Re-Admissions: The Big Problem in Psychiatric Hospitals

For once I am going to refer to a very recently published psychiatric literature article. It is published in the Efficacy and Safety of the 3-Month Formulation of Paliperidone Palmitate vs Placebo for Relapse Prevention of SchizophreniaA Randomized Clinical Trial,” by Joris Berwaerts MD, et.al. and “Long-Acting Injectable Risperidone for Relapse Prevention and control of Breakthrough Symptoms After a Recent First Episode of Schizophrenia: A Randomized Clinical Trial,” by Kenneth L. Subotnik, PhD, et.al.  However the editorial piece for that issue is what I will link the interested reader to as it has the “meat” of this topic and its lessons, written by William T. Carpenter MD, and, Robert W. Buchanan MD, titled, “Expanding Therapy with Long-Acting Antipsychotic Medications in Patients with Schizophrenia.”

First, the problem that these articles and editorial address. A huge percentage of psychotic patients, in this context, those with schizophrenia stop taking their oral medications that mostly prevent recurrent relapses of their illness. At the hospital level where i work, we call this “recidivism,” a term a I do not especially like as it comes from the correctional system [read jail/prison] but we are stuck with it. It means that a patient has again become ill and has to be readmitted and restarted on his/her medication and stabilized once again. This is a HUGE problem in psychiatry and costs untold tens if not hundreds of millions of dollars for each state hospital psychiatric system. Without an old fasshioned public health system as in the “old days,” where public health nurses went out to TB patients homes and saw to it that they took their anti-tubercular medicines daily in person, we do poorly with ensuring “compliance,” with chronically mentally ill (CMI) patients to ensure they take their oral medications everyday, and they relapse. Estimates from studies range all over the place but are often near or over 50%!

For more than three decades we have had older generation antipsychotic medications, that come in “depot” form, in which the medication can be administered in an injection in the arm or buttock and last from 2 to 4 weeks at a time. Administration and the right dosage are asssured; we know the patient receives the medication and relapses are much less common. These medications are Haldol, and Prolixin. But they are in the generation of antipsychotics that can cause muscle cramps and motoric restlessness (akathisia), both of which are unpleasant side effects. Medications can be given that largely prevent these but patients often do not like to stay on these two medicines long term though they work very well.

We have had  for several years recently two of the newer, “second generation,” antipsychotic medications, Abilify and Risperdol that come in long acting depot injectable forms. And while they have far less of the above side effects, they have other kinds of “metabolic,” side effects, but the big problem with them is that they are incredibly expensive. A dose of the Ability deopt from can cost up to $1700 a dose!

 

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Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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