Adherence to Antidepressant Medications Among Health Plan Members Diagnosed with Major Depression Ayse Akincigil, John R. Bowblis, Carrie Levin, James T. Walkup, Saira Jan, Stephen Crystal AcademyHealth 2006 Annual Research Meeting Monday, June 26 Background / 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. Supported in part through NIMH grant R01 MH60831, AHRQ grants U18 U18 HS016097 and HSHS-01182, and a grant by Horizon BCBSNJ Study Population Methods A retrospective, observational study of insurance claims. A large insurance company in Northeast, serving threethreemillion lives. Data are constructed from insurance claims, between January 2003 and January 2005. Pharmacy claims are used to construct the outcome measure -- refill persistence. Medical claims are used to identify patients with a new episode of depression. Outcome Measures Index prescription date Index prescription date Prescription look back period 90 days Medication window 30 Diagnosis look back period 120 days 14 Index episode start date (Date of Depression Diagnosis) Overall Rates of Refill Persistence 60 50 Effective Acute Phase Treatment 114 days Effective Continuation Phase Treatment 231 days 30 14 Index episode start date 40 27.4 % persistent 20 0 Acute Phase Continuation Phase 1 Demographic, SocioSocio-Economic Characteristics Gender (67% female) Age 1818-25 (11%) 2525-39 (32%) 4040-49 (28%) Comorbid Conditions Alcohol Abuse (5%) Substance Abuse (8%) Anxiety Disorder (28%) Cancer (18%) Number of Cardiovascular Risk Factors (18% suffer from one, 6% suffer from 2 or more) Median household income at the neighborhood (zip(zipcode) 5050-64 (26%) 65 or older (4%) <50k (29%) 50k50k-70k (42%) >70k (29%) Care Patterns for Depression Episode Type of Provider on Initial Visit (49% were mental health professional, 51% were general medical care). Initial antidepressant drug type (4% were on older generation drugs). 28% had a followfollow-up visit with a psychiatrist. 24% had a followfollow-up visit with another mental health provider (e.g., psychologists, social workers). Predictors of Refill Persistence in Acute Phase (1) Income 70,000 + 1.22 Income 50,000-70,000 1.3 2.47 Age 50-64 1.01 1 1 1 0.96 Age 25-39 Gen Med Provider MH Provider 1 1 1.18 0.69 1.22 0 4.5 32.6 62.9 Predictors of Refill Persistence in Acute Phase (2) Older Generation Drugs Newer Generation Drugs 1.71 Age <25 10.8 24.3 27.6 37.3 F/U with a Psychiatrist No F/U with a 1.95 Age 65 + Age 40-49 % Number of Medications Excluding Psychotropics 0 Medications 1-2 Medications 3-5 Medications 6 or more Medications Number of Outpatient Visits 0 Visits 1-4 Visits 5 or More Visits F/U with other MHP No F/U with other MHP 1 Income <50,000 General Use of Health and Pharmacy Services 2 1 3 0 1 2 Predictors of Refill Persistence in Acute Phase (3) Predictors of Refill Persistence in Acute Phase (4) 0.65 # of Cardiovascular Risk Factors2+ 1 # of Cardiovascular Risk Factors 0 0.96 5+ Visits 0.98 # of Cardiovascular Risk Factors1 1 1-4 Visits 0.75 0 Visits 0.49 Alcohol Abuse 1 No Alcohol Abuse 1.7 6+ Meds 1.33 3-5 Meds 0.72 Substance Abuse 1.1 1 No Substance Abuse 1-2 Meds 1 0 Meds 0 1 0 NonNon-Adherence Risk Factors for 0-8 Months (Continuation Phase) Males * Younger age Patients from low income neighborhoods Comorbid substance abuse Comorbid alcohol abuse 2+ CVD Protective Factors F/U care from a psychiatrist Number of medications other than psychotropics 1 2 Summary Adherence rates are low, problem worsens in continuation phase. Males, younger, and living in lower income neighborhoods are particularly at risk. No support to the scenario of “medication crowdcrowd-out” out” among users of multiple medications. Presence of multiple cardiovascular risk factors may crowd out depression. Depression care for those with comorbid substance abuse and alcohol abuse are further complicated due to adherence issues. Having a follow up with a psychiatrist improves odds of adherence. Those who had follow up visits with social workers or psychologists were equally likely to adhere, compared to those with no follow up. 3