Managing Schizophrenia: The Role of Pharmacies in Providing Continuing Care

As providers of long-acting treatment injections, pharmacists can postitvely impact medication adherence.

Untreated mental illness has taken a major economic, social, and personal toll in the United States. Yet despite the importance of treatment, many patients struggle to access appropriate care.^1,2

Approximately 1 in 4 Americans over the age of 18 years has a diagnosable mental disorder, and about 6% live with serious mental illnesses, including schizophrenia or bipolar I disorder. An estimated 2.4 million adults in the United States are living with schizophrenia, a chronic, severe, and disabling brain disorder.³

Once properly diagnosed, schizophrenia can be effectively managed. With a combination of treatments that may include medication and psychotherapy, many individuals living with schizophrenia are able to participate in daily activities and live productive and meaningful lives. Treatment offers hope for the future.

Pharmacies can play a critical role in helping patients obtain access to appropriate treatment. Consider that, nationwide, there are only 50,000 psychiatrists and a shrinking supply of primary care providers, while there are almost 275,000 pharmacists employed in the United States, a number that is growing.^5,6

Broadly speaking, pharmacists help fill the gaps in patient care by educating patients, monitoring medications, and administering injections prescribed by other health care professionals (HCPs) in states where pharmacists are licensed to do so. Pharmacists have demonstrated success in administering vaccinations, and further experience in this area will help determine the future role of pharmacists in the administration of HCP-ordered medication. The pharmacist role in filling gaps in care is especially critical when treating patients with schizophrenia, who have a unique set of care and treatment challenges.^7-12

Janssen Pharmaceuticals, Inc, pioneered the development of long-acting atypical injectable antipsychotics for schizophrenia to offer HCPs effective treatment options that provide patients with a choice of how often to take their medication.

However, if the only availability of long-acting treatment (LAT) administration is through an HCP’s office, patients with schizophrenia can face barriers to care, such as difficulty finding a location where an HCP is licensed to administer this type of medication. Many patients also have difficulty understanding reimbursement and following through with an HCP-ordered treatment plan. Not having the information and resources that support HCP-ordered treatment or an understanding of how to access that treatment can put people with schizophrenia at risk of relapse, possibly leading to disability, homelessness, and other serious consequences.

Janssen has become increasingly aware of patient needs regarding adherence to their HCP’s orders in the treatment of schizophrenia. Within 5 years, about 80% of patients with schizophrenia who responded to treatment of their first episode experience a relapse defined as schizophrenia symptoms such as delusions, hallucinations, impaired understanding, derailment, illogical thinking, and bizarre behavior. The risk for relapse in patients can substantially increase as a result of nonadherence. While no medication or delivery mechanism can ensure that patient adherence will improve, the use of a professionally administered injectable long-acting antipsychotic medication can give HCPs greater ability to identify when a patient has missed a dose and to intervene as appropriate.^13-15

A 2012 survey by the College of Psychiatric and Neurologic Pharmacists Foundation and National Alliance on Mental Illness found that 91% of individuals taking mental health medication are very comfortable going to community pharmacies to fill their medications and 83% report feeling respected by their pharmacist. Research shows that most Americans live within 5 miles of a pharmacy, and proximity is important to access.

Janssen Connect was created to help patients overcome barriers to following their HCP-ordered treatments. For individuals living with schizophrenia, adherence to therapy is critical.¹⁶ Giving patients the option of receiving an injection at a retail pharmacy (one example of a Janssen Connect injection center) helps facilitate important steps to start and stay on medication therapy. Janssen Connect offers information and assistance provided by a program administrator to help patients after their HCP has determined that an LAT is the most clinically appropriate treatment option. The Janssen Connect injection centers check for side effects before administration of the HCP-ordered injection and provide documentation to the HCP.

The Janssen Connect program offers comprehensive information and assistance to help appropriate patients with schizophrenia start and stay on their Janssen long-acting injectable atypical antipsychotic after it has been determined by their HCP to be the most clinically appropriate treatment option. The offerings provided by Janssen Connect vary by state and are applied to individual patient cases based on HCP directive. To aid access and understanding of reimbursement, the program provides research about Janssen LAT coverage status and helps patients identify the lowest co-pay options and navigate the complexities of benefits investigation and prior authorization. Bridging the inpatient/outpatient appointment gap, Janssen Connect offers information and assistance to help patients continue injections ordered by their HCP once they leave the hospital. The program assists in coordinating medication shipment to the HCP’s office so he or she can administer injections to patients, and determines additional injection center sites where patients can receive HCPordered injections at a location that may be more convenient for them. Janssen Connect encourages adherence to an HCP-ordered treatment plan by providing ongoing communication to patients and HCPs about patients’ treatment followthrough. HCPs receive documentation of patient visits and are notified if patients miss an injection appointment. A patient enrollment form requesting information regarding assistance must be completed and submitted by an HCP. Pharmacists who want to learn more about Janssen Connect can call (877) 524- 3579.

Janssen Connect has been working with participating pharmacies to provide information and assistance to patients since December 2010 and has served more than 20,000 patients of more than 3200 HCPs. Currently, about 150 patients per week request information and assistance. More than 30,000 HCPordered injections have been administered through Janssen Connect, and 85% of Janssen Connect patients returned to an injection center after their first injection. Encouragingly, 92% of answered Janssen Connect reminder calls resulted in an injection.^17,18

Pharmacists have demonstrated an important role in helping patients. Janssen Connect injection centers play a role in providing another point of contact to a licensed HCP for patients living with schizophrenia who are taking an HCPprescribed Janssen long-acting therapy. Retail pharmacies and other communitybased providers are increasingly important in reaching patients close to where they live. Pharmacies can serve as alternate injection centers for patients who have been prescribed a Janssen LAT.^19-21

Expanding injection center options for patients to receive HCP-ordered injections can help support patients in their overall treatment journey. It allows HCPs to potentially better focus on the practice of medicine by providing information about whether patients have received their injections. Similarly, other prescribers and social workers can concentrate on addressing the day-to-day needs of patients when they have additional clarity on the status of a patient’s HCP-ordered injection. Janssen Connect patients in 21 states now have greater choice of location for the administration of their HCP-ordered medicine. Pharmacists, in turn, can play an exciting new role in the evolution of the treatment experience of individuals living with schizophrenia.

Makis Papataxiarchis holds a PhD in pharmaceuticals, an MBA in marketing management, and an MS in pharmaceutical chemistry. He has extensive experience in the pharmaceutical business with 19 years in various executive roles, general management, and marketing and sales positions in Europe, including 5 years at Novartis and 14 years at Johnson & Johnson. During these years he has worked both operationally and strategically, managing the business while also contributing to the development of the health care system in several countries in Europe. Makis is an active member and coordinator of many teams for strategic planning for Europe, the Middle East, and Africa. He was also responsible for various projects of the Janssen Pharmaceuticals, Inc, strategic road map for Johnson & Johnson on health care access in Europe. He is currently the national director for systems of care at Janssen in the United States, and prior to that he was managing director of Johnson & Johnson and Janssen in Romania and Greece. Makis also served as president of the Association of International Pharmaceutical Manufacturers in Eastern Europe.

References

• Annual total direct and indirect costs of serious mental illness. National Institutes of Mental Health website. www.nimh.nih.gov/health/statistics/cost/index.shtml.
• Mental health expenditures as a percent of all health care expenditures. National Institute of Mental Health website. www.nimh.nih.gov/health/statistics/cost/mental-health-expenditures-as-a-percent-of-all-health-care-expenditures-2003.shtml.
• The numbers count: mental disorders in America. www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml. National Institute of Mental Health website. 2013.
• Frequently asked questions about schizophrenia. Brain & Behavior Research Foundation website. www.bbrfoundation.org/frequently-asked-questions-about-schizophrenia. Published 2013.
• Fewer US med students choose psychiatry: report. US News & World Report. March 30, 2012. http://health.usnews.com/health-news/news/articles/2012/03/30/fewer-us-med-students-choose-psychiatry-report. Accessed November 1, 2013.
• Characterizing the Relationship Between Individuals with Mental Health Conditions and Community Pharmacists. College of Psychiatric and Neurologic Pharmacists Foundation and National Alliance on Mental Illness. December 2012. Accessed November 25, 2013. http://cpnp.org/_docs/foundation/2012/nami-survey-report.pdf.
• A Report to the U.S. Surgeon General 2011. Office of the Chief Pharmacist. Updated December 2011.
• Mitchell AJ, Selmes T. Why don’t patients take their medicine? Reasons and solutions in psychiatry. Adv Psychiatr Treatments. 2007:13(5), 336-346.
• Fontaine KL. Chapter 14. In: Mental Health Nursing. 6th ed. Saddle River, NJ: Prentice Hall; 2008.
• Heyscue BE, Levin GM, Merrick JP. Compliance with depot antipsychotic medication by patients attending outpatient clinics. Psychiatr Serv. 1998;49(9):1232-1234.
• Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. Published February 17, 2006.
• A Report to the U.S. Surgeon General 2011. Office of the Chief Pharmacist. Updated 2011.
• Emsley R, Chiliza B, Asmal L, Harvey BH. (2013). The nature of relapse in schizophrenia. BMC Psychiatry. 2013;13:50.
• Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association: Washington, DC; 2013.
• Robinson D, Woerner MG, Alvir JM, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry. 1999;56(3):241-247.
• Emsley R, Chiliza, B, Asmal L, Harvey BH. The nature of relapse in schizophrenia. BMC Psychiatry. 2013;13:50.
• Janssen Connect program monthly analytics. August 1, 2014.
• National Transitions of Care Coalition Essential Resource Program Application.
• A Report to the U.S. Surgeon General 2011. Office of the Chief Pharmacist. Updated December 2011.
• Characterizing the Relationship Between Individuals with Mental Health Conditions and Community Pharmacists. College of Psychiatric and Neurologic Pharmacists Foundation and National Alliance on Mental Illness. December 2012. http://cpnp.org/_docs/foundation/2012/nami-survey-report.pdf.http://cpnp.org/_docs/foundation/2012/nami-survey-report.pdf. Accessed November 19, 2013.
• Krisberg K. Pharmacists taking on a greater role in fight against influenza. The Nation’s Health. 2012;42(1). www.medscape.com/viewarticle/757999. Accessed July 31, 2014.