Psychotropic Use in the Homeless Population

Transcription

1 Psychotropic Use in the Homeless Population Whitney Ruddock, PharmD Memorial Hospital West Objectives To investigate the correlation between mental illness and homelessness To identify the social, mental, and physical barriers that contribute to non-adherence to psychotropic medications in the homeless population To identify strategies for increasing adherence to psychotropic medications in the homeless population Homelessness and Mental Health 2008 survey of 25 cities, mental illness was the 3 rd leading cause of homelessness Contributing factors: Difficulty maintaining a job Risk of alcohol use and substance abuse Lack of familial support Closure of psychiatric institutions Lack of low-cost housing Lack of community-based resources United States Conference of Mayors. Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America's Cities Available from Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in Western countries: Systematic review and meta-regression analysis. PLoS Med. 2008;5:e225. 1

2 Homelessness and Mental Health 6% of Americans have a serious mental illness 2012 report estimated that there are ~633,780 homeless Americans (2012): 200,000 (32%) with any type of mental illness 165,000 (26%) have had serious mental illness National Coalition for the Homeless. Mental Illness and Homelessness HUD Annual Homeless Assessment Report, Vol. 2. Office of Community Planning and Development, U.S. Department of Housing and Urban Development, Abt Associates, Serious Mental Disorder Federal definition for patients 18+: Having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment substantially interferes with or limits one or more major life activities Includes major depression, schizophrenia, bipolar disorder, and other mental disorders that cause serious impairment Substance Abuse and Mental Health Services Administration. Mental and Substance Use Disorders. Accessed December 6, Schizophrenia POSITIVE SYMPTOMS Delusions Hallucinations Disorganized Speech Movement disorders (catatonia) DIAGNOSIS: 2 of the following ( 1 must be starred ) Delusions* Hallucinations* Disorganized speech* Grossly disorganized or catatonic behavior Negative symptoms Duration: significant portion during a 1-month period = change that was added in DSM-V that was not previously in DSM-IV = The exclusion for Schneiderian first-rank symptoms was deleted in DSM-V NEGATIVE SYMPTOMS Main: Diminished emotional expression Avolition Other: Apathy Alogia Asociality Anhedonia American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC. 2

3 AVAILABLE FIRST GENERATION ANTI-PSYCHOTICs AND DOSES Generic Name Trade Name Starting Dose Usual Dose Range Comments Chlorpromazine Thorazine ,000 Most weight gain among FGAs Fluphenazine Prolixin Haloperidol Haldol IM depot available; Dose carefully in CYP2D6 slow metabolizers Higher dropout rate in first episode; IM depot available; BBW for high dose (QTc prolongation) Loxapine Loxitane Loxapine inhaled Adasuve Maximum 10 mg per 24 hours Approved REMS program only Perphenazine Trilafon IM depot available; Dose carefully in CYP2D6 slow metabolizers Thioridazine Mellaril Significant QTc prolongation (BBW) Thiothixene Navane Trifluoperazine Stelazine AVAILABLE SECOND GENERATION ANTI-PSYCHOTICs AND DOSES Generic Name Trade Name Starting Dose Usual Dose Range Comments Aripiprazole Abilify Dose carefully in CYP2D6 slow metabolizers Asenapine Saphris Sublingual only (PO= <2% bioavailablity) Clozapine Clozaril Iloperidone Fanapt Lurasidone Latuda Olanzapine Zyprexa Used for refractory cases; check plasma level (< 350 ng/ml) before exceeding 600 mg; requires monthly CBCs due to possible agranulocytosis; titrate slowly due to orthostasis risk Dose carefully in CYP2D6 slow metabolizers; titrate slowly due to orthostasis risk Avoid in first episode because of weight gain; IM depot available Paliperidone Invega Bioavailability w/ food; IM depot available Quetiapine Seroquel Shorter half-life (6-7 hours) Risperidone Risperdal Ziprasidone Geodon IM depot available; Dose carefully in CYP2D6 slow metabolizers Take with food; metabolized mainly by aldehyde oxidase (not CYP enzyme); shorter half-life (7 hours) Available FGAs/SGAs slides adapted from Table 50-5 Available Antipsychotics and Dosage Ranges. Crismon M, Argo TR, Buckley PF. Crismon M, Argo T.R., Buckley P.F. Chapter 50. Schizophrenia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L eds. Bipolar I Disorder Bipolar Disorder Manic or mixed episodes 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care Depressive episodes lasting 14 days typically occur Bipolar II Disorder Pattern of depressive episodes and hypomanic episodes National Institute of Mental Health. How is bipolar disorder diagnosed?. Accessed November 28,

4 Bipolar Disorder Bipolar Disorder Not Otherwise Specified (BP-NOS) Patient has symptoms of the illness but do not meet diagnostic criteria for bipolar I or II Cyclothymic Disorder Mild form of bipolar disorder with hypomania and mild depression for at 2 years. Rapid-cycling Bipolar Disorder Patient has four or more episodes of major depression, mania, hypomania, or mixed states, all within a year National Institute of Mental Health. Bipolar disorder: How is bipolar disorder diagnosed?. Accessed November 28, Signs and Symptoms of Mania Mood Changes Feelings of a "high," or an overly happy or outgoing mood Extreme irritability Behavioral Changes Talking very fast, jumping from one idea to another, having racing thoughts Being easily distracted Increasing activities, such as taking on new projects Being overly restless Sleeping little or not being tired Having an unrealistic belief in one's abilities Behaving impulsively and engaging in pleasurable, high-risk behaviors National Institute of Mental Health. Bipolar disorder: How is bipolar disorder diagnosed?. Accessed November 28, Signs and Symptoms of Depression Persistent sad, anxious, or "empty" feelings Feelings of hopelessness or pessimism Feelings of guilt, worthlessness, or helplessness Irritability, restlessness Insomnia, early-morning wakefulness, or excessive sleeping National Institute of Mental Health. Depression: What is depression?. Accessed November 28, Overeating/appetite loss Loss of interest in activities or hobbies once pleasurable, including sex Fatigue and decreased energy Difficulty concentrating, remembering details, and making decisions Thoughts of suicide, suicide attempts 4

5 Drug Initial Dosing Usual Dosing Side effects Anti-epileptics Lithium (Lithobid) Divalproex sodium (Depakote) 300 mg BID 900-2,300 mg/day in 2-4 divided doses, preferably with food mg BID 750-3,000 mg/day (20-60 mg/kg/day) or in divided doses Cogwheel rigidity, fine hand tremor, weight gain Dizziness, nauseam, tremor, diplopia Lamotrigine (Lamictal) Carbamazepine (Tegretol) Valproic acid (Depakene) 25 mg daily mg/day in divided doses 200 mg BID 200-1,800 mg/day in 2-4 divided doses mg BID 750-3,000 mg/day (20-60 mg/kg/day) qday or in divided doses Oxcarbazepine 300 mg BID 300 mg 100-1,200 mg/day in 2 divided doses Somnolescence, diplopia, dizziness Somnolescence, diplopia, ataxia Alopecia, weight gain, tremor, blurred vision Dizziness, ataxia, abnormal gait, tremor, diplopia Drug Initial Dosing Usual Dosing Second-generation anti-psychotics Aripiprazole (Abilify) Asenapine (Saphris) Olanzapine (Zyprexa) Olanzapine and fluoxetine (Symbyax) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) mg daily mg/day once daily 5-10 mg daily sublingually 5 10 mg twice daily sublingually mg twice daily 5 20 mg/day once daily or in divided doses 6 mg olanzapine and 25 mg fluoxetine daily 6 12 mg olanzapine and mg fluoxetine daily 50 mg twice daily mg/day in divided doses or once daily when stabilized mg twice daily mg/day once daily or in divided doses mg twice daily mg/day in divided doses with food Side effects will be discussed on a subsequent slide Major depression Depression Severe symptoms that interfere with one s ability to work, sleep, study, eat, and enjoy life Persistent depressive disorder Depressed mood that lasts for 2 years National Institute of Mental Health. Depression: What is depression?. Accessed November 28,

6 Drug Initial Dosing Usual Dosing Selective Serotonin Reuptake Inhibitors (SSRIs) Side effects Citalopram (Celexa) Somnolescence, Escitalopram (Lexapro) insomnia, nausea, xerostomia, Fluoxetine (Prozac) diaphoresis, Fluvoxamine (Luvox) weakness, tremor, dizziness, headache Paroxetine IR (Paxil) Paroxetine CR (Paxil CR) Sertraline (Zoloft) Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) Desvenlafaxine (Pristiq) Same as SSRIs plus increased Duloxetine (Cymbalta) blood pressure Venlafaxine (Effexor) Drug Initial Dosing Select Tricyclic Anti-depressants (TCAs) Usual Dosing Side effects Amitriptyline (Elavil) Desipramine Anticholinergic effects, orthostasis, (Norpramine) Doxepin (Silenor) sexual dysfunction, vivid dreams, weight Imipramine (Tofranil) gain, myoclonus Nortriptyline (Palmelor) Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil) Anticholinergic effects, Tranylcypromine orthostasis, (Parnate) sexual Selegiline patch, dysfunction, transdermal hypertensive (Emsam) crisis Drug Initial Dosing Usual Dosing Side effects Norepinephrine and Dopamine Reuptake Inhibitor (NDRI) Bupropion (Wellbutrin) 150 Mixed Serotonergic Effects (Mixed 5-HT) Nefazodone (Serzone) Trazodone (Desyrel, Oleptro) 300 Dry mouth, insomnia, tremors/seizures Sedation, orthostasis, sexual dysfunction, risk of priapism Vilazodone (Viibryd) Serotonin and α 2 -Adrenergic Antagonist Mirtazapine (Remeron) Sedation and increased appetite, weight gain, dry mouth, dizziness 6

7 BARRIERS TO MEDICATION NON- ADHERENCE Non-adherence to Antipsychotics Medication non-adherence Failure to take medication as prescribed or to attend follow-up Non-adherence to psychotrophic medications: Major depressive disorder: 28% 52% Bipolar disorder: 20% 50% Schizophrenia: 20% 72% 21% of homeless unable to access healthcare for mental illness McIntosh A., et al. Compliance therapy for schizophrenia. Cochrane Database of Systematic Reviews, Issue 4. Art. No. CD, 2006 Hawton K. et al. Schizophrenia and suicide: systematic review of risk factors. The British Journal of Psychiatry 187, 9 20, 2005 Aldridge M.A. Addressing non-adherence to antipsychotic medication: a harm-reduction approach. Journal of Psychiatric and Mental Health Nursing, 2011 Baggett TP et al. The Unmet Health Care Needs of Homeless Adults: A National Study. Am J Public Health July; 100(7): Non-adherence to Antipsychotics Non-adherence in psychiatric patients leads to: Lack of symptom stabilization, hospitalization, homelessness, lower quality of life Non-adherence to anti-psychotics associated with a 3-fold increase in Suicide risk, number/frequency of psychotic relapses, admissions to hospital and poorer outcomes Mortality rates are higher in patients with schizophrenia than the general population Julius RJ, Novitsky MA, Jr, Dubin WR. Medication adherence: a review of the literature and implications for clinical practice. Journal of Psychiatric Practice. 2009;15: Magura S et al. Risk factors for medication non-adherence among psychiatric patients with substance misuse histories. Ment Health Subst Use Nov; 7(4): Published online 2013 Oct 1. 7

8 Barriers to Medication Adherence for the Homeless Social Stolen/lost medications Lack of social support Social stigma Financial Inability to afford medications Physical Lack of transportation Lack of storage space for medications Mental Alcohol/drug abuse Health literacy Unni EJ et al. Medication non-adherence in the homeless population in an Intermountain West city. Innovations in Pharmacy. 2014, Vol. 5, No. 2, Article 160 Barriers to Psychotrophic Medication Adherence Medication non-adherence due to: 1. Anosognosia 2. Alcohol and/or drug abuse 3. Medication side effects 4. Negative attitude toward medication 5. Symptom severity 6. Inadequate discharge planning or aftercare environment 7. Relationship with physician Day JC. Attitudes toward antipsychotic medication: the impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry Jul;62(7): Higashi K. Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Ther Adv Psychopharmacol Aug; 3(4): Anosognosia Anosognosia= Lack of insight of lack of awareness of one s condition. Leading cause of medication nonadherence in patients with schizophrenia and bipolar disorder (National Alliance on Mental Illness) 50% of patients with schizophrenia 40% of patients with schizophrenia Kessler RC et al. The prevalence and correlates of untreated serious mental illness. Health Services Research 2001;36: Lacro J, Dunn LB, Dolder CR, et al. Prevalence of risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry 2002;63: National Alliance on Mental Illness. Anosognosia. December 16,

9 Anosognosia Scandinavian study (n=218) of outpatients with severe mental illness found a correlation between anosognosia and medication adherence (p<0.007) Lacro et al.: 10 out of 14 studies showed a strong association between anosognosia and medication adherence Lacro J, Dunn LB, Dolder CR, et al. Prevalence of risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry 2002;63: Trauer T, Sacks T. The relationship between insight and medication adherence in severely mentally ill clients treated in the community. Acta Psychiatrica Scandinavica 2000;102: Drug Use and Abuse 10-20% of homeless patients have mental illness and SUD 30-40% abuse alcohol 10-20% abuse other drugs Substance use disorder (SUD) in patients with schizophrenia is 3x greater than the general population Kashner TM, Rader LE, Rodell DE, et al. Family characteristics, substance abuse, and hospitalization patterns of patients with schizophrenia. Hospital and Community Psychiatry 1991;42: Drake RE. Homelessness and Dual Diagnosis. American Psychologist, November 1991 Vol. 46, No. 11, Drug Use and Abuse In patients with schizophrenia, patients with SUD are 13x more likely patients to be non-adherent to antipsychotics than those without SUD 3x higher use in patients with schizophrenia Nicotine Alcohol Cannabis Green AI et al. Treatment of Psychiatry: Schizophrenia and Co-Occurring Substance Use Disorder. American Journal of Psychiatry. March 2007 Volume 164 Number 3 Kashner TM, Rader LE, Rodell DE, et al. Family characteristics, substance abuse, and hospitalization patterns of patients with schizophrenia. Hospital and Community Psychiatry 1991;42:

10 Medication Side Effects Loffler et al (n=307) Patients with schizophrenia undergoing psychiatric treatment Reasons for medication non-adherence Side effects (50%) Lack of acceptance of the necessity of pharmacological treatment (40%) Lack of insight (27%) Loffler W. et al. Schizophrenic patients subjective reasons for compliance and noncompliance with neuroleptic treatment Pharmacopsychiatry 36: SELECTED ANTI-PSYCHOTICs SIDE EFFECT CHART Sedation EPS Low-potency First-Generation Anti-psychotics (FGAs) Weight Prolactin Chlorpromazine Thioridazine Medium-potency FGAs Perphenazine ++ Thiothixene + High-potency FGAs Fluphenazine + Haloperidol EPS= extrapyramidal side effects. Relative side effect risk: ±, negligible; +, low; ++, moderate; +++, moderately high; ++++, high. Side effects shown are relative risk based on doses within the recommended therapeutic range. Sedation EPS Second-Generation Anti-psychotics (SGAs) Weight Anticholinergic Orthostasis Anticholinergic Orthostasis Prolactin Aripiprazole Asenapine + ++ ± Clozapine Iloperidone + ± Lurasidone ± ± Olanzapine Paliperidone Quetiapine Risperidone Ziprasidone Side effect slides adapted from Table 50-7 Relative Side Effect Incidence of Commonly Used Antipsychotics. Crismon M, Argo TR, Buckley PF. Crismon M, Argo T.R., Buckley P.F. Chapter 50. Schizophrenia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; Accessed 17 October,

11 Medication Side Effects Bipolar medications Somnolescence Dizziness Nausea Weight gain Tremor Depression medications Sexual dysfunction Somnolescence Insomnia Xerostomia Dizziness STRATEGIES TO INCREASE MEDICATION ADHERENCE Increasing Medication Adherence in the Mentally Ill Involuntary Outpatient Commitment (IOC) Also known as Assisted Outpatient Treatment (AOT) Court-ordered treatment for patients with severe mental health conditions Usually reserved for patients who are a danger to themselves In some states, additionally for those who are at risk for relapse due to treatment non-adherence Usually 6 months in duration IOC statues in 42 states and the District of Columbia Harvard Health Publications: Harvard Medical School. Involuntary Outpatient Commitment. Accessed December 6,

12 Involuntary Outpatient Commitment (IOC) Duke Study (1999) Involuntarily hospitalized patients randomly assigned to be released (n=135) or continue outpatient treatment (n=129) Combing court order with outpatient psychiatric services ( 6 months): rehospitaliza ons up to 74% arrests by 74% violence by up to 50% treatment adherence by 58% Swartz MS et al. Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry Dec;156(12): Antipsychotic Depot Medications Depot injections may increase adherence over oral agents follow-up if patient miss appointment withdrawal symptoms due to partial compliance drug-drug interactions due to bypassing firstpass metabolism Depot versus oral fluphenazine: Del Giudice et al (n=82) : depot superior in relapse Hogarty et al (n=105): depot relapse when combined with individual and family therapy Antipsychotic Depot Medications Prospective trial assessing medication adherence in homeless patients (n=30) who received customized adherence enhancement and long-acting injection antipsychotics for 6 months At enrollment, patients reported missing 46 57% of prescribed oral medications 76% adherence at 6 months Sajatovic M et al. A prospective trial of customized adherence enhancement plus long-acting injectable antipsychotic medication in homeless or recently homeless individuals with schizophrenia or schizoaffective disorder. J Clin Psychiatry Dec; 74(12):

13 Antipsychotic Risperidone microspheres Paliperidone palmitate Olanzapine pamoate Antipsychotic Depot Medications Dose interval (weeks) First-episode patients (mg) Second generation First-episode patients (mg) /2 weeks /4 weeks First generation /2 weeks /4 weeks Fluphenazine Haloperidol decanoate Perphenazine decanoate Hasan A et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. World J Biol Psychiatry Feb;14(1):2-44. doi: / Epub 2012 Dec 6. Summary Anosognosia is the leading cause to medication non-adherence in patients with schizophrenia and bipolar disorder Drug use and abuse as well as medication side effects also affect medication nonadherence in homeless patients with mental illness Involuntary Outpatient Commitment and use of depot antipsychotic medications may increase medication non-adherence in homeless patients with mental illness. True/False Questions 1. The use of long-acting injectable antipsychotic medication is a strategy used to increase medication adherence in the homeless population. 2. Anosognosia means lack of insight or lack of awareness. 3. Mortality rates are lower for homeless patients with schizophrenia than for the general population. 13