The Continuity of Medication Therapy for the Treatment of Schizophrenia & Other Serious Mental Illnesses

When taking into account the complex nature of mental illnesses and the multiplicity of treatments and services that are needed by people in search of recovery, continuity of care and the coordination of treatment and services are important factors in assuring quality of mental healthcare. More specifically, given the important role that medications play in allowing for symptom reduction or alleviation and the ability of consumers to participate in vocational, educational, and other rehabilitative activities, ensuring continuity of therapy in the form of access to medications must receive a higher priority.

In the context of mental health, continuity of care is defined as "a process involving the orderly, uninterrupted movement of patients among the diverse elements of the service delivery system" (Bachrach, 1981). While we know that continuity of care, including continuity of medication, are important, we also know however, that systems designed to serve mental health consumers experience serious shortcomings when it comes to the level and depth of communication, cooperation, and coordination of treatment and services that are necessary to avoid service fragmentation and discontinuity.

After discharge from inpatient settings, individuals are often placed on long waiting lists for community-based services only to have their intake and clinical appointments scheduled weeks apart. They often find that their treatment history has not been transferred from one provider to another or that they have an insufficient supply of medications causing, in too many cases, chaos and confusion that leads to an interruption, if not a discontinuation, of care. As an illustration of the seriousness of this issue, one study conducted by Janssen (2005) found that an alarming 50 percent of consumers diagnosed with schizophrenia who were discharged from a sample of psychiatric hospitals were lost in transition. In other words, they did not reappear in the community-based programs to which they were referred.

Medication is frequently a cornerstone of treatment for people with serious mental illnesses (Lieberman, et al., 2004), not only providing for symptom reduction or alleviation, but also allowing for participation in rehabilitative, educational, and vocational programs. If we cannot guarantee continuity of medications, how can we hope to achieve recovery?

Recent federal statistics confirm an over-representation of persons with mental health disorders in our jails and prisons, and the Institute of Medicine describes our nation's emergency rooms as overcrowded and dysfunctional when it comes to meeting the needs of patients who present mental health issues. Many communities have insufficient access to crisis and acute care beds. At the same time, policymakers and payers are increasingly calling for higher quality in healthcare with demonstrable improvements in consumer outcomes.

The results of this lack of system and services coordination and potential abatement of therapy can be disastrous and cause crises for consumers and their family members, with results including re-hospitalization and/or increased demand for other community services such as emergency room care or police involvement. Research continues to verify that appropriate follow-up care can help in reducing the need for re-hospitalization and it can also be helpful in identifying consumers needing more intense services before they reach a point of crisis (Boydell, et al., 1991).

The costs of poor care transition among service settings are high, yet many State policymakers and elected officials are unaware of the financial burden that their States bear due to a lack of continuity. Clearly, the field must respond to these problems in a proactive way.

The concepts of service fragmentation and discontinuity of care are not new issues to the behavioral health field. State mental health authorities, county administrators, and local providers have struggled with these challenges, but have yet to find and apply wide-scale, appropriate solutions.

In 1963, the landmark Community Mental Health Centers Act was passed in response to a national goal of moving people out of institutions and into communities where they were to be served by locally-based treatment and service providers. This Act led to the establishment of more than 750 federally funded community mental health centers (CMHCs) across the country.

The push for deinstitutionalization and the downsizing and closing of psychiatric hospitals came about due to a number of factors, including the development of a number of new antipsychotic medications, the emergence of a consumer rights movement, the recognition that the vast majority of people with mental illnesses did not need to be hospitalized for years on end,. According to the World Health Organization, deinstitutionalization was complex and should have led to "the implementation of a network of alternatives outside psychiatric institutions." The report goes on to lament that these networks never developed due to a lack of appropriate community services and funding (World Health Organization, 2001).

In the 1980s, direct federal funding of CMHCs was ended and replaced with a federal block grant to State mental health authorities. These shifts to State-based block grants came about, in part, due to the premise that States were better positioned to meet local needs, coordinate services, and more efficiently administer service delivery programs than the federal government.

In April 2002, President George W. Bush created, by Executive Order, the "President's New Freedom Commission on Mental Health." President Bush said in his address announcing the Commission, "Our country must make a commitment: Americans with mental illness deserve our understanding, and they deserve excellent care" (Commission Final Report, 2003). The New Freedom Commission identified stigma, unfair treatment limitations and financial requirements, and fragmentation of the delivery system as areas of weakness in the current mental healthcare system. The New Freedom Commission recommended "complete transformation" of the mental health system in America. Six goals were identified to serve as the foundation for this transformation:

1. Americans understand that mental health is essential to overall health.

2. Mental healthcare is consumer and family driven.

3. Disparities in mental health services are eliminated.

4. Early mental health screening, assessment, and referral to services are common practice.

5. Excellent mental healthcare is delivered and research is accelerated.

6. Technology is used to access mental healthcare and information.

One of the fundamental problems with the U.S. mental health system, as reinforced by the Commission's final report, is the fragmentation of treatment, services, and supports. Accompanying this fragmentation are myriad financing and funding sources that include complex eligibility and reimbursement mechanisms. Failure to ensure continuity of care, including continuity of medications, for people with mental illnesses is the direct consequence of systems, services, and funding fragmentation.

Continuity of therapy initiatives are likely to decrease inappropriate use of emergency room services by consumers with schizophrenia or other serious mental illnesses by assuring consistency in the disease management approaches and medications used by professionals and provider organizations that are part of the continuum of care. In addition to this financial and service system resource benefit, continuity of therapy initiatives provide consumers with stability by assuring access to required treatment components in all settings. And, for community hospitals, continuity of therapy initiatives provide another very tangible benefit--the relationships, process, and infrastructure for an overall discharge planning function for all consumers with mental illnesses.