The main article in this publication discusses the fact that psychotic agitation is characterized by motor restlessness, mental tension, and excitement, and that agitation includes a spectrum of abnormal behaviors frequently seen in patients with psychiatric illnesses, including in individuals with schizophrenia or bipolar disorder. This agitation is often marked by poorly organized, aimless psychomotor activity.1 Agitation accompanying psychosis often results in emergency department visits and admissions to psychiatric units,2 which may create burdens on emergency medical and psychiatric facilities. As payers, use of these resources is a major focus, as they account for a large portion of disease management. However, it is challenging for managed care organizations, especially pharmacy departments, to validate the prevalence of schizophrenia and bipolar disorder, because pharmacy claims are not associated with diagnosis codes. Therefore, payers may not be aware of the true impact of these conditions within their patient populations. Since much of the use of antipsychotic medications is “off-label,” an improved understanding of the causes of agitation and the development of more effective management strategies are important goals in the associated disorders, and these goals should be approached in a coordinated, integrated manner.
Healthcare professionals, specifically mental health professionals such as psychiatrists, psychologists, psychiatric social workers, and psychiatric nurses, manage patients in various settings, including community-based settings, hospitals, and day-hospitals. What is missing, and should be included, are pharmacists and payers. Payers are in a unique position concerning access to patient data, including drug use patterns and resource utilization. These data elements may provide necessary information to providers to improve coordination of care.
The author goes on to say that “community-based services help individuals with psychiatric illness integrate into society and into daily routines outside of hospitals. Such services emphasize personal goals and independence.3 Social support services and mental health services, provided by professionals, play an important role in community-based approaches.” Again, I think that it is important to include payers in this equation. Integrated care management and coordinated treatment across various types of community-based professional services are crucial—all caregivers must be trained to recognize and prevent relapses, identify drug-related problems, anticipate the use of high-cost resources such as emergency departments, and address formulary access issues.
Other healthcare approaches that community-based mental health facilities utilize are assertive community treatment (ACT) and intensive case management programs. These may also be augmented from a payer perspective and should be performed in an integrated manner. Payer data may help providers better understand a patient’s current situation and identify patients who are utilizing many resources and who may be at risk for episodes of agitation. Pharmacists and nurse care managers may help supplement the care provided to patients with schizophrenia or bipolar disorder.
Historically, the healthcare system has been fragmented, or “siloed,” with different budgetary requirements and reporting structures. This needs to change. A better approach is to have nurses, pharmacists, and mental health social workers collaborate as a team, as this would allow healthcare services to be better aligned and quicker to respond. For example, if a patient is transitioning from inpatient to outpatient status, the nurse can help coordinate and navigate the benefit system; the pharmacist can address formulary, drug–drug interactions, and adverse event issues; and the social worker can counsel the patient on effective behavioral approaches. This should be done in collaboration with the provider. If issues are identified, a process to notify and work with the physician needs to be in place. This also infers the importance of communication and integrated systems. In the future, within accountable care organizations and patient-centered medical homes, this coordination will be mandatory.
As discussed in the main article, few studies have been conducted on long-term follow-up of community-based services such as ACT. Therefore, it is imperative that all stakeholders continue their efforts to collaborate, validate, and publish best approaches to managing patients with schizophrenia or bipolar disorder to avoid inappropriate resource allocation and improve outcomes.
In summary, agitation remains a leading cause of healthcare resource utilization in schizophrenia and bipolar disorder, and we need additional data to help guide appropriate therapy. Access to medications that act quickly to resolve agitation will likely avoid some of the high costs associated with hospitalization and emergency department visits. Payers play a crucial role in coordination of care and should support education and management programs to help reduce the cost of treating agitated patients.
- Mohr P, Pečeňák J, Švestka J, et al. Treatment of acute agitation in psychotic disorders. Neuroendocrinol Lett. 2005;26:327-335.
- Citrome L. Addressing the need for rapid treatment of agitation in schizophrenia and bipolar disorder: focus on inhaled loxapine as an alternative to injectable agents. Ther Clin Risk Manag. 2013;9:235-245.
- Chang YC, Heller T, Pickett S, et al. Recovery of people with psychiatric disabilities living in the community and associated factors. Psych Rehabil J. 2013;36:80-85.