In this Issue: Is Your Patient Being Prescribed Antipsychotic Medication? Leadership:

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1 March 2017 NEWS In this Issue: MCPAP 2.0 Launch FREE Trainings Available Update on MCPAP Communications Clinical Connections Is Your Patient Being Prescribed Antipsychotic Medication? By Donald Sherak, MD, Heather Walter, MD, MPH, and Barry Sarvet, MD Antipsychotic medications, especially second generation antipsychotics (SGAs) are being prescribed to children and adolescents at an increased rate since the first medication in this class, Risperdal, was approved by the FDA in These medications are FDA-approved for some pediatric age ranges for indications such as schizophrenia, bipolar disorder, and irritability in autism. (See table on page 2). Continued on page 2 Leadership: John Straus, MD Founding Director Barry Sarvet, MD Medical Director Marcy Ravech, MSW Executive Director 1000 Washington St., Suite 310 Boston, MA mcpap@beaconhealthoptions.com MCPAP is funded by the Massachusetts Department of Mental Health

2 Is Your Patient is Being Prescribed Antipsychotic Medication? Continued from page 1 2 Additionally, these medications are commonly prescribed empirically to children for off-label indication to treat a variety of symptoms including depression, agitation, mood dysregulation, repetitive stereotypic behavior, and impulse dyscontrol associated with other psychiatric diagnoses. The evidence basis for off-label treatment with SGAs is substantially less. However for individual patients with such symptoms which are refractory to FDA-approved treatment, off-label treatment may be appropriate after careful risk/benefit analysis. Continued on page 3 ATYPICAL ANTIPSYCHOTICS GENERIC FDA- TARGET USUAL RECOMMENDED SUGGESTED NAME APPROVED SYMPTOMS STARTING DAILY DOSAGE MEDICAL (pediatric age range DOSE RANGE MONITORING in years) Aripiprazole (Abilify) Bipolar (10-17) Schizophrenia (13-17) Irritability in Autism (6-17) Mania Psychosis Irritability Aggression Agitation Bipolar and Schizophrenia: 2mg Autism: 2mg Bipolar and Schizophrenia: mg Autism: 5-15 mg glucose and lipids, abnormal movements; compulsive behaviors Olanzapine (Zyprexa) Bipolar (13-17) Schizophrenia (13-17) Mania Psychosis Agitation 2.5mg mg glucose & lipids, abnormal movements; skin rash (DRESS) Quetiapine (Seroquel) Bipolar (10-17) Schizophrenia (13-17) Mania Psychosis Agitation 25mg bid Bipolar: mg Schizophrenia: mg glucose and lipids, abnormal movements; opthalmological exam Risperidone (Risperdal) Bipolar (10-17) Schizophrenia (13-17) Irritability in Autism (5-17) Mania Psychosis Irritability Aggression Agitation Bipolar and Schizophrenia: 0.5mg Autism: <20 kg: 0.25mg 20 kg: 0.5mg Bipolar and Schizophrenia: 1-6mg Autism: mg glucose and lipids, prolactin, abnormal movements Paliperidone (Invega) Schizophrenia (12-17) Psychosis 3mg <51kg: 3-6mg 51kg: 3-12mg glucose and lipids, prolactin, abnormal movements, EKG (QT prolongation), Lurasidone (Latuda) Schizophrenia (13-17) Psychosis 40mg 40-80mg glucose and lipids, prolactin, abnormal movements Source: Walter HJ, DeMaso DR, Boston Children s Hospital, 2017

3 Is Your Patient is Being Prescribed Antipsychotic Medication? Continued from page 2 3 There is some concern regarding overprescribing of SGAs, particularly for young children, and there have been reports of higher than expected utilization of these medications in vulnerable populations such as children in state custody. Given the potential harms associated with SGAs, efforts should be made to ensure that patients under consideration for off-label treatment receive initial trials of approved treatments and/or psychosocial interventions prior to consideration of an SGA. When SGAs were first introduced, they were presented as being safer and easier to tolerate than the earlier first-generation antipsychotic agents (FGAs) such as Haldol or Thorazine. While SGAs are less likely than FGAs to cause movement disorders and sedation, they still will do this for some patients. Furthermore, these medications can have other significant adverse effects including: neutropenia, hyperlipidemia, glucose dysregulation, diabetes, weight gain, hypotension, sedation, elevated prolactin and gynecomastia, and a range of dystonic and dyskinetic movement disorders. Although it is not common, some SGAs have been associated with new onset hypertension in children, orthostatic hypotension, tachycardia, prolonged QT syndrome, suicidal thinking, photosensitivity, neuroleptic syndrome, and severe allergic reactions (DRESS). Given the complexity of factors needing to be considered in the decision to prescribe, pediatric primary care providers should seek consultation through MCPAP prior to initial prescribing of SGAs for children and adolescents. Ordinarily, the medication treatment for these patients will be recommended to be managed by a specialist. However, pediatric primary care providers may prescribe SGAs in collaboration with MCPAP consultants for selected patients. Growing concerns about potential side effects from SGAs have led several professional organizations including the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity to issue a joint consensus paper on monitoring for risk factors. The 2011 revisions of these recommendations are incorporated into the recommendations below. The recommendations are summarized in a checklist manifesto style outline (A. Gawande, 2009). Continued on page 4

4 4 Is Your Patient is Being Prescribed Antipsychotic Medication? Continued from page 3 Primary care monitoring recommendations for patients prescribed SGA medications based on American Diabetes Association/American Psychiatric Association consensus: 1 2 Use minimally effective dose of SGAs. For a patient whose symptoms are well-controlled for a sustained period of time, small dose reductions and/or tapering should be considered in consultation with the MCPAP consultant or the patient s psychiatric provider. Follow ADA guidelines in monitoring patients on SGAs for metabolic changes. (See the chart below.) Continued on page 5 Metabolic monitoring parameters based on American Diabetes Association/ American Psychiatric consensus guidelines Baseline Week 4 Week 8 Week 12 Every 3 months Annually thereafter Medical history* X Weight (BMI) X X X X X X Waist circumference X X X Blood pressure X X X Fasting glucose/hemoglobin A 16 X X X Fasting lipids X X X * Personal and family history of obesity, diabetes, hypertension, and cardiovascular disease Source: url?u=http-3a k7gretta02f6jwr5dixmtpyndczpbxt_1iec&r=m6-02txz8gbrvpji8vpsjcnsuekv_fn00ipjsadqsxs&m=n96mzdytduwxnsymjq2xhr5jjovaxs6odgtbtce6wry&s=rvl BLlk8YZM54nzgE0ZbcqSpFAjnDHA-Gb2K0KakeA8&e

5 Is Your Patient is Being Prescribed Antipsychotic Medication? Continued from page step Checklist for Pediatric Patients on SGAs: Monitoring for Efficacy, Safety, and Care Coordination. 1 Check Medication Efficacy Treatment rationale: Why is the patient taking this medication? Efficacy: Is this medication helping/is the patient doing better? l If yes, is the Member sufficiently stable so that a medication taper can be considered? l If no, does the prescriber know? What is the plan to address this? Weight gain: Has the patient been gaining an unexpected amount of weight? l If so, and the patient is on an SGA associated with weight gain, could the patient be switched to another agent such as Abilif? Note: In general, weight gain with SGAs is not dose-dependent. 2 Check Medication Safety Common or Concerning Side Effects Weight gain: significant gain or growth chart deviation; family history Blood glucose dysregulation: review family history; Obtain HbA1c Dyslipidemia: Obtain Lipid panel Blood dyscrasias: Check CBC with differential; inquire about bruising Gynecomastia: Physical exam; If positive, obtain prolactin level Sedation, hypotension: Check vital signs; sleep and alertness history and in office Movement disorders: Review parent/guardian report; observation 3 Check Treatment Integration Care Coordination Communicate findings and concerns with the parent/guardian. Communicate findings and concerns with the prescriber. Review prescriber feedback for any concerning findings. Develop a follow-up plan and communicate to the parent/guardian and prescriber.

6 MCPAP 2.0 Launch As many of you might be aware, Tuesday, January 3, 2017 was the official launch of MCPAP 2.0! Thank you for your patience as we work through some of the hiccups of a new system. Below is a summary of the changes. We would like to hear about your experience with the transition. Please mcpap@beaconhealthoptions.com or call with your feedback what has worked well, what hasn t, and suggestions for improvement. What hasn t changed? MCPAP will continue to operate Monday Friday 9 a.m. - 5 p.m. You will have access to telephone consultation within a maximum of 30 minutes and to face-to-face assessmentsfor your patients at a site most convenient for the family. MCPAP Regional Teams Western / Central Regional Team Baystate Medical Center UMass Memorial Medical Center Boston North Regional Team Massachusetts General Hospital North Shore Medical Center Boston South Regional Team Boston Children s Hospital McLean Hospital Southeast Tufts Medical Center What has changed? Our name and logo: our new name will be the Massachusetts Child Psychiatry Access Program. 6 MCPAP has moved to a new regional structure with three (3) Regional Teams. Each Regional Team includes multiple sites (locations). There are three statewide toll-free phone numbers, one per Regional Team, to access MCPAP Regional Team services. Continued on page 7

7 MCPAP 2.0 Launch Continued from page 6 7 Each phone line will be answered live by one of two Program Coordinators who will page for consult with the Regional Team on-call psychiatrist, therapist, or resource and referral specialist. Each Regional Team has two Child and Adolescent Psychiatry Consultants (CAPs) on duty simultaneously. This enhances our capacity for more robust practice-based consultation and training activities. We hope to enhance the relationship between MCPAP Team staff and PCP practices to gain a solid familiarity with enrolled practices behavioral health capabilities and capacities in order to best meet the needs of the practices. Care coordination has been reframed as a collaborative Resource and Referral (R&R) process with PCP practices. Tracking and follow-up will become a responsibility of the PCP practice with training and consultation from MCPAP. There will be two types of Resource and Referral: 1. Resources to Provider will respond to requests for behavioral health resources in the area to which providers can refer their own patients. R&R Specialists will provide a list of behavioral health resources in the local area, vetted for availability. This service will be provided within three business days of a request whenever possible. 2. Outreach to Patient in which the R&R Specialist will work directly with the family to recommend through a phone consultation or face-to-face assessment. Continued on page 8

8 MCPAP 2.0 Launch Continued from page 7 8 This will primarily take place for youth with complex needs or youth who have experienced previous unsuccessful referrals. The goal is to provide vetted referrals within 10 business days. This level of R&R will require a telephone consultation with the MCPAP CAP or behavioral health clinician. R&R Specialists, as well as Regional Team Therapists, are available to consult with embedded behavioral Health Clinicians, Care Coordinators, or other practice staff about making effective referrals, follow-up, and tracking. MCPAP staff will also be available to consult with practices about developing relationships with area behavioral health providers. Face-to-face evaluations with a MCPAP behavioral health clinician or child psychiatrist will only be scheduled subsequent to a telephone consultation. This ensures we can maintain capacity to provide evaluations for youth most in need of this service. Moving forward, MCPAP will take a more proactive approach to supporting practices ability to manage behavioral health by: supporting the collaborative care model, promoting the use of behavioral health clinical practice guidelines for pediatric primary care, and providing training and consultation on strategies for tracking and coordinating care for patients requiring specialty behavioral health services. MCPAP will also assist practices with leveraging existing educational and care coordination resources through their affiliations with health systems, physician organizations, and ACOs and through technical assistance available through the Health Policy Commission. MCPAP Mission Statement MCPAP provides collaborative support to pediatric primary care providers (PCPs) and their patient-care teams to enhance their ability to promote and manage their patients behavioral health as a fundamental component of overall health and wellness. Through consultation and education, MCPAP improves the pediatric team s competencies in screening, identification, and assessment; treating mild to moderate cases of behavioral health disorders; and in making effective referrals and coordinating the care for patients who need community-based specialty services.

9 9 MCPAP 2.0 Launch Continued from page 8 How will my experience as an enrolled provider be different? Regional Team assignments have changed for only a small number of practices. Practices can access a list of Regional Team assignments on the Regional Teams section of the MCPAP website. Most PCPs and their practice staff will interact with the same group of MCPAP staff you know well, along with additional staff through a larger on-call circle of child and adolescent psychiatrists, program coordinators (who will answer the phone), and resource and referral specialists. For questions or concerns about Team assignments please contact mcpap@beaconhealthoptions.com or call Your practice will gain a MCPAP Child and Adolescent Psychiatrist liaison, who will get to know your practice, how you currently manage behavioral health, how you want to evolve behavioral health management, goals for certification if any, challenges, and access to resources through affiliations. Your MCPAP liaison will also be available for practice-based rounds organized around cases or issues. Use of clinical guidelines to inform consultation and education activities (in development)? For further information, you can view our MCPAP 2.0 webinar at: marcy.ravech@beaconhealthoptions.com or call

10 Free Trainings Available 10 FREE Training Simulations: Behavioral Health Intervention with Adolescents Description: Substance use is a major issue among children and adolescents, with alcohol, tobacco, and marijuana used most often. The rise in marijuana use, prescription drug use, and electronic cigarettes warrants concern for adolescents. Substance use and mental health are interrelated. In 2012, the National Survey on Drug Use and Health found that over 40 percent of adults with a substance use disorder in the past year also had a co-occurring mental illness. Among youth aged 12 to 17 with a substance use disorder in the past year, over 23 percent had a major depressive episode in the past year. Pediatricians have an important role in preventing, identifying, and treating substance use disorders and mental health concerns. The American Academy of Pediatrics (AAP), thanks in part to the support of the Friends of Children Fund, is offering free access to training simulations that provide participants with effective brief intervention techniques for addressing substance use disorders and mental health concerns with adolescents. The virtual simulations, developed by Kognito, strive to increase comfort and improve the quality of care, ultimately leading to positive patient behavioral change. Use of the simulations are FREE to AAP members. Continued on page 11

11 Free Training Simulation Continued from page Audience: These simulations will be of interest to primary care pediatricians, subspecialists, residents in training, and other health care professionals working with children and their families in regard to substance use disorders and mental health concerns. Learning Objectives: Simulation #1: Screening and Brief Intervention (SBI) with Adolescents Simulation #2: SBI Assessment Simulation #3: Adolescent Mental Health and Risk Assessment To access the course, go to kognito.com/aap Create a new account Follow the onscreen instructions Choose your course Click LAUNCH Free Adolescent Waiver Training The American Academy of Pediatrics (AAP) recommends that pediatricians consider offering medication-assisted treatment to patients with severe opioid use or discuss referrals to other providers. Dissemination of available therapies for this age group are needed to save and improve lives of youth with opioid use disorder. Boston Medical Center will be hosting a waiver training on April 24 from 8-4:30 p.m. The training is free, has CEs and CMEs, validated parking, light breakfast, and lunch is included. Priority will be given to physicians, Physicians, NPs, and PAs medical support staff working with adolescents. The link below will bring you to the registration; if you have any questions please at colleen.labelle@bmc.org.

12 Update on MCPAP Communications 12 It has come to our attention that our MCPAP communications, including the bi-monthly newsletter and annual provider experience survey, have been mistakenly delivered to many providers spam folders. We want to ensure that all providers receive these important updates and opportunities for providing feedback, as this helps contribute to the quality of MCPAP services! Below are some directions on how to mark an as not spam so that our communications will be delivered to your inbox moving forward. Please share these directions with your colleagues! Mark An Message As Not Junk Outlook 1. In Mail, click the Junk folder in the Navigation Pane. 2. In the message list, click any message that you want to mark as not junk. 3. On the Home tab, in the Delete group, click Not Junk. Outlook - Office Support Gmail or Yahoo Open your Gmail or Yahoo Mail account. Click on Spam from the list of options on the left side of the page. Find the message from the sender whose designation you wish to change and click on the message to open it. Click Not Spam at the top of the page. The message will be automatically moved to your regular in-box, and the address will be removed from the list of senders sent to the spam folder. Hotmail Open your Hotmail account. Choose and click Junk from the left-hand menu. Click to open the message from the sender you wish to unspam or click inside the adjacent box to the left of the message. A check will appear in the box to signify that you have selected the corresponding message. Click Not Junk at the top of the page to move the message and remove the address of the sender from the list of spam senders.

13 What s Happening for you at MCPAP 13 Clinical Conversations We invite you to log in the on the fourth Tuesday of each month from 12:15-1:15 p.m. to learn more about managing pediatric behavioral health issues in your practice. March 28 Resource and Referral in the Primary Care Setting You can register for these webinars by visiting and clicking on the webinar(s) that you would like to register for. For any questions regarding the clinical conversations, please contact Mary Houghton at mary.houghton@beaconhealthoptions.com. April 25 Developmental Behavioral Health Screening in Pediatric Primary Care May 23 Psychological Testing in Pediatric Patients June 27 Addressing Trauma in Pediatric Primary Care In case you missed it The September 27, 2016 MCPAP Clinical Conversations: Irritability and Temper Outbursts in Youth: What the PCP Should Know By: Bruce Waslick, MD, MCPAP Baystate Team Medical Director and Deborah Buccino, MD, Pediatrician at Macony Pediatrics in Great Barrington, Massachusetts. View the PowerPoint slide show here