Factors Associated with Continuity of Antidepressant Treatment Among Medicaid Covered Youth

Purpose: Continuity of care is a critical indicator of quality of care and key to effective antidepressant medication management in youth. Regular follow-up visits are essential not only to assess treatment response, make medication adjustments, and monitor adherence but also to educate the child and parent about the benefits of antidepressants, side effects, and potential time lag in treatment response. Many youths do not receive minimal standards for follow-up visits or duration of treatment—in a statewide Medicaid program more than half of youths discontinued antidepressants within three months of initiating therapy and nearly one third of youths had no follow-up visits. The aims of this study were: (1) to assess the quality of follow-up care; (2) to identify individual and contextual factors associated with adequate follow-up and; (3) to examine the relationship between follow-up visits and medication adherence. Methods: A retrospective longitudinal cohort analysis was conducted using Ohio Medicaid claims data supplemented with data from the Area Resource File, and state licensure boards. The study population included youths (aged 5-17 years) with “new episodes” of depression who initiated antidepressant treatment during a three year period and were continuously enrolled in Medicaid for one year (N= 1,650). Youths were followed for 6 months from the first prescription fill date to determine continuity of depression treatment. The two outcome measures---continuity of care and medication adherence---were derived from the Health Plan Employer Data and Information Set (HEDIS) quality indicators for follow-up and antidepressant management (> 3 outpatient visits in the 3 months after initiation of antidepressant therapy and continuation of antidepressant use at 3 and 6 months). Multivariate logistic regression analyses evaluated the association between demographic, clinical, and contextual factors and continuity of care. Results: Two-thirds of youth met the HEDIS optimum contact criteria of 3 outpatient mental health contacts during the first 3 months of treatment. Youths with > 3 prior outpatient mental health visits were significantly more likely to receive adequate follow-up care (OR = 2.64; 95% CI, 2.06-3.39, p<0.001) compared to those with less than 3 prior outpatient visits. The odds of receiving adequate follow-up were significantly reduced for adolescents (OR=0.58, 95% CI, .41-.80, p=.001) and disabled youths (OR=.60, 95% CI, .38-.94, p=.03). Youths who lived in rural areas were less likely to receive adequate follow-up compared to those living in metro areas (OR=.40, 95% CI, .22-.74, p=.004). Controlling for demographic, clinical and type of antidepressant treatment a one unit increase in follow up visits was associated with a 4% increase in medication adherence at six months (OR=1.04, 95% CI, 1.02-1.07, p=.001). Implications: Rates of follow-up for Medicaid youth are low and underscores the need for quality improvement initiatives. Adolescents, disabled youths, and those living in rural areas are more likely to receive poor follow-up. Youths who receive better follow-up are more likely to be adherent with antidepressants. Study findings highlight the importance of continuity of care and emphasize the need for social workers to deliver guidelines-concordant care to improve treatment outcomes, particularly among vulnerable subgroups.