Factors Associated with Adding Adjunctive Psychotherapy for the Treatment of Major Depressive Disorder (MDD)

Tanya Hughes¹, Gwen Zeno¹, Emily Wiggins², Xiaoyun Yang², Joshua N. Liberman², Charles Ruetsch²

¹Orexo US, Inc, ²Health Analytics, LLC

A summary of our AMCP bronze ribbon acclaimed poster, presented at the AMCP Nexus 2022 conference (October 11-,20222 – October 14, 2022).

Study Background

To measure factors predictive of adding adjunctive psychotherapy among individuals with MDD who recently initiated pharmacotherapy.

Study Objective

To measure factors predictive of adding adjunctive psychotherapy among individuals with MDD who recently initiated pharmacotherapy.

Methodology

Study Design

This was a retrospective cohort study of individuals who initiated pharmacotherapy following a diagnosis of MDD.

Study Periods

• Case finding period: January 1, 2016 – February 28, 2019
• Index date was defined as the initiation of eligible antidepressant pharmacotherapy.
• Baseline period: 12 months prior to the index date.
• Follow-up period: 24 months following the index date.

Identification and Selection of Study Participants

Eligible participants were identified using a commercially-available open medical and pharmacy insurance claims database, licensed from Clarivate Real-World Data.

To be eligible for inclusion, an individual had to meet each of the following criteria:

• 18-55 years old age at the beginning of baseline.
• Diagnosed with MDD, defined by two or more outpatient claims for services related to MDD separated by at least 30 days or by a single inpatient hospitalization claim with an MDD code in the primary position.
• Initiation of eligible antidepressant therapy (SSRIs, SNRIs, bupropion, alpha-2 receptor antagonists, MAOIs, serotonin modulators, tricyclics, or tetracyclics) on or after the initial MDD diagnosis date.
• At least one medical or pharmacy claim in each 3-month period from the beginning of baseline through the end of follow up.
• Diagnosis of psychosis, bipolar disorder, schizophrenia, schizoaffective disorder or MDD with psychotic features (defined by 2+ outpatient claims, separated by 30 days) any time during the study period.

Individuals were stratified into two cohorts. The Adjunctive Psychotherapy cohort included individuals who added psychotherapy in the 24-month follow-up period. The Pharmacotherapy Only cohort included individuals who did not add psychotherapy in the follow-up period.

Covariates

The covariates in this study included demographics, comorbidities, baseline healthcare utilization, index antidepressant medication class, prescriber specialty, insurance, and region of residence.

Analysis

Chi-square tests of independence, with significance set at p<0.05, were performed to examine the relation between covariates and cohort. Adjusted odds ratios and 95% confidence intervals (CIs) were derived from logistic regression analysis (Adjunctive Psychotherapy = 1; Pharmacotherapy Only = 0). Hosmer and Lemeshow Goodness-of-Fit Test with p <0.05 was used to determine the fit of the model.

Results

A total of 146,086 individuals were deemed eligible and 19.8% added adjunctive psychotherapy (Adjunctive Psychotherapy cohort n=28,937), while 80.2% treated with pharmacotherapy only (Pharmacotherapy Only cohort n=117,149). Adjunctive Psychotherapy cohort was younger (40.3 vs. 42.4 years), more likely insured by Medicaid (59.5% vs 51.9%), and less likely insured commercially (34.8% vs. 39.9%), compared to the Pharmacotherapy Only cohort (all ps<0.05). The Adjunctive Psychotherapy cohort had a modestly higher Charlson Comorbidity Index score (1.17 vs 1.12) and had consistently higher rates of psychiatric comorbidities, including anxiety (excluding GAD) (49.6% vs 34.2%), substance use and addiction disorders (37.2% vs 28.6%), GAD (31.1% vs 14.2%), sleep-wake disorders (30.3% vs. 24.8%), and PTSD (16.2% vs. 5.0%) (all ps<0.05).

The factors with the strongest association with initiating adjunctive psychotherapy were diagnosis of generalized anxiety disorder (OR: 2.27); alcohol use disorder (OR: 1.72); diagnosis of anxiety (excl. GAD) (OR: 1.54), baseline psychiatry visit (OR: 1.37), psychiatrist associated with index antidepressant claim (OR: 1.30), and younger patient age with a nearly linear decline across age groups until 46 years. Factors associated with lower likelihood of adding psychotherapy included Medicare (OR: 0.84), primary care visits (OR: 0.93), and higher comorbidity burden measured by CCI score (OR: 0.98).

In the baseline period, the Adjunctive Psychotherapy cohort had higher rates of hospital admission (30.3% vs. 25.2%), ED visit (54.0% vs. 47.3%), psychiatry visit (34.4% vs 22.7%), other outpatient visits (76.3% vs 71.8%), and prescription medication use (40.5 fills PPPY vs. 27.2) (all ps<0.05). In the baseline period, the Adjunctive Psychotherapy cohort had a modestly lower rate of PCP visits (86.3% vs. 87.0%; p<0.05).

Summary

Adjunctive psychotherapy is most strongly associated with being under the care of a psychiatrist, with younger ages, and with the presence of psychiatric comorbidities. Identifying factors associated with adding adjunctive psychotherapy offers opportunities to identify individuals who may benefit from psychotherapy and potentially, from digital therapeutics and other alternative treatment approaches. Variables available in medical and pharmacy claims datasets may effectively predict individuals who will add psychotherapy. Future research can assist in determining what types of alternative care models that these individuals may be open to.

Limitations

Clarivate does not include continuous eligibility. The study required the presence of claims for healthcare services or pharmacy during each quarter of the measurement period as a proxy for eligibility. Initiating psychotherapy was a central outcome but is not directly measurable in claims data. The study used a paid claim for a psychotherapy visit as the closest proxy.

Citations

1. NIMH Health Statistics, Major Depression. https://www.nimh.nih.gov/health/statistics/major-depression.shtml (accessed 8/8/2022)
2. Gauthier, G., Guérin, A., Zhdanava, M., Jacobson, W., Nomikos, G., Merikle, E., François, C., & Perez, V. (2017). Treatment patterns, healthcare resource utilization, and costs following first-line antidepressant treatment in major depressive disorder: a retrospective US claims database analysis. BMC psychiatry, 17(1), 222. https://doi.org/10.1186/s12888-017-1385-0
3. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
4. Mohr, D. C., Hart, S. L., Howard, I., Julian, L., Vella, L., Catledge, C., & Feldman, M. D. (2006). Barriers to psychotherapy among depressed and nondepressed primary care patients. Annals of Behavioral Medicine, 32(3), 254-258.