Cluster Analysis of Care Pathways in Adults with Major Depressive Disorder with Acute Suicidal Ideation or Behavior in the USA

Abstract

Background and objective: Suicidal ideation or behavior are core symptoms of major depressive disorder (MDD). This study aimed to understand heterogeneity among patients with MDD and acute suicidal ideation or behavior.

Methods: Adults with a diagnosis of MDD on the same day or 6 months before a claim for suicidal ideation or behavior (index date) were identified in the MarketScan^® Databases (10/01/2014-04/30/2019). A mathematical algorithm was used to cluster patients on characteristics of care measured pre-index. Patient care pathways were described by cluster during the 12-month pre-index period and up to 12 months post-index.

Results: Among 38,876 patients with MDD and acute suicidal ideation or behavior, three clusters were identified. Across clusters, pre-index exposure to mental healthcare was revealed as a key differentiator: Cluster 1 (N = 16,025) was least exposed, Cluster 2 (N = 5640) moderately exposed, and Cluster 3 (N = 17,211) most exposed. Patients whose MDD diagnosis was first observed during their index event comprised 86.0% and 72.8% of Clusters 1 and 2, respectively; in Cluster 3, all patients had an MDD diagnosis pre-index. Within 30 days post-index, in Clusters 1, 2, and 3, respectively, 79.3%, 85.2%, and 88.2% used mental health services, including outpatient visits for MDD. Within 12 months post-index, 61.5%, 91.5%, and 84.6% had one or more antidepressant claim, respectively. Per-patient index event costs averaged $5614, $6645, and $5853, respectively.

Conclusions: Patients with MDD and acute suicidal ideation or behavior least exposed to the healthcare system pre-index similarly received the least care post-index. An opportunity exists to optimize treatment and follow-up with mental health services.

Fig. 1

Timing of major depressive disorder (MDD) diagnosis (before or during suicide-related event) among patients with major depressive disorder with acute suicidal ideation or behavior (MDSI). SIB suicidal ideation or behavior. ^aBased on claims over the entire study period prior to the SIB (index) event and not restricted to claims in the 12-month pre-index period

Fig. 2

Proportion of patients with major depressive disorder with acute suicidal ideation or behavior (MDSI) and a visit 30 days before and after suicide-related event for a any specialized mental health visit, b outpatient visit for major depressive disorder (MDD), c specialist, d psychotherapy, and e mental health evaluation. ^aAny specialized mental health visit includes outpatient care for MDD, specialist visits, psychotherapy visits, and mental health evaluations. ^bOutpatient visit for MDD was identified based on outpatient claims with an MDD diagnosis. ^cSpecialist visits were identified based on claims with a provider type, place of service, or revenue code for the following: inpatient psychiatric care/facility, intensive outpatient psychiatric program, intensive psychiatric care, mental health facility, psychiatric clinic, psychiatric facility partial hospitalization, psychiatric nurse, psychiatric residential treatment center, psychiatrist, or psychologist. ^dPsychotherapy visits were identified among all patients based on claims with the corresponding procedure codes. ^eMental health evaluations (i.e., psychiatric diagnostic evaluations and psychological and neuropsychological assessment and testing) were identified among all patients (not only patients with a specialist visit) based on claims with the corresponding procedure codes

Fig. 3

Proportion of patients with major depressive disorder with acute suicidal ideation or behavior (MDSI) and a visit during pre-index and post-index periods for a any specialized mental health visit, b outpatient visit for major depressive disorder (MDD), c specialist, d psychotherapy, and e mental health evaluation. PC predominantly involved in primary mental healthcare. ^aPre-index period is the 12-month period pre-index event. The mean duration of post-index period is 8.3 months for the overall population, 8.4 months for cluster 1, 8.5 months for clusters 2, and 8.2 months for cluster 3. ^bAny specialized mental health visit includes outpatient care for MDD, specialist visits, psychotherapy visits, and mental health evaluations. ^cOutpatient visit for MDD was characterized as follows: PC if ≥ 50% of outpatient claims with an MDD diagnosis were with specialists, or PC if <50% of outpatient claims with an MDD diagnosis were with specialists. ^dSpecialist visits were identified based on claims with a provider type, place of service, or revenue code for the following: inpatient psychiatric care/facility, intensive outpatient psychiatric program, intensive psychiatric care, mental health facility, psychiatric clinic, psychiatric facility partial hospitalization, psychiatric nurse, psychiatric residential treatment center, psychiatrist, or psychologist. ^ePsychotherapy visits were identified among all patients based on claims with the corresponding procedure codes. ^fMental health evaluations (i.e., psychiatric diagnostic evaluations and psychological and neuropsychological assessment and testing) were identified among all patients (not only patients with a specialist visit) based on claims with the corresponding procedure codes

Fig. 4

Proportion of patients with major depressive disorder with acute suicidal ideation or behavior (MDSI) using antidepressant therapy during pre- and post-index periods. AD aug antidepressant augmentation therapy, AD mono antidepressant monotherapy. ^aAntidepressant augmentation therapy was defined as an overlapping coverage for ≥ 60 consecutive days with no gaps > 7 days of either ≥2 antidepressant agents, or ≥ 1 augmentation agent and ≥1 antidepressant agent. Antidepressant monotherapy was defined as patients with ≥ 1 claim for an antidepressant agent who did not meet the criteria for antidepressant augmentation therapy. ^bPre-index period is the 12-month period pre-index event. The mean duration of post-index period is 8.3 months for the overall population, 8.4 months for cluster 1, 8.5 months for cluster 2, and 8.2 months for cluster 3

Fig. 5

Distribution of care setting at index event and mean total healthcare costs, by care setting among patients with major depressive disorder with acute suicidal ideation or behavior (MDSI) [N = 38,876]. ^aTotal healthcare costs were reported in 2019 USD from the private payer’s perspective and included medical and pharmacy costs. ^bAmong patients with an inpatient place of service, the index event was defined as the duration of the inpatient stay. Among patients with an emergency room or outpatient visit, the index event was defined as the date of the visit. ^cCosts during the 12-month pre-index period were reported per-patient-per-month, and excluded costs associated with the index event. ^dAmong patients with an emergency room or outpatient place of service for the index event, costs represent total healthcare costs on the day of the visit. Among patients with an inpatient place of service for the index event, costs represent total healthcare costs associated with the admission. ^eCosts during the post-index period were reported per-patient per-month and excluded costs associated with the index event

Fig. 6

Mean total healthcare costs, by cluster among patients with major depressive disorder with acute suicidal ideation or behavior (MDSI). ^aTotal healthcare costs were reported in 2019 USD from the private payer’s perspective and included medical and pharmacy costs. ^bCosts during the 12-month pre-index period were reported per-patient per-month, and excluded costs associated with the index event. ^cAmong patients with an emergency room or outpatient place of service for the index event, costs represent total healthcare costs on the day of the visit. Among patients with an inpatient place of service for the index event, costs represent total healthcare costs associated with the admission. ^dCosts during the post-index period were reported per-patient per-month and excluded costs associated with the index event. The mean duration of pre-index period is 8.3 months for the overall population, 8.4 months for cluster 1, 8.5 months for cluster 2, and 8.2 months for cluster 3