Fewer than 1 in 5 young patients with first-episode psychosis adhere to antipsychotics

Fewer than one in five young people with first episode psychosis filled enough antipsychotic prescriptions to be considered adherent during their first year of treatment, and those who were adherent had fewer emergency department visits and more behavioral health outpatient care, according to a cohort study published in JAMA Network Open.

Who the FEP study was about

This retrospective study was led by Emily Chi, M.S., who is a Ph.D. student in the Division of Health Services Management and Policy within the College of Public Health at The Ohio State University in Columbus, Ohio. She and her colleagues used Merative MarketScan claims data to identify 27,592 patients diagnosed with first episode psychosis from 2013 to 2021. The database covers roughly 30 million to 50 million people with employer-sponsored insurance.

Almost half, 11,889 (43.1%), received their first antipsychotic medication prescription. That group, who were an average of 22.7 years old, were followed for 365 days after the first fill.

Overall, the adherence rate was 19.1%, with schizophrenia patients exhibiting greater adherence than patients with other psychotic spectrum disorders. Greater adherence was also associated with fewer emergency department visits, more behavioral outpatient visits and more general outpatient visits, Chi and her team write in the study.

Adherence was measured using the proportion of days covered (PDC), divided by 365. A PDC score of 0.8 or higher is counted as adherent.

How many patients with FEP stayed on antipsychotics

On average, in the year after starting treatment, patients had their antipsychotics for approximately 158 of 365 days.

Adherence differed by diagnosis. It was 23.1% among people with schizophrenia spectrum disorder, 16.9% among those with mood disorders with psychotic features and 13.5% among those with other psychotic spectrum disorders. After adjusting for demographic and clinical factors, Chi and her team found that schizophrenia spectrum disorder patients were 78% more likely to be adherent than those with other psychotic disorders, and those with mood disorders were 21% more likely.

The authors noted that earlier studies using the same PDC measure in Medicare and Medicaid populations with chronic schizophrenia found adherence of 35.4% to 52.5%. Those patients were considerably older, with mean ages of 42.9 to 55 years. The researchers suggested that younger patients may have limited insight into their illness, uncertainty about long-term treatment and concerns about adverse effects such as weight gain and sedation and may be less connected to the health care system.

What adherence means for ED use and outpatient care

Adherent patients had 15% fewer ED visits, 53% more behavioral health outpatient visits and 7% more general outpatient visits than nonadherent patients. The study found no significant association between adherence and psychiatric or general hospitalization.

“Decreased adherence therefore appears to be associated with a shift in the site of care from outpatient services toward more intensive acute settings such as ED visits,” Chi and her team write in the study. “Continued reliance on ED-based care may be challenging and costly and could adversely affect patients’ quality of life. This is because emergency services are not structured to provide ongoing management; repeated reliance on ED care may contribute to fragmented treatment, limit continuity with outpatient clinicians, and disrupt educational, vocational and social stability.”

Low use of long-acting injectable antipsychotics

Long-acting injectable (LAI) formulations were rarely used at treatment initiation. Only 0.5% of the cohort received LAIs exclusively and 3.9% used both LAI and oral formulations. The authors cited prior research linking LAIs to better adherence and fewer readmissions and wrote that the low uptake "highlights a potential gap in early treatment strategies."

Limitations include reliance on pharmacy fills, which show that medication was available but not that it was taken, and the absence of publicly insured patients.

For health plans, the findings arrive amid broader gaps in early psychosis care. Nearly 100,000 people in the United States experience a first episode of psychosis each year. Additionally, most private health insurance does not cover the full package of coordinated specialty care services, which include medication management and employment and education services.

These system-level limitations highlight the importance of optimizing outpatient management, including sustained antipsychotic adherence and continuity of behavioral health care, to reduce reliance on emergency services and improve outcomes among individuals with FEP,” Chi and her team conclude in the study.