Nearly 19% of U.S. adults have experienced some form of mental illness and over 4% have a serious mental illness, according to the National Institute of Mental Health (NIMH)
Medicines are one part of a personalized treatment plan for mental illness. However, according to the NIMH, it often takes time and patience to find a combination of therapies that work best for each patient.
“A great challenge in treatment is that patients often experience more than one psychological issue—for example, schizophrenia, depression and substance abuse,” says Jennifer Seagle, PharmD, area clinical manager for CompleteRx. “It is not uncommon to see patients on multiple treatment agents, which all have the potential to interact with each other—or other medical treatments—and potentially exacerbate their comorbidities, cause excessive sedation, or have unwanted side effects.”
Several different classes of medications are used to treat mental illnesses and not all therapies work the same in every patient.
“The current DSM-5 (Diagnostic and Statistical Manual of Mental Disorders-5) manual does not provide treatment recommendations. Likewise, many mental health guidelines don’t recommend one class of agents over another for treatment of patients with mental health disorders, nor do they recommend a specific agent in a class, as exemplified by the APA guidelines on Major Depressive Disorder,” Seagle says. “There is also a distinct lack of data to support superior efficacy amongst antipsychotics for conditions such as schizophrenia and bipolar 1 disorder, apart from clozapine in treatment-resistant patients. Providers must consider side-effect profiles, patient preference, compliance issues and cost when selecting therapy.”
One trend Seagle is seeing is increased use of newer antipsychotics such as lurasidone (Latuda) and iloperidone (Fanapt) competing with much less-costly agents that have gone generic such as risperidone (Risperdal) and quetiapine (Seroquel).”
For patients where adherence or taking oral medications is an issue, there are several long-acting antipsychotic injectables available on the market, Seagle says. “These come with a hefty price tag and cost may be an issue for patients as well as the challenge prescribers would face titrating doses, as often these are weekly or monthly injections.”
According to the PhRMA “Medicines in Development for Mental Illnesses 2017 Report,” more than 140 medicines to treat mental illness are in development.
ALKS-5461 (Alkermes), a novel, once-daily oral agent for depression combines buprenorphine and samidorphan. It is in clinical trials and under review by the FDA. Alkermes has another candidate, ALKS 3831, a novel combination (samidorphan, olanzapine) antipsychotic that is expected to reduce the metabolic adverse events and weight gain associated with usual treatments, Seagle says.
Other potential pipeline therapies listed in the PhRMA report include an intranasal drug in development for treatment-resistant depression and a subcutaneous, long-acting formulation of buprenorphine for opioid use disorder.
“I expect we will see new combination products as well as agents that have longer frequencies, allowing for fewer administrations each month to address compliance issues known to be problematic in these patient populations,” Seagle says. “We will be watchful to see agents that reduce the adverse events associated with these therapies- metabolic, weight gain, extrapyramidal symptoms, etc.”
Erin Bastick, PharmD, RPh, is staff pharmacist at Southwest General Health Center, Middleburg Heights, Ohio.