Atypical antipsychotic adherence is associated with lower inpatient utilization and cost in bipolar I disorder

Real-World Evidence of Aripiprazole Tablets with Sensor: Treatment Patterns and Impacts on Psychiatric Healthcare Resource Utilization

Purpose

Maintaining adherence to antipsychotic (AP) medication is often challenging. Aripiprazole tablets with sensor (AS) contain an ingestible event marker and communicate with wearable patches and a smartphone app to provide objective medication ingestion data. This study evaluated real-world treatment patterns of AS usage and its impact on psychiatric healthcare resource utilization (HCRU).

Patients and Methods

This retrospective, observational cohort study identified individuals who initiated AS between 1/1/2019 and 6/30/2020 with 3 months baseline and 6 months of follow-up data using a commercial medical and pharmacy claims database (Clarivate). Controls were propensity score-matched (4:1) to AS initiators based on age (±2 years), sex, diagnosis (major depressive disorder [MDD], schizophrenia, bipolar I disorder [BP-I], other), insurance, and baseline oral AP use (yes/no). Days of AP supply were evaluated using a general regression model. The frequency of psychiatric HCRU during follow-up was compared between groups using a zero-inflated regression model.

Results

Most AS initiators were diagnosed with MDD (61.2%) and were women (61.2%); mean age was 37.7 years (standard deviation: 14.1). Most AS initiators (53.1%) continued treatment for >60 days (mean days of supply = 77). After adjusting for covariates, AS initiators had 41% more days of AP supply during follow-up compared with controls (P <0.0001) and significantly lower adjusted odds ratios (ORs) for psychiatric outpatient visits (adjusted OR = 0.80; P <0.05), emergency department visits (adjusted OR = 0.11; P <0.05), inpatient visits (adjusted OR = 0.42; P <0.05), and other medical services (adjusted OR = 0.25; P <0.05).

Conclusion

Participants who implemented AS had significantly more days of AP supply and fewer psychiatric care visits. These preliminary results suggest AS usage can help build regular medication-taking habits and holds promise for reducing psychiatric HCRU. Additional studies with larger sample sizes are warranted to inform clinical practice and coverage decisions.

Prepandemic psychotropic drug status in Portugal: a nationwide pharmacoepidemiological profile

The prescription of psychotropic drugs has been rising in Europe over the last decade. This study provides a comprehensive profile of prepandemic consumption patterns of antidepressant, antipsychotic, and anxiolytic drugs in Portugal considering full nationwide psychotropic drug prescription and dispensing records (2016-2019) against several criteria, including active ingredient, sociodemographics, medical specialty, and incurred costs. An increase of 29.6% and 34.7% in the consumption of antipsychotics and antidepressants between 2016 and 2019 is highlighted, accompanied by an increase of 37M Eur in total expenditure (> 20M Eur in public copay) for these classes of drugs. Disparities in sociodemographic and geographical incidence are identified. Amongst other pivotal results, 64% of psychotropic drug prescriptions are undertaken by general practitioners, while only 21% undertaken by neurological and psychiatric specialties. Nationwide patterns of psychotropic drug prescription further reveal notable trends and determinants, establishing a reference point for cross-regional studies and being currently assessed at a national level to establish psychosocial initiatives and guidelines for medical practice and training.

Unmet needs with antipsychotic treatment in schizophrenia and bipolar I disorder: patient perspectives from qualitative focus groups

BACKGROUND

Schizophrenia (SZ) and bipolar I disorder (BD-I) are chronic mental health disorders often treated with antipsychotic medications. This qualitative study sought to better understand disease burden and treatment experiences with oral antipsychotic medications in participants living with SZ or BD-I.

METHODS

Six 90-min focus groups were conducted with participants diagnosed with SZ or BD-I. Trained moderators facilitated discussions using a semistructured guide. Participants described symptoms, impacts of disease, and experiences with oral antipsychotic medications, whether favourable or unfavourable.

RESULTS

Among participants with SZ (n = 15; 3 groups, 5 per group), 53% were male and 33% were white, with a mean of 18.6 years since diagnosis. Of participants with BD-I (n = 24; 3 groups, 8 per group), 33% were male and 42% were white, with a mean of 13.0 years since diagnosis. Participants described numerous symptoms of their illnesses that impacted relationships and daily life, including effects on emotional health, the ability to work, and encounters with law enforcement. Previous antipsychotic medications were deemed effective by 14/15 (93%) participants with SZ and 12/16 (75%) participants with BD-I. Most participants with SZ (13/15; 87%) or with BD-I (16/24; 67%) reported discontinuing their antipsychotic medication at some point. Side effects were a common reason for discontinuing or switching medications for participants with SZ (8/15; 53%) and for those with BD-I (11/24; 46%). The most common side effects reported in both cohorts were weight gain, drowsiness, sexual problems, and neurologic symptoms. Side effects negatively affected quality of life, leading to serious health problems and issues with self-esteem.

CONCLUSIONS

People living with SZ or BD-I cited a range of favourable and unfavourable experiences with oral antipsychotic medications. Most participants reported that their antipsychotics were effective at controlling their symptoms, but multiple side effects impacted their quality of life, caused additional serious health problems, and often led to discontinuation of or switching antipsychotics. Findings from this study contribute to a better understanding of patients' experiences with antipsychotics and highlight a need for new medications with favourable benefit/risk profiles.

Prevalence and impact of antipsychotic discontinuation among commercially-insured patients with bipolar disorder

BACKGROUND

Antipsychotic discontinuation is common among patients with bipolar disorder, especially when psychotic symptoms are remitted. This analysis describes the prevalence, predictors, and economic impact of antipsychotic discontinuation among patients with bipolar disorder.

METHODS

A retrospective, observational study was conducted using administrative claims data in the IBM MarketScan Commercial Database. Patients with ≥1 claim with a diagnosis for bipolar disorder (manic or mixed) and newly-initiating antipsychotic therapy between 1 January 2011 and 30 June 2016 were included. Baseline characteristics were assessed in the 12 months prior to the initiation. Outcomes were assessed during a 24-month follow-up. Discontinuation of antipsychotic therapy was utilized as a predictor of healthcare costs in models adjusted for baseline characteristics. Using limited set of variables in the claims database, predictors of discontinuation were also assessed.

RESULTS

A total of 18,259 commercially-insured patients were identified as initiators of antipsychotics. Common comorbidities among the cohorts included major depressive disorder and dyslipidemia. Discontinuation was very common among these patients (85%). Major depressive disorder, drug abuse, and other substance abuse/dependency were predictive of discontinuation. Controlling for differences in baseline characteristics, discontinuation was associated with 33% higher inpatient and emergency visit costs (p <.001) among those using these services, and 24% higher total healthcare costs (p <.001) for the overall cohort.

CONCLUSIONS

Most patients with bipolar mania or mixed states discontinue antipsychotic treatment in less than 2 years. Antipsychotic discontinuation contributes to excess healthcare costs. Future research focusing on the reasons for discontinuation and tailoring disease management based on comorbidities may inform adherence improvement initiatives.

Adherence and persistence to long-acting injectable dopamine receptor blocking agent therapy in the United States: A systematic review and meta-analysis of cohort studies

The purpose of this systematic review and meta-analysis was to assess adherence and persistence to long-acting injectable dopamine receptor blocking agents (LAI DRBAs) in published observational cohort studies conducted in the United States. Adherence rate (proportion of days covered ≥80%) and persistence rate (no gap in therapy ≥60 days) to LAI DRBAs were examined in 26 articles for qualitative review and 8 articles for quantitative review. There was significant variability in adherence and persistence rates to LAI DRBAs in the reported observational cohort studies. The mean adherence and persistence rates to LAI DRBAs in the included studies were 36% (8-66%) and 56% (32-80%), respectively. The use of LAI DRBAs showed cumulative benefit of achieving adherence 1.40 times higher compared to oral agents. The persistence rate was measured by number of patients having no more than 60 days gap in therapy at follow-up, and the cumulative benefit of being persistently on the therapy was 1.65 times higher among the LAI agents-exposed group compared to the oral agents-exposed group. The use of LAI DRBAs confers benefit in adherence and persistence compared to oral DRBA formulations.

Hospitalization risk among adults with bipolar I disorder treated with lurasidone versus other oral atypical antipsychotics: a retrospective analysis of Medicaid claims data

OBJECTIVE

To compare the risk of hospitalization for adult Medicaid beneficiaries with bipolar I disorder treated with lurasidone vs. other oral atypical antipsychotics (AAPs) as monotherapy.

METHODS

A retrospective cohort study of the IBM MarketScan Multi-State Medicaid Claims database identified adults with bipolar I disorder who initiated an AAP (index date) between 1 January 2014 and 30 June 2019. Patients were continuously enrolled 12 months pre- and 24 months post-index date. Each month during the post-index period was categorized as monotherapy with lurasidone, aripiprazole, olanzapine, quetiapine or risperidone, no/minimal treatment, or other. Marginal structural models were performed to estimate hospitalization risk and length of stay (LOS) (all-cause and bipolar I disorder-related) compared to lurasidone.

RESULTS

The analysis included 8262 adults. Compared to lurasidone, the adjusted odds ratios (aORs) of all-cause hospitalization were significantly higher for olanzapine (aOR = 1.60, 95% CI = 1.09-2.10) and quetiapine (aOR = 1.54, 95% CI = 1.18-1.89). The risk was significantly higher for bipolar I disorder-related hospitalization for quetiapine (aOR = 1.57, 95% CI = 1.10-2.04) and risperidone (aOR = 1.80, 95% CI = 1.04-2.56) compared to lurasidone. The bipolar I disorder-related LOS per 100 patient-months was more than twice as long for quetiapine (8.42 days) compared to lurasidone (3.97 days, p < .01).

CONCLUSIONS

Lurasidone-treated adult Medicaid patients with bipolar I disorder had significantly lower risk of all-cause hospitalization than those treated with olanzapine and quetiapine and lower risk of bipolar I disorder-related hospitalization than quetiapine and risperidone. Bipolar I disorder-related hospital LOS was significantly shorter for patients treated with lurasidone compared to quetiapine.

Hospitalization Risk for Adults with Bipolar I Disorder Treated with Oral Atypical Antipsychotics as Adjunctive Therapy with Mood Stabilizers: A Retrospective Analysis of Medicaid Claims Data

Background: Atypical antipsychotics (AAPs) with mood stabilizers are recommended as a first-line treatment for patients with bipolar disorder. No studies have compared the inpatient health care resource utilization for patients with bipolar disorder treated with lurasidone as adjunctive therapy with mood stabilizers compared with other oral AAPs. Objective: To compare the risk of hospitalization for adult Medicaid beneficiaries with bipolar I disorder when treated with lurasidone compared with other oral AAPs as adjunctive therapy with mood stabilizers. Methods: This retrospective cohort study used the MarketScan Research Databases Multi-State Medicaid Database (IBM, Armonk, NY) claims data to assess patients with bipolar I disorder between January 1, 2014, and June 30, 2019. Adult patients who initiated oral AAP treatment with mood stabilizers (index date) and who were continuously enrolled 12 months before (pre-index) and 24 months after (post-index) the index date were included. Treatment categories assigned by patient-month included lurasidone, aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone with mood stabilizers; no/minimal treatment; AAP monotherapy; and other. Marginal structural models were performed to estimate the all-cause and psychiatric hospitalization rates and hospital length of stay associated with each adjunctive AAP therapy by controlling for both time-invariant and time-varying confounders. Results: Adults with bipolar I disorder (N = 11,426; mean age = 39.4 years; female=73%) treated with an adjunctive oral AAP with mood stabilizers during the index month were categorized into lurasidone (12%), aripiprazole (17%), olanzapine (7%), quetiapine (32%), risperidone (11%), ziprasidone (7%), or other (15%) treatment groups. The adjusted odds of all-cause and psychiatric hospitalization were significantly higher for olanzapine (all causes: adjusted odds ratio [aOR] = 1.59; 95% CI, 1.13-2.25; psychiatric: aOR = 1.61, 95% CI, 1.12-2.32), quetiapine (all-causes: aOR = 1.27, 95% CI, 1.01-1.58; psychiatric: aOR = 1.28, 95% CI, 1.02-1.59), and ziprasidone (all-causes: aOR = 1.68, 95% CI, 1.05-2.66; psychiatric: aOR = 1.55, 95% CI, 1.02-2.35) compared with lurasidone with mood stabilizers. The adjusted odds of all-cause and psychiatric hospitalizations were numerically lower for lurasidone compared with aripiprazole. The all-cause hospital length of stay per 100 patient-months was significantly higher for olanzapine (20.3 days) and quetiapine (16.0 days) compared with lurasidone (12.2 days, both P values < 0.05). Conclusions: In a Medicaid population, adults with bipolar I disorder treated with lurasidone as adjunctive therapy with mood stabilizers had significantly lower all-cause and psychiatric hospitalization rates compared with olanzapine, quetiapine, and ziprasidone. Fewer hospitalizations may reduce the economic burden associated with bipolar disorder. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).

Real-World Patterns of Utilization and Costs Associated with Second-Generation Oral Antipsychotic Medication for the Treatment of Bipolar Disorder: A Literature Review

OBJECTIVE

Treatment with second-generation antipsychotics (SGAs) for bipolar disorder, including bipolar I disorder (BD-I), is common. This review evaluated real-world utilization patterns with oral SGAs in the United States (US) for bipolar disorder (and BD-I specifically when reported) and economic burden associated with these patterns.

METHODS

Structured, systematic searches of MEDLINE^®, EMBASE^®, and National Health Service Economic Evaluation Database identified primary research studies (published 2008-2018) describing real-world SGA use in adults with bipolar disorder/BD-I.

RESULTS

Among 769 studies screened, 39 met inclusion criteria. Most studies (72%) were analyses of commercial or Medicare/Medicaid claims databases. Patient-related (eg, demographic, comorbidities) and disease-related (eg, mania, psychosis) factors were associated with prescribed SGA. Suboptimal utilization patterns (ie, nonadherence, nonpersistence, treatment gaps, medication switching, and discontinuation) were common for patients treated with SGAs. Also common were SGAs prescribed with another psychotropic medication and SGA combination treatment (use of ≥2 SGAs concurrently). Suboptimal adherence and SGA combination treatment were both associated with increased health care resource use (HCRU); suboptimal adherence was associated with higher total direct medical and indirect costs.

LIMITATIONS

Different definitions for populations and concepts limited between-study comparisons. Focusing on SGAs limits contextualizing findings within the broader treatment landscape (eg, lithium, anticonvulsants). Given the nature of claims data, prescribing rationale (eg, acute episodes vs maintenance) and factors influencing observed utilization patterns could not be fully derived.

CONCLUSION

Despite increased use of SGAs to treat bipolar disorder over the last decade, reports of suboptimal utilization patterns of SGAs (eg, nonadherence, nonpersistence) were common as was combination treatment. Patterns of SGA use associated with additional HCRU and/or costs were suboptimal adherence and SGA combination treatment; economic consequences associated with other utilization patterns (eg, nonpersistence) were unclear. Strategies to improve SGA treatment continuity, particularly adherence, may improve clinical and economic outcomes among people living with bipolar disorder.

Predictors of 1-year rehospitalization in inpatients with bipolar I disorder treated with atypical antipsychotics

Bipolar disorder (BPD) is debilitating disorder, and patients can experience multiple relapses and subsequent hospitalizations. Since pharmacotherapy is the mainstay of treatment for patients with BPD, investigations on the effects of atypical antipsychotics (AAP) on reducing rehospitalization risk are crucial. The objective of study is to explore predictors of 1-year rehospitalization in patients with bipolar I disorder treated with AAP. A retrospective chart review on inpatients with bipolar I disorder was conducted. All participants were followed up for 1 year, and they were subdivided into three AAP treatment groups (olanzapine, risperidone, and quetiapine group). Kaplan-Meier survival analysis was implemented to detect time to rehospitalization due to any mood episodes within 1 year after discharge. Cox proportional regression model was adopted to find predictors of 1-year hospitalization in patients who experienced rehospitalization. One hundred thirty-eight participants were included in the study, and a 1-year rehospitalization rate was 18.1%. Time to rehospitalization did not differ between three AAP treatment groups. Predictors of rehospitalization due to any episode within 1 year were family history of depression and number of previous admission. Our findings can be conducive to understanding prognosis, and predicting rehospitalization risk in patients with BPD on AAP.

Adherence to neuroleptic treatment in psychiatric practices: A retrospective study of 55 practices with more than 5000 bipolar and schizophrenic patients in Germany

BACKGROUND

The aim of this study was to investigate the effect that treating physicians have on the compliance of their psychiatric (schizophrenia (SP) and bipolar disorder (BP)) patients.

METHODS

This retrospective study was based on data from the Disease Analyzer database (IQVIA). It included 2870 SP and 2327 BD patients who had received at least two neuroleptic prescriptions from 55 psychiatric practices between January 2016 and December 2018. The average proportion of days covered (PDC) per patient was calculated. Patients were considered adherent if their PDC was greater than or equal to 80%. Practice adherence was considered high if at least 70% of patients in the practice of interest were adherent.

RESULTS

The mean PDC was 59.8% (SD: 13.9%) in SP and 65.0% (SD: 11.5%) in BD patients. The share of patients with an optimal PDC value (≥80%) differed considerably between practices (between 28% and 92% for SP and between 33% and 92% for BP). The prevalence of practices with high adherence was lower for schizophrenia than for bipolar disorder (21.9% versus 45.5%).

CONCLUSION

Psychiatrists play an important role in the compliance of SP and BP patients treated with neuroleptics.