Improving antipsychotic adherence among patients with schizophrenia: savings for states

The Relationship Between Level of Education, Cognitive Function and Medication Adherence in Patients with Schizophrenia

Purpose

Several studies have explored the relationship between level of education and medication adherence, as well as the relationship between level of education and cognitive function. However, there have been few studies on the relationships between level of education, cognitive function, and medication adherence. This study aimed to explore whether cognitive function has a mediating effect between level of education and medication adherence in patients with schizophrenia.

Patients and Methods

A total of 329 participants were included in this study. Cognitive function was assessed using the Brief Assessment of Cognition in Schizophrenia, and medication adherence using the Medication Adherence Questionnaire. The relationships between the clinical factors and cognitive function that contributed to medication adherence were tested through multivariable linear regression analysis. The mediating effect of medication adherence was tested using the bootstrapping approach with the PROCESS macro.

Results

Family history, insight and executive function were associated with medication adherence in individuals with schizophrenia, and executive function had a mediating effect between level of education and medication adherence.

Conclusion

Adopting specific education programs that promote cognitive development as well as actively intervening in executive function might be conducive to improve medication adherence in patients with schizophrenia.

Incremental Health Care Costs of Anxiety and Depression Among Medicare Beneficiaries With Cancer

PURPOSE

Mental health comorbidities are commonplace among patients with cancer and have been associated with adverse health outcomes and elevated health care costs. Given the rapidly evolving cancer care landscape, an updated understanding of the prevalence and costs of mental health conditions among patients with cancer is needed. This study assessed the incremental costs of anxiety and depression among Medicare beneficiaries with cancer.

METHODS

This retrospective cohort study used the SEER-Medicare database. Patients diagnosed with melanoma, breast, lung, prostate, or colorectal cancer between July 2013 and December 2017 were followed for at least 12 months and up to 36 months after cancer diagnosis. Patients were categorized on the basis of anxiety/depression (AD) diagnosis: (1) predating cancer, (2) onset after cancer, or (3) no AD. Multivariable regression was used to estimate differences in all-cause incremental costs (before v after cancer) between the three groups.

RESULTS

Of 230,626 patients, 10% had AD before their cancer diagnosis and 22% were diagnosed after cancer. In the first year after cancer diagnosis, average monthly health care costs were $5,750 in US dollars (USD) for patients with newly onset, $5,208 (USD) for patients with preexisting, and $3,919 (USD) for patients without a diagnosis of AD. The incremental cost of cancer was the greatest among patients with newly onset AD-$1,458 (USD) per month greater than those with no AD. Similar patterns were observed across cancer types and stages.

CONCLUSION

One in three Medicare beneficiaries with cancer in this study had a diagnosis of anxiety or depression. Newly onset AD is associated with an increase in health care costs of $17,496 (USD) per year. Screening and management of mental health conditions for patients with cancer should be part of coordinated oncology care.

An update on recently approved long-acting injectable second-generation antipsychotics: Knowns and unknowns regarding their use

There are now 9 available FDA-approved second-generation long-acting injectable antipsychotics including aripiprazole (3), olanzapine (1), paliperidone (3), and risperidone (2). These high-cost medications are commonly used with the goal of improving adherence and patient outcomes. With almost 2 decades of use, key aspects have been well studied, including population pharmacokinetics, CYP interactions and various clinical and economic outcomes. However, there are still unknowns with these medications. Issues including adherence, transition from oral antipsychotics, renal dosing, pharmacogenomics, and managing missed doses will be addressed in the context of 4 patient cases.

Impact of treatment-related discussions on healthcare resource use and costs among patients with severe mental illness

OBJECTIVE

Serious mental illnesses (SMIs), including schizophrenia, bipolar disorder, and major depressive disorder (MDD), are often treated with antipsychotic medications. Unfortunately, medication non-adherence is widespread and is associated with serious adverse outcomes. However, little real-world data are available describing adherence, compliance, or other medication-taking-related discussions between providers and patients. This study described these communications in ambulatory care.

METHODS

Commercially insured patients having acute (emergency or inpatient) behavioral health (BH) events were included by specific criteria: age 18-65 years; diagnoses of schizophrenia, bipolar disorder, or MDD; continuous health insurance coverage 6 months before to 12 months after the first claim (index) date during 01/01/2014‒12/31/2015; and prescribed antipsychotic medication. Medical charts were abstracted for ambulatory visits with a BH diagnosis through 12 months after the acute event, describing any treatment compliance discussions that occurred. BH-related healthcare utilization and costs were measured via insurance claims. Results were analyzed by observation of an antipsychotic medication taking-related (i.e. compliance or adherence) discussion at the initial abstracted visit.

RESULTS

Ninety patients were included: 62% female, mean age 41 years. Only 58% had antipsychotic compliance discussions during the first abstracted ambulatory visit. A total of 680 BH-related visits were abstracted for the 90 patients. Providers frequently discussed any psychotropic medication use (97% of all visits abstracted); however, discussion of compliance with BH talk therapies was less common (49% of visits among patients with a first visit antipsychotic discussion and 23% without, p < .001). Follow-up BH-related healthcare utilization and costs were not significantly different by cohort. Patients with ≥2 compliance discussions had a significantly lower risk of follow-up acute events, which are the costliest components of healthcare for SMI (p = .023).

CONCLUSION

Increasing the frequency of antipsychotic treatment-related adherence/compliance discussions may represent an opportunity to improve the quality of care for these vulnerable patients and reduce the overall economic burden associated with the treatment of SMI diagnosis.

A Program to Increase the Appropriate Use of Long-Acting Injectable Antipsychotic Medications in Community Settings

OBJECTIVE

The Multilevel Facilitation of Long-Acting Antipsychotic Medication Program (MAP) is a novel intervention to increase the appropriate use of long-acting injectable (LAI) antipsychotics in community mental health clinics. The authors investigated the feasibility of MAP, facilitators and barriers to use, and preliminary impact on LAI medication use.

METHODS

Two clinics in Texas and two in Ohio serving 750 and 617 individuals with schizophrenia receiving oral antipsychotics, respectively, were asked to change clinical procedures for 1 year by using either the not receiving optimum benefit (NOB) checklist or the checklist plus MAP. Providers used the NOB checklist to identify individuals who could benefit from switching to LAI antipsychotics. MAP clinics used the NOB checklist plus nonbranded academic detailing for providers and a shared-decision-making video and tool for consumers. Use of MAP components was tracked, and barriers and facilitators were collected quarterly. Antipsychotic prescription counts were provided by participating clinics.

RESULTS

Barriers to use of MAP included loss of local champions and administrators, difficulty with provider buy-in, limited availability of peer specialists, and a lack of infrastructural support to integrate MAP into clinic flow. Higher scores on the NOB checklist were associated with more provider LAI medication offers and greater patient acceptance of LAI antipsychotics. LAI medication use increased in clinics over time, but it is unclear whether this increase was due to MAP.

CONCLUSIONS

Changing MAP components to fit local procedures and to circumvent unique barriers could aid implementation. Further research should investigate the potential impact of MAP components on LAI medication use.

Impact of antipsychotic polypharmacy on nonadherence of oral antipsychotic drugs - A study based on blood sample analyses from 24,239 patients

Nonadherence to oral antipsychotic drugs is a major issue in clinical psychiatry giving rise to treatment failure. Further, polypharmacy is common in the treatment of psychotic disorders due to insufficient treatment effect during monotherapy. As a potential circuit problem, we hypothesized that antipsychotic polypharmacy is associated with increased risk of nonadherence. To investigate this, in terms of 'complete' nonadherence, the rates of undetectable serum drug concentrations during prescribing of doses used in psychotic disorders were compared during antipsychotic 'monotherapy' vs 'polypharmacy' treatment using therapeutic drug monitoring (TDM) data of 24,239 patients. A complete nonadherence patient was objectively defined as the detection of at least one event of undetectable serum concentration of a prescribed antipsychotic drug. The rate of complete nonadherence patients was compared between antipsychotic monotherapy and polypharmacy by multivariate logistic regression analyses. The overall rate of complete nonadherence in the population was 6.8% (n = 1,644; 95%CI: 6.5-7.1). Compared to monotherapy patients, the rate of nonadherence increased significantly with the number of co-prescribed antipsychotic drugs. After adjusting for sex (p = 0.091) and age (p < 0.001) as covariates, the rates of nonadherence vs monotherapy were 1.69-fold (95% CI: 1.48-1.92; p < 0.001) for two, 2.60-fold (95% CI: 1.88-3.59; p < 0.001) for three, and 3.54-fold (95% CI: 1.46-8.58; p = 0.005) for four or more co-prescribed antipsychotics, respectively. The present naturalistic study shows that antipsychotic polypharmacy significantly increases the rate of complete nonadherence, which is positively correlated with increasing number of concurrently used antipsychotic drugs. Thus, the intended clinical benefit of combining oral antipsychotic drugs may probably be reduced by increased nonadherence.

Simulated long-term outcomes of early use of long-acting injectable antipsychotics in early schizophrenia

AIM

Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach.

METHODS

A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP.

RESULTS

An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%).

CONCLUSIONS

While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

Temporal associations between medication adherence for patients with schizophrenia and opioid dependence: A 17-year Canadian Cohort Study

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained <0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

Comparisons of the risk of medication noncompliance and suicidal behavior among patients with depressive disorders using different monotherapy antidepressants in Taiwan: A nationwide population-based retrospective cohort study

BACKGROUND

The aim of this study was to assess the association between various classes of antidepressants and the risk of medication noncompliance as well as suicidal behavior among depressed patients.

METHODS

A retrospective cohort study was conducted utilizing two nationwide population-based datasets in Taiwan from 2010 to 2016. The outcome measures included the risk of medication noncompliance, attempted suicide, and completed suicide. Cox proportional hazards models with stratification of the propensity score deciles were performed.

RESULTS

A total of 447,411 new antidepressant users were identified. Compared to SSRIs, patients who received SARIs [adjusted hazard ratio (aHR) = 1.124, 95% confidence interval (CI) = 1.108-1.142], SNRIs (aHR = 1.049, 95% CI = 1.033-1.065), and other classes of antidepressants (aHR = 1.037, 95% CI = 1.024-1.051) were more likely to exhibit poor medication noncompliance. Patients who received SNRIs had a higher risk of attempted suicide (aHR = 1.294, 95% CI = 1.114-1.513), compared to SSRIs. However, patents in the TCAs group revealed the opposite result (aHR = 0.543, 95% CI = 0.387-0.762). Concerning the risk of completed suicide, this analysis detected no statistical significance across different types of antidepressants.

LIMITATIONS

Although the universal coverage of Taiwan's national health insurance program tends to minimize the risk of selection and recall bias, it is difficult to rule out medical surveillance bias by using claim data.

CONCLUSIONS

This study demonstrated that classes of antidepressants exert different degrees of impact on the risk of medication noncompliance and attempted suicide, but not completed suicide, among depressed patients.

Does knowledge of patient non-compliance change prescribing behavior in the real world? A claims-based analysis of patients with serious mental illness

Background

New digital technologies offer providers the promise of more accurately tracking patients’ medication adherence. It is unclear, however, whether access to such information will affect provider treatment decisions in the real world.

Methods

Using prescriber-reported information on patient non-compliance from health insurance claims data between 2008 and 2014, we examined whether prescribers’ knowledge of non-compliance was associated with different prescribing patterns for patients with serious mental illness (SMI). We examined patients who initiated an oral atypical antipsychotic, but were later objectively non-adherent to this treatment, defined as proportion of days covered (PDC) <0.8. We examined how a physician’s awareness of patient non-compliance (ICD-9 diagnosis code: V15.81) was correlated with the physician’s real-world treatment decisions for that patient. Treatment decisions studied included the share of patients who increased antipsychotic dose, augmented treatment, switched their antipsychotic, or used a long-acting injectable (LAI).

Results

Among the 286,249 patients with SMI who initiated an antipsychotic and had PDC <0.8, 4,033 (1.4%) had documented non-compliance. When prescribers documented non-compliance, patients were more likely to be switched to another antipsychotic (32.8% vs 24.7%, P<0.001), have their dose increased (24.4% vs 22.1%, P=0.004), or receive an LAI (0.09% vs 0.04%, P=0.008), but were less likely to have augmented therapy with another antipsychotic (1.1% vs 1.3%, P=0.035) than patients without documented non-compliance.

Conclusion

Among SMI patients with documented non-compliance, the frequency of dose, medication switches, and LAI use were higher and augmentation was lower compared to patients without documented non-compliance. Access to adherence information may help prescribers more rapidly switch ineffective medications as well as avoid unnecessary medication augmentation.

Classics in Chemical Neuroscience: Haloperidol

The discovery of haloperidol catalyzed a breakthrough in our understanding of the biochemical basis of schizophrenia, improved the treatment of psychosis, and facilitated deinstitutionalization. In doing so, it solidified the role for chemical neuroscience as a means to elucidate the molecular underpinnings of complex neuropsychiatric disorders. In this Review, we will cover aspects of haloperidol's synthesis, manufacturing, metabolism, pharmacology, approved and off-label indications, and adverse effects. We will also convey the fascinating history of this classic molecule and the influence that it has had on the evolution of neuropsychopharmacology and neuroscience.

Adherence to antipsychotic medication among homeless adults in Vancouver, Canada: a 15-year retrospective cohort study

PURPOSE

The purpose of this study was to investigate the level of adherence to antipsychotic prescription medication in a well-defined homeless cohort over a 15-year period. We hypothesized that adherence would be well below the recommended threshold for clinical effectiveness (80 %), and that it would be strongly associated with modifiable risk factors in the social environment in which homeless people live.

METHOD

Linked baseline data (including comprehensive population-level administrative prescription records) were examined in a subpopulation of participants from two pragmatic-randomized trials that investigated Housing First for homeless and mentally ill adults. Adherence to antipsychotic medication was operationalized using the medication possession ratio. Multivariable logistic regression was used to estimate effect sizes between socio-demographic, homelessness-related and illness factors, and medication possession ratio.

RESULTS

Among the 290 participants who met inclusion criteria for the current analysis, adherence to antipsychotic prescription was significantly associated with: history of psychiatric hospitalization; receipt of primary medical services; long-acting injectable antipsychotic formulations; and duration of homelessness. Mean medication possession ratio in the pre-randomization period was 0.41. Socio-demographic characteristics previously correlated with antipsychotic non-adherence were not significantly related to medication possession ratio.

CONCLUSIONS

This is the first study to quantify the very low level of adherence to antipsychotic medication among homeless people over an extended observation period of 15 years. Each of the four factors found to be significantly associated with adherence presents opportunities for intervention. Strategies to end homelessness for this population may represent the greatest opportunity to improve adherence to antipsychotic medication.