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PolicyLab to Study Effect of Narratives on Antipsychotic Prescribing

Published on
Mar 4, 2015

A team of investigators from PolicyLab recently received an award from the William T. Grant Foundation to examine 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.

Dr. Rubin and colleagues — including Zachary Meisel, MD, MPH, MSc, from the University of Pennsylvania’s Department of Emergency Medicine — plan to compare narrative-accompanied prescription guidelines with more traditional, “didactic” evidence-based prescription guidelines. Over the course of their 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 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 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.

A Powerful Story Will Stick

The study team plans to 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 will 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 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.”

In the study’s second phase, the researchers will test the effectiveness of the narrative-influenced guidelines. They plan to target psychiatrists, pediatricians, and family practitioners across Pennsylvania, whom 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.

To read more about this project, see this February issue of CHOP Research’s Bench to Bedside.