Focus on Depression

Increasing Antidepressant Medication Adherence in Adults

The consequences of untreated, or inadequately treated, depression are significant; therefore, adherence to antidepressant medication is very important. Pharmacotherapy has been shown to be a critical part of the effective treatment of patients with depression. Coupled with appropriate forms of psychological therapy, most patients experience good outcomes with appropriate antidepressants taken for the proper duration. Patients need to be monitored very carefully during the acute phase (the first three months) and the initial continuation phase (the first six months) of treatment, so the clinician can adjust the dosage or type of medication, if necessary.

The health plan featured in this Quality Profile found that the prevalence of depression among its 2.1 million adult members was 5.6% from 1999 to 2000 and increased to 8.2% in 2001. The health plan determined that the prevalence of depression among Medicare members was 5.8%. Baseline (HEDIS^®) data collected by the plan indicated that 69.6% of adult members who started on antidepressant medications continued to use them for at least three months, and that 53.3% of adult members continued to use them for at least six months. While above the average for all health plans, the rates were below the benchmark 90th percentile level in the 2000 Quality Compass^® for commercial members of 70.5% for the acute phase of treatment and 54.3% for the continuation phase of treatment.

The health plan in this Quality Profile is a group model in which all of the health care services, including behavioral health services, are provided by employees of the organization’s affiliated medical group. In contrast, the majority of health plans contract with broad networks of providers, multiple medical groups, and/or individual practices. Although the structure of this health plan is atypical, this quality improvement project could be adapted for use in other settings including group practices and HMO or PPO network model insurance plans.

In 1999, the health plan began efforts to improve adherence to antidepressant medication use in its members by implementing the HEDIS^®-based initiatives on medication adherence. All health plan members over the age of 18 years and newly diagnosed with depression were included in the study. To evaluate the impact of interventions on the rate of antidepressant medication adherence, the health plan chose HEDIS^® 2.0H (which incorporated Consumer Assessment of Health Plans [CAHPS^®] 2.0H and was used for 1999 reporting) measures related to effective acute- and continuous-phase treatment for antidepressant medications. All measures followed HEDIS^® specifications with the exception of combined commercial and Medicare results. The health plan elected to combine results for these products for the purpose of analysis and planning interventions. The delivery system and potential barriers to care for both the commercial and Medicare populations are similar in this organization and combined analysis was the preferred approach. Note to reader: In 1999 when this study was initiated, health plans undergoing survey by NCQA were permitted to modify HEDIS^® for demonstrating significant improvement as long as the methodology was sound. Today, managed care organizations must present HEDIS^® data as specified in order to receive credit for a significant improvement.

Data were collected from January 1999 through December 2001.

The first quantifiable measure was the proportion of eligible members who received acute-phase treatment. This measure determined the percentage of health plan members aged 18 years or older who were diagnosed with a new episode of depression during the first 120 days of the measurement year and who filled a sufficient number of separate prescriptions or refills of antidepressant medication to provide continuous therapy for at least 84 days. The initial goal of the program was to attain a rate of antidepressant medication adherence of 70.5% for the combined commercial and Medicare population during the acute treatment phase of depression. This goal reflected using as a benchmark the 90th percentile for plans reporting in the 2000 NCQA Quality Compass for the commercial and Medicare populations of 70.5% and 69.3%, respectively.

The second quantifiable measure was the proportion of eligible members who received continuous-phase treatment. These members were newly diagnosed with an episode of major depressive disorder during the first 120 days of the measurement year and treated with antidepressant medication. This measure was used to determine the percentage of these members who filled a sufficient number of separate prescriptions or refills of antidepressant medication to provide continuous therapy for at least 180 days. The health plan determined an initial goal for the rate of antidepressant mediation adherence of 54.4% for the combined commercial and Medicare population during the continuation phase of treatment for depression. Again this goal is based on the 2000 NCQA Quality Compass 90th percentile for the commercial and Medicare populations of 54.3% and 54.4%, respectively (Table 1).

The plan did not use all three components of the HEDIS^® Antidepressant Medication Management measure. The measure of practitioner contact within a specified period of time was not included primarily because the measure was not structured in a manner that allowed the managed care organization to capture all of the ways in which care for persons with depression was monitored in their system. For example, at the time this study was undertaken, HEDIS^® specifications did not define telephone contacts as a means of follow-up. The specifications for the Antidepressant Medication Management measure now includes this mode of contact

Data were collected via administrative records only. The table below summarizes the plan’s results.

The sponsor group for this activity was the Behavioral Health Quality Improvement Committee (BHQIC), a regional committee comprised of psychiatrists, behavioral medicine psychologists, primary care physicians, behavioral health administrators, and other health professionals. This committee evaluates the quality of behavioral health services and supports continuous improvement activities. The Antidepressant Medication Management results are included in the health plan’s annual Behavioral Health Quality report card. HEDIS^® results were reviewed by the BHQIC, affiliated medical groups’ chief of psychiatry and primary care, who are responsible for overseeing all depression-related activities at each facility. This group met quarterly and offered feedback to regional staff on barriers and potential interventions. Behavioral health educators annually reviewed the behavioral health education class attendance and the demographics of health plan membership to identify barriers and opportunities.

The BHQIC determined that several interventions already in place had a beneficial impact on the rates of medication adherence. These interventions included the Behavioral Medicine Specialist Program, the Pilot Medication Follow-up Program, and health education for members.

The Behavioral Medicine Specialist Program was designed to promote collaboration between behavioral medicine (psychologists and licensed clinical social workers) and PCPs through quick appointment access. The program provides brief visits with a behavioral health practitioner (15 to 30 minutes) who is co-located with the PCPs. Therefore, the PCPs were able to encourage their patients starting antidepressants to make an appointment with a behavioral health practitioner because of the convenience in appointment scheduling. If the case required urgent attention, the PCP would walk the patient over to the appointment desk and facilitate quick access to behavioral health services. The visits were usually limited in number (one to six), so members were not overwhelmed by the time commitment to treatment but were still able to discuss their adherence to their medications and receive therapy with an appropriate health care professional.

The Pilot Medication Follow-Up Program involved one-on-one educational sessions between a pharmacist and the member. Many members starting antidepressant therapy do not take their medication for the prescribed time frame; therefore, having the pharmacist interact with the patient early in therapy (as opposed to later) provides an opportunity to reinforce the importance of long-term compliance. Preliminary results demonstrated greater improvements in adherence to medication for members in this program compared with members that did not receive this intervention. Over time, the program was expanded to include further follow-up to assess relapse in this population.

Barriers identified during analysis of the baseline results included:

• Lack of practitioner understanding regarding how cultural diversity can affect the appropriate management of depression
• Lack of member understanding of the proper use of antidepressant medications and the importance of staying on therapy
• Lack of practitioner knowledge and expertise regarding the recognition of depression, appropriate treatments for depression, and the availability of behavioral health education classes

Because depression may interfere with a patient’s ability to be active in his or her own follow-up, the health plan felt that additional member education was needed. A handout for members, referred to as a tip sheet, was developed as a useful reference for patients and provided detailed information on the proper use of antidepressants. The health plan also considered the need to provide practitioners with up-to-date information regarding medications for depression. Because the health plan membership is becoming increasingly more culturally diverse, the health plan felt that practitioners needed education regarding how cultural background can affect optimal management of depression.

The health plan also participated in a Cooperative Healthcare Reporting Initiative, which produced a state health care quality report card. The state report card included both HEDIS^® and CAHPS survey measures for all participating health plans, representing about 90% of the managed care membership in the region. Additionally, a report card produced by the BHQIC was distributed regionally to the chiefs of psychiatry, chemical dependency and medicine. It was also distributed to the quality “chairs” for psychiatry, chemical dependency, and behavioral medicine psychologists at each of the medical center facilities throughout the region. This internal report card contained the Antidepressant Medication Management measures, a measure of SSRI use, and primary care diagnosis of depression measure. Based on the barriers identified from the analysis of baseline results and building on the existing programs, several interventions were implemented during the following year. These interventions included:

• Practitioner education via a continuing medical education videoconference on the presentation and treatment of depression in culturally diverse populations
• Self-care tip sheet on antidepressant medication use for members
• Handout for members on frequently asked questions regarding the use of generics versus brand names
• Revision and distribution via Lotus Notes and plan’s Web site of adult primary care clinical practice guidelines in depression and a live presentation

Tip Sheets for Patients To address the lack of member knowledge and understanding of depression and the use of antidepressant medication, the health plan developed educational materials for members that were distributed by practitioners at primary care and specialty clinics. These materials were also available at educational centers and on the health plan’s Web site. An antidepressant self-care tip sheet for patients with depression contained information on the use of antidepressant medication, possible side effects and how to handle them, and common myths and facts about the drugs. The health plan found these tip sheets to be a substantial benefit to treatment adherence. Patients were given a single sheet that answered many common questions related to the use of antidepressant medication. Based on feedback from practitioners, the health plan viewed the tip sheets as an excellent way to educate members about antidepressant medications, and the success of the tip sheets has supported their continued use. This type of intervention is a simple and effective method for increasing the rate of adherence to antidepressant medication and can be easily applied to network models. However, this intervention may not be possible in those physician groups that are not able to easily identify which patients in the practice have been diagnosed with depression.

The first remeasurement, based on data from January 2000 to December 2000, revealed improvements in the rate of antidepressant medication adherence during the acute treatment phase but not in the continuation treatment phase. From baseline to the first Remeasurement One, the rate of medication adherence increased 0.9% for members in the acute phase of treatment, while the rate of adherence increased only 0.1% for members in the continuation phase of treatment. Because the goal was met for the rate of medication adherence in the acute-phase treatment, a new goal was set by the BHQIC for 2001, the second remeasurement period. The new goal of 73% was based on a clinical consensus of the BHQIC group (Table 2).

Education materials for members were developed by a Behavioral Health Regional Health Education department. These materials were made available to members at the adult primary care clinics, the health education centers, and on the health plan’s Web site. Within the health plan’s service area, there were about 40 ethnic groups and over 140 languages spoken. The health plan recognized the importance of educating practitioners on the cultural needs of this diverse membership and developed a videoconference for practitioners that addressed cultural differences in the presentation of symptoms of depression and accepted treatments among diverse cultural groups (Appendix 4). The practitioners included all physicians, nurse practitioners, and physician assistants in emergency medicine, family practice, internal medicine, and selected medical subspecialties - obstetrics/gynecology, psychiatry, behavioral medicine psychologists, chemical dependency, and urgent care.

Depression Education Classes for Members The health plan has long recognized the need to improve the detection and treatment of depression. To educate members, health education classes have been offered since 1995. As a part of this quality improvement initiative, the health plan updated and revised the content of these classes. The plan offered both one-session classes, which provided an overview of depression and its treatment, as well as eight-session classes, which taught members skills needed for the management of mild-to-moderate members. The health plan has found these classes to be extremely popular and has been challenged with offering a sufficient number of classes to meet the high demand. The plan attributes the high attendance to a variety of factors, such as encouragement from practitioners, advertisements in newsletters, word of mouth, and multiple class offerings at flexible times. The classes continue to be offered, and, in selected locations, are being rotated through different satellite clinic locations. Part of the success of the educational program was attributed to the fact that the health education classes were offered at the treatment site and were strongly supported by the treating physician. In many network model health plans, members would not experience this same type of access and practitioner support. In this situation, the MCO would need to work closely with practitioners to ensure that patients are encouraged to attend classes that were offered at locations other than the treatment facility. Providing practitioners with printed invitations to give members, or posting signage about the class in their offices or waiting rooms, may lead to better attendance.

As a group model with employed physicians, videoconference is a realistic approach. For managed care organizations with a network model, distribution of videotaped education or Web-based training may be a more practical approach to reaching practitioners in multiple geographic locations.

Analysis of the results from the first year suggested that adherence to medication was a continuing barrier. Other barriers that were identified during the Remeasurement One period included a lack of:

• Member education
• Efficient member access to order prescriptions
• Member follow-up
• Affordable prescriptions

To see where interventions could be modified to enhance improvement, the health plan further examined the first-year experience. For example, the BHQIC and the behavioral health education department reviewed the behavioral health class attendance and the demographics of members to identify additional barriers to the education of members. The BHQIC and the behavioral health education department felt that continued attendance at the behavioral health education classes by members did contribute to increased rates of medication adherence. Self-management for depression was considered important to integrate into a patient’s treatment plan, in addition to the behavioral health education classes, to improve member awareness of depressive symptoms. Web-based formats and interactive educational materials were considered potentially useful in assisting members in their recovery from depression and an adjunct to the care they received from their health care practitioner.

The behavioral health education department revised the curriculum for these behavioral health education classes. To improve member compliance for adherence to their medications, several enhancements were made to simplify prescription ordering for members.

Based on the first-year analysis of adherence the health plan revised and implemented additional interventions including:

• Revising the curriculum of the behavioral health education classes for members
• Providing online prescription refills, including for patients with no refills remaining on their prescriptions
• Mailing a publication to seniors on dealing with depression
• Distributing a weekly report showing the percentage of all prescriptions that were SSRIs
• Updating the discussion board on the plan’s Web site

Increasing Adherence Through Easy Prescription Refills The BHQIC agreed with the health plan that easy access to prescription refills was important, both in terms of member satisfaction and impact on medication adherence. As a result, this health plan streamlined and facilitated quick access to medications by allowing members to request refills online. Members could request refills anytime, have prescriptions mailed to them at no extra charge, pick up their prescriptions at any health plan pharmacy, check on the status of each refill, and research information on medications. Both the member guidebook and the member newsletter contained information on how to request prescription refills online. Members could also request prescription refills for medications without any refills remaining. Previously, the process to request refills for prescriptions with no refills remaining was done by fax and phone and took several days. E-refill is a Web-based electronic refill authorization request system designed to make the review, authorization, and denial process for a member’s prescription refill request easier and more efficient. Inefficiencies associated with the paper-based system were dramatically reduced or eliminated. This improved member compliance by making it more efficient for them to refill prescriptions and to continue taking their medications.

Following the implementation of the revised program, the health plan again analyzed medication adherence using the measurement criteria. Although the rate of medication adherence during the acute-phase treatment improved from 70.5% in 2000 to 71.7% in 2001, this did not meet the performance goal of 73%. The rate of adherence during the continuation phase of treatment also continued to increase, from 53.4% in 2000 to 53.9% in 2001, although again this increase did not meet the performance goal (Table 3).

Despite the lack of major improvements, the BHQIC felt that the SSRI Use Report had resulted in an increased awareness by practitioners of the use of SSRIs that extended beyond prescribing the medication to following up with the member. The committee also determined that because fluoxetine hydrochloride was evaluated and studied as safe and effective, and was on the formulary as a generic drug with a low member copayment that made the medication affordable, medication adherence was increased. The availability of an online discussion for behavioral health was also seen as helpful to some members. In this intervention, concerns posted to the online discussion were addressed daily by a health care professional or a pharmacist to reinforce the importance of proper follow-up and adherence to medication. However, the online discussion was removed from the Web site due to the potential risk of not providing timely assistance or information to members in crisis and because of confidentiality concerns.

Since the rate of medication adherence was still below the targeted goal, the health plan reviewed the barriers that had been previously identified as well as identifying some additional barriers. The barriers seen as most critical to increased adherence to antidepressant mediation included a lack of:

• Updated and concise patient education information
• Education of practitioners about the management of antidepressant medication and the recognition and treatment of depression
• Treatment algorithms for depression as a comorbid condition
• Educational materials for members about medications and about communicating the symptoms of depression and medications to their practitioners

During the third year of the initiative, the health plan was not able to achieve statistically significant improvement for either measure. However, the improvement in the rate of antidepressant medication adherence did reach statistical significance for patients in the acute phase of treatment as compared to the baseline measurement period, but did not reach the revised goal for the acute-phase treatment. It is important to note, however, that the plan: 1) started from a relatively high level of performance and 2) continued to show steady, if modest, improvement throughout the three years of the project. From baseline to Remeasurement Two, the rate of adherence during the acute-phase treatment rose 2.1%, and during the continuation phase of treatment rose 0.6% (Table 4).

Another Plan's Approach Telephone Contact in the Management of Depression Maintaining close contact with patients is crucial to increasing medication adherence and improving the overall management of their depression. A mixed-model (group and network) health plan used a telephone information line to provide patients with information about depression and to encourage them to keep their first appointment with the physician. The telephone information line was made available to all members of the health plan who called to request authorization for outpatient services. Following the authorization process, those patients presenting with symptoms of depression (telephonically) were asked if they would like to listen to a brief message about depression. If the patient agreed, the message was made available to them. The message provided information regarding the assessment of depression and effective treatment options, including medication and therapy. The health plan felt that the intervention fostered trust and adherence by providing patients with important information describing what would take place at their first visit with the behavioral health practitioner. The health plan has continued to offer the telephone information line because the basic information it conveys to patients encourages them to keep their first appointment and allows them to have realistic expectations when they arrive for their appointment. Telephone intervention is a simple method health plans can implement to help establish the close contact needed with patients in order to successfully manage their depression and increase persistency of treatment.

The health plan has continued its efforts to improve the treatment of depression across the organization focusing on increasing the rate of antidepressant medication adherence. The health plan continues to collect data and review it through the BHQIC with continued evolving interventions across the region. The program has continued to expand the antidepressant self-care tip sheets to include a comprehensive overview of depression and use of antidepressant medications. The program has also continued its videoconferencing program, distribution of its member educational brochures and publications, and to enhance pharmacy access and improve behavioral health education classes. Expansion of the Pilot Medication Follow-Up Program has occurred in selected regions. Finally, the health plan has introduced a presentation for practitioners on depression and diabetes.

Through persistence of its efforts, the plan has achieved further success after the quality improvement activity was reported. Using preliminary combined commercial and Medicare data from 2002, the rate of adherence to antidepressant medication during the acute-phase treatment was 73.8%, an increase of 2.1% over the previous year, which exceeded their goal. Likewise, the rate of adherence during the continuation phase of treatment reached 56.3%, an increase of 2.4%, putting this measure above goal. The plan attributes the success of this activity to its persistent, broad-based approach, including efforts aimed at the education of members and practitioners and at improvements in the collaboration and coordination of care. Other factors that have contributed to the success of the activity include careful selection of interventions, sensitivity to the needs of members and practitioners, and willingness to adapt the program in response to changing needs.