Christine Stewart

Use of antipsychotic medications in pediatric populations: what do the data say?

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

Racial/ethnic differences in health care visits made before suicide attempt across the United States

Background:Suicide is a public health concern, but little is known about the patterns of health care visits made before a suicide attempt, and whether those patterns differ by race/ethnicity. Objectives:To examine racial/ethnic variation in the types of health care visits made before a suicide attempt, when those visits occur, and whether mental health or substance use diagnoses were documented. Research Design:Retrospective, longitudinal study, 2009–2011. Participants:22,387 individuals who attempted suicide and were enrolled in the health plan across 10 health systems in the Mental Health Research Network. Measures:Cumulative percentage of different types of health care visits made in the 52 weeks before a suicide attempt, by self-reported racial/ethnicity and diagnosis. Data were from the Virtual Data Warehouse at each site. Results:Over 38% of the individuals made any health care visit within the week before their suicide attempt and ∼95% within the preceding year; these percentages varied across racial/ethnic groups (P<0.001). White individuals had the highest percentage of visits (>41%) within 1 week of suicide attempt. Asian Americans were the least likely to make visits within 52 weeks. Hawaiian/Pacific Islanders had proportionally the most inpatient and emergency visits before an attempt, but were least likely to have a recorded mental health or substance use diagnosis. Overall, visits were most common in primary care and outpatient general medical settings. Conclusions:This study provides temporal evidence of racial/ethnic differences in health care visits made before suicide attempt. Health care systems can use this information to help focus the design and implementation of their suicide prevention initiatives.

National Prevalence of Receipt of Antidepressant Prescriptions by Persons Without a Psychiatric Diagnosis

OBJECTIVE The study addressed recent concerns regarding increasing prescription of antidepressant drugs to patients with no recorded psychiatric diagnosis. METHODS Records from ten large integrated health systems in the Mental Health Research Network were used to examine diagnoses received by 1,011,946 health plan members who filled at least one antidepressant prescription in 2010. RESULTS Among individuals filling antidepressant prescriptions, psychiatric diagnoses recorded during the year were depressive disorders (48%), anxiety disorders (27%), bipolar disorders (3%), and attention deficit disorders (3%). The proportion of those filling prescriptions who had no psychiatric diagnosis was 39%, which fell to 27% after the analysis excluded prescriptions for antidepressants often prescribed for nonpsychiatric indications (tricyclic antidepressants, trazodone, and bupropion). CONCLUSIONS Prescription of antidepressants to patients without an appropriate diagnosis appears to be less common than previously reported.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network

OBJECTIVE The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems. METHODS Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings. RESULTS Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64). CONCLUSIONS There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

ANTIDEPRESSANT ADHERENCE ACROSS DIVERSE POPULATIONS AND HEALTHCARE SETTINGS

Early adherence is key to successful depression treatment, but nearly 60% of patients discontinue antidepressants within 3 months. Our study aimed to determine factors associated with poor early adherence to antidepressants in a large diverse sample of patients.

How complete are E‐codes in commercial plan claims databases?

We advise caution in applying the claim-based algorithm developed by Callahan et al.1 to identify suicidal behavior using claims data. The Callahan et al. method uses external cause of injury codes (E-codes) in combination with diagnosis codes for poisoning derived from the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) coding scheme to identify hospitalizations for suicide attempts. In recent years, there has been considerable concern that suicidal behavior is a potential adverse outcome of prescription drug use such as antidepressant and anticonvulsant agents.2 Nonfatal, deliberate self-harms resulting in emergency department treatments and hospitalizations can be identified in administrative databases using E-codes.3–5 These codes are part of the ICD-9-CM and are used to provide information about the cause and intent of an injury or poisoning. E-coding is mandatory in about half of US states,6 and the completeness of E-codes in state hospital discharge databases typically exceeds 90%.7 As part of a study of effects of safety warnings on antidepressant use and suicidality in youth, we assessed the completeness of E-codes in commercial health plan databases.

Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

OBJECTIVE The purpose of the study was to examine whether individuals with diagnoses of schizophrenia were differentially adherent to their statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) medications compared to individuals without psychiatric illness. METHOD Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of schizophrenia or schizoaffective disorder receiving two or more medication dispensings of a statin or an ACEI/ARB in 2011 (N=710) were identified and matched on age, sex and Medicare status to controls with no documented mental illness and two or more medication dispensings of a statin in 2011 (N=710). Medication adherence, and sociodemographic and clinical characteristics of the study population were assessed. RESULTS Multivariable models indicated that having a schizophrenia diagnosis was associated with increased odds of statin medication adherence; the odds ratio suggested a small effect. After adjustment for medication regimen, schizophrenia no longer showed an association with statin adherence. Having a schizophrenia diagnosis was not associated with ACEI/ARB medication adherence. CONCLUSIONS Compared to patients without any psychiatric illness, individuals with schizophrenia were marginally more likely to be adherent to their statin medications. Given that patterns of adherence to cardioprotective medications may be different from patterns of adherence to antipsychotic medications, improving adherence to the former may require unique intervention strategies.

First Presentation With Psychotic Symptoms in a Population-Based Sample

OBJECTIVE Increasing evidence supports the effectiveness of comprehensive early intervention at first onset of psychotic symptoms. Implementation of early intervention programs will require population-based data on overall incidence of psychotic symptoms and on care settings of first presentation. METHODS In five large health care systems, electronic health records data were used to identify all first occurrences of psychosis diagnoses among persons ages 15-59 between January 1, 2007, and December 31, 2013 (N=37,843). For a random sample of these putative cases (N=1,337), review of full-text medical records confirmed clinician documentation of psychotic symptoms and excluded those with documented prior diagnosis of or treatment for psychosis. Initial incidence rates (based on putative cases) and confirmation rates (from record reviews) were used to estimate true incidence according to age and setting of initial presentation. RESULTS Annual incidence estimates based on putative cases were 126 per 100,000 among those ages 15-29 and 107 per 100,000 among those ages 30-59. Rates of chart review confirmation ranged from 84% among those ages 15-29 diagnosed in emergency department or inpatient mental health settings to 19% among those ages 30-59 diagnosed in general medical outpatient settings. Estimated true incidence rates were 86 per 100,000 per year among those ages 15-29 and 46 per 100,000 among those ages 30-59. CONCLUSIONS When all care settings were included, incidence of first-onset psychotic symptoms was higher than previous estimates based on surveys or inpatient data. Early intervention programs must accommodate frequent presentation after age 30 and presentation in outpatient settings, including primary care.

Adjusting Antidepressant Quality Measures for Race and Ethnicity

Adjusting Antidepressant Quality Measures for Race and Ethnicity Increasing awareness of health care disparities has prompted reexamination of the National Quality Forum recommendation that measures of health care quality not be adjusted for patients’ sociodemographic characteristics. Adjustment might appear to endorse poorer-quality care for those traditionally underserved. However, Fiscella and colleagues1 pointed out that failure to adjust for sociodemographic differences might unfairly penalize health systems serving disadvantaged groups. Jha and Zaslavsky2 argued that quality measures should be adjusted for patient characteristics when differences between health systems are confounded by differences between the patients they serve. In those cases, stratified reporting of quality measures would both reveal health disparities and permit fairer comparisons of quality across health systems or facilities. Given that rates of mental health treatment differ markedly by race and ethnicity,3 this cohort study examined how stratifying by race/ethnicity would affect a specific mental health care quality measure: the proportion of outpatients starting antidepressant treatment who receive adequate or potentially effective acute-phase treatment.4

Organized Self-Management Support Services for Chronic Depressive Symptoms: A Randomized Controlled Trial

OBJECTIVE This study aimed to determine whether a self-management support service was more effective than treatment as usual in reducing depressive symptoms and major depressive episodes and increasing personal recovery among individuals with chronic or recurrent depressive symptoms. METHODS The study was a randomized controlled trial of a self-management support service consisting of depression self-management training, recovery coaching, and care coordination. The 18-month intervention included regular telephone or in-person contacts with a care manager and a structured group program co-led by a professional therapist and a trained peer specialist. Intervention (N=150) and control (N=152) participants ages ≥ 18 with chronic or recurrent depressive symptoms were recruited from five clinics in Seattle, Washington. Outcome measures included the Hopkins Symptom Checklist depression scale, the Recovery Assessment Scale, the Patient-Rated Global Improvement scale, and the percentage of participants with a major depressive episode. Interviewers were masked to treatment condition. RESULTS Repeated-measures estimates of the long-term effect of the intervention versus usual care (average of the six-, 12-, and 18-month outcomes adjusted for age, gender, and site) indicated that intervention participants had less severe symptoms (p=.002) and higher recovery scores (p=.03), were less likely to be depressed (odds ratio [OR]=.52, p=.001), and were more likely to be much improved (OR=1.96, p=.001). CONCLUSIONS These findings support providing regular outreach care management and a self-care group offering a combined behavioral and recovery-oriented approach for people with chronic or recurrent depressive symptoms.