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Addressing the Challenges of Treating Schizophrenia and Bipolar Disorder

Pharmacist Perspective
Faculty Perspectives: The Spectrum of Agitation Associated with Schizophrenia and Bipolar Disorder

Schizophrenia and bipolar disorder are difficult to treat disease states with significant clinical sequelae, high costs, and prevalence. However, it is challenging for managed care organizations, especially pharmacy departments, to validate the prevalence and costs of schizophrenia and bipolar disorder because pharmacy claims are not associated with diagnosis codes. As a result, payers may not be aware of the true impact of these conditions within their patient populations.

Even when linked to medical claims, the overall use of antipsychotic drugs is much greater than it should be, given the reported prevalence of bipolar disorder and schizophrenia.1 If antipsychotic use were limited to the treatment of these conditions, medication management would not be a priority.

Although it is widely recognized that schizophrenia and bipolar disorder have a significant impact on health economics and personal productivity, these outcomes are often associated with indirect costs that are difficult to measure by payers, with the exception of hospitalizations or emergency department visits. Furthermore, given this assumption, many patients with schizophrenia would be expected to be in the Medicaid population or uninsured (not considering the impact of the Affordable Care Act).2

The impact of the clinical features of schizophrenia and bipolar disorder are not transparent to payers. Disease-related effects, such as delusions, hallucinations, negative symptoms, positive symptoms, among others, cannot be addressed by payers.

Patients with schizophrenia or bipolar disorder and their treatment plans need to be individually identified and managed by clinicians. Although the treatment of schizophrenia and bipolar disorder relies heavily on pharmacotherapy, specifically antipsychotic drugs, it is difficult for payers to compare medications that are used to treat these conditions. When the Pharmacy and Therapeutics Committee is tasked with evaluating therapies for formulary inclusion, they must make several assumptions based on indirect comparisons of efficacy, safety, cost, and indications. Unfortunately, formularies are population-based and cannot be developed to address each individual patient issue.3

Until fairly recently, the atypical antipsychotic class of drugs was largely branded and relatively expensive.4 Given the increased use of atypical antipsychotic drugs, payers struggled with the appropriate use of these medications and how to manage them. The traditional pharmacy management tools, such as step therapy, were difficult to implement because requiring antidepressants for first-line therapy, for example, could be inappropriate in bipolar disorder. Furthermore, prior authorization protocols are associated with administrative costs and low denial rates.

With the loss of patents for several atypical antipsychotics, it has become easier to manage atypical antipsychotics through step therapy, thereby lowering the cost of this class of agents. These cost-savings, however, have lessened the focus on the treatment of schizophrenia and bipolar disorder, making it even more imperative that patients are appropriately managed.

The role of agitation in schizophrenia and bipolar disorder is not well-understood. The treatment of agitation that is associated with psychiatric illnesses should be a management priority because it creates dangerous situations for patients and caregivers, and is one of the leading contributors of direct costs, including emergency department visits. The effective treatment of disease-related symptoms and agitation will improve patients’ quality of life and reduce the overall costs associated with these diagnoses.

The main article in this publication does a nice job of explaining the role of psychotherapy and pharmacotherapy in the treatment of agitation associated with schizophrenia and bipolar disorder. The drugs that are used to treat schizophrenia- and bipolar disorder–related agitation have limitations, including delayed onset of action, route of administration, and adverse events.5 The role of choosing an atypical antipsychotic agent with efficacy for agitation as monotherapy versus adding an adjunctive therapy needs to be carefully evaluated for additive adverse events, drug–drug interactions, compliance, and cost; newer formulations of antipsychotic drugs have helped to address some of these shortcomings.6

The management of patients with schizophrenia or bipolar disorder, and associated agitation, remains challenging. Improved education regarding the disease and associated costs, less stereotyping, and more treatment options that are cost-effective are needed to improve patient outcomes.

1. Centers for Disease Control and Prevention. Burden of mental illness. Accessed October 2, 2014.
2. Wu EQ, Shi L, Birnbaum H, et al. Annual prevalence of diagnosed schizophrenia in the USA: a claims data analysis approach. Psychol Med. 2006;36:1535-1540.
3. Academy of Managed Care Pharmacy. Managed care terms. 2014. Accessed December 15, 2014.
4. Consumer Health Choices. Using antipsychotics to treat: depression comparing effectiveness, safety, and price. 2011. Accessed December 16, 2014.
5. Schleifer JJ. Management of acute agitation in psychosis: an evidence-based approach in the USA. Adv Psychiatr Treat. 2011;17:91-100.
6. Owens RT. Inhaled loxapine: a new treatment for agitation in schizophrenia or bipolar disorder. Drugs Today (Barc). 2013;49:195-201.

Last modified: August 30, 2021