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The American Journal of Managed Care December 2013
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Generic Initiation and Antidepressant Therapy Adherence Under Medicare Part D
Yuhua Bao, PhD; Andrew M. Ryan, PhD; Huibo Shao, MS; Harold Alan Pincus, MD; and Julie M. Donohue, PhD
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Generic Initiation and Antidepressant Therapy Adherence Under Medicare Part D

Yuhua Bao, PhD; Andrew M. Ryan, PhD; Huibo Shao, MS; Harold Alan Pincus, MD; and Julie M. Donohue, PhD
This study shows that generic initiation improves adherence to antidepressant therapy among Medicare patients and mitigates the negative effects of the Part D coverage gap.
Other limitations include the following. Our data are for Medicare fee-for-service patients only; our findings may not extend to  Medicare managed care patients. Like all studies that use claims data for adherence research, we based inferences on  antidepressant possession, not drugs taken. As a result, the sharp decline in adherence seen at the end of the  first month reflects failures to renew 30-day prescriptions and should not be interpreted as nonadherence at exactly 30 days after initiation. Our  measures of antidepressant adherence reflected 1 dimension of guideline-concordant care: namely, continuation of therapy for an  extended period of time. We did not have information on adequacy of dosage. We did not examine medication switches or  augmentations, 2 recommended strategies when patients fail to respond to initial treatment or have serious side effects,3,4,29  because we were not able to determine the clinical validity of either. The clinical significance of missing a few days of antidepressant medication on a monthly basis is less clear than having a significant gap in treatment since some antidepressants  have long halflives. Thus, findings regarding monthly possession should be interpreted as secondary to those pertaining to  disruption. We focused on generic (vs branded) initiation and did not consider subsequent switches between generic and branded antidepressants, which were infrequent. We also do not have information on prescribers or the benefit design of the Part D prescription drug plans.

CONCLUSIONS

Our study provides strong evidence supporting generic initiation to improve adherence to antidepressant therapy among Medicare  patients. The benefits result from the lower out-ofpocket cost associated with generic antidepressants. These benefits were augmented while patients were experiencing the coverage gap under Part D. Our findings imply that generic prescribing, a strategy within easy reach of clinicians, can be an important tool to further improve adherence to antidepressant  treatment and to mitigate negative effects of the Part D benefit structure. More broadly, to assist their patients in making  healthcare more affordable, clinicians should consider the economic impact of their treatment decisions, raise the issue of ability to pay with patients, and  discuss options. States that do not urrently mandate generic substitution (unless with a “dispense as written” request by the prescriber or patient) or that require patient consent for generic substitution may consider more restrictive policies to further reap the benefits of generic use. 

Author Affiliations: From Department of Public Health, Weill Cornell Medical College (YB, AMR, HS), New York, NY; Department of Psychiatry, College of Physicians and Surgeons, Columbia University (HAP), New York, NY; NewYork-Presbyterian Hospital (HAP), New York, NY; University of Pittsburgh, School of Public Health (JMD), Pittsburgh, PA.

Funding Source: This research was funded by the National Institutes of Health, National Institute of Mental Health, Agency for Healthcare Research and Quality, National Institutes of Aging, Centers for Disease Control and Prevention, and the Pfizer Scholar’s Grant in Health Policy.

Author Disclosures: Dr Bao’s participation was supported by a career development award from the National Institute of Mental Health (NIMH) (K01 MH090087) and the Pfizer Scholar’s Grant in Health  Policy. Dr Ryan was supported by a career development award from the Agency for Healthcare Research and Quality (AHRQ) (K01 HS018546). Dr Pincus has received grants from NIMH, the National  Institute on Drug Abuse, the National Institute on Alcoholism and Alcohol Abuse, Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment/Center for Mental Health Services, The Robert Wood Johnson Foundation, The John A. Hartford Foundation, The Heinz Endowments, Atlantic Philanthropies, the Centers for Disease Control and Prevention,  National Center for Research Resources/National Center for Advancing Translational Sciences, UPMC Health Plan (Community Care Behavioral Health), The Highmark Foundation, Staunton Farm  Foundation, FISA Foundation, The Eden Hall Foundation, Centers for Medicare & Medicaid Services, AHRQ, the governments of Australia, Canada, England, Germany, Japan, Ireland, The  Netherlands, New Zealand, Norway, Scotland, and Taiwan, the New York State Health Foundation, the Graham Boeckh Foundation, the Administration on Aging, and the National Institute on Nursing Research. He has been a consultant or on an Advisory Board for the National Committee on Quality Assurance (travel only), the National Quality Forum (travel only), Medicare Policy Advisory Committee/US Congress, Veterans Health Administration, Albert Einstein College of Medicine, Tufts University, University of Michigan, Rutgers University, Mathematica Policy Research, Manila Consulting, Commonwealth  Fund, and Johnson & Johnson. He has received royalties for publications (none of which involved specific products) from American Psychiatric Press, Current Opinion in  Psychiatry/Lippincott, and William and Wilkins. He has been paid for presentations (eg, Grand Rounds) by New York University and Ohio State University, and is a board member of the American  Society for Clinical Psychopharmacology (no compensation) and a member of the Council on Psychiatric Services and Financing, American Psychiatric Association (no compensation). Mr Shao was supported by a grant from NIMH (K01 MH090087). Dr Pincus was supported by the Irving Institute for Clinical and Translational Research at Columbia University (UL1 RR024156) from the National  Center for Research Resources, a component of the National Institutes of Health, and the Mental Health Center for Education and Research on Therapeutics at Rutgers, the State University of New  Jersey, subcontract to Columbia University, funded by AHRQ (5 U18 HS016097). Dr Donohue was supported by grants from AHRQ (R01HS017695), NIMH (P30 MH090333 and R34 MH082682), the National Institute on Aging (R01-1AG034056),  and the Centers for Disease Control and Prevention (1U48DP001918-01). Funding from the Pfizer Scholar’s Grant and the NIMH Advanced Research Center in Geriatric Mental Health at Weill Cornell Medical College supported purchase of the Medicare the Chronic Condition Data Warehouse data.

Authorship Information: Concept and design (YB,  AMR, HAP, JMD); acquisition of data (YB); analysis and interpretation of data (YB, AMR, HS, HAP, JMD); drafting of the manuscript (YB, AMR, HS,  JMD); critical revision of the manuscript for important intellectual content (YB, AMR, HAP, JMD); statistical analysis (YB, HS); obtaining funding (YB); and supervision (YB, HAP).

Address correspondence to: Yuhua Bao, PhD, 402 E 67th St, New York, NY 10065. E-mail: yub2003@med.cornell.edu.
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