Increased Costs of Treatment due to the DSM-V: Implications for Pharmacy Practice

By: James W. Schurr and David Gao, PharmD Candidates 2014

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A recent Op-ed in Newsday by Allen Frances, MD (of Duke University School of Medicine and chairman of the task force that produced the DSM-IV, the current guidelines for psychiatric disease diagnosis) criticizes the American Psychiatric Association for being “extravagantly indifferent to all matters of cost” in preparing the DSM-V.¹  This new manual, he argues, will vastly expand psychiatric diagnoses to those who do not require treatment.  He also posits that the pharmaceutical industry, and not the patients, will be the only beneficiaries of this new manual.  If there is any merit to these claims, it is imperative for pharmacists to help mitigate these increases in costs through collaborative practice.  The medical literature is replete with examples that illustrate the benefits pharmacists provide to patients through direct care models.

One collaborative care model for the treatment of depression was studied by Finley et al. and published in Pharmacotherapy in 2003.²  In this study, 13 primary care providers (PCPs) referred patients who were newly diagnosed with depression and started on antidepressant therapy to clinical pharmacy services within the Health Maintenance Organization (HMO).  Clinical Pharmacy Specialists provided medication maintenance and follow-up patient care at the clinic.  In this setting, pharmacists were granted prescribing privileges for co-managing their patients in conjunction with psychiatrists.  Pharmacists performed intake interviews with patients that involved active listening for patient assessment as well as education on depression as an illness, their pharmacologic treatment, and importance of adherence to therapy. When this model was studied for impact on depression in primary care, the authors concluded that the interdisciplinary treatment model emphasizing clinical pharmacy services was associated with significant increases in treatment adherence, greater patient satisfaction, and improved resource utilization.³

            A study published in 1982 by Berchow in the American Journal of Hospital Pharmacy examined the effects of adding a clinical consultant pharmacist to a multi-disciplinary team at an institution for the mentally disabled.  The facility was reviewed twice—before and after the service was added.  Over one year, the long-term use of drugs fell from 76.1% – 56.8%.  Antipsychotic drug use fell from 34.2% – 16.8%.  Although a pharmacoeconomic analysis was not provided for this study, the decreases in drug use were significant (p < 0.001).⁴

A similar study was performed at another institution for the mentally disabled by Ellenor et al.  This group implemented a drug assessment program for individual patients, performed a chart review, and determined the impact of a pharmacist team member on prescribing patterns over 2 years.  This non-controlled and non-randomized study revealed that pharmacist involvement reduced antipsychotic agent use by 18%, antianxiety and antidepressant use by 58%, and sedative-hypnotic use by 58%.  Net savings were projected to be $10,000 per year after subtracting a full-time pharmacist’s salary.⁵

Lobeck et al. performed a retrospective chart review to determine the effectiveness of pharmacy services in an outpatient mental health clinic at a Veterans Affairs (VA) hospital.  Over 3 months, pharmacist recommendation decreased clinic visits by 44%, the number of prescriptions per patient by 16%, and actual cost per prescription by 35%.  Projected annual net savings were $22,241 per year after deducting a pharmacist’s salary.⁶

Gray et al. determined the impact of adding clinical pharmacy services at a VA day-treatment center.  Data gathered from patient interviews, drug history records, and medical records over 3 months were analyzed according to a Likert Scale.  Although mental functioning scores dropped slightly from 55.8 to 52.7, reductions were observed in adverse effects (62 to 21) and drug use problems (61 to 3).  The yearly savings in drug costs was $27,750 and personnel cost savings was $18,750.⁷

Nonadherence to antipsychotics has long been associated with relapse and re-hospitalization and, consequently, an increase in cost of treatment.  In fact, hospitalization can account for up to 40% of direct costs involved with schizophrenia.  Long-acting injectable antipsychotics (LAIAs) have been suggested as a cost-saving alternative.  However, inpatient administration of LAIA has financial limitations.  In particular, second generation LAIA cost more but don’t garner any additional reimbursement.  Phan and Vandenberg conducted a study evaluating the financial impact of shifting LAIA administration from an inpatient to a pharmacy-run outpatient setting.  Based on quarterly charges and costs, annual pharmacy purchase savings were projected at least $12,000 per year and unreimbursed inpatient charges avoided were projected at $25,000 per year.⁸

                        Pharmacy practice models for the treatment of patients with psychiatric illnesses have been developed and studied with positive humanistic, clinical, and economic outcomes.  Pharmacists specializing in psychiatric pharmacotherapy, especially those with board certification, are in a prime position to manage psychiatric patients.  If costs rise as predicted by Dr. Frances, the medical field should turn to pharmacists, the pharmacotherapy experts, to ensure that patients receive optimal and cost-effective pharmaceutical care.

SOURCES:

1. Frances, Allen. New psych manual will hike health costs. Newsday. January 1^st, 2013. http://www.newsday.com/opinion/oped/frances-new-psych-manual-will-hike-health-costs-1.4393434
2. Finley PR, Rens HR, Pont JT, et al. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003;23(9):1175-85.
3. Finley PR, Rens HR, Pont JT, et al. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003;23(9):1175-85.
4. Berchow RC. Effect of a consultant pharmacist on medication use in an institution for the mentally retarded. Am J Hosp Pharm 1982;39:1671-4.
5. Ellenor GL, Frisk AP. Pharmacist idpact on drug use in an institution for the mentally retarded. Am J Hosp Pharm 1977;34:604-8.
6. Lobeck F, Traxler WT, Bobinet DD. The cost-effectiveness of a clinical pharmacy service in an outpatient mental health clinic. Hosp Commun Psychiatry 1989;40:643-4.
7. Gray DR, Namikas EA, Sax MJ, et al. Clinical pharmacists as allied health care providers to psychiatric patients. Contemp Pharm Pract 1979;2(3):108-16.
8. Phan SV, Vandenberg AM. Financial impact of a pharmacist-managed clinic for long-acting injectable antipsychotics. Am J Health Syst Pharm. 2012;69(12):1014-5.