The boy, 20 months old, is a maelstrom of tears and self-abusive behavior. Simply holding him sets off hours of crying, banging of his head or biting himself. His mother used drugs during her pregnancy. Clinical notes recommend he receive potent antipsychotic medication, one for adults suffering bipolar disorder and schizophrenia. -- State medical records
With little oversight and apparent carte blanche, a relative handful of Texas physicians wrote $47 million worth of Medicaid prescriptions for powerful antipsychotic and anti-anxiety drugs over the past two years, according to a Star-Telegram analysis.
The top five doctors alone wrote $18 million worth.
Most of the drugs have gone to children and adolescents, although prescribing the drugs to children, such as a toddler, is considered "off-label" -- uses not approved by the federal Food and Drug Administration.
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Now the state's Medicaid program is among others under scrutiny, after Sen. Charles Grassley, R-Iowa, began investigating the use of mental-health drugs this year. Grassley, the ranking member of the Senate Finance Committee, told federal health officials to keep a better watch on top prescribers. His conclusion: Either some physicians have specialized expertise or the number of prescriptions suggests "overutilization or even health care fraud," according to an October letter sent to the Health and Human Services Department.
Some advocates are concerned that the drugs are unsafe for children, who make up nearly 75 percent of Texas Medicaid's 3.2 million recipients. In a 16-state study, Texas had the maximum rate of prescribing multiple mental-health drugs to youths in foster care. Although the number of prescriptions had dropped 19 percent by 2007, Texas was still tops, according to the June study.
John Breeding, a psychologist concerned that the drugs may cause permanent neurological and metabolic damage, told the state, "That so many of our very young children, younger than 4 or even 3 years old, are being given these drugs is so very sad and upsetting."
And some doctors churn out prescriptions for children and others at an alarming rate. Antipsychotic drugs prescribed to children under 6 grew by 20 percent from 2007 to 2009, according to a November report by the Texas Health and Human Services Commission.
About 1.7 percent of children on Medicaid received antipsychotic drugs in fiscal 2009, state officials said.
Some children are overmedicated: One area doctor routinely prescribes five potent mental-health drugs simultaneously, said one of the state's top prescribers. He said he tries to scale back the number of drugs the children are on.
Some experts believe that medication has pushed aside talk therapy, which might be effective and reduce medication needs.
"I do think that a lot of people receive medication without any therapy," said Tami Mark, a researcher with Thomson Reuters in Washington, D.C. "Most of the literature suggests that therapy is effective and can improve the effectiveness of the medication. So it's better to get both."
The child, 31/2, suffers from shaken baby syndrome. When stressed, he pulls at his ventilator hoses and tracheotomy tube so much that his hands must be tied to the bed. He is prescribed antipsychotics because other sedatives could suppress the breathing centers of the brain.
Grassley asked Texas and other states for the top 10 prescribers who billed Medicaid for certain drugs. The Star-Telegram used prescriber numbers to identify the doctors, then sorted and tallied the drugs they were prescribing. Also reviewed was information on other mental-health drugs that have cost taxpayers about $1.3 billion during the past five years.
The analysis and research found:
In the past two years, 72 Medicaid providers wrote 186,992 prescriptions, an average of 2,597 each.
The state's top prescriber, child psychiatrist G.K. Ravichandran of Houston's Shamrock Psychiatric clinic wrote 27,000 scripts for the anti-anxiety drug Xanax in the past two years. The next-closest physician wrote 6,300.
Under his license, 44,138 prescriptions for antipsychotic drugs were written, at a cost to Medicaid of $6.4 million.
Ravichandran did not respond to repeated requests for comment.
Dr. Fernando Siles, a child psychiatrist in Greenville, is the second most prolific Medicaid prescriber. He sees children from across North Texas, including Tarrant County.
In the past two years, Siles' medical license was used to write 13,601 antipsychotic prescriptions at a cost of $4.6 million.
Siles, who treats solely Medicaid recipients, some as young as 3, has three nurse practitioners who also write prescriptions under his license, he said.
Many children referred to him are already on multiple antipsychotic drugs, and he tries to cut back, he said. "Fifty percent of the medications I prescribe, I did not start them on the medicine," he said. "They came from other doctors."
There may be other physicians who are also prescribing high volumes of antipsychotic drugs but aren't as easily detected, state officials say.
Some physicians use a clinic to hide the volume of their prescribing, said Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission, which oversees Medicaid.
"To be quite honest, we feel like single doctors have started to bill under clinics to maybe hide that, to make it look like it's not a single doctor prescribing all these," she said.
The 13-year-old girl suffered depression and post traumatic stress disorder. She cut her arms and stomach. Her stepfather molested her, and then beat her when she refused to have sex. She cannot sleep at night for the nightmares of being locked in a closet. Prescribed an antipsychotic off label, she begins to have fewer flashbacks and nightmares.
Another top prescriber, Dr. Adolphus Lewis of Fort Worth, is a family physician who also treats the elderly. In one year ending in 1994, he wrote 61 prescriptions for one male patient, including enough Vicodin and Valium to pop seven pills a day.
The state medical board accused Lewis of prescribing "medically excessive" numbers of pills to a woman who later died, court documents show. Her death, which was due to respiratory failure, implicated three drugs, including two that Lewis previously prescribed, according to the documents.
Lewis did not respond to multiple requests for comment.
About 40 percent of the 72 top Medicaid prescribers among certain antipsychotic drugs have been disciplined by the state medical board. By comparison, last year the state disciplined less than 1 percent of the state's 62,521 doctors.
In 2002, the Texas Medical Board restricted Ravichandran's license for five years for "unprofessional or dishonorable conduct that is likely to deceive or defraud the public or injury the public." The restriction, which was not related to prescriptions, was lifted within three years.
Siles' license is spotless.
Lewis was restricted in 1998 for failure to practice medicine in an acceptable manner because of his prescribing. From 2008 to 2009, he wrote 3,696 prescriptions for antipsychotics -- roughly 10 each day -- that cost taxpayers $1,395,595. Lewis' license is connected with 10,000 prescriptions of mental-health drugs to 1,864 clients from 2005 to 2009, fifth most in the state among Medicaid providers.
The state has automated checks, called edits, to catch overuse, incorrect dosage and misuse, Goodman said.
Identifying even one inappropriate prescription is difficult, Goodman said.
"To really prove up a case, you have to prove some of those prescriptions were inappropriate. And it's not just the volume alone that does that," she said. "It's really going in and looking at the patient's records and getting another doctor to say, 'That prescription was not appropriate in that case.'"
Darren Barbee, 817-390-7126