{"id":54926,"date":"2015-03-07T14:31:11","date_gmt":"2015-03-07T19:31:11","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=54926"},"modified":"2015-03-07T14:47:39","modified_gmt":"2015-03-07T19:47:39","slug":"impossibility","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/03\/07\/impossibility\/","title":{"rendered":"impossibility…"},"content":{"rendered":"\n
As the comments rolled in on the post about the British Psychological Society<\/font>‘s Report [back to the drawing board…<\/a>], my mind was wandering. I was thinking about how similar the topics of contention sounded to the ones I heard 40 years ago when I arrived.  Then I clicked on Psychiatric<\/font>News<\/font><\/strong>, and this article [from the RAND<\/font> Corporation] jumped up at me:<\/div>\n
\n
Better Antipsychotic Adherence Could Save Governments Millions<\/a><\/div>\n
Psychiatric<\/font>News<\/font><\/strong><\/div>\n
by Vabren Watts, <\/div>\n
March 3, 2015<\/div>\n
[full text on-line<\/a>] <\/div>\n
&<\/div>\n
Improving Antipsychotic Adherence Among Patients With Schizophrenia: Savings for States<\/a><\/div>\n
Psychiatric Services in Advance:
Economic Grand Rounds<\/font><\/strong><\/div>\n
by Zachary S. Predmore, Soeren Mattke,, Marcela Horvitz-Lennon<\/div>\n
January 2, 2015<\/div>\n
[full text on-line<\/a>]<\/div>\n

<\/p>\n

Absract:<\/font><\/strong><\/em> This column presents findings of an analysis conducted to quantify the potential net savings to state budgets from interventions to improve adherence to antipsychotic drugs among patients with schizophrenia. Using a financial model based on published data, the authors estimated costs of direct medical care and criminal justice system involvement at state and national levels and validated it against findings from other cost studies. The model estimated an annual cost of $21.4 billion [in 2013 dollars] to Medicaid programs and other state agencies for people with schizophrenia. On the basis of data on the effect on outcomes of increased medication adherence, better adherence could yield annual net savings of $3.28 billion to states or $1,580 per patient per year. Innovations to improve adherence to antipsychotic drugs among schizophrenia patients can yield substantial savings in state budgets. States should consider interventions shown to increase medication adherence in this patient group.<\/div>\n<\/blockquote>\n
[A Deinstitutionalization Timeline<\/a>]. In the 1970s, as psychiatry residents, we still heard lofty lectures from administrative types about deinstitutionalization as a great triumph, and in some ways it was. But the part we saw didn’t look that way.   It was called the revolving door<\/font><\/em> – chronic patients in the cycle of psychotic episode ···<\/strong><\/font><\/em><\/span>» hospitalization ···<\/strong><\/span>» stopping medication ···<\/strong><\/span>» another psychotic episode ···<\/strong><\/span>» another hospitalization ···<\/strong><\/span>»<\/font><\/em><\/div>\n

<\/p>\n

… and around and around it went. They were closing a huge hotel. In Georgia, it was Central State Hospital AKA Milledgeville<\/em> with 12,000 patients,<\/font> with no place in the community that could absorb its occupants, particularly when psychotic. And so we heard a lot about medication compliance<\/font><\/em> and depot medications<\/font><\/em>. These mostly non-medical planners talked like psychotic illness is a medication deficiency syndrome<\/font><\/em>. So, here we go again – as in "interventions shown to increase medication adherence<\/font><\/em>":<\/div>\n
\n
Research has shown that several interventions improve antipsychotic adherence among persons with schizophrenia. Some of these studies have also provided direct evidence of the cost-effectiveness of these interventions. A recent study of patients with schizophrenia in the United Kingdom demonstrated that even small financial incentives [less than $25 per patient per month] increased adherence to antipsychotic medications from a baseline of 69% to 85%…<\/div>\n

Replacing traditional oral therapy with long-acting injectable [LAI] antipsychotics has been shown to increase adherence… Thus using generic LAI antipsychotics could save more than $1,000 per patient per year…<\/p>\n

Medication management programs, such as counseling by pharmacists or advanced practice nurses, are another potential method for increasing adherence. Two specific medication management programs — cognitive adaptive training, which attempts to change patients ’ behavior by modifying their home environment through use of signs, alarms, and checklists, and electronic medication monitoring, a computerized system that reminds patients to take their medications and tracks adherence — have also been shown to increase adherence to antipsychotics among patients with schizophrenia to 92%, compared with 73% adherence in the group that received treatment as usual…<\/div>\n<\/blockquote>\n
Were I a patient reading that, I would likely be offended, maybe even wounded. "You think we stop medications in droves because we’re dumb, or forgetful? Why don’t you try taking it all the time!<\/font><\/em>" And if you read the APA guidelines [1], medication adherence is in the background of many of the recommendations. And the IRT training Manual [3] for the NIMH\/SAMHSA RAISE program spends no small amount of time trying to encourage medication adherence as in cooperation with treatment<\/font><\/em> as in relapse prevention<\/font><\/em>: <\/div>\n
    <\/p>\n
  1. \n
  2. \n
  3. \n
    Individual Resiliency Training Manual<\/a> [NIMH 2014]<\/div>\n<\/li>\n

    <\/span><\/ol>\n

    And what about Tardive Dyskinesia<\/font><\/em>? This from the European Schizophrenia Study of over 7000 patients on medications for three years: <\/div>\n
    <\/a><\/div>\n
    And so it has gone throughout history – the problem of Schizophrenia, of the psychotic states. Everyone has a solution for the part of the problem they are involved with themselves, and wants to overlook the other side of the coin. In this case, the RAND group is looking at the cost of recidivism to the State budgets [a very real problem], suggesting a policy that the mental health advocates will surely oppose [with very real examples of negative consequences]. And if you think about it, paying sick people to take medicine does have a bizarre ring to it. In this Rand example, the proposed solution is for society, not necessarily a given patient.<\/div>\n

    In my view, these are problems that have no<\/u> general solution at present. If I hadn’t been a Straw Man in these discussions so frequently [I should say Straw Psychiatrist], I could work up a real dander about this report\/recommendation. Instead, I’ve developed a hobby to occupy myself during debates of this kind – some way to silence my mind [and mouth] to keep me out of a dead-end discussion. I think about the impossibility of the problem as framed [I think that’s called being a contrarian<\/font><\/em> if you say it out loud], or about why trying to answer it is a double bind. And I particularly try to think about the cases being brought up as exceptions as people wax eloquently pro and con. I tell myself that such reflections remind me of the essential impossibility of psychotic experience and illness; they remind me that the only real solutions come on a case by case basis and they are tentative; and thinking privately keeps me out of run-on arguments that I don’t want to be in. But sometimes, I find an opinion in there that seems right to me. This may be one of those times. This scheme has been tried, and it just didn’t work…<\/p>\n

    And I worry about this – a lot…<\/div>\n
    \n
    Dr. Mattke has received speaker fees and travel support from Janssen<\/font><\/strong> Diagnostics. The other authors report no financial relationships with commercial interests.<\/div>\n<\/blockquote>\n
    Janssen makes RISPERDAL® CONSTA<\/font><\/strong> and now INVEGA® SUSTENNA®<\/font><\/strong> – leading LAIs…<\/div>\n","protected":false},"excerpt":{"rendered":"

    As the comments rolled in on the post about the British Psychological Society‘s Report [back to the drawing board…], my mind was wandering. I was thinking about how similar the topics of contention sounded to the ones I heard 40 years ago when I arrived.  Then I clicked on PsychiatricNews, and this article [from the […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-54926","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/54926","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=54926"}],"version-history":[{"count":71,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/54926\/revisions"}],"predecessor-version":[{"id":54997,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/54926\/revisions\/54997"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=54926"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=54926"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=54926"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}