Antidepressants 'Fall' Through Doughnut Hole

July 5, 2012— -- Depressed Medicare beneficiaries in the so-called coverage doughnut hole were more likely to cut back on their antidepressants than those who had full insurance coverage, a study has found.

Seniors taking heart failure drugs and diabetes drugs also were just as likely to reduce their monthly prescriptions while in the doughnut hole, Yuting Zhang, PhD, of the University of Pittsburgh, and colleagues wrote in the July issue of the Archives of General Psychiatry. Those results mirror an earlier study on the doughnut hole's effect on seniors' adherence to cardiovascular drugs.

The doughnut hole is the the coverage gap in Medicare where beneficiaries must pay the full cost of drugs until they meet a certain level, at which point Medicare coverage kicks back in. In 2012, most Medicare Part D enrollees reach the doughnut hole after they spend $2,930 on drug copays and deductibles; they then have to pay 100 percent of costs until they spend $4,700.

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Depression affects 13 percent of Medicare beneficiaries, the authors noted. Treating late-life depression with antidepressants has been shown to reduce episodes of major depression, and Medicare Part D covers depression drugs.

However, adherence to recommended drugs can get lost in the doughnut hole, the researchers found.

Zhang and colleagues used data from a random 5 percent sample of fee-for-service Medicare beneficiaries who were enrolled in Part D plans in 2007. From that data sample, researchers identified seniors who had been diagnosed with depression and excluded those with bipolar disorder or schizophrenia.

Researchers then compared drug adherence (based on medication use, mean number of prescriptions filled per month, and monthly pharmacy spending) in seniors with full Medicare drug coverage and in seniors who were footing their entire drug bill because they were in the doughnut hole.

Having a gap in drug coverage was associated with a significant reduction in all measures of use among those with no coverage in the doughnut hole. The doughnut hole group reduced the number of monthly prescriptions by 12.1 percent compared with a group with full Part D coverage. Most of that reduction was for brand-name antidepressants, which are more expensive than their generic counterparts.

The average Medicare patient with depression also has at least four other coexisting conditions, such as hypertension, heart failure, and diabetes, and the researchers found adherence to drugs for those conditions also was affected by being in the doughnut hole. Patients in the doughnut hole reduced their monthly use of heart failure drugs by 12.9 percent and anti-diabetics by 13.4 percent, relative to the group with full coverage.

That reduction in drug adherence did not, however, drive more seniors into the doctor's office or the hospital as might be expected, the researchers found.

Still, when seniors reduce their medication suddenly, it can have harmful effects, they said.

"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 study authors wrote. "If they do not notice any effects, they might decide not to resume taking antidepressants. Thus, a gap in drug coverage could place older adults in harm's way, as a result of disruptions in appropriate maintenance antidepressant pharmacotherapy."

The Affordable Care Act (ACA) phases out the doughnut hole year by year, and eliminates the gap completely starting in 2020. This year, seniors are receiving rebates to cover 50 percent of their costs of brand-name drugs while in the doughnut hole.

Even with a rebate, that could be a lot of out-of-pocket money for a large number of seniors.

"Facing such high out-of-pocket cost in this period could pose potential harm for beneficiaries, especially those with mental disorders," the study authors concluded. "Our findings reinforce the necessity of evaluating the unique benefit design of Medicare Part D to create the best approach to cover the essential medications for beneficiaries whose total drug spending exceeds the coverage gap threshold."