with low family income as compared with those with middle and high income.38 Comorbid substance use, use of older gen- eration antidepressants, and living in lower in- come neighborhoods is associated with lower rates of adherence.41 Being treated by a non-psychiatric specialist as opposed to a primary care physician or psy- chiatrist is associated with higher odds of nonad- herence.42 Younger patient age is associated with greater rates of nonadherence.41 Conversely, receiving mental health specialty care in addition to being prescribed antidepres- sants is associated with higher rates of adher- ence: Patients are significantly more likely to con- tinue antidepressant treatment past 30 days if they receive psychotherapy.41 Receipt of mental health specialty care in addition to antidepressants is strongly associ- ated with adherence to an antidepressant regi- men.40,41 improvement strategies may improve rates of adherence to antidepres- sants: Improving provider-patient communication can have a positive impact on rates of adher- ence to antidepressants. Specifically, three key messages increase the odds of being adherent to antidepressant treatment. These consist of talking with patients about expectations with re- spect to change in mood and potential side ef- fects, and letting patients know what to do if they have questions about the medication.43 Implementing a telephone care management program for outpatients prescribed antidepres- sants by primary care physicians can help im- prove adherence rates.44 However, a more recent study revealed that this same type of model did not improve adher- ence rates over usual care for patients pre- scribed antidepressants by psychiatrists.45 Implementing a telemedicine model for pri- mary care clinics that lack on-site psychiatrists can improve adherence rates, especially in rural communities with limited access to psychia- trists.46
Treat ADHD as a chronic condition, Recommend stimulant medication and/or behavior therapy, Evaluate original diagnosis, adherence to treatment plan, and presence of coexist- ing conditions, Follow up with child and family periodically to assess effects of treatment and ad- verse reactions to medication. (AAP ADHD guidelines). Adherence to these guidelines among pediatri- cians and family physicians was examined in a 2004 study and revealed that only 53% reported following the guideline regarding periodic follow- up to assess effects of treatment and adverse reactions. The study also found that family physi- cians (67.5%) reported significantly more fre- quent follow up compared with pediatricians (41.6%).52 Relatively few studies have examined factors associated with suboptimal follow up care for chil- dren prescribed ADHD medications. One study examined factors associated with overall follow- up care for children identified with ADHD, whether or not they were prescribed medication, and found that: Follow up visits with primary care provid- ers were more common with those physi- cians that completed a fellowship that in- cluded mental health training Children receiving Medicaid were more likely to see specialists after being diag- nosed with ADHD American families were more likely to see a specialist after their child was diagnosed with ADHD, especially if their child was prescribed medication (Gardner et al, 2004) Monastra (2005) surveyed families of 856 chil- dren with ADHD on the reasons that they post- poned or discontinued the use of ADHD treat- ment for their child.53 The most common reasons included: Fear of medication side effects, Lack of information about ADHD, Distrust in the brief assessment process that their child received for diagnosis, Development of side effects such as in- somnia or loss of appetite on medications. Building off of these findings, some ways to im- prove rates of follow up care for children pre- scribed ADHD medication could be: Provide education, both verbal and writ- ten, to parents or caregivers on ADHD, treatment options, and importance of fol- low up Address concerns of parents and children on ADHD medications including their side effects, and what to do if these arise Provide training on the AAP ADHD clinical guidelines to pediatricians and family phy- sicians
Statistical Summary— Comparison to 2007 Rates: Nat’l Nat’l Mcaid 75th Mcaid Pctile Mean MA Comm Mean Plan’s 2005 Rate PCCP(A) * * * * O * * * * • O O * O O O O NHP(A) NH(A) FCHP(A) BMCHP(A) 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 92.5% Nat'l Mcaid Mean: 83.3% MassHealth Weighted Mean: 87.9% Nat'l Mcaid 75th Pctile: 89.3% MA Commercial Mean: 90.7% MassHealth Median: 90.1% MassHealth Plan Rates 2007 Num Den Rate * LCL UCL 2005 Num Den Rate * LCL UCL PCCP (A) 2,513 15,692 84.0% 83.4% 84.6% PCCP (A) 4,673 15,607 70.1% 69.3% 70.8% NHP (A) 535 6,504 91.8% 91.1% 92.4% NHP (A) 498 6,113 91.9% 91.2% 92.5% NH (A) 557 4,652 88.0% 87.1% 89.0% NH (A) 310 3,059 89.9% 88.8% 91.0% FCHP (A) 48 487 90.1% 87.4% 92.9% FCHP (A) 43 440 90.2% 87.3% 93.1% BMCHP (A) 948 10,656 91.1% 90.6% 91.6% BMCHP (A) 731 8,191 91.1% 90.5% 91.7% * Reported percentages are inverted rates (i.e., 1-(numerator/denominator)).