In the debate about children and psychotropic medications, everyone is looking for better outcomes. Foster youth are seeking to assert more control over their lives and their health care, and they want people to understand that medications alone cannot fix the hurt they feel.
Doctors and other health care providers are struggling to address mental health needs with limited, often inadequate resources, while insurers are searching for more effective management tools. Children’s advocates want to prevent the use of medications as punishment or as behavioral control for caretakers’ convenience, and to reduce the side effects and other risks that attend the use of powerful medications on young people.
Tossed in for good measure: fears of profiteering, experimenting on children, and a calculating pharmaceutical industry that’s just in it for the money.
These interests and concerns are being vetted in this year’s California legislative session via a slate of bills that are intended to “reduce the overmedication of foster youth.” Unfortunately, the proposed fix, Senate Bill 253, centers on something virtually no one would recommend for their own health care decisions: putting a judge in charge.
As the cornerstone of the effort to reduce psych meds use among foster youth, S.B. 253 seeks to “double down” on the “JV-220 process,” whereby judges decide what medications are provided, and in what amount, to foster youth. California is virtually alone among the states in taking this approach.
But the escalation of psychotropic use happened in spite of the JV-220 process. This primary “fix” is to require thousands of second opinions for prescriptions, even though there are not enough psychiatrists to provide adequate access to care for existing needs.
A recent study by professors at Columbia Medical School and Yale analyzing the treatment of young people with antipsychotic medications prescribed the following approaches for reducing the use of medications:
Expanded use of quality measures, physician education, telephone-and Internet-based child and adolescent psychiatry consultation models, and improved access to alternative, evidence-based psychosocial treatments.
S.B. 253 does not do any of these things.
The problem is in its premise: that the medications are the problem. In fact, quality of care is the real challenge. Foster children who are overmedicated are getting inadequate mental health care. In an improved system of care, foster children would be offered individualized, intensive therapies that allow them to live at home whenever possible; provided interventions before crises happen; treated with effective evidence-based practices; and receive coordinated care consistent with their expressed needs and treatment goals.
By focusing on improving quality of care instead of limiting access to medication, S.B. 253 could be much improved. Mandating second opinions doesn’t directly improve health care practice. In most cases, nothing happens, except added time and costs, because the two doctors’ opinions will be the same. In cases where there’s a difference of opinion, the decision maker has more treatment options.
But, as the decision making judge has no mental health training, what you will get is a somewhat random decision on which of two proposed courses of action is “better.” Taking a quality-based approach can improve both individual interventions and the quality of mental health care overall.
Providing expert consultation to the initial prescriber (rather than a second opinion from the judge) can directly improve the quality of the assessment, diagnosis and/or prescribing, especially in cases where the prescriber is a general practitioner and the consultant is a child or adolescent psychiatrist. Systemic consulting can also improve overall care as doctors become better trained through expert mentoring. It’s been done in other states and it works.
There are additional ways to improve S.B. 253 and its companion bills, but that will take time because we need to take a fundamentally different approach.
This bill will not give foster youth the relief they hope for from over-medication or the system’s disregard for their expressed treatment needs and goals.