Antidepressant Medication Management Research Articles

Differences across race and ethnicity in the quality of antidepressant medication management.

To illustrate the importance of a multidimensional view of disparities in quality of antidepressant medication management (AMM), as well as discriminating "within-facility" disparities from disparities that exist between facilities. We used data from the Veterans Health Administration's (VA) Corporate Data Warehouse (CDW) which contains clinical and administrative data from VA facilities nationally. CDW data were used to measure five indicators of AMM quality, including the HEDIS Effective Acute-Phase and Effective Continuation-Phase measures. Mixed effects regression models were used to examine differences in quality indicators between racial/ethnic groups, controlling for other demographic and clinical factors. An adaptation of the Kitagawa-Blinder-Oaxaca (KBO) method was used to decompose mean differences in treatment quality between racial and ethnic groups into within- and between-facility effects. Demographic, clinical, and health service utilization data were extracted for patients in fiscal year 2017 with a diagnosis of depression and a new start of an antidepressant medication. The decomposition of the overall differences between White and Black patients on receiving an initial 90-day prescription (46.7% vs. 32.7%), Effective Acute-Phase (79.7% vs. 66.8%), and Effective Continuation-Phase (64.0% vs. 49.6%) HEDIS measures revealed that most of the overall effects were "within-facility," meaning that Black patients are less likely to meet these measures regardless of where they are treated. Although the overall magnitude of disparities between White and Hispanic patients on these three measures was very similar (46.7% vs. 32.7%; 79.7% vs. 69.2%; 64.0% vs. 53.6%), the differences were more attributable to Hispanic patients being treated in facilities with overall lower performance on these measures. Discriminating within- and between-facility disparities and taking a multidimensional view of quality are essential to informing efforts to address disparities in AMM quality.

Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure

Heart failure (HF) affects more than 6 million adults in the US and more than 64 million adults worldwide, with 50% prevalence of depression. Patients and clinicians lack information on which interventions are more effective for depression in HF. To compare the effectiveness of behavioral activation psychotherapy (BA) vs antidepressant medication management (MEDS) on patient-centered outcomes inpatients with HF and depression. This pragmatic randomized comparative effectiveness trial was conducted from 2018 to 2022, including 1-year follow-up, at a not-for-profit academic health system serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participant included inpatients and outpatients diagnosed with HF and depression, and data were analyzed as intention-to-treat. Data were analyzed from 2022 to 2023. BA is an evidence-based manualized treatment for depression, promoting engagement in personalized pleasurable activities selected by patients. MEDS involves the use of an evidence-based collaborative care model with care managers providing coordination with patients, psychiatrists, and primary care physicians to only administer medications. The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9). Secondary outcomes included physical and mental health-related quality of life (HRQOL), measured using the Short-Form 12-Item version 2 (SF-12); heart failure-specific HRQOL, measured using the Kansas City Cardiomyopathy Questionnaire; caregiver burden, measured with the Caregiver Burden Questionnaire for Heart Failure; emergency department visits; readmissions; days hospitalized; and mortality at 3, 6, and 12 months. A total of 416 patients (mean [SD] age, 60.71 [15.61] years; 243 [58.41%] male) were enrolled, with 208 patients randomized to BA and 208 patients randomized to MEDS. At baseline, mean (SD) PHQ-9 scores were 14.54 (3.45) in the BA group and 14.31 (3.60) in the MEDS group; both BA and MEDS recipients experienced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months (eg, mean [SD] score at 12 months: BA, 7.62 (5.73); P < .001; MEDS, 7.98 (6.06); P < .001; between-group P = .55). There was no statistically significant difference between BA and MEDS in the primary outcome of PHQ-9 at 6 months (mean [SD] score, 7.53 [5.74] vs 8.09 [6.06]; P = .88). BA recipients, compared with MEDS recipients, experienced small improvement in physical HRQOL at 6 months (mean [SD] SF-12 physical score: 38.82 [11.09] vs 37.12 [10.99]; P = .04), had fewer ED visits (3 months: 38% [95% CI, 14%-55%] reduction; P = .005; 6 months: 30% [95% CI, 14%-40%] reduction; P = .008; 12 months: 27% [95% CI, 15%-38%] reduction; P = .001), and spent fewer days hospitalized (3 months: 17% [95% CI, 8%-25%] reduction; P = .002; 6 months: 19% [95% CI, 13%-25%] reduction; P = .005; 12 months: 36% [95% CI, 32%-40%] reduction; P = .001). In this comparative effectiveness trial of BA and MEDS in patients with HF experiencing depression, both treatments significantly reduced depressive symptoms by nearly 50% with no statistically significant differences between treatments. BA recipients experienced better physical HRQOL, fewer ED visits, and fewer days hospitalized. The study findings suggested that patients with HF could be given the choice between BA or MEDS to ameliorate depression. ClinicalTrials.gov Identifier: NCT03688100.

Patient Race or Ethnicity, Health Care System Characteristics, and Community Factors Associated with Quality of Antidepressant Medication Management (AMM)

Research ObjectiveClinical practice guidelines emphasize the importance of effective antidepressant medication management (AMM). One marker of AMM quality is if the patient remains on the medication through the acute phase of treatment (about 3 months), which has been shown to improve psychosocial functioning and reduce risk of suicide. The quality of AMM is monitored by many health care organizations to evaluate and improve depression care. Furthermore, data on AMM quality are now being stratified by race and ethnicity and reported publicly for Medicare Advantage plans due to concern for persistent racial and ethnic disparities in the U.S. However, there are few studies of the multiple, interacting factors important to stakeholders who conduct quality improvement efforts aimed at reducing racial/ethnic disparity in quality. This study analyzed patient, health care system, and community factors associated with AMM quality for patients with major depression, especially among Black/African American and Hispanic/Latino populations.Study DesignThis national cohort study analyzed health record data from 129 U.S. Veterans Health Administration (VA) facilities. Race/ethnicity was identified from medical record data following U.S. federal standards for categorization. We identified patients' demographics, medical and mental health comorbidities, past‐year health care utilization before initiating an antidepressant, and county‐level factors. Using the Healthcare Effectiveness Data and Information Set AMM acute phase measure as a marker of quality, we calculated each facility's percentage of patients who were dispensed at least 84 days of antidepressant medication. A mixed effects logistic regression tested associations between patient, health care system, and community factors and a patient's likelihood of meeting the AMM measure.Population StudiedVA patients whose health care met criteria for inclusion in the AMM measure denominator in 2017 (N = 104,287): a major depression diagnosis and initiating antidepressant treatment.Principal FindingsAdjusting for socio‐demographics, comorbidities, healthcare utilization, and community factors in the regression model, care provided to Black/African American patients (odds ratio [OR] =0.62, 95% CI 0.59–0.64, p &lt; 0.01) or to Hispanic/Latino patients (OR = 0.85, 95% CI 0.80–0.90, p &lt; 0.01) was less likely to meet the AMM measure, compared to White or Non‐Hispanic/Latino patients, respectively. Care for men met the measure less often than for women (OR = 0.92, 95% CI 0.88–0.96, p &lt; 0.01). Outpatient mental health visits before starting an antidepressant was positively associated with meeting the AMM measure, whereas violent crime rate and severe housing problems in a patient's county were negatively associated with meeting the AMM measure.ConclusionsAmong people with major depression treated with antidepressants, racial/ethnic minority patients had a lower likelihood of receiving treatment that meets quality standards. Future research should investigate causality more thoroughly to inform quality improvement efforts that would reduce disparities, such as the utilization of healthcare, socioeconomic factors, or institutionalized racism.Implications for Policy or PracticeGiven the mounting evidence that Black/African American and Hispanic/Latino patients receive lower quality of mental health care, it is important for health care organizations to move beyond identifying disparities in quality to understanding and addressing the systematic barriers that patients and providers must overcome to improve overall quality of mental health care for racial/ethnicity minorities.Primary Funding SourceDepartment of Veterans Affairs.

PQA measures to expand beyond dispensing and claims data

The shift to quality-based incentives continues to emerge in pharmacy. The Pharmacy Quality Alliance (PQA) is currently working to develop pharmacy measures for A1C and blood pressure reporting; adherence to medications for hypertension, high cholesterol, and diabetes treatment; and antidepressant medication management. These are important measures that address chronic, high-cost, and high-burden diseases, PQA noted. According to Lynn Pezzullo, RPh, senior director of quality innovation at PQA, there’s a strong interest in these measures not only from payers, but also because pharmacists are able to directly improve their patients’ health in these areas. The measures, once completed, will be appropriate to use in value-based plan pharmacy agreements. PQA’s work on these new measures began in 2020, a continuation of work on pharmacy measures that started in 2019. Their efforts were in response to interest from members and policymakers who wanted to better evaluate pharmacy quality as well as assess pharmacist-provided care and pharmacy-based services. “Multistakeholder groups have helped in the prioritization and development of these measures,” said Pezzullo. Moving to an outcomes-based system of care means developing clinical measures to assess whether patients are meeting specified clinical goals. PQA got its start in 2006 developing performance measures that center on addressing the appropriate and safe use of medications. The work began with measures for the Medicare Part D prescription drug program. Within Medicare Part D, the Medicare star ratings program awards quality bonus payments within the Medicare Advantage program on the basis of how well health plans execute a set of performance measures. Five PQA measures are included in the Medicare Part D star ratings program. There are three types of PQA measures: ▪Performance measures▪Monitoring measures▪Quality improvement indicatorsOnly PQA performance measures can be used in accountability programs and only for the intended level of attribution.PQA measures are grouped into four domains: ▪Adherence▪Appropriate medication use▪Medication safety▪Medication management servicesPQA has two measure sets focused on opioids and specialty medications. Most PQA measures are for evaluating health plan performance and quality improvement. PQA also has a set of pharmacy measures for evaluating pharmacy performance and quality improvement. There are three types of PQA measures: ▪Performance measures▪Monitoring measures▪Quality improvement indicators Only PQA performance measures can be used in accountability programs and only for the intended level of attribution. PQA measures are grouped into four domains: ▪Adherence▪Appropriate medication use▪Medication safety▪Medication management services PQA has two measure sets focused on opioids and specialty medications. Most PQA measures are for evaluating health plan performance and quality improvement. PQA also has a set of pharmacy measures for evaluating pharmacy performance and quality improvement. However, PQA measures are beginning to be used in other sectors, including state-based and private sector programs. Overall, 15 PQA measures are used across CMS’ quality programs and more are used in state and regional quality programs. “Our measures we develop can be used beyond Medicare Part D,” said Pezzullo. This is especially true as more pharmacists move away from dispensing and toward providing patient care services. Even so, the new PQA pharmacy measures in development align with CMS’s star ratings program as well as CMS’s Healthcare Effectiveness data and Information Set (HEDIS) measures, which are a set of standardized performance measures that provide purchasers and consumers with information to compare health plan performance. PQA’s foundational measures rely on prescription claims data. But in the shift to value-based care, the performance measures being developed by PQA are based on pharmacy data that expand beyond dispensing and claims data. “Health plans recognize that pharmacists improve patients’ outcomes,” said Pezzullo. For example, pharmacists can close gaps in care by administering appropriate immunizations to patients and improve clinical measures such as A1C levels. “Improving patients’ health outcomes is a goal for all stakeholders across health care,” Pezzullo said. PQA aims to complete development of these pharmacy measures and have them available for use by early 2022 and 2023.

Adherence and persistence among patients with major depressive disorder enrolled in the vortioxetine tAccess Patient Support Program

Objective The tAccess Patient Support Program (PSP) is a personalized support program for patients prescribed vortioxetine therapy. We assessed the impact of the tAccess PSP on adherence to and persistence with vortioxetine among adult patients with major depressive disorder (MDD). Methods A retrospective observational cohort study was conducted in patients with MDD receiving vortioxetine who were enrolled in the tAccess PSP. Eligible patients were 18 to 64 years of age and had ≥1 vortioxetine claim and ≥1 inpatient/outpatient medical MDD claim during the 12 months preceding or on the index date, defined as the date of the earliest vortioxetine claim. Study outcomes included medication adherence (proportion of days covered [PDC], adherent ≥80%) and persistence (the total number of days on therapy without a ≥30-day gap) at 90, 180, and 365 days. Additionally, persistence was reported for a subset of patients meeting the standardized Healthcare Effectiveness Data and Information Set (HEDIS) Antidepressant Medication Management (AMM) criteria (the percentage of adults aged 18–64 years who remained on an antidepressant for ≥84 days or ≥180 days), as defined by the National Committee for Quality Assurance. These data were reviewed alongside current HEDIS AMM data for commercially insured patients meeting the standardized metric. Results The study identified a total of 2635 patients with an MDD diagnosis and ≥90 days of follow-up time and a subset of 2238 patients meeting HEDIS AMM criteria. Mean PDC among all patients with MDD was 0.78, with 58.3% of patients achieving PDC ≥80%. During the 90-day follow-up, 62.1% of patients with MDD were persistent on vortioxetine. Among the subset of patients who met HEDIS AMM criteria, persistence was 83.4% and 69.9% at 84 and 180 days, respectively. In comparison, in 2017, HEDIS AMM criteria for antidepressant persistence were met by 67.8% of commercially insured patients at 84 days and 51.8% at 180 days. Conclusions These initial results, reviewed alongside recent available HEDIS AMM data, suggest that the tAccess PSP may be beneficial in addressing treatment adherence and persistence in patients with MDD.

Personalized treatments for depressive symptoms in patients with advanced heart failure: A pragmatic randomized controlled trial.

ObjectivesHeart Failure is a chronic syndrome affecting over 5.7 million in the US and 26 million adults worldwide with nearly 50% experiencing depressive symptoms. The objective of the study is to compare the effects of two evidence-based treatment options for adult patients with depression and advanced heart failure, on depressive symptom severity, physical and mental health related quality of life (HRQoL), heart-failure specific quality of life, caregiver burden, morbidity, and mortality at 3, 6 and 12-months.MethodsTrial design. Pragmatic, randomized, comparative effectiveness trial.Interventions. The treatment interventions are: (1) Behavioral Activation (BA), a patient-centered psychotherapy which emphasizes engagement in enjoyable and valued personalized activities as selected by the patient; or (2) Antidepressant Medication Management administered using the collaborative care model (MEDS).Participants. Adults aged 18 and over with advanced heart failure (defined as New York Heart Association (NYHA) Class II, III, and IV) and depression (defined as a score of 10 or above on the PHQ-9 and confirmed by the MINI International Neuropsychiatric Interview for the DSM-5) selected from all patients at Cedars-Sinai Medical Center who are admitted with heart failure and all patients presenting to the outpatient programs of the Smidt Heart Institute at Cedars-Sinai Medical Center. We plan to randomize 416 patients to BA or MEDS, with an estimated 28% loss to follow-up/inability to collect follow-up data. Thus, we plan to include 150 in each group for a total of 300 participants from which data after randomization will be collected and analyzed.ConclusionsThe current trial is the first to compare the impact of BA and MEDS on depressive symptoms, quality of life, caregiver burden, morbidity, and mortality in patients with depression and advanced heart failure. The trial will provide novel results that will be disseminated and implemented into a wide range of current practice settings.RegistrationClinicalTrials.Gov Identifier: NCT03688100.

Behavioral Health Care Quality Among Marketplace Insurers in 2019.

Using 2019 Centers for Medicare and Medicaid Services data, the authors analyzed performance on behavioral health care quality measures among 168 marketplace insurers offering 185 products and investigated whether performance differed by insurer attributes. The authors considered four quality measures: antidepressant medication management, follow-up care for children prescribed attention-deficit hyperactivity disorder medication, follow-up care within 7 days after hospitalization for mental illness, and initiation and engagement of alcohol and other drug dependence treatment. Multivariate regression was used to determine whether performance varied by insurers' nonprofit ownership, Blue Cross-Blue Shield affiliation, Medicaid-managed care participation, and preferred provider organization status. Performance levels were highest for management with antidepressant medication and lowest for initiation and engagement of drug dependence treatment. Systematic differ-ences were observed by ownership status and Medicaid-managed care plan status. Increasing the transparency of health plan quality information is important for aiding enrollee decision making and encouraging quality improvement among providers and insurers.

Health Outcomes Associated with Adherence to Antidepressant Use during Acute and Continuation Phases of Depression Treatment among Older Adults with Dementia and Major Depressive Disorder.

Objectives: To examine health outcomes associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management (AMM) during acute and continuation phases of depression treatment among older adults with dementia and major depressive disorder (MDD). Design: Retrospective cohort study. Setting: Medicare 5% sample data (2011–2013). Participants: Older adults (aged 65 years or older) with dementia and MDD. Measurements: The first antidepressant prescription claim from 1 May 2011 through 30 April 2012 was considered the index prescription start date (IPSD). Adherence during acute- and continuation-phase AMM was based on HEDIS guidelines. Study outcomes included all-cause mortality, all-cause hospitalization, and falls/factures (with mortality being the competing event for hospitalization and falls/fractures) during follow-up from end of acute-/continuation-phase AMM adherence. Due to the proportionality assumption violation of Cox models, fully non-parametric approaches (Kaplan–Meier and modified Gray’s test) were used for time-to-event analysis adjusting for the inverse probability of treatment weights. Results: Final study samples consisted of 4330 (adherent (N) = 3114 (71.92%)) and 3941 (adherent (N) = 2407 (61.08%)) older adults with dementia and MDD during acute- and continuation-phase treatments, respectively. No significant difference (p > 0.05) between adherent and non-adherent groups was observed for all-cause mortality and falls/fractures in both the acute and continuation phases. There was a significant difference in time to all-cause hospitalization during acute-phase treatment (p = 0.018), with median times of 530 (95% CI: 499–587) and 425 (95% CI: 364–492) days for adherent and non-adherent groups, respectively. Conclusions: Acute-phase adherence to HEDIS AMM was associated with reductions in all-cause hospitalization risk among older adults with dementia and MDD.

M21. THE STEP TRIAL: A SEQUENTIAL MULTIPLE ASSIGNMENT RANDOMISED TRIAL (SMART) OF INTERVENTIONS FOR PATIENTS AT ULTRA-HIGH RISK OF PSYCHOSIS - STUDY RATIONALE, DESIGN AND BASELINE DATA

BackgroundAlthough approximately twenty randomised controlled trials have now been conducted with young people identified as being at high clinical risk of psychotic disorder, it remains unclear what the optimal type and sequence of treatments are for this clinical population. There has also been increased focus on clinical outcomes other than transition to psychotic disorder, such as psychosocial functioning, persistent attenuated psychotic symptoms and non-psychotic disorders. At Orygen, we are currently conducting a trial of a sequence of interventions consisting of two psychosocial therapies (support and problem solving [SPS] and cognitive-behavioural case management [CBCM]) and antidepressant medication. The primary outcome of the study is functional outcome after 6 months. This presentation will outline the background, rationale, design, recruitment and retention data and preliminary baseline results.MethodsSTEP is a sequential multiple assignment randomised trial (SMART) of treatments for young people (12–25 year olds) who meet ultra high risk for psychosis (UHR) criteria. Participants were recruited from primary (headspace) and secondary/tertiary (Orygen Youth Health) mental health services in Melbourne, Australia. The trial consists of three steps: Step 1: SPS (1.5 months); Step 2: SPS vs Cognitive Behavioural Case Management (4.5 months); Step 3: Cognitive Behavioural Case Management + Antidepressant Medication vs Cognitive Behavioural Case Management + Placebo (6 months). Patients who do not respond by the end of each step graduate to the next step in treatment. Responders are randomised to SPS or monitoring. Treatment response is based a combination of reduced attenuated psychotic symptoms, rated using the Comprehensive Assessment of At-Risk Mental States (CAARMS), and functional improvement (Social and Occupational Functioning Assessment Scale [SOFAS]) at the end of the treatment step. A ‘fast fail’ option is built into Step 3, whereby patients who deteriorate or have not responded 3 months into Step 3 are offered a choice of continuing existing treatment or commencing omega-3 fatty acids or low-dose antipsychotic medication. The intervention is for 12 months, with follow up at 18 and 24 months. A pilot study using the same design is currently being conducted at The University of California Davis.ResultsRecruitment has recently completed, with 342 patients recruited over a 2.4 year period, representing the largest UHR treatment study conducted to date. Preliminary results indicate an 8% response rate to Step 1 and a 23% response rate to Step 2. Discontinuation rates are 15% (step 1), 43% (step 2), 32% (step 3), primarily due to participants being lost to follow up or not wanting to start medication. The current transition to psychosis rate is 10.2%. Baseline clinical data are currently being analysed and will be presented at the conference.DiscussionPreliminary results indicate high non-response rates following SPS and moderate non-response rates following extended SPS or CBCM, possibly partly due to the stringent definition of response, which required substantial and persistent improvement in both attenuated psychotic symptoms and functioning. Discontinuation rates are low to moderate, reflecting the complexity and severity of this clinical population. The recruitment and retention data show that it is possible to conduct large-scale and complex stepped care trials with this high risk population in a primary mental health care setting (headspace services). Outcomes will inform the most effective type and sequence of treatments for improving psychosocial functioning, symptoms and reducing risk of developing psychotic disorder in this group, as well as identify predictors of treatment response.

The Application of Community-Based Information from the American Community Survey in a Large Integrated Health Care Organization.

The American Community Survey (ACS) is the largest household survey conducted by the US Census Bureau. We sought to describe the community-level characteristics derived from the ACS among enrollees of Kaiser Permanente Southern California (KPSC), evaluate the associations between ACS estimates and selective individual-level health outcomes, and explore how using different scales of the census geography and the linearity assumption affect the associations. We examined the associations between track-level and block group-level ACS 5-year estimates and 4 individual-level Healthcare Effectiveness Data and Information Set (HEDIS) outcome measures (comprehensive diabetes care, postpartum care, antidepressant medication management, and childhood immunization status) using multilevel generalized linear models. Odds ratios and their 95% confidence intervals were estimated for every 10% increase in ACS measures. 6,357,841 addresses were successfully geocoded to at least the tract level. The community-level demographic, socioeconomic, residential, and other ACS measures varied among KPSC health plan enrollees. A majority of these ACS measures were associated with the selected HEDIS health outcomes. The directions of the effects were consistent across health outcomes; however, the magnitudes of the effect sizes varied. Within each HEDIS health outcome, the relative size of the effects appeared to remain similar. Differences between the census tract- and block group-level estimates were minor, especially for measures related to race/ethnicity, education, income, and occupation. These findings support the use of many ACS measures at neighborhood levels to predict health outcomes. The geographic units might have little effect on the results. The linearity assumption should be made with caution.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States–based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010–2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

PND3 HEALTH OUTCOMES ASSOCIATED WITH ADHERENCE TO HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) ANTIDEPRESSANT MEDICATION MANAGEMENT MEASURES DURING ACUTE AND CONTINUATION PHASES OF DEPRESSION TREATMENT AMONG OLDER ADULTS WITH DEMENTIA AND MAJOR DEPRESSIVE DISORDER

To examine health outcomes associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management (AMM) during acute and continuation phases of depression treatment among older adults (age≥65 years) with dementia and major depressive disorder (MDD). A retrospective cohort study was conducted using Medicare 5% sample data (2011-2013), where first antidepressant prescription claim from May 1, 2011 through April 30, 2012 was considered Index prescription start date (IPSD). Based on HEDIS guidelines, adherence during acute and continuation phase AMM was defined as: (i) at least 84 days of antidepressant use during 114 days post-IPSD and (ii) at least 180 days of antidepressant use during 231 days post-IPSD, respectively. Study outcomes included all-cause mortality, all-cause hospitalization, and falls/factures (with mortality being the competing event for hospitalization and falls/fractures) during follow-up from end of acute/continuation phase AMM adherence. Due to proportionality assumption violation of Cox models, fully non-parametric approaches (Kaplan-Meier analysis and Modified Gray’s test) were used for time-to-event analysis adjusting for inverse probability of treatment weights. Final study samples consisted of 4,330 [adherent(N)=3,114 (71.92%)] and 3,941 [adherent(N)=2,407 (61.08%)] older adults with dementia and MDD during acute and continuation phase treatments, respectively. No significant difference (p>0.05) between adherent and non-adherent groups were observed in terms of all-cause mortality and falls/fractures in both acute and continuation phases. There was a significant difference in time to all cause hospitalization (p=0.018), with median times 530 (95%CI: 499-587) and 425 (95%CI: 364-492) days for adherent and non-adherent groups, respectively. However, no significant (p=0.126) all-cause hospitalization risk was observed with continuation phase AMM adherence. Acute phase adherence to HEDIS AMM was associated with reductions in all-cause hospitalization risk among older adults with dementia and MDD; however, no other difference was observed with other study outcomes between adherent and non-adherent groups.

PMH63 - Differences in Antidepressant Medication Management Between Commercially Insured and Traditional Medicaid for Low Income Adults in Arkansas

PMH63 - Differences in Antidepressant Medication Management Between Commercially Insured and Traditional Medicaid for Low Income Adults in Arkansas

Antidepressant Medication Management Among Older Patients Receiving Home Health Care.

Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay. Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients aged 65 years or older who received HHC in 2006-2007 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (versus discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy. About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10- to 20-percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change. Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions.

Antidepressant Medication Management in Primary Care: Not Just Another Pill

Primary care nurse practitioners can manage antidepressant medications in a moderate amount of patients with major depression. Standardized depression screening instruments can identify symptom severity, engage patients and families, and monitor antidepressant treatment response. Medical conditions need to be ruled out before diagnosing a patient with major depression. It is critical to screen for substance use problems, suicidal ideation, and history of mania. Major depression care management includes knowing cytochrome P450 drug-to-drug interactions, improving medication adherence, developing follow-up plans, determining need for maintenance therapies, deciding when to augment antidepressants, and consulting or referring to mental health specialists.

Continuity of Care and Adherence to Antidepressant Treatment Among Medicaid-Covered Youth

Continuity of care is a critical indicator of quality of care and key to effective antidepressant medication management in children and adolescents. Little is known about the characteristics associated with receiving guidelines concordant care. Using a retrospective, longitudinal cohort design of youth with a new episode of depression, this study reviewed records and pre-existing data to (1) examine rates of conformance to continuity of care treatment guidelines (Health Plan Employer Data and Information Set [HEDIS]) for antidepressant management; (2) identify individual- and community-level characteristics associated with continuity of antidepressant treatment; and (3) investigate the relationship between continuity of care and antidepressant adherence. Two-thirds of youth met the HEDIS optimum contact criteria of three outpatient mental health contacts during the first 3 months of treatment. Good continuity of care was associated with prior outpatient treatment and taking other psychotropic medications while inadequate follow-up was associated with older adolescents, disabled children, and youths living in rural areas. Guidelines concordant follow-up was associated with better antidepressant adherence. Findings underscore the need to deliver guidelines concordant care, particularly among vulnerable subgroups.

Feasibility of Nurse-Led Antidepressant Medication Management of Depression in an HIV Clinic in Tanzania

Sub-Saharan Africa has the highest HIV prevalence worldwide and depression is highly prevalent among those infected. The negative impact of depression on HIV outcomes highlights the need to identify and treat it in this population. A model for doing this in lower-resourced settings involves task-shifting depression treatment to primary care; however, HIV-infected individuals are often treated in a parallel HIV specialty setting. We adapted a model of task-shifting, measurement-based care (MBC), for an HIV clinic setting and tested its feasibility in Tanzania. MBC involves measuring depressive symptoms at meaningful intervals and adjusting antidepressant medication treatment based on the measure of illness. Twenty adults presenting for care at an outpatient HIV clinic in Tanzania were enrolled and followed by a nurse care manager who measured depressive symptoms at baseline and every 4 weeks for 12 weeks. An algorithm-based decision-support tool was utilized by the care manager to recommend individualized antidepressant medication doses to participants' HIV providers at each visit. Retention was high and fidelity of the care manager to the MBC protocol was exceptional. Follow through of antidepressant prescription dosing recommendations by the prescriber was low. Limited availability of antidepressants was also noted. Despite challenges, baseline depression scores decreased over the 12-week period. Overall, the model of algorithm-based nursing support of prescription decisions was feasible. Future studies should address implementation issues of medication supply and dosing. Further task-shifting to relatively more abundant and lower-skilled health workers, such as nurses' aides, warrants examination.

Trends in Antidepressant Prescribing for New Episodes of Depression and Implications for Health System Quality Measures

The nationally reported Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management measure assesses whether patients with new episodes of depression receive antidepressant coverage for 84 of the first 114 days of treatment. Although initial prescriptions for a 90-day supply satisfy measure requirements, they may circumvent its purpose of ensuring adequate medication management. To assess the extent to which 90-day initial prescriptions have contributed to health system performance on the HEDIS antidepressant measure from fiscal years 2001 to 2008. Retrospective cohort analysis of Veterans Health Administration administrative data. Patients with a new diagnosis of depression and a new antidepressant prescription (N=383,634). HEDIS antidepressant measures, days supply of initial antidepressant prescriptions, antidepressant refills, and clinical encounters. Health system performance on the HEDIS acute phase antidepressant measure increased from 63.1% in 2001 to 71.0% in 2008. Receipt of an initial 90-day antidepressant supply increased from 10.5% to 29.1% during this same period; when these are excluded, HEDIS performance was 58.8% in 2001 and 59.4% in 2008. Receiving an initial 90-day prescription was associated with prior antidepressant treatment, fewer clinical encounters, and similar rates of antidepressant refills compared with patients prescribed less than 90-day supplies. Although increases in initial 90-day supplies contribute to improved performance on the HEDIS measure, actual adherence during the acute treatment phase may not be changed by this practice. Quality measures based on pharmacy fills may need modification in the setting of large initial prescriptions.

Feasibility of Integrated Depression Care in an HIV Clinic

Feasibility of Integrated Depression Care in an HIV Clinic

Assessment of evidence-based psychotherapy practices in usual care: challenges, promising approaches, and future directions.

Assessment of evidence-based psychotherapy practices in usual care: challenges, promising approaches, and future directions.