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Prevalence of Psychotherapy Surrounding Initiation of Psychotropic Polypharmacy in the Medicaid-Insured Population, 1999-2010

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Title:
Prevalence of Psychotherapy Surrounding Initiation of Psychotropic Polypharmacy in the Medicaid-Insured Population, 1999-2010
Creator:
Hincapie Castillo, Juan Manuel
Place of Publication:
[Gainesville, Fla.]
Florida
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University of Florida
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english
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1 online resource (44 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.P.)
Degree Grantor:
University of Florida
Degree Disciplines:
Pharmaceutical Sciences
Pharmaceutical Outcomes and Policy
Committee Chair:
WINTERSTEIN,ALMUT GERTRUD
Committee Co-Chair:
XIAO,HONG

Subjects

Subjects / Keywords:
polypharmacy -- psychotherapy
Pharmaceutical Outcomes and Policy -- Dissertations, Academic -- UF
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bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Pharmaceutical Sciences thesis, M.S.P.

Notes

Abstract:
Guidelines published for the management of the most common psychiatric disorders suggest initiating therapy with behavioral or psychotherapy modalities followed by concomitant pharmacotherapy. This is especially the case for pediatric patients for whom behavioral therapy is recommended as the first line of treatment for conditions such as attention deficit-hyperactivity disorder (ADHD), depression, and conduct disorder. Notwithstanding these recommendations, multiple reports on the treatment of psychiatric disorders continue to show overutilization of psychotropic drugs and increasing trends of psychotropic medication polypharmacy (PMP). These previous findings might suggest over-reliance on pharmacotherapy use and underuse of other treatment strategies like behavioral therapy. This research aimed to quantify the prevalence of psychotherapy among Medicaid-insured patients within six months of initiating psychotropic medication polypharmacy (PMP). Using the Medicaid Analytic eXtract database for 29 states from 1999 to 2010, investigators established ten two-year cohorts of pediatric and adult patients who received two or more psychotropic drugs with a 45-day overlapping days' supply. Among PMP initiators, the prevalence of psychotherapy services, identified from encounter claims via Current Procedural Terminology and Healthcare Common Procedure Coding System codes, was calculated for the six months before and the six months after initiation of PMP. PMP prevalence varied from 21.2% to 27.7% and from 48.5% to 58.0% in pediatric and adult Medicaid-insured patients, respectively. Among pediatric patients who started PMP (N=397,728), the proportion who had received psychotherapy before PMP varied from 21.0% in the 1999-2000 cohort to 40.0% in 2005-2007. After PMP initiation, psychotherapy prevalence was higher, with estimates ranging from 25.4% in 1999-2000 to 44.1% in 2005-2007. Among adults (N=773,205), the prevalence of psychotherapy after PMP initiation ranged from 12.6% in 1999-2001 to 19.25% in 2003-2005. Psychotherapy prevalence prior to PMP initiation varied greatly across states. Although the prevalence of psychotherapy provided immediately before and after initiation of psychotropic polypharmacy has slightly increased in the past decade, it remains low among Medicaid-insured patients, particularly among adults. Reasons for variation in psychotherapy utilization across states deserve further exploration. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (M.S.P.)--University of Florida, 2017.
Local:
Adviser: WINTERSTEIN,ALMUT GERTRUD.
Local:
Co-adviser: XIAO,HONG.
Statement of Responsibility:
by Juan Manuel Hincapie Castillo.

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UFRGP
Rights Management:
Applicable rights reserved.
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LD1780 2017 ( lcc )

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PREVALENCE OF PSYCHOTHERAPY SURROUNDING INITIATION OF PSYCHOTROPIC POLYPHARMACY IN THE MEDICAID INSURED POPULATION, 1999 2010 By JUAN M. HINCAPIE CASTILLO A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTE R OF SCIENCE IN PHARMACY UNIVERSITY OF FLORIDA 2017

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2017 Juan M. Hincapie Castillo

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To my family

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4 ACKNOWLEDGMENTS I would like to express my gratitude to my primary advisor, Dr. Almut Winterstein whose support and mentorship helped me achieved this new milestone in my academic career. I also would like to thank Dr. Hong Xiao for her trust and advice. Finally, I would like to thank my husband Philip Daniels and the rest of my family for their constant support and love.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 6 LIST OF FIGURE S ................................ ................................ ................................ .......... 7 LIST OF ABBREVIATIONS ................................ ................................ ............................. 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Prevalence of Mental Health Disorders ................................ ................................ ... 11 Role of Psychotherapy in Mental Health Disorders ................................ ................. 11 Psychotropic Medication Polypharmacy ................................ ................................ 12 2 METHODS ................................ ................................ ................................ .............. 14 Study Design and Data Sources ................................ ................................ ............. 14 Study Population ................................ ................................ ................................ ..... 14 Data Analysis ................................ ................................ ................................ .......... 16 3 RESULTS ................................ ................................ ................................ ............... 22 Pediatric Population ................................ ................................ ................................ 22 Adult Po pulation ................................ ................................ ................................ ...... 26 Age Group and State Level Analyses ................................ ................................ ..... 30 4 DISCUSSION ................................ ................................ ................................ ......... 34 5 CONCLUSIONS ................................ ................................ ................................ ..... 39 LIST OF REFERE NCES ................................ ................................ ............................... 40 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 44

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6 LIST OF TABLES Table page 2 1 List of CPT Codes for Psychotherapy ................................ ................................ 18 2 2 List of H Codes for Psychotherapy ................................ ................................ ..... 21 3 1 D e mographic c ha r acteri s tics of Medicaid pediatric study patients across 29 states, 1999 2010 ................................ ................................ ............................... 23 3 2 Prevalence of behavioral therapy surrounding polypharmacy in pediatric Medicaid patients across 29 states, 1999 2010 ................................ ................. 24 3 3 D e mographic c ha r acteri s tics of Medicaid adult study patients across 29 states, 1999 2010 ................................ ................................ ................................ .......... 27 3 4 Prevalence of behavioral therapy surrounding polypharmacy in adult Medicaid patients across 29 states, 1999 2010 ................................ ................. 28 3 5 Prevalence of behavioral therapy surrounding polypharmacy by age group, in Medicaid patients across 29 states ................................ ................................ ..... 31 3 6 Prevalence of behavioral therapy surrounding polypharmacy across 29 states, 1999 2010 ................................ ................................ ............................... 32

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7 LIST OF FIGURES Figure page 2 1 Study design schematic illustrating ascertainment period for psychotherapy befo re and after start of psychotropic medication polypharmacy (PMP) ............. 15 3 1 Prevalence of psychotherapy before and after start of psychotropic medication polypharmacy (PMP) among pediatric Medicaid patients across 29 states, 1999 2010 ................................ ................................ .......................... 25 3 2 Prevalence of psyc hotherapy before and after start of psychotropic medication polypharmacy (PMP) among pediatric Medicaid patients across 29 states, 1999 2010 ................................ ................................ .......................... 29 3 3 Prevalence of behavioral therapy before and after start of polypharmacy across 29 states, 1999 2010 ................................ ................................ .............. 33

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8 LIST OF ABBREVIATIONS ADHD Attention deficit hyperactivity disorder CPT Current Procedure Terminology FDA Food and Drug Administration FFS Fee for service MAX Medicaid Analytic eXtract NSDUH National Survey on Drug Use and Health PCCM Primary Care Case Management PMP Psychotropic medication polypharmacy

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science in Pharmacy PREVALENCE OF PSYCHOTHERAPY SURROUNDING INITIATION OF PSYCHOTROPIC POLYPHARMACY IN THE MEDICAID INSURED POPULATION, 1999 2010 By Juan M. Hincapie Castillo December 2017 Chair: Almut G. Winterstein Major: Pharmaceutical Sciences Guidelines published for the management of the most common psychiatric disorders suggest initiating therapy with behavioral or psychotherapy modalities followed by concomitant pharmacotherapy. This is especially the case for pediatric patients for whom behavioral therapy is recommended as the f irst line of treatment for conditions such as attention deficit hyperactivity disorder (ADHD), depression, and conduct disorder. Notwithstanding these recommendations, multiple reports on the treatment of psychiatric disorders continue to show overutilizat ion of psychotropic drugs and increasing trends of psychotropic medication polypharmacy (PMP). These previous findings might suggest over reliance on pharmacotherapy use and underuse of other treatment strategies like behavioral therapy. This research aime d to quantify the prevalence of psychotherapy among Medicaid insured patients within six months of initiating psychotropic medication polypharmacy (PMP). Using the Medicaid Analytic eXtract database for 29 states from 1999 to 2010, investigators establishe d ten two year cohorts of pediatric and adult patients who received two or more psychotropic drugs with a 45

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10 Among PMP initiators, the prevalence of psychotherapy services, identified from encounter claims via Current Procedur al Terminology and Healthcare Common Procedure Coding System codes, was calculated for the six months before and the six months after initiation of PMP. PMP prevalence varied from 21.2% to 27.7% and from 48.5% to 58.0% in pediatric and adult Medicaid insur ed patients, respectively. Among pediatric patients who started PMP (N=397,728), the proportion who had received psychotherapy before PMP varied from 21.0% in the 1999 2000 cohort to 40.0% in 2005 2007. After PMP initiation, psychotherapy prevalence was hi gher, with estimates ranging from 25.4% in 1999 2000 to 44.1% in 2005 2007. Among adults (N=773,205), the prevalence of psychotherapy after PMP initiation ranged from 12.6% in 1999 2001 to 19.25% in 2003 2005. Psychotherapy prevalence prior to PMP initiati on varied greatly across states. Although the prevalence of psychotherapy provided immediately before and after initiation of psychotropic polypharmacy has slightly increased in the past decade, it remains low among Medicaid insured patients, particularly among adults. Reasons for variation in psychotherapy utilization across states deserve further exploration.

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11 CHAPTER 1 INTRODUCTION Prevalence of Mental Health Disorders The 2014 National Survey on Drug Use and Health (NSDUH) estimated that 18.1% of the United States adult population had a mental illness in the past year (approximately 43.6 million people) (1) The prevalence of mental illness in the past year was estimated at 15.4% among adults with private insurance and at almost twice that amount, 29. 7%, among persons ages 18 and older who are insured by Medicaid. Among the U.S. pediatric population, an estimated 13% of children between the ages of eight and 15 had any mental disorder in the previous year, and 46.3% of 13 to 18 year olds had lifetime prevalence of a ny mental disorder (2) Role of Psychotherapy in Mental Health Disorders Published guidelines for the management of the most common psychiatric disorders consistently suggest providing initial behavioral or psychotherapy followed by concomitant pharmacothe rapy (3 6) This guidance is especially appropriate for pediatric patients, for whom behavioral therapy is recommended as the first l ine of treatment for conditions such as attention deficit hyperactivity disorder (ADHD), de pression, and conduct disorder (7 9) Combining medication use with psychotherapy in the treatment of psychiatric disorders is strongly recommended, based on a diverse body of literature that shows that combined treatment has higher effectivene ss on symptom control compared with only pharmacotherapy. For treatment of ADHD among adults and children, for example, multiple studies consistently report on the substantial contribution of behavioral therapy strategies, such as cognitive behavioral ther apy and family or group therapy, in achievement of symptom resolution, improvement of social

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12 behavior, and in some cases decreased need for pha rmacotherapy augmentation (10 12) Notwithstanding these recommendations, multiple reports on the treatment of psychiatric disorders continue to show overutilization of psychotropic drugs, including increasing trends in use of psychotropic medic ation polypharmacy ( PMP) (13 20) Psychotropic Medication Polypharmacy PMP is defined as the use of two or more psychotropic medications from the same or different drug classes, and it is one of the most common patterns of presc ribing in the United States (21) To illustrate, an analysis of a national sample of ambulatory care visits identified that the percentage of outpatient psychiatry visits for which two or more psychotropic drugs were prescribed increased from 42. 6% in 1997 to 59.8% in 2006 (22) In contrast, it has been estimated that the use of psychotherapy is well below that of PMP. In a recent study of Medicaid insured children with ADHD, 7% of patients received psychotherapy tre atment alone and 32% received both m edication and psychotherapy (23) Although evidence of the prevalence of PMP and trends toward increased use of PMP among various patient populations is abundant, to date no study has evaluated the prevalence of psychotherapy r elative to the initiation of PMP. Given that pharmacotherapy alone might not be sufficient to achieve desired outcomes among many patients with psychiatric disorders, efforts should be made to evaluate the extent to which ancillary treatment strategies are adopted and provide information about patterns of utilization of these strategies. The initiation of PMP among patients receiving psychotropic monotherapy might indicate that patients require additional treatment strategies. Therefore, this period may be particularly important for optimizing the care of Medicaid patients with mental illness. The aim of this study was to quantify the

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13 prevalence of psychotherapy among Medicaid pediatric and adult patients within six months of initiating PMP.

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14 CHAPTER 2 METHODS Study Design and Data Sources We conducted a retrospective, cross sectional analysis of a cohort of Medicaid insured pediatric and adult patients ages 64 and younger to determine the prevalence of psychotherapy in the six months before an d after the initiation of PMP. Prevalence was estimated in two year periods and stratified by age group and state. The data set for this study was established from the Medicaid Analytic eXtract (MAX) files from 1999 to 2010 for 29 states. This large databa se contains individual level information on monthly Medicaid enrollment, demographic variables, and adjudicated inpatient and outpatient medical encounter claims as well as detailed prescription dispensing data. The 29 states selected for the study are tho se with the largest fee for service (FFS) population, representing over 80% of the entire Medicaid FFS population, per 2002 estimates. The study was approved by the institutional review and privacy boards of the University of Florida and the privacy office of the Centers for Medicare and Medicaid Services. Study Population Patients were selected for the study if they were enrolled in Medicaid under FFS or Primary Care Case Management (PCCM). We excluded patients enrolled in comprehensive managed care becau se of concerns about the completeness and usability of claims for research purposes (24) We established ten cohorts of patients between the ages of zero and 64 who were enrolled in Medicaid between 1999 and 2010 and who had two years of continuous enrollment after receipt of a prescription for a psychotropic medication, resulting in ten two year blocks. For each two year block, we identified the first dispensing of a psychotropic medication (cohort entry date) and

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15 required ea ch qualifying patient to have continuous enrollment for at least two years thereafter. We further restricted our study population to patients who started PMP between six months after cohort entry and six months before cohort exit (the end of the two year f ollow up period). This strategy ensured that prevalence estimates for psychotherapy reflected the enrollment period that was included in the assigned two year block (Figure 2 1). P atients could be included in multiple blocks if they met all inclusion crite ria. For additional stratified analyses by age and state, we assigned patients to a group by using information from the earliest two year block. For example, a child in Florida who entered Medicaid at age 5 during 2001 and remained continuously enrolled un til 2006 would contribute data only for the Florida and five and younger groups. Figure 2 1. Study design schematic illustrating ascertainment period for psychotherapy before and after start of psychotropic medication polypharmacy (PMP)

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16 Data Analysis For each patient from the two year cohorts, we extracted all prescription pharmacy claims for all psychotropic medications with FDA approval for treatment of psychiatric disorders. Drug classes included alpha agonists, antidepressants, antipsychotics, lith ium, anticonvulsants, and sedatives/hypnotics/anxiolytics. Medications were identified by National Drug Code, and the duration of active pharmacotherapy was determined from the dispensing date plus the reported days of supply listed in the billing claim an d a ten day grace period to account for late refills. For PMP was defined by an ove rlap of greater than 45 days in the active periods of two or more psychotropic medications with different active ingredients. This overlap method is consistent with previous studies published on polypharmacy, and it is a generally accepted threshold (25) The first fill date of the second medication contributing to the overlap definition was considered to be the date of PMP initiation. Prevalence of psychotherapy was estimated as the proportion of PMP patients with a claim for psychotherapy within six months before and within six months after the start of PMP, respectively. We determined psyc hotherapy from selected outpatient and inpatient claims by using Current Procedure Terminology (CPT) and Healthcare Common Proced ure Coding System (H) codes (26) We included CPT codes for indiv idual psychotherapy (90804 90829) and psychotherapy with family members and group settings (90857 90876) and selected H codes for services used in billing for provision of behavioral, psychosocial, or psychiatric support services. (Table 2 1, Table

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17 2 2). A ll data management and statistical analyses were conducted with SAS, version 9.4, and ArcGIS 10.2.2.

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18 Table 2 1. List of CPT Codes for Psychotherapy Code Description 90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face to face with the patient 90805 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face to face with the patient; with medical evaluation and management services 90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face to f ace with the patient 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face to face with the patient; with medical evaluation and management services 90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient 90809 Individual psychotherapy, insight oriented, behavior modifyin g and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient; with medical evaluation and management services 90810 Individual psychotherapy, interactive, using play equipment, physical devices, la nguage interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face to face with the patient 90811 Individual psychotherapy, interactive, using play equipment, physical devices, lan guage interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face to face with the patient; with medical evaluation and management services 90812 Individual psychotherapy, interact ive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face to face with the patient 90813 Individual psychotherapy, interacti ve, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face to face with the patient; with medical evaluation and management ser vices 90814 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient

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19 Table 2 1. Continued Code Description 90815 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient; with medical evaluation and management services 90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face to face with the patient 90817 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 30 minut es face to face with the patient; with medical evaluation and management services 90818 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face to face with the patient 90819 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face to face wit h the patient; with medical evaluation and management services 90821 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face to face with the patient 90822 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face to face with the patient; wit h medical evaluation and management services 90823 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an inpatient hospital, partial hospital or resident ial care setting, approximately 20 to 30 minutes face to face with the patient 90824 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an inpatient hosp ital, partial hospital or residential care setting, approximately 20 30 minutes face to face with the patient; with medical evaluation and management services 90826 Individual psychotherapy, interactive, using play equipment, physical devices, language in terpreter, or other mechanisms of non verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face to face with the patient 90827 Individual psychotherapy, interactive, using play equipm ent, physical devices, language interpreter, or other mechanisms of non verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face to face with the patient; with medical evaluation and management services

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20 Table 2 1. Continued Code Description 90828 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face to face with the patient 90829 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 80 minutes face to face with the patient; with medical evaluation and management services 90857 Interactive group psychotherapy 90832 Psychotherapy, 30 minutes with patient and/or family member 90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service 90834 Psychotherapy, 45 minutes with patient and/or family member 90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service 90837 Psychotherapy, 60 minutes with patient and/or family member 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluati on and management service 90839 Psychotherapy for crisis; first 60 minutes 90840 Psychotherapy for crisis; each additional 30 minutes 90846 Family psychotherapy (without the patient present) 90847 Family psychotherapy (conjoint pyschotherapy) (with patient present) 90849 Multiple family group psychotherapy 90853 Group Psychotherapy (other than of a multiple family group) 90863 Pharmacologic managament, including prescription and review of medication, when performed with psychotherapy services 908 75 Individual psychophysiological therapy incorporating biofeedback training by any modality, with psychotherapy; 30 minutes 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality, with psychotherapy; 45 minutes 4050F Patient referral for psychotherapy documented 4060F Psychotherapy services provided

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21 Table 2 2 List of H Codes for Psychotherapy Code Description H0004 Behavioral health counseling and therapy, per 15 minutes H0017 Behavioral health; residential (hospital residential treatment program), without room and board, per diem H0018 Behavioral health; short term residential (non hospital residential treatment program), without room and board, per diem H0019 Behavioral health; long term residential (non medical, non acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem H0036 Community psychiatric supportive treatment, face to face, per 15 minutes H0037 Community psychiatric supp ortive treatment program, per diem H0038 Self help/peer services, per 15 minutes H0039 Assertive community treatment, face to face, per 15 minutes H0040 Assertive community treatment program, per diem H0046 Mental health services, not otherwise specified H2012 Behavioral health day treatment, per hour H2013 Psychiatric health facility service, per diem H2017 Psychosocial rehabilitation services, per 15 minutes H2018 Psychosocial rehabilitation services, per diem H2019 Therapeutic behavioral services, per 15 minutes H2020 Therapeutic behavioral services, per diem

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22 CHAPTER 3 RESULTS Pediatric Population Most of the included pediatric patients were male and nonwhite (Table 3 1). The decline in the number of patients in the sample size for each cohort in the last years of the study is consistent with the shift from FFS and PCCM to managed care programs, a shift that led to increasing exclusion of Medicaid beneficiaries from our analysis. Approximately 10% of children included in eac h of the cohorts were in foster care, and more than 30% required cash assistance. More than 20% of children across the cohorts received Medicaid because of disability, and there was an increasing trend in the number of pediatric patients who qualified on t he basis of poverty. There was an increasing trend in the prevalence of PMP among children who received at least one psychotropic medication, with estimates ranging from 21.2% to 27.7% b etween 1999 2001 and 2008 2010 (results presented elsewhere) (27) Among children who initiated PMP (N=397,728), we found increasing prevalence in the use of prior psychotherapy across our study period, starting with 21% of patients in the 1999 2000 cohort to a maximum of 40% of patients in the 2005 2007 cohort ( Table 3 2) ( Figure 3 1 ). From 1999 2001 to 2008 2010, there was an 11% increase in the prevalence of psychotherapy before PMP initiation and a 12% increase in the prevalence of psychotherapy after the start of PMP. Pediatric cohorts consistently showed higher prevalence of psychotherapy after PMP initiation than before PMP initiation, with estimates of prevalence of psychotherapy after PMP initiation ranging between 25.4% in the 1999 2000 cohort to 44.0 5% in the 2005 2007 cohort

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23 Table 3 1. D e mographic c ha r acteri s tics of Medicaid pediatric study patients across 29 states, 1999 2010 Characteristic 1 9 99 2 0 01 2 0 00 2 0 02 2 0 01 2 0 03 2 0 02 2 0 04 2 0 03 2 0 05 2 0 04 2 0 06 2 0 05 2 0 07 2 0 06 2 0 08 2 0 07 2 0 09 2 0 08 2 0 10 Sample size* 637,174 683,280 769,872 8 23,047 966,613 8 09,466 6 39 182 5 52,980 557,371 485,874 % Male 59.1 58 9 58 7 58 8 58.5 59.3 59 8 59 6 59.5 59.7 % White 44 5 45 4 46 8 48 8 49.6 48.1 46.6 45.4 44.6 44.5 % Black 32 4 33.2 31 6 31 5 29.5 28 8 28 5 26 9 26.8 25.4 % American India n / Alask a n Native 0.7 0.7 0.8 0.9 0.8 0.9 1.1 1.3 1.3 1.1 % Asian 1.0 0.9 0.9 0.9 0.8 0.8 0.9 1.0 1.1 1.2 % Hispanic/ Latino 15.4 15.3 15.8 14.2 15.6 17.4 18.6 21.2 21.9 23.5 % Native Hawaiian/ Pacific islander 0.2 0.2 0.2 0.1 0.2 0.1 0.1 0.1 0.1 0.1 % Hispanic/ Latino a nd 1 Races 1.7 1.3 1.1 0.9 0.8 1.0 1.2 1.3 1.5 1.7 R ace 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.2 0.2 0.3 % Unkno w n Race 3.1 3.0 2.7 2.7 2.7 2.9 2.8 2.6 2.6 2.3 Age <=5 30.6 30.5 31.1 28.5 29.8 27.9 25.7 26.7 27.1 26.1 Age 6 9 28.9 28.0 26.8 26 8 25 8 25 9 26 2 26 4 26 9 27 3 Age 1 0 14 32.4 32.9 33.3 35 2 34.6 35.4 36.3 35.2 34.4 34.8 Age 15 17 8.1 8.5 8.9 9.6 9.8 10 8 11 8 11 8 11 6 11 8 Foster care 11 5 11 3 10 6 10.3 9.2 10.3 12 5 12 5 11.3 11.7 Cash assistance 46 5 43.0 41.0 39 .2 38.2 37.1 36.4 33.9 33 5 33 1 Poverty 35 6 39.0 41.6 43.6 44.4 45 2 46.5 49 6 52 0 52.4 Disability 24.2 22.3 20.6 20.6 19.6 21.5 23.4 22 8 23.1 23.4 ( Children age 0 1 7 with 1 psych o tropic d r ug claim followed b y 2 y e ars cont i nu o us F F S/PC C M eligibility )

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24 Table 3 2. Prevalence of behavioral therapy surrounding polypharmacy in pediatric Medicaid patients across 29 states, 1999 2010 Y ear Eligible patients* Behavioral therapy prior to PMP % Behavioral therapy after PMP % 1999 2001 34,846 7,456 21.40 8,851 25.40 2000 2002 37,349 8,386 22.45 9,986 26.74 2001 2003 42,822 9,936 23.20 11,650 27.21 2002 2004 49,612 11,520 23.22 18,259 36.80 2003 2005 59,886 17,802 29.73 25,677 42.88 2004 2006 46,576 17,910 38.45 20,241 43.46 2005 2007 36,307 14,654 40.36 15,995 44.05 2006 2008 31,117 12,091 38.86 12,993 41.76 2007 2009 31,124 11,365 36.52 12,446 39.99 2008 2010 28,089 9,083 32.34 10,479 37.31 *Defined as patients (children and adults) with a minimum of 2 years FFS/PCCM eligibility after the first psychotropic drug claim (index date) and start of polypharmacy.

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25 Figure 3 1. Prevalence of psychotherapy before and after start of psychotropic medication polypharmacy (PMP) among pediatric Medicaid patients across 29 states, 1999 2010

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26 Adult Population Baseline characteristics for adult Medicaid insured patients d iffered from those of t he pediatric population (Table 3 3 ). For example, the majority of adult patients who used at least one psychotropic drug claim were female rather than male, the proportion of patients who qualified for Medicaid benefits because of disability was larger, and the vast majority received cash assistance versus 47% or less among children. The prevalence of PMP among patients who received at least one psychotropic medication was consistently higher among adults than among pediatric cohort s, ranging from 48.5% in the 1999 2001 cohort to 58% in the 2007 2009 group (results pr esented elsewhere) (28) When evaluating the prevalence of psychotherapy among adult PMP initiators (N=773,205), we saw that at best 16.7% rece ived this treatment strategy in the six months prior to the start of PMP ( Table 3 4 ) ( Figure 3 2). Prevalence of psychotherapy after the start of PMP was only slightly higher, ranging from 12.6% in the 1999 2001 cohort to 19.3% in the 2003 2005 block. Amon g adults, the increase in prevalence of psychotherapy from 1999 2001 to 2008 2010, both before (2%) and after (3%) PMP start, was smaller than among pediatric patients

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27 Table 3 3 D e mographic c ha r acteri s tics of Medicaid adult study patients acro ss 29 states, 1999 2010 Characteristic 1 9 99 2 0 01 2 0 00 2 0 02 2 0 01 2 0 03 2 0 02 2 0 04 2 0 03 2 0 05 2 0 04 2 0 06 2 0 05 2 0 07 2 0 06 2 0 08 2 0 07 2 0 09 2 0 08 2 0 10 Sample size* 836,878 841,956 892,070 915,863 1,068,432 873,102 756,488 607,417 575,093 515,730 % Male 33.5 33.3 33.0 33.0 32.5 33.9 35.7 36.8 37.1 37.9 % White 52.8 52.7 53.5 55.1 59.0 56.0 56.1 55.9 55.9 56.0 % Black 26.1 26.4 26.3 25.9 24.3 24.9 24.0 23.8 23.9 22.6 % American India n / Alask a n Native 0.7 0.6 0.7 0.8 0.7 0.9 1.0 1.2 1.2 1.1 % Asian 1.6 1.4 1.3 1.3 1.1 1.3 1.4 1.5 1.5 1.7 % Hispanic/ Latino 8.1 8.3 8.2 7.5 6.5 7.9 8.2 8.7 9.0 10.0 % Native Hawaiian/ Pacific islander 2.0 2.0 1.9 1.8 1.5 1.8 2.2 2.5 2.4 2.5 % Hispanic/ Latino a nd 1 Races 2.7 2.7 2.6 2.6 2.3 0.8 2.8 2.1 2.0 2.0 Race 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 % Unkno w n Race 6.0 5.8 5.4 4.9 4.4 4.4 4.2 4.2 4.0 4.0 Age 18 29 17.1 17.6 18.4 19.6 20.5 19.9 18.8 19.6 20.6 21.2 Age 30 39 21.7 21.3 21.1 20.9 20.5 18.9 17.3 16.9 16.9 17.0 Age 40 49 27.6 27.5 27.5 27.4 26.9 27.0 27.1 26.5 26.0 25.4 Age 50 64 33.6 33.7 33.0 32.2 32.1 34.2 36.9 37.1 36.6 36.4 Cash assistance 93.2 92.7 92.7 91.8 85.5 90.4 90.3 88.9 90.1 87.2 Poverty 0.5 0.5 0.7 1.0 1.1 1.3 1.3 1.5 1.7 1.5 Disability 86.9 85.5 83.4 81.8 75.5 82.9 86.9 86.8 86.1 84.6 *( Adults aged 18 64 with 1 psych o tropic d r ug claim followed b y 2 y e ars cont i nu o us F F S/PC C M eligibility)

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28 Table 3 4 Prevalence of behavioral therapy surrounding polypharmacy in adult Medicaid patients across 29 states, 1999 2010 Y ear Eligible patients* Behavioral therapy prior to PMP % Behavioral therapy after PMP % 1999 2001 84,107 8,794 10.46 10,608 12.61 2000 2002 85,668 8,681 10.13 11,506 13.43 2001 2003 89,149 9,914 11.12 12,738 14.29 2002 2004 92,541 10,526 11.37 15,586 16.84 2003 2005 110,316 13,352 12.10 21,239 19.25 2004 2006 82,403 12,744 15.47 15,598 18.93 2005 2007 71,075 11,551 16.25 13,545 19.06 2006 2008 56,211 9,369 16.67 10,235 18.21 2007 2009 53,656 8,317 15.50 9,534 17.77 2008 2010 48,079 6,216 12.93 7,559 15.72 *Defined as patients (children and adults) with a minimum of 2 years FFS/PCCM eligibility after the first psychotropic drug claim (index date) and start of 6 months FFS/PCCM after start of polypharmacy.

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29 Figure 3 2. Prevalence of psychotherapy before and after start of psychotropic medication polypharmacy (PMP) among pediatric Medicaid patients across 29 states, 1999 2010

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30 Age Group and State Level Analyses Results for the age stratified analysis in Table 3 5 show that pediatric patients between the ages of six and 14 had the highest prevalence of psychotherapy both before (33%) and after (40%) initiation of PMP. The prevale nce of psychotherapy among adults remained lower than among pediatric patients and showed a decreasing trend with increasing age. The prevalence of psychotherapy before PMP initiation declined from 19.9% among patients ages 18 to 29 to 10.3% in the 50 to 64 year old group. Similarly, prevalence of psychotherapy after start of PMP decreased from 26.0% to 13.0% in the same age groups. We observed significant variation in the prevalence of psychotherapy surrounding PMP initiati on at the state level (Table 3 6 ) (Figure 3 3). We suppressed results for six of the 29 states in our data set because of small sample size and unreliable prevalence estimates. Among children, prevalence of psychotherapy prior to PMP initiation was highest in Indiana, Kansas, and Missour i. Among adults, the prevalence was highest in I ndiana, Kansas, and New Jersey.

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31 Table 3 5 Prevalence of behavioral therapy surrounding polypharmacy by age group, in Medicaid patients across 29 states Age group Eligible patients* Behavioral therapy prior to PMP % Behavioral therapy after PMP % <=5 35,092 9,663 27.54 11,983 34.15 6 9 73,588 24,083 32.73 29,563 40.17 10 14 73,009 24,222 33.18 29,668 40.64 15 17 14,696 4,667 31.76 5,513 37.51 18 29 82,055 16,328 19.90 21,256 25.90 30 39 92,265 16,078 17.43 21,301 23.09 40 49 116,317 17,163 14.76 22,302 19.17 50 64 108,243 11,144 10.30 14,369 13.27 *Defined as patients with a m inimum of 2 years F F S/PC C M eligibility af t er the first ps y chotr o pic dr u g claim (i n dex date) and s t art of p o lypharm a cy ( 2 c o ncomitant psy c hotr o pics) more th a n 6 months a f ter i ndex date a nd at least 6 mon t hs FF S /PC C M aft e r start of pol yp harma c y.

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32 Table 3 6 Prevalence of behavioral therapy surrounding polypharmacy across 29 states, 1999 2010 State Pediatric patients Adult patients Eligible patients* Behavioral therapy prior to PMP % Behavioral therapy after PMP % Eligible patients* Behavioral therapy prior to PMP % Behavioral therapy after PMP % Arkansas 4,872 1,077 22.11 1,121 23.01 2,942 413 14.04 474 16.11 California 13,845 130 0.94 231 1.67 71,084 479 0.67 530 0.75 Florida 10,317 2,621 25.40 1,533 14.86 15,117 2,928 19.37 1,535 10.15 Georgia 10,280 3,015 29.33 1,495 14.54 15,403 2,635 17.11 1,350 8.76 Idaho 2,711 1,089 40.17 420 15.49 2,954 664 22.48 428 14.49 Illinois 15,933 5,824 36.55 2,722 17.08 20,831 5,946 28.54 2,474 11.88 Indiana 7,668 4,756 62.02 990 12.91 13,274 5,086 38.32 1,827 13.76 Kansas 3,180 1,919 60.35 436 13.71 2,917 1,225 42.00 357 12.24 Louisiana 14,555 1,461 10.04 1,382 9.50 18,146 1,463 8.06 1,002 5.52 Massachusetts 1,259 319 25.34 124 9.85 1,893 436 23.03 208 10.99 Minnesota 4,484 2,471 55.11 547 12.20 6,563 2,834 43.18 808 12.31 Mississippi 5,101 1,384 27.13 876 17.17 7,821 1,019 13.03 794 10.15 Missouri 6,754 4,313 63.86 755 11.18 21,286 5,699 26.77 2,942 13.82 New Jersey 1,741 758 43.54 215 12.35 5,544 1,775 32.02 548 9.88 New York 11,984 405 3.38 282 2.35 53,481 3,682 6.88 2,412 4.51 North Carolina 14,143 7,097 50.18 2,336 16.52 24,717 6,023 24.37 3,516 14.23 Ohio 15,173 1,713 11.29 1,010 6.66 32,445 2,974 9.17 2,020 6.23 South Carolina 7,266 3,433 47.25 993 13.67 9,572 2,167 22.64 1,068 11.16 Tennessee 5,052 796 15.76 1,464 28.98 18,921 1,316 6.96 3,054 16.14 Texas 23,332 11,489 49.24 3,646 15.63 22,940 5,785 25.22 2,622 11.43 Virginia 4,764 2,620 55.00 590 12.38 6,891 1,549 22.48 794 11.52 West Virginia 3,437 891 25.92 483 14.05 11,915 1,738 14.59 1,133 9.51 Wisconsin 5,991 2,654 44.30 816 13.62 7,503 2,239 29.84 945 12.59 *Defined as patients (children and adults) with a m inimum of 2 years F F S/PC C M enrollment af t er the first ps y chotr o pic dr u g claim (i n dex date) and s t art of p o lypharm a cy ( 2 c o ncomitant psy c hotr o pics) more th a n 6 months a f ter i ndex date a nd at least 6 mon t hs enrollment aft e r start of pol yp harma c y.

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33 Figure 3 3. Prevalence of behavioral therapy before and after start of polypharmacy across 29 states, 1999 2010

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34 CHAPTER 4 DISCUSSION We aimed to quantify the prevalence of psychotherapy use among Medicaid insured patients within six months of initiating PMP. Our analysis revealed several important findings. First, utilization of psychotherapy surrounding initiation of polypharmacy was low for both pediatric and adult Medicaid insured patients This finding suggests a potential overreliance on the use of medications, including the practice of polypharmacy, and underutilization of nonpharmacological modalities indicated for the treatment of mental illness. Our results suggest that among pediatri c patients who started PMP, fewer than half received any kind of psychotherapy in the six months surrounding the addition of one or more psychotropic drugs to their pre existing pharmacotherapy regimen. The six month period after initiation of the first ps ychotropic previously pointed out, psychotherapy can play an important role in achieving desired clinical end points and its use might prevent the start of polypharmacy i n some cases. Second, the proportion of pediatric patients who received psychotherapy was lower than recommended in clinical guidelines both before and after the start of PMP, although it was higher than the proportion among adults. For example, the Americ an Academy of Family Physicians recommends behavioral therapy as a component of treatment for depression among children and adolescents, especially among those with moderate to severe depression (8). Likewise, the guidelines for treatment of ADHD from the American Academy of Pediatrics strongly recommend that behavioral therapy ought to be the first line of treatment for patients younger than five years of age and should also be given in combination with pharmacotherapy for elementary school aged

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35 children. Besides patients with depression and ADHD, psychotherapy is also recommended for pediatric patients presenting with other conditions, such as conduct disorders, anxiety, and posttraumatic stress disorder, among others (9, 29, 30) Among all Medicaid insured children, the prevalence of psycho therapy before and after PMP initiation was lowest for patients younger than five years of age and younger. This finding is concerning, given that psychotherapy is strongly and consistently recommended for pediatric patients with psychiatric disorders and, more important, for the youngest of these patients. Although we found an increasing trend in prevalence in the use of psychotherapy surrounding PMP initiation, the increase was not great, and the gap between recommended mental health care and utilization remains a concern. Polypharmacy safety issues are not negligible and should be considered in the benefit risk assessment of a pharmacotherapy regimen prior to the start of treatment. PMP carries inherent risks, given that patients are exposed to multiple d rugs with distinct side effect profiles and potential for interactions. Common drug drug interactions among psychotropic medications have been found to lead to respiratory depression, risk of cardiac arrhythmias through QT prolongation, depression of the c entral nervous system, and manifestat ion of serotonin syndrome (31, 32) In light of the potential for these safety concerns, the disconnect between the underutilization of effective evidence based psychotherapy approaches and overutilization of highly risky polypharmacy practices needs to be explored. In order to achieve the appropriate equilibrium between pharmacological treatment and psychotherapy for mental disorders, both types of treatment mus t be accessible to patients (33) Recent reports found that the number of psychiatrists

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36 practicing in the United States did not increase between 2000 and 2013, and, if adjusted for population size, the mean number of psychiatrists actually decreased b y almost 10% in this period (34) Adding to these shortages, clinics may refuse to take Medicaid insured patients because of unsatisfactory reimbursement agreements. Psychiatris ts in fact have been found to be the least likely medical specialty to accept in surance plans from Medicaid (35) Primary care providers are left with the responsibility to address complex mental health care needs but may not have the training or the resources required for proper psychotherapeutic man agement of these conditions (36) Future studies should aim at evaluating the specific barriers and challenges faced by Medicaid insured patients in obtaining psychotherapy and determine what groups benefit the most from psychotherapy in order to optimize resource utilization. Similarly, psychotherapy might not be initiated for certain patients for multiple reasons, and future research should also evaluate the conditions that lead to underutilization of this treatmen t strategy. Our study is the first to evaluate the prevalence of psychotherapy in relationship to initiation of polypharmacy. Previous studies have reported prevalence of these two treatment modalities separately, but no information to date has been provid ed for a adequate and a more comprehensive approach appears necessary. We used a large database that includes data for all medical encounters for pediatric and adult pat ients enrolled in Medicaid programs in 29 states, which allowed age specific and spatial analyses of treatment disparities.

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37 Aside from these strengths, results should be carefully interpreted in light of the data used. First, we used only Medicaid data, an d results should be generalized only to patients insured under this program. Use of psychotherapy and other metrics of adequate care have shown pronounced differences between Medicaid and privately insured populations. It is important to note that besides factors related to physicians and patients in choosing psychotherapy, Medicaid enrollees may face additional barriers in receiving adequate mental health care. A st udy by Melfi and colleagues (37) evaluating treatment modalities for depression in an adult population showed tha t whereas 45.0% of patients with private insurance received any kind of psychotherapy, the same was true for only 20.0% of patients insured by Medicaid. Second, psychotherapy use was ascertained from billing codes; thus encounters that were paid out of poc ket might have been missed. In addition to CPT codes, however, our study also included H codes, which have not been considered in previous studies and which should aid in comprehensive capture of all related services that were reimbursed by Medicaid (23) Pediatr ic patients might also receive psychotherapy through participation in school based programs, for example, and these too would not be captured by the claims data. Third, our analyses included results for only Medicaid patients in the FFS and PCCM programs a nd therefore cannot provide assessments of patients enrolled in managed care programs or in plans with mental health carve outs, both increasingly common in Medicaid benefit sche mes (38) Finally, our state analysis showed some states with very low prevalence of psychotherapy surrounding PMP [see online supplement]. This finding might reaffirm the issue raised earlier on the move toward

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38 managed care and carving out of mental health services in some states that might reflect in low capture of psychotherapy from our data. Notwithstanding these limitations, this study suggest s underutilization of psychotherapies among Medicaid insured patients receiving psychiatric polypharmacy.

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39 CHAPTER 5 CONCLUSIONS Although prevalence of psychotherapy immediately before and after initiation of psychotropic polypharmacy among Medicaid insured patients has slightly increased in the past decade, it remains low, particularly among adults. Future research should determin e barriers that are limiting the use of psychotherapy and their potential treatment strategies to counter increasing psychotropic polypharmacy trends.

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40 LIST OF REFERENCES 1. SAMHSA: 2014 National Survey on Drug Use and Health: Mental Health Detailed Tables. Edited by Administration SAaMHS. Rockville, MD, 2015 2. Merikangas KR, He JP, Burstein M, et al.: Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidi ty Survey Replication -Adolescent Supplement (NCS A). J Am Acad Child Adolesc Psychiatry 49:980 9, 2010 3. Qaseem A, Barry MJ, Kansagara D, et al.: Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 164:350 9, 2016 4. Koran LM, Hanna GL, Hollander E, et al.: Practice guideline for the treatment of patients with obsessive compulsive disorder. Am J Psychiatry 164:5 53, 2007 5. L ocke AB, Kirst N, Shultz CG: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician 91:617 24, 2015 6. Ursano RJ, Bell C, Eth S, et al.: Practice guideline for the treatment of patients with acute stress dis order and posttraumatic stress disorder. Am J Psychiatry 161:3 31, 2004 7. Wolraich M, Brown L, Brown RT, et al.: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention deficit/hyperactivity disorder in children and ado lescents. Pediatrics 128:1007 22, 2011 8. Clark MS, Jansen KL, Cloy JA: Treatment of childhood and adolescent depression. Am Fam Physician 86:442 8, 2012 9. Searight HR, Rottnek F, Abby SL: Conduct disorder: diagnosis and treatment in primary care. Am Fam Physician 63:1579 88, 2001 10. Van der Oord S, Prins PJ, Oosterlaan J, et al.: Efficacy of methylphenidate, psychosocial treatments and their combination in school aged children with ADHD: a meta analysis. Clin Psychol Rev 28:783 800, 2008 11. Abramowitz A J, Eckstrand D, O'Leary SG, et al.: ADHD children's responses to stimulant medication and two intensities of a behavioral intervention. Behav Modif 16:193 203, 1992 12. Safren SA, Sprich S, Mimiaga MJ, et al.: Cognitive behavioral therapy vs relaxation wit h educational support for medication treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 304:875 80, 2010

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41 13. Comer JS, Olfson M, Mojtabai R: National trends in child and adolescent psychotropic polypharmacy in office base d practice, 1996 2007. J Am Acad Child Adolesc Psychiatry 49:1001 10, 2010 14. Constantine RJ, Andel R, Tandon R: Trends in adult antipsychotic polypharmacy: progress and challenges in Florida's Medicaid program. Community Ment Health J 46:523 30, 2010 15. Constantine RJ, Boaz T, Tandon R: Antipsychotic polypharmacy in the treatment of children and adolescents in the fee for service component of a large state Medicaid program. Clin Ther 32:949 59, 2010 16. De las Cuevas C, Sanz EJ: Polypharmacy in psychiatr ic practice in the Canary Islands. BMC Psychiatry 4:18, 2004 17. Spencer D, Marshall J, Post B, et al.: Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics 132:833 40, 2013 18. Olfson M, Marcus SC, Weissman M M, et al.: National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry 41:514 21, 2002 19. Fontanella CA, Warner LA, Phillips GS, et al.: Trends in psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002 2008. Psychiatr Serv 65:1332 40, 2014 20. Fontanella C, Hiance D, Phillips G, et al.: Trends in Psychotropic Medication Use for Medicaid Enrolled Preschool Children. J Child Fam Stud 23:617, 2014 21. Kukreja S, Kalra G, Shah N, et al.: Polypharmacy i n psychiatry: a review. Mens Sana Monogr 11:82 99, 2013 22. Mojtabai R, Olfson M: National trends in psychotropic medication polypharmacy in office based psychiatry. Arch Gen Psychiatry 67:26 36, 2010 23. Hoagwood KE, Kelleher K, Zima BT, et al.: Ten Year Trends In Treatment Services For Children With Attention Deficit Hyperactivity Disorder Enrolled In Medicaid. Health Aff (Millwood) 35:1266 70, 2016 24. Byrd VL, Dodd AH: Assessing the usability of MAX 2008 encounter data for comprehensive managed care. Me dicare Medicaid Res Rev 3, 2013 25. Chen H, Patel A, Sherer J, et al.: The definition and prevalence of pediatric psychotropic polypharmacy. Psychiatr Serv 62:1450 5, 2011

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42 26. Kautz C, Mauch D, Smith S: Reimbursement of mental health services in primary ca re settings. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2008 27. Soria Saucedo R LX, Hincapie Castillo JM, Winterstein AG: Prevalence, Time Trends and Utilization Patterns of Psychotropic Po lypharmacy: Evidence from Children and Adolescent Medicaid Beneficiaries, 1999 2010; in 32nd International Conference of Pharmacoepidemiology & Therapeutic Risk Management. Dublin: Pharmacoepi Drug Saf, 2016 28. Soria Saucedo R LX, Hincapie Castillo JM, Wi nterstein AG: Prevalence, Time Trends and Utilization Patterns of Psychotropic Polypharmacy: Evidence from Adult Medicaid Beneficiaries, 1999 2010; in 32nd International Conference of Pharmacoepidemiology & Therapeutic Risk Management. Dublin: Pharmacoepi Drug Saf, 2016 29. Fisher PH, Tobkes JL, Kotcher L, et al.: Psychosocial and pharmacological treatment for pediatric anxiety disorders. Expert Rev Neurother 6:1707 19, 2006 30. Keeshin BR, Strawn JR: Psychological and pharmacologic treatment of youth with posttraumatic stress disorder: an evidence based review. Child Adolesc Psychiatr Clin N Am 23:399 411, x, 2014 31. Feinstein J, Dai D, Zhong W, et al.: Potential drug drug interactions in infant, child, and adolescent patients in children's hospitals. Pedi atrics 135:e99 108, 2015 32. Zonfrillo MR, Penn JV, Leonard HL: Pediatric psychotropic polypharmacy. Psychiatry (Edgmont) 2:14 9, 2005 33. Mechanic D: More people than ever before are receiving behavioral health care in the United States, but gaps and chal lenges remain. Health Aff (Millwood) 33:1416 24, 2014 34. Bishop TF, Seirup JK, Pincus HA, et al.: Population Of US Practicing Psychiatrists Declined, 2003 13, Which May Help Explain Poor Access To Mental Health Care. Health Aff (Millwood) 35:1271 7, 2016 35. Bishop TF, Press MJ, Keyhani S, et al.: Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry 71:176 81, 2014 36. Staller JA: Service delivery in child psychiatry: provider shortage isn't the on ly problem. Clin Child Psychol Psychiatry 13:171 8, 2008 37. Melfi CA, Croghan TW, Hanna MP: Access to treatment for depression in a Medicaid population. J Health Care Poor Underserved 10:201 15, 1999

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43 38. Robst J: Changes in antipsychotic medication use af ter implementation of a Medicaid mental health carve out in the US. Pharmacoeconomics 30:387 96, 2012

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44 BIOGRAPHICAL SKETCH Juan Hincapie Castillo was born in Cali, Colombia. He received his Associate in Arts degree from the Florida State College in Jacksonville, Florida in 2009 He continued his education at the University of Florida where he received his Doctor of Pharmacy degree in 2013. He is a licensed pharmacist in the State of Florida. In the fall of the 2013, he started his PhD in the Department of Pharmaceutical Outcomes and Policy at the University of Florida. Juan has held several student leadership positions Notably during his tenure at the Department of Pharmaceutical Outcomes and Policy he has served as president of the graduate students at the University of Florida College of Pharmacy, president of the Florida student chapter of the International Society of Pharmacoepidemiology (ISPE), student council chair of ISPE, member of the College of Pharmacy Dean Council, the Diversity and Inclusion Task Force, and the Alumni Association Committee. Juan was appointed as a graduate fellow for the American Association of Hispanics in Higher education in 2015. He received the University of Florida Gradu ate Student Teaching Award and the College of Pharmacy Teaching Assistant of the Year Award in 2016. Later in 2016, h e was appointed to the DuBow Family Graduate Student Education Fellowship He received the Deborah Klapp Memorial Award in 2017. Juan has co authored several peer reviewed publications including two book chapters and he has presented his research in national and international conferences. His research interests include pharmacoepidemiologic studies in pain management, substance abuse, and dr ug policy. His clinical specialty is management of chronic pain.