Customization in prescribing for bipolar disorder.

For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient's needs. We test for the existence of customization in physicians' prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician's choice among five combinations of drug classes. We find that our observed measure of the patient's clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician's prescribing, but the results do not suggest a high degree of customization in physicians' prescribing, based on our measure of clinical status.

Management of access to branded psychotropic medications in private health plans.

BACKGROUND: In the past decade, health insurers have increased their reliance on cost control policies such as prior authorization and 3-tier formularies. Little is known about how these policies are being applied to psychotropic medications, many of which have low rates of patient adherence. OBJECTIVE: This study reports on plans' cost-sharing tier placement and authorization policies for 12 brand only psychotropic medications in 3 classes: antidepressants, anti-psychotics, and medications for attention deficit/hyperactivity disorder (ADFID). METHODS: Data were from a nationally representative survey of private health plans regarding mental health and substance-abuse services in 2003; 368 plans responded (83% response rate). Results were weighted and represent national estimates of health-plan characteristics. RESULTS: The majority of insurance products provided unrestricted placement on Tier 2 (medium copayment) for at least 2 brand-only antidepressants and at least 2 brand-only antipsychotics. This approach allows clinicians some limited leeway in initial medication selection. However, most patients who did not respond to the Tier-2 options typically faced a substantial escalation in copayment (Tier 3), possibly leading to premature medication discontinuation. For ADHI)5 the options were considerably more limited, with 22.1% of products applying some restriction to all 3 medications and only 15.9% of products leaving all 3 medications unrestricted. Plans with specialty contracts for mental health were considerably more likely to use Tier 3 (highest copayment) as their only restriction approach. CONCLUSIONS: Based on the results of this analysis,private plans were managing psychotropic costs using copayment incentives rather than administrative controls. This approach was less intrusive for clinicians, but resulting higher copayments could worsen already high rates of nonadherence; future research should examine this issue.

Alcohol & drug abuse: Revisiting employee assistance programs and substance use problems in the workplace: key issues and a research agenda.

This column describes employee assistance program (EAPs) and identifies key issues for contemporary EAPs. These programs began as occupational alcohol programs and have evolved into more comprehensive resources. To better understand contemporary EAPs, the authors suggest a research agenda that includes descriptive studies to provide an up-to-date picture of services; investigations of how contemporary EAPs address substance use problems, including management consultation for early identification; further study of EAPs' effects on outcomes, such as productivity and work group outcomes; examination of the relationship between EAPs and other workplace resources; further examination of influences on EAP utilization; and development and testing of EAP performance measures.

Discontinuation of antidepressant medication among Latinos in the USA.

Despite recent growth in the variety of antidepressant medications available, many patients discontinue medication prematurely for reasons such as nonresponse, side effects, stigma, and miscommunication. Some analysts have suggested that Latinos may have higher antidepressant discontinuation rates than other US residents. This paper examines Latino antidepressant discontinuation, using data from a national probability survey of Latinos in the USA. In this sample, 8% of Latinos had taken an antidepressant in the preceding 12 months. Among those users, 33.3% had discontinued taking antidepressants at the time of interview, and 18.9% had done so without prior input from their physician. Even controlling for clinical and other variables, patients who reported good or excellent English proficiency were less likely to stop at all. Patients were also less likely to stop if they were older, married, had public or private insurance, or had made eight or more visits to a nonmedical therapist.