Medication nonadherence can adversely affect patients with bipolar disorder, which can result in attempted suicides and suicides, emergency department (ED) visits, homelessness, hospitalizations, increased health care costs, and relapses (figure).1 Adherence is generally defined as taking at least 80% of the prescribed doses, and various factors, such as adverse reactions, drug costs, health literacy, and substance abuse, can affect a patient’s decision to comply with a medication regimen.Pharmacists can play an important role to improve medication adherence for patients with bipolar disorder through medication therapy management (MTM) services that focus on promoting mental health.


Figure. Complications of medication nonadherence1

About 41% of adults in the United States with any psychiatric disorder receive mental health care.Medication nonadherence rates for patients experiencing serious mental illness range from 23% to 50% for individuals with bipolar disorder.2 One systematic review analyzed 38 studies, which included individuals with bipolar disorder.3 The study found that the average medication adherence rates were 41% for patients with bipolar disorder.3

The College of Psychiatric and Neurologic Pharmacists article emphasized the need for psychiatric pharmacists who have specialized training in mental health disorders to provide comprehensive medication management (CMM) and direct patient care, preferably through face-to-face contact.2 Evidence has shown that when psychiatric pharmacists are included in the health care team, medication-related outcomes for patients with neurologic and psychiatric disorders improve.2

Psychiatric pharmacists can perform an assessment that encompasses the patient’s medications, possible adverse effects (AEs), drug interactions, and lifestyle, such as substance abuse or tobacco use. Patients who benefit the most from these interventions include those experiencing a transition in care, taking multiple long-term medications, and using medications that require frequent monitoring.2 In 2012, the Patient-Centered Primary Care Collaborative created guidelines for CMM to ensure that each drug in a patient’s regimen is evaluated to determine whether it is appropriate.2 There is a growing trend toward implementing CMM within family medicine practices with pharmacist involvement to identify and resolve drug therapy problems.4

One recent cross-sectional study, published in the Journal of the American Pharmacists Association, set out to compare the delivery of MTM between Medicare beneficiaries with and without mental health conditions.5 Comprehensive medication review use and MTM delivery were analyzed in a subset of 825,003 MTM-enrolled beneficiaries. The results showed that MTM enrollment in the mental health group was significantly higher than the non mental health group (P <.001). However, a greater number of those in the non-mental health group received comprehensive medication reviews (P <.001). Also, patients in the mental health group were more likely to have been hospitalizated (P <.001) or visited the ED (P <.001) and used more medications (P <.001).5 This study shows a great need for pharmacists to perform MTM services for patients with mental health conditions.

Zeina Tal, PharmD, RPh, a pharmacist at Genoa Healthcare in Toledo, Ohio, discussed MTM services for patients with psychiatric disorders in an interview. Genoa Healthcare is a chain pharmacy that operates independently inside mental health clinics and recently opened its 500th pharmacy in the United States. Genoa Healthcare Medication Management Solutions focuses on medication adherence to improve outcomes and lower health care costs.6 Within the first year of any program, the medication management services have achieved an average of 5 stars for MTM.6

“When I’m providing MTM services to a consumer living with bipolar disorder, it’s important to understand their medication experience so that I can identify why they might not be taking medications as prescribed,” Tal said.

Solutions to improve adherence include phone reminders and using weekly prefilled pill organizers. Tal often contacts the health care provider to discuss other medication options if patients are experiencing significant adverse effects on their drug regimen.

Patients with bipolar disorder often have other comorbidities, such as diabetes, and Tal shared an adherence success story of encouraging a patient to continue with her insulin therapy.

“Bipolar disorder is a lifelong condition, and I see my role in providing MTM as helping empower patients to be as healthy as possible. I’m proud of the impact it can have,” Tal said.
 
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REFERENCES
  1. Bauer M, Glenn T, Alda M, et al. Trajectories of adherence to mood stabilizers in patients with bipolar disorder. Int J Bipolar Disord. 2019;7(1):19. doi:10.1186/s40345-019-0154-z.
  2. Goldstone LW, DiPaula BA, Caballero J, Park SH, Price C, Slater MZ. Improving medication-related outcomes for patients with psychiatric and neurologic disorders: value of psychiatric pharmacists as part of the health care team. Ment Health Clin.  2015;5(1):1-28. doi.org/10.9740/mhc.2015.01.001
  3. Garcia S, Martinez-Cengotitabengoa M, Lopez-Zurbano S, et al. Adherence to antipsychotic medication in bipolar disorder and schizophrenic patients. J Clin Psychopharmacol. 2016;36(4):355-371. doi: 10.1097/JCP.0000000000000523.
  4. Castelli G, Bacci JL, Dombrowski SK, et al. Pharmacist-delivered comprehensive medication management within family medicine practices an evaluation of the SCRIPT project. Fam Med. 2018;50(8):605-612. doi: 10.22454/FamMed.2018.391124.
  5. Murugappan MN, Seifert RD, Farley JF. Examining Medicare Part D medication therapy management program in the context of mental health. J Am Pharm Assoc. 2020. doi: 10.1016/j.japh.2019.12.008.
  6. Genoa Healthcare. Improving outcomes and reducing costs with medication management services for health plans. genoahealthcare.com/medication-management-solutions/. Accessed January 20, 2020.