Anti-anxiety and anti-insomnia prescriptions surged after mid-March after the coronavirus disease 2019 (COVID) pandemic was declared, said Glen Stettin, senior vice president and chief innovation officer at Express Scripts, who discussed the use of mental health and behavioral health prescriptions during the current public health emergency.
AJMC®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences News Network, The American Journal of Managed Care® is pleased to welcome Dr. Glen Stettin, senior vice president & chief innovation officer at Express Scripts.
AJMC®: Why may common mental health conditions such as depression, anxiety, and insomnia be intensified amid the pandemic?
Dr Stettin: Yeah, it was very interesting. You see in our report that the use of medications for depression, medications for anxiety, and medications for insomnia vary significantly from the months of mid-February to mid-March. We have to speculate because we don't know for sure, but you can imagine that people are pretty stressed thinking about having to shelter in place, worrying about getting the virus, worrying about their jobs, and what was also really interesting to us was the fact that over the course of the last 5 years while antidepressant use had been increasing, anti-anxiety medicine and anti-insomnia medicine—that use had actually been decreasing significantly, and then all of a sudden spiked.
AJMC®: Can you discuss Express Scripts’ America’s State of Mind report? What findings surprised you the most?
Dr Stettin: Yeah, so one is, when we look at the mental health, these 3 categories of mental health medications—the antidepressants, anti-anxiety medicines, sleep medicines, over a 5-year period that one, a lot of people in America take these medicines; two, for antidepressants, the use of antidepressants has been increasing over that 5-year period, and in particularly for adolescents. If you remember back, oh, probably 15 years already, there was some scare as it related to antidepressants and the use in adolescence about maybe they would be associated with increased risk of suicide, but also over that same time period, I think that we see more appropriate use of the medicine and follow-up. So that increased use is probably a good thing, as well as [for] people, the social stigma I think has decreased somewhat, at least as it relates to depression.
The anti-anxiety medicines, on the other hand, have had a pretty steep decline over the 5-year period—a lot of that really being the fact that they're controlled substances. There was a lot of use with opioids—obviously a very dangerous combination—and I think physicians have been more reluctant to prescribe them except for people with more severe anxiety disorders in general.
AJMC®: Before COVID-19, anti-anxiety medications exhibited a constant decline from 2015 to 2019. Aligned with the hysteria of the pandemic, these medication prescriptions have increased by approximately 34% based on the report. Can you explain the significance of this finding?
Dr Stettin: Yeah, if you think about people being nervous and anxious, and seeking treatment, most of the increase in use were actually what we would call new starts of medication, meaning people who had not been previously on these medicines. They certainly look like that, at least the prescribing data suggests, that they were sharing their feelings and their worries with physicians and other prescribers, and had prescriptions. What was also very interesting and not in the report, but a follow-up on the report in the weeks that followed March 15 [after] the pandemic was declared, the shelter-in-place orders in many states were put in effect. So, it peaked on March 15, and then new starts dropped a bit, and what's interesting about that is that these are medicines that physicians generally don't prescribe by telemedicine, they generally think about wanting to see the patient in person before they would prescribe a controlled substance
AJMC®: What implications may the stark increase of anti-depressant and anti-anxiety prescriptions indicated in the report have for employers? Are there any barriers to care that may affect wider distribution of necessary medications?
Dr Stettin: I think that, in in general, if you think about the pandemic, and the shelter in place, and the lockdown, and also access to the physician and the physician office, right, if it's not urgent care, most people are staying home and not seeking care, and many of the offices are closed and only seeing people on a limited basis. So, in general, we saw increasing fills of most medications, particularly maintenance medications leading up to the pandemic, but by and large, those were refills for existing users. And people you know, there are also some questions for people about stockpiling their medicines and recommendations, but particularly in states where emergency declarations were made, recommendations for people to have a longer supply and medication on hand if they had to wait things out at home.
AJMC®: Can you discuss what is Express Scripts’ Neuroscience Therapeutic Resource Center? And how it can prove vital for patients who may have regular therapy appointments postponed or cancelled due to COVID-19?
Dr Stettin: One of the advantages for Express Scripts in terms of how we practice pharmacy, we have a pharmacy practice that dispenses more than 85 million prescriptions a year. We're able to segment the practice by specialty and 1 of those specialties is our neuroscience specialty, which addresses the use of medications for mental health and pain, and other conditions that you would think about as affecting the nervous system and brain. As a result of specializing in depression and anxiety medicines and sleep medicine, they know not just about the medications and their side effects, the patient's benefits, and the cost of their therapy, but they also can provide counseling that goes along with that medication to help people understand how to get the most from their medicine.
One of the examples in sleep medicine is a general recommendation that is consistent with best practices in clinical care. For most people, sleep hygiene is the treatment for sleep disorders, insomnia, not taking medication, right? If you have some acute issue, take sleep medicine for a few days, many physicians will prescribe, but by and large it should be things like not drinking caffeine in the evening or maybe not at all, and not having too much to drink just in terms of liquid, alcohol too before you go to bed, and just general good sleep habits to get ready as opposed to medication. So our pharmacists often help with that.
Then for people who have depression or anxiety, and other issues, including sleep disorders, we do some work with digital therapeutics and the pharmacist can help make a connection for the patient to these digital therapeutics. Examples would be SilverCloud, which is, particularly now, is important during the pandemic, but modules with cognitive behavioral therapy for improving resilience, for working on insomnia, for dealing with mild depression symptoms, for dealing with the thoughts you can't get out of your head for people who are suffering from anxiety. So, it's a combination of being able to better serve them for the safety, effectiveness, and affordability of their medication, but also to connect people to digital and non-drug resources that they might not have known were available to them.
AJMC®: Amid the pandemic, the role of social determinants of health have shined an unfortunate light on rural communities who do not have immediate access to care. Can you discuss how Express Scripts’ Digital Health Formulary can provide vital assistance to these populations?
Dr Stettin: Well, I think telehealth services in general, for people who live in remote areas and don't have access to care, are really, really helpful, and we're certainly very happy that the government has eased some of the restrictions on telehealth services recognizing that not just in remote areas, but even in urban areas, people don't have the access that they previously did, as many offices, pharmacies, and retail locations may be closed. So, by virtue of being able to provide telepharmacy services, by virtue of being able to connect people to medications that they need as well as to connect people with digital therapeutics that can help them, it eases the burden for anybody who needs or are seeking care, particularly for mild depression, mild anxiety issues, as well as, sleep issues.
AJMC®: People with substance abuse are additional populations at-risk for mental conditions during this crisis. Are there current recommendations employed by Express Scripts that apply to these groups?
Dr Stettin: Yes, so we have a number of programs in place to help people who may become addicted or have issues with opioid dependence. As part of our Advanced Opioid Program, which we launched several years ago, one of the things that we do is we recognize that some people get hooked on a first prescription, and if you limit the days-supply of a first prescription, most people, when they have an acute injury, prior to our program, you could look in a medicine cabinet, and you'd find they'd have leftover medicine, which is a potential issue for them if they continue to take it for some other event, but also for people who may be in their house or come to their house and have access to that meditation.
So, what we found was that by recommending to our clients as part of their benefit coverage to limit the first fill to no more than 7 days, unless there was a special circumstance, I want to be very clear, we have a way to override that for patients who really need it. Most people, we reduce the day supply dispensed on first fills by over 96%, and we also recommend for physicians who have electronic medical record systems, they have to do an active step to override that and allow more medication for the patients who need it, but these kind of speed bumps make people think twice.
The other things that we've done is we measure the patient's use of opioid over time across all their prescriptions against a morphine equivalent dose. So, we can recognize when people have particularly high doses of overall opioid use or high cumulative doses over time. These are people who really need to have access and their families need to have access to rescue medications, in case they wind up overdosing inadvertently, and there are also people who need additional help potentially to get to lower doses and maybe off of opioids all together.
AJMC®: What further innovations in the behavioral health pipeline are under consideration for Express Scripts?
Dr Stettin: So, we're looking at other ways to help people as they relate to telehealth services, and this is something that has come to us and been made available as a result of Express Scripts acquisition by Cigna. They have behavioral health services, telebehavioral health services, and the ability to help patients in terms of finding therapists and psychiatrists that we look forward to being able to deploy to populations that are served by Express Scripts—to our clients’ populations to the extent that they need those services for their folks. I would say that in general, we hear from our clients who are large employers, large health plans that pay for care, that the main issues in mental health are really around access, being able to find the people to provide the treatment and to make it easier for patients to get the access and treatment that they need.
Last thing I would just say is that not everyone who has mental health issues needs to have a specialist or a psychiatrist as their therapist. Most of the patients are treated very well by primary care physicians, but sometimes people need extra help or counseling or other things that the primary care physicians may feel that someone else is better suited to provide for the patient. So, having that access available, gives the patient and the physicians options for the treatment and cure for the patient.
AJMC®: To learn more, visit our website at ajmc.com. I'm Matthew Gavidia. Thanks for joining us.