Depression monitoring and patient behavior in the Clinical Outcomes in MEasurement-Based Treatment (COMET) trial.

OBJECTIVE: In this secondary analysis of results of the Clinical Outcomes in MEasurement-Based Treatment (COMET) trial, patient behaviors that might account for the differences observed in clinical outcomes were examined. METHODS: Patients (N=914) diagnosed as having major depressive disorder participated in telephone interviews either monthly for six months (intervention) or at three and six months (usual care) asking about antidepressant medication-taking, use of psychotherapy or counseling, and participation in depression support groups. Physicians (N=83) in the intervention arm received monthly feedback regarding their patients' depression severity. RESULTS: A total of 664 (73%) patients completed the month 6 interview. The adjusted odds of current antidepressant use at six months were 85% greater (p=.01) for patients in the intervention (N=380) versus usual care (N=284) arms, according to multivariate regression analyses. CONCLUSIONS: More frequent measurement of depression symptoms was associated with greater medication persistence, which in turn may have mediated clinical improvements.

Use of augmentation agents for treating depression: analysis of a psychiatric electronic medical record data set.

OBJECTIVE: This study evaluated the relationship between patient characteristics and augmentation strategies for the treatment of major depressive disorder. METHODS: This retrospective, cross-sectional study used data from a psychiatric electronic medical record database for patients with depression without psychosis or psychotic features who initiated augmentation therapy between January 2001 and June 2011. Medical records were evaluated to identify factors predicting use of specific augmentation agents, and a multivariate logistic regression model was used to assess clinical and demographic predictors of augmentation strategy. RESULTS: Of 3,209 patients initiating augmentation therapy for depression, 75% received augmentation with an antidepressant combination and 11% received augmentation with second-generation antipsychotics. Baseline clinical severity (Clinical Global Impressions-Severity score) most strongly and consistently predicted augmentation with second-generation antipsychotics. CONCLUSIONS: Treatment of patients in specialty settings with depression was often augmented with an antidepressant combination, whereas those with severe depression had an increased likelihood of augmentation with second-generation antipsychotics.

Comparing adherence to and persistence with antipsychotic therapy among patients with bipolar disorder.

BACKGROUND: Medication nonadherence is a significant problem among patients with bipolar disorder. OBJECTIVE: To compare adherence and persistence among patients with bipolar disorder initiated on antipsychotics in a state Medicaid system over a 12 month follow-up period. METHODS: Claims data for patients with bipolar disorder from a de-identified Medicaid database were examined. Patients were classified into 4 monotherapy treatment groups (risperidone, olanzapine, quetiapine, or typical antipsychotic) based on the first prescription filled between January 1, 1999, and December 31, 2001. Adherence and persistence were analyzed over a 12 month follow-up period. Adherence was measured using the Medication Possession Ratio (MPR). Persistence was defined as the total number of days from the initiation of treatment to therapy modification (ie, discontinuation, switching, or combination with another antipsychotic). Adjustment for confounding variables was undertaken using ordinary least-squares and Cox proportional hazard regression modeling. RESULTS: The mean MPRs were 0.68 for risperidone (n = 231), 0.68 for olanzapine (n = 283), 0.71 for quetiapine (n = 106), and 0.46 for typical antipsychotics (n = 205). Patients initiated on typical antipsychotics were 23.6% less adherent than patients initiated on risperidone (p < 0.001). Mean persistence (days) was 194.8 for risperidone, 200.9 for olanzapine, 219.8 for quetiapine, and 179.2 for typical antipsychotics. Extended Cox regression modeling indicated no significant differences between antipsychotics in hazards of therapy modification within 250 days of initiation. However, patients initiated on typical antipsychotics were 5.2 times more likely to modify therapy compared with those initiated on risperidone after 250 days of antipsychotic therapy (p < 0.001). CONCLUSIONS: Adherence and persistence were similar between atypical antipsychotic groups. The typical antipsychotic group, however, demonstrated lower adherence and a greater likelihood of patients modifying therapy compared with the risperidone cohort.

Impact of depression on utilization patterns of oral hypoglycemic agents in patients newly diagnosed with type 2 diabetes mellitus: a retrospective cohort analysis.

BACKGROUND: Oral hypoglycemic agents (OHAs) are an important component in the management of type 2 diabetes mellitus (DM). Large-scale studies have demonstrated that tight glycemic control with such agents can reduce the frequency and severity of long-term DM-related complications. OBJECTIVES: The main goal of this study was to examine the impact of depression on utilization patterns of OHAs in patients newly diagnosed with type 2 DM. A secondary objective was to estimate the impact of depression on discontinuation and modification of pharmacotherapy for DM in these patients. METHODS: Patients newly diagnosed with type 2 DM during a 3-year period (1998-2000) were identified from a Medicaid claims database. Presence of preexisting depression was determined on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The patient cohort was followed up until they received their first prescription for an OHA (1998-2001); this date was treated as the index date for the study. Utilization patterns (ie, discontinuation, augmentation, switching, non-modification) for OHAs were computed for a 12-month follow-up period after the index date. A multivariate framework was used to estimate the impact of depression on utilization patterns, controlling for confounders such as demographics, comorbidity, provider interaction, drug regimen complexity, and DM severity. RESULTS: A total of 1237 newly diagnosed type 2 DM patients were identified (depressed, n=446; nondepressed, n=791). A higher number of depressed patients (23.32%) switched or augmented therapy compared with nondepressed patients (16.18%). Also, a higher fraction of depressed patients (39.46%) discontinued OHA therapy compared with nondepressed patients (32.87%). Results of a multinomial logistic regression indicated that, controlling for covariates, patients with depression were 1.72 times more likely to switch (P=0.046) and 1.89 times more likely to augment therapy (P=0.004) compared with nondepressed patients. Logistic regression analysis also indicated that, controlling for confounding covariates, patients with depression were 1.72 times more likely to modify initial OHA therapy compared with patients without depression (P=0.003). CONCLUSION: Depression was significantly associated with utilization patterns of OHAs in these patients newly diagnosed with type 2 DM, thus possibly affecting their disease management.

The effect of depression on health care utilization and costs in patients with type 2 diabetes.

The objective of the study was to estimate the effect of depression on health care utilization and costs in patients newly diagnosed with type 2 diabetes. Patients were identified during a four-year enrollment period (1998-2001) from a Medicaid claims database. The final cohort consisted of 4,294 patients with type 2 diabetes (1,525 patients with depression; 2,769 patients without depression). Multivariate results indicated that significant utilization differences existed between the two groups: Patients who were depressed incurred a higher number of physician office visits, emergency room/inpatient admissions, and more prescriptions compared with patients who had diabetes but were not depressed. Patients with depression had nearly 65% higher overall health care costs than those without depression. Recognizing that depression is as a risk factor for increasing health care expenditures has the potential to improve diabetes management and related outcomes.

Depression in patients with type 2 diabetes: impact on adherence to oral hypoglycemic agents.

BACKGROUND: Adherence to oral hypoglycemic agents (OHAs) is important for adequate glycemic control and prevention of future complications in patients with type 2 diabetes. OBJECTIVE: To examine the impact of depression on adherence to OHAs in patients newly diagnosed with type 2 diabetes. METHODS: Patients newly diagnosed with type 2 diabetes during a 4 year period were identified from a Medicaid claims database. Presence of preexisting depression was determined on the basis of ICD-9-CM codes. Adherence to OHAs was computed using prescription refill data for a 12 month follow-up period from the date of the index OHA prescription. Two separate adherence indices (Medication Possession Ratio-1 [MPR-1], Medication Possession Ratio-2 [MPR-2]) were computed. The impact of depression on adherence was assessed after controlling for confounders such as demographics, comorbidity, provider interaction, complexity of regimen, and diabetes severity. RESULTS: A total of 1326 newly diagnosed patients with type 2 diabetes were identified (depressed = 471; nondepressed = 855). Results of the study indicated that patients with depression had significantly lower adherence (MPR-1 86%; MPR-2 66%) to OHAs compared with patients without depression (MPR-1 89%; MPR-2 73%). Multivariate results indicated that depression was a significant predictor of adherence, with depressed patients being 3-6% less adherent to OHAs than nondepressed patients, after controlling for confounding factors. CONCLUSIONS: Depression significantly impacts adherence to OHAs in patients with type 2 diabetes. The study results imply that depression screening and treatment need to be included in the protocol for management of patients with type 2 diabetes.

Appalachian teen smokers: not on tobacco 15 months later.

High school smokers from 2 central Appalachian states received the American Lung Association's 10-session Not On Tobacco (N-O-T) program or a 15-minute brief self-help intervention. Our study compared the efficacy of N-O-T with that of the brief intervention by examining group differences in the 15-month-postbaseline (12-month-postprogram) smoking quit rates. N-O-T youths had higher overall quit rates. Review of end-of-program (3-month-postbaseline) and 3-month-postprogram (6-month-postbaseline) follow-up data showed state-level differences and positive cessation trends over time, regardless of treatment intensity. Quit rates were lower than rates found in other N-O-T studies of nonrural youths, suggesting that Appalachian youths are a recalcitrant smoking sample. Findings suggest that N-O-T is one option for long-term smoking cessation among rural teens.

Analysis of West Virginia medicaid claims data for the prevalence of medical conditions and use of drugs likely to cause QT prolongation in patients with schizophrenia.

BACKGROUND: An important concern with antipsychotic drugs used for the treatment of schizophrenia is the prolongation of the QT interval on the electrocardiogram. Concomitant use of other QT-prolonging drugs and the presence of certain medical conditions may lead to excessive QT prolongation and subsequent cardiac arrhythmias. OBJECTIVE: The aim of this study was to assess the utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation in a large population of patients with schizophrenia in practice settings. METHODS: The study was conducted using West Virginia Medicaid claims data for patients aged 18 to 64 years with ≥1 medical claim for schizophrenia between January 1, 1997, and December 31, 1999. A comprehensive list of drugs and medical conditions causing QT prolongation was obtained from the literature. The drugs were identified in the prescription claims data using their specific National Drug Classification codes. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify the medical conditions as described in the medical claims files. Descriptive statistics on utilization of drugs and prevalence of medical conditions were reported and demographic differences were examined. RESULTS: The final sample consisted of 1699 patients with schizophrenia. The mean (SD) age was 40.8 (11.35) years (range, 18-63 years); 55% of the patients were women. A total of 76.9% of patients utilized ≥1 nonantipsychotic QT-prolonging drug in a year, with a mean (SD) of 2.1 (1.3) such drugs used per patient per year. A total of 15.9% of patients with schizophrenia had ≥1 medical condition associated with QT prolongation. Patients with ≥1 such medical condition had a mean (SD) of 1.2 (0.57) conditions potentially causing QT prolongation. The number of nonantipsychotic QT-prolonging prescriptions filled and the prevalence of medical conditions leading to QT prolongation were found to be significantly higher for women (both P<0.001) and patients aged 34 to 64 years (both P<0.001). CONCLUSIONS: In this study, a high utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation were found. These results merit assessment of predisposing risk factors, such as concurrent use of other QT-prolonging drugs and the presence of cardiovascular and other conditions associated with QT prolongation, before prescribing antipsychotics, especially in women and older patients with schizophrenia.

The economic burden of Barrett's esophagus in a Medicaid population.

OBJECTIVE: To estimate the overall healthcare expenditures of patients with Barrett's esophagus in the West Virginia Medicaid population. METHODS: West Virginia Medicaid-paid claims data for the period January 1, 1995, to December 31, 1999, were used for the study. The population included all individuals eligible for West Virginia Medicaid during the study period except for Medicare eligible- and Medicaid managed-care recipients. A prevalence-based approach was used to determine the cost of illness for Barrett's esophagus. RESULTS: The total cost of illness for Barrett's esophagus more than tripled, from $182399 in 1995 to $623864 in 1999, with approximately a 4(1/2)-fold increase in medical and more than a threefold increase in pharmacy costs. The average cost of treating Barrett's esophagus was found to be approximately $1207 per patient in 1999. Overall, pharmacy costs accounted for >66% of the total costs. Controlling for age, gender, and number of comorbidities, patients with Barrett's esophagus incur 21.2% higher overall costs than patients with gastroesophageal reflux disease and 62.4% higher overall costs than the general Medicaid population. CONCLUSIONS: The increasing prevalence of and resource utilization for Barrett's esophagus provide a framework for further analysis and implementation of policies aimed at appropriate allocation of resources for the state's Medicaid program.