Adherence to Adherence to Antidepressant Antidepressant

Medications Among Medications Among Health Plan Members Health Plan Members Diagnosed with Major Diagnosed with Major

DepressionDepressionAyse Akincigil, John R. Bowblis, Carrie Ayse Akincigil, John R. Bowblis, Carrie Levin, Levin,

James T. Walkup, Saira Jan, Stephen Crystal James T. Walkup, Saira Jan, Stephen Crystal

AcademyHealth 2006 Annual Research AcademyHealth 2006 Annual Research MeetingMeeting

Monday, June 26Monday, June 26

Supported in part through NIMH grant R01 MH60831, AHRQ Supported in part through NIMH grant R01 MH60831, AHRQ grants U18 HS016097 and HS-01182, and a grant by Horizon grants U18 HS016097 and HS-01182, and a grant by Horizon

BCBSNJBCBSNJ

Background / ObjectivesBackground / Objectives

There is a large amount of evidence that antidepressants are effective in reducing symptoms of depression and preventing relapse; however, poor adherence to medication is a major obstacle to effective care.

We describe characteristics of patients at risk for low adherence, and implications for policy and practice.

MethodsMethods A retrospective, observational study of A retrospective, observational study of

insurance claims.insurance claims. A large insurance company in Northeast, A large insurance company in Northeast,

serving three-million lives. serving three-million lives. Data are constructed from insurance Data are constructed from insurance

claims, between claims, between January 2003 and January 2003 and January 2005. January 2005.

Pharmacy claims are used to construct Pharmacy claims are used to construct the outcome measure -- refill persistence.the outcome measure -- refill persistence.

Medical claims are used to identify Medical claims are used to identify patients with a new episode of depression.patients with a new episode of depression.

Study PopulationStudy Population

30 14

Prescription look back period90 days

Index prescription date

Index episode start date(Date of Depression Diagnosis)

Diagnosis look back period120 days

Medication window

Outcome Measures Outcome Measures

30 14

Index prescription date

Index episode start date

Effective Acute Phase Treatment114 days

Effective Continuation Phase Treatment231 days

Overall Rates of Refill Overall Rates of Refill PersistencePersistence

50

27.4

0

20

40

60

Acute Phase Continuation Phase

% persistent

Demographic, Socio-Demographic, Socio-Economic CharacteristicsEconomic Characteristics

Gender (67% Gender (67% female)female)

Age Age 18-25 (18-25 (11%11%)) 25-39 (25-39 (32%32%)) 40-49 (40-49 (28%28%)) 50-64 (50-64 (26%26%)) 65 or older (65 or older (4%4%))

Median Median household household income at the income at the neighborhood neighborhood (zip-code)(zip-code) <50k (<50k (29%29%)) 50k-70k (50k-70k (42%42%)) >70k (>70k (29%29%))

Comorbid ConditionsComorbid Conditions

Alcohol Abuse (5%)Alcohol Abuse (5%) Substance Abuse (8%)Substance Abuse (8%) Anxiety Disorder (28%)Anxiety Disorder (28%) Cancer (18%)Cancer (18%) Number of Cardiovascular Risk Number of Cardiovascular Risk

FactorsFactors ( (18% suffer from one, 6% 18% suffer from one, 6% suffer from 2 or more)suffer from 2 or more)

Care Patterns for Depression Care Patterns for Depression EpisodeEpisode

Type of Provider on Initial VisitType of Provider on Initial Visit (49% were (49% were mental health professional, 51% were general mental health professional, 51% were general medical care).medical care).

Initial antidepressant drug type Initial antidepressant drug type (4% were on (4% were on older generation drugs).older generation drugs).

28% had a follow-up visit with a 28% had a follow-up visit with a psychiatrist.psychiatrist.

24% had a follow-up visit with another 24% had a follow-up visit with another mental health provider (e.g., psychologists, mental health provider (e.g., psychologists, social workers).social workers).

General Use of Health and General Use of Health and Pharmacy ServicesPharmacy Services

Number of Medications Excluding Psychotropics

%

0 Medications 10.8 1-2 Medications 24.3 3-5 Medications 27.6 6 or more Medications 37.3 Number of Outpatient Visits 0 Visits 4.5 1-4 Visits 32.6 5 or More Visits 62.9

Predictors of Refill Predictors of Refill Persistence Persistence

in Acute Phase (1)in Acute Phase (1)

1

1.71

2.47

1.95

1

1.22

1.22

1.3

0 1 2 3

Age <25

Age 25-39

Age 40-49

Age 50-64

Age 65 +

Income <50,000

Income 50,000-70,000

Income 70,000 +

Predictors of Refill Predictors of Refill Persistence Persistence

in Acute Phase (2)in Acute Phase (2)

1.18

1.01

1

0.69

1

1

1

0.96

0 1

MH ProviderGen Med Provider

Newer Generation DrugsOlder Generation Drugs

No F/U with aF/U with a Psychiatrist

No F/U with other MHPF/U with other MHP

Predictors of Refill Predictors of Refill Persistence Persistence

in Acute Phase (3)in Acute Phase (3)

1

1

0.49

1

0.98

0.72

0.65

0 1

No Substance Abuse

Substance Abuse

No Alcohol Abuse

Alcohol Abuse

# of Cardiovascular Risk Factors 0

# of Cardiovascular Risk Factors1

# of Cardiovascular Risk Factors2+

Predictors of Refill Predictors of Refill Persistence Persistence

in Acute Phase (4)in Acute Phase (4)

1

1.33

1.7

1

0.96

1.1

0.75

0 1 2

0 Meds

1-2 Meds

3-5 Meds

6+ Meds

0 Visits

1-4 Visits

5+ Visits

Non-Adherence Risk Non-Adherence Risk Factors for Factors for

0-8 Months (Continuation 0-8 Months (Continuation Phase)Phase) Males *Males *

Younger ageYounger age Patients from low income neighborhoodsPatients from low income neighborhoods Comorbid substance abuseComorbid substance abuse Comorbid alcohol abuseComorbid alcohol abuse 2+ CVD2+ CVD

Protective FactorsProtective Factors F/U care from a psychiatristF/U care from a psychiatrist Number of medications other than Number of medications other than

psychotropicspsychotropics

SummarySummary Adherence rates are low, problem worsens in Adherence rates are low, problem worsens in

continuation phase.continuation phase. Males, younger, and living in lower income Males, younger, and living in lower income

neighborhoods are particularly at risk.neighborhoods are particularly at risk. No support to the scenario of “medication No support to the scenario of “medication

crowd-out” among users of multiple crowd-out” among users of multiple medications. medications.

Presence of multiple cardiovascular risk Presence of multiple cardiovascular risk factors may crowd out depression.factors may crowd out depression.

Depression care for those with comorbid Depression care for those with comorbid substance abuse and alcohol abuse are further substance abuse and alcohol abuse are further complicated due to adherence issues.complicated due to adherence issues.

Having a follow up with a psychiatrist Having a follow up with a psychiatrist improves odds of adherence.improves odds of adherence.

Those who had follow up visits with social Those who had follow up visits with social workers or psychologists were equally likely to workers or psychologists were equally likely to adhere, compared to those with no follow up.adhere, compared to those with no follow up.