James Walkup

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.

Assessing clinical predictions of early rehospitalization in schizophrenia.

This study determines patient characteristics that predict early hospital readmission in schizophrenia and evaluates the extent to which inpatient staff accurately predict these readmissions. Adult inpatients with schizophrenia or schizoaffective disorder (N = 262) were evaluated at hospital discharge and 3 months later to assess hospital readmission. At hospital discharge, inpatient staff were asked to identify which patients were likely to be readmitted during this period. Comparisons were made between patients who were or were not readmitted and between readmitted patients who were or were not identified by staff as likely to be readmitted; 24.4% of the sample were readmitted within 3 months of hospital discharge. Early readmission was associated with four or more previous hospitalizations (85.7% vs. 57.7%, p = .004), comorbid substance use disorder (60.3% vs. 35.5%, p = .0006), major depression (40.6% vs. 26.8%, p = .04), absence of a family meeting with inpatient staff (58.2% vs. 41.8%, p = .02), and prescription of a conventional rather than an atypical antipsychotic medication (93.7% vs. 83.8%, p = .045). Twelve of the 63 readmitted patients were correctly predicted by staff to re-hospitalize. Staff tended to overestimate the risk of rehospitalization in patients with a poor therapeutic alliance, low global function, or initial involuntary admission and to underestimate the risk in patients with alcohol use disorders or four or more previous psychiatric hospitalizations. Early rehospitalization is common in schizophrenia and difficult to predict. Greater emphasis on comorbid alcohol use disorders and a history of multiple previous admissions may help clinicians identify patients at greatest risk for early rehospitalization.

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.

Antidepressant treatment and health services utilization among HIV-infected medicaid patients diagnosed with depression

AbstractOBJECTIVE: To characterize the prevalence and predictors of diagnosed depression among persons with HIV on Medicaid and antidepressant treatment among those diagnosed, and to compare utilization and costs between depressed HIV-infected individuals treated with and without antidepressant medications. DESIGN: Merged Medicaid and surveillance data were used to compare health services utilized by depressed individuals who were or were not treated with antidepressant medications, controlling for other characteristics. SETTING AND PARTICIPANTS: The study population comprised Medicaid recipients in New Jersey who were diagnosed with HIV or AIDS by March 1996 and received Medicaid services between 1991 and 1996. MEASUREMENTS AND MAIN RESULTS: Logistic regression and ordinary least squares regressions were employed. Women were more likely and African Americans were less likely to be diagnosed with depression. Women and drug users in treatment were more likely to receive antidepressant treatment. Depressed patients treated with antidepressants were more likely to receive antiretroviral treatment than those not treated with antidepressants. Monthly total expenditures were significantly lower for individuals diagnosed with depression and receiving antidepressant therapy than for those not treated with antidepressants. After controlling for socioeconomic and clinical characteristics, treatment with antidepressant medications was associated with a 24% reduction in monthly total health care costs. CONCLUSIONS: Depressed HIV-infected patients treated with antidepressants were more likely than untreated subjects to receive appropriate care for their HIV disease. Antidepressant therapy for treatment of depression is associated with a significantly lower monthly cost of medical care services.

The impact of mental health and substance abuse factors on HIV prevention and treatment.

The convergence of HIV, substance abuse (SA), and mental illness (MI) represents a distinctive challenge to health care providers, policy makers, and researchers. Previous research with the mentally ill and substance-abusing populations has demonstrated high rates of psychiatric and general medical comorbidity. Additionally, persons living with HIV/AIDS have dramatically elevated rates of MI and other physical comorbidities. This pattern of co-occurring conditions has been described as a syndemic. Syndemic health problems occur when linked health problems involving 2 or more afflictions interact synergistically and contribute to the excess burden of disease in a population. Evidence for syndemics arises when health-related problems cluster by person, place, or time. This article describes a research agenda for beginning to understand the complex relations among MI, SA, and HIV and outlines a research agenda for the Social and Behavioral Science Research Network in these areas.

Drug abuse, methadone treatment, and health services use among injection drug users with AIDS☆

This paper compares health care use across subgroups of injection drug users (IDUs) with AIDS, as defined by current drug abuse status and participation in methadone maintenance treatment (MMT), using surveillance-identified IDU status and health care claims data. Merged Medicaid and AIDS surveillance data were analyzed using ordinary least squares regression, simple logistic regression and multinomial logistic regression. Consistent MMT was more likely among women, Whites and older subjects. Monthly total expenditures and inpatient expenditures were significantly lower for IDUs in MMT than for IDUs with claims indicative of current drug abuse. Consistent participation in MMT was associated with a higher probability of antiretroviral use and, among antiretroviral users, more consistent use of antiretrovirals. Merged administrative data sets can be an important data source that illuminate the relationships among drug abuse, drug treatment, and HIV-related health care. For AIDS-infected IDUs, consistent MMT may lower barriers to receipt of appropriate HIV-related health care and reinforce adherence to medical recommendations.

Reliability of Medicaid Claims Files for Use in Psychiatric Diagnoses and Service Delivery

To investigate the reliability of Medicaid claims data for use in research, clinical decision-making, and policy, medical records were abstracted of 105 inpatient stays on the psychiatric service of a large general hospital. Primary and secondary diagnoses and outpatient specialty mental health services after hospitalization were compared between Medicaid claims data and medical record information. Primary and secondary diagnoses were reliable, but claims data failed to capture several types of outpatient services. This suggests strategies to use claims files more appropriately.

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

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

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

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.