The Role of Clinical Setting and Management Approach in Metabolic Testing Among Youths and Adults Treated With Antipsychotics.

OBJECTIVE: This study compared metabolic screening among patients who received antipsychotic treatment at community mental health centers (CMHCs), with or without case management, and patients treated elsewhere. METHODS: Rates of glucose and lipid testing among youths and adults in Missouri Medicaid (N=9,473) who received antipsychotic treatment at CMHCs, with and without case management, were evaluated. Multivariable logistic regressions determined which characteristics were independently associated with metabolic testing. RESULTS: A total of 37.0% and 17.3% of youths and 68.7% and 34.9% of adults had glucose and lipid testing, respectively. Compared with treatment elsewhere, treatment at CMHCs, with or without case management, respectively, was associated with higher odds of glucose testing (youths, adjusted odds ratio [AOR]=1.68 and 1.89; adults, AOR=1.43 and 1.44) and lipid testing (youths, AOR=2.40 and 2.35; adults, AOR=1.97 and 1.48). CONCLUSIONS: CMHCs had higher rates of metabolic testing, possibly reflecting Missouri's efforts to promote testing in these settings.

The Affordable Care Act and Implications for Health Care Services for American Indian and Alaska Native Individuals.

American Indian and Alaska Native (AI/AN) populations report poor physical and mental health outcomes while tribal health providers and the Indian Health Service (IHS) operate in a climate of significant under funding. Understanding how the Patient Protection and Affordable Care Act (ACA) affects Native American tribes and the IHS is critical to addressing the improvement of the overall access, quality, and cost of health care within AI/AN communities. This paper summarizes the ACA provisions that directly and/or indirectly affect the service delivery of health care provided by tribes and the IHS.

Psychotropic drug use among preschool children in the Medicaid program from 36 states.

OBJECTIVES: We determined the prevalence of and indications for psychotropic medication among preschool children in Medicaid. METHODS: We obtained 2000 to 2003 Medicaid Analytic Extract data from 36 states. We followed children in 2 cohorts, born in 1999 and 2000, up to age 4 years. We used logistic regression to model odds of receiving medications for (1) attention-deficit disorder/attention-deficit hyperactivity disorder, (2) depression or anxiety, and (3) psychotic illness or bipolar. RESULTS: Overall, 1.19% of children received at least 1 psychotropic drug. Medications for attention-deficit disorder/attention-deficit hyperactivity disorder treatment were most common (0.61% of all children), followed by depression or anxiety (0.59%) and psychotic illness or bipolar (0.24%). Among children, boys, those of other or unknown race compared with White, and those with other insurance compared with fee for service-only had higher odds of receiving a prescription (odds ratio [OR]=1.80 [95% confidence interval (CI)=1.74, 1.86], 1.75 [corrected] [1.66, 1.85], and 1.14 [1.01, 1.28], respectively), whereas Black and Hispanic children had lower odds (OR=0.51 [95% CI=0.48, 0.53] and 0.37 [0.34, 0.39], respectively). CONCLUSIONS: Preschoolers are receiving psychotropic medications despite limited evidence supporting safety or efficacy. Future research should focus on implementing medication use practice parameters in infant and toddler clinics, and expanding psychosocial interventions for young children with behavioral problems.

Challenges in using medicaid claims to ascertain child maltreatment.

Medicaid data contain International Classification of Diseases, Clinical Modification (ICD-9-CM) codes indicating maltreatment, yet there is a little information on how valid these codes are for the purposes of identifying maltreatment from health, as opposed to child welfare, data. This study assessed the validity of Medicaid codes in identifying maltreatment. Participants (n = 2,136) in the first National Survey of Child and Adolescent Well-Being were linked to their Medicaid claims obtained from 36 states. Caseworker determinations of maltreatment were compared with eight sets of ICD-9-CM codes. Of the 1,921 children identified by caseworkers as being maltreated, 15.2% had any relevant ICD-9-CM code in any of their Medicaid files across 4 years of observation. Maltreated boys and those of African American race had lower odds of displaying a maltreatment code. Using only Medicaid claims to identify maltreated children creates validity problems. Medicaid data linkage with other types of administrative data is required to better identify maltreated children.

Medicaid expenditures on psychotropic medications for maltreated children: a study of 36 States.

OBJECTIVE: Children with histories of abuse or neglect are the most expensive child population to insure for their mental health needs. This study aimed to quantify the magnitude of Medicaid expenditures incurred in the purchase of psychotropic drugs for these children. METHODS: Children (N=4,445) participating in the National Survey of Child and Adolescent Well-Being (NSCAW) and from households under investigation for suspected child abuse and neglect were linked to their Medicaid claims from 36 states. Expenditures on psychotropic medications between the NSCAW sample and a propensity score-matched comparison sample of Medicaid-enrolled children were compared in a two-part regression of logistic and generalized linear models. RESULTS: Children in the NSCAW sample had twice the odds of psychotropic drug use and $190 higher mean annual expenditures on psychotropic drugs than children in the comparison sample. Increased expenditures on antidepressants and antimanic drugs were the primary drivers of these increased expenditures. Male gender and white race-ethnicity were associated with significantly increased expenditures. Children in primary care case management had $325 lower expenditures than those in fee-for-service Medicaid. Among NSCAW children alone, male gender, older age, being in poorer health, and scoring in the clinical range of the Child Behavior Checklist (CBCL) all increased expenditures on psychotropic drugs. CONCLUSIONS: Medicaid agencies should focus their cost containment strategies on antidepressants and antimanic drugs, consider expanding primary care case management arrangements, and expand use of instruments such as the CBCL to identify and treat high-need children.

Racial/ethnic differences in Medicaid expenditures on psychotropic medications among maltreated children.

This study quantifies racial/ethnic differences in Medicaid expenditures on psychotropic drugs among a national sample of children with suspected maltreatment. We linked 4,445 child participants in the National Survey of Child and Adolescent Well-Being (NSCAW) - consisting of children investigated for suspected abuse and neglect - to their Medicaid claims obtained from 36 states. We used propensity score matching to construct a comparison group of children without known child welfare involvement, and estimated two-part generalized linear models to examine differences in annual psychotropic drug expenditures per child between children of different races/ethnicities. When compared to a matched sample of children, African American and Latino children incur $292 and $144 less expenditures on psychotropic drugs, respectively, than white children. Among NSCAW children alone, African American children display $614 less spending on psychotropic drugs when compared to white children. Racial/ethnic differences in expenditures on psychotropic drugs occur among all children on Medicaid, but the differences are especially pronounced among African American children in contact with the child welfare system. These findings demonstrate that policymakers will need to pay special attention to the needs of children of color as Medicaid expansions proceed nationwide.

Association of anxiety disorders and depression with incident heart failure.

OBJECTIVE: Depression has been associated with increased risk of heart failure (HF). Because anxiety is highly comorbid with depression, we sought to establish if anxiety, depression, or their co-occurrence is associated with incident HF. METHODS: A retrospective cohort (N = 236,079) including Veteran's Administration patients (age, 50-80 years) free of cardiovascular disease (CVD) at baseline was followed up between 2001 and 2007. Cox proportional hazards models were computed to estimate the association between anxiety disorders alone, major depressive disorder (MDD) alone, and the combination of anxiety and MDD, with incident HF before and after adjusting for sociodemographics, CVD risk factors (Type 2 diabetes, hypertension, hyperlipidemia, obesity), nicotine dependence/personal history of tobacco use, substance use disorders (alcohol and illicit drug abuse/dependence), and psychotropic medication. RESULTS: Compared with unaffected patients, those with anxiety only, MDD only, and both disorders were at increased risk for incident HF in age-adjusted models (hazard ratio [HR] = 1.19 [ 95% confidence interval {CI} = 1.10-1.28], HR = 1.21 [95% CI = 1.13-1.28], and HR = 1.24 [95% CI = 1.17-1.32], respectively). After controlling for psychotropics in a full model, the association between anxiety only, MDD only, and both disorders and incident HF increased (HRs = 1.46, 1.56, and 1.74, respectively). CONCLUSIONS: Anxiety disorders, MDD, and co-occurring anxiety and MDD are associated with incident HF in this large cohort of Veteran's Administration patients free of CVD at baseline. This risk of HF is greater after accounting for protective effects of psychotropic medications. Prospective studies are needed to clarify the role of depression and anxiety and their pharmacological treatment in the etiology of HF.

Common selective serotonin reuptake inhibitor side effects in older adults associated with genetic polymorphisms in the serotonin transporter and receptors: data from a randomized controlled trial.

OBJECTIVE: Antidepressant side effects are a significant public health issue, associated with poor adherence, premature treatment discontinuation, and, rarely, significant harm. Older adults assume the largest and most serious burden of medication side effects. We investigated the association between antidepressant side effects and genetic variation in the serotonin system in anxious, older adults participating in a randomized, placebo-controlled trial of the selective serotonin reuptake inhibitor (SSRI) escitalopram. METHODS: Adults (N = 177) aged ≥ 60 years were randomized to active treatment or placebo for 12 weeks. Side effects were assessed using the Udvalg fur Kliniske Undersøgelser side-effect rating scale. Genetic polymorphisms were putative functional variants in the promoters of the serotonin transporter and 1A and 2A receptors (5-HTTLPR [L/S + rs25531], HTR1A rs6295, HTR2A rs6311, respectively). RESULTS: Four significant drug-placebo side-effect differences were found: increased duration of sleep, dry mouth, diarrhea, and diminished sexual desire. Analyses using putative high- versus low-transcription genotype groupings revealed six pharmacogenetic effects: greater dry mouth and decreased sexual desire for the low- and high-expressing serotonin transporter genotypes, respectively, and greater diarrhea with the 1A receptor low-transcription genotype. Diminished sexual desire was experienced significantly more by high-expressing genotypes in the serotonin transporter, 1A, or 2A receptors. There was not a significant relationship between drug concentration and side effects nor a mean difference in drug concentration between low- and high-expressing genotypes. CONCLUSION: Genetic variation in the serotonin system may predict who develops common SSRI side effects and why. More work is needed to further characterize this genetic modulation and to translate research findings into strategies useful for more personalized patient care.

Genetic variation in the serotonin transporter and HTR1B receptor predicts reduced bone formation during serotonin reuptake inhibitor treatment in older adults.

OBJECTIVES: Studies have reported an association between serotonin reuptake inhibitors (SRIs) and accelerated bone loss. Genetic variation in the serotonin system might modulate bone metabolism changes during SRI treatment. In a clinical trial we examined functional genetic polymorphisms of serotonin transporter and receptors involved in bone metabolism to determine whether they predict changes in bone metabolism during SRI treatment. METHODS: In 69 adults (age ≥ 60) participating in a 12-week, open-label trial of the SRI venlafaxine for major depression, serum markers of bone formation (P1NP) and resorption (ß-CTX) were assayed before and after treatment. Participants were genotyped for putative high- versus low-expressing polymorphisms in the serotonin transporter (5HTTLPR) and 1B receptor (HTR1B) genes. RESULTS: Bone formation was significantly reduced with administration of venlafaxine in participants with the high-expressing 5HTTLPR genotype and those with the low-expressing HTR1B genotype. This primarily occurred in individuals with the combination of the high-expressing 5HTTLPR genotype and the low-expressing HTR1B genotype. CONCLUSIONS: These preliminary findings indicate that genetic variation in the serotonin receptors predicts changes in bone metabolism during SRI use. If these results are replicated and clinically confirmed, we will have identified a genetic subgroup at high risk for deleterious bone outcomes with the use of SRIs.

Treatment-resistant and insufficiently treated depression and all-cause mortality following myocardial infarction.

BACKGROUND: Depression is a known risk factor for mortality after an acute myocardial infarction. Patients with treatment-responsive depression may have a better prognosis than those with treatment-resistant depression. AIMS: We sought to determine whether mortality following acute myocardial infarction was associated with treatment-resistant depression. METHOD: Follow-up began after myocardial infarction and continued until death or censorship. Depression was counted as present if diagnosed any time during the study period. Treatment for depression was defined as receipt of 12 or more weeks of continuous antidepressant therapy at a therapeutic dose during follow-up. Treatment-resistant depression was defined as use of two or more antidepressants plus augmentation therapy, receipt of electroconvulsive therapy or use of monoamine oxidase inhibitors. Mean duration of follow-up was 39 months. RESULTS: During follow-up of 4037 patients with major depressive disorder who had had a myocardial infarction, 6.9% of those with insufficiently treated depression, 2.4% of those with treated depression and 5.0% of those with treatment-resistant depression died. A multivariable survival model that adjusted for sociodemographics, anxiety disorders, beta-blocker use, mortality risk factors and health service utilisation indicated that compared with treated patients, insufficiently treated patients were 3.04 (95% CI 2.12-4.35) times more likely and patients with treatment-resistant depression were 1.71 (95% CI 1.05-2.79) times more likely to die. CONCLUSIONS: All-cause mortality following an acute myocardial infarction is greatest in patients with depression who are insufficiently treated and is a risk in patients with treatment-resistant depression. However, the risk of mortality associated with treatment-resistant depression is partly explained by comorbid disorders. Further studies are warranted to determine whether changes in depression independently predict all-cause mortality.

Increased risk of myocardial infarction in depressed patients with type 2 diabetes.

OBJECTIVE: To investigate major depressive disorder (MDD), which complicates the course of type 2 diabetes and is associated with an increased risk of cardiovascular disease and death. This risk may be due to a greater susceptibility for myocardial infarction (MI) in depressed patients with type 2 diabetes compared with nondepressed patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Veterans Administration electronic medical records were analyzed to identify a cohort free of cardiovascular disease in fiscal years 1999 and 2000, aged 25 to 80 years. ICD-9-CM codes were used to create a four-level risk group indicating 1) neither diabetes nor MDD (n = 214,749), 2) MDD alone (n = 77,568), 3) type 2 diabetes alone (n = 40,953), and 4) comorbid MDD and type 2 diabetes (n = 12,679). Age-adjusted Cox proportional hazards models were computed before and after adjusting for baseline sociodemographic and time-dependent covariates. RESULTS: After adjusting for covariates, patients with type 2 diabetes alone and patients with MDD alone were at ∼30% increased risk for MI, and patients with type 2 diabetes and MDD were at 82% increased risk for MI (hazard ratio 1.82 [95% CI 1.69-1.97]) compared with patients without either condition. CONCLUSIONS: Compared with patients with only diabetes or only MDD, individuals with type 2 diabetes and MDD are at increased risk for new-onset MI. Monitoring cardiovascular health in depressed patients with type 2 diabetes may reduce the risk of MI in this especially high-risk group.

Factors associated with receipt of adequate antidepressant pharmacotherapy by VA patients with recurrent depression.

OBJECTIVE: Adequate treatment of depression improves the prognosis of depressed individuals. This study identified sociodemographic, medical, psychiatric, and health care utilization factors associated with receipt of adequate antidepressant pharmacotherapy by Veterans Health Administration (VHA) patients with recurrent depression. METHODS: National VHA electronic medical records were used to construct a cohort of depressed patients who were experiencing a recurrent episode of depression between 1999 and 2006. Multinomial logistic regression determined factors that were associated with no receipt of treatment and with three levels of treatment: some antidepressant pharmacotherapy, adequate acute-phase pharmacotherapy, and adequate continuation-phase pharmacotherapy. RESULTS: A total of 26,770 patients aged 25 to 80 years, most of whom were male (84.5%), who were experiencing a recurrent episode of depression were identified. Female patients and those with substance abuse or dependence, nicotine dependence, or panic disorder were more likely to receive adequate acute-phase or continuation-phase treatment (or both) than to receive no treatment. Nonwhite race, being unmarried, having only VA benefits, having generalized anxiety disorder, and receiving treatment outside the mental health specialty sector were associated with a lower likelihood of receiving guideline-concordant care. CONCLUSIONS: Factors associated with receipt of adequate treatment for recurrent depression were similar to those found in previous studies for patients with new episodes of depression. This study was one of the first to focus specifically on patients experiencing recurrent depression, rather than combining patients with new and recurrent episodes in one sample. Continued research is warranted on how to modify factors to increase receipt of adequate care.

Antidepressant drug compliance: reduced risk of MI and mortality in depressed patients.

BACKGROUND: The long-term risk of myocardial infarction (MI) associated with use of antidepressants is uncertain, especially for nontricyclic antidepressants. The present study uses a national Veterans Affairs cohort to test whether antidepressants increase or decrease risk of MI and all-cause mortality. METHODS: US Department of Veterans Affairs patient records were analyzed to identify a cohort free of cardiovascular disease in fiscal years 1999 and 2000, aged 25-80 years, who had an International Classification of Diseases, Ninth Revision, Clinical Modification code indicating an episode of depression (n=93,653). Incident MI and all-cause mortality were modeled in patients who received 12 weeks or more of antidepressant pharmacotherapy as compared with 0-11 weeks during follow-up. Age-adjusted Cox proportional hazard models were computed before and after adjusting for baseline sociodemographics and time-dependent covariates. RESULTS: Receipt of 12 or more weeks of continuous antidepressant therapy was associated with significantly reduced rates of incident MI across classes of antidepressants: selective serotonin reuptake inhibitor (SSRIs) (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.44-0.52), serotonin-norepinephrine reuptake inhibitors (SNRIs) (HR 0.35; 95% CI, 0.32-0.40), tricyclic antidepressants (TCAs) (HR 0.39; 95% CI, 0.34-0.44), and "Other" (HR 0.41; 95% CI, 0.37-0.45). Risk of all-cause mortality also was decreased with receipt of 12 weeks of pharmacotherapy with all classes of antidepressants (SSRI, SNRI, TCA, Other), with HRs ranging from 0.50 to 0.66. CONCLUSIONS: Across classes of antidepressants, 12 weeks of pharmacotherapy appears to be safe in terms of MI risk. Although the mechanism for this association remains uncertain, it is possible that compliance with pharmacotherapy for depression reflects compliance with cardiovascular medications. It also is possible that a direct drug effect or improved depressed mood may attenuate the risk of MI in depressed patients.

Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients.

BACKGROUND: Depression is a risk factor for incident myocardial infarction (MI), but little is known about the independent or additive risk from anxiety disorders. METHODS: In a 7-year retrospective cohort design, we identified a cohort free of cardiovascular disease in fiscal years 1999 and 2000 that contained 96,612 patients between 25 and 80 years of age who had an International Classification of Diseases, Ninth Revision, Clinical Modification code indicating a diagnosis of depression in 2000 (baseline) and 259,387 patients without depression. Cox proportional hazards models stratified by depression were computed to test for a main effect of anxiety disorder unspecified, generalized anxiety disorder, panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder (PTSD) on risk of incident MI. The models were adjusted for multiple MI risk factors and sociodemographics. RESULTS: Depressed as compared to nondepressed Veterans Administration patients were at increased risk for incident MI (HR 1.39; 95% CI 1.34-1.45). In nondepressed patients those with anxiety disorder unspecified (HR 1.34; 95% CI 1.21-1.47), panic disorder (HR 1.43; 95% CI 1.11-1.83), and PTSD (HR 1.25; 95% CI 1.16-1.36) were at increased risk for incident MI. The independent risk associated with anxiety disorders was reduced in patients comorbid for depression. CONCLUSIONS: In Veterans Administration patients free of heart disease in 1999 and 2000, those with depression, anxiety disorder unspecified, panic disorder, and PTSD were at increased risk of incident MI. Anxiety disorders are independent risk factors for MI. Depression partially accounts for the effect of anxiety disorders on risk of MI in patients with both conditions.