Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states, 2003.

OBJECTIVE: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. METHODS: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. RESULTS: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and .7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. CONCLUSIONS: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

Using medical records to supplement a claims-based comparative effectiveness analysis of antidepressants.

PURPOSE: Because health insurance claims lack clinical information, comparative effectiveness research studies that rely on these data may be challenging to interpret and may result in biased inference. We conducted an exploratory study to determine if medical information contained in patient charts could offer clinical details that would assist in interpreting the results of a claims-based comparative effectiveness study of selective serotonin reuptake inhibitors (SSRIs). METHODS: Retrospective review of 457 charts of patients initiating SSRI treatment. Descriptive data elements included patient diagnosis, symptoms of depressive and anxiety disorders, provider's assessment, and medication treatment and side effects. RESULTS: Most subjects were excluded from the study because their charts were not accessible (58.7%), they did not have a follow-up visit (55.6%), providers could not be contacted (58.0%), or providers refused participation in the study (36.5%). Among those included in the study, most patients were noted to have depression, but most charts lacked information on the majority of depression symptoms at baseline and follow-up. Few concomitant symptoms, side effects, and other important clinical and treatment characteristics were recorded. CONCLUSIONS: Inability to obtain charts due to plan or provider refusal, lack of available information in charts at key times in the course of illness, and missing data elements posed considerable challenges and prevented firm conclusions beyond those drawn from the parent, claims-based study.

Differences in prevalence, treatment, and outcomes of asthma among a diverse population of children with equal access to care: findings from a study in the military health system.

OBJECTIVE: To assess racial and ethnic differences in asthma prevalence, treatment patterns, and outcomes among a diverse population of children with equal access to health care. DESIGN: Retrospective cohort analysis. SETTING: The Military Health System. PARTICIPANTS: A total of 822 900 children aged 2 through 17 years continuously enrolled throughout 2007 in TRICARE Prime, a health maintenance organization-type benefit provided by the Department of Defense. MAIN OUTCOME MEASURES: Prevalence of diagnosed asthma, potentially avoidable asthma hospitalizations, asthma-related emergency department visits, visits to asthma specialists, and use of asthma medications among children aged 2 to 4, 5 to 10, and 11 to 17 years. RESULTS: Black and Hispanic children in all age groups were significantly more likely to have an asthma diagnosis than white children (ranging from odds ratio [OR]=1.16; 95% confidence interval [CI], 1.09-1.24; to OR=2.00; 95% CI, 1.93-2.07). Black children in all age groups and Hispanic children aged 5 to 10 years were significantly more likely to have any potentially avoidable asthma hospitalizations and asthma-related emergency department visits (ranging from OR=1.24; 95% CI, 1.11-1.37; to OR=1.99; 95% CI, 1.37-2.88) and were significantly less likely to visit a specialist (ranging from OR=0.71; 95% CI, 0.61-0.82; to OR=0.88; 95% CI, 0.79-0.98) compared with white children. Black children in all age categories were significantly more likely to have filled any prescriptions for inhaled corticosteroids compared with white children (ranging from OR=1.11; 95% CI, 1.02-1.21; to OR=1.11; 95% CI, 1.04-1.19). CONCLUSIONS: Despite universal health insurance coverage, we found evidence of racial and ethnic differences in asthma prevalence, treatment, and outcomes.

Temporal trends in anti-diabetes drug use in TRICARE following safety warnings in 2007 about rosiglitazone.

PURPOSE: To describe utilization patterns for anti-diabetes medications among a cohort of diabetes patients in the Military Health System (MHS) before and after warnings about rosiglitazone issued in May 2007. METHODS: We used segmented regression analysis to compare changes in the level and trend of rosiglitazone utilization and use of other anti-diabetes therapies in the period prior to the drug warnings (between April 2006 and May 2007) and the period after the warnings were issued (between October 2007 and May 2008). RESULTS: The level and trend of rosiglitazone use changed after the highly publicized warnings. The number of prescriptions filled fell by almost 7000 after the warning (p < 0.001). The number of prescriptions filled for pioglitazone, sulfonylureas, and other diabetes drugs increased significantly after the warnings (p < 0.05 in all models). Overall, the level and trend of filled prescriptions per month for all anti-diabetic drugs did not significantly change after the warnings. CONCLUSIONS: Utilization patterns changed in response to warnings about rosiglitazone. While overall utilization of anti-diabetic drugs did not change, further study is needed to determine the associated health outcomes.

Results of a retrospective claims database analysis of differences in antidepressant treatment persistence associated with escitalopram and other selective serotonin reuptake inhibitors in the United States.

BACKGROUND: Although previous studies have found no differences in response to antidepressant pharmacotherapy between selective serotonin reuptake inhibitors (SSRIs), some recent trials suggest benefits associated with more rapid onset of action. OBJECTIVE: The aim of this work was to compare the likelihood that patients initiating treatment with branded escitalopram, rather than with any of 3 SSRIs (ie, citalopram, fluoxetine, and paroxetine) that are available in generic or branded formulations, would continue therapy with the initial medication after 2 and 6 months. METHODS: We used propensity score-weighted logistic regression to assess the effect of antidepressant choice on the likelihood of continuing treatment, based on data from a large administrative claims database with information about US patients. We modeled the propensity to initiate treatment with escitalopram based on demographic, diagnostic, insurance, and service-use characteristics in the 6 months before treatment initiation and used the results to calculate weights for analysis of treatment continuation. The primary outcome measures were receipt of 2 prescriptions of the index drug in the first 2 months and, among those continuing at 2 months, 4 prescriptions in the first 6 months. Antidepressant choice, cost, and service-use characteristics during the treatment period were included as covariates. Patients who initiated therapy between July 2002 and April 2005 were eligible for inclusion. RESULTS: Based on data for 43,921 patients, at 2 months, escitalopram initiators were more likely to have continued initial medication than those receiving the other SSRIs (66.1% vs 61.9%, respectively; P < 0.01) and less likely to have switched or augmented treatment (4.8% vs 7.6%; P < 0.01). At 6 months, escitalopramtreated patients were also more likely to have continued initial medication (47.1% vs 41.0%; P < 0.01) and less likely to have switched or augmented treatment (9.4% vs 14.4%; P < 0.01). CONCLUSION: Patients initiating treatment with escitalopram were more likely to continue and less likely to switch or augment treatment at 2 and 6 months of therapy compared with those who initiated with alternative SSRIs.

Antidepressant use in a nationally representative sample of community-dwelling US Latinos with and without depressive and anxiety disorders.

BACKGROUND: Antidepressant drugs are among the most widely prescribed drugs in the United States; however, little is known about their use among major ethnic minority groups. METHOD: Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of Latino and non-Latino White adults antidepressant use. SETTING: The 48 coterminous United States was the setting. PARTICIPANTS: Household residents aged 18 years and older (N=9,250). MAIN OUTCOME: Past year antidepressant use. RESULTS: Compared to non-Latino Whites, few Latinos, primarily Mexican Americans, with 12-month depressive and/or anxiety disorders reported past year antidepressant use. Mexican Americans (OR=0.48; 95%CI=0.30-0.77) had significantly lower odds of use compared to non-Latino Whites, which were largely unaffected by factors associated with access to care. Over half of antidepressant use was by respondents not meeting 12-month criteria for depressive or anxiety disorders. Lifetime depressive and anxiety disorders explained another 21% of past year antidepressant use, leaving another 31% of drug use unexplained. DISCUSSION: We found a disparity in antidepressant use for Mexican Americans compared to non-Latino Whites that was not accounted for by differences in need and factors associated with access to care. About one third of antidepressant use was by respondents not meeting criteria for depressive or anxiety disorders. Our findings underscore the importance of disaggregating Latino ethnic groups. Additional work is needed to understand the medical and economic value of antidepressant use beyond their primary clinical targets.

Routes to better health for children in four developing countries.

Despite the availability of effective, affordable interventions for the most common causes of death, more than ten million children in developing countries die each year. This article describes the circumstances of four countries whose reductions in child mortality exceeded what might be expected from their poor economic circumstances, and it asks whether they followed common routes to improved health for children. The findings suggest that contextual factors, such as the degree of economic development, good governance, and strong health care systems, matter less than do targeted health intervention, foreign aid, and technical assistance. In general, these findings contradict prevailing U.S. foreign policy regarding the circumstances in which progress toward health goals can be made.

A framework to improve the quality of treatment for depression in primary care.

New forms of medication and brief psychotherapy have dramatically changed how depressive disorders have been treated over the past two decades. In spite of these changes, the quality of treatment for depression remains poor at the population level. In this article, the authors review current concepts and theory regarding the quality of treatment for depression. They present a conceptual model of four points in the course of a treatment episode when clinicians could deviate from guidelines. Using the model, the authors review research that supports guideline recommendations and that can inform clinicians' decisions. They suggest several areas for future study and action, including extending awareness and recognition outside the medical care setting to schools and workplaces, addressing growing concerns about possible overtreatment, using qualitative research approaches to gain an understanding of patient perspectives on treatment, and improving the measurement for quality of treatment.

Provider type and depression treatment adequacy.

We investigate the effect of initial provider (psychiatrist versus primary care physician or non-physician mental health specialist) on the adequacy of subsequent treatment for persons with depression. Our data are from MarketScan, a medical and pharmacy insurance claims database, which we use to estimate models of the likelihood of treatment for depression and the likelihood that any anti-depression treatments received are adequate. Patients initially seeing psychiatrists are most likely to receive adequate treatment. Provider type has a statistically and medically significant effect on whether any treatment occurs but a smaller effect on treatment adequacy among treated patients. Our results show the importance of provider type in treatment patterns, but the effects on patient outcomes are yet to be determined definitively.

Characteristics, treatment patterns, and outcomes of persistent depression despite treatment in primary care.

We examine the sociodemographic and clinical characteristics of depressed primary care patients who receive at least minimal standards of evidence-based treatment, comparing those who remain depressed with those who recover; and their subsequent treatment patterns and other outcomes. We used observational data from a subset of 542 treated patients participating in a group-level randomized controlled trial of quality improvement interventions for depression conducted in six managed care organizations. Nonresponse to treatment was defined as having at least minimally appropriate treatment for at least two of three 6-month periods but continuing to have probable depression. Our definitions of depression and appropriate treatment are broader than those used in clinical trials, but relevant to primary care settings. Many of the factors predictive of treatment resistance in clinical trials predict nonresponse to guideline concordant care among diverse primary care, depressed patients. The main unique predictors of nonresponse to treatment include a clinical factor (suicide ideation) requiring clinician assessment and intervention, a social/economic factor (unemployment) usually not addressed by medical interventions, and medication nonadherence. Nonresponders used more adjunctive therapies and combination medications, suggesting clinicians and patients were searching for solutions. High rates of service use and poor outcomes emphasize the urgency of new research to find solutions for these patients.

The medicine cabinet: what's in it, why, and can we change the contents?

The failure of the pharmaceutical industry to produce drugs for common chronic diseases, emerging diseases, and the potential threats of bioterrorism or the spread of tropical diseases contrasts sharply with the industry's output of lifestyle and "me-too" drugs. In this paper we review the decision-making process that resulted in our current portfolio of medicines and offer several alternatives to better align business incentives with medical need.

Patterns of medical resource and psychotropic medicine use among adult depressed managed behavioral health patients.

Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

Impact of pain on depression treatment response in primary care.

OBJECTIVE: Pain commonly coexists with depression, but its impact on treatment outcomes has not been well studied. Therefore, we prospectively evaluated the impact of comorbid pain on depression treatment response and health-related quality of life. METHODS: We analyzed data from the ARTIST study, a randomized controlled trial with naturalistic follow-up conducted in 37 primary care clinics. Participants were 573 clinically depressed patients randomized to one of three selective serotonin reuptake inhibitor (SSRI) antidepressants: fluoxetine, paroxetine, or sertraline. Depression as assessed by the Symptom Checklist-20 (SCL-20) was the primary outcome. Secondary outcomes included pain and health-related quality of life. RESULTS: Pain was reported by more than two thirds of depressed patients at baseline, with the severity of pain mild in 25% of patients, moderate in 30%, and severe in 14%. After 3 months of antidepressant therapy, 24% of patients had a poor depression treatment response (ie, SCL-20 >1.3). Multivariate odds ratios for poor treatment response were 1.5 (95% confidence interval, 0.8-3.2) for mild pain, 2.0 (1.1-4.0) for moderate pain, and 4.1 (1.9-8.8) for severe pain compared with those without pain. Increasing pain severity also had an adverse impact on outcomes in multiple domains of health-related quality of life. CONCLUSIONS: Pain is present in two thirds of depressed primary care patients begun on antidepressant therapy, and the severity of pain is a strong predictor of poor depression and health-related quality of life outcomes at 3 months. Better recognition, assessment, and treatment of comorbid pain may enhance outcomes of depression therapy.

Access to drug therapy and substitution between alternative antidepressants following an expansion of the California Medicaid formulary.

In May 1996, the California Medicaid Program (Medi-Cal) added two SSRI antidepressants to its formulary to facilitate the substitution of the SSRIs for older medications as clinically warranted, especially in minority patients thought to be particularly at risk for poor outcomes using older medications. Moreover, it was expected that the overall use of antidepressants would increase as patients who experienced sub-optimal outcomes prior to the formulary expansion would again seek treatment once new options were available. The formulary expansion did significantly alter the clinical treatment decision process, resulting in an immediate and sustained increase in the number of depressed patients initiating antidepressant therapy, primarily with the added SSRIs. This increase in SSRI use after the formulary expansion cannot be fully attributed to desired substitution effects, such as the narrowing of racial differences in SSRI use. However, while some expansion in overall antidepressant use may have been desired, the clinical validity of this expansion cannot be determined based on the results presented here.

Remission, residual symptoms, and nonresponse in the usual treatment of major depression in managed clinical practice.

BACKGROUND: Although published guidelines recommend the continuation of treatment for depression until full remission of symptoms and restoration of functioning, little is known about how often remission is achieved in usual practice and the precipitants of treatment termination when treatment outcome has not been optimal. METHOD: A naturalistic study design examined 1859 patients receiving treatment for DSM-III-R major depression between 1995 and 1997 in the national provider network of a managed behavioral health organization (MBHO). Symptom and impairment ratings by clinicians were used to group patients into full remission, partial remission, and no response. Claims data were used to characterize treatment and identify comorbid medical conditions. RESULTS: According to clinician ratings, approximately 27% to 39% of patients achieved full remission. Medical and substance use comorbidity and hospital admission were more common in those with a partial response to treatment. Only half of patients without a treatment response received a trial of medication during their treatment. Patient choice was the most common reason for termination of treatment, although nearly 40% of clinicians concurred with patients' decisions even when symptoms had not improved. CONCLUSION: Although rates of full remission were comparable to those in clinical trials of antidepressants, results suggest that clinicians may fail to recommend continuation and maintenance treatment consistent with best practice guidelines and that unsuccessful treatment often does not include antidepressant medication.

A national study of the effect of chronic pain on the use of health care by depressed persons.

OBJECTIVE: The objective of this study was to provide national estimates of the impact of common pain conditions such as back pain, chronic headache, self-reported arthritis, and unspecified chronic pain on the use of health services and quality of care among persons with depression. METHODS: This was a cross-sectional study of data from a U.S. national household survey conducted in 1997-1998. The participants were 1,486 community-dwelling adults who met criteria for major depression or dysthymia according to the Composite International Diagnostic Interview Short-Form. RESULTS: Depressed persons with comorbid pain (N=938) were older, had lower incomes, and reported more severe psychiatric distress than depressed persons who did not have pain. When sociodemographic characteristics and severity of psychological distress were adjusted for, comorbid pain was associated with about 20 percent more visits to medical providers by patients who made at least one visit during a year. However, the patients with comorbid pain were about 20 percent less likely to see a mental health specialist than patients without pain. Pain was also shown to be associated with greater use of complementary or alternative medicine but not with differences in the use of antidepressants. CONCLUSION: Comorbid pain among persons with depression is associated with more intensive use of general medical services but lower rates of use of mental health services.

American attitudes toward and willingness to use psychiatric medications.

Despite recent advances in treatment, many Americans decline to take prescribed psychiatric medication. This study explores the role of attitudes regarding the effectiveness of and potential problems associated with psychiatric medications on Americans' willingness to use them. Face-to-face interviews of a US household population sample were done with 1387 volunteers. The 1998 General Social Survey's (response rate, 76.4%) included questions about efficacy, problems, and potential use. Most Americans agree that psychiatric medications are effective, and fewer than half had concerns regarding potential problems. However, the majority of respondents would not be willing to take them. Willingness to use is influenced by these attitudes and other factors, including health status and past use of mental health treatments. Although Americans perceive psychiatric medications to be effective, and this influences their willingness to take them, many still are not willing to take them.

A retrospective analysis of the revocation of prior authorization restrictions and the use of antidepressant medications for treating major depressive disorder.

BACKGROUND: The California Medicaid (Medi-Cal) program removed prior authorization restrictions for 2 selective serotonin reuptake inhibitors (SSRIs), fluoxetine and paroxetine, in May 1996. OBJECTIVE: This article documents how open access affected patient compliance and the likelihood of switching antidepressant therapies. METHODS: All Medi-Cal patients with a paid claim who had a diagnosis of major depressive disorder (MDD) from September 1994 through January 1999 were eligible. The impact of open access on patient compliance and drug switching was investigated using logistic regression models. Completed therapy was defined as 180 days of uninterrupted drug therapy at a minimum therapeutic dose. RESULTS: A total of 6409 patient treatment episodes were identified, of which 80% involved the use of an antidepressant. The aggregate rate of drug therapy completion dropped from 23.2% before the change in formulary policy to 20.5% in the open-access period. There was no corresponding change in the likelihood of switching therapies. For fluoxetine-treated patients, the odds ratio for completing therapy relative to tricyclic antidepressant-treated patients dropped from 3.916 to 1.706 in the open-access period. Corresponding results for paroxetine-treated patients were 1.591 and 0.726, respectively. The reduction in the likelihood of completed therapy without a corresponding increase in switching is consistent with earlier results. Open access resulted in an influx of patients who were not previously treated with an antidepressant or reported by their physician as having an MDD. Physicians may have expanded the use of the open-access SSRIs to treat less severely ill patients. However, paid claims data do not provide sufficient information to accurately measure severity of illness. CONCLUSIONS: It is unclear whether patients benefited clinically from the expansion of the Medi-Cal formulary. The significant changes in the characteristics of the patient population in response to open access (access effect) complicate attempts to measure the impact of open access on treatment patterns. Future analysis of the impact of open access on the cost of treating an episode of depression will also have to address this issue.

Patient adherence and medical treatment outcomes: a meta-analysis.

BACKGROUND: Adherence is a factor in the outcome of medical treatment, but the strength and moderators of the adherence-outcome association have not been systematically assessed. OBJECTIVES: A quantitative review using meta-analysis of three decades of empirical research correlating adherence with objective measures of treatment outcomes. METHOD: Sixty-three studies assessing patient adherence and outcomes of medical treatment were found involving medical regimens recommended by a nonpsychiatrist physician, and measuring patient adherence and health outcomes. Studies were analyzed according to disease (acute/chronic, severity), population (adult/child), type of regimen (preventive/treatment, use of medication), and type and sensitivity of adherence and outcomes measurements. RESULTS: Overall, the outcome difference between high and low adherence is 26%. According to a stringent random effects model, adherence is most strongly related to outcomes in studies of nonmedication regimens, where measures of adherence are continuous, and where the disease is chronic (particularly hypertension, hypercholesterolemia, intestinal disease, and sleep apnea). A less stringent fixed effects model shows a trend for higher adherence-outcome correlations in studies of less serious conditions, of pediatric patients, and in those studies using self-reports of adherence, multiple measures of adherence, and less specific measures of outcomes. Intercorrelations among moderator variables in multiple regression show that the best predictor of the adherence-outcome relationship is methodological-the sensitivity/quality of the adherence assessment.

Appropriateness of prescribing practices for serotonergic antidepressants.

OBJECTIVE: Data from prescribing physicians were used to assess whether serotonergic antidepressants were used for appropriate indications and at appropriate initial dosages. METHODS: Data were derived from the confidential logs of psychiatrists and primary care physicians who provided prescription information from January 1, 1997, through June 30, 1999, as part of the National Disease and Therapeutic Index physician survey. The survey is not affiliated with a reimbursement system and therefore minimizes bias related to reimbursement. Data on the primary reason for use and the dosage at the time of first use were obtained for prescriptions of citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, and extended-release venlafaxine. RESULTS: Depressive disorders accounted for the majority of the 3,206 prescriptions for the six antidepressants (74 percent to 86.2 percent). The next most common indications for use were anxiety (4.1 percent to 12.6 percent) and obsessive-compulsive disorder (1.3 percent to 3.3 percent). For patients with depressive disorders, psychiatrists prescribed slightly higher antidepressant dosages than primary care physicians. CONCLUSIONS: Serotonergic antidepressants are used primarily for the treatment of depression and depression-related disorders and are prescribed at the recommended starting dosages.