Activity Overview In this activity, faculty will describe a patient with newly diagnosed schizophrenia who has not been adherent to the prescribed antips chotic medications Participants ill prescribed antipsychotic medications. Participants will evaluate data about proven methods for improving medication adherence. In addition, faculty will discuss the benefits and limitations of integrating long-acting injectable antipsychotics, particularly for patients with a history of nonadherence to medication. Target Audience This activity is intended for psychiatrists.
23
Embed
OT007 Schizophrenia Cliffhangers Webisode #3 v3 FINAL
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Activity OverviewIn this activity, faculty will describe a patient with newlydiagnosed schizophrenia who has not been adherent to theprescribed antips chotic medications Participants illprescribed antipsychotic medications. Participants willevaluate data about proven methods for improvingmedication adherence. In addition, faculty will discuss thebenefits and limitations of integrating long-acting injectableantipsychotics, particularly for patients with a history ofnonadherence to medication.
Target AudienceThis activity is intended for psychiatrists.
Accreditation / Designation Statements
Med-IQ is accredited by the Accreditation Council forMed IQ is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Med-IQ designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure PolicyMed-IQ requires any person in a position to control the content of an educational activity to disclose all relevant financial relationships with any commercial interest Thefinancial relationships with any commercial interest. The ACCME defines “relevant financial relationships” as those in any amount occurring within the past 12 months, including those of a spouse/life partner, that could create a conflict of interest (COI). Individuals who refuse to disclose will not be permitted to contribute to this CME activity in any way. Med-IQ has policies in place that will identify and resolve COIs prior to this educational activity Med-IQ alsoresolve COIs prior to this educational activity. Med-IQ also requires faculty to disclose discussions of investigational products or unlabeled/unapproved uses of drugs or devices regulated by the US Food and Drug Administration.
Disclosure Statement
The content of this activity has been peer reviewed and has been approved for compliance. The faculty and contributors pp p yhave indicated the following financial relationship, which have been resolved through an established COI resolution process, and have stated that this reported relationship will not have any impact on their ability to give an unbiased presentation.
John Lauriello, MD, has indicated no real or apparent conflicts.
Disclosure Statements
The activity planners and peer reviewers have no financial relationships to disclose.
Acknowledgment of Commercial Support
This activity is supported by an educational grant from Otsuka America Pharmaceutical, Inc.
Medium & Method of ParticipationTo receive credit, read the introductory CME material, watch the Webcast, and complete the evaluation, attestation, and post-test, answering at least 70% of the post-test questions correctly. g p q y
The evaluation, attestation, and post-test will be accessible by clicking the “Get Credit” tab at the bottom of the Webcast at the conclusion of the activity.
Please visit us online at www.Med-IQ.com for additional activities sponsored by Med-IQ.
Sara C. Miller, MS
Assistant Director Educational Strategy and Content
Activity Planners
Assistant Director, Educational Strategy and Content
Med-IQ
Baltimore, MD
Amy Sison
Director of Continuing Medical EducationDirector of Continuing Medical Education
Med-IQ
Baltimore, MD
John Lauriello, MD
Professor and Chairman
Faculty
Professor and Chairman
Chancellor’s Chair of Excellence in Psychiatry
University of Missouri Department of Psychiatry
Columbia, MO
Upon completion, participants should be able to:
• Describe methods for improving medication
Learning Objectives
• Describe methods for improving medication nonadherence in the management of schizophrenia
• Outline the benefits and limitations of LAI medications for the treatment of schizophrenia
Meet Joe Again• Joe is a college student who has been diagnosed with
schizophrenia
• Has had several exacerbations/relapses attributed to substance use and not taking his oral medication consistently
• Factors commonly linked to adherence issues were discussed
• Joe’s psychiatrist discussed the diagnosis of schizophrenia and the importance of medication continuity
• His psychiatrist recommendsHis psychiatrist recommends that Joe take an LAI antipsychotic, but Joe would like to try an oral again
Solutions to Nonadherence
• PsychotherapeuticPatient and family education about the illness– Patient and family education about the illness
– Identifying any attitude and cognitive barriers
– Employing specific adherence strategies
• Psychopharmacologic– Long-acting medication
• Allows guaranteed delivery of medication• Allows guaranteed delivery of medication
• Immediately identifies nonadherence
• Not a “cure all”
• Can have in common and unique risks vs. orals
APA20041
TMAP20062
PORT20093
Guideline / Algorithm Recommendations
First episode SGA SGA SGA, FGA
Second choice SGA, FGA, C SGA, FGA SGA, FGA
Third choice C C C
Fourth choice (C+) C+ –
Fifth choice – FGA or SGA –
Combinations – C + SGA + FGA + ECT +
MS
–
MS
FGA: first-generation antipsychotic SGA: second-generation (atypical) antipsychotic C: clozapine C+: clozapine augmentation with FGA,SGA or ECTMS: mood stabilizer 1. APA. Practice Guideline for the Treatment of
Patients With Schizophrenia, 2e. 2004;2. Moore T, et al. J Clin Psychiatry. 2007;68:1751-62;
3. Kreyenbuhl J, et al. Schizophr Bull. 2010;36:94-103.
Family Psychoeducation Interventions
• Offer family psychosocial intervention to patients who have ongoing contact (< 9 months) with their family or nonfamily
icaregivers
• Program should combine education about illness, family support, crisis intervention, and problem-solving skills training
• Do not restrict programs from families identified as having highlevels of “expressed emotion”(eg, criticism, hostility, ( g yoverinvolvement)
• Do not employ therapies based on thepremise that family dysfunction is theetiology of the problem
Dixon L, et al. Schizophr Bull. 2000;26:5-20.
Cognitive Adaptation Training
“A h i l t t t th t“A psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization
of belongings to cue and sequence adaptive behaviors in the home.”
CAT bypasses deficits in cognitive function
Velligan DJ, et al. Schizophr Bull. 2008;34:483-93.
Using CAT to Address Nonadherence
• Reasons for nonadherence– Failure to establish routines that promote adherenceFailure to establish routines that promote adherence
– Chaotic surroundings
– Unstable living arrangements
– Lack of necessary household items to track time/days
• Utilizes supports for medication adherence– Alarms
– SignsSigns
– Checklists
– New technologies (eg, Med-eMonitor™ System)
• Shown to improve adherence and community function and reduce rates of relapse
Velligan DJ, et al. Psychiatr Serv. 2006;57:219-24; Velligan DJ, et al. Psychiatr Serv. 2003;54:665-7.
Prior to CAT Intervention:Dresser and Drawers
Courtesy of Dawn Velligan, PhD
CAT Interventions
Did I takemy medication
today?
Courtesy of Dawn Velligan, PhD
1.00
Tailored Environmental Supports to Improve Medication Adherence
0.75
0.50
0.25Pro
po
rtio
n W
ith
ou
t S
ign
ific
ant
Rel
apse
or
Sig
nif
ican
t E
xace
rbat
ion
PharmCAT (n = 32)
CAT (n = 34)
CAT: cognitive adaptation therapy, environmental supports to cue behaviorPharmCAT: focus on medication and appointment adherence
3 6 9 12 15 180.00
Months to Relapse
S
( )
Treatment as usual (n = 29)
Velligan DJ, et al. Schizophr Bull. 2008;34:483-93.
Compliance Therapy
Multiple sessions (4-6) focused on:
A k l d t f ill (i i ht)• Acknowledgment of illness (insight)
• Misgivings about medication
• Analogies for maintenance treatmentof physical illness
• Medication to facilitate life goals
• Weighing of benefits and disadvantages
Kemp R, et al. Br J Psychiatry. 1998;172:413-9.
Joe’s Treatment Plan• Dr. L works with Joe to reduce side effects
from the medication
• Dr. L also refers the family to psychoeducation, a support group, and a “staying sober” group for Joe
• To help with remembering to take the medication, Dr. L’s nurse develops some environmental cues to remind Joe to take his pillstake his pills
• It seems like this is helpful, but Joe stillmisses doses and is experiencing paranoia
Treatment Options for Joe
• Dr. L decides to introduce a peer bridger, Manuel, at the clinic who is taking an LAI, g
• Manuel and Joe talk over several weeks, and Joe decides to give the LAI antipsychotic a try
• Joe’s psychiatrist opts for an atypical antipsychotic with a 4-week interval
• He also recommends that Joe continueworking with his peer bridger andworking with his peer bridger and attending sobriety groups
Peer Support / Bridger
• Can be patient-to-patient or family member-to-family membermember
– NAMI: Family-to-Family http://www.nami.org/
– WRAP®: www.mentalhealthrecovery.com/wrap/
• Can be a complementary relationship to the traditional medical model
• Recent study showed improved medication adherence with a problem-solving, peer-support program
– Weekly telephone contact between peer and patient
Duckworth, et al. Curr Opin Psychiatry. 2014;27:216-21.
Does Delivery Matter?
Continuous vs. Targeted Maintenance
33
Rates of Relapse After 1 Year
35
30
29
55
15
7
10
Pietzcker, et al
Jolley, et al
Herz, et al
Carpenter et al
Continuous therapy
32
20
0 10 20 30 40 50 60
Schooler, et al
Rates of Relapse, %
Kane JM. N Engl J Med. 1996;334:34-41.
Continuous therapyTargeted therapy
Options to Deliver Antipsychotic Medication
• Pills including one sublingualPills, including one sublingual
• Liquid: common option for typicals and some atypicals
• Quick dissolve
• Patches: no options
• Pumps: no options
• Long-acting injectable agentsg g j g
LAI Antipsychotics to Improve Medication Adherence
Balancing
• Ensured medication delivery• Continuous antipsychotic coverage• Reduced risk of relapse• More frequent contact with
treatment team • Increasing number of options
available
Advantages and Disadvantages• Cost/insurance coverage• More appointments• Oral-to-LAI conversion• Perceived stigma• Negative perceptions by clinicians
Relapse-Free Survival Rates With Oral and Depot Fluphenazine
100 –
Fluphenazine decanoate (n = 55)O l fl h i ( 50)
9 –
8 –
7 –
6 –
5 –
4 –rop
ort
ion
Su
rviv
ing
–0 3 6 9 12 15 18 21 24
Months in Community
Oral fluphenazine (n = 50)
3 –
Pr
Hogarty GE, et al. Arch Gen Psychiatry. 1979;36:1283-94.
Analysis limited to patients who were adherent for at least the first 60 days on first-generation oral (n = 202) or LAI (n = 97) agents. Adherence determined by switch or gap > 30 days; log-rank P < 0.001.
Zhu B, et al. Psychiatr Serv. 2008;59:315-7.
LAI
50
pit
al
%
Rehospitalization Rates in Schizophrenia: Naturalistic Study
34
12*14* 13*
10
20
30
40
ents
Rea
dm
itte
d t
o H
osp
hin
1 Y
ear
of
Dis
char
ge,
0Decanoate
(Haloperidol, Fluphenazine;
n = 58)
Risperidone(n = 109)
Clozapine(n = 49)
Olanzapine(n = 156)
Pat
ieW
ith
Conley RR, et al. Ann Clin Psychiatry. 2003;15:23‐31.*P = 0.0008 vs. decanoate.
Nationwide Cohort Study of Oral and Depot Antipsychotics After First
Hospitalization for Schizophrenia
• 2,588 patients with schizophrenia in Finland
• First hospitalization, 2000-2007
• 54.3% did not pick up medication within 30 days of hospitalization
• Patients receiving depots had a one-third risk of hospitalization compared with those receiving orals
• Use of any antipsychotic is associated with lower mortality
Tihonen J, et al. Am J Psychiatry. 2011;168:603-9.
Relapse Prevention With Risperidone LAI vs. Oral Quetiapine
1.0
se
0.9
0.8
0.7
0.6
0.5
0.4
y o
f N
ot
Hav
ing
a R
elap
s
Quetiapine (n = 337)0 3
Gaebel W, et al. Neuropsychopharmacol. 2010;35:2367-77.
High dose: 300 mg every 2 weeksMedium dose: 405 mg every 4 weeksLow dose: 150 mg every 2 weekVery low dose: 45 mg every 4 weeks Kane J, et al. Am J Psychiatry. 2010;167:181-9.