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Articles   |    
Social Inequalities in Early Antidepressant Discontinuation
Aurélie Bocquier, M.S.; Sébastien Cortaredona, M.S.; Hélène Verdoux, M.D., Ph.D.; Ludovic Casanova, M.D., M.S.; Vincent Sciortino, M.D.; Stève Nauleau, M.S.; Pierre Verger, M.D., M.S.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300184
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Ms. Bocquier, Mr. Cortaredona, and Dr. Verger are with ORS PACA, Southeastern Health Regional Observatory, Marseille, France, and the Institut national de la santé et de la recherche médicale (INSERM), UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille (e-mail: aurelie.bocquier@inserm.fr). Prof. Verdoux is with the Department of Psychiatry, Bordeaux University, and INSERM, U657, Bordeaux. Dr. Casanova is with ORS PACA, Southeastern Health Regional Observatory, Marseille, and the Department of General Practice, Aix Marseille University, Marseille. Dr. Sciortino is with the Regional Bureau of Medical Services PACA-Corsica, National Health Insurance Fund for Salaried Workers, Marseille. Mr. Nauleau is with the Department of Studies and Observation, PACA Regional Health Agency, Marseille.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  This study aimed to test for social disparities in early discontinuation of antidepressant treatment and to explore associations with type of drug and composition of prescriber’s clientele.

Methods  The cohort was 14,518 Marseille residents (ages 18–64 years) covered by the National Health Insurance Fund who had a new episode of antidepressant treatment (specifically, no prescription claim in the six months before the index claim) prescribed by a private general practitioner in 2008 or 2009. Factors associated with early discontinuation (prescription filled or refilled fewer than four times in the six months after the index claim) were analyzed with multilevel models that were adjusted for patient morbidity and number of consultations with private general practitioners and psychiatrists. Sensitivity analyses were conducted with different definitions of new treatment and early discontinuation.

Results  Low income, type of antidepressant (tricyclics versus selective serotonin reuptake inhibitors), and prescribers’ clientele composition (specifically, a high proportion of socioeconomically disadvantaged patients) were independently associated with an increased risk of early antidepressant discontinuation. A significant interaction was found between low income and gender. Low-income patients were more likely than other patients to receive tricyclic antidepressants.

Conclusions  These results add further evidence of inequalities in care for major depression and suggest that women are at greater disadvantage than men. Educational programs for general practitioners should focus on the risks of antidepressant discontinuation among disadvantaged patients. Enhancing therapeutic education of low-income patients may improve their treatment adherence.

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Table 1Characteristics of a cohort of 14,518 individuals in Marseille and its drug treatment at study inclusion, by low-income health care coverage
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a CMUC, Couverture Maladie Universelle Complémentaire (Complementary Universal Health Insurance program), which covers persons with very low income

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b Comparison, by chi square test, between patients covered and not covered by CMUC

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c “Expensive chronic disease” status, for which treatment is completely free of charge

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d Selective serotonin reuptake inhibitors

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Table 2Distribution of a cohort of 14,518 individuals in Marseille, by prescriber and patient characteristics and low-income health care coverage
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a CMUC, Couverture Maladie Universelle Complémentaire (Complementary Universal Health Insurance program), which covers persons with very low income. All comparisons, by chi square test, between patients covered and not covered by CMUC were significant (p<.001).

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b “Expensive chronic disease” status, for which treatment is completely free of charge

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Table 3Factors associated with early discontinuation of antidepressant treatment for a cohort of 14,518 individuals in Marseillea
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a Results of unadjusted and multivariate multilevel logistic regression analyses. The analyses included 1,437 prescribers. Estimated odds ratios were corrected with the method of Zhang and Yu (39) to estimate relative risk (RR) and confidence intervals. The multivariate model was adjusted for all variables.

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b “Expensive chronic disease” status, for which treatment is completely free of charge

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c Selective serotonin reuptake inhibitors

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d CMUC, Couverture Maladie Universelle Complémentaire (Complementary Universal Health Insurance program), which covers persons with very low income

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Table 4Interprescriber variability in multilevel regression analyses for a cohort of 14,518 individuals, including 1,437 prescribers, in Marseille
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a Median odds ratio

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b Variation between each model and the previous one

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