1. UNDERSTANDING THE MENTAL HEALTH SERVICE NEEDS OF DEPRESSED OLDER ADULTS: A STUDY OF AGE DIFFERENCES IN RECEIPT OF EVIDENCE BASED TEREATMENT FOR MAJOR DEPRESSIVE DISORDER Prague, Czech Republic IFA May 30, 2012
Bonnie L. Yegidis, Ph. D. and Marion Becker, Ph. D.
School of Social Work
University of South Florida, Tampa, FL. USA

2. Major Depressive Disorder (MDD)
Common, but under-recognized
Diagnosable, but under-diagnosed
Treatable, but under-treated

3. Depression Second leading cause of disability
18.8 million adults at any time (9.5% of population)
Estimated cost of $43.7 billion annually
Two-thirds of people who die by suicide have a depressive illness; often unrecognized and untreated
A major risk factor for death related to medical illnesses

4. EBP Story
The current belief is that evidence-based practices (EBP) will achieve greater consistency and improve quality of care
One approach to implementing EBPs has been the development of EBP guidelines
EBP guidelines are an integration of:
Best research evidence
Clinical expertise
Values

5. Study Objectives
Determine rates of adherence to American Psychiatric Association (APA) EBP guidelines for Medicaid enrollees in Florida with MDD
Examine factors associated with adherence to EBP guidelines
Examine relationship of adherence to healthcare costs by age

6. Study Plan
Identify adult Medicaid enrollees in Florida with a diagnosis of major depressive disorder
Characterize treatment for those persons after diagnosis
Determine whether treatment complied with guidelines
Summarize treatment utilization and outcome for 18 months following diagnosis
Examine factors associated with adherence, utilization, and outcomes

7. Data Sources Data Sets used Date range – 7/1/03 – 12/31/05
Medicaid enrollment and recipient information
Medicaid fee for service claims (inpatient, outpatient, pharmacy)
Vital statistics data
Date range – 7/1/03 – 12/31/05

8. Inclusion Criteria Florida Medicaid enrollees 18 years or older
Diagnosis of MDD based on at least one inpatient or two outpatient claims containing ICD-9-CM codes for MDD
Medicaid FFS enrollment for at least 33 of 36 months after the claim that identified the enrollee’s diagnosis for MDD
Not in a nursing home

9. Inclusion Criteria (cont.)
Initial sample with MDD (N = 42,009)
Excluded
Under 18
Schizophrenia/Bipolar Dx (N = 11,142)
Subjects included (N = 15,950)

10. Reasons for Non-Adherence
Below recommended dose
Above recommended dose
Polypharmacy
Problematic combinations
Inadequate follow-up

11. Reasons for Non-Adherence
Below recommended dose
Used APA dosing guidelines
Based on average daily dosage over duration of treatment episode
Only applied when the person was receiving only 1 antidepressant

12. Reasons for Non-Adherence
Above recommended dose
Used APA dosing guidelines
Based on average daily dosage over duration of treatment episode
Applied if the person was over dosing range for any antidepressant

13. Reasons for Non-Adherence
Polypharmacy
3 or more antidepressants concurrently for at least 45 days
Problematic combinations
2 SSRIs concurrently
SSRI + SNRI concurrently
MAOI + SSRI concurrently
Person received combination for at least 45 days

14. Reasons for Non-Adherence
Problematic combinations
2 SSRIs concurrently
SSRI + SNRI concurrently
MAOI + SSRI concurrently
Person received combination for at least 45 days

15. Reasons for Non-Adherence
Inadequate follow-up
Very liberal criterion for “follow-up visit”
Needed 3 follow-up visits within the first 90 days (new or recent initiators)
Needed one follow-up visit within the next 90 days (continuers)

16. Overall Findings 15,950 persons met study inclusion criteria
37% White, 9% Black, 42% Hispanic and 12% Other Races (Native American, Asian, Multi-racial)
Almost half (47%) were years of age
76% were female
More than half (N = 8,545, 54%) had dual enrollment in Medicaid and Medicare

17. The Bottom Line
Only 33% of participants received services that adhered to the APA guidelines
Racial and age disparities were evident
Guideline adherence costs more

18. Medication
Most (91%) of participants were prescribed antidepressant medication
36% received SSRI’s only, 2.8% received SNRI’s only, and 2.5% received TCA’s only
The majority (52%) were prescribed more than one antidepressant or switched antidepressants during the study timeframe

19. Adherence & Medication Type

20. Predictors of Adherence
Predictor Variable OR
95% CI
Wald X2 P
Younger age (18-44)
1.31
18.60
<.0001
Middle age (45-64)
1.43
48.56
Female
1.03
0.34
0.56
Black
.95
0.49
0.48
Hispanic
1.25
25.86
Other race/ethnicity
1.11
2.58
0.11
Combination meds
1.26
33.49
TCA only
0.41
35.55
SNRI only
1.04
0.09
0.76
Dual enrollment
0.25
Charlson Index
1.33
44.58
For age – 65+ is reference group, so older adults less likely to receive adherent care
For race, white is reference group, so Hispanics more likely to receive adherent care.
For drug class – SSRI is reference group, so those with no meds or TCAs only less likely to receive adherent care compared to those on SSRI, and those on combo more likely to receive adherent care than SSRI.
Less likely to be adherent if dually enrolled.

21. Specific Findings for Age
Sample characteristics by age
Adherence
Reasons for non-adherence
Medicaid costs

22. Sample Characteristics by Age
18-64
65+
Race
White
4,678 (41%)
1,248 (28%)
Black
1,295 (11%)
154 (3%)
Hispanic
4,255 (37%)
2,489 (55%)
Other
1,181 (10%)
650 (14%)
Sex
Male
2,819 (25%)
1,071 (24%)
Female
8,590 (75%)
3,470 (76%)
Charlson Index
1.5 (2%)
1.8 (2%)
Dual enrollment
4,569 (40%)
3,976 (88%)
N (% within age group)

23. Adherence Status

24. Reasons for Medication Non-adherence
This graph only for those who got medications.
We see that the main reasons for nonadherence for OA is low dosing range and inadequate monitoring.
Low dosing range issue: we recognize that OA may be more likely to receive low dose antidepressants for other conditions such as sleep, but they should still have an antidepressant in therapeutic range to treat their depression.
Inadequate monitoring issue: may not have captured all treatment, if receiving antidepressant med mgmt through general medical services paid by Medicare.

25. Total Pharmacy Costs (PUPM)
Overall costs: hospitalization, outpatient BH and PH, and pharmacy – BH and other.
We see that adherence costs more, and younger adults cost more. Perhaps because OA getting more services through Medicare?

26. Outpatient Behavioral Health Costs (PUPM)

27. Summary of age findings
Older adults less likely to receive adherent care:
Lower doses
Less monitoring
Fewer costs to Medicaid for older adults, except for physical health
May not be capturing some services reimbursed by Medicare

28. Study Limitations
Don’t know if non-adherence is a result of the provider’s or patient’s behavior (e.g., patient refused medication or follow-up versus provider did not prescribe or offer follow-up)
Reliance on Medicaid claims and data and the absence of Medicare data
The study does not include out-of-pocket data so the true service costs in this study are underestimated

29. EBP Training
Training often focuses on guideline criteria and ignores the process of engaging consumers and families to create a person-centered, recovery-oriented treatment plan that gets consumer buy-in and is needed to support adherence

30. Recommendations to Improve EBP Implementation
Given that non-adherence to EBP guidelines is the norm rather than the exception for all ages increased dissemination, provider training and consumer education will be required to increase adherence.
Greater consumer involvement in guideline development is essential
Further outcome research is needed to support the utility of practice guidelines for diverse populations

31. Questions