Physician alerts to increase antidepressant adherence: fax or fiction?

Efficacy and safety of zuranolone for the treatment of depression: A systematic review and meta-analysis

Major depressive disorder (MDD) and postpartum depression (PPD) are common and burdensome conditions. This study aims to evaluate the efficacy and safety of zuranolone, a neuroactive steroid γ-aminobutyric acid type A receptors-positive allosteric modulator, in treating MDD and PPD. A comprehensive literature search was conducted until September 2023, identifying seven randomized controlled trials (RCTs). The results demonstrated that zuranolone significantly decreased Hamilton Rating Scale for Depression (HAM-D) scores in patients with PPD or MDD at day 15 (concluding the 14-day course) and day 42-45 (4 weeks after treatment cessation) compared with the placebo, albeit exhibiting a diminishing trend. Moreover, a higher percentage of patients with PPD or MDD achieved HAM-D response and remission with zuranolone treatment compared with placebo at day 15. However, zuranolone did not significantly increase the proportion of MDD patients achieving HAM-D remission at 42/43 days. Adverse events (AEs) such as somnolence, dizziness, and sedation were linked to zuranolone, with a higher but not statistically significant rate of discontinuation due to AEs in the zuranolone group. Overall, our findings support the rapid antidepressant effects of zuranolone in MDD and PPD, along with a relatively favorable safety and tolerability. Large-scale longitudinal RCTs are needed to evaluate the long-term efficacy of zuranolone.

Efficacy and safety of zuranolone in Japanese adults with major depressive disorder: A double-blind, randomized, placebo-controlled, phase 2 clinical trial

AIM

To evaluate the efficacy and safety of an oral, once-daily, 14-day treatment course of zuranolone in Japanese patients with major depressive disorder (MDD).

METHODS

This multicenter, randomized, double-blind, placebo-controlled study randomized eligible patients (1:1:1) to receive oral zuranolone 20 mg, zuranolone 30 mg, or placebo once daily for 14 days (treatment-period), followed by two 6-week follow-up periods. The primary endpoint was change from baseline in the 17-item Hamilton Depression Rating Scale (HAMD-17) total score on Day 15.

RESULTS

Overall, 250 patients (enrolled: 07/07/2020-05/26/2021) were randomized to receive placebo (n = 83), zuranolone 20 mg (n = 85), or zuranolone 30 mg (n = 82). The demographic and baseline characteristics were balanced between groups. The adjusted mean (standard error) change from baseline in the HAMD-17 total score on Day 15 was -6.22 (0.62), -8.14 (0.62), and - 8.31 (0.63) in the placebo, zuranolone 20-mg, and zuranolone 30-mg groups, respectively. Significant differences in the adjusted mean (95% confidence interval [CI]) for zuranolone 20 mg versus placebo (-1.92; [-3.65, -0.19]; P = 0.0296) and zuranolone 30 mg versus placebo (-2.09; [-3.83, -0.35]; P = 0.0190) groups were observed on Day 15, and also as early as Day 3. A nonsignificant yet distinct drug-placebo separation was observed during follow-up. Somnolence (placebo [3.7%], zuranolone 20 mg [10.6%], and zuranolone 30 mg [20.7%]) and dizziness (3.7%, 9.4%, and 9.8%, respectively) were more common with zuranolone.

CONCLUSION

Oral zuranolone was safe and demonstrated significant improvements in depressive symptoms, as assessed by HAMD-17 total score change from baseline over 14 days in Japanese patients with MDD.

Examining the Use of Antidepressants for Adolescents with Depression/Anxiety Who Regularly Use Cannabis: A Narrative Review

Depression and anxiety disorders are two of the most common and growing mental health concerns in adolescents. Consequently, antidepressant medication (AD) use has increased widely during the last decades. Several classes of antidepressants are used mainly to treat depression, anxiety, and obsessive-compulsive disorders by targeting relevant brain neurochemical pathways. Almost all randomized clinical trials of antidepressants examined patients with no concomitant medications or drugs. This does not address the expected course of therapy and outcome in cannabis users. Cannabis is the most commonly used illicit substance globally. Substantial changes in its regulation are recently taking place. Many countries and US states are becoming more permissive towards its medical and recreational use. The psychological and physiological effects of cannabis (mainly of its major components, tetrahydrocannabinol (THC) and cannabidiol (CBD)) have been extensively characterized. Cannabis use can be a risk factor for depressive and anxiety symptoms, but some constituents or mixtures may have antidepressant and/or anxiolytic potential. The aim of this literature review is to explore whether simultaneous use of AD and cannabis in adolescence can affect AD treatment outcomes. Based on the current literature, it is reasonable to assume that antidepressants are less effective for adolescents with depression/anxiety who frequently use cannabis. The mechanisms of action of antidepressants and cannabis point to several similarities and conjunctions that merit future investigation regarding the potential effectiveness of antidepressants among adolescents who consume cannabis regularly.

How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations

Adherence to antidepressants is crucial for optimal treatment outcomes when treating depressive disorders. However, poor adherence is common among patients prescribed antidepressants. This targeted review summarizes the main factors associated with poor adherence, interventions that promote antidepressant adherence, pharmacological aspects related to antidepressant adherence, and formulates 10 clinical recommendations to optimize antidepressant adherence. Patient-related factors associated with antidepressant non-adherence include younger age, psychiatric and medical comorbidities, cognitive impairment, and substance use disorders. Prescriber behavior-related factors include neglecting medical and family histories, selecting poorly tolerated antidepressants, or complex antidepressant regimens. Multi-disciplinary interventions targeting both patient and prescriber, aimed at improving antidepressant adherence, include psychoeducation and providing the patient with clear behavioral interventions to prevent/minimize poor adherence. Regarding antidepressant choice, agents with individually tailored tolerability profile should be chosen. Ten clinical recommendations include four points focusing on the patient (therapeutic alliance, adequate history taking, measurement of depressive symptoms, and adverse effects improved access to clinical care), three focusing on prescribing practice (psychoeducation, individually tailored antidepressant choice, simplified regimen), two focusing on mental health services (improved access to mental health care, incentivized adherence promotion and monitoring), and one relating to adherence measurement (adherence measurement with scales and/or therapeutic drug monitoring).

Identifying the Prescribing Physician in US Healthcare Claims Data

BACKGROUND

Identifying the prescribing physician may be essential in studies that use health care claims databases but often there is no single consistent physician identifier (ID) available that spans an entire database and no standard methods have emerged to address this issue.

METHODS

Unique Drug Enforcement Administration (DEA) numbers (N=36,721) were identified from the pharmacy claims of a cohort of postmenopausal (55+) initiators of osteoporosis medications (2008-2011) in the United Healthcare database. The proportion of times a Provider ID appeared at least once on the outpatient medical service claims (OMSCs) in the 14 days before a new prescription (Rx) out of the total number of new Rxs for each DEA was calculated and the Provider ID with the highest proportion was considered the most likely match to the DEA. We used regression models to evaluate how characteristics of OMSCs (N=36,721) related to the probability that the provider would be the prescribing physician on a proximal pharmacy claim for each patient (N=20,058).

RESULTS

A total of 37,448,056 new Rxs and 132,135,673 OMSCs were associated with the DEAs. Family and general practitioner, hospitalist, and osteoporosis diagnoses were strong predictors of a match. Our models had sensitivities ranging from 81.9% to 82.8% and specificities ranging from 52.4% to 53.5%.

CONCLUSIONS

Our algorithms were good at identifying matches for the prescribing physician according to our reference standard but may have included some false positives. Predicted probabilities from our models could be used in other databases where physician IDs are unavailable to help identify the prescriber.

Policy and Practice Innovations to Improve Prescribing of Psychoactive Medications for Children

Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.

Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis

BACKGROUND

Major psychiatric disorders are growing public health concern that attributed 14% of the global burden of diseases. The management of major psychiatric disorders is challenging mainly due to medication non-adherence. However, there is a paucity of summarized evidence on the prevalence of psychotropic medication non-adherence and associated factors. Therefore, we aimed to summarize existing primary studies' finding to determine the pooled prevalence and factors associated with psychotropic medication non-adherence.

METHODS

A total of 4504 studies written in English until December 31, 2017, were searched from the main databases (n = 3125) (PubMed (MEDLINE), Embase, CINAHL, PsycINFO, and Web of Science) and other relevant sources (mainly from Google Scholar, n = 1379). Study selection, screening, and data extraction were carried out independently by two authors. Observational studies that had been conducted among adult patients (18 years and older) with major psychiatric disorders were eligible for the selection process. Critical appraisal of the included studies was carried out using the Newcastle Ottawa Scale. Systematic synthesis of the studies was carried out to summarize factors associated with psychotropic medication non-adherence. Meta-analysis was carried using Stata 14. Random effects model was used to compute the pooled prevalence, and sub-group analysis at 95% confidence interval.

RESULTS

Forty-six studies were included in the systematic review. Of these, 35 studies (schizophrenia (n = 9), depressive (n = 16), and bipolar (n = 10) disorders) were included in the meta-analysis. Overall, 49% of major psychiatric disorder patients were non-adherent to their psychotropic medication. Of these, psychotropic medication non-adherence for schizophrenia, major depressive disorders, and bipolar disorders were 56%, 50%, and 44%, respectively. Individual patient's behaviors, lack of social support, clinical or treatment and illness-related, and health system factors influenced psychotropic medication non-adherence.

CONCLUSION

Psychotropic medication non-adherence was high. It was influenced by various factors operating at different levels. Therefore, comprehensive intervention strategies should be designed to address factors associated with psychotropic medication non-adherence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067436.

Adherence to antidepressant medications is associated with reduced premature mortality in patients with cancer: A nationwide cohort study

BACKGROUND

Depression and anxiety are common in cancer and antidepressants (AD) are efficacious treatment. The relationship between AD adherence and mortality in cancer is unclear. This study aimed to evaluate the association between adherence to AD and all-cause mortality in a population-based cohort of patients with cancer.

MATERIALS AND METHODS

We conducted a 4-year historical prospective cohort study including 42,075 patients with cancer who purchased AD at least once during the study period. Adherence to AD was modeled as nonadherence (<20%), poor (20-50%), moderate (50-80%), and good (>80%) adherence. We conducted multivariable survival analyses adjusted for demographic and clinical variables that may affect mortality.

RESULTS

During 1,051,489 person-years at risk follow-up, the adjusted hazard ratios (HR) for mortality were 0.89 (95% confidence interval [CI]: 0.83-0.95), 0.77 (95% CI: 0.66-0.72), and 0.80 (95% CI: 0.76-0.85) for the poor, moderate, and good adherence groups, respectively, compared to the nonadherent group. Analysis of the entire sample and a subgroup with depression, for cancer subtypes, revealed similar patterns for breast, colon, lung, and prostate cancers, but not for melanoma patients. Multivariate predictors of premature mortality included male gender (HR 1.48 [95% CI: 1.42-1.55]), current/past smoking status (HR 1.1, [95% CI: 1.04-1.15]; P < .0001), low socioeconomic status (HR 1.1, [95% CI: 1.03-1.17]; P < .0001) and more physical comorbidities.

CONCLUSIONS

The present study is the first to demonstrate that higher adherence to AD is associated with a decrease of all-cause mortality in a large nationwide cohort of cancer patients. Our data add to the pressing need to encourage adherence to AD among cancer patients.

The Effect of an Educational Intervention on Adherence to Intraocular Pressure-Lowering Medications in a Large Cohort of Older Adults with Glaucoma

BACKGROUND

Glaucoma is a progressive, irreversible disease that can lead to vision loss and lower quality of life if treatment is not optimized. Effective glaucoma therapies are available to lower intraocular pressure (IOP) and minimize or delay disease progression. Nonetheless, adherence to treatment remains suboptimal for many patients.

OBJECTIVE

To identify potentially nonadherent patients and evaluate the effect of patient- and physician-centric educational interventions on adherence by using a validated predictive model of nonadherence to glaucoma medication.

METHODS

This prospective, randomized, controlled, and interventional study included Humana Medicare Advantage Prescription Drug plan patients with a glaucoma diagnosis between May and October 2014, ≥ 1 pharmacy claim for glaucoma medication, and ≥ 50% likelihood of nonadherence. Patients and physicians were randomized to cohorts A (no interventions), B (physician intervention), or C (patient and physician interventions). Physicians in cohorts B and C received information on the model, adherence, and patient profiles at baseline and months 3, 6, and 9. Patients in cohort C received educational materials on glaucoma and adherence (same schedule). The primary outcome was the proportion of days covered (PDC) with medication over 12 months. Adherence was defined as PDC ≥ 0.80.

RESULTS

Overall, 23,306 patients and 2,955 physicians were eligible. After excluding physicians with < 3 nonadherent patients, each cohort included 200 physicians and 600 patients. Mean PDC was 0.54-0.56 across cohorts. At 12 months, ≥ 90.5% of physicians and ≥ 75.5% of patients remained in the study; mean PDC was 0.53-0.54 across cohorts. No statistically significant between-cohort differences in PDC and adherence were observed.

CONCLUSIONS

Intensive educational mailings to patients and their physicians did not improve PDC or adherence in this large population of potentially nonadherent patients with glaucoma. Findings highlight the difficulty of improving adherence in a disease that requires lifelong therapy despite being largely asymptomatic and can inform development of future interventions aimed at improving adherence to glaucoma therapy.

DISCLOSURES

This study was sponsored by Allergan plc (Dublin, Ireland). Fiscella and Chandwani are employees of Allergan plc. Caplan, Kamble, Bunniran, and Uribe are employees of Comprehensive Health Insights, a Humana company. The authors did not receive honoraria or other payments for authorship.

Adherence to Antidepressants and Mortality in Elderly Patients with Cardiovascular Disease

BACKGROUND AND OBJECTIVE: Conflicting findings from studies evaluating the association between use of antidepressant drugs and mortality have been reported. We tested the hypothesis that better adherence to antidepressant therapy may reduce mortality.

METHODS

The cohort included 29,845 individuals aged ≥ 65 years from several Italian health units who were newly treated with antidepressant drugs after hospital discharge with a diagnosis for cardiovascular disease during 2008-2010. These individuals were observed from the first prescription until the end of data availability (i.e. 2012-2014, depending on the local database). During this period, information on (1) prescription of antidepressants and other medications and (2) death from any cause (outcome) was recorded. Proportional hazards models were fitted to estimate the association between better adherence to antidepressants (defined as proportion of days covered ≥ 75%) and outcome, by adjusting and stratifying for several covariates.

RESULTS

Patients with better adherence to antidepressants had a reduced mortality of 9% (95% CI 3-14). Patients who did not use other medicaments during follow-up had reduced mortality associated with better adherence to antidepressants of 21% (- 1-38), 14% (7-20), 20% (13-26) and 13% (7-19) for no users of antihypertensive agents, lipid-lowering agents, other cardiovascular drugs and antidiabetics, respectively.

CONCLUSIONS

Better adherence to antidepressants is associated with reduced all-cause mortality, mainly in patients who did not use other pharmacological treatments. Behavioural changes to enhance adherence among the elderly with cardiovascular disease might offer important benefits in reducing their mortality.

Providing physicians with feedback on medication adherence for people with chronic diseases taking long-term medication

BACKGROUND

Poor medication adherence decreases treatment efficacy and worsens clinical outcomes, but average rates of adherence to long-term pharmacological treatments for chronic illnesses are only about 50%. Interventions for improving medication adherence largely focus on patients rather than on physicians; however, the strategies shown to be effective are complex and difficult to implement in clinical practice. There is a need for new care models addressing the problem of medication adherence, integrating this problem into the patient care process. Physicians tend to overestimate how well patients take their medication as prescribed. This can lead to missed opportunities to change medications, solve adverse effects, or propose the use of reminders in order to improve patients' adherence. Thus, providing physicians with feedback on medication adherence has the potential to prompt changes that improve their patients' adherence to prescribed medications.

OBJECTIVES

To assess the effects of providing physicians with feedback about their patients' medication adherence for improving adherence. We also assessed the effects of the intervention on patient outcomes, health resource use, and processes of care.

SEARCH METHODS

We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase, all from database inception to December 2016 and without any language restriction. We also searched ISI Web of Science, two trials registers, and grey literature.

SELECTION CRITERIA

We included randomised trials, controlled before-after studies, and interrupted time series studies that compared the effects of providing feedback to physicians about their patients' adherence to prescribed long-term medications for chronic diseases versus usual care. We included published or unpublished studies in any language. Participants included any physician and any patient prescribed with long-term medication for chronic disease. We included interventions providing the prescribing physician with information about patient adherence to medication. Only studies in which feedback to the physician was the sole intervention or the essential component of a multifaceted intervention were eligible. In the comparison groups, the physicians should not have had access to information about their patients' adherence to medication. We considered the following outcomes: medication adherence, patient outcomes, health resource use, processes of care, and adverse events.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted and analysed all data using standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. Due to heterogeneity in study methodology, comparison groups, intervention settings, and measurements of outcomes, we did not carry out meta-analysis. We describe the impact of interventions on outcomes in tabular form and make a qualitative assessment of the effects of studies.

MAIN RESULTS

We included nine studies (23,255 patient participants): eight randomised trials and one interrupted time series analysis. The studies took place in primary care and other outpatient settings in the USA and Canada. Seven interventions involved the systematic provision of feedback to physicians concerning all their patients' adherence to medication, and two interventions involved issuing an alert for non-adherent patients only. Seven studies used pharmacy refill data to assess medication adherence, and two used an electronic device or self-reporting. The definition of adherence differed across studies, making comparisons difficult. Eight studies were at high risk of bias, and one study was at unclear risk of bias. The most frequent source of bias was lack of protection against contamination.Providing physicians with feedback may lead to little or no difference in medication adherence (seven studies, 22,924 patients), patient outcomes (two studies, 1292 patients), or health resource use (two studies, 4181 patients). Providing physicians with feedback on medication adherence may improve processes of care (e.g. more medication changes, dialogue with patient, management of uncontrolled hypertension) compared to usual care (four studies, 2780 patients). None of the studies reported an adverse event due to the intervention. The certainty of evidence was low for all outcomes, mainly due to high risk of bias, high heterogeneity across studies, and indirectness of evidence.

AUTHORS' CONCLUSIONS

Across nine studies, we observed little or no evidence that provision of feedback to physicians regarding their patients adherence to prescribed medication improved medication adherence, patient outcomes, or health resource use. Feedback about medication adherence may improve processes of care, but due to the small number of studies assessing this outcome and high risk of bias, we cannot draw firm conclusions on the effect of feedback on this outcome. Future research should use a clear, standardised definition of medication adherence and cluster-randomisation to avoid the risk of contamination.

Automated Reminders and Physician Notification to Promote Immunosuppression Adherence Among Kidney Transplant Recipients: A Randomized Trial

BACKGROUND

Immunosuppression nonadherence increases the risk for kidney transplant loss after transplantation. Wireless-enabled pill bottles have created the opportunity to monitor medication adherence in real time. Reminders may help patients with poor memory or organization. Provision of adherence data to providers may motivate patients to improve adherence and help providers identify adherence barriers.

STUDY DESIGN

Randomized controlled trial.

SETTING & PARTICIPANTS

Kidney transplant recipients (n=120) at a single center.

INTERVENTION

Participants were provided wireless pill bottles to store tacrolimus and record bottle openings. Participants were randomly assigned 1:1:1 to adherence monitoring with customized reminders (including alarms, texts, telephone calls, and/or e-mails), monitoring with customized reminders plus provider notification (every 2 weeks, providers received notification if adherence decreased to <90% during that period), or wireless pill bottle use alone (control).

OUTCOMES

The main outcome was bottle-measured tacrolimus adherence during the last 90 days of the 180-day trial. A secondary outcome was tacrolimus whole-blood concentrations at routine clinical visits.

MEASUREMENTS

Adherence for the primary outcome was assessed via wireless pill bottle openings.

RESULTS

Mean participant age was 50 years; 60% were men, and 40% were black. Mean adherence was 78%, 88%, and 55% in the reminders, reminders-plus-notification, and control arms (P<0.001 for comparison of each intervention to control). Mean tacrolimus levels were not significantly different between groups.

LIMITATIONS

The study did not assess clinical end points. Participants and study coordinators were not blinded to intervention arm.

CONCLUSIONS

Provider notification and customized reminders appear promising in helping patients achieve better medication adherence, but these strategies require evaluation in trials powered to detect differences in clinical outcomes.

Predicting persistence to antidepressant treatment in administrative claims data: Considering the influence of refill delays and prior persistence on other medications

BACKGROUND

Many patients with major depressive disorder (MDD) who begin antidepressant treatment discontinue use before for six months, the recommended minimum treatment length. This study sought to identify predictors of six-month antidepressant persistence including predictors utilizing patients' electronic prescription records.

METHODS

Commercially insured children (3-17 years) and adults (18-64 years) with MDD who initiated antidepressant treatment, 1/1/2003-2/28/2010, were assessed for six-month persistence (based on prescriptions' days supply, allowing a 30-day grace period). Antidepressant persistence prediction models were developed separately for children and adults. Two additional measures, days without medication between the first and second antidepressant fill (children and adults) and prior persistence on other medications (adults only), were added to the models, concordance (c) statistics were compared and risk reclassification evaluated.

RESULTS

Among children (n=8837 children) and adults (n=47,495) with MDD, six-month antidepressant persistence was low and varied by age (37%, 18-24 years to 52%, 3-12 and 50-64 years). Independent baseline predictors of persistence were identified, with model c-statistics: children=0.582, adults=0.584. Patients with more days without medication between fills were less likely to be persistent (10-30 vs. 0 days, children: RR=0.72, adults: RR=0.74), as were adults not previously persistent to other medications (RR=0.73).

LIMITATIONS

The definition of six-month persistence is dependent on correct days supply values and the grace period utilized; potential predictors were limited to measures available in claims data.

CONCLUSIONS

Six-month antidepressant persistence was low and overall prediction of persistence was poor; however, days without medication between fills and prior persistence on other medications marginally improved the ability to predict antidepressant persistence.

Evaluating Pharmacist-Written Recommendations to Providers in a Medicare Advantage Plan: Factors Associated with Provider Acceptance

BACKGROUND

Pharmacist-written recommendation letters to physicians, through mail or fax, are common practice in managed care settings. While rates of physician acceptance of pharmacist recommendations have been reported to average around 50%, the factors affecting the provider's acceptance of recommendations have not been adequately explored. Identifying these factors may help to improve pharmacist-physician communication and help identify areas where physician education may benefit patient care.

OBJECTIVES

To (a) determine the percentage of pharmacist-written recommendations for members enrolled in a Medicare Advantage Plan with prescription drug coverage that was accepted by providers and (b) examine member and provider factors associated with provider acceptance.

METHODS

A retrospective cohort study was conducted among members enrolled in a Medicare Advantage Plan in Texas. Members were included if their medication profiles were reviewed by a health plan resident pharmacist and resulted in a recommendation letter sent directly to the member's provider between July 1, 2012, and March 15, 2014. Pharmacist-written recommendation letters were retrieved from the archived files and were assessed for factors such as type of recommendation made, the member's disease state affected by the recommendation, and the letter format. Other factors assessed included member and provider characteristics such as demographics, participation in the health plan pay-for-performance program, physician specialty, and region of practice. Acceptance was defined as a change in pharmacy claims that reflected the change suggested in the letter within 6 months of the recommendation. The percentage of recommendations accepted by providers was calculated. Chi-square tests were used to examine group differences in recommendation acceptances with recommendation type as well as member and prescriber characteristics. Logistic regression was used to identify significant predictors of an accepted change.

RESULTS

From 158 pharmacist-written recommendation letters, 228 recommendations were identified, of which 115 (50.4%) were accepted. Ninety-five (41.7%) recommendations were to add a drug; 80 (35.1%) recommendations were to discontinue a drug; and 53 (23.2%) recommendations were to change a drug. The member population affected by these recommendations had a mean [SD] age of 69 [± 11] years. Recommendations to discontinue or change a drug were more likely to be accepted than to add a drug (P = 0.007), but recommendation type was not determined as a significant predictor in the multivariate model. Recommendations for heart failure were less likely to be followed compared with recommendations for diabetes (OR = 0.31; 95% CI = 0.10-0.96; P = 0.043). A regional trend was identified in which recommendations in Southeast Texas were more likely to be implemented than those in West Texas, but it did not reach a level of significance (OR = 0.51; 95% CI = 0.24-1.07; P = 0.074), possibly because of the relatively limited sample size.

CONCLUSIONS

Overall, pharmacist-written recommendations were commonly accepted by physicians. Recommendations for heart failure were less likely followed versus those for diabetes. Since most recommendations for heart failure concerned changing drugs within the beta-blocker class, physicians may not have seen the value in modifying current therapy. This finding points to a potential need for physician education. Further research with larger samples is warranted to increase the power to identify significant differences in other variables that may need to be addressed in order to increase the rates of recommendation acceptance and improve patient care.

The impact of age and gender on adherence to antidepressants: a 4-year population-based cohort study

INTRODUCTION

Impaired adherence is common among patients using antidepressant drugs (ADs). However, few studies investigated the role of age and gender in adherence to AD and finding conflict.

OBJECTIVE

This study aimed to determine how gender and age impact adherence to AD in a large-scale cohort.

METHODS

We conducted a historical cohort study (N = 310,994 individuals) that claimed AD prescriptions during a 4-year period. Adherence was defined as the ratio between the duration of claimed AD prescriptions and the duration of continuously prescribed AD.

RESULTS

Substantial differences in the mean adherence to AD were noted throughout the lifespan, ranging from 0.38 (first decade) to 0.63 (tenth decade). Average adherence was significantly higher for males aged 20-40 years than for females of that age, but this relationship reversed later in life (50-70 years). A regression analysis model of adherence as the dependent variable showed a significant interaction between age and gender variables (beta = 0.001, p < 0.0001).

CONCLUSIONS

This study demonstrates the effect of age and gender, and their interaction, on adherence to AD across the entire life span. The marked age- and modest, yet significant, gender-related effects should be taken into consideration when targeting impaired adherence to these commonly prescribed medications.

Adherence to antidepressant therapy and mortality rates in ischaemic heart disease: cohort study

BACKGROUND

The use of antidepressant drugs in patients with ischaemic heart disease (IHD) has been debated owing to scarcity of data and conflicting results regarding the effect of these drugs on mortality.

AIMS

To evaluate the association between adherence to antidepressant therapy and all-cause mortality in a population-based cohort of patients with IHD.

METHOD

A total of 63 437 patients with IHD who purchased antidepressants at least once during the years 2008-2011 were retrospectively followed for all-cause mortality over 4 years. Adherence was measured as a ratio between claimed and prescribed durations of medication and modelled as non-adherence (<20%), poor (20-50%), moderate (50-80%) and good (>80%). We used multivariable survival analyses adjusted for demographic and clinical variables that may affect mortality.

RESULTS

The moderate and good adherence groups had significantly reduced adjusted mortality hazard ratios of 0.83 (95% CI 0.78-0.88) and 0.86 (95% CI 0.82-0.90) respectively, compared with the non-adherence group.

CONCLUSIONS

Adherence to antidepressant pharmacotherapy is associated with reduced all-cause mortality in a population-based large sample cohort of patients with IHD. Physicians and health policy decision-makers should step up their efforts to sustain and enhance these patients' adherence to their antidepressant regimen.

A randomized controlled trial to provide adherence information and motivational interviewing to improve diabetes and lipid control

PURPOSE

The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control.

METHODS

Study participants were adult members of a health system in southeast Michigan, were using both oral diabetes and lipid-lowering medications, and had glycated hemoglobin (A1C) or low-density lipoprotein cholesterol (LDL-C) levels not at goal. Participants were randomly assigned to receive usual care (UC), n = 567; have medication adherence information (AI) provided to their physician, n = 569; or have AI and receive motivational interviewing (MI) though trained staff (AI + MI), n = 556. Primary outcomes were A1C and LDL-C levels at 18 months post randomization.

RESULTS

Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC. Similarly, neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups. Patient participation in the AI + MI arm was low and limit the interpretation of the study results, but post hoc analysis of the AI + MI study arm showed that the number of MI sessions received was positively associated with only oral diabetes medication adherence.

CONCLUSION

Neither AI nor MI significantly improved diabetes and lipid control when compared with UC. Moreover, patient participation appeared to be a particular barrier for MI.

Association between antidepressant side effects and functional impairment in patients with major depressive disorders

Patients with depression may not well be aware of antidepressant adverse events (AEs); however, no studies have assessed how these AEs affect their daily function. Therefore, to evaluate the relationship between the quality of AEs and functional impairment, we studied 482 outpatients with depressive disorders who were not receiving any antidepressant treatment prior to the baseline visit and started it thereafter in usual clinical settings. The Quick Inventory for Depressive Symptomatology Self-Report Japanese version and antidepressant AEs for subjective assessment (antiAS) were performed at baseline and 10 days after antidepressant initiation (i.e. second visit). Functional impairment was evaluated with the Sheehan Disability Scale (SDS) on the second visit. As a result, the SDS was positively associated with the number of AEs (β=0.089, p=0.022) in multiple linear regression analysis (adjusted R(2)=0.357, p<0.001). Subjects who experienced vertigo, nausea and insomnia had significantly more functional impairment than those who did not. Additionally, the number of severe AEs (β=0.151, p<0.001) was associated with a higher SDS score, and those AEs with a negative causal attribution to antidepressants in the antiAS significantly affected the SDS (β=0.105, p=0.008). AEs of antidepressants should be carefully monitored since they could negatively affect their daily function.

Evaluation of a drug-drug interaction: fax alert intervention program

BACKGROUND

Clinicians often encounter information about drug-drug interactions (DDIs) during clinical practice. This information is found within product information (hardcopy and electronic) and various electronic systems. Prescribers may receive medication-related communications in practice that are distributed by facsimile (fax), mail, or telephone from pharmacies and pharmacy benefit managers (PBMs). The purpose of this study was to determine if near-real time fax alerts for potential drug-drug interactions (PDDIs) would influence prescribing.

METHODS

A prospective study, in cooperation with a pharmacy benefit manager (PBM), was conducted targeting 18 clinically important PDDIs. Fax alerts included an individualized letter to the prescriber with a list of the interacting drugs, PDDI evidence summaries with citations, and recommended clinical management strategies. Among the 18 PDDIs, 13 PDDIs could be assessed for prescription therapy changes using pharmacy claims data. A prospective cohort design was used to evaluate changes in prescription dispensing 90-days following a PDDI fax alert.

RESULTS

A total of 8,075 fax alerts were sent to prescribers and there were 4,712 alerts for the 13 PDDIs that could be assessed for change using pharmacy claims data. There were 2,019 patients (interventions) for which fax alerts were sent to their prescribers who were matched with a control group consisting of patients with the same PDDIs but for whom no fax alert was sent. Overall, this study found 154 (7.6%) of patients in the fax alert group compared to 132 (6.5%) in the control group had changes in therapy (p = 0.177).

CONCLUSIONS

This fax alert intervention program observed no statistically significant differences in prescribing with a fax alert compared to the control group. If PBMs chose to send individualized, evidence-based information to clinicians regarding drug-drug interactions, this study suggests it may not be an effective intervention to mitigate harm.

Mood disorders and complementary and alternative medicine: a literature review

Mood disorders are a major public health problem and are associated with considerable burden of disease, suicides, physical comorbidities, high economic costs, and poor quality of life. Approximately 30%-40% of patients with major depression have only a partial response to available pharmacological and psychotherapeutic interventions. Complementary and alternative medicine (CAM) has been used either alone or in combination with conventional therapies in patients with mood disorders. This review of the literature examines evidence-based data on the use of CAM in mood disorders. A search of the PubMed, Medline, Google Scholar, and Quertile databases using keywords was conducted, and relevant articles published in the English language in the peer-reviewed journals over the past two decades were retrieved. Evidence-based data suggest that light therapy, St John's wort, Rhodiola rosea, omega-3 fatty acids, yoga, acupuncture, mindfulness therapies, exercise, sleep deprivation, and S-adenosylmethionine are effective in the treatment of mood disorders. Clinical trials of vitamin B complex, vitamin D, and methylfolate found that, while these were useful in physical illness, results were equivocal in patients with mood disorders. Studies support the adjunctive role of omega-3 fatty acids, eicosapentaenoic acid, and docosahexaenoic acid in unipolar and bipolar depression, although manic symptoms are not affected and higher doses are required in patients with resistant bipolar depression and rapid cycling. Omega-3 fatty acids are useful in pregnant women with major depression, and have no adverse effects on the fetus. Choline, inositol, 5-hydroxy-L-tryptophan, and N-acetylcysteine are effective adjuncts in bipolar patients. Dehydroepiandrosterone is effective both in bipolar depression and depression in the setting of comorbid physical disease, although doses should be titrated to avoid adverse effects. Ayurvedic and homeopathic therapies have the potential to improve symptoms of depression, although larger controlled trials are needed. Mind-body-spirit and integrative medicine approaches can be used effectively in mild to moderate depression and in treatment-resistant depression. Currently, although CAM therapies are not the primary treatment of mood disorders, level 1 evidence could emerge in the future showing that such treatments are effective.

Coping strategies for antidepressant side effects: an Internet survey

BACKGROUND

Patients' coping methods to palliate side effects of antidepressants have not been reported in the literature.

METHODS

Through an Internet survey, 856 participants who were diagnosed with depression and receiving antidepressants were recruited to report on the methods of coping with side effects. They were asked which side effect(s) they experienced and to write freely about the way they tried to counteract these effects. We classified active coping methods into the following sub-types: adjustment of prescriptions, additional medication, complementary therapy, consultation with physicians, and daily relief.

RESULTS

The prevalence of active coping differed across side effects (from 26.7%, sexual dysfunction, to 89.5%, dry mouth). Events with a lower percentage of active coping were more likely to be managed with "adjustment of prescriptions": (sexual dysfunction, 41.9%; fatigue, 36.8%; sweating, 20.0%; tremor, 42.5%; and somnolence, 31.8%). Further, a strong negative correlation was found between the percentage of participants reporting an adjustment of prescription and that reporting an active coping (r=-0.907, p<0.001). The "daily relief" sub-type contained a variety of strategies, including negative methods such as vomiting for nausea and weight gain and drinking alcohol for insomnia.

LIMITATIONS

Sampling of subjects were biased due to an Internet survey and diagnosis of depression and experience of side effects were self-reported.

CONCLUSION

Patients with depression use various ways in alleviating antidepressants side effects. Some effects such as sexual dysfunction and fatigue may not be amenable to subjective coping efforts and others are sometimes managed inappropriately, which warrants a prudent attention.

Subjective recognition of adverse events with antidepressant in people with depression: a prospective study

BACKGROUND

While it has been reported that physicians may under-recognize adverse effects of antidepressants thoroughly in clinical settings, subjective bias in recognition of adverse effects (AEs) with antidepressants has not been specifically investigated.

METHODS

Four-hundred ninety-three participants with depressive disorders (ICD-10) were assessed for the severity of 20 common AEs and their inferred causal relationship with antidepressants, together with the Quick Inventory for Depressive Symptoms (QIDS). These assessments occurred twice at the 1st visit (when they were antidepressant free) and 2nd visit (10 days after the initiation of antidepressants). 'Possible AEs' and 'under-recognized AEs' were defined as 'events with exacerbation in the severity' and 'events with negative causal attribution to antidepressants' at the time of the 2nd visit, respectively.

RESULTS

Three-hundred sixty-three participants (73.6%) experienced ≥ 1 under-recognized AEs. Flu like symptoms (96.5% of participants who experienced possible AEs), sexual dysfunction (94.2%), blurred vision (93.4%), anxiety/tension (91.1%) and sweating (89.2%) were found to be prevalent as under-recognized AEs. Participants with under-recognized AEs had less improvement in the QIDS than those without (27.1% vs. 11.1% decrease, p<0.001).

LIMITATIONS

It is intrinsically challenging to exactly differentiate between antidepressant AEs and symptoms of depression. And the severity of depression, that of AEs and causal relationship between AEs and antidepressants were assessed not by objective but subjective scales.

CONCLUSIONS

An overall trend to under-recognize AEs of antidepressants was found and people with a lesser degree of early improvement tend to understate the causality, which has an implication in interpreting voluntarily expression of AEs.

Simulation-based power calculation for designing interrupted time series analyses of health policy interventions

OBJECTIVE

Interrupted time series is a strong quasi-experimental research design to evaluate the impacts of health policy interventions. Using simulation methods, we estimated the power requirements for interrupted time series studies under various scenarios.

STUDY DESIGN AND SETTING

Simulations were conducted to estimate the power of segmented autoregressive (AR) error models when autocorrelation ranged from -0.9 to 0.9 and effect size was 0.5, 1.0, and 2.0, investigating balanced and unbalanced numbers of time periods before and after an intervention. Simple scenarios of autoregressive conditional heteroskedasticity (ARCH) models were also explored.

RESULTS

For AR models, power increased when sample size or effect size increased, and tended to decrease when autocorrelation increased. Compared with a balanced number of study periods before and after an intervention, designs with unbalanced numbers of periods had less power, although that was not the case for ARCH models.

CONCLUSION

The power to detect effect size 1.0 appeared to be reasonable for many practical applications with a moderate or large number of time points in the study equally divided around the intervention. Investigators should be cautious when the expected effect size is small or the number of time points is small. We recommend conducting various simulations before investigation.

Patients' attitudes toward side effects of antidepressants: an Internet survey

Patients' attitudes toward side effects of antidepressants are likely to differ according to gender, which has not yet been fully addressed in the literature. From the 228,310 registrants, 1,305 participants who had received antidepressant drugs within the past year were identified with the Yahoo Japan research monitor through four-step screening procedures. Participants were asked as to which side effect(s) they had experienced, whether they had reported those side effects to their physicians, and whether they had taken any action to counteract them. The questionnaire was completed by 1,187 participants. Side effects were reported in 73.4% of the participants; the prevalence of self-reported side effects was significantly higher in men than women (80.4% vs. 68.3%, P <0.05). The percentage of participants who reported side effects to their physicians widely differed depending on the nature of their experience, ranging from 45.7% to 89.9%; the lowest was for sexual dysfunction. The percentage of participants who had taken any action to relieve side effects varied among side effects from 26.3% for sexual dysfunction to 89.5% for dry mouth. Moreover, a lower percentage of women had reported sexual dysfunction to physicians (36.6% vs. 60.7%, P <0.05) and had taken any action to counteract the problem (19.8% vs. 36.9%, P <0.05). Given that patients experienced with antidepressants are likely to be reluctant to report sexual side effects, physicians should be cognizant of the potential presence of sexual dysfunction in patients who are taking antidepressants, especially for women.

Knowledge of and attitudes towards depression and adherence to treatment: the Antidepressant Adherence Scale (AAS)

BACKGROUND

Non-adherence to treatment can result from forgetting, carelessness, stopping the drug when feeling worse, or stopping the drug when feeling better.

OBJECTIVE

To develop and psychometrically assess a brief instrument that can be easily used in clinical practice to measure adherence to antidepressants.

METHOD

We developed the Antidepressants Adherence Scale (AAS); a self report rating scale including four items to assess the degree to which forgetting, carelessness, and stopping due to feeling worse or feeling better interfere with adherence in the last 4 weeks. Our proposed four-item adherence instrument was developed based on previous research and theory.

PARTICIPANTS

Experts in mood disorders (n=12) participated in the formal validity assessment of the instrument, and the developed instrument was administered to patients who were prescribed antidepressants (n=63). All patients also completed a multiple choice question instrument to measure knowledge of depression, and a Likert self report questionnaire to assess attitudes towards depression and its treatment.

RESULTS

There was 90% agreement among experts that the items were highly relevant providing strong evidence for content validity. Also, there was empirical evidence for validity. There were significant correlations (p<0.05) between knowledge and attitude subscales and adherence items. The internal consistency reliability (Cronbach's alpha) was 0.66 for the instrument.

CONCLUSION AND SIGNIFICANCE

Knowledge of and attitudes to depression and its treatment may have significant impact on the adherence to antidepressants. The AAS can be used in clinical settings (2-3 min to administer) to evaluate patients' adherence to antidepressants.

Prescription refill records as a screening tool to identify antidepressant non-adherence

PURPOSE

Non-adherence is a significant problem with antidepressants. Identifying patients at highest risk for discontinuing antidepressant treatment can be used to target clinical management. Accordingly, our purpose was to determine the shortest gap in medication supply that is predictive of discontinuation, while minimizing false positive results.

METHODS

A retrospective cohort study of medical and prescription claims from a national health plan affiliated with i3 Innovus. Sensitivities, specificities, and positive and negative predictive values were calculated for gap lengths to assess how well they predicted discontinuation. Continuously insured individuals aged 18-65 with newly diagnosed major depression and an antidepressant prescription within 45 days of diagnosis were included. Gap length was defined as the maximum number of continuous days without medication supply during acute phase treatment. Discontinuation was defined as a continuous gap of 30 or more days between an expected refill and actual refill.

RESULTS

Of 4545 eligible patients, 73% discontinued antidepressant treatment during the study period. A maximum continuous gap of 14 days had a sensitivity of 87% and a specificity of 82% for predicting discontinuation. In analyses that varied the way gaps and discontinuation were defined, gap lengths between 8 and 19 days were highly predictive of discontinuation without exceeding a 20% false positive rate.

CONCLUSIONS

Based on administrative pharmacy records, screening for gaps in medication supply of at least 14 days can accurately identify four of every five patients at risk for discontinuing. This early indicator can be used to target clinical interventions.

Patients' concerns about and problems experienced with discontinuation of antidepressants

Objective

Clinical trials and epidemiological studies have shown that premature discontinuation is a major problem during antidepressant therapy. Unfortunately, there is little information on how patients perceive treatment with antidepressants in clinical practice, and it is unclear whether patients perceive discontinuation as a problem. The objective of this study is to assess whether concerns and problems experienced with drug discontinuation occur more frequently in patients using antidepressants than in patients using benzodiazepines, antipsychotics or non-psychiatric medication.

Method

All calls to a national telephone medicines information service received between 1990 and 2004 were examined using retrospective examination. Calls about discontinuation were identified and classified either as a general question about discontinuation, or as a problem experienced with discontinuation. These calls were grouped into the following main classes: antidepressants, antipsychotics, benzodiazepines or non-psychiatric medicines.

Key findings

Of all 39 786 registered phone calls, 6159 (15,5%) related to antidepressants, 1658 (4.2%) to antipsychotics and 3916 (9.8%) to benzodiazepines. Patients calling about antidepressants called about discontinuation three times as often (odds ratio (OR) 2.8; 95% confidence interval (CI) 2.6–3.0), and reported a problem with discontinuation five times more often (OR 5.4; 95% CI 4.6–6.3), compared to patients who called about non-psychiatric medicines. The proportion of questions about discontinuation and problems experienced with discontinuation was also higher in patients calling about benzodiazepines and antipsychotics compared to patients calling about non-psychiatric medication.

Conclusion

Patients perceive discontinuation of antidepressants, as well as discontinuation of antipsychotics and benzodiazepines, as a problem. Discontinuation seems a general problem for all psychiatric medicines, and needs more attention in the communication between patients and healthcare providers.

Does daily Naikan therapy maintain the efficacy of intensive Naikan therapy against depression?

AIM

Naikan Therapy, which has been applied to treating patients with various mental difficulties, can be classified into two major categories: intensive Naikan therapy, which lasts for seven days in a Naikan center or a clinical institute secluded from the outside world for the purpose of deep introspection, and daily Naikan therapy, which can be integrated into regular daily activities. The aim of this research is to evaluate daily Naikan therapy as a maintenance treatment for depression.

METHODS

Forty-seven patients, who were diagnosed as having major depressive disorder using DSM-IV criteria and who practiced intensive Naikan therapy participated in the present study. Two groups of patients were compared: 24 patients who conducted daily Naikan therapy and 23 patients who did not, after practicing intensive Naikan therapy. To evaluate efficacy, the Beck Depression Inventory was used as a primary outcome measure for the assessment of depression. The State-Trait Anxiety Inventory and the Cornell Medical Index were also used as secondary outcome measures to evaluate anxiety and psychosomatic conditions before, immediately after and three months after intensive Naikan therapy.

RESULTS

Significant between-group differences were obtained in the time course change of depression, anxiety and psychosomatic scores within three months following the completion of intensive Naikan therapy.

CONCLUSION

The current study indicates that conducting daily Naikan therapy is effective for maintaining the psychological and psychosomatic state at 3 months following the intensive Naikan therapy, while a lack of therapy may allow the patients to exacerbate their conditions to the level they held before practicing intensive Naikan therapy.

Diabetes and poor disease control: is comorbid depression associated with poor medication adherence or lack of treatment intensification?

OBJECTIVE

To hypothesize that patients with comorbid depression and diabetes and poor disease control will have poorer adherence to disease control medication and less likelihood of physician intensification of treatment. Many patients with diabetes fail to achieve American Diabetes Association Guidelines for glycemic, blood pressure and lipid control. Depression is a common comorbidity and may affect disease control through adverse effects on adherence and physician intensification of treatment.

METHODS

In a cohort of 4117 patients with diabetes, depression was measured at baseline with the Patient Health Questionnaire-9 (PHQ-9). Patient adherence and physician intensification of treatment were measured in those who had evidence of poor disease control (HbA(1c) >or=8.0%, LDL >or=130 mg/dL, systolic blood pressure >or=140 mm Hg) over this 5-year period. Poor adherence was defined as having medication refill gaps for >or=20% of days covered for medications prescribed for each of these conditions. Treatment intensification was defined as an increased medication dosage in a class, an increase in the number of medication classes, or a switch to a different class within 3-month periods before and after notation of above target levels.

RESULTS

Among patients with diabetes and poor disease control, depression was associated with an increased likelihood of poor adherence to diabetes control medications (odds ratio [OR] = 1.98; 95% Confidence Interval [CI] = 1.31, 2.98), antihypertensives (OR = 2.06; 95% CI = 1.47, 2.88), and LDL control medications (OR = 2.43; 95% CI = 1.19, 4.97). In patients with poor disease control who were adherent to medication or not yet started on a medication, depression was not associated with differences in likelihood of physician intensification of treatment.

CONCLUSIONS

In patients with diabetes and poor disease control, depression is an important risk factor for poor patient adherence to medications, but not lack of treatment intensification by physicians.

Duration of antidepressant drug treatment and its influence on risk of relapse/recurrence: immortal and neglected time bias

Several observational studies have found a higher risk of recurrence/relapse of depression for patients who discontinue antidepressant use compared with those who continue. This study demonstrated that measurement of follow-up time can be subject to immortal and neglected time bias. Data were obtained from the 2001 Second Dutch National Survey of General Practice. The study population was composed of antidepressant users with a registered depression diagnosis, divided into early discontinuers and continuing users. Two methods were used to measure time to relapse/recurrence. Method 1, used in previously mentioned studies, measured the beginning of follow-up 6 months after starting antidepressant therapy. Method 2 constructed individual treatment episodes for each patient and measured follow-up from actual end-of-treatment episode. The Cox proportional hazards model produced a risk ratio of 1.58 (95% confidence interval: 1.02, 2.45) for method 1, suggesting a higher risk of relapse/recurrence for early discontinuers. In method 2, a statistically nonsignificant risk ratio of 0.77 (95% confidence interval: 0.49, 1.21) was produced, indicating no difference in risk of relapse/recurrence. The authors found the method used in previous studies subject to bias. Applying a different method, accounting for immortal and neglected time bias, eliminated the protective effects of longer treatments.

Antidepressant adherence after psychiatric hospitalization among VA patients with depression

Depressed patients discharged from psychiatric hospitalizations face increased risks for adverse outcomes including suicide, yet antidepressant adherence rates during this high-risk period are unknown. Using Veterans Affairs (VA) data, we assessed antidepressant adherence and predictors of poor adherence among depressed veterans following psychiatric hospitalization. We identified VA patients nationwide with depressive disorders who had a psychiatric hospitalization between April 1, 1999 and September 30, 2003, received antidepressant medication, and had an outpatient appointment following discharge. We calculated medication possession ratios (MPRs), a measure of medication adherence, within 3 and 6 months following discharge. We assessed patient factors associated with having lower levels of adherence (MPRs < 0.8) after discharge. The criteria for 3- and 6-month MPRs were met by 20,931 and 23,182 patients respectively. The mean 3 month MPR was 0.79 (SD = 0.37). The mean 6 month MPR was 0.66 (SD = 0.40). Patients with poorer adherence were male, younger, non-white, and had a substance abuse disorder, but were less likely to have PTSD or other anxiety disorders. Poor antidepressant adherence is common among depressed patients after psychiatric hospitalization. Efforts to improve adherence at this time may be critical in improving the outcomes of these high-risk patients.

How do different age groups use benzodiazepines and antidepressants? Analysis of an Australian administrative database, 2003-6

BACKGROUND

The use of antidepressants and benzodiazepines is increasing in Australia and worldwide, and it is thought that some of the prescribing of these classes of drugs may be inappropriate. However, the demographic characteristics of the subgroups of the population responsible for this increase remain unexplored.

OBJECTIVE

The aim of this study was to examine changes in the utilization of antidepressants and benzodiazepines between different age groups within Australia from 2003 to 2006.

METHODS

The Australian Pharmaceutical Benefits Scheme administrative database was used to obtain dispensing data for all antidepressants and publicly subsidized benzodiazepines. Changes in utilization (amounts and patterns of use of different compounds) were compared between different age groups from 2003 to 2006. The WHO Anatomic Therapeutic Chemical/Defined Daily Dose system was used.

RESULTS

Use of antidepressants increased from 2003 to 2006, and in each year increased with age, with those > or = 65 years having the greatest use. Differences were seen in the antidepressant most utilized, with the elderly using more tricyclic antidepressants than those who are younger. The utilization of benzodiazepines decreased from 2003 to 2006 in elderly individuals and those receiving social welfare benefits. Individuals aged > or = 85 years had the highest use of benzodiazepines and used more long-acting benzodiazepines compared with those aged 35-44 years.

CONCLUSION

The elderly still account for most use per capita of benzodiazepines. Some of this use may be inappropriate (e.g. use of long-acting benzodiazepines) and, hence, may represent a useful target for future educational intervention. The elderly also still account for the largest per capita use of antidepressants.

Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature - 2001-2007

Background

Managed care organizations use a variety of strategies to reduce the cost and improve the quality of medication use. The effectiveness of such policies is not well understood. The objective of this research was to update a previous systematic review of interventions, published between 1966 and 2001, to improve the quality and efficiency of medication use in the US managed care setting.

Methods

We searched MEDLINE and EMBASE for publications from July 2001 to January 2007 describing interventions targeting drug use conducted in the US managed care setting. We categorized studies by intervention type and adequacy of research design using commonly accepted criteria. We summarized the outcomes of well-controlled strategies and documented the significance and magnitude of effects for key study outcomes.

Results

We identified 164 papers published during the six-year period. Predominant strategies were: educational interventions (n = 20, including dissemination of educational materials, and group or one-to-one educational outreach); monitoring and feedback (n = 22, including audit/feedback and computerized monitoring); formulary interventions (n = 66, including tiered formulary and patient copayment); collaborative care involving pharmacists (n = 15); and disease management with pharmacotherapy as a primary focus (n = 41, including care for depression, asthma, and peptic ulcer disease). Overall, 51 studies met minimum criteria for methodological adequacy. Effective interventions included one-to-one academic detailing, computerized alerts and reminders, pharmacist-led collaborative care, and multifaceted disease management. Further, changes in formulary tier-design and related increases in copayments were associated with reductions in medication use and increased out-of-pocket spending by patients. The dissemination of educational materials alone had little or no impact, while the impact of group education was inconclusive.

Conclusion

There is good evidence for the effectiveness of several strategies in changing drug use in the managed care environment. However, little is known about the cost-effectiveness of these interventions. Computerized alerts showed promise in improving short-term outcomes but little is known about longer-term outcomes. Few well-designed, published studies have assessed the potential negative clinical effects of formulary-related interventions despite their widespread use. However, some evidence suggests increases in cost sharing reduce access to essential medicines for chronic illness.

Evaluation of patients' experiences with antidepressants reported by means of a medicine reporting system

OBJECTIVE

To assess experiences related to antidepressant use reported to an internet-based medicine reporting system and to compare the nature of the side effects reported by patients with those reported by health care professionals (HCPs).

METHODS

All reports submitted from May 2004 to May 2005 to an internet-based medicine reporting system in The Netherlands related to the use of antidepressants were analysed. Spontaneous reports of adverse drug reactions on antidepressants from HCPs received by The Netherlands Pharmacovigilance Centre Lareb from May 2004 to May 2005 were included for comparison.

RESULTS

Of the 2232 individuals who submitted a report to the internet-based medicine reporting system, 258 submitted a report on antidepressants. Of these, 92 individuals (36%) reported on effectiveness, 40 (16%) of whom reported on ineffectiveness, and 217 (84%) submitted a report on side effects, with 202 (78%) reporting a total of 630 side effects that were experienced as negative. Fourteen individuals (5%) reported a practical issue and four (2%) reported a reimbursement issue. Of all 630 side effects reported, 48% resulted in the patient discontinuing the antidepressant therapy; of these 29% did not inform their HCP. Of all the side effects reported, 52% were perceived as "very negative". In comparison to the side effects reported by HCPs, patients more often reported apathy, excessive sweating, ineffectiveness, somnolence, insomnia, sexual problems and weight increase.

CONCLUSION

Patients report the ineffectiveness and side effects of antidepressant therapy as negative and leading to discontinuation of the therapy. Patients and HCPs differ in the nature of the reported side effects. Patient experiences should be included in the evaluation of antidepressant treatment in clinical practice.

The Medical License Number Accurately Identifies the Prescribing Physician in a Large Pharmacy Claims Database

BACKGROUND

Medical license numbers that identify physicians in pharmacy claims data are used increasingly for both research and quality improvement efforts; however, little is known about how well this information identifies the physician who wrote the prescription. We studied the accuracy of the medical license number in data from a state-run drug benefit plan by assessing its consistency with 2 external sources of data.

METHODS

We studied a cohort of new users of osteoporosis medications who participated in Medicare and a state-run pharmaceutical benefit program. The medical license number from the prescription data were merged with the American Medical Association's (AMA) Masterfile to determine if the physician on the pharmacy claim existed in the AMA directory and practiced in the area under study. The prescription data were then merged with Medicare Part B data to determine if the physician on the prescription had an outpatient visit with the patient who received the medication.

RESULTS

Of the 40,002 index prescriptions, 38,671 (96.7%) were written by physicians or doctors of osteopathy. Of those, 38,618 (99.9%) could be matched to the AMA Masterfile of which 37,375 (98%) had a local address. Of the AMA-matched prescriptions with a valid Unique Physician Identification Number (UPIN), 28,888 (96.1%) could be matched to Medicare Part B data, indicating that the physician whose license number appeared on the prescription had at least 1 outpatient visit with the patient who received the medication.

CONCLUSIONS

The state medical license number in the pharmacy claims dataset studied seems to identify the prescribing physician with a high degree of accuracy.

Adherence behaviour with psychotropic medication is a form of self-medication

Adherence with psychotropic medication is at least at poor as adherence with medication for physical health problems. There has been an assumption this was due to loss of insight resulting from psychiatric disorders themselves. Consequently, interventions have focussed on treating the underlying psychiatric disorder and generating psychological strategies to promote awareness. Recent surveys of patient preferences for information and involvement in health care decisions highlight that most individuals want to participate in the process of medical care. Patients often have strong pre-existing beliefs about different therapeutic options. This is supported by the self-determination theory which distinguishes between autonomous behaviour and behaviours that are influenced by external forces. When considering the patient perspective in medication adherence, it is useful to consider the self-medication hypothesis. This can equally be applied to prescribed and non-prescribed drugs. The self-medication hypothesis states that patients decide to start, adjust or stop prescribed medication according to perceived health needs. Such decisions are often conducted intentionally and rationally, given the information available to the patient and their understanding of their condition. In this narrative review, the evidence for and against intentionality in psychotropic adherence behaviour is examined. Studies of compliance and related predictors are examined in depression, schizophrenia and bipolar affective disorder. Results suggest that although concordance depends on patient, illness and clinician factors, patient choice is usually the final common pathway. Illness severity and insight is important in some cases but can act in concert with cognitive factors. Individuals appear to prefer to take medication "as required" (symptomatically) rather than prophylactically. Significant influences upon self-medication habits are prior health beliefs, medication attitudes, adverse effects and adequacy of communication from the health care professional. The self-medication hypothesis applied to prescribed psychotropic medication should assist rather than heed clinicians in improving adherence by taking a patient centred approach and where possible promoting patient autonomy.

Hospital Pharmacy Pulse - Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this new feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.