Antipsychotic Medication Use and Metabolic Monitoring in an Integrated Outpatient Clinic for Individuals with Autism and Other Neurodevelopmental Disabilities

Background:  Antipsychotic medications are frequently taken by individuals with neurodevelopmental disabilities to address co-occurring psychiatric conditions.    These medications increase metabolic syndrome risk and subsequent cardiovascular complications. The American Diabetes Association and American Psychiatric Association have established metabolic monitoring guidelines, but low reported rates of monitoring for medical complications of antipsychotic medications demonstrate a substantial gap between recommendations and clinical practice. The Neurobehavior HOME program (HOME) is an outpatient clinic with integrated primary and psychiatric care, funded by Medicaid, for individuals across the lifespan with neurodevelopmental disabilities and co-occurring psychiatric disorders. The majority of HOME enrollees have autism spectrum disorder (ASD) with or without intellectual disability (ID).  HOME provides a unique setting to study prescribing and monitoring practices for antipsychotic medications in this high risk population. 

Objectives:  This study aims (1) to describe antipsychotic use among children and adults with neurodevelopmental disabilities served in an outpatient clinic, and (2) identify subsequent metabolic monitoring rates.    

Methods:  Participants included all patients enrolled in HOME from January through June 2013.  Participant characteristics (i.e., antipsychotic use, demographics, insurance coverage, and disability type, see Table 1) and metabolic monitoring were obtained from billing records, Medicaid pharmacy data, and electronic medical records. Multiple and single variable logistic regression models were fit to investigate the association between antipsychotic medication use, medication monitoring, and participant characteristics.  The models that included HOME program enrollment duration, insurance category, and co-occurring metabolic conditions as independent variables were adjusted for age.

Results:  HOME program enrollees totaled 832 participants (67% males; mean age: 29.1 years, range: 4-82).  Disability types were as follows: 9.3% ASD only, 30.2% ID only, and 54.8% ASD and ID.  Sixty-one percent (n=508) of participants were taking antipsychotic medication. Compared with those not taking antipsychotics, participants taking antipsychotics did not experience significantly higher rates of prediabetes/diabetes, dyslipidemia, or hypertension.  Antipsychotic use was significantly associated with male gender (p<0.01) and having both ASD and ID (p=0.02).  Participants with triple insurance coverage (Medicaid, Medicare, and private) were less likely to take an antipsychotic medication (p=0.01) than those with Medicaid alone.   Metabolic monitoring rates among participants taking antipsychotics were as follows: lipids, 75%; glucose/Hemoglobin A1c (BG/HbA1c), 85%; weight, 91%; and blood pressure, 93%.  Advanced age was associated with BG/HbA1c (p<0.001) and lipids (p<0.01), whereas younger age was associated with monitoring weight (p=0.01).

Conclusions:  Our findings demonstrate high antipsychotic medication use among participants with neurodevelopmental disabilities in this outpatient setting.  A greater likelihood of antipsychotic use was associated with male gender and the co-occurrence of ASD and ID, but not with ASD only.  Overall, most participants were monitored for weight and blood pressure and the majority, for BG/HbA1c and lipids. Notably, advanced age was associated with BG/HbA1c and lipid monitoring and inversely associated with weight monitoring.   Metabolic monitoring rates for participants taking antipsychotics were high in HOME, suggesting the importance of an integrated care model for patients at risk for medical complications from psychiatric medication.   Further study is needed to identify factors that facilitate medical monitoring of medication in individuals with neurodevelopmental disabilities.