Iowa Senator’s Letter to Oregon Hits Hot-Button Issue: Child Psychiatrist’s Prescribing Rate

By Nick Budnick, The Oregonian, Friday, March 02, 2012

Abilify header_logo

Psychiatrist Curt Sturos tends to troubled kids in southern Oregon and considers himself part of a growing awareness that mental health drugs may be overused.

So it was a surprise to find himself exhibit A in a recent letter from a powerful U.S. Senator, demanding to know what Oregon is doing to crack down on doctors who overprescribe.

State Medicaid records show Sturos authorized more of the mental health drug Abilify for the last three years than any other Oregon doctor. A letter to the Oregon Health Authority from Sen. Chuck Grassley, R-Iowa, who wants to curb Medicaid spending nationwide, called the rate “shocking.”

While Sturos calls the letter unfair, and an Oregon Health Authority review found nothing wrong, his situation shows how psychiatrists and other doctors face increasing scrutiny of their prescribing, particularly when it comes to children. Yet doctors in Oregon say the state lacks options beyond drugs to treat severely troubled children.

Ajit Jetmalani, M.D.

Ajit Jetmalani, M.D.

Young brains are considered more vulnerable and few drug safety studies exist due to ethical concerns about testing children, said Dr. Ajit Jetmalani, director of the Oregon Health & Science University’s Child Psychiatry Program. He also believes the mental health system needs more non-drug alternatives.

“If we’re all expecting medical providers to write prescriptions – and are not willing to invest in alternatives – then we’re going to get more prescriptions,” he said. “I think that is a duty of medical providers to push back.”

Pushing Begins

Earlier this week, the American Academy of Child and Adolescent Psychiatry issued cautious new prescribing guidelines for child welfare agencies. And a December federal report found that foster kids in five states, including Oregon, were more likely to be prescribed psychiatric medication — including at levels not considered safe.

Sturos cares for 250-300 People — about 200 are children or teens, he said. Many are foster kids and autistic with significant behavioral problems. He favors Abilify, a drug the Food and Drug Administration has approved for children 10 and above with bipolar disorder and other mental health conditions, because of fewer side effects than comparable drugs, including less weight gain.

In 2009, Sturos wrote 1,104 prescriptions costing Oregon’s Medicaid program $457,335, nearly twice the next highest prescriber, records show. In 2010 he wrote more than 1,000 compared to 666 for No. 2. In 2011, his total grew to 1,243 prescriptions, though Sturos says some of these were written to help a colleague in training.

“On a weekly basis I am working with our teams to try to provide the best access to non-medication treatments for kids with various conditions such as depression, schizophrenia, PTSD, bipolar disorder,” he said.

Prompted by Grassley’s letter – versions of which went to other states – the Oregon Health Authority in January reviewed Sturos’ numbers. “We do not feel this doctor’s prescribing practices are out of line,” wrote Tom Burns, director of pharmaceutical programs for the Oregon Health Authority, in a Feb. 9 reply.

Little Tested

Last year, Harvard researchers evaluating the scientific evidence for long-term use of Abilify for bipolar disorder essentially found only one clinical trial met scientific standards but a design flaw may have made the drug appear more effective.

“Frankly, I think it’s an embarrassment to the profession that (Abilify) has been accepted so uncritically for this indication,” one of the professors told CNN.

Terry Lee, an instructor at the University of Washington, treats kids in the state’s foster care and the juvenile justice systems. He often weans his less-troubled kids off Abilify and other medications, finding psychotherapy, anger management and social skills training is what’s needed. “They lose weight, they report feeling more alert, more awake and less sedated,” he said.

Similarly, psychologist Peter Sprengelmeyer says children often improve with scaled-back medications.

“I think sometimes what we’re doing is medicating for a chaotic environment,” says Sprengelmeyer, who heads OSLC Community Programs, a Eugene nonprofit that provides mental health care to kids in foster homes and the juvenile justice system.

Other states do more than Oregon to oversee prescribing to kids, experts say.

In Illinois, for instance, youths in foster care or state custody receive an independent medication review by a state psychiatrist, and the drugs’ effects are tracked over time, says Dr. Michael Naylor, who heads the program. He says medication should be only part of treatment — but qualified people to provide psychotherapy for kids are hard to find.

Jetmalani of OHSU says good things are happening in Oregon, including a new hotline to help primary care physicians make better prescribing decisions for children. And state health reform could result in a better, team-based approach to children’s mental health.

Meanwhile, though Sturos was supported by the state, his prescribing practices are now being reviewed by Jefferson Behavioral Health, which manages prescribing practices for Jackson County and several others. Sturos says it’s good to ask questions, and he has nothing to hide.

“If Senator Grassley or any state officials wish to come and look at the details of what we’re doing I’d be happy to show them,” he says.

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