Some patients stop taking depression drugs during Medicare coverage gap

Washington About 12% of Medicare patients diagnosed with depression who exhaust their initial Medicare prescription drug coverage will choose to go without drug therapy instead of paying the full cost of the medicine.

A study published in the July issue of Archives of General Psychiatry reviewed how Medicare beneficiaries diagnosed with major depression respond once their spending on prescribed drugs causes them to reach the Part D coverage gap. Researchers used Medicare claims data from 2007, when Part D beneficiaries reached the gap after $2,400 of total spending on prescriptions. Catastrophic coverage that year kicked in when total out-of-pocket spending hit $3,850.

Medicare patients had very limited drug coverage before the Part D program launched in 2006. The coverage gap, also known as the “doughnut hole,” has been called problematic by patients and physicians. The 2010 health system reform law will close the gap gradually, with the hole disappearing in 2020.

After reaching the initial coverage limit in 2007, patients without supplemental insurance were left with a choice of paying the whole cost of the drug, splitting pills or waiting for the initial coverage to reset at the end of the year, said Yuting Zhang, PhD, the lead author of the study and a professor of health and economics at the University of Pittsburgh. Some patients also sought less-costly alternatives by switching to generic drugs.

“If patients discontinue their appropriate medication therapy abruptly, they could be placing themselves at risk for medication withdrawal effects and for relapse or recurrence,” the authors said. “If they do not notice any effects, they might decide not to resume taking antidepressants.”

The reduction pattern in drug use seen for patients on antidepressants was similar for patients taking heart failure drugs and anti-diabetic medicines. However, more patients taking brand-name antidepressants went without their medicine than did beneficiaries using generic drugs. More than three-quarters of patients who stopped their treatments had been using brand-name antidepressants.

The costs of drugs to patients falling in the coverage gap often are unaffordable, said Brent Forester, MD, director of the geriatric mood disorders research program at McLean Hospital in Belmont, Mass. Dr. Forester also is Harvard Medical School’s psychiatry clerkship director. He has heard from a number of Medicare patients who say they decided to stop taking their medications or cut their household budgets while struggling to afford drugs.

“I have tried to switch patients to generics if they exist, but sometimes the generic isn’t as effective,” he said.

The costs of generic drugs are so much lower that physicians should consider prescribing them to patients well before the coverage gap, Dr. Forester said. Psychotherapy also can be quite effective in addition to, or sometimes in lieu of, medication.

Discontinuing antidepressants did not lead to higher rates of hospitalizations or other medical spending, according to the study. However, the authors said this was because the amount of time patients generally spent in the coverage gap was shorter than the period in which they had initial coverage.