ABSTRACT
Introduction Health care cost is projected to reach 20% of the nation's gross national product (GNP) by 2016. 6.2% of this is from mental health. The National Institute of Mental Health (NIMH) estimates the prevalence of serious mental illness (SMI) at 13.1 million or 5.2% of American adults age 18 or over. Hence, mental health care cost for this patient population is significant. Patients with SMI involved in an Assertive Community Treatment (ACT) program are individuals who experience the most intractable symptoms and the greatest level of dysfunction from their mental illness. These individuals typically are institutionalized in a long-term facility such as the state hospital. Clozapine has shown superior efficacy over first- and most second-generation antipsychotics in both treating treatment-resistant and non-treatment-resistant schizophrenia which has been supported by several large trials. There is also evidence of its efficacy in suicidality, aggression and substance misuse. In fact, clozapine has been approved by the FDA for use in refractory schizophrenia and suicidality in schizoaffective disorder. Due to the risk of agranulocytosis, clozapine is underutilized. The purpose of this study is to conduct a retrospective cohort study through chart review to analyze whether the addition of clozapine to ACT treatment of SMI patients in a community hospital from 2008 to 2018 led to decreased frequency of hospitalizations and increased clinical stability. Materials and methods A retrospective study using electronic medical record (EMR) of patients ages 20 and above who were enrolled in the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified during data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their data was extracted from the EMR. Twenty-five (62.5%) of these patient enrollments were on clozapine. They were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 to 50 years old, 30.2% were aged 18 to 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, and insurance type in ACT program between those using clozapine and those not on clozapine. There was a higher proportion of psychiatric hospitalizations among clozapine users compared with the non-clozapine user group (62.5% vs 41.5%, p = 0.019). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.128) or frequency of ACT visits (p = 0.002). Conclusion Effective treatment that will reduce hospitalizations and the burden of chronic disability in patients with SMI would greatly reduce mental health care cost. Clozapine remains the gold standard in the treatment of refractory schizophrenia. But due to the risk of agranulocytosis, clozapine is underutilized. It was hoped that this study will support the use of clozapine in SMI patients. Disappointingly, the use of clozapine did not prevent relapses and hospitalizations in this patient population and patients on clozapine seemed to have increased hospitalizations, compared to those who were not on clozapine. Perhaps, a different outcome would have occurred if the focus was limited to the patients themselves who were on Clozapine and ascertain what the rate of hospitalization was before the start of clozapine vs after the use of clozapine.
ABSTRACT
Introduction Patients with serious mental illness (SMI) experience highly intractable symptoms and great levels of dysfunction from their mental illness. Relapse prevention is critical as psychopathology, social and occupational functioning worsen with repeated psychotic episodes. Poor medication adherence is a strong predictor of relapse. Use of long-acting injectable antipsychotics (LAI) is among the most effective treatment specially in the context of non-adherence and yet remains underutilized. This single center retrospective study conducted using the electronic medical record (EMR) of patients enrolled in an Assertive Community Treatment (ACT) program at a community hospital was analyzed as to whether use of LAI among these patients reduce the frequency of emergency room visits and hospitalizations. Materials and methods Single center retrospective study using EMR of patients ages 20 and above who were enrolled at the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified into an Excel spreadsheet for data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their hospitalizations were extracted from the EMR. Seventy-six (42.5%) of these hospitalizations had patients on LAI. The hospitalizations were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 and 50 years old, 30.2% ages between 18 and 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, insurance type and time spent in ACT program between those using LAI and those not on LAI. There was a higher proportion of psychiatric hospitalizations among LAI users compared with the non-LAI user group (57.9% vs 37.4%, p = 0.007). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.266) or frequency of ACT visits (p = 0.062). Conclusion To date, all of the new-generation antipsychotic LAI have demonstrated a statistically and clinically significant decrease of relapse rates over placebo. Despite this, LAIs are not widely prescribed for a variety of reasons, including the reservations of patients, clinicians and payers. It would seem, though, that our patient population at the ACT program do not seem to benefit from use of LAI in relapse prevention. These results are counterintuitive in that one would expect that patients with serious mental illness would benefit from use of LAI. Perhaps, individuals with SMI are a different subset of population and they do not respond as well to LAI.
