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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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 45-64 years of age 76% were female More than half (N = 8,545, 54%) had dual enrollment in Medicaid and Medicare

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

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

Adherence & Medication Type

Predictors of Adherence Predictor Variable OR 95% CI Wald X2 P Younger age (18-44) 1.31 1.16-1.47 18.60 <.0001 Middle age (45-64) 1.43 1.30-1.59 48.56 Female 1.03 0.94-1.12 0.34 0.56 Black .95 0.83-1.09 0.49 0.48 Hispanic 1.25 1.15-1.36 25.86 Other race/ethnicity 1.11 0.98-1.25 2.58 0.11 Combination meds 1.26 1.17-1.37 33.49 TCA only 0.41 0.31-0.55 35.55 SNRI only 1.04 0.83-1.30 0.09 0.76 Dual enrollment 0.25 0.23-0.27 1094.20 Charlson Index 1.33 1.22-1.45 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.

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

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)

Adherence Status

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.

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?

Outpatient Behavioral Health Costs (PUPM)

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

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

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

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

Questions