Antipsychotic prescribing patterns in a Medicare Advantage population of older individuals with dementia.

BACKGROUND: Antipsychotic medications are widely used to treat behavioral symptoms of dementia. However, studies have shown that antipsychotic use in patients with dementia is associated with risk of side effects. AIMS: The aim of this study is to examine antipsychotic prescribing patterns for beneficiaries with dementia enrolled in a Medicare Advantage program and identify opportunities to improve prescribing practices. METHODS: This study includes Medicare Advantage beneficiaries who were 65 years of age or older with dementia. We examined the number of participants that were prescribed an antipsychotic medication. Descriptive analysis was performed, and logistic regression models were used to describe the correlates of antipsychotic exposure. RESULTS: Of the 8688 individuals in the Medicare Advantage population with a dementia diagnosis, 1061 (12.2%) received an antipsychotic medication. Correlates of receiving an antipsychotic medication included older age, dual eligibility for Medicare and Medicaid, and having a co-morbid diagnosis of depressive disorder or substance use disorder. Being female was associated with decreased antipsychotic medication use. Regional variations were also noted. CONCLUSIONS: Care management programs under Medicare Advantage have opportunities to address behavioral health needs of older adults with dementia and to limit inappropriate use of antipsychotic medications.

Pharmacologic management of bipolar disorder in a Medicare Advantage population.

OBJECTIVE: The purpose of this study was to examine patterns of pharmacotherapy for beneficiaries in a high-risk Medicare Advantage program who were diagnosed with bipolar disorder. METHODS: This was a cross-sectional study of 2338 Medicare Advantage beneficiaries diagnosed with bipolar disorder. Pharmacotherapy treatment was assessed via receipt of (1) a mood stabilizer or antipsychotic or both (i.e., guideline concordant bipolar care) and (2) unopposed antidepressant (i.e., without prescription of a mood stabilizer or an antipsychotic). Logistic regression was used to examine correlates of bipolar disorder care. RESULTS: Among those younger than 65 years of age (n = 1395), 54% received guideline concordant therapy and 29% received unopposed antidepressant therapy. Among those 65 years and older (n = 943), 40% received guideline concordant therapy and 33% received unopposed antidepressant therapy. CONCLUSION: Overall, about half of beneficiaries in this Medicare Advantage plan received guideline concordant pharmacotherapy for bipolar disorder, while approximately one-third received an unopposed antidepressant prescription. Antipsychotic medications accounted for most of the monotherapy observed. This study identifies opportunities for further improvements in the pharmacotherapy of bipolar disorder in high-risk Medicare patients.

To tell or not to tell? factors influencing young people's informal disclosures of child sexual abuse.

The aim was to understand the factors influencing informal disclosure of child sexual abuse experiences, taking account of dynamics operating prior to, during, and following disclosure. In-depth semi-structured interviews were conducted with 22 young people who experienced child sexual abuse and 14 parents. Grounded theory methodology informed the study. The key factors identified as influencing the disclosure process included being believed, being asked, shame/self-blame, concern for self and others, and peer influence. Many young people both wanted to tell and did not want to tell. Fear of not being believed; being asked questions about their well-being; feeling ashamed of what happened and blaming themselves for the abuse, for not telling, and for the consequences of disclosure; concern for how both disclosure and nondisclosure would impact on themselves and others; and being supported by and yet pressurized by peers to tell an adult, all illustrate the complex intrapersonal and interpersonal dynamics reflecting the conflict inherent in the disclosure process. These findings build on previous studies that emphasize the dialogic and interpersonal dynamics in the disclosure process. Both intrapersonal and interpersonal influencing factors need to be taken account of in designing interventions aimed at helping children tell. The importance of asking young people about their psychological well-being and the role of peer relationships are highlighted as key to how we can help young people tell.

Specialty behavioral health service use among chronically ill medicare advantage patients with substance use problems.

OBJECTIVE: This study examines the use of substance abuse and mental health services among older adults with substance use disorders. METHODS: Participants were members of Humana Cares, a subsidiary of Humana, Inc., a care management program for chronically ill Medicare Advantage members, between 2008 and 2010. All adults aged 65 and older with a substance use disorder identified with International Classification of Diseases-9 codes were included. We compared utilization of substance abuse and mental health services among participants with no psychiatric comorbidity (n = 585), with comorbid depression (n = 605), and with comorbid severe and persistent mental illness (severe and persistent mental illness, n = 95). RESULTS: Twenty-eight percent utilized substance abuse services and 36% utilized mental health services. After adjusting for covariates, comorbid depression (odds ratio = 4.27, 95% confidence interval: 3.22-5.65) and severe and persistent mental illness (odds ratio = 10.75, 95% confidence interval: 5.22-20.13) were independently associated with specialty service use (either substance abuse or mental health services). CONCLUSION: Although few chronically ill older adults with substance use disorders in this Medicare Advantage program received any specialty substance abuse or mental health services, utilization was higher among those who had concurrent psychiatric disorders.

Depression care and treatment in a chronically ill Medicare population.

OBJECTIVE: The purpose of this study is to examine depression care among chronically ill Medicare Advantage beneficiaries. METHODS: This study includes 5898 Medicare Advantage members with a depression diagnosis enrolled between 2008 and 2010 in a care management program. Two depression care indicators were created: (a) any depression care (≥ 1 antidepressant prescription or ≥ 1 specialty mental health visit) and (b) among those receiving any depression care, those receiving an antidepressant prescription for ≥ 90 days or ≥ 2 specialty visits. Multivariable analysis using logistic regression was used to examine correlates of depression care. RESULTS: Among those <65 years old, 72% received any depression care with 75% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. Among ≥ 65 years old, 65% received any depression care with 67% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. For both age groups, female gender, medical comorbidities and dual eligibility were positively associated with an antidepressant prescription. In the older group, female gender was positively associated with at least a 90-day supply of an antidepressant prescription, while substance use disorders were negatively associated with receiving a minimum of 90 days of an antidepressant. Regional differences and certain psychiatric comorbidities were also associated with receiving depression care. CONCLUSION: Two thirds of the depressed patients in this Medicare Advantage population received depression care. Further studies are needed to examine the effects of quality improvement efforts in the context of care management programs for chronically ill older adults.

"Like an uncle but more, but less than a father"--Irish children's relationships with nonresident fathers.

Although previous research has highlighted the importance of the quality of nonresident father-child relationships for children's well-being, little is known about children's perspectives on what underpins feelings of closeness to their nonresident fathers. This qualitative study explored the processes that facilitate or constrain children's feelings of closeness to their nonresident fathers. Semistructured interviews were conducted with 27 children (ages 8 to 17) who had grown up in a single-mother household, where fathers were nonresident from early in the child's life. Findings revealed the fragility of children's ties with their nonresident fathers and the risk that nonresidence from the outset placed upon these relationships. Children's experiences of closeness to fathers were related to perceptions of their fathers' commitment to their relationship and his obligation to his parenting role, and to a sense of connection to and familiarity with their fathers. It was a challenge for children to feel connected to their fathers when contact arrangements were detached from caregiving activities and precluded immersion in each other's daily lives. Lack of effort on the part of fathers to maintain contact or failure to keep arrangements constrained children's feelings of closeness and gave rise to feelings of disappointment and anger. Children demonstrated their capacity to act as agents within their families as they made sense of these relationships for themselves and accepted or rejected their father as a person who could play a meaningful role in their lives. The implications of the findings for promoting positive relationships with nonresident fathers are discussed.

Containing the secret of child sexual abuse.

This study reports a grounded theory study of the process of how children tell of their experiences of child sexual abuse from the perspectives of young people and their parents. Individual interviews were conducted with 22 young people aged 8 to 18, and 14 parents. A theoretical model was developed that conceptualises the process of disclosure as one of containing the secret of child sexual abuse. Three key dynamics were identified: the active withholding of the secret on the part of the child, the experience of a 'pressure cooker effect' reflecting a conflict between the wish to tell and the wish to keep the secret, and the confiding itself which often occurs in the context of an intimacy being shared. Children's experiences of disclosure were multidetermined and suggest the need for multifaceted and multisystemic approaches to prevention and intervention. The need for the secret to be contained, individually and interpersonally in appropriate safeguarding and therapeutic contexts needs to be respected in helping children tell.

Healthcare costs associated with depression in medically Ill fee-for-service medicare participants.

OBJECTIVES: To examine the association between depression and healthcare costs in medically ill fee-for-service (FFS) Medicare recipients. STUDY DESIGN: Observational analysis of Medicare claims data. SETTING: Medicare Health Support (MHS) program at Green Ribbon Health. PARTICIPANTS: Fourteen thousand nine hundred two participants with diabetes mellitus, congestive heart failure (CHF), or both. MEASUREMENTS: This study examined participant data for a 12-month period before MHS enrollment (collected between November 2004 and August 2006). Twelve-month healthcare costs (based on Medicare claims) in 2,108 participants with International Classification of Diseases, Ninth Revision, claims diagnoses of depression, 1,081 participants with possible depression (positive depression screen on the two-item Patient Health Questionnaire or self reported antidepressant use), and 11,713 participants without depression were compared. Gamma regression models were used to adjust for demographic and clinical differences and nonnormal distribution of cost data. RESULTS: Participants with depression had significantly higher total healthcare costs than those without ($20,046 vs $11,956; P<.01). Higher costs were observed in participants with depression in every cost category except specialty mental health care, which accounted for less than 1% of total healthcare costs. Participants with depression had higher costs in each quartile of increasing medical severity (measured using the Charlson Comorbidity Index). These differences remained statistically significant after adjusting for demographic and other clinical differences. CONCLUSION: Depression is associated with significantly higher healthcare costs in FFS Medicare recipients with diabetes mellitus and CHF. Only a small proportion of the increased costs are spent on mental health specialty care.

Strategies for identifying and channeling patients for depression care management.

OBJECTIVE: To determine optimal methods of identifying enrollees with possible depression for additional depression screening in the context of a care management program for chronically ill Medicare recipients. STUDY DESIGN: Observational analysis of telephone and mail survey and claims data collected for the Medicare Health Support (MHS) program. METHODS: This study examines data from 14,902 participants with diabetes mellitus and/or congestive heart failure in the MHS program administered by Green Ribbon Health, LLC. Depression screening was performed by administering a 2-item screen (the Patient Health Questionnaire 2 [PHQ-2]) by telephone or by mail. Additional information about possible depression was drawn from International Classification of Diseases, Ninth Revision (ICD-9) depression diagnoses on claims and from self-reported use of antidepressant medications. We evaluated positive depression screens using the PHQ-2 administered via telephone versus mail, examined variations in screener-positive findings by care manager, and compared rates of positive screens with antidepressant use and with claims diagnoses of depression. RESULTS: Almost 14% of participants received an ICD-9 diagnosis of depression during the year before program enrollment; 7.1% reported taking antidepressants, and 5.1% screened positive for depression on the PHQ-2. We found substantial variation in positive depression screens by care manager that could not be explained by case mix, prior depression diagnoses, or current depression treatment. After adjusting for demographic and clinical differences, the PHQ-2-positive screen rates were 6.5% by telephone and 14.1% by mail (P <.001). CONCLUSION: A multipronged effort composed of mail screening (using the PHQ-2), self-reported antidepressant use, and claims diagnoses of depression may capture the greatest number of enrollees with possible depression.

Parenting beliefs and practices of opiate-addicted parents: concealment and taboo.

The lifestyle associated with opiate dependence, including drug taking, the buying and selling of drugs, and contact with other drug users, carries potential risks for the safety and well-being of children of drug-using parents. Based on a qualitative interview study conducted with 50 opiate-dependent parents in Dublin, Ireland, the parenting beliefs and practices in relation to children's exposure to drugs and the associated lifestyle are described. Parents saw their lifestyle as potentially risky for their children and their families. The most common strategy adopted by parents was to conceal their drug-related activities and maintain a strict family taboo about these activities. Intervention programmes should be offered to support effective family communication about parental drug dependence.