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Underwriting with Prescription HistoriesAcross the Mental Health ContinuumScott Coller, Pharm.D. – Pharmacy Consultant
Midwestern Underwriting Conference
21 September 2016
Psychotropic Medications
Rule Results, UW Guidelines and Decisions
Rule Engines Interpret Psych Meds
Drug Combinations and Mortality
Medications and Disease Progression
Agenda
Drug therapies impact many neurotransmitters.
Drug NameDopamineHistamineNorepinephrineSerotoninAcetylcholineGlutamateGABA
Dopamine & Histamine
Cognition(Mental Alertness)
Norepinephrine & Acetylcholine
Vigilance(Sustained Concentration)
Serotonin & Glutamate
Perception(Sensory Satisfaction)
Appetite Intuition
Attention
MOOD
GABA
Neurotransmitters influence a wide range of mental states.
There are a few key categories of psychotropic meds.
Antidepressants and Anxiolytics
Antipsychotics
Mood Stabilizers
Others
Stimulants
Cognitive Enhancers
Doctors prescribe by condition.Depression
Anxiety
Insomnia
Nausea
Neuropathy
Migraine Prevention
Tourette’s
Obsessive/Compulsive
Bipolar
Schizophrenia
ADHD
Benzodiazepines
SSRI’s, SNRI’s
Tricyclics, Tetracyclics, Modified Cyclics
Antipsychotics
Anticonvulsants
Stimulants
GABA Analogs
Bupropion
Epilepsy
Benzodiazepines
SSRI’s, SNRI’s
Tricyclics, Tetracyclics, Modified Cyclics
Antipsychotics
Anticonvulsants
Stimulants
GABA Analogs
Depression
Anxiety
Insomnia
Nausea
Neuropathy
Migraine Prevention
Tourette’s
Obsessive/Compulsive
Bipolar
Schizophrenia
ADHD
Smoking Cessation
Bupropion
Underwriters use Rx histories to interpret conditions.
Rules engines can be used to map drugs to likely conditions.
A Sesame Street Mnemonic for Mental Disorders
Insomnia
Depression
Obsessive Compulsive Disorder (Anxiety)
Bipolar Disorder
Schizophrenia
Fall asleep or stay asleep as long as desired Symptom of another disorder
Functional impairment while awake
< 3 hrs or >10 hrs increases mortality by 50-100%. 7 hours per night: lowest mortality†
Insomnia
†Kripke DF, et al. Arch Gen Psychiatry. 2002;59(2):131-136.
How Medications Treat Insomnia
Benadryl
Trazodone & Seroquel
Melatonin
Rozerem
Temazepam & Ambien
Belsomra
Major Depressive Disorder (MDD)
Low mood, low self-esteem, loss of interest
Targets:Norepinephrine, Serotonin, Dopamine
SSRI, SNRI
Bupropion
Tricyclic
MAO-I
Antipsychotic
Estimating MDD Progression
Single agentSSRI or SNRI
Multiple agents, non-concurrentTrial and transition
Multiple agents, concurrentAD + BZD
Multiple AD
AD + AP
AD + AC
How Medications Treat AnxietyGAD, Panic, Social Anxiety, Phobias, OCD, PTSD
Targets:GABA Serotonin
SSRI, SNRI, TCA
Benzodiazepines
GABA analogs
Buspirone
Antipsychotic
Estimating Anxiety ProgressionSSRI for maintenance with benzodiazepine for breakthrough / symptomatic relief
Benzodiazepine monotherapy
Pregabalin or buspirone monotherapy
Multiple agents, concurrent
Combinations of aboveAnticonvulsantsAntipsychotics
Bipolar Disorder
Periods of mania/hypomania alternating with depression
Bipolar I, Bipolar II, Cyclothymia, Mixed, Rapid Cycling
Estimating Bipolar ProgressionStarting therapy:Lithium and/or Depakote +/- antipsychoticLithium and/or Lamictal +/- antidepressant
Maintenance:Lithium, Depakote, Lamictal, Tegretol, Trileptal or Antipsychotics
Schizophrenia
Suicide Risk
At least 2 symptoms present for six months
Negative: Flat affect, lack of pleasure in daily life, lack of drive, speaks little
Positive: Hallucinations, delusions, thought disorders, movement disorders
Cognitive: Poor executive functioning, trouble focusing, problems with working memory
Estimating Schizophrenia Progression
Thought disorder, mood disorder, and anxiety disorder
Antipsychotics are first line but others may be added onClozaril is probably most effective
Three-quarters of all patients stop taking their medications
Rule engines can manage relative mortality.
What is RxRules?
RxRulesData Input Rx info Application data Other (MIB, MVR)
UW Guidance Conditions Severity Decisions
Rule Variables Indication / Therapeutic class Drug combinations Fill timing(date or duration ranges) Fill counts / patterns Dosage / quantity Physician specialty / count Gender / Age Other variables
Insomnia Treatment
Possible
Treatment-resistantDepression
PossibleBipolar
Treatment Likely
Schizophrenia Treatment
Likely
RxRules
Underwriting expertise remains critical.
Accept
Decline
ReviewRxRulesData Input
Rx info App data Other (MIB, MVR)
Interpreting a long list of psych meds? Yikes!
Fill details provide insight to conditions and severity.
A rule engine supports easy decision-making.
Summary
There is a wide range of psychotropic medications used to treat a wide range of mental health disorders.
It is difficult to reverse engineer medications to determine likely conditions and severity.
A rule engine can bring consistency and efficiency to a very challenging job!
