Costs of schizophrenia during 5 years

Resource utilization in mental illness - evaluation of an instrument for measuring direct costs of treatment for patients with severe mental illness (SMI)

PURPOSE

Serious mental illnesses (SMIs) exert a considerable financial burden on health-care systems. In this study, the resource utilization in mental illness (RUMI) tool was developed and employed to evaluate resource utilization in patients with SMI.

MATERIALS AND METHODS

Data from 107 patients with SMI treated in four psychiatric outpatient clinics in Sweden were collected. The relationships between costs for physical and psychiatric care, social services, and the justice system, to self-reported health and quality of life, educational level, Global Assessment of Functioning (GAF), the Clinical Global Impressions scale score (CGI), and body mass index (BMI) were studied.

RESULTS

Sixteen out of 107 patients accounted for 74% of the total costs. The mean and median cost for 6 months included in the survey for social services, family and social welfare and healthcare, psychiatric and physical treatment interventions, mean 8349 EUR, median 2599 EUR per patient (currency value for 2021). Education and psychosocial function (GAF) were both negatively correlated with costs for the social services (education, r=-0.207, p < 0.014; GAF, r=-0.258, p < 0.001). CGI was correlated with costs for physical and psychiatric healthcare (r = 0.161, p < 0.027), social services support (r = 0.245, p = 0.002) and total cost (r = 0.198, p = 0.007). BMI correlated with costs for psychiatric and physical health settings interventions (r = 0.155, p < 0.019) and for somatic and psychiatric medicines (r = 0.154, p < 0.019).

CONCLUSION

The RUMI scale was acceptable and enabled estimation of resource utilization in a comparable manner across different care settings. Such comparable data have potential to provide a basis for budgeting and resource allocation.

Assisted living for mentally ill-a systematic literature review and its recommendations

BACKGROUND

The reduction in psychiatric hospital beds in the past decades has created a need for assisted living (AL). Even though AL is widely used, studies on it are scarce.

AIMS

To identify (1) study characteristics of the reviewed articles, (2) characteristics of inhabitants and characteristics of different types of AL, (3) financial costs in different types of AL, (4) the individual outcomes in AL inhabitants and quality of care.

METHODS

A systematic literature review on AL for the mentally ill focusing on inhabitant and AL features and their costs was conducted. Articles written in English from January 2000 to June of 2020, concerning adults were included. Simple Taxonomy of Supported Housing (STAX-SA) was applied and used for categorizing types of AL.

RESULTS

Twenty-five papers met our criteria. The majority of inhabitants were unemployed single male with psychotic disorders. The type of AL is mainly categorized according to staffing, provided support, and housing arrangement. In UK ALs with moderate support (STAX-SA 2-3) had the best quality of care while ALs with low support (STAX-SA 4) was the cheapest. Quality of care was better in small units with preset expected length of stay for inhabitants. Hospital treatment was significantly more expensive than any type of AL. Living in AL improved quality of life compared to hospital treatment, also psychiatric symptoms were reduced.

CONCLUSION

There is an evident need for evidence-based studies in a longitudinal comprehensive manner that evaluates different AL types, function of the inhabitants, and costs with respect to the quality of AL and care and outcome.

Value configurations for balancing standardization and customization in chronic care: a qualitative study

BACKGROUND

Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions.

METHODS

A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach.

RESULTS

Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process.

CONCLUSIONS

The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

Comparison between long-acting injectable aripiprazole versus paliperidone palmitate in the treatment of schizophrenia: systematic review and indirect treatment comparison

We investigated the relative efficacy and tolerability of aripiprazole once monthly (AOM) versus paliperidone palmitate (PP) for treating schizophrenia. Extensive databases searches on short-term, placebo-controlled, randomized studies of AOM and PP were performed. Indirect treatment comparisons were performed between the two long-acting injectable antipsychotics (LAIAs). The primary efficacy endpoint was the mean change in the Positive and Negative Syndrome Scale total score from baseline between each LAIA and placebo. The effect sizes were mean differences and odds ratio (ORs) with 95% confidence intervals (CIs) for the primary efficacy endpoint and safety/tolerability between two LAIAs, respectively. Mean difference in the primary efficacy endpoint was significantly different, favouring AOM over PP (OR: -6.4; 95% CI: -11.402 to -1.358); sensitivity analyses and noninferiority test (AOM vs. PP) confirmed the primary results. The overall early dropout rate was not significantly different between AOM and PP (OR: 1.223; 95% CI: 0.737-2.03). However, there was a significant difference in the early dropout rate in terms of lack of efficacy favouring AOM over PP (OR: 0.394; 95% CI: 0.185-0.841). Within the context of the inherent limitations of the current analysis, our results may suggest that there may be relative advantages for AOM over PP in the short-term treatment of schizophrenia.

Global economic burden of schizophrenia: a systematic review

BACKGROUND

Schizophrenia is one of the top 25 leading causes of disability worldwide in 2013. Despite its low prevalence, its health, social, and economic burden has been tremendous, not only for patients but also for families, caregivers, and the wider society. The magnitude of disease burden investigated in an economic burden study is an important source to policymakers in decision making. This study aims to systematically identify studies focusing on the economic burden of schizophrenia, describe the methods and data sources used, and summarize the findings of economic burden of schizophrenia.

METHODS

A systematic review was performed for economic burden studies in schizophrenia using four electronic databases (Medline, EMBASE, PsycINFO, and EconLit) from inception to August 31, 2014.

RESULTS

A total of 56 articles were included in this review. More than 80% of the studies were conducted in high-income countries. Most studies had undertaken a retrospective- and prevalence-based study design. The bottom-up approach was commonly employed to determine cost, while human capital method was used for indirect cost estimation. Database and literature were the most commonly used data sources in cost estimation in high-income countries, while chart review and interview were the main data sources in low and middle-income countries. Annual costs for the schizophrenia population in the country ranged from US$94 million to US$102 billion. Indirect costs contributed to 50%-85% of the total costs associated with schizophrenia. The economic burden of schizophrenia was estimated to range from 0.02% to 1.65% of the gross domestic product.

CONCLUSION

The enormous economic burden in schizophrenia is suggestive of the inadequate provision of health care services to these patients. An informed decision is achievable with the increasing recognition among public and policymakers that schizophrenia is burdensome. This results in better resource allocation and the development of policy-oriented research for this highly disabling yet under-recognized mental health disease.

Efficacy, tolerability, and safety of aripiprazole once-monthly versus other long-acting injectable antipsychotic therapies in the maintenance treatment of schizophrenia: a mixed treatment comparison of double-blind randomized clinical trials

BACKGROUND

Treatment with long-acting injectable (LAI) antipsychotic medication is an important element of relapse prevention in schizophrenia. Recently, the intramuscular once-monthly formulation of aripiprazole received marketing approval in Europe and the United States for schizophrenia.

OBJECTIVE

This study aimed to compare aripiprazole once-monthly with other LAI antipsychotics in terms of efficacy, tolerability, and safety.

DATA SOURCES

A systematic literature review was conducted to identify relevant double-blind randomized clinical trials of LAIs conducted in the maintenance treatment of schizophrenia. MEDLINE, MEDLINE In-Process, Embase, the Cochrane Library, PsycINFO, conference proceedings, clinical trial registries, and the reference lists of key review articles were searched. The literature search covered studies dating from January 2002 to May 2013.

STUDY SELECTION

Studies were required to have ≥24 weeks of follow-up. Patients had to be stable at randomization. Studies were not eligible for inclusion if efficacy of acute and maintenance phase treatment was not reported separately. Six trials were identified (0.5% of initially identified studies), allowing comparisons of aripiprazole once-monthly, risperidone LAI, paliperidone palmitate, olanzapine pamoate, haloperidol depot, and placebo.

DATA EXTRACTION

Data extracted included study details, study duration, the total number of patients in each treatment arm, efficacy, tolerability, and safety outcomes. The efficacy outcome contained the number of patients that experienced a relapse, tolerability outcomes included the number of patients that discontinued treatment due to treatment-related adverse events (AEs), and that discontinued treatment due to reasons other than AEs (e.g., loss to follow-up). Safety outcomes included the incidence of clinically relevant weight gain and extrapyramidal symptoms.

DATA SYNTHESIS

Data were analyzed by applying a mixed treatment comparison competing risks model (efficacy) and using binary models (safety). There was no statistically significant difference between any study outcome, including the risk of relapse, the risk of discontinuations, and safety outcomes.

CONCLUSIONS

Aripiprazole once-monthly is similarly efficacious to other LAIs with relatively low rates of discontinuation due to AEs and due to reasons other than AEs than other LAIs.

Understanding the direct and indirect costs of patients with schizophrenia

BACKGROUND

Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries.

OBJECTIVE

The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them.

RESULTS

Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives.

CONCLUSIONS

Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Understanding the direct and indirect costs of patients with schizophrenia

Background : Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries. Objective : The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them. Results : Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives. Conclusions : Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Pharmacoeconomics of depot antipsychotics for treating chronic schizophrenia in Sweden

AIMS

To determine the cost-effectiveness of long-acting injectable (LAI) antipsychotics for chronic schizophrenia in Sweden.

METHODS

A 1-year decision tree was developed for Sweden using published data and expert opinion. Five treatment strategies lasting 1 year were compared: paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol decanoate (HAL-LAI) and olanzapine tablets (oral-OLZ). Patients intolerant/failing drugs switched to another depot; subsequent failures received clozapine. Resources and employment time lost (indirect costs) were costed in 2011 Swedish kroner (SEK), from standard government lists. The model calculated the average cost/patient and quality-adjusted life-years (QALYs), which were combined into incremental cost-effectiveness ratios. Multivariate and 1-way sensitivity analyses tested model stability.

RESULTS

PP-LAI followed by OLZ-LAI had the lowest cost/patient (189,696 SEK) and highest QALYs (0.817), dominating in the base case. OLZ-LAI followed by PP-LAI cost 229,775 SEK (0.812 QALY), RIS-LAI followed by HAL-LAI cost 221,062 SEK (0.804 QALY), HAL-LAI followed by oral-OLZ cost 243,411 SEK (0.776 QALY), and oral-OLZ followed by HAL-LAI cost 249,422 SEK (0.773 QALY). The greatest proportions of costs (52.5-83.8%) were for institutional care; indirect costs were minor (2.4-3.8%). RESULTS were sensitive to adherence and hospitalization rates, but not drug cost. PP-LAI followed by OLZ-LAI dominated OLZ-LAI followed by PP-LAI in 59.4% of simulations, RIS-LAI followed by HAL-LAI in 65.8%, HAL-LAI followed by oral-OLZ in 94.0% and oral-OLZ followed by HAL-LAI in 95.9%; PP-LAI followed by OLZ-LAI was dominated in 1.1% of the 40,000 iterations.

CONCLUSION

PP-LAI followed by OLZ-LAI was cost-effective in Sweden for chronic schizophrenia and cost-saving overall to the healthcare system.

Estudos transcriptômicos no contexto da conectividade perturbada em esquizofrenia

Esquizofrenia é uma severa doença neurobiológica com fatores genéticos e ambientais desempenhando um papel na fisiopatologia. Diversas regiões cerebrais têm sido implicadas no processo da doença e estão conectadas em complexos circuitos neuronais. Nos níveis molecular e celular, a conectividade afetada entre essas regiões, envolvendo mielinização disfuncional dos axônios neuronais, bem como as alterações no nível sináptico e metabolismo energético levando a distúrbios na plasticidade sináptica, são os maiores achados em estudos post-mortem. Estudos de microarranjos investigando a expressão gênica contribuíram para os achados de alterações em vias complexas em regiões cerebrais relevantes na esquizofrenia. Além disso, estudos utilizando microdissecção e captura a laser permitiram a investigação da expressão gênica em grupos específicos de neurônios. Entretanto, deve ser mantido em mente que em estudos post-mortem, confusos efeitos de medicação, qualidade de RNAm, bem como capacidade de mecanismos regenerativos neuroplásticos do cérebro em indivíduos com história de vida de esquizofrenia, podem influenciar o complexo padrão de alterações no nível molecular. Apesar dessas limitações, estudos transcriptômicos livres de hipóteses em tecido cerebral de pacientes esquizofrênicos oferecem uma possibilidade única para aprender mais sobre os mecanismos subjacentes, levando a novas ópticas da fisiopatologia da doença.

Cost effectiveness of paliperidone palmitate versus risperidone long-acting injectable and olanzapine pamoate for the treatment of patients with schizophrenia in Sweden

OBJECTIVE

To model the cost effectiveness of paliperidone palmitate (paliperidone long-acting injectable; PLAI), a new once-monthly long-acting antipsychotic therapy, compared with risperidone long-acting injectable (RLAI) and olanzapine pamoate (OLAI), in multi-episode patients (two or more relapses) with schizophrenia in Sweden.

METHODS

A Markov decision analytic model was developed to simulate the history of a cohort of multi-episode patients transitioning through different health states on a monthly basis over a 5-year time horizon from the perspective of the Swedish healthcare system. Therapeutic strategies consisted of starting treatment with RLAI (mean dose 37.5 mg every 2 weeks), PLAI (mean dose 75 mg equivalent (eq.) every month) or OLAI (150 mg every 2 weeks or 300 mg every 4 weeks). Probability of relapse, level of adherence, side-effects (extrapyramidal symptoms, tardive dyskinesia, weight gain and diabetes) and treatment discontinuation (switch) were derived from long-term observational data when feasible. Incremental cost-effectiveness outcomes, discounted at 3% annually, included cost per quality-adjusted life-year (QALY) and cost per relapse avoided (expressed in 2009 Swedish Krona SEK).

RESULTS

Relative to RLAI and OLAI, PLAI is economically dominant: more effective (additional QALYs, less relapses) and less costly treatment option over a 5-year time horizon. The results were robust when tested in sensitivity analysis.

LIMITATIONS

The impact of once-monthly treatment on adherence levels is not yet known, and not all variables that could impact on real-world outcomes and costs were included in this model.

CONCLUSION

PLAI was cost saving from a Swedish payer perspective compared with RLAI and OLAI in the long-term treatment of multi-episode (two or more relapses) schizophrenia patients.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Metabolic effects and cost-effectiveness of aripiprazole versus olanzapine in schizophrenia and bipolar disorder

OBJECTIVE

To assess the cost-effectiveness of aripiprazole versus olanzapine in the treatment of patients with schizophrenia or bipolar disorder in Sweden with focus on the metabolic impact of the treatments.

METHOD

A Markov health-state transition model was developed. The risks of developing metabolic syndrome after one year of treatment with aripiprazole or olanzapine were derived from a pooled analysis of three randomised clinical trials. The subsequent risks of developing diabetes or coronary heart disease were based on previously published risk models. A societal perspective was applied, adopting a lifetime horizon. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

Treatment with aripiprazole dominates over olanzapine in both schizophrenia and bipolar disorder. In schizophrenia, quality-adjusted life-years (QALYs) gained were 0.08 and cost savings Swedish kronor (SEK) 30,570 (USD 4000); in bipolar disorder, QALYs gained were 0.09 and cost savings SEK 28,450 (USD 3720). In probabilistic sensitivity analyses, aripiprazole resulted in a dominant outcome in 84% of cases in schizophrenia and in 77% of cases in bipolar syndrome.

CONCLUSION

The significantly lower risk of developing metabolic syndrome observed with aripiprazole compared with olanzapine is associated with less risk of diabetes and cardiovascular morbidity and mortality that translates into lower overall treatment cost and improved quality of life over time.

Public interest and private concern: the role of family carers for people suffering mental illness in the twenty first century

OBJECTIVES

This paper looks to examine the emerging role of carers as essential components in the management of individuals affected by severe mental illness in the context of modern legal and health policy environments.

CONCLUSIONS

Cultural and legal concepts of confidentiality within the doctor-patient relationship are complex. Increasingly, evidence is recognizing the essential role of carers in the quality management of individuals affected by severe mental illness and this emphasis is being further supported by innovative health policy and legislation. A public health definition for the role of carers may be a more appropriate way to consider their role in mental health management strategies.

Naturalistic studies--researching the everyday clinical world

During the last decade, a vast amount of research has been produced concerning the efficacy of different pharmacological and psychological treatments in psychiatry for various diagnoses. This movement towards evidence-based practices has aimed at grounding clinical practice in evidence derived from research, to optimize outcomes. Such developments should translate into the successful management of seriously mentally ill persons, allowing them to remain safely and productively in their communities rather than in more restrictive settings. Treatment regimens grounded in evidence are well behind the deinstitutionalization of mentally ill persons, which has sometimes even led to their reinstitutionalization in unfavorable settings (jails, nursing homes, etc.) and unsafe living conditions (shelters, streets).

Five-year follow-up during antipsychotic treatment: efficacy, safety, functional and social outcome

OBJECTIVE

Explore the long-term course of schizophrenia and related disorders.

METHOD

Naturalistic study of 225 patients initially treated with risperidone (monotherapy or in combination with other psychotropic drugs) over 5 years.

RESULTS

Stable symptomatology and side effects were observed. Clinician GAF scores were 55-61, but patients' self-ratings were higher. Clinician and patient CGI scores were at the same level. Annual in-patient days decreased but days in sheltered accommodations increased still more. Only 12% of the patients studied or worked full-time. One in four had no social contacts except with staff. Eight patients died during the 5 years.

CONCLUSION

The findings underline the chronicity and seriousness of psychotic disorders in terms of social outcome and, indirectly, the low quality of life of this group of persons. Patients were generally well aware of their illness and able to sort out symptoms from drug side effects. This opens for more active involvement of patients in monitoring their own treatment.