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Examining Parental Medication Adherence as a Predictor of Child Medication Adherence in Pediatric Anxiety Disorders

Bushnell, Greta, A., PhD, MSPH*; Brookhart, M., Alan, PhD*; Gaynes, Bradley, N., MD, MPH; Compton, Scott, N., PhD; Dusetzina, Stacie, B., PhD§; Stürmer, Til, MD, PhD*

doi: 10.1097/MLR.0000000000000911
Original Articles

Background: Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line pharmacotherapy for pediatric anxiety disorders but adherence remains difficult to predict.

Objectives: To estimate SSRI adherence in children with anxiety disorders and determine if prior parental medication adherence is predictive of child high SSRI adherence.

Methods: We identified children (3–17 y) initiating SSRI treatment after an anxiety disorder diagnosis in a commercial claims database (2005–2014). We evaluated parent SSRI, statin, and antihypertensive adherence [6-mo proportion days covered (PDC), high adherence=PDC≥0.80] in the year before child SSRI initiation. We estimated risk differences (RD) of child high SSRI adherence (6-mo PDC) stratified by parent adherence and multivariable risk ratios using modified Poisson regression. We estimated change in c-statistic and risk reclassification when adding parent-level covariates with child-level covariates to predict child adherence.

Results: In 70,979 children with an anxiety disorder (59%=female, 14=median age), the mean 6-month SSRI PDC was 0.72, with variation by anxiety disorder. Overall 64% of children had high adherence if their parent had high SSRI adherence versus 53% of children with parents with low SSRI adherence (RD, 12%; multivariable risk ratios, 1.17; 95% confidence interval, 1.14–1.20). Findings were similar for parent statin (RD=10%) and antihypertensive adherence (RD=8%) and when stratified by child age and parent sex. There was minor improvement in risk reclassification and the c-statistic after adding parent adherence and parent-level covariates.

Conclusions: Parental medication adherence could help providers identify children at risk of nonadherence to inform the treatment decision, reduce unnecessary medication switches, and lead to broader effective interventions.

*Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health

Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham

§Department of Health Policy, School of Medicine, Vanderbilt University Medical Center, Nashville, TN

Present address: Greta A. Bushnell, PhD, MSPH, Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032.

Supported by the National Institute of Mental Health of the National Institutes of Health under Award Number F31MH107085 and, in part, under T32MH013043. The database infrastructure was funded by the Department of Epidemiology, UNC Gillings School of Global Public Health, the Cecil G. Sheps Center for Health Services Research, UNC, the CER Strategic Initiative of UNC’s Clinical Translational Science Award (UL1TR001111), and the UNC School of Medicine (Chapel Hill, NC).

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Presented as an abstract at the 33rd International Conference on Pharmacoepidemiology and Therapeutic Risk Management, August 29, 2017, Montreal, Canada.

G.A.B.: receives support from the National Institute of Mental Health, previously as a Ruth L. Kirschstein National Research Service Award (NRSA) Individual Predoctoral Fellow (F31MH107085) and currently under award number T32MH013043. She previously held a graduate research assistantship with GlaxoSmithKline and was the Merck fellow for the Center for Pharmacoepidemiology (both ended 12/2015). M.A.B.: receives investigator-initiated research funding from the National Institutes of Health and through contracts with the Agency for Healthcare Research and Quality’s DEcIDE program and the Patient Centered Outcomes Research Institute. Within the past 3 years, he has received research support from Amgen and AstraZeneca and has served as a scientific advisor for Amgen, Merck, GlaxoSmithKline, TargetPharma, RxAnte, and Genentech. He owns equity in NoviSci, LLC. S.N.C.: receives research support from the National Institute of Mental Health, NC GlaxoSmithKline Foundation, Mursion Inc. and has been a consultant for Shire, received honoraria from the Journal of Consulting and Clinical Psychology, Nordic Long-Term OCD Treatment Study Research Group, and The Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, and given expert testimony for Duke University. T.S.: receives investigator-initiated research funding from the National Institutes of Health (Principal Investigator, R01/56 AG023178 and R01 AG056479; Co-Investigator: R01 CA174453, R01 HL118255, R21-HD080214). He also receives salary support as Director of the Comparative Effectiveness Research Strategic Initiative, NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR001111) and as Director of the Center for Pharmacoepidemiology, Department of Epidemiology UNC Gillings School of Global Public Health (current members: GlaxoSmithKline, UCB BioSciences, Merck, Shire) and research support from pharmaceutical companies (Amgen, AstraZeneca) to the Department of Epidemiology, University of North Carolina at Chapel Hill. He does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, and Novo Nordisk. The remaining authors declare no conflict of interest.

Reprints: Greta A. Bushnell, PhD, MSPH, 722 West 168th Street, Room 720c, New York, NY 10032. E-mail:

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