Suicidality Is Associated With Medication Access Problems in Publicly Insured Psychiatric Patients

Background: Beginning January 1, 2006, the Medicare Part D prescription drug benefit shifted drug coverage from Medicaid to the new Medicare Part D program for patients who were eligible for both Medicare and Medicaid benefits ("dual-eligibles"). These patients were randomly assigned to a private Part D plan and came under specific formulary and utilization management procedures of the plan in which they were enrolled.

Objective: To examine the relationship between physician-reported medication switches, discontinuations, and other access problems and suicidal ideation or behavior among "dual-eligible" psychiatric patients.

Method: Data were collected in 3 cross-sectional cycles in 2006 (January-April, May-August, and September-December) as part of the National Study of Medicaid and Medicare Psychopharmacologic Treatment Access and Continuity using through-the-mail, practice-based survey research methods. Data from the third cycle, representing all events since January 1, 2006, were used for these analyses. A national sample of psychiatrists randomly selected from the AMA Masterfile provided clinically detailed data on 1 systematically selected, dual-eligible psychiatric patient (N = 908). Propensity score analyses adjusted for patient sociodemographics, treatment setting, diagnoses, and psychiatric symptom severity.

Results: Patients who experienced medication switches, discontinuations, and other access problems had 3 times the rate of suicidal ideation or behavior compared with patients with no access problems (22.0% vs 7.4%, P < .0001). Mean odds ratios and excess probabilities were highest for patients who were clinically stable but were required to switch medications (31.8%; mean OR = 4.87, mean P = 8.92-5, excess probability = 0.21). Patients who experienced discontinuations (26.4%; mean OR = 2.13, mean P = 2.12-2, excess probability = 0.12), other access problems (18.7%; mean OR = 3.01, mean P = 1.03-5, excess probability = 0.15), and multiple access problems (22.3%; mean OR = 2.88, mean P = 4.10-5, excess probability = 0.14) also had significantly increased suicidal ideation or behavior.

Conclusion: Increased occurrences of suicidal ideation or behavior appear to be associated with disruptions in patient medication access and continuity. Clinicians need to be aware of the possibility of increased suicidality when, for administrative reasons, a clinically stable patient’s medication regimen is altered. Dual-eligible psychiatric patients represent a highly vulnerable group with a substantial burden of illness; these findings underscore the need to provide special protections for this population.

J Clin Psychiatry 2010;71(12):1657-1663

Submitted: April 14, 2010; accepted September 13, 2010(doi:10.4088/JCP.10m06177gre).

Corresponding author: Eve K. Mościcki, ScD, MPH, 1000 Wilson Blvd, Ste 1825, Arlington, VA 22209 ([email protected]).