Taming TD; Transdermal Rx; Small-Town Solutions; Integrated Care


SAN DIEGO — Tardive dyskinesia (TD) is a common side-effect experienced by persons with schizophrenia who are treated with atypical antipsychotics — a side-effect that is stigmatizing and can result in non-adherence — but treatment with valbenazine can effectively control TD in some patients. 

In a poster presented at Psych Congress 2019, Craig Chepke, MD, of the University of North Carolina School of Medicine in Charlotte, and colleagues, noted that in a 6-week trial, the benefit of valbenazine was greatest at 80 mg daily, but importantly, “treatment with valbenazine 40 mg also showed greater improvement in [Abnormal Involuntary Movement Scale] compared to placebo.” 

Three long-term studies investigated the durability of response at 72 weeks, but those studies had fewer patients at the 40 mg dose, so Chepke et al pooled findings from all participants at the 40 mg dose (including those who were reduced from 80 mg to 40 mg) to assess durability of response. They found that “40 mg may be an effective long-term option for some TD patients, and dose reduction from 80 to 40 mg did not appear to compromise long-term benefit.”

Novel Transdermal Formulation of Asenapine Effective in Phase III Trial 

Asenapine, a second-generation antipsychotic that is marketed in a sublingual form, was studied in a transdermal system (HP-3070) in a double-blind study of hospitalized schizophrenia patients. 

Leslie Citrome, MD, MPH, of New York Medical College in Valhalla, and colleagues reported results from 485 patients who completed the trial. Two doses — the low dose was the equivalent of 5 mg bid sublingual and the high dose was the equivalent of 10 mg bid sublingual — were compared to placebo. The primary efficacy endpoint was change in PANSS score from baseline. 

Both doses demonstrated efficacy against placebo (P <0.05) — the benefit observed for the low dose beginning at week 2 and at weeks 3, 5, and 6 for the high dose. Both doses were well tolerated. If approved, HP-3079 would be the first transdermal antipsychotic available in the U.S. It is being developed by Noven Pharmaceuticals. 

Treating Mental Illness in Rural Alabama: Cost versus Benefit 

Nestled on the eastern shore of Mobile Bay, cheek-by-jowl against the Florida panhandle, Baldwin County is the largest county in Alabama with a population of close to 220,000. And, Baldwin County faces the same challenges of treating the mentally ill as New York County, New York, which is the second smallest county in the U.S. but the most densely populated, with more than 28 million people occupying roughly 23 square miles. 

But Baldwin County is experimenting with a federally-supported “Assisted Outpatient Treatment Program” to provide a wide-range of services for mentally ill residents who are involuntarily committed to outpatient treatment. The primary goals of the program are to reduce hospitalizations, emergency department visits, interactions with the criminal justice system, and homelessness, all while keeping costs at a minimum. 

Praveen Narahari, MD, of the University of South Alabama College of Medicine, and colleagues reported on the first year of operation of the program in a poster at Psych Congress 2019

Among the findings:

  • In the year before the program, 65 individuals were hospitalized 96 times for a total of 1,610 days.
  • In the first year of the program, 10 individuals accounted for 16 hospitalizations for a total of 315 days.
  • Hospitalizations were reduced by 83.3% and days in the hospital were reduced by 80.4%.
  • 16 participants made 27 emergency department visits before the program; 9 participants made 12 visits after enrolling in the program.
  • Emergency department visits were reduced by 44.4%.
  • In the 12 months prior to the program, there were 80 encounters with law enforcement for the 65 participants in the sample versus 29 encounters in the program’s first year.
  • In the year before, four participants were homeless for a total of 477 days. In the year after, three were homeless for a total of 56 days.

But what about costs? 

Using cost estimates provided by local law enforcement, municipalities, and hospitals, the authors estimated that over the course of a year the program saved Baldwin County taxpayers more than $1 million. 

Schizophrenia and Integrated Healthcare: A Not-So-Good Fit 

Current estimates are that treatment of schizophrenia is associated with more than $155.7 billion annually in the U.S., a figure that includes $9.3 billion in “incremental direct medical costs and $117.3 billion in incremental indirect costs such as unemployment.” 

At the same time, integrated healthcare is fast becoming a popular delivery model, but can it deliver schizophrenia care? 

That was the question posed by Oleg Tcheremissine, MD, of Behavioral Health, and colleagues from Atrium Health, both in Charlotte, North Carolina. They provided answers in a poster presented at Psych Congress 2019

They conducted a retrospective analysis comparing a cohort of schizophrenia patients (1,733) to determine their utilization of healthcare resources. All patients were identified in a query of Atrium Health’s database of medical records. 

Among the findings:

  • Patients with schizophrenia consume a substantial amount of healthcare services — including inpatient visits for comorbid, non-schizophrenia conditions.
  • There are “high rates of inpatient visits, readmissions, and ER visits and low rates of 30- ,60-, and 90-day follow-up outpatient visits with an associated schizophrenia/mental health diagnosis after inpatient visits indicating a need to re-evaluate health management strategies in these patients.”

 

Written by Peggy Peck, Editor-in-Chief, BreakingMED, is a service of @Point of Care, LLC, which provides daily medical news reports curated to serve the unique needs of busy physicians and other healthcare professionals.