Accepted Article
MR. JOSEPH L SMITH (Orcid ID : 0000-0003-0288-5538)
Received Date : 04-Nov-2016 Revised Date : 21-Dec-2016 Accepted Date : 10-Jan-2017 Article type
1
: Research Article
Outpatient Treatment of Tic Disorders Among Children and Adults
Joseph L. Smith, M.P.H,1 Sean Gregory, Ph.D.,1 Nicole McBride, B.S.,1,2 Tanya K. Murphy, M.D.,3-5 and Eric A. Storch, Ph.D.1-6
Department of Health Policy & Management, College of Public Health, University of South
Florida 2
Department of Psychology, University of South Florida
3
Department of Pediatrics, University of South Florida
4
Rogers Behavioral Health – Tampa Bay
5
All Children’s Hospital – Johns Hopkins Medicine
6
Department of Psychiatry & Behavioral Neurosciences, University of South Florida
Running title: Outpatient Treatment of Tic Disorders
KEY WORDS: tic disorders, Tourette Syndrome, pharmacotherapy, psychotherapy, ADHD
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/mdc3.12472 This article is protected by copyright. All rights reserved.
Accepted Article
Corresponding author info: Joseph L. Smith, MPH, University of South Florida, Department of Health Policy & Management, 12901 Bruce B Downs Blvd., Tampa, FL 33612. Phone: 813-974-5605. E-mail:
[email protected]
Abstract Introduction. Limited information is available regarding treatment practices in applied settings for children and adults with tic disorders. We describe, for the first time, treatment of tic disorders in U.S. children and adults in the outpatient setting. Methods. Data from the 2003-2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey was utilized. Descriptive statistics for modality of treatment and class of pharmacological medications were reported by patient and visit characteristics. Separate multivariable logistic regression models were used to examine associations between patient and visit characteristics and classes of medications prescribed. Results. One-third (n= 99) of the sample did not receive any psychiatric or psychological treatment. Nearly-two thirds received a psychotropic medication. The most common class of medication was alpha-2 agonists (25%), followed by stimulants (23%), serotonin-reuptake inhibitors (19%), atypical antipsychotics (18%), anxiolytics (14%), anticonvulsants (11%), and typical antipsychotics (8%). Comorbid disorders and chronicity of problems were significantly associated with receipt of certain classes of medications. Relatively few patients (18%) received psychotherapy. Conclusion. If the decision is made to treat tic disorders, the choice of medication is dependent on the primary complaints, severity, chronicity and the presence of comorbid psychiatric disorders. In general, comorbid externalizing, anxiety, and mood disorders appear to influence treatment decisions in addition to tic disorders.
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Accepted Article
Introduction Tic disorders (TDs) are childhood onset neuropsychiatric disorders (1-3) that are
associated with functional impairment (4, 5), reduced quality of life (5), and high comorbidity (1, 6-9). TDs include Tourette Syndrome, transient tics, chronic vocal and motor tics, and not otherwise specified tic disorders. In children, transient TDs are most common (2.99%), followed by chronic TDs (1.61%), and Tourette syndrome, (0.77%) (10). Many adolescents with TDs improve in adulthood, with 63% exhibiting sustained tics of varying severity (11, 12). In adults, prevalence of Tourette Syndrome is 0.05%, while estimates of all TDs range from 0.08% to 0.42% (10). Tic disorder symptoms range in severity and duration, resulting in a range of functional
impairment (6, 13, 14). Current research suggests that treatment for TDs should only be administered in cases where these symptoms cause significant impairment (7-9, 15-18). At the time data were collected, treatments included alpha-2 agonists (e.g., guanfacine, clonidine) (7, 8, 17, 19), atypical antipsychotics (e.g., risperidone, ziprasidone, olanzapine, quetiapine) (7, 8, 20, 21), typical antipsychotics (e.g., pimozide, haloperidol) (20, 21), anticonvulsants (e.g., topiramate, baclofen) (21), and behavioral therapy (e.g., habit reversal therapy) (7, 8). Several factors must be considered when making treatment decisions: the waxing and waning nature of TDs, severity of impairment, social distress, and comorbid psychiatric conditions (7-9). Complicating treatment, TDs frequently co-occur with attention deficit-hyperactivity
disorder (ADHD) (22), obsessive-compulsive disorder (OCD) (22, 23), disruptive behavior disorders (i.e., oppositional defiant disorder [ODD], conduct disorder [CD]) (24) and depressive and anxiety disorders (7, 8, 16, 22, 23). Generally, the symptoms perceived as the most problematic plays a major role in the type of treatment provided (7, 8). For example, for patients with primary OCD and secondary TD, serotonin-reuptake inhibitors (SRIs) are recommended (17, 21); while stimulants or alpha-2 agonists are indicated for patients with primary ADHD and
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Accepted Article
secondary TD (21, 25). In addition, current treatment guidelines in youth call for behavioral interventions for patients with a TD and comorbid psychiatric disorders (18). Only one large U.S. study has described treatment of TDs in children and adolescents.
Olfson et al. (26), compared children and adolescents enrolled in Medicaid to children covered by private insurance, finding a higher prevalence of comorbid ODD (3.3% vs 0.6%) and ADHD (7.4% vs 3.5%) in the Medicaid sample. The authors reported very low rates of psychotherapy claims (30%). Differences between patient and visit characteristics were compared using a survey-weighted, Rao-Scott adjusted χ2 to test differences in proportions at α=.05 level. The association between prescription of a psychotropic medication and patient and visit
characteristics were assessed through a logistic regression model for each class of medication. The dependent variable, in each model, was an indicator variable representing the prescription of a given class of medication. We used a build-down approach to create a parsimonious model,
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Accepted Article
which included covariates that were theoretically important or based on previous research (2629). A variable for year of visit was included to control for temporal effects. To ease in interpretation and add context to our logit results, marginal effects (MEs) were calculated; MEs describe the percent change in baseline probability, associated with a one-unit change in the covariate of interest. Only MEs of >1% were reported.
Results Patient and visit characteristics by mutually-exclusive modality are provided in Table 2
for all 306 visits. Chi-square tests of proportions suggest that there was a difference in treatment modality by primary payer (p
