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A large new study finds that mental health care for many children in the U.S. falls far short, particularly when it comes to the follow-up treatment they receive.

The study, published Monday in Proceedings of the National Academy of Sciences, examined insurance claims from children between the ages of 10 and 17 covered by Blue Cross Blue Shield. Of the more than 2 million children included in the study, nearly one in 10 had a claim related to mental illness between 2012 and 2018.

The authors found that only 71% of the children received treatment in the 3 months that followed an initial insurance claim — but the study found that rate varied widely from one ZIP code to the next. In the best-performing ZIP codes, nearly 90% of children received follow-up care within three months of an initial insurance claim. In the worst-performing areas, only half of the children got that care.

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Roughly 23% of children in the study received medication alone as a treatment during the first three months after the initial claim, and another 6% were treated with both medication and therapy. By comparison, 42% of adolescents were treated with therapy in the three months after their first claim.

Pratibha Gopalakrishna/STAT Source: “Treatment of mental illness in American adolescents varies widely within and across areas,” PNAS 2020.

The study also examined the specific types of medications prescribed to children, including whether they were approved by the FDA for use in children.

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Of the children treated with medication, nearly 45% were given benzodiazepines, tricyclic antidepressants, or a drug that isn’t approved by the FDA for their age range. The study’s authors referred to those as “red flag drugs” — meaning how they’re being used warrants a closer look.

The analysis also found that children whose first insurance claim came from a hospitalization were more likely than their peers to be treated with drugs and therapy, and were also more likely to be given red-flag drug treatments.

The findings on red flag drugs are particularly concerning, the study’s authors said, given that most professional guidelines would suggest starting with another type of antidepressant — an SSRI — in combination with therapy for the majority of children included in the study.

Pratibha Gopalakrishna/STAT Source: “Treatment of mental illness in American adolescents varies widely within and across areas,” PNAS 2020.

In the past, some experts have suggested that shortages of qualified mental health providers are to blame for shortcomings in adolescent mental health care, with pediatricians often left to fill the gap. But the authors concluded that the disparities detailed in the study couldn’t be simply explained by staffing shortages.

The study found that the number of therapists in a given area is slightly associated with the chance that a child will receive follow-up treatment — but is far more closely correlated with the type of treatment a child receives. In communities where there are more psychiatrists, drug-only treatment and treatment with red flag drugs is more common. In communities with more of a supply of therapists, therapy-only treatment is more prevalent.

The study’s authors say that suggests other factors — such as a physician’s style of practice — might also play a role.

“There is a shortage of mental health professionals, but even in places that are well served, the same conditions are treated in many different ways, some of them harmful,” said Janet Curie, an economics and public affairs professor at Princeton University and the study’s co-author.

There are still more details to tease out of the data, including the impact of the treatments — or lack of follow-up care — on adolescent’s health going forward. Curie said she’s hopeful that other researchers will look into solutions that could improve care for children.

“I would hope that people will look into this to try to determine what might be effective in remedying the situation: such as better training, clearer guidelines that are available to both doctors and patients —in language patients can understand — mechanisms for patients to report negative effects of treatment, and so on,” said Curie.

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