The effect of low-cost maintenance medication on the rehospitalization of schizophrenic outpatients

Antipsychotic medication for elderly people with schizophrenia

BACKGROUND

A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice.

OBJECTIVES

To find and assimilate good evidence of the effects of antipsychotic medication for treatment of schizophrenia in people over 65 years of age.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (May 2003). We inspected references of all included studies for further trials and contacted relevant pharmaceutical companies.

SELECTION CRITERIA

All clinical randomised trials evaluating antipsychotic drugs for schizophrenia and schizophrenia-like psychoses in older people.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data, the random effects, relative risk (RR), and 95% confidence interval (CI) and, where appropriate, the numbers needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

Two hundred and fifty two elderly people with schizophrenia participated in three relevant randomised controlled studies. We were unable to extract usable data on quality of life, satisfaction, service use, or economic outcomes. One small study (n=18) compared thioridazine with remoxipride (RR leaving the study early 1.0 CI 0.07 to 13.6). A second study (n=175) compared risperidone with olanzapine. Global state 'not improved/worse' was not significantly different between treatments (n= 171, RR 1.26 CI 0.8 to 1.9); mental state PANSS total endpoint scores were also equivocal (n=171, RR 0.98 CI 0.76 to 1.26) as were all cognitive function tests. The third study (subset n=59) compared olanzapine with haloperidol and mental state change scores (BPRS WMD -3.60 CI -10.8 to 3.6; PANSS WMD -6.00 CI -18.3 to 6.3) were equivocal.

AUTHORS' CONCLUSIONS

Antipsychotics may be widely used in the treatment of elderly people with schizophrenia, however, based on this systematic review, there are little robust data available to guide the clinician with respect to the most appropriate drug to prescribe. Clearly reported large short, medium and long-term randomised controlled trials with participants, interventions and primary outcomes that are familiar to those wishing to help elderly people with schizophrenia are long overdue.

Patient compliance behavior: the effects of time on patients' values of treatment regimens

Present medical models of treatment compliance have not addressed the role that time plays in the perception of a treatment regimen's costs and benefits. This paper re-evaluates the role of time in understanding compliance behavior. Models from the economic and psychological literature are used to demonstrate that the 'discounting effect' associated with future events, and the 'sunk cost effect' associated with past events may have a direct and predictable impact on the patient's values in health care choices. This article suggests that when the effects of time are incorporated into expectancy models of compliance behavior (such as the Health Belief Model) the resulting predictions are supported by numerous findings in the compliance literature, many of which were previously unaccountable by these expectancy models. From this finding an explanation is derived for the variable results of educational and attitudinal change programs upon compliance behavior, the success of patient contracts, the sudden occurrence of preference reversals in health care choices, and the 'confusing' effect of treatment cost on treatment adherence. This paper also introduces to the compliance literature the concept of a treatment's 'time adjusted rate of return', and speculates upon how this concept may be used to understand the relationship between a treatment's 'desirability' or its ability to motivate a person to start the treatment, and its 'resistance' or its capacity to help a person to finish the treatment once it has begun. It proposes that changes in the temporal distribution of a treatment's benefits and costs can improve the treatment's desirability and resistance, and that a treatment's time adjusted rate of return can be used to allocate more efficiently the effort that providers spend monitoring patient compliance.

Benefit--cost methodology in the evaluation of therapeutic services for alcoholism

Benefit--cost analysis as a form of "social profitability analysis" can be a powerful tool in the overall evaluation of alcoholism treatment efforts. Alcoholism treatment potentially leads to a multiplicity of benefits in addition to sobriety. Benefit--cost analysis provides a methodology for converting many of these diverse benefits into a common metric (dollars), thereby allowing the comparison of aggregate benefits and treatment costs. The analysis thus leads to the expression of treatment outcome in terms of the return on investment. A benefit--cost analysis conducted on 3034 clients from the Oklahoma data base indicated a return to society of $1.98 for every $1 invested in alcoholism treatment. Such data may represent a critical portion of the information required for responsible resource allocation decisions.