(255) Trends of Antidepressant Use Among Children in Commercial and Public Payer Systems in the United States, 2001-2019

Background: Use of antidepressants (ADs) has been increasing among adolescents in many countries. In the US, trends in pediatric AD use received more attention after the 2004 black box warning. However, recent evidence is limited on US pediatric AD use overall and across different payer systems.

Objectives: To compare trends of AD use by type of insurance coverage among young people enrolled in commercial or public insurance in the US from 2001-19.

Methods: We performed a serial cross-sectional drug utilization study using national MarketScan (commercial insurance) and Medicaid (public insurance) data for children and adolescents ages 3-17 years with continuous annual enrollment. Analyses of Medicaid data were limited to 26 states with suffcient data quality in 2001-19. We identified children with ≥1 dispensed AD per calendar year and estimated the annual prevalence of AD use, overall and stratified by payer system (commercial, Medicaid comprehensive managed care (CMC), or Medicaid fee-for-service (FFS)).

Results: There were a total of 5.1 million person-years with >1 AD claim (36.8% commercial, 20.9% FFS, 42.3% CMC). Compared with those with Medicaid (FFS+CMC), a greater percentage of AD users enrolled in commercial insurance were female (58.2% vs. 53.3% in 2019) and adolescents ages 12-17 (86.6% vs. 78.6% in 2019). The percentage of AD users diagnosed with depression in 2019 was similar in the commercially insured (44.9%) and Medicaid (45.8%) populations, but diagnoses of anxiety were more common in 2019 among those with commercial insurance (64.5%) than those with Medicaid (43.6%). Overall prevalence of AD use declined across several years following the 2004 black box warning, from 2.9% in 2004 to a low of 2.1% in 2010, before rising to 3.2% in 2019. Prevalence varied by payer system: AD use among those with commercial insurance was lower in 2001 (2.3%) than those with Medicaid (FFS+CMC) (2.8%). However, by 2019, AD use among the commercially insured (4.1%) exceeded that of the combined Medicaid population (3.0%). AD use was greater throughout the study period among those enrolled in FFS (4.1% in 2001, 5.5% in 2019) versus CMC (1.3% in 2001, 2.9% in 2019).

Conclusions: Following stable or declining pediatric AD use from 2004-2010, the prevalence of AD use among young people in the US increased in 2011-2019, corresponding to increasing recognition and treatment of mental health problems in the pediatric population. Compared with the publicly insured, a higher prevalence of anxiety diagnoses and greater increases in AD use were noted in those with commercial insurance. Among those with public insurance, rates of AD use were substantially higher in FFS than CMC plans. Further research is needed to understand the factors underlying the differing trends in AD use across payer systems.