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PSYCHIATRY

Utilization of Pharmacologic Treatment in Youths with Attention Deficit/Hyperactivity Disorder in Medicaid Database

Assistant Professor, Department of Healthcare Administration, College of Pharmacy, and Department of Epidemiology and Biostatistics, College of Public Health and Health Professions, University of Florida, Gainesville, FL

Tobias Gerhard, PhD

at the time of the study, Department of Healthcare Administration, College of Pharmacy, University of Florida; now, Associate Director, Center for Education and Research on Mental Health Therapeutics, Institute for Health, Health Care Policy, and Aging Research, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ

Jonathan Shuster, PhD

Professor, Department of Epidemiology, Biostatistics and Health Policy, General Clinical Research Center, College of Medicine, University of Florida

Julie Zito, PhD

Associate Professor, Department of Pharmaceutical Health Services Research, School of Pharmacy, and Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, MD

Michael Johnson, MD

Psychiatrist, Gainesville Mental Health Partners, Gainesville

Huazhi Liu, MS

Statistical Research Coordinator, Department of Healthcare Administration and PA Foote Health Outcomes Modeling Laboratories, College of Pharmacy, University of Florida

Arwa Saidi, MBBCh FAAP

Associate Professor, Department of Pediatrics, College of Medicine, University of Florida

Reprints: Dr. Winterstein, College of Pharmacy, University of Florida, PO Box 100496, Gainesville, FL 32610, fax 352/273-6270, almut{at}ufl.edu

BACKGROUND: Little is known about longitudinal changes in drug utilization in attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE: To describe longitudinal trends in ADHD drug utilization and explore demographic differences among youths eligible for a large Southern state Medicaid program.

METHODS: A cross-sectional and longitudinal analysis of 10 years of claims data for all Medicaid beneficiaries younger than 20 years of age with 6 months or more of continuous insurance (N = 2,131,953) was conducted. Annual prevalence, incidence, and persistence in ADHD medication use (stimulants and atomoxetine) were estimated based on pharmacy claims and clinician-reported ADHD diagnosis.

RESULTS: ADHD prevalence increased 1.70-fold (95% CI 1.67 to 1.73) from 3.10% (21,904 of 705,573 beneficiaries) in fiscal year 1995-1996 to 5.27% (41,681 of 790,338) in 2003-2004, paralleled by a 1.84-fold (95% CI 1.81 to 1.87) increase in drug use to 4.63%. In 2003-2004, 0.89% of youths were diagnosed and newly started on drugs, reflecting a 1.38-fold (95% CI 1.33 to 1.43) increase over 1995-1996. One in five white males between the ages of 10 and 14 years (19.24%; 95% CI 18.81 to 19.67) received ADHD medication in 2003-2004. Males continued to be more likely diagnosed and treated than females (prevalence ratio [PR] in 2003-2004 = 2.96; 95% CI 2.90 to 3.03 vs 3.82; 95% CI 3.69 to 3.96 in 1995-1996), as were whites when compared with Hispanics (PR in 2003-2004 = 2.65; 95% CI 2.57 to 2.73 vs 3.78; 95% CI 3.57 to 3.99 in 1995-1996) and blacks (PR in 2003-2004 = 1.81; 95% CI 1.76 to 1.85 vs 2.00; 95% CI 1.93 to 2.07 in 1995-1996). The most common starting age throughout the study period was 5-9 years, with 2.45% (95% CI 2.37 to 2.52) new ADHD drug users in 2003-2004, but largest increases in prevalence were observed in adolescents 15-19 years of age, with 2.47% (95% CI 2.38 to 2.55) in 2003-2004 compared with 0.45% (95% CI 0.41 to 0.49) in 1995-1996. Medication persistence varied, with only 49.9% (95% CI 49.4 to 50.5) of new users receiving drugs after 1 year, with yet another 17.2% (95% CI 16.4 to 18.0) continuing for 5 years or more.

CONCLUSIONS: ADHD drug utilization continues to increase due to steady increases in diagnosis and chronic use of the drugs over several years. While racial, ethnic, and sex differences persist, the age distribution of drug users has shifted toward older children. These findings emphasize the need for studies that analyze determinants of treatment as well as outcomes, both benefits and risks, associated with long-term medication use.

Key Words: attention-deficit/hyperactivity disorder, child and adolescent mental health, Medicaid, pharmacoepidemiology, stimulants

Published Online, November 27, 2007. www.theannals.com, DOI 10.1345/aph.1K143