The Use of Long-Acting Injectable Antipsychotic Therapy for Schizophrenia

Introduction Antipsychotic medications form the cornerstone of schizophrenia treatment. However, only a minority of patients adhere to their initial antipsychotic regimen. It’s expected that Long-Acting Injectable (LAI) antipsychotics improves patient adherence to treatment, however previous research comparing the use of first generation LAI’s against oral antipsychotics reported results that were inconclusive. Objectives and Approach Explore the effectiveness of the use of LAI’s in the delivery of mental health services in Alberta. Using linked data from AHS Analytics: • Physician claims • National Ambulatory Care Reporting System (NACRS), • Discharge Abstract database (DAD) • Pharmacy Information Network (PIN) • Alberta Provincial Registry data • Define a cohort of patients on antipsychotic medications. • Explore and contrast outcomes related to the use of LAIs against other antipsychotic medication types. Specifically using linked data to define: • Treatment Adherence • Utilization of LAI vs. other medication • Demographic differences • Outcomes pre- and post-LAI treatment Results A patient cohort was established containing only cases from April 1, 2013 to March 31, 2015. Additional data was used to perform a two year washout and a one year follow-up. Case and medication definitions were determined by a team of psychiatric clinicians. Patient comorbidity information was extracted using previously validated methods. Overall, 6349 incident cases were identified. Preliminary analysis indicate: • Overall patient cohort is older than expected • Use of additional medication types is correlated with greater health services utilization after diagnosis • Patients on only oral medications appear to have lower treatment adherence • Males seem to have higher treatment adherence than females • No significant differences were found between patients with rural vs. urban postal codes Conclusion/Implications We faced significant challenges when defining cases, medication use and outcomes. However, the linkage of a large number of data sources gives us powerful and multi-faceted insight into the use of antipsychotic medication use in Alberta. Future work will include work on definition validations and deeper analysis of outcomes

Automatic pacing: on the use of external timing cues to regulate speed during human walking and running

Out of all parameters used to describe gait, overground speed is one of the most important. The importance of gait speed is highlighted when used as a measure of performance during exercise, or as a measure of function when walking ability is compromised. Because the ability to control gait speed is imperative to reach optimal results in both exercise and gait rehabilitation, a system that helps people to control their overground speed more accurately might be beneficial. Developing an overground speed control system was the main goal of this thesis. To gain insight in the performance enhancing effects that can be expected from such a system, my colleagues and I first determined the ability of recreational runners to accurately control their own speed. We then used a simulation approach to estimate the effect of pacing inaccuracy on optimal running performance. Our simulation results suggested that the existing pacing error (2.3±4.6%) would decrease optimal performance by approximately 5% for an average recreational runner. These results indicate that the performance of recreational runners could be improved by minutes for typical race distances, simply by helping them achieve and maintain their optimal speed. To determine the viability of controlling overground speed by prescribing step frequency, we quantified the dynamic response in walking and running speed following controlled perturbations in prescribed metronome frequency. We found that perturbations in metronome frequency triggered rapid and predictable changes in speed, suggesting that overground speed is indeed controllable by prescribing step frequency. However, due to the variability present in the speed response, both within and between individuals, accurately controlling overground speed using an open-loop speed control system is not possible. To improve speed control performance we developed and built a closed-loop speed control system, which made the metronome frequency directly dependent on the instantaneous speed error. We tested the performance of this system in both walking and running, and found that the speed control accuracy of a closed-loop system was significantly better compared to self-paced running and an open-loop speed control system. Finally, we translated the speed control system into a training tool available to the general public

Shared Care Practices in Community Addiction and Mental Health Services: A Qualitative Study on the Experiences and Perspectives of Stakeholders

Shared care involves collaboration between primary care, secondary and tertiary care that enables the allocation of responsibilities of care according to the treatment needs of patients over the course of a mental illness. This study aims to determine stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs in Edmonton, Canada. This is a qualitative cross-sectional study with data collected through focus group discussions. Participants included patients, general practitioners, psychiatrists, management, and therapists working in primary and secondary addiction and mental health. Responses were audio-recorded, transcribed, and analyzed thematically. Perceived barriers to the implementation of an ideal shared care model identified by participants include fragmented communication between primary and secondary healthcare providers, patient and family physician discomfort with discussing addiction and mental health, a lack of staff capacity, confidentiality issues, and practitioner buy-in. Participants also identified enablers to include implementing shared electronic medical record systems, improving communication and collaboration, physical co-location, and increasing practitioner awareness of appropriate referrals and services. This original research provides stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs

Clinical Outcomes in Routine Evaluation Measures for Patients Discharged from Acute Psychiatric Care: Four-Arm Peer and Text Messaging Support Controlled Observational Study

Background: Peer support workers (PSW) and text messaging services (TxM) are supportive health services that are frequently examined in the field of mental health. Both interventions have positive outcomes, with TxM demonstrating clinical and economic effectiveness and PSW showing its utility within the recovery-oriented model. Objective: To evaluate the effectiveness of PSW and TxM in reducing psychological distress of recently discharged patients receiving psychiatric care. Methods: This is a prospective, rater-blinded, pilot-controlled observational study consisting of 181 patients discharged from acute psychiatric care. Patients were randomized into one of four conditions: daily supportive text messages only, peer support only, peer support plus daily text messages, or treatment as usual. Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM), a standardized measure of mental distress, was administered at four time points: baseline, six weeks, three months, and six months. MANCOVA was used to assess the impact of the interventions on participants’ scores on four CORE-OM subscales across the three follow-up time points. Recovery, clinical change, and reliable change in CORE-OM all-item analysis were examined across the four groups, and the prevalence of risk symptoms was measured. Results: A total of 63 patients completed assessments at each time point. The interaction between PSW and TxM was predictive of differences in scores on the CORE-OM functioning subscale with a medium effect size (F1,63 = 4.19; p = 0.045; ηp2 = 0.07). The PSW + TxM group consistently achieved higher rates of recovery and clinical and reliable improvement compared to the other study groups. Additionally, the text message group and the PSW + TxM group significantly reduced the prevalence of risk of self/other harm symptoms after six months of intervention, with 27.59% (χ2(1) = 4.42, p = 0.04) and 50% (χ2(1) = 9.03, p < 0.01) prevalence reduction, respectively. Conclusions: The combination of peer support and supportive text messaging is an impactful intervention with positive clinical outcomes for acute care patients. Adding the two interventions into routine psychiatric care for patients after discharge is highly recommended

Health resource utilization and cost before versus after initiation of second-generation long-acting injectable antipsychotics among adults with schizophrenia in Alberta, Canada: a retrospective, observational single-arm study

Abstract Background Long-acting injectable (LAI) antipsychotics, along with community treatment orders (CTOs), are used to improve treatment effectiveness through adherence among individuals with schizophrenia. Understanding real-world medication adherence, and healthcare resource utilization (HRU) and costs in individuals with schizophrenia overall and by CTO status before and after second generation antipsychotic (SGA)-LAI initiation may guide strategies to optimize treatment among those with schizophrenia. Methods This retrospective observational single-arm study utilized administrative health data from Alberta, Canada. Adults (≥ 18 years) with schizophrenia who initiated a SGA-LAI (no use in the previous 2-years) between April 1, 2014 and March 31, 2016, and had ≥ 1 additional dispensation of a SGA-LAI were included; index date was the date of SGA-LAI initiation. Medication possession ratio (MPR) was determined, and paired t-tests were used to examine mean differences in all-cause and mental health-related HRU and costs (Canadian dollars), comprised of hospitalizations, physician visits, emergency department visits, and total visits, over the 2-year post-index and 2-year pre-index periods. Analyses were stratified by presence or absence of an active CTO during the pre-index and/or post-index periods. Results Among 1,211 adults with schizophrenia who initiated SGA-LAIs, 64% were males with a mean age of 38 (standard deviation [SD] 14) years. The mean overall antipsychotic MPR was 0.39 (95% confidence interval [CI] 0.36, 0.41) greater during the 2-year post-index period (0.84 [SD 0.26]) compared with the 2-year pre-index period (0.45 [SD 0.40]). All-cause and mental health-related HRU and costs were lower post-index versus pre-index (p < 0.001) for hospitalizations, physician visits, emergency department visits, and total visits; mean total all-cause HRU costs were $33,788 (95$38,993, -$28,583) lower post- versus pre-index ($40,343 [SD $68,887] versus$74,131 [SD $75,941]), and total mental health-related HRU costs were$34,198 (95%CI -$39,098, -$29,297) lower post- versus pre-index ($34,205 [SD$63,428] versus $68,403 [SD$72,088]) per-patient. Forty-three percent had ≥ 1 active CTO during the study period; HRU and costs varied according to CTO status. Conclusions SGA-LAIs are associated with greater medication adherence, and lower HRU and costs however the latter vary according to CTO status