Ayse Akincigil

Diagnosis and Treatment of Depression in the Elderly Medicare Population: Predictors, Disparities, and Trends

Objectives: To develop nationally representative estimates of rates of diagnosis of depression; to determine rates and type of treatment received by those diagnosed with depression; and to ascertain socioeconomic differences and trends in treatment rates of depression, including the effect of supplemental insurance coverage, for elderly Medicare fee‐for‐service beneficiaries.

Adherence to Antidepressant Treatment Among Privately Insured Patients Diagnosed With Depression

Background:Antidepressants are effective in treatment of depression, but poor adherence to medication is a major obstacle to effective care. Objective:We sought to describe patient and provider level factors associated with treatment adherence. Methods:This was a retrospective, observational study using medical and pharmacy claims from a large health plan, for services provided between January 2003 and January 2005. We studied a total of 4312 subjects ages 18 or older who were continuously enrolled in the health plan with a new episode of major depression and who initiated antidepressant treatment. Treatment adherence was measured by using pharmacy refill records during the first 16 weeks (acute phase) and the 17–33 weeks after initiation of antidepressant therapy (continuation phase). Measures were based on Health Plan Employer Data and Information Set (HEDIS) quality measures for outpatient depression care. Results:Fifty-one percent of patients were adherent through the acute phase; of those, 42% remained adherent in the continuation phase. Receipt of follow-up care from a psychiatrist and higher general pharmacy utilization (excluding psychotropics) were associated with better adherence in both phases. Younger age, comorbid alcohol or other substance abuse, comorbid cardiovascular/metabolic conditions, use of older generation antidepressants, and residence in lower-income neighborhoods were associated with lower acute-phase adherence. Continuation-phase adherence was lower for HMO participants than for others. Conclusion:In an insured population, many patients fall short of adherence to guideline recommended therapy for depression. Information from existing administrative data can be used to predict patients at highest risk of nonadherence, such as those with substance abuse, and to target interventions.

Studying Prescription Drug Use and Outcomes With Medicaid Claims Data Strengths, Limitations, and Strategies

Medicaid claims and eligibility data, particularly when linked to other sources of patient-level and contextual information, represent a powerful and under-used resource for health services research on the use and outcomes of prescription drugs. However, their effective use poses many methodological and inferential challenges. This article reviews strengths, limitations, challenges, and recommended strategies in using Medicaid data for research on the initiation, continuation, and outcomes of prescription drug therapies. Drawing from published research using Medicaid data by the investigators and other groups, we review several key validity and methodological issues. We discuss strategies for claims-based identification of diagnostic subgroups and procedures, measuring and modeling initiation and persistence of regimens, analysis of treatment disparities, and examination of comorbidity patterns. Based on this review, we discuss “best practices” for appropriate data use and validity checking, approaches to statistical modeling of longitudinal patterns in the presence of typical challenges, and strategies for strengthening the power and potential of Medicaid datasets. Finally, we discuss policy implications, including the potential for the research use of Medicare Part D data and the need for further initiatives to systematically develop and optimally use research datasets that link Medicaid and other sources of clinical and outcome information.

the Diverse Older Hiv-positive Population: A National Profile of Economic Circumstances, Social Support, and Quality of Life

Summary: The objectives of this study were to provide a national profile of socioeconomic circumstances of the middle‐aged and older population living with HIV and to evaluate variations in social support and quality of life (QOL) across age and socioeconomic subgroups, controlling for indicators of disease progression. The design used was a cross‐sectional analysis of nationally representative interview data on HIV‐infected individuals collected in the HIV Cost and Services Utilization Study. Multiple measures of social support and QOL were used. Bivariate comparisons of outcomes across categories of age and exposure category were performed; multivariate analyses to isolate the effect of older age on outcomes within exposure categories were performed, controlling for socioeconomic and clinical co‐variates. Study results indicate that older gay men with HIV/AIDS are a predominantly white population and more likely to have health insurance than their younger counterparts; 38% were employed and 48% reported incomes of more than

Diagnosis and Treatment of Depression in Older Community-Dwelling Adults: 1992–2005

25,000. Older injection drug users (IDUs) with HIV/AIDS are a predominantly black population with a particularly high concentration of disadvantages; only 11% were employed and 74% reported incomes of less than

Racial and Ethnic Disparities in Depression Care in Community-Dwelling Elderly in the United States

10,000. Older IDUs reported especially low levels of physical functioning and emotional support in comparison with their younger counterparts, whereas older gay men did not significantly differ from younger gay men in these respects. The authors conclude that characteristics and care needs of the older HIV‐positive population are very diverse and vary sharply by exposure route. Interventions need to be tailored to the needs of these distinct subpopulations, with an emphasis on development of supportive care interventions for older IDUs.

The Relationship Between Organizational Factors and Resident Satisfaction with Nursing Home Care and Life

OBJECTIVE: To examine evolving patterns of depression diagnosis and treatment in older U.S. adults in the era of newer‐generation antidepressants.

National Trends in Second-Generation Antipsychotic Augmentation for Nonpsychotic Depression

OBJECTIVES We investigated racial/ethnic disparities in the diagnosis and treatment of depression among community-dwelling elderly. METHODS We performed a secondary analysis of Medicare Current Beneficiary Survey data (n = 33,708) for 2001 through 2005. We estimated logistic regression models to assess the association of race/ethnicity with the probability of being diagnosed and treated for depression with either antidepressant medication or psychotherapy. RESULTS Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted for a range of covariates including a 2-item depression screener, we found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66). CONCLUSIONS Among elderly Medicare beneficiaries, significant racial/ethnic differences exist in the diagnosis and treatment of depression. Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.

Predictors of Maternal Depression in the First Year Postpartum: Marital Status and Mediating Role of Relationship Quality

Abstract We examined the relationships between nursing home (NH) resident satisfaction and NH organizational characteristics, while controlling for the effect of resident characteristics within facilities. We used a stratified, random sample of NHs (N=72) from two states and a prescreened and randomized sample of 1496 residents. Data sources included resident interviews, an administrator survey, the Minimum Data Set (MDS), and the Online Survey, Certification and Reporting System (OSCAR). Using Hierarchical Linear Modeling (HLM) techniques, we found that non-chain affiliation, certified nursing assistant staffing, and provision of a family council had significant positive effects on total resident satisfaction. The presence of a special care unit was associated with lower levels of satisfaction.

Substance abuse and hospitalization for mood disorder among Medicaid beneficiaries.

OBJECTIVE This study estimates national trends and patterns in use of second-generation antipsychotics (SGAs) for adjunctive treatment of nonpsychotic adult depression in office-based practice. METHOD Twelve consecutive years (1999-2010) of the National Ambulatory Medical Care Survey were analyzed to estimate trends and patterns of adjunctive SGA treatment for adult (≥ 18 years) nonpsychotic depression in office-based visits. Adjunctive SGA use was examined among all office visits in which depression was diagnosed (N = 7,767), excluding visits with diagnoses for alternative SGA indications (schizophrenia, bipolar disorder, pervasive development disorder, psychotic depression, dementia) and those without an active antidepressant prescription. RESULTS From 1999 to 2010, 8.6% of adult depression visits included an SGA. SGA use rates increased from 4.6% in 1999-2000 to 12.5% in 2009-2010, with an adjusted odds ratio (AOR) for time trend of 2.78 (95% CI, 1.84-4.20). The increase in SGA augmentation was broad-based, with no significant differences in time trends between demographic and clinical subgroups. For the most recent survey years (2005-2010), SGA use rates were higher in visits to psychiatrists than to other physicians (AOR = 5.08; 95% CI, 2.96-8.73), visits covered by public than private insurance (AOR = 3.20; 95% CI, 2.25-4.54), visits with diagnosed major depressive disorder than other depressive disorders (AOR = 1.49; 95% CI, 1.08-2.06), and visits with diabetes, hyperlipidemia, or cardiovascular disease (AOR = 2.13; 95% CI, 1.12-4.03) and lower in visits by patients > 65 years than 18-44 years (AOR = 0.51; 95% CI, 0.32-0.82) and visits that included psychotherapy (AOR = 0.68; 95% CI, 0.47-0.96). CONCLUSIONS Between 1999 and 2010, SGAs were increasingly accepted in the outpatient treatment of adult nonpsychotic depression.