Antipsychotic Medication Adherence and Healthcare Services Utilization in Two Cohorts of Patients with Serious Mental Illness

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.

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BACKGROUND

Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.

METHOD

Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.

RESULTS

Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.

CONCLUSION

Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Factors Influencing Adherence to Antipsychotic Medications in Women with Delusional Disorder: A Narrative Review

BACKGROUND

Adherence to medication regimens is of great importance in psychiatry because drugs sometimes need to be taken for long durations in order to maintain health and function.

OBJECTIVE

To review influences on adherence to antipsychotic medications, the treatment of choice for delusional disorder (DD), and to focus on adherence in women with DD.

METHOD

A non-systematic narrative review of papers published since 2000 using PubMed and Google Scholar and focusing on women with DD and medication adherence.

RESULTS

Several factors have been identified as exerting influence on adherence in women with persistent delusional symptoms who are treated with antipsychotics. Personality features, intensity of delusion, perception of adverse effects, and cognitive impairment are patient factors. Clinical time spent with the patient, clarity of communication and regular drug monitoring are responsibilities of the health provider. Factors that neither patient nor clinician can control are the social determinants of health such as poverty, easy access to healthcare, and cultural variables.

CONCLUSIONS

There has been little investigation into factors that influence adherence in the target population discussed here -e.g. women with DD. Preliminary results of this literature search indicate that solutions from outside the field of DD may apply to this population. Overall, a solid therapeutic alliance appears to be the best hedge against non-adherence.

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.

Treatment Compliance Communications Between Patients with Severe Mental Illness and Treating Healthcare Providers: A Retrospective Study of Documentation Using Healthcare Reimbursement Claims and Medical Chart Abstraction

Introduction

Successful treatment for serious mental illnesses (SMIs) requires a good therapeutic alliance with healthcare providers and compliance with prescribed therapies such as antipsychotic medications. This retrospective study, which utilized administrative claims linked with abstracted medical chart data, addressed a data gap regarding compliance-related discussions between providers and patients.

Methods

Commercially insured patients in ambulatory care post-acute (emergency or inpatient) event were eligible. Criteria included age 18–65 years; schizophrenia, bipolar disorder, or major depressive disorder diagnoses; continuous enrollment 6 months before to 12 months after the first acute event claim dated 01/01/2014 to 12/31/2015; and antipsychotic medication prescription. Demographic and clinical data, and patient–provider discussions about treatment compliance were characterized from claims and abstracted medical charts.

Results

Ninety patients (62% female, mean age 41 years) were included and 680 visits were abstracted; only 58% had first-visit antipsychotic compliance discussions. Notably, 18% of patients had discussions using the specific terms “compliance,” “persistence,” or “adherence,” whereas half were identified by more general terms. Compliance discussions were observed least often among the patients with schizophrenia, as compared with bipolar or major depressive disorders—a counterintuitive finding.

Discussion

Compliance discussions may represent intervention opportunities to optimize treatment, yet their study is a complex endeavor. The results of this study show an opportunity to improve this valuable treatment step.

Serious mental illness, other mental health disorders, and outpatient health care as predictors of 30-day readmissions following medical hospitalization

OBJECTIVE

Prior research has not addressed whether both serious mental illness (SMI) and other mental health (OMH) disorders affect the likelihood of 30-day readmissions after medical hospitalizations, or whether post-discharge use of outpatient medical, mental health, and pharmacy services is associated with readmission likelihood.

METHODS

Using the Truven Health Analytics MarketScan® Medicaid Multi-State Database, we studied 43,817 Medicaid beneficiaries, age 18-64, following discharge from medical hospitalizations in 2011. Logistic regression models compared all-cause, 30-day readmissions among those with SMI, OMH, and no psychiatric diagnosis, and examined associations of 30-day outpatient service use with 30-day readmissions.

RESULTS

Thirty-day readmission rates were 15.9% (SMI), 13.8% (OMH), and 11.7% (no mental illness). In multivariable analysis, compared to patients without mental illness, odds of readmission were greater for those with SMI (aOR = 1.43, 95%CI:1.32-1.51) and OMH (aOR = 1.21, 95%CI:1.12-1.30), and lower among those using outpatient mental health services (aOR = 0.50, 95%CI: 0.44-0.56).

CONCLUSION

The adult Medicaid population disproportionately includes patients with SMI and OMH disorders, both of which were found to be associated with 30-day hospital readmissions. Receiving outpatient mental health services after hospital discharge may be protective against readmission following medical hospitalizations, suggesting the need for further research on these topics.