Managing Mental Health: Tackling Schizophrenia Head On

While many pharmacy benefit and managed care strategies are designed to reduce the health care costs associated with schizophrenia, some of these tactics may actually unintentionally create barriers to treatment access.

It’s an intriguing thought posed by Junqing Liu, PhD, MSW. “Despite the ongoing medical research into schizophrenia and the increasing amount of literature that is published every decade, the mental disorder continues to be incompletely understood,” she wrote in a study published by the American Journal of Managed Care.

Liu indicated that the big picture must be taken into account when attempting to minimize the high costs associated with schizophrenia treatment. And the price tag is high, indeed. According to an examination of the economic burden of the illness in the United States using data from 2002, the cost has been estimated at $62.7 billion in total, with $22.7 billion in direct health care costs, $7.6 billion in direct non-health care costs, and $32.4 billion in indirect costs such as the loss of productivity and the loss of life.

“Managed care professionals must translate the available evidence into comprehensive disease management plans that include stringent monitoring of disease progression and treatment adherence,” she concluded, “and effectively balance the implementation of best clinical practices with cost-containment strategies.”
 

Battling Medication Nonadherence

One of the key care and cost-related challenges of the illness remains treatment adherence. While antipsychotic medication is the main intervention for the stabilization of acute psychotic episodes and the prevention of recurrences and relapses, nonadherence—rampant among those suffering from schizophrenia—puts patients at risk for repeated relapse and rehospitalization, which in turn, leads to increased costs for the health care system.

A study provided by the Postgraduate Institute for Medicine and the Center of Excellence Media and supported by an independent grant from pharmaceutical manufacturing company Alkermes, examined this issue from a managed care perspective. Nonpharmacologic interventions for improving medication adherence were highlighted, including methods broadly categorized as educational, behavioral, or affective.

“A systematic review of 39 studies found that adherence interventions that focused solely on education without behavioral modifications were usually ineffective,” noted the team of authors including Robert Navarro, PharmD, clinical professor, Department of Pharmaceutical Outcomes & Policy at the University of Florida–College of Pharmacy; Peter J. Weiden, MD, Director of Psychotic Disorders Program Center for Cognitive Medicine at the University of Illinois Medical Center; and Matthew Mitchell, PharmD, MBA, pharmacy director at SelectHealth.

On the other hand, they wrote, interventions that focused on nonadherence alone were more likely to be successful than more broadly focused mediations. Effective strategies included motivational interviewing, disease education, counseling, reinforcement and rewards skill building, behavioral modeling and contracting, dosage modifications, reminders, computer-based patient interaction, and appeal to emotions, as well as family interventions and support.

“Managed care pharmacists play a unique role in the multidisciplinary team and are often presented interventional opportunities to improve adherence in patients with schizophrenia,” the team of researchers pointed out. “For example, they can conduct drug utilization reviews and assess hospitalizations to identify patients who need adherence interventions; implement individualized disease management programs that include motivational interviewing and patient engagement; monitor the impact of interventions; and arrange follow-up programs to reevaluate and personalize programs.”

“Since managed care pharmacists possess a deeper understanding of the relationship between pharmacokinetic, dose-response, and pharmacologic characteristics of medications including LAIs [long-acting injectables], they are ideally suited to educate and collaborate with mental health professionals to promote appropriate use of LAI therapy options,” they added. “In essence, they must balance gatekeeper and advocacy roles in medication selection and maintain an administrative perspective on drug utilization.”

The clinical and socioeconomic burden of non-adherence in schizophrenia underscores the importance of medication adherence, the authors concluded. LAI therapy has emerged as an important maintenance treatment option for improving adherence in patients with the disease. In addition to comparable clinical effectiveness, long-acting therapy is associated with lower utilization of health resources compared with oral antipsychotic therapy. Pharmacy-led nonpharmacologic interventions are also valuable.

“Given that nonadherence is a complex, multifaceted issue,” the study concluded, “multifocal interventions focusing on patients, their families, and their health care providers are critical to achieving optimal outcomes in schizophrenia.”

Comprehensive Care Worth Upfront Cost

A new contribution to this ongoing examination and discussion of how to better treat schizophrenia while focusing on cost containment has been put forth by Dr Robert Rosenheck, professor of psychiatry and public health at Yale Medical School. According to his research, recently published in Schizophrenia Bulletin, treating individuals who have just experienced their first psychotic episode with more comprehensive care is worth the added up-front costs because of the significant quality of life improvements that can be achieved.

The study included 183 people who received typical care and 223 who received more comprehensive services, such as family counseling and help with jobs or school in comparison to traditional out-patient care, which typically provides only the forms of support that are covered by insurance such as drugs and psychotherapy.

“There have been a number of experiments throughout the world demonstrating that if you treat people with schizophrenia early on in the course of the illness you have a chance of generating improvement,” Dr Rosenheck told FRMC, “and the hope is that you can actually change the course of the illness.”

The research is part of a larger study called the RAISE Early Treatment Program (ETP), which was founded by the National Institute of Mental Health (NIMH) to look at the impact of early intervention. The study attempted to determine whether investing more heavily up front during early treatment could prevent much higher costs further down the road.

While the more comprehensive treatment package is roughly $3600 per year more than traditional care—a 27% increase—the study found that the interventions did improve both quality of life and symptoms to an extent that justifies the additional up-front cost. “It turned out that the health benefits were actually greater in economic value than the additional costs,” said Dr Rosenheck. “The program was economically supportable because the benefits exceeded the costs.”

Moral and Medical Concerns

From his perspective, these findings imply that the program is something that society ought to implement. “If you have, using standard measures, an intervention that costs more but the benefits are worth it, then society should invest in the intervention,” he explained.

From a purely logical standpoint it makes sense, but Dr Rosenheck acknowledged that it isn’t that straightforward or simplistic. “Whether people running mental health centers have the money to invest in things that are worthwhile entails a lot of other considerations,” he said, “and policy makers are not just guided by scientific findings. I’m realistic enough to know that.”

On the other hand, he continued, this is a terrible illness that is devastating to families. “These young people who seem to be developing along in life suddenly run into a wall of a horrible illness that deprives them of their special capabilities and motivation,” he said, “and it’s a simply devastating experience.”

A more comprehensive support system is something that should be provided to the suffering in the same way society steps up to help victims of a natural disaster, Dr Rosenheck said. “When there’s a tornado and people’s lives are destroyed, we feel compassion and we don’t do a cost benefit analysis,” he continued. “We do what needs to be done to get them on their feet.”

“From that point of view, I think this is something that unquestionably we should be doing to help this relatively small part of the population that experiences a medical catastrophe in their families,” he added.

Between the moral consideration for our fellow citizens, the medical and scientific results showing this intervention is effective in improving health, and the economic data showing that the amount of benefit it produces is worth the extra cost, Dr Rosenheck said more comprehensive care for schizophrenia patients is something that should be implemented on a larger scale.

One of the clear ongoing challenges, however, is the sense of shame, disgrace, and humiliation that continues to surround mental health issues. “The main reason there’s a tendency to ignore these problems is because of a longstanding social stigma,” he said. “There’s a huge social stigma toward mental illness in general and toward people with schizophrenia in particular that has been a part of our society for thousands of years.”

The traditional method of dealing with a mentally ill relative was to send that individual away to an institution and forget about them. “We’ve come a long way since that mentality,” he added, “but we still have biases against mental illness.” There have been various movements to reduce that stigma such as the National Alliance on Mental Illness, he acknowledged, but there’s still plenty of progress to be made.■