Association of Social Determinants of Health With Adherence to Second-generation Antipsychotics for People With Bipolar Disorders in a Medicaid Population

Med Care. 2022 Feb 1;60(2):106-112. doi: 10.1097/MLR.0000000000001670.


Background: About 7 million people, 2.8% of US adults, have bipolar disorder (BD). While second-generation antipsychotics (SGA) are indicated as acute and maintenance treatments for BD, therapeutic success requires medication adherence and reported nonadherence estimates to range as high as 60%. Identifying patient risk factors for nonadherence is important for reducing it.

Objective: The objective of this study was to quantify the associations of risk factors, including social determinants of health, with SGA nonadherence among patients with BD.

Methods: In this cross-sectional study of 2015-2017 MassHealth Medicaid data, we examined several definitions of adherence and used logistic regression to identify risk factors for nonadherence (medication possession ratio <0.8) among all adults aged 18-64 diagnosed with BD who could be followed for 12 months following SGA initiation.

Results: Among 5197 patients, the mean (±SD) age was 37.7 (±11.4) years, and 42.3% were men. Almost half (47.7%) of patients were nonadherent to SGAs when measured by medication possession ratio. The prevalence of nonadherence peaked at middle age for men and younger for women. Nonadherence was less common among Massachusetts' Department of Mental Health clients (odds ratio=0.60, 95% confidence limit: 0.48-0.74) and among those who used other psychotropic medications (odds ratios between 0.45 and 0.81); in contrast, increase in neighborhood socioeconomic stress was associated with increased odds of nonadherence.

Conclusions/implications: Adherence to SGA treatment is suboptimal among people with BD. Recognizing risk factors, including those related to social determinants of health, can help target interventions to improve adherence for people at high risk and has implications for adherence-based quality measures.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Antipsychotic Agents / administration & dosage
  • Antipsychotic Agents / therapeutic use*
  • Bipolar Disorder / drug therapy*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Insurance Claim Review
  • Male
  • Medicaid / statistics & numerical data
  • Medication Adherence / statistics & numerical data*
  • Middle Aged
  • Residence Characteristics
  • Social Determinants of Health / statistics & numerical data*
  • Socioeconomic Factors
  • United States
  • Young Adult


  • Antipsychotic Agents