Schizophrenia: Current Concepts and Approaches to Patient Care
Schizophrenia is the most serious of all mental conditions. It is typically a long-lasting condition characterized by repeated relapses and by marked functional impairment. Genetic and environmental factors are important. Exactly which factors and how these combine to cause schizophrenia is still unclear. Antipsychotic medications form the bedrock for treatment. These drugs are effective, but not entirely so, and are associated with negative side effects. Individual differences among the available medications suggest that trials with a different medication may be appropriate when one agent fails or is not appropriate for the specific patient. Monitoring for side effects is important to ensure efficacy and compliance. Often, patients choose to stop taking their medications for a variety of reasons, which invariably will lead most patients to a relapse of illness. Beyond medications, patients need considerable support and specialized services. Families are a key resource. The recent focus on personal determination has led to recovery-based services, including the incorporation of peer support into patient care. [AHDB. 2008;1(4):13-22.]
PAYORS: Payors have had a difficult time understanding how to approach schizophrenia. In the private sector, payors are accustomed to taking action when possible. Employers expect contracted insurance companies to take action on their behalf whenever it makes sense. This disease state, however, does not lend itself to such a direct treatment approach. Patients with schizophrenia-related disorders are often reluctant to adhere to medication regimens. The results are often viewed in one of two ways: The sick member who avoids medication, or the sick member who takes expensive medications in a nonadherent manner—both of which result in less-than-optimal health.
The major payors in this arena are state Medicaid agencies. Medicaid dollars pay for a substantial amount, perhaps half, of all prescriptions for schizophrenia, and must then pay for all related healthcare costs. So what are the goals of these state agencies? The states seek to ensure that people have access to care. Unfortunately, effectiveness is secondary to access.
This theme seems to be consistent regardless of who the payor is—private or public. As we do for other disease states, the payor community should push for a metric that demonstrates effective care for the patient with schizophrenia. Granting access to a random assortment of nonadherent monotherapies and combination therapies is not the answer. We should strive to ensure that patients and their providers make valiant attempts at treatment protocols before abandoning them in favor of the next horse on the schizophrenia drug carousel.
In the 1970s, advocates fought against the use of "depo-products" (eg, injected haloperidol) on the basis that some patients were overmedicated, and that one did not have the ability to immediately reverse the course of treatment if desired when using such extended-release products. Over the past 35 years, reverting to daily oral medications as standard treatment has witnessed the reemergence of patient nonadherence. A call for a return to forced medication has now been heard to redress the situation. Where shall it go from here?
PATIENTS: Ultimately, the direction should be determined by what is best for the patient. Neither legal advocates interested in outlawing extendedrelease medications as a civil rights infringement, nor state agencies willing to throw the entire medicine cabinet at patients without regard to medication effectiveness, should be making this decision.
Michael Schaffer, PharmD
Director of Pharmacy
HealthMarkets, Philadelphia, PA
Prior Authorization for Antipsychotics Complicates Adherence
BENEFIT MANAGERS: The question of open versus restrictive access to the newer (atypical) antipsychotic medications lingers, as prior authorization (PA) and step-edit policies are being used to control costs,1 and nonadherence remains a major concern. In his article, Dr Buckley notes that schizophrenia is the most serious mental condition, which requires optimal therapy.
Findings from a study just published in Health Affairs and led by Dr Steven B. Soumerai of Harvard Medical School's Department of Ambulatory Care and Prevention "provide strong evidence of both intended and unintended consequences of the Maine PA policy" 2 implemented in a Medicaid program from July 2003 through March 2004. Dr Soumerai and colleagues compared antipsychotics use in the Maine program pre- and postimplementation of the PA policy; an open access Medicaid program in New Hampshire was used as control. The Maine PA policy resulted in a 29% greater risk of treatment discontinuation compared with the period before implementing the PA policy.2 No differences in discontinuation risk were found in the New Hampshire program.
The authors concluded that "the most adverse clinical outcome was treatment discontinuation, which is a strong predictor of acute psychotic episode, hospitalization, and other negative clinical and economic outcomes. Pharmacy savings were minimal."2 They admit that restrictive policies may control costs when applied to more homogeneous drug classes (eg, nonsteroidal anti-inflammatory drugs or angiotensinconverting enzyme inhibitors), but because of marked differences in patients' response to antipsychotics, such tools are not productive and can be harmful when used for antipsychotics the authors say. In an interview with Newswire, Dr Soumerai said, "Given the tremendous variation in individual responses to these drugs as well as the devastating impact of treatment disruption on schizophrenic patients, a policy that pushes all patients toward a limited number of preferred drugs may do more harm than good."3
More than 30% of Medicare Part D and Medicaid programs have PA policies for antipsychotics.1,2
- Polinki JM, Wang PS, Fischer MA. Medicaid's prior authorization program and access to atypical antipsychotic medications. Health Aff. 2007;26:750-760.
- Soumerai SB, Zhang F, Ross-Deganan D, et al. Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change. Health Aff. 2008;27:w185-w195; DOI 10.1377/hlthaff. 27.3.w185.
- Plasso A. Restrictive drug policies often cause schizophrenic patients to discontinue medications. Newswire; April 1, 2008. www.PharmExec.findpharma.com. Accessed April 6, 2008.
Last modified: November 10, 2011