Costs of schizophrenia

Impact on carer burden when stable patients with schizophrenia transitioned from 1-monthly to 3-monthly paliperidone palmitate

RATIONALE

Reducing the frequency of long-acting injectable antipsychotic medication may reduce carer burden.

OBJECTIVES

To evaluate the impact of reduced frequency of long-acting injectable antipsychotic medication on carer burden in stable patients with schizophrenia.

METHODS

Carer burden was assessed using the Involvement Evaluation Questionnaire (IEQ) within a 52-week, prospective, single-arm, non-randomised, open-label, international, multicentre study evaluating the impact of transitioning stable patients with schizophrenia to paliperidone palmitate 3-monthly (PP3M) from paliperidone palmitate 1-monthly (PP1M).

RESULTS

159 carers completed the IEQ (mean [standard deviation, SD] age: 54.8 [12.8] years); 52.2% were the patients' parent and > 50% had >32 h/week of patient contact. At baseline, mean [SD] IEQ total score was in the lower range (23.8 [12.6]), reflecting patient stabilisation. At last observation carried forward (LOCF) endpoint, the IEQ total score decreased by a mean (95% CI) of -4.0 (-5.9, -2.1), indicating a significant overall reduction in carer burden (P < 0.0001). The six IEQ items with the highest carer burden at baseline were within the urging and worrying domains, in which burden was significantly improved at LOCF endpoint (P < 0.0001). Exploratory analyses found that higher carer burden was associated with lower functional remission (Personal and Social Performance score >70) at baseline and LOCF endpoint, and with the patient being part of the carer's household. Shorter disease duration correlated with better general health of carers at LOCF endpoint.

CONCLUSION

Reducing the frequency of antipsychotic medication administration in stable patients with schizophrenia by switching from PP1M to PP3M may reduce carer burden.

Habits and Attitudes of Video Gaming and Information Technology Use in People with Schizophrenia: Cross-Sectional Survey

Background

Information technology and video gaming have potential advantages in the treatment of schizophrenia. However, information regarding the habits and attitudes related to internet use and video gaming in people with schizophrenia is limited.

Objective

The aim of this study was to explore the habits and attitudes regarding video gaming and information technology usage and their associated factors in people with schizophrenia in Hong Kong.

Methods

In this cross-sectional survey, service users with schizophrenia were recruited from 6 halfway hostels and 7 integrated centers for mental wellness in Hong Kong. A 79-item self-report questionnaire was utilized to explore the habits of internet use and video gaming in these people with schizophrenia. The attitude toward video gaming was assessed using the Gaming Attitudes, Motivations, and Experiences Scales. Of the 148 individuals in a convenience sample who were invited to participate in this study, 110 willingly participated (a response rate of 74.3%). The data were analyzed using descriptive statistics, a two-tailed independent t test, Pearson correlation, and principal analysis with 3 methods of rotation (varimax, equimax, and promax).

Results

Most participants (100/110, 90.9%) had access to the internet and half of them (54/110, 49.1%) used the internet daily mostly to watch videos (66/110, 60.0%) or read news or books, etc (42/110, 38.2%). One-third of the participants (36/110, 32.7%) used the internet to play web-based games, and most of them (88/110, 80.0%) had played a video game in the past year. The most favorable gaming platforms were cellular phones (43/88, 49%) followed by computers (19/88, 22%) and arcade cabinets (6/88, 7%). The most favorable game genre was action games (34/145, 23.4%). Those who had a bachelor’s degree or higher scored lower in social interaction than those with a lower education level (P=.03). Those who played video games daily scored higher in the category of story than those who did not play daily (t₈₆=2.03, P=.05). The most popular gaming category was autonomy and the least popular categories were violent catharsis and violent reward. Two motives, “social playing” and “evasive playing,” were formed to describe the characteristics of playing video games.

Conclusions

Our data showed a high internet utilization rate among people with schizophrenia in Hong Kong. Only a few of them used the internet to search for health-related information. Our study also exemplified the unique habits of gaming among the participants. Health care professionals could utilize video games to engage people with schizophrenia and promote coping with stress and provide social skills training to such people with schizophrenia. Identification of the gaming attitudes can contribute to the development of serious games for the schizophrenic population. Further investigation is vital for the promotion of mental health through web-based platforms.

The promises and pitfalls of pharmacoeconomics in schizophrenia

Pharmacoeconomic studies are often performed in order to evaluate the cost-effectiveness of different treatments in clinical practice. Such studies are exerting an increasingly important influence on treatment choices in all areas of medicine, including psychiatry, and reflect the desire to contain rising costs of medical care [27]. Pharmacoeconomic analyses indicating cost savings can even be a prerequisite for inclusion of a new drug on national formularies [28].

The socio-economical burden of schizophrenia: A simulation of cost-offset of early intervention program in Italy

Schizophrenia is associated with a high familiar, social and economic burden. During the recent years early and specific intervention for first psychotic episodes has been suggested to improve the long term outcome of the disease. Despite the promising results obtained so far, early intervention is still scarcely applied. One major problem arises from the translation of research findings into stakeholder policies. In fact very few analyses of cost reductions obtained with early intervention have been reported. In the present paper we present a simulation of direct cost reduction that can be obtained with early intervention programmes. We based our analysis on available data about schizophrenia care costs in Italy and the expected cost reduction with the use of early intervention. We observed that the increase in costs due to the more intensive early intervention is largely compensated by the reduction of inpatient admissions with a reduction of direct costs of 6.01%. Despite the apparently small economic gain, early intervention offers more clinical and social benefits as it seems to be effective also in decreasing relapse rates, in improving the patients' quality of life and disability associated with psychosis and in increasing employment rates. Those indirect costs however are difficult to estimate and were not included in our model.

In conclusion, our study supports the use of early intervention in schizophrenia, which could allow an outcome improvement with lower direct and indirect costs.

Community perceptions of barriers to management of chronic psychotic disorders and knowledge and attitudes about long-acting injectable antipsychotic medication: qualitative study in Dar es Salaam, Tanzania

BACKGROUND

Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10-24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA.

AIMS

To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania.

METHOD

In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes.

RESULTS

Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context.

CONCLUSIONS

Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

Key Worker-Mediated Enhancement of Physical Health in First Episode Psychosis: Protocol For a Feasibility Study in Primary Care

BACKGROUND

Studies have demonstrated that, for patients with psychosis, a majority of the decline in health status and functioning emerges during the first few years after the onset of illness. This knowledge led to the development of specialized early intervention services (EISs) targeting patients experiencing their first episode of psychosis. The central component of EISs is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users.

OBJECTIVE

This paper outlines the protocol for a feasibility study examining how key workers may enhance physical health by supporting integration between primary and secondary care.

METHODS

Semistructured interviews were conducted with key stakeholder groups (General Practitioners and health care professionals working in mental health services). The interviews informed the development of the complex intervention involving a longitudinal pre-post intervention in 8 general practices in 2 regions in Ireland (one urban and one rural). Patients with first episode psychosis (FEP) will be identified from clinical records at general practices and mental health services.

RESULTS

Baseline and follow-up data (at 6 months) will be collected, examining measures of feasibility, acceptability, and intervention effect size.

CONCLUSIONS

Study findings will inform future practice by examining feasibility of key workers enhancing physical health through improved interaction between primary and secondary care. By identifying issues involved in enhancing recruitment and retention, as well as the likely effect size, the study will inform a future definitive intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13115.

Acute hospital care in inner London: splitting from mental health services in the community

Acute hospital care in psychiatry has been described as inefficient and disorganised (Muijen, 1999). Worrying as it may be, this is neither new nor surprising. Following the closure of large mental institutions and the advent of community care, hospital services were supposed to provide acute in-patient care as part of a wider system. Long-term needs of patients in the community should henceforth be met by community services that would be fully equipped and resourced to undertake this task. However, it was not long before acute wards were overwhelmed by occupancy rates of 100% and above, particularly in inner cites (Powell et al, 1995). The reason for the ‘bed crisis' that followed seems essentially twofold: community services were neither equipped nor resourced as required, and the number of acute beds was not adjusted to the ensuing demand. As hospital care has come to represent the only option for many patients whose needs could not be met in the community, acute wards have become overcrowded and ‘a bizarre and illogical mixture … of old and young, male and female, psychotic and depressed, retarded and agitated and voluntary and detained’ (Muijen, 1999).

Health professionals' views of services for schizophrenia – fragmentation and inequality

There has been much debate about effective treatments, service configurations and costs within Britain's mental health care system, but it has largely taken place in academic and management circles. We were interested in the views of those providing care. We organised a meeting of community psychiatric nurses, general practitioners and consultant psychiatrists (funded with an educational grant from Zeneca Pharmaceuticals). Participants worked in various parts of Great Britain, including rural and inner city areas. The authors facilitated the discussion, the emphasis of which was on participants' clinical experience.

Postcode prescribing in psychiatry

Aims and Method

We aimed to examine variations in clozapine prescribing in all 12 NHS trusts with catchment area mental health services in one English county, over a 2-year period. We tested a series of hypotheses to explain the variation in prescribing of clozapine.

Results

A 34-fold variation between trusts in rates of clozapine provision was found after adjusting for measures of local population need. This variation did not change over the 2 years examined. It was not explained by differences in resource level.

Clinical Implications

The evidence base is strong for the effectiveness and likely cost-effectiveness of clozapine in severe schizophrenia. Our data indicate that variations in evidence-based clinical practice at the provider level led to the wide variation in clozapine prescribing.

Reasons associated with treatment non-adherence in schizophrenia in a Pakistan cohort

non-adherence in patients with schizophrenia is the most common reason for a relapse of psychosis. In a cohort of participants in Pakistan who suffered a relapse of psychosis, we aimed to identify the principal factors associated with non-adherence, including any culture specific factors that might not be as significant in other jurisdictions. Semi-structured interviews were undertaken at four psychiatric hospitals in the Peshawar region in Pakistan with 55 participants (44 male and 11 female) diagnosed with schizophrenia, who had suffered a relapse of psychosis subsequent to treatment non-adherence. The five principal documented reasons for treatment non-adherence were: 1) alternative treatment pathway chosen with a traditional faith healers (n=53, 96.4%), 2) lack of insight (n=36, 65.5%), 3) poor economic status (n=33, 60.0%), 4) adverse effects of medications (n=33, 60.0%) and 5) utilising psycho-active substances as an alternative to psychotropic medications (n=27, 41.1%). A number of identified factors associated with a relapse of psychosis are potentially modifiable including the provision of a range of pharmacological options including second generation antipsychotic agents, long acting injectable antipsychotics and psycho-therapeutic interventions including psycho-education. These interventions should prove cost effective and be associated with reduced relapse rates of psychosis.

Burden of care amongst caregivers who are first degree relatives of patients with schizophrenia

Introduction

Caring for a mentally ill family member is a challenging task. Caregivers who are first-degree relatives (FDR) are at a higher risk of experiencing the negative consequences of caregiving. This study was aimed at determining burden of care and its correlates in caregivers who are first-degree relatives of patients with schizophrenia.

Methods

A dyad of 255 patients and caregivers was recruited. A socio-demographic questionnaire was administered to both. The GHQ-12 was used to screen for psychiatric morbidity in the FDRs. Caregiver's burden was assessed with the Zarit Burden Interview. Patients' illness severity and level of functioning were assessed using the Brief Psychiatric Rating Scale and the Global Assessment of Functioning scales respectively.

Results

The mean ± SD age of caregivers and patients were 45.1 ±12.3 and 36.7 ±13.4 years respectively. About 49% of caregivers experienced high burden of care. Older caregiver's age (r = 0.179; p < 0.004) and greater illness severity (r = 0.332; p < 0.0001) in the patient had weak to moderate positive correlation with burden of care. Caregiver's burden also increased with poorer functioning of the patient (r = -0.467 p < 0.0001). Independent predictors of caregiver burden were low level of education of the caregiver (OR 2.45; 95% CI 1.27-4.73), psychiatric morbidity in the caregiver (OR 6.74; 95% CI 2.51-18.15) and poor patient functioning (OR 2.81; 95% CI 1.27-6.18).

Conclusion

Caregivers who are first-degree relatives of patients with schizophrenia experience varying degrees of burden of care during caregiving. Routine screening and early psychological intervention would help to ameliorate these negative consequences of caregiving.

Nurses' perceptions of medication adherence in schizophrenia: results of the ADHES cross-sectional questionnaire survey

OBJECTIVES

Poor adherence to antipsychotic treatment is a widespread problem within schizophrenia therapy with serious consequences including increased risks of relapse and rehospitalization. Mounting evidence supports the key roles that nurses play in monitoring patient progress and facilitating long-term treatment adherence. The Adherencia Terapéutica en la Esquizofrenia (ADHES) nurses' survey was designed to assess the opinions of nurses on the causes and management of partial/nonadherence to antipsychotic medication.

METHODS

A questionnaire-based cross-sectional survey of 4120 nurses from Europe, the Middle East and Africa. Interpretation of results was based on a descriptive comparison of responses.

RESULTS

Nurses perceived 54% of patients seen in the preceding month to be partially/nonadherent to treatment. Most nurses (90%) reported some level of experience with administration of long-acting injectable (LAI) antipsychotics, with 24% of nurses administering >10 injections per month. The majority (85%) of nurses surveyed believed that improving adherence would improve patient outcomes. Nearly half (49%) reported that most of their patients depend on a family member or other nonprofessional carer to remind them to take their medication as prescribed. A similar proportion of nurses (43%) reported that most of their patients relied on a professional to remind them to take medication. Most nurses (92%) felt that ensuring continuous medication with LAI antipsychotics would yield long-term benefits for patients, but their opinion was that over a third of patients were unaware of LAI antipsychotic treatments. In a series of forced options, the strategy used most often by respondents (89%) to promote medication adherence was to build trusting relationships with patients while listening to and interpreting their needs and concerns. Respondents also rated this as the most effective strategy that they used (48%).

CONCLUSION

Nurses are highly aware of adherence issues faced by their patients; further patient education on treatment options is needed.

Determinants of subjective and objective burden of informal caregiving of patients with psychotic disorders

BACKGROUND

In a previous study, the objective burden of informal caregiving to patients with psychotic disorders amounted to 22 hours/week, and the subjective burden was huge with predominately anxiety and depression as main symptoms. In this study, determinants of the informal caregiving burden are analyzed to find foci for interventions to ease the size of burden.

METHODS

Patients with psychotic disorders (n = 107) and their informal caregivers (n = 118) were included. They were assessed with a comprehensive battery of rating scales including patient and caregiver characteristics as well as the amount and quality of health-care provision.

RESULTS

A multiple linear regression analysis showed that the subjective burden was significantly lower when patients had higher levels of functioning and when the health status of the informal caregivers was good. No significant determinants were found for the objective burden, but an association was found between a higher socioeconomic status of the caregivers and the amount of money provided for the patient. An association was also found between a positive perception of caregiving and more hours spent on caregiving.

CONCLUSION

The functioning level of the patients was the main determinant of the subjective burden of informal care. For the objective burden, no main determinant was found.

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.

The cost reduction in hospitalization associated with paliperidone palmitate in the People's Republic of China, Korea, and Malaysia

BACKGROUND

Schizophrenia results in substantial health care utilization costs. Much of these costs can be attributed to health care use resulting from nonadherence to treatment, relapse, and hospitalization.

AIMS OF THE STUDY

The objective of this research is to further estimate the health care resource utilization costs of patients with schizophrenia in the People's Republic of China, Korea, and Malaysia with a specific focus on the reduction in hospitalization costs associated with the use of long-acting, injectable paliperidone palmitate (PP) relative to alternative treatment medications.

METHODS

The study focuses exclusively on the estimated reduction in hospitalization days following treatment with PP and the potential associated cost savings. Cost analysis was done using a payer's perspective and only includes direct health care costs associated with hospitalization. Localized cost data were taken from published sources, and health care utilization was estimated based on a clinical study conducted in countries in the Asia-Pacific region. People's Republic of China, Korea, and Malaysia had the highest number of patients enrolled in the clinical study, and thus were chosen for this research. Analysis looked at 12-month and 18-month periods following initial treatment with PP relative to a retrospective 12-month period utilizing alternative treatment medications.

RESULTS

Results suggest that reductions in hospital utilization cost over 12 months may occur through the use of PP relative to alternatives-ranging from $1,991 for the People's Republic of China to $6,698 for Korea and $6,716 for Malaysia.

CONCLUSION

Given the substantial costs associated with the treatment of schizophrenia both worldwide and in Asia, it is important to fully understand the costs and outcomes associated with various treatment options. In this research, we have specifically analyzed the direct health care cost savings associated with hospital utilization for patients taking PP relative to alternative treatment methods. The results suggest that reductions in hospital utilization cost were associated with PP treatment, likely largely due to increased adherence to treatment.

Changes in cost of treating schizophrenia: comparison of two studies done a decade apart

Objective of this study was to compare the cost of care of schizophrenia estimated in the same catchment area separated by a decade. Cost of care of schizophrenia was estimated in 50 outpatients in 2001-2002 and 53 outpatients 2010-2011 using the same methodology along with structured assessments of psychopathology. Overall cost of care of schizophrenia has doubled in the last one decade. The total direct cost of the treatment has not changed much in the monetary terms in last one decade, but total indirect cost has increased 2.35 times. In terms of proportion of cost, there was no significant change in the proportion of the provider cost, however, the proportion of indirect cost increased from 63% to 77.57% from the year 2001-2002 to the year 2010-2011. Cost of care of schizophrenia is more for those have lower level of functioning and have to visit the hospital more often. Cost of care of schizophrenia in India has doubled in the last one decade.

Efficacy and tolerability of quetiapine versus haloperidol in first-episode schizophrenia: a randomized clinical trial

Background

Schizophrenia is a chronic disease of global importance. The second-generation antipsychotic quetiapine has a favorable side-effect profile, however, its clinical effectiveness has been called into question when compared with first-generation antipsychotics such as haloperidol. This study evaluates the efficacy and tolerability of quetiapine versus haloperidol for first-episode schizophrenia in the outpatient setting.

Methods

156 adult patients with first-episode schizophrenia participated in an outpatient clinical trial and were randomized to quetiapine (200 mg/d; n = 78) or haloperidol (5 mg/d; n = 78). The study medications were titrated to a mean daily dose of 705 mg for quetiapeine and 14 mg for haloperidol. The patients were assessed at baseline, six weeks, and twelve weeks. The primary outcome measures were positive and negative scores of the Positive and Negative Syndrome Scale (PANSS). Secondary measures were Global Assessment of Functioning (GAF) scale for overall psychosocial functioning, and Simpson-Angus Scale (SAS) for extra-pyramidal symptoms.

Results

At twelve weeks, the quetiapine group had a greater decrease in PANSS positive (18.9 vs. 15.3, p = 0.013) and negative scores (15.5 vs. 11.6, p = 0.012), however, haloperidol showed a greater decrease in general psychopathology score (23.8 vs. 27.7, p = 0.012). No significant difference between groups were found for total PANSS (58.3 vs. 54.8, p = 0.24) and GAF (45.7 vs. 46.2, p = 0.79).

ANOVA identified significant group interactions on PANSS positive (F = 18.72, df = 1.6,52.4, p < 0.0001), negative (F = 5.20, df = 1.1,35.7, p < 0.0001), depression/anxiety (F = 106.49, df = 1.14,37.8, p < 0.0001), and total scores (F = 7.51, df = 1.4,45.6, p = 0.001).

SAS (8.62 vs. 0.26, p < 0.0001) and adverse events of akathisia (78% vs. 0%, p = 0.000), parkinsonism (66.6% vs. 0%, p < 0.0001), and fatigue (84.6% vs. 66.6%, p = 0.009) were greater in haloperidol compared to quetiapine, whereas headache was more common in quetiapine treated patients (11.5% vs. 35.9%, p < 0.0001).

Conclusions

Quetiapine has greater efficacy for positive and negative symptoms with less extra-pyramidal symptoms than haloperidol when used for first-episode schizophrenia in the outpatient setting.

The association between labour force participation and being in income poverty amongst those with mental health problems

OBJECTIVES

Mental health conditions are associated with lower standards of living. This study quantifies the relationship between employment, depression and other mental health conditions and being in income poverty.

METHODS

Cross-sectional analysis was undertaken using the 2003 Survey of Disability, Ageing and Carers data for Australians aged 45-64 years.

RESULTS

Those not in the labour force due to depression and other mental health conditions are significantly more likely (odds ratio (OR) 12.53, 95% CI: 12.20-12.86, p < 0.0001; OR 20.10, 95% CI: 19.67-20.54, p < 0.0001) to be in income poverty than those not in the labour force with no chronic health condition. Amongst those with depression and other mental health conditions, those who were in employment were significantly less likely to be in income poverty than those who have had to retire because of the condition.

CONCLUSION

Due to the association between leaving the workforce due to mental health problems and poverty status, efforts to increase the employment of individuals with mental health conditions, or prevent the onset of the conditions, will likely improve living standards.

The cost of schizophrenia in Japan

INTRODUCTION

Schizophrenia is a disorder that produces considerable burdens due to its often relapsing/remitting or chronic longitudinal course. This burden is felt not only by patients themselves, but also by their families and health care systems. Although the societal burden caused by this disorder has been evaluated in several countries, the magnitude of the societal cost of schizophrenia in Japan has never been estimated. The aim of this study is to clarify the societal burden of schizophrenia by estimating the cost of schizophrenia in Japan in 2008.

METHODS

A human capital approach was adopted to estimate the cost of schizophrenia. The total cost of schizophrenia was calculated as the sum of the direct, morbidity, and mortality costs. Schizophrenia was defined as disorders coded as F20.0-F20.9 according to the International Classification of Diseases-10. The data required to estimate the total cost was collected from publicly available statistics or previously reported studies.

RESULTS

The total cost of schizophrenia in Japan in 2008 was JPY 2.77 trillion (USD 23.8 billion). While the direct cost was JPY 0.770 trillion (USD 6.59 billion), the morbidity and mortality costs were JPY 1.85 trillion (USD 15.8 billion) and JPY 0.155 trillion (USD 1.33 billion), respectively.

CONCLUSION

The societal burden caused by schizophrenia is tremendous in Japan, similar to that in other developed countries where published data exist. Compared with other disorders, such as depression or anxiety disorders, the direct cost accounted for a relatively high proportion of the total cost. Furthermore, absolute costs arising from unemployment were larger, while the prevalence rate was smaller, than the corresponding results for depression or anxiety in Japan.

The cost effectiveness of long-acting/extended-release antipsychotics for the treatment of schizophrenia: a systematic review of economic evaluations

BACKGROUND

Antipsychotic medication is the mainstay of treatment in schizophrenia. Long-acting medication has potential advantages over daily medication in improving compliance and thus reducing hospitalization and relapse rates. The high acquisition and administration costs of such formulations raise the need for pharmacoeconomic evaluation.

OBJECTIVE

The aim of this article is to provide a comprehensive review of the available evidence on the cost effectiveness of long-acting/extended-release antipsychotic medication and critically appraise the strength of evidence reported in the studies from a methodological viewpoint.

METHODS

Relevant studies were identified by searching five electronic databases: PsycINFO, MEDLINE, EMBASE, the NHS Economic Evaluation Database and the Health Technology Assessment database (HTA). Search terms included, but were not limited to, 'long-acting injection', 'economic evaluation', 'cost-effectiveness' and 'cost-utility'. No limits were applied for publication dates and language. Full economic evaluations on long-acting/extended-release antipsychotics were eligible for inclusion. Observational studies and clinical trials were also checked for cost-effectiveness information. Conference abstracts and poster presentations on the cost effectiveness of long-acting antipsychotics were excluded. Thirty-two percent of identified studies met the selection criteria. Pertinent abstracts were reviewed independently by two reviewers. Relevant studies underwent data extraction by one reviewer and were checked by a second, with any discrepancies being clarified during consensus meetings. Eligible studies were assessed for methodological quality using the quality checklist for economic studies recommended by the NICE guideline on interventions in the treatment and management of schizophrenia.

RESULTS

After applying the selection criteria, the final sample consisted of 28 studies. The majority of studies demonstrated that risperidone long-acting injection, relative to oral or other long-acting injectable drugs, was associated with cost savings and additional clinical benefits and was the dominant strategy in terms of cost effectiveness. However, olanzapine in either oral or long-acting injectable formulation dominated risperidone long-acting injection in a Slovenian and a US study. Furthermore, in two UK studies, the use of long-acting risperidone increased the hospitalization days and overall healthcare costs, relative to other atypical or typical long-acting antipsychotics. Finally, paliperidone extended-release was the most cost-effective treatment compared with atypical oral or typical long-acting formulations. From a methodological viewpoint, most studies employed decision analytic models, presented results using average cost-effectiveness ratios and conducted comprehensive sensitivity analyses to test the robustness of the results.

LIMITATIONS

Variations in study methodologies restrict consistent and direct comparisons across countries. The exclusion of a large body of potentially relevant conference abstracts as well as some papers being unobtainable may have increased the likelihood of misrepresenting the overall cost effectiveness of long-acting antipsychotics. Finally, the review process was restricted to qualitative assessment rather than a quantitative synthesis of results, which could provide more robust conclusions.

CONCLUSIONS

Atypical long-acting (especially risperidone)/extended-release antipsychotic medication is likely to be a cost-effective, first-line strategy for managing schizophrenia, compared with long-acting haloperidol and other oral or depot formulations, irrespective of country-specific differences. However, inconsistencies in study methodologies and in the reporting of study findings suggest caution needs to be applied in interpreting these findings.

Can repetitive magnetic stimulation improve cognition in schizophrenia? Pilot data from a randomized controlled trial

BACKGROUND

Working memory represents a core cognitive domain that is impaired in schizophrenia for which there are currently no satisfactory treatments. Repetitive transcranial magnetic stimulation (rTMS) targeted over the dorsolateral prefrontal cortex has been shown to modulate neurophysiological mechanisms linked to working memory in schizophrenia and improves working memory performance in healthy subjects and might therefore represent a treatment modality for schizophrenia patients. The objectives were to evaluate the effects of rTMS on working memory performance in schizophrenia patients and evaluate whether rTMS normalizes performance to healthy subject levels.

METHODS

In a 4-week randomized double-blind sham-controlled pilot study design, 27 medicated schizophrenia patients were tested at the Centre for Addiction and Mental Health (a university teaching hospital that provides psychiatric care to a large urban catchment area and serves as a tertiary referral center for the province of Ontario). Patients performed the verbal working memory n-back task before and after rTMS magnetic resonance image targeted bilaterally sequentially to left and right dorsolateral prefrontal cortex 750 pulses/side at 20 Hz for 20 treatments. The main outcome measure was mean magnitude of change in the n-back accuracy for target responses with active (n = 13) or sham (n = 12) rTMS treatment course.

RESULTS

The rTMS significantly improved 3-back accuracy for targets compared with placebo sham (Cohen's d = .92). The improvement in 3-back accuracy was also found to be at a level comparable to healthy subjects.

CONCLUSIONS

These pilot data suggest that bilateral rTMS might be a novel, efficacious, and safe treatment for working memory deficits in patients with schizophrenia.

Common use of anticholinergic medications in older patients with schizophrenia: findings of the Research on Asian Psychotropic Prescription Pattern (REAP) study, 2001-2009

OBJECTIVE

This study surveyed the use of anticholinergic medications (ACMs) in older Asian patients with schizophrenia and examined its demographic and clinical correlates.

METHOD

A total of 1452 hospitalized patients with schizophrenia aged 55 years or older in nine Asian countries and territories were surveyed between 2001 and 2009. The cross-sectional data of patients' socio-demographic and clinical characteristics and the prescriptions of antipsychotic drugs and ACM were recorded using a standardized protocol and data collection procedure.

RESULTS

The frequency of ACM prescription was 64.6% in the pooled sample, with 72.4%, 61.9%, and 59.5% in 2001, 2004, and 2009, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on ACM had a higher dose of antipsychotic medications, and were more likely to have extrapyramidal side effects and receive first-generation antipsychotic medications.

CONCLUSIONS

Anticholinergic medications were frequently used in older Asian patients with schizophrenia. Considering the potential side effects of ACM, the rationale for their widespread use in this patient population should be revisited.

Clinical consequences of switching from olanzapine to risperidone and vice versa in outpatients with schizophrenia: 36-month results from the Worldwide Schizophrenia Outpatients Health Outcomes (W-SOHO) study

BACKGROUND

With many atypical antipsychotics now available in the market, it has become a common clinical practice to switch between atypical agents as a means of achieving the best clinical outcomes. This study aimed to examine the impact of switching from olanzapine to risperidone and vice versa on clinical status and tolerability outcomes in outpatients with schizophrenia in a naturalistic setting.

METHODS

W-SOHO was a 3-year observational study that involved over 17,000 outpatients with schizophrenia from 37 countries worldwide. The present post hoc study focused on the subgroup of patients who started taking olanzapine at baseline and subsequently made the first switch to risperidone (n=162) and vice versa (n=136). Clinical status was assessed at the visit when the first switch was made (i.e. before switching) and after switching. Logistic regression models examined the impact of medication switch on tolerability outcomes, and linear regression models assessed the association between medication switch and change in the Clinical Global Impression-Schizophrenia (CGI-SCH) overall score or change in weight. In addition, Kaplan-Meier survival curves and Cox-proportional hazards models were used to analyze the time to medication switch as well as time to relapse (symptom worsening as assessed by the CGI-SCH scale or hospitalization).

RESULTS

48% and 39% of patients switching to olanzapine and risperidone, respectively, remained on the medication without further switches (p=0.019). Patients switching to olanzapine were significantly less likely to experience relapse (hazard ratio: 3.43, 95% CI: 1.43, 8.26), extrapyramidal symptoms (odds ratio [OR]: 4.02, 95% CI: 1.49, 10.89) and amenorrhea/galactorrhea (OR: 8.99, 95% CI: 2.30, 35.13). No significant difference in weight change was, however, found between the two groups. While the CGI-SCH overall score improved in both groups after switching, there was a significantly greater change in those who switched to olanzapine (difference of 0.29 points, p=0.013).

CONCLUSION

Our study showed that patients who switched from risperidone to olanzapine were likely to experience a more favorable treatment course than those who switched from olanzapine to risperidone. Given the nature of observational study design and small sample size, additional studies are warranted.

How depression and other mental health problems can affect future living standards of those out of the labour force

OBJECTIVES

To estimate the extent to which those who exit the workforce early due to mental health problems have less savings by the time they reach retirement age.

METHODS

Using Health & WealthMOD--a microsimulation model of Australians aged 45-64 years that predicts accumulated savings at age 65, regression models were used to analyse the differences between the projected savings and the retirement incomes of people at age 65 for those currently working with no chronic condition, and people not in the labour force due to mental health problems.

RESULTS

Females who retire early due to depression have a median value of total savings by the time they are 65 of $300. For those with other mental health problems the median figure was $0. This is far lower than the median value of $227,900 for females with no chronic condition who remained employed full-time. Males showed similar differences. Both males and females who were out of the labour force due to depression or other mental health problems had at least 97% (95% CI: -99.9% to -68.7%) less savings and retirement income by age 65 that those who remained employed full-time.

CONCLUSIONS

People who retire from the labour force early due to mental health problems will face long term financial disadvantage compared to people who are able to remain in employment.

Costs and outcomes associated with an aripiprazole add-on or switching open-label study in psychosis

Health service providers increasingly need to consider not only the efficacy and safety of a therapy, but also its cost. Our hypothesis was that in our previously reported aripiprazole add-on or switching study, the improved outcomes would be associated with reduced costs. We here report data from this study, now to 52-week follow-up, with 27 total recruits (outpatients partially refractory or intolerant of their current antipsychotic regime). Serial clinical ratings included the Quality of Life Scale and Client Service Receipt Inventory, applied at baseline (N = 24), week 26 (N = 21) and 52 (N = 18). Cost data were unavailable for the drop outs. On last observation carried forward (LOCF) analysis, there was a significant increase in the Quality of Life Scale between baseline and one year (p = 0.007). There were also reductions over time in total direct and indirect costs. For study completers, the total costs at the one-year follow-up period were £ 482 less than those for the corresponding baseline period, with the Quality of Life Scale score at one year being 21.6 points (or 16.4 on LOCF analysis) higher. Therefore, in the completers, improved outcome was associated with reduced costs. Cost-effectiveness could be similarly investigated in a controlled trial.

The personal and national costs of mental health conditions: impacts on income, taxes, government support payments due to lost labour force participation

BACKGROUND

Mental health conditions have the ability to interrupt an individual's ability to participate in the labour force, and this can have considerable follow on impacts to both the individual and the state.

METHOD

Cross-sectional analysis of the base population of Health&WealthMOD, a microsimulation model built on data from the Australian Bureau of Statistics' Survey of Disability, Ageing and Carers and STINMOD, an income and savings microsimulation model was used to quantify the personal cost of lost income and the cost to the state from lost income taxation, increased benefits payments and lost GDP as a result of early retirement due to mental health conditions in Australians aged 45-64 in 2009.

RESULTS

Individuals aged 45 to 64 years who have retired early due to depression personally have 73% lower income then their full time employed counterparts and those retired early due to other mental health conditions have 78% lower incomes. The national aggregate cost to government due to early retirement from these conditions equated to $278 million (£152.9 million) in lost income taxation revenue, $407 million (£223.9 million) in additional transfer payments and around $1.7 billion in GDP in 2009 alone.

CONCLUSIONS

The costs of mental health conditions to the individuals and the state are considerable. While individuals has to bear the economic costs of lost income in addition to the burden of the conditions itself, the impact on the state is loss of productivity from reduced workforce participation, lost income taxation revenue, and increased government support payments--in addition to direct health care costs.

Economic aspects of peer support groups for psychosis

Peer support groups are rarely available for patients with psychosis, despite potential clinical and economic advantages of such groups. In this study, 106 patients with psychosis were randomly allocated to minimally guided peer support in addition to care as usual (CAU), or CAU only. No relevant differences between mean total costs of both groups were found, nor were there significant differences in WHOQoL-Bref outcomes. Intervention adherence had a substantial impact on the results. It was concluded that minimally guided peer support groups for psychosis do not seem to affect overall healthcare expenses. Positive results of additional outcomes, including a significant increase in social contacts and esteem support, favour the wider implementation of such groups.

Burden of schizophrenia in recently diagnosed patients: healthcare utilisation and cost perspective

BACKGROUND

Inpatient care to manage relapse of patients with schizophrenia contributes greatly to the overall financial burden of treatment. The present study explores to what extent this is influenced by duration of illness.

METHODS

Medical and pharmaceutical claims data for patients diagnosed with schizophrenia (ICD-9 295.xx) were obtained from the PharMetrics Integrated Database, a large, regionally representative US insurance claims database, for the period 1998-2007. Recently diagnosed (n = 970) and chronic patients (n = 2996) were distinguished based on ICD-9 295.xx classification, age and claims history relative to the first year (recently diagnosed) and the third year onwards (chronic) after the first index schizophrenia event.

RESULTS

The medical resource use and costs during the year following the index schizophrenia event differed significantly between cohorts. A higher proportion of recently diagnosed patients were hospitalised compared with chronic patients (22.3% vs 12.4%; p < 0.0001), spending a greater mean number of days in hospital (5.1 days vs 3.0 days; p = 0.0065) as well as making more frequent use of emergency room (ER) resources during this time. The mean annual healthcare costs of recently diagnosed patients were also greater ($20,654 vs $15,489; p < 0.0001) with inpatient costs making up a higher proportion of total costs (62.9%) compared with chronic patients (38.5%).

CONCLUSIONS

There is a considerably higher overall economic burden in the year following their first schizophrenia event in the treatment of recently diagnosed schizophrenia patients compared with chronic patients. Since hospitalisations and ER visits are the most significant components contributing to this finding, efforts that focus on measures to reduce the risk of relapse, particularly amongst recently diagnosed patients, such as improved adherence programs, may lead to better clinical and economic outcomes in the management of schizophrenia.

LIMITATIONS

Only commercially insured patients and direct medical costs were included, therefore, results may underestimate the economic burden of schizophrenia.

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.

Cost-effectiveness of long-acting risperidone injection versus alternative atypical antipsychotic agents in patients with schizophrenia in China

OBJECTIVES

To determine the most cost-effective strategy involving first-line treatment with long-acting risperidone, olanzapine, and quetiapine from the perspective of the Chinese health-care system.

METHODS

A decision analytical model was applied. The model used a time horizon of 2 years. The probabilities of treatment response of different agents and the relapse and hospitalization rates were estimated by a Delphi panel of 17 senior psychiatrists in China. The unit cost for each medical service was calculated from the price system database built by China National Development and Reform Commission and the medical resource utilization was estimated by the Delphi panel. The principal efficacy measure was the proportion of patients successfully treated. Various sensitivity analyses were carried out to test the robustness of the model.

RESULTS

The proportion of patients successfully treated over the 2-year period was 46.71% for long-acting risperidone, 39.93% for olanzapine, and 31.28% for quetiapine. The mean cost-effectiveness ratios were RMB189,427, RMB202,432, and RMB233,015 per successfully treated patient for long-acting risperidone, quetiapine and olanzapine, respectively. Results of the sensitivity analyses confirmed that the results were robust.

CONCLUSIONS

The results showed that long-acting risperidone is more cost-effective than olanzapine and quetiapine for patients with schizophrenia in long-term maintenance treatment.

[Schizophrenic patients' length of stay: mental health care implication and medicoeconomic consequences]

A striking reduction in hospital beds can be seen as the defining characteristic of mental health services in many western countries during the last 30 years. The politic of shortening hospital stays for persons with psychosis has been questioned by a number of authors. Studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapies and lower mortality rates. An interesting comparison between three contrasting mental care systems in Holland, Italy and Australia concluded not surprisingly that hospital stays are shortest where community care is more developed, although long term hospitalization will always be required for a small number of very severe patients. The general conclusion was that shorter stays work best if and only if there is high quality community care which comes into play immediately on discharge. The central issue appears to be that the beneficial effects of short stays are modulated by conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off staying longer, in order that a structured rehabilitation plan may be put in place. The process of deinstitutionalisation has been driven by a variety of forces. One is to reduce costs, since hospital inpatient costs are very high. Generally, between one- and two-thirds of the total health care cost of schizophrenia is for hospitalization, even in countries that have already substantially reduced their inpatient provision. Recent years have seen a trend toward mental health services provided from community-based settings for defined catchment areas. The development of these services has a heavy cost, with the opening of replacement accommodation and other community facilities and large teams. While few patients or clinicians would contest today that a return to normal community life is preferable to institutionalization, the adoption of shorter hospital stays was not an evidence-based policy and no adequate evaluation study was ever put in place to predict the social, clinical and economic consequences of this widespread practice.

Comparing the cost effectiveness of risperidone and olanzapine in the treatment of schizophrenia using the net-benefit regression approach

To estimate the cost effectiveness of olanzapine and risperidone for the treatment of schizophrenia in Belgium. Data were retrieved from a prospective, observational, non-randomized, follow-up survey. Clinical investigators assigned 265 patients with schizophrenia to either olanzapine (n = 136) or risperidone (n = 129). Patients were followed up for 2 years. Total healthcare costs were determined from the public payer perspective and calculated by multiplying resource use with official tariffs; effectiveness of the drugs was measured with the EQ-5D. This study uses a net-benefit regression approach to accommodate for baseline differences between treatment groups and uncertainty. Total 2-year costs were very similar for patients receiving risperidone and olanzapine (euro20 915.33 and euro20 569.69, respectively; p = 0.925) [year 2002 values]. The health condition of the patients receiving risperidone was better than that of patients receiving olanzapine but not significantly so (1.46 and 1.41, respectively; p = 0.191). Simple ordinary least squares (OLS) regressions indicated that, for lambda = euro40 000, we could not reject the null hypothesis that the drugs provide similar net monetary benefits to the patient (risperidone vs olanzapine euro2046.95; p = 0.656). When we controlled for several patient characteristics, risperidone moved further away from olanzapine but the difference did not reach statistical significance (risperidone vs olanzapine euro3198.07; p = 0.595). Numerous sensitivity analyses confirmed the robustness of the results. Results of this study suggest that it is important to control for baseline patient characteristics when performing a cost-effectiveness analysis. No significant difference in net monetary benefit was found between risperidone and olanzapine.

The cost-effectiveness of atypicals in the UK

BACKGROUND

In 2002, the National Institute for Health and Clinical Excellence (NICE), recommended atypical antipsychotics over conventional ones for first-line schizophrenia treatment, based on their lower risk of extrapyramidal symptoms.

OBJECTIVE

To estimate the incremental cost-effectiveness of atypical relative to conventional antipsychotics for the treatment of schizophrenia in the UK.

METHODS

A discrete event simulation (DES) model was adopted to reflect the treatment of schizophrenia in the UK. The model estimates symptoms (using the Positive and Negative Symptom Score [PANSS]), psychiatrist visits, pharmacological treatment and treatment location, number and duration of psychotic relapses, level of compliance, quality-adjusted life-years (QALYs), and side effects over a 5-year time period. Probabilistic sensitivity analyses were carried out. Following NICE's "atypical" recommendation, the cost-effectiveness of atypical versus conventional antipsychotics was estimated in a scenario analysis, assuming both groups differ only in side-effect profile.

RESULTS

When comparing conventional and atypical antipsychotics, the model predicts that the latter would decrease 5-year costs by 1633 Pound per patient and result in a QALY gain of 0.101. The probabilistic sensitivity analysis suggests these results are robust. The sensitivity analyses indicate that incremental costs and effects are most sensitive to the differential efficacy of atypicals and conventionals, as measured by PANSS. When it is assumed that the only differences between atypicals and conventionals are found in side-effect profiles, the incremental cost-effectiveness ratio of the atypicals is 45,000 Pound per QALY gained.

CONCLUSION

According to this DES model for schizophrenia, atypical antipsychotics are cost-effective compared to the conventional antipsychotics. The assumptions used in the model need further validation through large naturalistic based studies with reasonable follow-up to determine the real-life differences between atypicals and conventional antipsychotics.

Predictors for starting depot administration of risperidone in chronic users of antipsychotics

BACKGROUND

Risperidone long-acting injectable (RLAI), the first second-generation depot antipsychotic, has extensively been studied before introduction. Thereafter, questions about the type of patients actually treated with RLAI in daily practice remain to be answered for making valid antipsychotic treatment comparisons involving RLAI in observational studies.

OBJECTIVE

We aimed to determine in chronic antipsychotic users who switched treatment, predictors for the prescription of (1) depot versus oral antipsychotics and (2) RLAI versus first-generation antipsychotics (FGAs) depot.

METHODS

We used pharmacy dispensing data from 53 community pharmacies in the northeast of the Netherlands containing approximately 500,000 persons. Chronic antipsychotic users were defined and followed up for a switch in antipsychotic treatment within the first period that RLAI was on the market. Multivariable analysis was performed to relate patient, prescriber, and medication characteristics to prescription of a new antipsychotic drug.

RESULTS

Predictors for switching to depot versus oral antipsychotics were male sex, previous use of depot antipsychotics, recent anticholinergic drug use, and a gap in antipsychotic dispensation history. Predictors for switching to RLAI versus FGA depot were previous use of depot and consulting a specialist.

CONCLUSIONS

The results suggest that, compared with oral antipsychotics, patients receiving a depot are less compliant users, with more extrapyramidal side effects. Compared with FGA depot, patients receiving RLAI tend to be more severely ill patients. We conclude that RLAI may be partly channeled to patients as a last resort, which may have important consequences for the interpretation of observational effectiveness comparisons between RLAI and other antipsychotics in daily practice.

Costs and effects of paliperidone extended release compared with alternative oral antipsychotic agents in patients with schizophrenia in Greece: a cost effectiveness study

BACKGROUND

To compare the costs and effects of paliperidone extended release (ER), a new pharmaceutical treatment for the management of schizophrenia, with the most frequently prescribed oral treatments in Greece (namely risperidone, olanzapine, quetiapine, aripiprazole and ziprasidone) over a 1-year time period.

METHODS

A decision tree was developed and tailored to the specific circumstances of the Greek healthcare system. Therapeutic effectiveness was defined as the annual number of stable days and the clinical data was collected from international clinical trials and published sources. The study population was patients who suffer from schizophrenia with acute exacerbation. During a consensus panel of 10 psychiatrists and 6 health economists, data were collected on the clinical practice and medical resource utilisation. Unit costs were derived from public sources and official reimbursement tariffs. For the comparators official retail prices were used. Since a price had not yet been granted for paliperidone ER at the time of the study, the conservative assumption of including the average of the highest targeted European prices was used, overestimating the price of paliperidone ER in Greece. The study was conducted from the perspective of the National Healthcare System.

RESULTS

The data indicate that paliperidone ER might offer an increased number of stable days (272.5 compared to 272.2 for olanzapine, 265.5 f risperidone, 260.7 for quetiapine, 260.5 for ziprasidone and 258.6 for aripiprazole) with a lower cost compared to the other therapies examined (euro 7,030 compared to euro 7,034 for olanzapine, euro 7,082 for risperidone, euro 8,321 for quetiapine, euro 7,713 for ziprasidone and euro 7,807 for aripiprazole). During the sensitivity analysis, a +/- 10% change in the duration and frequency of relapses and the economic parameters did not lead to significant changes in the results.

CONCLUSION

Treatment with paliperidone ER can lead to lower total cost and higher number of stable days in most of the cases examined.

Importance of open access to atypical antipsychotics for the treatment of schizophrenia and bipolar disorder: a European perspective

OBJECTIVE

To assess European psychiatrists' prescribing behaviour and their perceived need for access to a wide range of atypical antipsychotics for patients with schizophrenia and bipolar disorder.

METHODS

A blinded, internet survey of psychiatrists from the UK, Germany, Italy and the Netherlands occurred in 2007. Key inclusion criteria for psychiatrists: practising full time; practising for 5-35 years; prescribed atypical antipsychotics in prior 6 months to > or =20 patients with schizophrenia or bipolar disorder. Eligible psychiatrists selected records for four patients with schizophrenia or bipolar disorder for whom they prescribed > or =1 atypical antipsychotic since January 2004.

RESULTS

Survey response rates were: UK, 14.8% (n = 107); Germany, 9.6% (n = 104); Italy, 8.9% (n = 101) and the Netherlands, 3.7% (n = 51); 363 psychiatrists reported on 1442 patients. Psychiatrists perceived a greater difference among atypical antipsychotics as a class (mean, 5.1 on a 7-point scale [7 = 'highly differentiated']) but not selective serotonin reuptake inhibitors (mean, 3.6). On average, psychiatrists used 6.8 different atypical antipsychotics across their patients with schizophrenia and 4.4 across their patients with bipolar disorder, with 2.5 and 2.4 changes required following first-line treatment to stabilise therapy, respectively. The most common reason for switching medication was lack of efficacy. Psychiatrists reported that expected consequences for patients should access to atypical antipsychotics be restricted would include illness deterioration, non-adherence and hospitalisation.

CONCLUSIONS

Although this study is limited by potential selection biases, these data suggest that European psychiatrists tailor antipsychotic medications for patients with schizophrenia or bipolar disorder according to patients' needs and specific drug attributes.

A pharmacoeconomic analysis of atypical antipsychotics and haloperidol in first-episode schizophrenic patients in taiwan

The study prospectively examined the economic outcomes and co-medications among first-episode schizophrenic patients treated with monotherapy of second-generation antipsychotic agents (SGAs) continuously as compared with each other and with haloperidol. The sample included 3047 out of Taiwan's national sample of 29,341 first-episode schizophrenic patients, who were selected, based on International Classification of Disease, Ninth Revision code 295, from the National Health Insurance original claims data from 1999 to 2004. They were treated with only 1 of the following antipsychotic agents: haloperidol (n = 526), clozapine (n = 224), risperidone (n = 827), olanzapine (n = 824), zotepine (n = 286), or quetiapine (n = 360), without changing antipsychotics during the observation for at least 1 year (mean, 1.80 years; SD, 0.93 years) for each subject. Economic outcomes included clinic visits, prescription days, frequencies and duration of hospitalizations, and total and separate treatment costs (outpatient department- and hospital-related costs). Co-medications included use of anticholinergic, anxiolytic, hypnotic/sedative, and antidepressant agents. Patients treated with SGAs had lower number and shorter durations of hospitalizations than did haloperidol-treated patients, except for the clozapine group. Olanzapine was associated with the lowest hospitalization rates per year (mean, 1.63 vs 2.83). In terms of cost, haloperidol was more expensive in total hospitalization expenses (mean, US $3215 per year) and total treatment cost (mean, $3769 per year) than olanzapine, zotepine, or quetiapine. In general, there was no difference among the haloperidol and SGA groups in terms of rates of co-medications. The reduced number of hospitalizations and then lower total hospitalization costs seem to be more than the offset of high medication acquisition costs of SGAs.

Clinical questions and uncertainty--prolactin measurement in patients with schizophrenia and bipolar disorder

Many antipsychotic medications have the potential to raise prolactin levels leading to a range of negative consequences. In addition to symptoms such as gynaecomastia, galactorrhoea, menstrual irregularities and sexual dysfunction it is becoming clear that there are a number of important and potentially serious long-term consequences, including a loss of bone mineral density and a possible association with the development of breast cancer. It is clear, therefore, that the tendency to raise prolactin should be an important consideration in the use of antipsychotics but, to a large degree, this area has been neglected in clinical practice and research when compared with other potential adverse effects. We consider some of the practical clinical issues in prolactin measurement and the management of high results. We will identify the areas of uncertainty that remain for clinicians and consider the practical questions that future research should address.

A prospective 6-month analysis of the naturalistic use of aripiprazole - factors predicting favourable outcome

OBJECTIVE

To evaluate the effectiveness of aripiprazole in clinical practice.

METHOD

Prospective follow-up of patients consecutively prescribed aripiprazole in an acute mental health unit. Retrospective analysis of outcome from casenotes.

RESULTS

Data were available on 228 patients. Fifty-one per cent discontinued aripiprazole over 6-month follow-up. Continuation with treatment was more likely in out-patients [relative risk (RR) 1.50; 95% CI: 1.13-2.00], those never before considered for clozapine treatment (RR 1.61, 95% CI: 1.06-2.44) and older patients [RR 1.05, 95% CI: 1.01-1.09 (per 5-year increase)]. The main reason for early discontinuation was the occurrence of minor adverse effects.

CONCLUSION

Aripiprazole is effective in practice. Outcome is likely to be improved by careful patient selection and by attending to adverse effects experienced early in treatment.

Costs of schizophrenia during 5 years

OBJECTIVE

To explore the direct and indirect costs in a cohort of 225 risperidone-treated patients with schizophrenia followed up annually during 5 years.

METHOD

Data on costs for medication, hospitalization, sheltered living and productivity losses, as well as degree of social isolation, were collected.

RESULTS

The direct costs were dominated by hospitalization and sheltered living expenses, while drug costs only represented 7% of the direct costs. Indirect costs represented 43% of the total costs during the 5 years. About 12% worked full-time, and 12% worked part-time, implying large productivity losses. As a consequence of the national mental health care reform, a substantial shift of costs from hospital care to sheltered living took place on the national level, but the reduction of hospital days for the study patients over time was much larger suggesting that the switch from first to second generation compounds was therapeutically successful. A high degree of social isolation was seen, with more than 20% being completely without social contacts and 30% seeing friends/relatives less often than once a week.

CONCLUSION

The economic costs of schizophrenia are high and driven by the need for assisted living and hospitalizations, together with productivity losses. In addition, the intangible costs, such as social contacts, are also high.

Australian Schizophrenia Care and Assessment Programme: real-world schizophrenia: economics

OBJECTIVE

The treatment of patients with schizophrenia consumes a considerable proportion of health service budgets, yet there have been few attempts to prospectively analyse the costs associated with this condition. Amid the current debate about where to invest scarce treatment resources to achieve optimal outcomes, real-world studies, such as the Schizophrenia Care and Assessment Programme (SCAP) contrast with hypothetically based models and provide comprehensive and broad-ranging data.

METHOD

Direct health-care costs were prospectively studied in a cohort of 347 patients with schizophrenia in Dandenong, Australia over 3 years. Indirect costs were estimated from patient self-reported information.

RESULTS

The average annual societal cost was AU $32,160 per participant in the first year of the study, AU $27,190 in the second year and AU $29,181 in the third year. Indirect costs accounted for 46% of the total costs in the first year, 52% of the total costs in the second year and 50% of the total costs in the third year. The most expensive component of treatment was inpatient hospital care, which accounted for 42%, 34% and 36% of the total costs in the first, second and third year, respectively.

CONCLUSIONS

Considerable resources are required for the provision of treatment for patients with schizophrenia. But for the majority of people in this cohort, funding assertive treatment programmes and measures to reduce hospitalization was accompanied with enhanced functioning and quality of life, as well as a reduction in long-term societal and government costs. The distribution of health-care costs is highly skewed, with a relatively small proportion of patients (39%) consuming the majority of resources (80%). Improving rates of employment for this patient group could hold substantial benefits in reducing the overall economic and personal impact of this disorder.

Healthcare in schizophrenia: effectiveness and progress of a redesigned care network

Background

The aim of this study was designed to investigate the care-effectiveness of different healthcare models for schizophrenic patients and the impact of it on caregivers.

Methods

Sample cases were randomly selected from southern Taiwan, 257 patients in redesigned care network, including a general hospital, a chronic ward, 10 outpatient clinics, and multialternative community programs, was compared to 247 patients in other traditional healthcare provider that were utilized as the control group. The quality of life (QOL) questionnaire and the Chinese health questionnaire (CHQ) were used.

Results

The controls had longer duration of illness (p = 0.001) and were older (p = 0.004). The average resource utilization in the study group (US$ 2737/year, per case) was higher than the control group (US$ 2041) (t = 7.91, p < 0.001). For the study group, the average length of stay was shorter, but the admission rate was higher. The QOL of the patients in the study group was better than that of the controls (p = 0.01). The family burden of the study group was lower (p = 0.035) and the score of general health questionnaire higher (p = 0.019).

Conclusion

We found that patients in the redesigned care network had a better QOL, lower family burden, decreased days of hospital stay, higher medical resource utilization and less frequent admission to a hospital, and the caregivers had better mental health. Although the costs were higher, the continued care network was more helpful in providing comprehensive mental illness services.

Affect recognition deficits in schizophrenia: neural substrates and psychopharmacological implications

Impaired emotional functioning is a prominent feature of schizophrenia that includes significant deficits in the ability to accurately recognize facial expressions of emotion. Recent work demonstrates that deficits in affect perception are related to functional outcome and negative symptoms, suggesting that remediation of these deficits may contribute to symptomatic and functional improvements. Thus far, antipsychotic drug treatments appear to be relatively ineffective as a remedial tool. However, investigations into the neurobiology of affective dysfunction show abnormal amygdala activation in schizophrenia during affect recognition tasks. Such findings indicate that regulation of amygdala responses may aid in more accurate emotion processing. Both serotonergic and anxiolytic GABAergic agents that modulate activation of the limbic system offer promising avenues for remediation efforts.

Medical cost analysis of family psychoeducation for schizophrenia

Family psychoeducation has been shown to prevent the relapse of schizophrenia. However, whether medical costs are reduced by this approach remains uncertain. The subjects were patients with schizophrenia who lived with high-expressed emotion (EE) families and were at high risk of relapse. A total of 30 patients whose families underwent psychoeducation and intensive family sessions or psychoeducation and subsequent support were regarded as the psychoeducation group. A high-EE group without family psychoeducation made up of 24 patients was used as a control group. The mean outpatient medical cost, duration of hospitalization, inpatient medical cost, and total medical cost during the follow-up period were compared between the psychoeducation group and the control group. The mean inpatient medical cost was 270,000 yen in the psychoeducation group and 470,000 yen in the control group. The mean total medical costs were 500,000 yen in the psychoeducation group and 710,000 yen in the control group. The cost in the psychoeducation group was significantly lower than the control group by Mann-Whitney U-test. The proportion of patients with a total medical cost greater than the median value was 23% in the psychoeducation group and 54% in the control group with a significant difference. The medical cost can be reduced in the psychoeducation group compared with the control group due to the prevention of re-hospitalization by family psychoeducation.

Project among African-Americans to explore risks for schizophrenia (PAARTNERS): recruitment and assessment methods

The Project among African-Americans to Explore Risks for Schizophrenia (PAARTNERS) is a multi-site, NIMH-funded study that seeks to identify genetic polymorphisms that confer susceptibility to schizophrenia among African-Americans by linkage mapping and targeted association analyses. Because deficits in certain dimensions of cognitive ability are thought to underlie liability to schizophrenia, the project also examines cognitive abilities in individuals affected by schizophrenia and their extended family members. This article describes PAARTNERS study design, ascertainment methods and preliminary sample characteristics. We aim to recruit a sample of 1260 African-American families, all of whom have at least one proband with schizophrenia or schizoaffective disorder. The data collection protocol includes a structured Diagnostic Interview for Genetic Studies, Family Interview for Genetic Studies, focused neurocognitive assessment, medical records review, and the collection of blood or buccal cells for genetic analyses. We have currently completed study procedures for 106 affected sib-pair, 457 case-parent trio and 23 multiplex families. A total of 289 probands have completed the best estimate final diagnosis process and 1153 probands and family members have been administered the computerized neuropsychological battery. This project lays the foundation for future analysis of cognitive and behavioral endophenotypes. This novel integration of diagnostic, neurocognitive and genetic data will also generate valuable information for future phenotypic and genetic studies of schizophrenia.

The costs of schizophrenia in Spain

This study estimated the economic impact of schizophrenia-related direct costs (medical and nonmedical costs) in Spain. Direct medical costs (hospitalizations, outpatient consultations, drug costs) and direct nonmedical costs (costs of informal care) were estimated based on prevalence costs for 2002. The total costs of schizophrenia were estimated at euro 1,970.8 million; direct medical costs accounted for 53% and informal care costs 47%. Despite having implemented a conservative approach, the health care costs associated with schizophrenia account for 2.7% of total public health care expenditure in Spain. The sum of medical and nonmedical costs give us a better definition of the magnitude of the problem in Spain as well as contributing to helping make the debate on this issue more transparent.

A decision model to compare health care costs of olanzapine and risperidone treatment for schizophrenia in Germany

Second-generation atypical antipsychotics such as clozapine, olanzapine, risperidone, quetiapine, ziprasidone, amisulpride and ariprazole offer the potential to reduce the significant health care resource demands in the treatment of schizophrenia through improved levels of initial clinical response and reduced levels of long-term acute relapse. However, the optimal sequencing of these drugs remains unclear. To consider this issue from a health economic viewpoint a decision model approach was used comparing healthcare costs and clinical outcomes when treating patients with alternative sequences of atypical antipsychotic treatment. Treated patients were assumed to be in a current acute episode with at least a 10-year history of disease and to be naive to previous atypical treatments. Treatment strategies were based on either first-line olanzapine or risperidone with switching to the alternative drug as second-line treatment following an inadequate clinical response to first-line drug therapy. Clinical response data were derived from a pivotal published comparative study of both olanzapine and risperidone. Published data on the long-term use of antipsychotic drugs where used wherever possible to populate the model for relapse rates during the maintenance phase. Health care resource data were defined for Germany based on expert clinical opinion. A treatment strategy of first-line olanzapine was shown to be cost saving over a 1-year period, with additional clinical benefits in the form of avoided relapses. The model suggests that over the first year of treatment a strategy of first-line olanzapine is associated with lower risk of additional relapse (0.33 fewer acute relapses per 100 patients per year) and with cost savings (euro 35,306 per 100 patients per year). There is a need for longer term direct in-trial comparisons of atypical antipsychotics to confirm these indicative results.

Severe and persistent mental illness: a useful definition for prioritizing community-based mental health service interventions

OBJECTIVE

There is a lack of consensus on the identification of seriously mentally ill patients (SMI). This study investigates the external and predictive validity of an operationalized definition for the severity and persistency of mental illness applied to a sample of service users attending a community mental health service.

METHOD

The definition is based on the fulfilment of dysfunction (GAF < or = 50) and illness duration (> or = 2 yrs) criteria. The study was conducted with a two-year longitudinal design. External and predictive validity of the SMI definition were assessed against the diagnosis of psychosis.

RESULTS

Our data show evidence for an overall high predictive and external validity of the SMI definition and high sensitivity in predicting those with high burden of mental illness.

CONCLUSIONS

In order to identify people with high levels of psychiatric burden, the SMI working definition seems to be more useful than that simply based on diagnostic criteria.