and Relevance  Medicaid-insured children received substantial mental health services and had prolonged exposure to psychotropic medications in the early years of life. These findings highlight the need for outcomes research in pediatric populations.