A team of investigators from The Children’s Hospital of Philadelphia’s PolicyLab recently received nearly $600,000 from the William T. Grant Foundation to lead an innovative study examining antipsychotic prescribing practices. Led by David Rubin, MD, MSCE, the co-director of PolicyLab, the researchers plan to study whether novel, narrative-informed guidelines that tell stories have a deeper impact on clinicians’ practices than standard guidelines.
As one of CHOP Research’s Centers of Emphasis, PolicyLab’s mission is to achieve optimal child health and well-being by informing program and policy changes through interdisciplinary research. At PolicyLab, the team’s experience caring for children and families informs its “evidence to action” approach to improving children’s health. Current projects include a Pennsylvania-wide evaluation of maternal and child home visiting programs, research addressing barriers to timely immunization, and a study of changes in children’s health care coverage under the Affordable Care Act.
With their current project, Dr. Rubin and colleagues — including his co-Principal Investigator, Zachary Meisel, MD, MPH, MSc, from the University of Pennsylvania’s Department of Emergency Medicine; and Kathleen Noonan, JD, the co-director of PolicyLab — plan to compare narrative-accompanied prescription guidelines with more traditional, “didactic” evidence-based prescription guidelines. Over the course of their three-year project, Dr. Rubin and his team hope to determine whether guidelines that both involve a narrative component and give clinicians a voice have any effect on antipsychotic prescribing habits.
The study comes as concerns grow about the increasing rate of antipsychotic prescriptions for children. Antipsychotics are a class of medications used to treat mental and behavioral health disorders. Traditionally, antipsychotics, which act like powerful sedatives, have been prescribed only to children with major psychotic disorders such as schizophrenia, bipolar disorder, and autism. But these medications are increasingly being prescribed off-label to treat disruptive behaviors, a practice that lacks supporting safety and efficacy data.
The use of antipsychotic medications among children has risen significantly over the past twenty years, largely because of their growing use to manage disruptive behaviors. Youth who are especially at-risk for increasing prescription of antipsychotic medications are Medicaid-enrolled children, for whom antipsychotic prescribing has grown at a rate far exceeding that for children who are privately insured.
Overall, some 25 percent of Medicaid-enrolled children receiving mental health treatment were prescribed antipsychotics by 2007, largely for less severe disorders like attention deficit hyperactivity disorder (ADHD). Particularly alarming, especially given their complex trauma histories, children in foster care are prescribed antipsychotic medications at a rate three times higher than children enrolled in Medicaid overall.
Another cause for concern is the growing practice of polypharmacy, the prescription of antipsychotic medications prescribed in combination with other mental health drugs. In a study published recently in the Journal of the American Academy of Child & Adolescent Psychology, Dr. Rubin and colleagues found that children were increasingly prescribed antipsychotic medications alongside other psychotropic medications, such as stimulants, at the same time.
The rise in antipsychotic prescriptions also points to a need for — and a lack of — non-pharmaceutical behavioral health treatment options for an at-risk population of children and youth. Only specialized behavioral health treatments can address the underlying trauma often driving disruptive behaviors.
Moreover, antipsychotic medications can cause challenging side effects. Particularly concerning have been reports of serious adverse metabolic effects, including rapid weight gain, glucose intolerance, and type 2 diabetes, which may affect children more than adults.
Clinician Narratives Wanted
The study team will conduct their study in two parts. In its first phase, they will conduct semi-structured interviews with a sampling of Pennsylvania clinicians to elicit narratives from them. They will seek to interview between 30 and 50 clinicians across a range of specialties, with the goal of identifying key themes and constructs that influence clinicians’ prescribing habits.
By synthesizing data from the clinician interviews, the investigators plan to create sample narratives that use real events but redact confidential information. A focus group will help the investigators narrow these synthesized narratives down to three “core” narratives to be tested in the second phase of the research project.
Narratives have been shown to promote behavior change on the part of patients, helping clinicians improve assessments of falls in older patients, promote well-being after stroke, and in the research of CHOP’s Roy Wade Jr., MD, MPH, use children’s feedback to inform responses to childhood adversity. But what remains less clear is the impact narratives can have on clinicians.
However, as Dr. Meisel points out in a blog post written for PolicyLab, “a powerful story will stick.”
“We know that stories can help patients – there are some excellent studies showing that stories which maximize concepts such as homophily (where the audience identifies with the storyteller) can move patients to engage in healthier behavior, including controlling their blood pressure and getting a cancer screening,” he writes. In addition, “stories can help researchers and clinicians translate evidence to policymakers in salient and coherent ways.”
Dr. Meisel has done other work on narrative implementation for physicians. “If you ask them, physicians will tell you that they want to learn new information in a probabilistic way,” Dr. Meisel said. “But when you compare narratives to bare-bones data presentations (which we have done in other work looking at guideline adoption), the stories do better. From a cognitive perspective, it makes sense. After all, doctors are people too.”
In the study’s second phase, which Drs. Rubin and Meisel hope to begin by the middle of 2016, the researchers will test the effectiveness of the narrative-influenced guidelines. They plan to target roughly 3000 to 4000 psychiatrists, pediatricians, and family practitioners across Pennsylvania, who they will break into three groups. One group, a control, will only receive standard recommendations, while the “low-dose” and “high-dose” arms of the study will receive one and three narratives, respectively. Medicaid claim data will be used to ascertain how effective each arm was.
“We are concerned about the rate at which children — particularly those in foster care — are prescribed powerful antipsychotic medications, and are interested in learning whether prescribing guidelines accompanied by narratives have more of an effect on clinicians than traditional guidelines,” said Dr. Rubin. “We are grateful to the William T Grant Foundation for giving us the opportunity to impact this issue.”