The relationship of antipsychotic medication class and adherence with treatment outcomes and costs for Florida Medicaid beneficiaries with schizophrenia

Psychotropic medications induced parkinsonism and akathisia in people attending follow-up treatment at Jimma Medical Center, Psychiatry Clinic

OBJECTIVE

To determine the magnitude and factors associated with psychotropic drug-induced parkinsonism and akathisia among mentally ill patients.

METHODS

A hospital-based cross-sectional study was conducted with a total of 410 participants attending a follow-up treatment service at Jimma Medical Center, a psychiatry clinic from April to June 2019. Participants were recruited using a systematic random sampling method. Drug-induced parkinsonism and akathisia were assessed using the Extra-pyramidal Symptom Rating Scale. Substance use was assessed using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test. Data entry was done using EpiData version 3.1, and analysis done by the Statistical Package for Social Sciences version 22. Statistically, the significant association was declared by adjusted odds ratio, 95% confidence interval, and p-value less than or equal to 0.05.

RESULTS

The mean age of the respondents was 33.3 years (SD ± 8.55). Most of the participants 223 (54.4%) had a diagnosis of schizophrenia. The prevalence of drug-induced parkinsonism was 14.4% (95% CI: 11.0 to 18.0) and it was 12.4% (95% CI: 9.3 to 15.4) for drug-induced akathisia. The result of the final model found out drug-induced parkinsonism was significantly associated with female sex, age, type of antipsychotics, physical illness, and anti-cholinergic medication use. Similarly, female sex, chlorpromazine equivalent doses of 200 to 600 mg, combined treatment of sodium valproate with antipsychotic, and severe khat/Catha edulis use risk level was significantly associated with akathisia.

CONCLUSION

One of seven patients developed drug-induced parkinsonism and akathisia. Careful patient assessment for drug-induced movement disorders, selection of drugs with minimal side effects, screening patients for physical illness, and psycho-education on substance use should be given top priority.

Does Non-Adherence Increase Treatment Costs in Schizophrenia?

INTRODUCTION

Medication non-adherence is a serious barrier to treatment of schizophrenia. Understanding the impact of non-adherence on costs is essential to the assessment of the cost effectiveness of interventions in which adherence to treatment is a concern.

OBJECTIVES

We undertook a comprehensive review of the available literature on the impact on costs of non-adherence to antipsychotics in the treatment of schizophrenia.

METHODS

We performed a search on multiple databases (MEDLINE, Embase, PsycINFO and Health Management Information Consortium) for any study reporting the impact of adherence to antipsychotics on costs in patients with schizophrenia up to February 2018. We included trials of behavioural interventions but excluded comparisons of different pharmacological therapies. Studies were included if at least one-third of the study population had schizophrenia and costs were reported.

RESULTS

Thirty-four publications on 28 studies met the inclusion criteria. Twenty studies reported analyses of administrative databases, primarily Medicaid. Findings on healthcare costs were mixed but suggested that lower pharmacy costs in non-adherent patients may outweigh increased hospitalisation costs where drug costs are relatively high. A few studies published analysis of prospective cohort data, or trials of behavioural interventions intended to influence adherence, mainly in a European setting. Findings were again mixed but indicate that increasing adherence does not reduce overall costs.

CONCLUSIONS

Inference from analysis of administrative data is limited by the risk of selection bias. Inference from trials is limited by small sample sizes. The literature does not consistently support an assumption that non-adherence increases healthcare costs.

Economic impact of medication non-adherence by disease groups: a systematic review

OBJECTIVE

To determine the economic impact of medication non-adherence across multiple disease groups.

DESIGN

Systematic review.

EVIDENCE REVIEW

A comprehensive literature search was conducted in PubMed and Scopus in September 2017. Studies quantifying the cost of medication non-adherence in relation to economic impact were included. Relevant information was extracted and quality assessed using the Drummond checklist.

RESULTS

Seventy-nine individual studies assessing the cost of medication non-adherence across 14 disease groups were included. Wide-scoping cost variations were reported, with lower levels of adherence generally associated with higher total costs. The annual adjusted disease-specific economic cost of non-adherence per person ranged from $949 to $44 190 (in 2015 US$). Costs attributed to 'all causes' non-adherence ranged from $5271 to $52 341. Medication possession ratio was the metric most used to calculate patient adherence, with varying cut-off points defining non-adherence. The main indicators used to measure the cost of non-adherence were total cost or total healthcare cost (83% of studies), pharmacy costs (70%), inpatient costs (46%), outpatient costs (50%), emergency department visit costs (27%), medical costs (29%) and hospitalisation costs (18%). Drummond quality assessment yielded 10 studies of high quality with all studies performing partial economic evaluations to varying extents.

CONCLUSION

Medication non-adherence places a significant cost burden on healthcare systems. Current research assessing the economic impact of medication non-adherence is limited and of varying quality, failing to provide adaptable data to influence health policy. The correlation between increased non-adherence and higher disease prevalence should be used to inform policymakers to help circumvent avoidable costs to the healthcare system. Differences in methods make the comparison among studies challenging and an accurate estimation of true magnitude of the cost impossible. Standardisation of the metric measures used to estimate medication non-adherence and development of a streamlined approach to quantify costs is required.

PROSPERO REGISTRATION NUMBER

CRD42015027338.

Real-world adherence assessment of lurasidone and other oral atypical antipsychotics among patients with schizophrenia: an administrative claims analysis

OBJECTIVE

To compare adherence with lurasidone to other oral atypical antipsychotics among Medicaid and commercially insured patients with schizophrenia.

RESEARCH DESIGN AND METHODS

Administrative claims of patients with schizophrenia treated with atypical antipsychotics (lurasidone, aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) from October 2010 to September 2011 were identified from MarketScan Commercial and Medicaid Databases, and were classified by the first (index) antipsychotic. Patients were 18-64 years, had insurance coverage 12 months pre- and 6 months post-index, and no pre-index use of the index drug.

MAIN OUTCOME MEASURES

Medication possession ratio (MPR), discontinuation rate, and mean time to discontinuation were assessed post-index. Pairwise comparisons (lurasidone versus each drug) were conducted using chi-square tests and Student's t-tests.

RESULTS

There were 146 Medicaid (mean age 43.5 years, 47.9% female) and 63 commercial (mean age 40.0 years, 42.9% female) patients treated with lurasidone. In the Medicaid population, the MPR for patients treated with lurasidone was 0.60, versus 0.41-0.48 for patients treated with other antipsychotics (all p < .05). Patients treated with lurasidone exhibited a lower discontinuation rate compared to patients treated with all other antipsychotics (49.3% versus 62.3%-68.3%, all p < .05). The mean time to discontinuation with lurasidone was significantly longer than with ziprasidone (p < .05). In the commercial population, the MPR for patients treated with lurasidone (0.61) was higher compared to patients treated with quetiapine (0.44) and ziprasidone (0.43) (both p < .05). The discontinuation rate (44.4%) was lower for patients treated with lurasidone compared to patients treated with all other antipsychotics except risperidone (p < .05). The mean time to discontinuation was longer for lurasidone than with other antipsychotics.

CONCLUSIONS

In Medicaid and commercial populations, patients treated with lurasidone demonstrated greater adherence compared to patients treated with other atypical antipsychotics. Limitations of using administrative claims data include potential errors or inconsistencies in coding, and lack of complete clinical information.

Estimating the Impact of Adherence to and Persistence with Atypical Antipsychotic Therapy on Health Care Costs and Risk of Hospitalization

STUDY OBJECTIVE

To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity.

DESIGN

Retrospective cohort study using medical and pharmacy claims data.

DATA SOURCE

Humana health care insurance database.

PATIENTS

A total of 32,374 patients with a diagnosis of schizophrenia or bipolar disorder and who had a prescription for noninjectable atypical antipsychotics (aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone), after a washout period of at least 180 days during which there was no use of any atypical antipsychotics, between January 2007 and June 2013.

MEASUREMENTS AND MAIN RESULTS

The effects of adherence (proportion of days covered by all atypical antipsychotic prescription fills) to and persistence (time from initiation to discontinuation of therapy) with atypical antipsychotics on outcomes (all-cause total health care costs, medication costs, medical services costs, and inpatient admissions) were examined. To exclude potential bias due to mutual causality between drug use patterns and health care utilization, the effects of adherence and persistence measured in the first year on outcomes measured in the second year were investigated. Instrumental variable regressions using reimbursement rate and mail order as instrumental variables were conducted to correct potential endogeneity due to omitted variable bias. Being adherent decreased total costs by $19,497 (p<0.05), increased medication costs by $8194 (p<0.001), decreased medical services costs by $27,664 (p<0.001), and reduced hospitalization risk by 27% (p<0.001). Being persistent decreased individual total costs by $23,927 (p<0.05), increased medication costs by $10,278 (p<0.001), and decreased medical services costs by $34,178 (p<0.001). We could not identify a significant association between persistence and the risk of hospitalization.

CONCLUSION

Good adherence to and persistence with atypical antipsychotics led to lower total costs than poor adherence and persistence. Thus efforts should be made to improve adherence and persistence in patients taking atypical antipsychotics.

Therapeutic alliance in forensic mental health: coercion, consent and recovery

OBJECTIVE

We examined the Working Alliance Inventory (WAI) and Interpersonal Trust in Physician (ITP) in a forensic psychiatry hospital, where all patients were detained under mental health legislation for psychosis. We hypothesised that working alliance and trust are bilateral and can be measured.

METHOD

We adapted the WAI and ITP minimally so that patients rated both their treating psychiatrist and primary nurse. We also adapted them minimally so that clinicians could rate WAI and ITP with the patient. A total of 81 of 83 patients completed the assessments. The clinicians (seven consultant psychiatrists and 43 nurses) also completed a minimally altered version of the same questionnaires. All three (patient, nurse and psychiatrist) were blind to the ratings of the others.

RESULTS

Cronbach's alpha was greater than 0.9 for both patient and clinician versions of the WAI and greater than 0.8 for the ITP. The WAI and ITP correlated with each other (Spearman r > 0.67 for patients, for psychiatrists and for nurses). Patients rated clinicians higher than clinicians rated patients. Ratings were higher in pre-discharge wards than in acute wards. Patients' ratings of WAI for their psychiatrist and nurse correlated r = 0.75, and patients rating of IPT for psychiatrist and nurse correlated 0.67. Psychiatrists correlated with nurses 0.38 for WAI, 0.53 for IPT. Psychiatrists and patients mutual ratings correlated r = 0.35 for WAI, 0.24 for IPT. Nurses and patients correlated r = 0.34 for WAI, 0.25 for IPT. All correlations were statistically significant. Mental state (PANSS) and global function (GAF) correlated with all ratings and confounded most patient-clinician correlations.

CONCLUSION

Working alliance and interpersonal trust can be measured reliably even in forensic settings. The extent to which they measure a mutual quality is unclear.

The impact of non-adherence to medication in patients with schizophrenia on health, social care and societal costs. Analysis of the QUATRO study

Aims. For people with schizophrenia, non-adherence to antipsychotic medications may result in high use of health and other services. The objective of our research was to examine the economic consequences of non-adherence in patients with schizophrenia taking antipsychotic medication. Methods. Data were taken from QUATRO, a randomized controlled trial that drew a sample of adults with schizophrenia receiving psychiatric services in four European cities: Amsterdam, Leipzig, London and Verona. Trial inclusion criteria were a clinical diagnosis of schizophrenia, requiring on-going antipsychotic medication for at least 1-year following baseline assessment, and exhibiting evidence of clinical instability in the year prior to baseline. The patient-completed Medication Adherence Questionnaire (MAQ) was used to calculate the 5-point Morisky index of adherence. Generalized linear models (GLM) were developed to determine the effect of adherence on (i) health and social care and (ii) societal costs before and after treatment, taking into account other potential cost-influencing factors. Results. The effect of non-adherence on costs was mixed. For different groups of services, and according to treatment group assignment, non-adherence was both negatively and positively associated with costs. Conclusions. The impact of non-adherence on costs varies across the types of services used by individuals with schizophrenia.

Approaches to improve adherence to pharmacotherapy in patients with schizophrenia

PURPOSE

In patients with schizophrenia, nonadherence to prescribed medications increases the risk of patient relapse and hospitalization, key contributors to the costs associated with treatment. The objectives of this review were to evaluate the impact of nonadherence to pharmacotherapy in patients with schizophrenia as it relates to health care professionals, particularly social workers, and to identify effective team approaches to supporting patients based on studies assessing implementation of assertive community treatment teams.

MATERIALS AND METHODS

A systematic review of the medical literature was conducted by searching the Scopus database to identify articles associated with treatment adherence in patients with schizophrenia. Articles included were published from January 1, 2003, through July 15, 2013, were written in English, and reported findings concerning any and all aspects of nonadherence to prescribed treatment in patients with schizophrenia.

RESULTS

Of 92 unique articles identified and formally screened, 47 met the inclusion criteria for the systematic review. The burden of nonadherence in schizophrenia is significant. Factors with the potential to affect adherence include antipsychotic drug class and formulation, patient-specific factors, and family/social support system. There is inconclusive evidence suggesting superior adherence with an atypical versus typical antipsychotic or with a long-acting injectable versus an oral formulation. Patient-specific factors that contribute to adherence include awareness/denial of illness, cognitive issues, stigma associated with taking medication, substance abuse, access to health care, employment/poverty, and insurance status. Lack of social or family support may adversely affect adherence, necessitating the assistance of health care professionals, such as social workers. Evidence supports the concept that an enhanced team-oriented approach to managing patients with schizophrenia improves adherence and supports corresponding reductions in relapse rates, inpatient admissions, and associated costs.

CONCLUSION

Optimization of medication and involvement of caregivers are important to promoting adherence. A multidisciplinary team approach may be invaluable in identifying barriers to adherence and helping schizophrenia patients overcome them.

Affective temperaments and psychotropic adherence

BACKGROUND

It is generally accepted that a range of factors affect adherence to psychotropic medications. In the present study, we focused on the influence of affective temperaments (i.e., depressive, hyperthymic, cyclothymic, irritable, and anxious temperaments) on treatment adherence.

METHODS

Thirty-eight psychiatric consecutive inpatients were instructed to perform Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire version (TEMPS-A) for affective temperaments, Drug attitude inventory-10 (DAI-10) for concordance and persistence, and Visual Analogue Scale (VAS) for compliance.

RESULTS

VAS scores for dose compliance were significantly and negatively associated with irritable temperament scores whereas DAI-10 scores were significantly and positively associated with male gender, depressive temperament scores and hyperthymic temperament scores.

LIMITATIONS

The main limitations of the study were the relatively small number of subjects and the lack of objective method of adherence.

CONCLUSIONS

These findings suggest that patients with irritable temperament may be poor in their compliance with treatment, and that more education may be required for patients with irritable temperament in order to maintain good compliance. In contrast, men and patients with depressive or hyperthymic temperament have a relatively positive attitude towards medication.

Rates and predictors of antipsychotic non-adherence and hospitalization in Medicaid and commercially-insured patients with schizophrenia

OBJECTIVE

To assess rates and predictors of antipsychotic non-adherence and hospitalizations among patients with schizophrenia in separate Medicaid and commercial populations.

METHODS

This retrospective analysis used the Thomson Reuters MarketScan Multi-State Medicaid and IMS LifeLink Health Plan claims databases. These analyses included patients with a diagnosis of schizophrenia (295.xx) who received a prescription for an antipsychotic between January 1, 2008, and June 30, 2009 (date of first claim in window defined as index). Patients were required to have one additional antipsychotic prescription in the 1 year following index. Rates of adherence and psychiatric and all-cause hospitalization were evaluated. Multivariate logistic regression models identified predictors of antipsychotic non-adherence and hospitalization. These analyses were not intended to compare outcomes between the Medicaid and commercial populations.

RESULTS

Patients, 20,710 Medicaid and 7528 commercial, met all inclusion criteria. Both populations were ∼47% male, with a younger mean ± SD age among the Medicaid population (42.6 ± 14.1 vs 47.9 ± 17.1 years). Mean ± SD MPR in follow-up was 0.77 ± 0.25 in the Medicaid population (37.5% non-adherent) and 0.73 ± 0.27 in the commercial group (44.6% non-adherent). Rates of all-cause and psychiatric hospitalizations were 28.6% and 27.2%, respectively, among Medicaid and 29.2% and 26.3% among commercial patients. Newly starting antipsychotics and being non-adherent to therapy at baseline were both found to significantly increase the likelihood of non-adherence 12-fold in the Medicaid population (both p < 0.001) and 8-fold in the commercial population (both p < 0.001). Medicaid patients with a baseline psychiatric hospitalization had a 3-fold increased likelihood of hospitalization (p < 0.001) and commercial patients had a 2-fold increase (p < 0.001).

LIMITATIONS

These two populations were not compared statistically; no conclusions as to the cause of any observed differences in outcomes can be made.

CONCLUSIONS

Previous non-adherence, newly starting antipsychotic therapy, and previous hospitalization were significant predictors of non-adherence and hospitalization in Medicaid and commercial populations.

Effectiveness of sulpiride in adult patients with schizophrenia

The objective of this study is to compare the effectiveness among sulpiride, risperidone, olanzapine, and haloperidol by evaluating the persistence of drug use. A retrospective cohort study was conducted by analyzing the National Health Insurance Research Database of Taiwan. Patients with schizophrenia aged 18-65 years and newly prescribed with a single oral antipsychotic medication between years 2003 and 2008 were included. The primary outcome was the persistence of antipsychotic agents by calculating the treatment duration till treatment changed. All defined treatment changes were also analyzed separately, including discontinuation, switching, augmentation, and hospitalization. A total of 1324 eligible patients were included, with an average age of 36 years old and approximately 45% of them were female. The most prevalent antipsychotic use was risperidone (42.1%), followed by sulpiride (36.0%), haloperidol (14.2%), and olanzapine (7.7%). After adjusting for patient demographics, mental illness characteristics, and propensity score, the Cox regression models found that the risk of nonpersistence was significantly higher in patients receiving risperidone (hazard ratio [HR], 1.22; 95% CI, 1.06-1.40), haloperidol (HR, 1.98; 95% CI, 1.63-2.40), and olanzapine (HR, 1.34; 95% CI, 1.07-1.68), as compared with sulpiride, suggesting the effectiveness of sulpiride was better than the other 3 antipsychotics. Therefore, this study would provide strong grounds for a properly conducted randomized controlled trial of the clinical- and cost-effectiveness of sulpiride vs atypical antipsychotics.

Systematic review of the economic aspects of nonadherence to antipsychotic medication in patients with schizophrenia

PURPOSE

There is strong evidence supporting the link between nonadherence to antipsychotic medication and relapse of schizophrenia. However, less obvious are the economic consequences of nonadherence. The systematic review reported here evaluated the economic aspects of nonadherence to antipsychotic medication.

METHODS

A systematic review of scientific papers in the PubMed MEDLINE, Embase, PsychINFO, BIOSIS, and Evidence-Based Medicine Reviews databases was undertaken. Studies that measured adherence to antipsychotic medication and that provided comparative information on health care costs were included.

RESULTS

Eight studies met the inclusion criteria. All were observational. Despite the differences between the studies in terms of design, adherence measures, and cost components analyzed, the results of this systematic review indicate that nonadherence to antipsychotic medication is associated with increased hospitalization rates and resource utilization, resulting in increased direct health care costs.

CONCLUSION

Nonadherence to antipsychotic medication results in poor health and economic outcomes; therefore, the authors suggest endorsing interventions aimed at improving adherence because they can improve patient health without substantially increasing costs.

Medication adherence and utilization in patients with schizophrenia or bipolar disorder receiving aripiprazole, quetiapine, or ziprasidone at hospital discharge: a retrospective cohort study

BACKGROUND

Schizophrenia and bipolar disorder are chronic debilitating disorders that are often treated with second-generation antipsychotic agents, such as aripiprazole, quetiapine, and ziprasidone. While patients who are hospitalized for schizophrenia and bipolar disorder often receive these agents at discharge, comparatively little information exists on subsequent patterns of pharmacotherapy.

METHODS

Using a database linking hospital admission records to health insurance claims, we identified all patients hospitalized for schizophrenia (ICD-9-CM diagnosis code 295.XX) or bipolar disorder (296.0, 296.1, 296.4-296.89) between January 1, 2001 and September 30, 2008 who received aripiprazole, quetiapine, or ziprasidone at discharge. Patients not continuously enrolled for 6 months before and after hospitalization ("pre-admission" and "follow-up", respectively) were excluded. We examined patterns of use of these agents during follow-up, including adherence with treatment (using medication possession ratios [MPRs] and cumulative medication gaps [CMGs]) and therapy switching. Analyses were undertaken separately for patients with schizophrenia and bipolar disorder, respectively.

RESULTS

We identified a total of 43 patients with schizophrenia, and 84 patients with bipolar disorder. During the 6-month period following hospitalization, patients with schizophrenia received an average of 101 therapy-days with the second-generation antipsychotic agent prescribed at discharge; for patients with bipolar disorder, the corresponding value was 68 therapy-days. Mean MPR at 6 months was 55.1% for schizophrenia patients, and 37.3% for those with bipolar disorder; approximately one-quarter of patients switched to another agent over this period.

CONCLUSIONS

Medication compliance is poor in patients with schizophrenia or bipolar disorder who initiate treatment with aripiprazole, quetiapine, or ziprasidone at hospital discharge.

The Potential Role of Long-acting Injectable Antipsychotics in People with Schizophrenia and Comorbid Substance Use

OBJECTIVE: Treatment of schizophrenia in patients with comorbid substance use (alcohol/illicit drug use, abuse or dependence) presents challenges for public health systems. Substance use in people with schizophrenia is up to four times greater than the general population and is associated with medication nonadherence and poor outcomes. Therefore, continuous antipsychotic treatment in this population may pose more of a challenge than for those with schizophrenia alone. Many clinical trials and treatment recommendations in schizophrenia do not take into consideration substance use as people with comorbid substance use have typically been excluded from most antipsychotic trials. Nonetheless, antipsychotic treatment appears to be as efficacious in this population, although treatment discontinuation remains high. The objective of this review was to highlight the importance and utility of considering long-acting injectable antipsychotics for patients with schizophrenia and comorbid substance use. METHODS: We did a literature search using PubMed with key words schizophrenia and substance use/abuse/dependence, nonadherence, antipsychotics, long acting injectables, relapse, and psychosocial interventions. We limited our search to human studies published in English and 4,971 articles were identified. We focused on clinical trials, case reports, case series, reviews and meta-analyses resulting in 125 articles from 1975-2011. RESULTS: Our review suggests the potential role of long-acting injectables for people with comorbid substance use and schizophrenia in leading to improvements in psychopathology, relapse prevention, fewer rehospitalizations, and better outcomes. CONCLUSIONS: While more research is needed, long-acting antipsychotics should be considered an important option in the management of people with schizophrenia and comorbid substance use.

Does assertive community treatment increase medication adherence for people with co-occurring psychotic and substance use disorders?

OBJECTIVE

This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM).

METHOD

Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days ("poor adherence") versus less than 20% missed medication days ("adequate adherence").

RESULTS

Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM.

CONCLUSIONS

Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

Medicaid medication access problems and increased psychiatric hospital and emergency care

OBJECTIVES

To quantify the extent to which Medicaid programs may incur increased psychiatric emergency department and hospital use associated with clinically unintended medication discontinuations, gaps, switches and other access problems attributed to prescription drug coverage and management.

METHOD

This study uses clinically detailed, physician-reported data. A total of 4866 psychiatrists in 10 states were randomly selected from the AMA Masterfile; 62% responded and 32% treated Medicaid patients and reported on 1625 systematically selected Medicaid patients. Propensity score multivariate models assessed predicted probabilities and mean number of emergency department visits and hospital days.

RESULTS

Many patients (46.0%, S.E.=1.3%) had medication access problems reported during the past year, including discontinuing or switching medications or inability to obtain clinically indicated prescriptions because of drug coverage or management. The expected number of emergency department visits was estimated to be 73.8% higher among patients with medication access problems reported compared to matched patients without access problems reported. Among acute stay inpatients, the expected number of hospital days was 71.7% higher for patients with medication access problems reported.

CONCLUSIONS

Medication access problems may have significant implications for Medicaid programs. The potential indirect costs of these policies in psychiatric and social services utilization should be considered in addition to direct pharmacy costs.

Duration of pharmacotherapy with long-acting injectable risperidone in the treatment of schizophrenia

Although long-acting injectable risperidone (LAIR) has been hypothesized to improve medication adherence compared to oral medications, data from real-world practice have yet to be presented on time to treatment discontinuation. Records of all new prescriptions for antipsychotic medication during the first 2 months of FY 2006 for VA patients diagnosed with schizophrenia (N = 11,821) were examined and duration of treatment with LAIR and oral antipsychotics were calculated for the next 2 years. Multivariable logistic regression was used to identify patient characteristics independently associated with receipt of LAIR. Proportional hazards models were used to compare the likelihood of discontinuing each of the medications as compared to LAIR. Altogether, 2.4% of the 11,821 new starts were prescribed LAIR, 44.6% of whom continued therapy for 540-720 days (18-24 months), less than the 77.1% of those on clozapine, 57.9% on oral conventional antipsychotics, 55.0% on olanzapine, and 49.5% on risperidone, but more than the 27.7% on aripiprazole. After adjusting for potentially confounding factors, patients who were initiated on LAIR were more likely to discontinue their medication than those who were initiated on oral first- or second-generation antipsychotics (SGAs) with the exception ziprasidone and aripiprazole. Less than half of patients on LAIR continued treatment for 18 months, a smaller proportion than of those started on most oral first- or second-generation antipsychotics, suggesting that for many patients with schizophrenia improved adherence from this treatment may not be sustained.

Changes over time and disparities in schizophrenia treatment quality

BACKGROUND

Schizophrenia medication and psychosocial treatment options have expanded since the Schizophrenia PORT was conducted. However, there also have been considerable changes in the delivery of mental health care in the public sector, as well as increasing state concerns about Medicaid cost containment.

OBJECTIVES

To examine trends and patient characteristics associated with differences in schizophrenia medication and visit treatment quality in a Medicaid population.

RESEARCH DESIGN

Observational study of claims data from July 1, 1996 to June 30, 2001.

SUBJECTS

Florida Medicaid enrollees diagnosed with schizophrenia (N = 23,619).

MEASURES

We examined the likelihood of meeting any 1 and all 4 of the following quality standards: (1) receiving antipsychotic medication, (2) antipsychotic continuity, (3) dosing consistent with PORT recommendations, and (4) mental health visit continuity. Separate models were fit for acute and maintenance phases of treatment.

RESULTS

Approximately 18% of acute and 7% of maintenance phases met all 4 quality standards. Antipsychotic quality improved (largely driven by an increasingly likelihood of receiving any antipsychotic), while visit continuity declined. The greatest disparities were seen for persons with co-occurring substance use disorders and of black race. Quality differences were often phase specific and at times in opposite directions across treatment phases.

CONCLUSIONS

The improvement in antipsychotic treatment quality is encouraging. However, visit continuity declined. This study highlights the importance of quality measurement that includes focus on different treatment modalities and phases of care, as well as for potentially vulnerable populations (such as persons with co-occurring substance use disorders and racial/ethnic minorities).

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review

OBJECTIVE

Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.

METHODS

MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.

RESULTS

In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.

CONCLUSIONS

Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

Tactics and technologies to manage nonadherence in patients with schizophrenia

The occurrence of treatment nonadherence among patients with schizophrenia is clinically significant. However, studies show that clinicians do not make systematic efforts to identify and monitor it over time. This paper reviews the various tactics for identifying and monitoring adherence behavior. A comprehensive review of published studies comparing typical and atypical antipsychotics in terms of medication adherence yields mixed results at best. Changing forces in the delivery of health care in the United States will promote efforts to improve the recognition of nonadherence in patients with schizophrenia and develop strategies and tactics to decrease the current rates of nonadherence. Such tactics are described in this paper, and emerging best practices are identified. Ultimately, if nonadherence rates are to decrease, it will be necessary to align the incentives of the treater and the treated.

Reducing variation in the pharmacologic treatment of schizophrenia: defining acceptable standards of treatment

Clinicians are exhorted to improve the quality of care for patients with schizophrenia by applying evidence-based medication treatment guidelines. Unfortunately, although there are many guidelines, they are all more or less out of date, and their recommendations often are inconsistent, leaving clinicians uncertain about the definition of acceptable standards of care. This paper reviews existing guideline recommendations and recently published research related to two parameters of care: 1) first-line treatment of multiepisode psychosis and 2) the care of treatment-resistant patients. Its purpose is to help clinicians understand the implications of the latest research for the content of schizophrenia guidelines and for the clinical practice they are supposed to inform.