The cost of schizophrenia in Japan

Factors influencing the length of stay in forensic psychiatric settings: a systematic review

BACKGROUND

Forensic psychiatry is often associated with long admissions and has a high cost of care. There is little known about factors influencing length of stay (LOS), and no previous systematic review has synthesised the available data. This paper aims to identify factors influencing the LOS in forensic psychiatry hospitals to inform care and interventions that may reduce the length of admissions.

METHODOLOGY

A systematic review was conducted by searching major databases, including PubMed, EMBASE and PsycInfo, from inception until May 2022. Observational studies conducted in forensic hospitals that examined associations between variables of interest and LOS were included. Following data extraction, the Newcastle‒Ottawa Scale was used for quality appraisal. No meta-analysis was conducted due to heterogeneity of information; a quantitative measure to assess the strength of evidence was developed and reported.

RESULTS

A total of 28 studies met the inclusion criteria out of 1606 citations. A detailed quantitative synthesis was performed using robust criteria. Having committed homicide/attempted homicide, a criminal legal status with restrictions, and a diagnosis of schizophrenia-spectrum disorders were all associated with longer LOS. Higher Global Assessment of Functioning (GAF) scores were associated with a shorter LOS.

CONCLUSION

High-quality research examining factors associated with LOS in forensic psychiatry is lacking, and studies are heterogeneous. No modifiable characteristics were identified, and thus, practice recommendations were not made. There is an increasing necessity to understand the factors associated with longer admissions to inform care and increase success in reintegration and rehabilitation. This paper provides recommendations for future research.

Burden of narcolepsy in Japan: A health claims database study evaluating direct medical costs and comorbidities

OBJECTIVE

This study aimed to determine the burden of narcolepsy in terms of direct medical costs and comorbidities and compare it with the respective burden of schizophrenia, epilepsy, and ulcerative colitis as controls.

METHODS

Patients diagnosed with narcolepsy (at least once based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, code G47.4) between April 2017 and March 2022 were identified on the health insurance claims database compiled by JMDC Inc. Patients with schizophrenia (F20), epilepsy (G40), and ulcerative colitis (K51) were matched as controls. Direct medical costs (including inpatient, outpatient, and medication costs) and comorbidities were analyzed.

RESULTS

We identified 4,594 patients with narcolepsy (≥18 years), 18,376 with schizophrenia, 18,376 with epilepsy, and 4,594 with ulcerative colitis. The total annual direct medical cost per person with narcolepsy was 349,188 JPY. The cost for narcolepsy was less than that for schizophrenia, epilepsy, and ulcerative colitis. Several comorbidities, such as sleep apnea, attention deficit hyperactivity disorder (ADHD), and obesity were more prevalent in the narcolepsy group.

CONCLUSIONS

The total direct cost for narcolepsy was approximately three times higher than the national medical expense for people aged 15-44 years (122,000 JPY in 2020), but lower than the total cost for all control diseases. The patients with narcolepsy were also likely to have comorbidities that affected their burden. These findings can contribute to future discussions on medical expense assistance programs for patients with narcolepsy.

The Societal Cost of Schizophrenia: An Updated Systematic Review of Cost-of-Illness Studies

BACKGROUND

Schizophrenia imposes a substantial economic burden on society. This updated systematic review aims to collate the latest societal cost of schizophrenia across countries by reviewing recent cost-of-illness (COI) studies.

METHODS

An electronic search was conducted across several databases (MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Health Management Information Consortium, and System for Information on Grey Literature) to identify COI studies published from 2016 to 2022. Two independent reviewers selected studies for inclusion. The cost components and estimates reported by included studies were descriptively summarised. All costs were converted to US dollars (2022 values). Study quality was assessed using a checklist adapted from Larg & Moss.

RESULTS

Twenty-four studies were included (5 from the update review and 19 from the original review), of which only two were conducted for low- and middle-income countries (LMICs). Widespread methodological heterogeneity among included studies was observed. The annual societal cost per person varied from US$819 in Nigeria to US$94,587 in Norway. Productivity losses accounted for 32-83% of the overall societal cost, whilst direct healthcare cost made up 11-87%. The reporting quality of included studies varied.

CONCLUSION

This review highlights the substantial economic burden of schizophrenia and a lack of COI studies for LMICs. Recommendations on future research, and good practices on improving the methodological and reporting quality of COI research for schizophrenia are provided.

Comparative effectiveness of long-acting injectable antipsychotics in patients with schizophrenia in Japan

OBJECTIVE

To compare the effectiveness of different long-acting injectable antipsychotics (LAIs) (aripiprazole, paliperidone, risperidone, and fluphenazine/haloperidol) in patients with schizophrenia in Japan.

METHODS

We conducted a retrospective cohort study using two administrative claims databases. The study population consisted of outpatients with schizophrenia who initiated LAIs between May 1, 2015, and November 30, 2019. We directly compared the risk of psychiatric hospitalization and LAI discontinuation among the LAIs based on hazard ratios (HRs) using Cox proportional hazards regression models.

RESULTS

The numbers of eligible patients who initiated aripiprazole, paliperidone, risperidone, and fluphenazine/haloperidol were 303, 124, 73, and 123, respectively. Regarding psychiatric hospitalization, aripiprazole and paliperidone were associated with significantly lower risk compared to fluphenazine/haloperidol (HR of aripiprazole: 0.47, 95 % CI: 0.28-0.78, HR of paliperidone: 0.50, 95 % CI: 0.28-0.89); HR of risperidone showed the same trend as the aripiprazole and paliperidone. Regarding LAI discontinuation, aripiprazole and paliperidone were associated with significantly lower risk of LAI discontinuation compared to fluphenazine/haloperidol (HR of aripiprazole: 0.53, 95 % CI: 95 % CI: 0.35-0.80, HR of paliperidone: 0.57, 95 % CI: 0.35-0.92). Aripiprazole was also associated with a significantly lower risk compared to risperidone (HR: 0.56, 95 % CI: 0.32-0.98).

CONCLUSION

Our study suggests that aripiprazole and paliperidone are superior to fluphenazine/haloperidol in the risk of psychiatric hospitalization and LAI discontinuation. Aripiprazole is superior to risperidone in the risk of LAI discontinuation.

Socioeconomic burden of schizophrenia: a targeted literature review of types of costs and associated drivers across 10 countries

AIMS

Schizophrenia has the highest median societal cost per patient of all mental disorders. This review summarizes the different costs/cost drivers (cost components) associated with schizophrenia in 10 countries, including all cost types and stakeholder perspectives, and highlights aspects of disease associated with greatest costs.

MATERIALS AND METHODS

Targeted literature review based on a search of published research from 2006 to 2021 in the United States (US), United Kingdom (UK), France, Germany, Italy, Spain, Canada, Japan, Brazil, and China.

RESULTS

Sixty-four published articles (primary studies and literature reviews) were included. Comprehensive data were available on costs in schizophrenia overall, with very limited data for individual countries except the US. Most data is related to direct and not indirect costs, with extremely scarce data for several key cost components (adverse events, suicide, long-term care). Total schizophrenia-related per person per year (PPPY) costs were $2,004-94,229, with considerable variability among countries. Indirect costs were the main cost driver (50-90% of all costs), ranging from $1,852 to $62,431 PPPY. However, indirect costs are not collected systematically or incorporated in health technology assessments. Total schizophrenia-related PPPY direct costs were $4,394-31,798, with inpatient cost as the main cost driver (∼20-99% of direct costs). Intangible costs were not reported. Despite limited evidence, total schizophrenia-related costs were higher in patients with than without negative symptoms, largely due to increased costs of medication and medical visits.

LIMITATIONS

As this was not a systematic review, prioritization of studies may have resulted in exclusion of potentially relevant data. All costs were converted to USD but not corrected for inflation or subjected to a gross domestic product deflator.

CONCLUSIONS

Direct costs are most commonly reported in schizophrenia. The substantial underreporting of indirect and intangible costs undervalues the true economic burden of schizophrenia from a payer, patient, and societal perspective.

Effectiveness of Clozapine on Employment Outcomes in Treatment-Resistant Schizophrenia: A Retrospective Bidirectional Mirror-Image Study

Purpose

Clozapine is more effective than other antipsychotics and is the only antipsychotic approved for treatment-resistant schizophrenia. The objective of this study is to reveal the effect of clozapine on employment using a bidirectional mirror-image model.

Patients and Methods

This design was a retrospective observational study that investigated the employment status of patients with treatment-resistant schizophrenia based on medical records. The bidirectional mirror-image model consisted of 1) switching from other antipsychotics to clozapine and 2) switching from clozapine to other antipsychotics. The observation period was 1 year for each pre- and post-clozapine initiation and discontinuation.

Results

We included 36 patients in the bidirectional mirror-image model. The regular employment plus employment support rate was significantly higher in the clozapine phase than in the other antipsychotic phase in the bidirectional mirror-image model (30.6% vs 11.1%, P = 0.039). The days of regular employment plus employment support were also significantly longer in the clozapine phase (61.3 ± 106.2 vs 24.7 ± 82.7 days, P = 0.032). As per the unidirectional mirror-image model, switching to clozapine resulted in significantly higher regular employment plus employment support rates in the clozapine phase than those in the other antipsychotic phase (33.3% vs 10.0%, P = 0.039). Switching from clozapine to other antipsychotics did not exhibit significant differences in any outcomes.

Conclusion

The results suggest that clozapine is superior to other antipsychotics with respect to achieving employment in patients with treatment-resistant schizophrenia. However, biases specific to the mirror-image model need to be considered.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Burden of schizophrenia among Japanese patients: a cross-sectional National Health and Wellness Survey

BACKGROUND

Schizophrenia places a great humanistic and financial burden to patients, families, and societies, and the burden is substantially impacted by comorbid conditions. This study aimed to estimate the lifetime prevalence of schizophrenia and to assess the health-related quality of life (HRQoL), work productivity, and indirect cost among schizophrenia patients with and without comorbidities (depressive symptoms, sleep disturbances, and anxiety problems).

METHODS

This is a secondary analysis of existing data collected in 2019 from the Japan National Health and Wellness Survey. The schizophrenia patients were categorized based on their Patient Health Questionnaire-9 score, self-reported experience of sleep disturbances, and anxiety problems. The lifetime prevalence was estimated using the total number of diagnosed schizophrenia patients as the numerator and the total number of respondents as the denominator. The HRQoL was evaluated through the Short Form 12-Item (version 2) Health Survey and EuroQoL 5-dimensions scale. Work productivity and annual indirect costs were evaluated through the Work Productivity and Activity Impairment instrument and monthly wage rates. Multivariate analyses included the comparison of outcomes using generalized linear models.

RESULTS

The study was conducted with 178 schizophrenia patients with an average age of 42.7 years old and an estimated lifetime prevalence of 0.59% (95% CI: 0.51%, 0.68%). Patients who experienced sleep disturbances, more severe depressive symptoms, and anxiety problems had lower HRQoL, higher levels of absenteeism, presenteeism, total work productivity and activity impairment, and almost twice more indirect costs, compared to those without these conditions.

CONCLUSION

Comorbid conditions among patients with schizophrenia impact significantly on their quality of life, work productivity as well as indirect costs.

Cardiac surgery for patients with schizophrenia: clinical experience of six patients

PURPOSE

The incidence of schizophrenia in Japan is 0.7%, which is similar to the worldwide incidence. The mortality rate of patients with schizophrenia is reported to be higher than that of the general population, and cardiovascular disease is high among the causes of death. Hence, strategies for cardiovascular surgery for patients with schizophrenia are necessary.

METHODS

We studied six patients with schizophrenia (five males, one female) who underwent cardiac surgery in our hospital between April 2008 and December 2019.

RESULT

The mean age was 63.6 years. The surgical procedures were coronary artery bypass grafting (CABG) (n = 4), CABG concomitant with valve procedures (n = 1), and resection of myxoma (n = 1). There were no major cardiovascular complications and no other fatal complications. The mean observation period was 1510.6 ± 1430.1 (140-4068) days, the mean post-operative hospital stay was 17.8 ± 3.5 (13-22) days, and there was no mortality within 30 days after surgery. During the observation period, one patient died. The survival rate was 83.3% at 1, 3, and 5 years.

CONCLUSION

Cardiac surgery for patients with schizophrenia is possible with careful monitoring of indications and perioperative management.

Costs of providing hospital-based psychotic disorder treatment in Indonesia

BACKGROUND

Mental illness prevalence is increasing globally and has caused a significant economic burden. However, information from developing countries regarding this issue is still limited.

AIMS

To estimate the cost of treating psychotic disorders in outpatient and inpatient wards in a provincial referral mental health hospital in West Java province, Indonesia.

METHODS

We collected data on the direct cost of treating psychotic disorders within 2014-2015. Billing data from 1565 patients were used to calculate inpatient cost, while micro-costing was used to estimate outpatient cost. One hundred and five patients visiting the hospital were interviewed to estimate indirect costs, for example, patients' and caretakers' travel, meal, and opportunity costs.

RESULTS

For inpatient care, the average direct and indirect cost/patient/episode are USD328.84 and USD213.22, respectively. For outpatient care, the direct and indirect costs are USD148,484.83/year (USD25.38/visit) and USD88,503.70/year (USD15.13/visit), respectively. The total societal cost of treating patients in the hospital is USD1,085,310.21/year (39% is an indirect cost, dominated by productivity loss).

CONCLUSION

The societal cost of treating psychotic disorders is large and potentially catastrophic to the patients. Early treatment for mental illness may avoid the high costs and lead to better productivity. Potential access barriers such as financial factors and stigma should be addressed.

Neuroscience20 (BRAIN20, SPINE20, and MENTAL20) Health Initiative: A Global Consortium Addressing the Human and Economic Burden of Brain, Spine, and Mental Disorders Through Neurotech Innovations and Policies

Neurological disorders significantly impact the world's economy due to their often chronic and life-threatening nature afflicting individuals which, in turn, creates a global disease burden. The Group of Twenty (G20) member nations, which represent the largest economies globally, should come together to formulate a plan on how to overcome this burden. The Neuroscience-20 (N20) initiative of the Society for Brain Mapping and Therapeutics (SBMT) is at the vanguard of this global collaboration to comprehensively raise awareness about brain, spine, and mental disorders worldwide. This paper aims to provide a comprehensive review of the various brain initiatives worldwide and highlight the need for cooperation and recommend ways to bring down costs associated with the discovery and treatment of neurological disorders. Our systematic search revealed that the cost of neurological and psychiatric disorders to the world economy by 2030 is roughly $16T. The cost to the economy of the United States is $1.5T annually and growing given the impact of COVID-19. We also discovered there is a shortfall of effective collaboration between nations and a lack of resources in developing countries. Current statistical analyses on the cost of neurological disorders to the world economy strongly suggest that there is a great need for investment in neurotechnology and innovation or fast-tracking therapeutics and diagnostics to curb these costs. During the current COVID-19 pandemic, SBMT, through this paper, intends to showcase the importance of worldwide collaborations to reduce the population's economic and health burden, specifically regarding neurological/brain, spine, and mental disorders.

An age-period-cohort analysis for prevalence of common psychiatric disorders in Japan, 1999-2017

PURPOSE

This study aimed to analyze the prevalence of common psychiatric disorders in Japan via an age-period-cohort (APC) analysis.

METHODS

Data were used on the prevalence of schizophrenia, schizotypal, and delusional disorders; mood [affective] disorders (mood disorders, hereafter); and neurotic, stress-related, and somatoform disorders from the 1999-2017 Patient Survey in Japan. The age group was defined as 20-89 years with 5-year increments; the cohort was assigned for each age group of each year with a 1-year shift. A Bayesian APC analysis was used to decompose changes in prevalence into three effects: age, period, and cohort.

RESULTS

The APC analysis revealed that the peaks of age effect varied among sexes and diseases. The period effects for all the diseases showed increasing trends over the analyzed years. Although the cohort effect for the prevalence of schizophrenia, schizotypal, and delusional disorders increased until the 1960s, it decreased afterwards. On the other hand, the cohort effects for the prevalence of mood disorders and neurotic, stress-related, and somatoform disorders increased from around the 1950s, and it indicates the prevalence increased particularly in young ages over the years. Also, the trends of each effect were relatively similar between mood disorders and neurotic, stress-related, and somatoform disorders.

CONCLUSION

Increase in public awareness and psychological stress associated with a change in a social environment is thought to affect the period and cohort effects on the prevalence of mood disorders and neurotic, stress-related, and somatoform disorders.

The Use of the Japanese Public Financial Support Has Positive Impact on Persistence with Outpatient Treatments for Schizophrenia: Single-center Retrospective Cohort Study in Japan

PURPOSE

One of the challenges of treating schizophrenia is how to improve persistence with outpatient treatments. Lengthening community life by improving persistence and preventing relapse and rehospitalization can have positive influence on the patients' personal recovery and well-being. In Japan, there is "Medical Expenses for Services and Supports for Persons with Disabilities" ("Jiritsu-shien-iryo-hi" in Japanese) which is the public financial support system for psychiatric outpatient treatments. However, it is not clear how this financial support affects persistence with outpatient treatments for patients with schizophrenia. The purpose of the study is to investigate how the financial support affects persistence with outpatient treatments for schizophrenia.

PATIENTS AND METHODS

Data of outpatients who visited the clinic between October 1, 2006 and September 30, 2016 was collected. The variables for the analysis were continuation and discontinuation of treatment of those who used the financial support (user) and those who did not (nonuser). The covariates were sex, age, time from onset of the disease to first visit to the clinic, number of hospitalizations in the past, use of psychiatric day care, and use of psychiatric home nursing care. Kaplan-Meier analysis was performed using propensity score matching. The observation period was five years from the first visit to the clinic.

RESULTS

Among 1155 patients who were diagnosed with schizophrenia, 718 were excluded, based on the exclusion criteria. The propensity score matching was performed for 437 patients, and the subjects for the final analysis were 278. Average survival period was 1.09 (SD ±1.66) years for nonuser, 3.02 (SD ±1.77) years for users, and users exhibited a significantly longer number of years of outpatient treatments (P<0.001).

CONCLUSION

The results indicated that use of the financial support can contribute to persistence with outpatient treatments.

Brexpiprazole for the Treatment of Schizophrenia in Adults: An Overview of Its Clinical Efficacy and Safety and a Psychiatrist's Perspective

While the prognosis of patients with schizophrenia has dramatically improved after the advent of chlorpromazine, the antipsychotics currently available are so numerous that it has become a challenge for psychiatrists to choose from among these drugs for each patient presenting for care. In addition, while numerous studies show that an effective antipsychotic should be continued indefinitely to prevent relapses or worsening, many patients appear to have difficulty remaining on any drug thus initiated. Brexpiprazole, a dopamine D₂ receptor partial agonist, appears to provide a unique profile that has much to offer in this light. Specifically, this novel drug is potentially better suited for long-term use, with decreased risk of extrapyramidal side effects, hyperprolactinemia, weight gain, psychosis, insomnia, akathisia, nausea/vomiting or restlessness, thus potentially facilitating patients' reintegration into society. Indeed, brexpiprazole has been shown in randomized, double-blind, placebo-controlled trials to have proven efficacy not only in improving the symptoms of schizophrenia but in preventing relapses. It is also suggested in both short- and long-term studies that brexpiprazole offers a favorable safety and tolerability profile. This review also includes a proposed treatment algorithm incorporating brexpiprazole, based on the clinical trial results available, as well as on the authors' clinical experience, where brexpiprazole may be best used as a drug of first choice for the treatment of schizophrenia. Thus, overall, brexpiprazole appears to play a more significant role in the treatment of schizophrenia than other antipsychotics.

The Effects of Paliperidone Palmitate 1 Month on the Employment Status and Social Functioning of Patients with Schizophrenia

Objective: We sought to evaluate the effects of a one-month paliperidone palmitate formulation (PP1M) on employment status, social function, symptomatology, and safety and conducted a two-year postmarketing surveillance study of Paliperidone Palmitate 1 Month (PP1M). Methods: Patients diagnosed with schizophrenia participated in the study. Employment status was recorded at baseline and changes were measured at one and two years. Social functioning and symptomatology were assessed using the Social and Occupational Functioning Assessment Scale (SOFAS) and the Clinical Global Impression-Schizophrenia (CGI-SCH). Data on adverse events were also collected. Results: A total of 1,319 patients were enrolled in this investigation, including 1,306 who were evaluable for safety and 1,279 who were evaluable for efficacy. The maintenance rate during the observation period was 49.4 percent. During the observation period, the percentages of patients reporting employment significantly increased: 24.3 percent of patients were employed in some capacity at baseline, 32.5 percent of patients were employed at one year, and 34.6 percent of patients were employed at two years. Significant improvements were observed in both SOFAS and CGI-SCH scores during the observation period. The percentage of patients with socially functional remission also significantly increased. A strong association between the improvement of social function, gender, and monotherapy versus polypharmacy and the improvement of employment status was observed. A total of 29.3 percent of patients experienced at least one adverse event. There were no unexpected findings from long-term treatment and a safety profile, including mortality. Conclusion: PP1M treatment appears to improve not only schizophrenic symptoms but also functional outcomes.

Modeling the Choice Between Risperidone Long-Acting Injectable and Generic Risperidone from the Perspective of a Japanese Hospital

INTRODUCTION

The Japanese government's current policy is to encourage hospitals to discharge hospital patients with schizophrenia earlier and provide them with community care. This study aims to analyze clinical and economic outcomes of different discharge strategies in psychiatric hospitals in Japan.

METHODS

A simulation was conducted to compare patient relapse and hospital revenues for different discharge plans. We constructed a decision tree where each tree consists of a different Markov chain that models hospital revenue for four different discharge plans: discharge of the patient after 1, 2, or 3 months, or 4 months or more. The simulation also included variations in the medical treatment regimen in an outpatient setting as part of the discharge strategy. In particular, we looked at the choice between risperidone long-acting injectable (RLAI) and generic risperidone (RIS GE).

RESULTS

The use of RLAI in an outpatient setting reduced the number of rehospitalizations compared to generic risperidone use under all discharge plans. Different discharge plans were associated with differences in economic outcomes as well. One of the key revenue drivers for the hospital was the continuation of treatment in the outpatient setting after discharge.

CONCLUSION

The use of RLAI in an outpatient setting could help to prevent rehospitalization, thereby contributing to better community care.

FUNDING

The Rapid Service Fee was funded by Janssen KK.

Neural changes following cognitive remediation therapy for schizophrenia

Patients with schizophrenia experience cognitive impairments that relate to poorer social functioning even after amelioration of positive symptoms. Pharmacological treatment and cognitive remediation are the two important therapeutic approaches for cognitive impairment in schizophrenia. Cognitive remediation therapy (CRT) for schizophrenia improves cognitive functioning and induces neuroplasticity, but different approaches and durations of CRT and different neuroimaging devices have led to varying results in meta-analyses. The objective of this review was to explore the impact of CRT on neurobiology. Several studies have provided evidence of increased activation in the frontal brain regions, such as the prefrontal cortex, anterior cingulate cortex, and parietal and occipital regions during working memory or executive function tasks after CRT. Two studies have shown alterations in resting-state connectivity between the prefrontal cortex and temporal regions. Two studies have reported that CRT induces changes in gray matter volume in the hippocampus. Further, one study observed that patients who had received CRT had elevated fractional anisotropy in the basal ganglia. We conclude that neuroimaging studies assessing CRT in patients with schizophrenia showed functional, structural, and connectivity changes that were positively correlated with cognitive improvements despite heterogeneous CRT approaches. Future studies that combine multiple modalities are required to address the differences, effects of intrinsic motivation, and pharmacological augmentation of CRT. Further understanding of the biological basis might lead to predictions of the CRT response in patients with schizophrenia and contribute to identification of schizophrenia patients for future interventions.

Predictive factors of the duration of sick leave due to mental disorders

Background

This study aimed to examine potential predictors of duration of sick leave due to mental disorders in Japan.

Methods

A total of 207 employees at a manufacturing company in Japan with a past history of sick leave due to mental disorders participated in this study. Mental disorders were defined as those listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). All of the participants used the mental health program that the company provided. The predictive power of the variables was tested using a Cox proportional hazard analysis. The hazard ratios in the final model were used to identify the predictor variables of the duration of sick leave. We included socio-demographic (age, sex, tenure), clinical (diagnosis and number of previous sick leave), and work-related factors (employment rank) as possible predictors. Data on these variables were obtained through the psychiatrists and psychologists in the company’s mental health program.

Results

The results of the univariate analyses showed that the number of previous sick leave episodes, diagnosis and employee rank were significant predictors of the duration of sick leave due to mental disorders. A multivariate analysis indicated that age, number of previous sick leave and employee rank were statistically significant predictors of return to work.

Conclusions

Diagnosis, number of previous sick leave episodes, and employee rank are predictors of the duration of sick leave due to mental disorders. This study’s findings have implications in the development of effective interventions to prevent protracted sick leave.

Antipsychotic use and related factors among people with dementia aged 75 years or older in Japan: A comprehensive population-based estimation using medical and long-term care data

OBJECTIVES

Antipsychotics are used to manage the behavioral and psychological symptoms of dementia (BPSD), despite their association with greater risks for mortality and cerebrovascular events. Previous studies in Japan have estimated the prevalence of antipsychotics among older adults who took antidementia drugs. Using long-term care (LTC) data, we aimed to obtain more accurate estimates of the prevalence of antipsychotics and to determine factors related to their use in older adults with dementia.

METHODS

Medical and LTC claims data and LTC certification data between April 2012 and September 2013 were obtained from a middle-sized suburban city. The 1-year prevalence of antipsychotic use was estimated among individuals with probable dementia aged greater than or equal to 75 years who were prescribed antidementia drugs and/or had dementia based on LTC needs certification data.

RESULTS

Of 25 919 participants, 4865 had probable dementia and 1506 were prescribed antidementia drugs. The prevalence of antipsychotics among participants with probable dementia was 10.7%, which was lower than that in those who were prescribed antidementia drugs (16.4%). Among participants with probable dementia with LTC certification data available (N = 4419), lower cognitive function (vs mild; adjusted odds ratio 2.16, 95% confidence interval 1.63-2.86), antidementia drug use (2.27, 1.84-2.81), and institutional LTC services use (2.34, 1.85-2.97) were associated with greater odds of antipsychotic use, whereas older age (greater than or equal to 92 years) was associated with lower odds (vs less than 77 years; 0.42, 0.27-0.65).

CONCLUSIONS

These findings may be useful for estimating the burden of BPSD and for taking measures to reduce inappropriate antipsychotic prescription.

Economic burden of caregiving for persons with severe mental illness in sub-Saharan Africa: A systematic review

Background

Over the past two decades, the focus of mental health care has shifted from institutionalisation to community-based programs and short hospital stays. This change means that there is an increased role for caregivers, mostly family members, in managing persons with mental illness. Although there is evidence to support the benefits of deinstitutionalisation of mental health care, there are also indications of substantial burden experienced by caregivers; the evidence of which is limited in sub-Saharan Africa. However, knowledge of the nature and extent of this burden can inform the planning of mental health services that will not only benefit patients, but also caregivers and households.

Objective

To systematically review the available evidence on the economic burden of severe mental illness on primary family caregivers in sub-Saharan Africa.

Methods

A comprehensive search was conducted in Pubmed, CINAHL, Econlit and Web of Science with no date limitations up to September 2016 using keywords such as "burden", "cost of illness" and "economic burden" to identify relevant published literature. Articles were appraised using a standardised data extraction tool covering themes such as physical, psychological and socioeconomic burden.

Results

Seven papers were included in the review. Caregivers were mostly family members with a mean age of 46.34, female and unemployed. Five out of seven studies (71%) estimated the full economic burden of severe mental illness on caregivers. The remainder of studies just described the caregiver burden. All seven papers reported moderate to severe caregiver burden characterised by financial constraint, productivity loss and lost employment. The caregiver’s level of income and employment status, severity of patient's condition and duration of mental illness were reported to negatively affect the economic burden experienced by caregivers.

Conclusion

There is paucity of studies reporting the burden of severe mental illness on caregivers in sub-Saharan Africa. Further research is needed to present the nature and extent of this burden to inform service planning and policymaking.

Regional supply of outreach service and length of stay in psychiatric hospital among patients with schizophrenia: National case mix data analysis in Japan

Several clinical trials have demonstrated that linkage to an outreach service can prevent prolonged length of stay of patients at psychiatric hospitals. However, there has been no investigation of the association between length of stay in psychiatric hospital and regional supply of outreach services using national case mix data. The aim of this study was to clarify the relationship between length of stay in psychiatric hospital and regional supply of outreach services. We used data from the National Patient Survey in Japan, a nationally representative cross-sectional survey of inpatient care conducted every three years from 1996 to 2014. Data from 42,268 patients with schizophrenia who had been admitted to psychiatric hospitals were analyzed. After controlling for patient and regional characteristics, patients in regions with fewer number of visits for psychiatric nursing care at home had significantly longer length of stay in psychiatric hospitals. This finding implies that enhancement of the regional supply of outreach services would prevent prolonged length of stay in psychiatric hospitals.

Drug Utilization of Japanese Patients Diagnosed with Schizophrenia: An Administrative Database Analysis

Background and objective

Patient characteristics require consideration for optimal treatment in order to achieve clinical remission for an improved quality of life and social functioning. Prior evidence supports long-acting injectable antipsychotics (LAIs) in the relapse prevention of schizophrenia. This study aimed to characterize Japanese patients diagnosed with schizophrenia and to compare the outcomes of LAIs and oral antipsychotics (AP) in re-hospitalization or emergency room visit rates.

Methods

Diagnostic Procedure Combination (DPC) designated hospital data in Japan with ICD-10 code F20x between July 2013 and June 2015 were obtained from the Medical Data Vision Co. Ltd. Patients were divided into sub-groups in order to filter co-diagnostic conditions. Differences across sub-groups were assessed using a Chi square test or ANOVA. The incidence rate ratio (IRR) was calculated to compare the re-hospitalization (30 days post discharge) or emergency room visit rates between pharmacotherapy groups of oral versus LAI or typical versus atypical within LAI patients. Adjusted estimates were provided by propensity scores that were assigned for age, gender, and Charlson co-morbidity index (CCI) scores.

Results

A quarter of the data sourced were attributed to co-diagnosis with dementia/delirium with antipsychotic prescriptions despite reported risks of antipsychotic use. After adjusting for age, gender, and co-morbidity, LAI reduced re-hospitalization and emergency (ER) visit rates more than oral APs (LAI vs. oral IRR = 0.38 (95% CI 0.17–0.74), IRR = 0.56 (95% CI 0.34–0.91), respectively).

Conclusion

The study findings demonstrate usage of DPC hospital data in schizophrenia pharmacotherapy based on classification of co-diagnoses. In comparison with oral APs only, LAI utilization can provide an opportunity for reduced re-hospitalization and ER visit rates among patients with schizophrenia.

Reliability and validity of the Japanese version of the Community Integration Measure for community-dwelling people with schizophrenia

BACKGROUND

Community integration is an essential right for people with schizophrenia that affects their well-being and quality of life, but no valid instrument exists to measure it in Japan. The aim of the present study is to develop and evaluate the reliability and validity of the Japanese version of the Community Integration Measure (CIM) for people with schizophrenia.

METHODS

The Japanese version of the CIM was developed as a self-administered questionnaire based on the original version of the CIM, which was developed by McColl et al. This study of the Japanese CIM had a cross-sectional design. Construct validity was determined using a confirmatory factor analysis (CFA) and data from 291 community-dwelling people with schizophrenia in Japan. Internal consistency was calculated using Cronbach's alpha. The Lubben Social Network Scale (LSNS-6), the Rosenberg Self-Esteem Scale (RSE) and the UCLA Loneliness Scale, version 3 (UCLALS) were administered to assess the criterion-related validity of the Japanese version of the CIM.

RESULTS

The participants were 263 people with schizophrenia who provided valid responses. The Cronbach's alpha was 0.87, and CFA identified one domain with ten items that demonstrated the following values: goodness of fit index = 0.924, adjusted goodness of fit index = 0.881, comparative fit index = 0.925, and root mean square error of approximation = 0.085. The correlation coefficients were 0.43 (p < 0.001) with the LSNS-6, 0.42 (p < 0.001) with the RSE, and -0.57 (p < 0.001) with the UCLALS.

CONCLUSIONS

The Japanese version of the CIM demonstrated adequate reliability and validity for assessing community integration for people with schizophrenia in Japan.

Productivity and deadweight losses due to relapses of schizophrenia in Japan

BACKGROUND

No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia.

METHODS

The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income.

RESULTS

Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis.

CONCLUSION

Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia.

The Societal Cost of Schizophrenia: A Systematic Review

BACKGROUND

Cost-of-illness (COI) studies provide useful information on the economic burden that schizophrenia imposes on a society.

OBJECTIVES

This study aims to give a general overview of COI studies for schizophrenia and to compare the societal cost of schizophrenia across countries. It also aims to identify the main cost components of schizophrenia and factors associated with higher societal cost to improve the quality and reporting of COI studies for schizophrenia.

METHODS

We performed an electronic search on multiple databases (MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Health Management Information Consortium [HMIC] and the System for Information on Grey Literature [openSIGLE]) to identify COI studies of schizophrenia published between 1996 and 2016. The primary outcome of this review was societal cost per schizophrenia patient, by cost component. All costs were converted to $US, year 2015 values.

RESULTS

We included 19 studies in this review. The annual societal cost per patient varied from $US5818 in Thailand to $US94,587 in Norway; whereas the lifetime societal cost per patient was estimated to be $US988,264 in Australia (all year 2015 values). The main cost drivers were direct healthcare costs and productivity losses. Factors associated with higher individual costs included patient demographics, severity of disease and methods used to calculate the costs of productivity losses and comorbidities.

CONCLUSIONS

This review highlights the large economic burden of schizophrenia. The magnitude of the cost estimates differs considerably across countries, which might be caused by different economic conditions and healthcare systems and widespread methodological heterogeneity among COI studies. Proposed recommendations based on this review can be used to improve the consistency and comparability of COI studies for schizophrenia.

Early intervention services in psychosis: from evidence to wide implementation

AIM

Early intervention (EI) in psychosis is a comprehensive and evidence-based approach aimed at detection and treatment of psychotic symptoms in their early stages. This paper presents core features and noteworthy aspects of the evidence basis and limitations of EI, the importance of programme fidelity, challenges for its widespread dissemination and economic perspectives related to it.

METHODS

This paper is a narrative review about the evidence supporting EI and the challenges to its widespread dissemination.

RESULTS

In spite of evidence of a wide range of benefits, widespread dissemination has been slow, and even currently implemented programmes might be threatened. This reflects in part the shortcomings of mental health care in general, such as low priority for funding, stigma and structural problems. Successful examples of advocacy, mobilization and destigmatization campaigns have overcome these difficulties.

CONCLUSIONS

Funding for mental health in general and for EI services appears low relative to need. One key argument for better funding for EI can be found in its favourable cost-effectiveness, but not all stakeholders beyond mental health administrators are aware of this. Positive impacts of EI programmes on excess unemployment and tax forgone suggest that social affairs and labour ministries - and not only health ministries - could be more involved in governance of mental health issues; ministries of justice and education are other sector stakeholders than can benefit. Wider dissemination of EI services will probably benefit from better integration of potential funders, promotion of joint targets and shared financial or budgetary incentives.

The Cost of Inpatient Care of Schizophrenia and Treatment Schedules Used in German Academic Center: Kiel

The authors aimed at analyzing the costs of inpatient care of schizophrenia in Kiel (Germany). The study was also to present treatment regimens used at the German Academic Center. Moreover, the study is a continuation and complement of the previous study conducted in Polish and Ukrainian Academic Center. Therefore, it helps increase the awareness and knowledge of residents concerning the cost of inpatient care of schizophrenia. The analysis was based on 105 hospital records of patients treated between January 2012 and June 2013. According to inclusion criteria, 50 adult patients (27 women and 23 men) were included in the study. The study was approved by the Ethics Committee of the Medicine Faculty of CAU in Kiel. The cost of schizophrenia treatment of 50 patients in Kiel was EUR 604,280.90 ([Formula: see text] = EUR 12,085.62). The duration of hospital stay was on average [Formula: see text] = 51.02 days. The patients were treated with neuroleptics of all generations. The most popular atypical neuroleptic was amisulpride and the most popular typical neuroleptic was haloperidol. Patients from Kiel were provided a comprehensive non-pharmacological treatment. Treatment regiments and evaluations of costs of schizophrenia vary between countries. The costs of inpatient care of schizophrenia are high in Kiel. Treatment of schizophrenia seems to be comprehensive in Kiel and wide range of treatment opportunities contribute to a more effective treatment confirmed by less frequent relapses of schizophrenia than in Lviv (Ukraine), for example. Comprehensive treatment should be available everywhere, because it is a right of every patient.

Feasibility and effectiveness of a cognitive remediation programme with original computerised cognitive training and group intervention for schizophrenia: a multicentre randomised trial

Devising new methods to improve neurocognitive impairment through cognitive remediation is an important research goal. We developed an original computer programme termed the Japanese Cognitive Rehabilitation Programme for Schizophrenia (JCORES) that provides cognitive practice across a broad range of abilities. The current study examined for the first time whether a cognitive remediation programme, including both computerised cognitive training using JCORES and group intervention such as enhancing meta-cognition and teaching strategies, is more effective than treatment as usual for improving neurocognitive and social functioning. Sixty-two outpatients with schizophrenia were randomised to either a cognitive remediation group or a control group. Participants engaged in two computerised cognitive training sessions and one group meeting per week for 12 weeks. The average number of total sessions attended (computerised cognitive practice + group intervention) was 32.3 (89.7%). The cognitive remediation group showed significantly more improvements in verbal memory, composite score of the Brief Assessment of Cognition in Schizophrenia, Japanese version (BACS-J), and general psychopathology on the Positive and Negative Syndrome Scale (PANSS) than the control group. These findings demonstrate that a cognitive remediation programme is feasible in Japan and is a more effective way to improve neurocognitive functioning and psychiatric symptoms.

The readmission rate and medical cost of patients with schizophrenia after first hospitalization - A 10-year follow-up population-based study

BACKGROUND

Hospital readmissions caused by relapse in patients with schizophrenia are associated with prognosis. Identifying individuals at high risk of readmission and providing interventions to lower the readmission rate are important.

METHODS

Patients with schizophrenia who were hospitalized for the first time were recruited from the National Health Insurance Research Database from 2001 to 2010 (n=808, mean age 28.9years) and compared with matched controls. Data on the demographics, cost, and utilization of medical resources of patients who were readmitted were compared with non-readmitted patients. The readmission time curve was analyzed by the Kaplan-Meier method.

RESULT

570 (70.5%) patients were readmitted within 10years; the median time between admissions was 1.9years, and 25% of subjects were readmitted within 4months of the first hospitalization. There were no significant differences in age, gender, or length of hospitalization between the readmission and non-readmission groups. Taking into account all psychiatric medical services, the readmission group had a significantly higher mean frequency of care and a greater medical cost than the non-readmission group and matched controls. However, there were no significant differences with regard to non-psychiatric medical services.

CONCLUSION

Schizophrenia has a high rate of readmission and high medical cost in naturalistic settings. In addition to the traditional hospital-based treatment model for patients with schizophrenia, the development of an effective intervention program is important, especially in the early years of the disease.

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.

Individual risk alleles of susceptibility to schizophrenia are associated with poor clinical and social outcomes

Many patients with schizophrenia have poor clinical and social outcomes. Some risk alleles closely related to the onset of schizophrenia have been reported to be associated with their clinical phenotypes, but the direct relationship between genetic vulnerability to schizophrenia and clinical/social outcomes of schizophrenia, as evaluated by both practical clinical scales and 'real-world' function, has not been investigated. We evaluated the clinical and social outcomes of 455 Japanese patients with schizophrenia by severity of illness according to the Clinical Global Impression-Severity Scale (CGI-S) and social outcomes by social adjustment/maladjustment at 5 years after the first visit. We examined whether 46 single nucleotide polymorphisms (SNPs) selected from a Japanese genome-wide association study of susceptibility to schizophrenia were associated with clinical and social outcomes. We also investigated the polygenic risk scores of 46 SNPs. Allele-wise association analysis detected three SNPs, including rs2623659 in the CUB and Sushi multiple domains-1 (CSMD1) gene, associated with severity of illness at end point. The severity of illness at end point was associated with treatment response, but not with the severity of illness at baseline. Three SNPs, including rs2294424 in the C6orf105 gene, were associated with social outcomes. Point estimates of odds ratios showed positive relationships between polygenic risk scores and clinical/social outcomes; however, the results were not statistically significant. Because these results are exploratory, we need to replicate them with a larger sample in a future study.

Modeling the budget impact of long-acting injectable paliperidone palmitate in the treatment of schizophrenia in Japan

Background

The cost of schizophrenia in Japan is high and new long-acting injectable (LAI) antipsychotics might be able to reduce costs by causing a reduction of hospital stays. We aim to estimate budget effects of the introduction of a new 1-month LAI, paliperidone palmitate, in Japan.

Methods

A budget impact analysis was conducted from a payer perspective. The model took direct costs of illness into account (ie, costs for inpatient and outpatient services, as well as drug costs). The robustness of the model was checked using a sensitivity analysis.

Results

According to our calculations, direct total costs of schizophrenia reach 710,500 million yen a year (US$6 billion). These costs decrease to 691,000 million yen (US$5.9 billion) 3 years after the introduction of paliperidone palmitate.

Conclusion

From a payer point of view, the introduction of a new treatment for schizophrenia in Japan helps to save resources and is not associated with a higher financial burden.

Adherence and rehospitalizations in patients with schizophrenia: evidence from Japanese claims data

BACKGROUND

The aim of this study is to analyze if there is a relationship between adherence to antipsychotic medication and rehospitalization for patients diagnosed with schizophrenia in Japan.

METHODS

Based on Japanese claims data, we constructed three patient groups based on their medication possession ratio (MPR). Controlling for potential confounders, a Cox proportional hazard model was employed to assess if medication adherence affects the risk of rehospitalization.

RESULTS

Patients with good adherence (MPRs from 0.8-1.1) had the lowest rates of admission. Both poor adherence (MPRs <0.8) and overadherence (MPRs >1.1) were associated with a significant higher risk of rehospitalization with hazard ratios of 4.7 and 2.0, respectively.

CONCLUSION

The results of this study support the notion that good adherence to antipsychotic medication reduces the risk of rehospitalization of schizophrenia patients. Appropriate measures should be taken to improve adherence of schizophrenia patients.

Health care resource use and direct medical costs for patients with schizophrenia in Tianjin, People's Republic of China

OBJECTIVE

Information concerning the treatment costs of schizophrenia is scarce in People's Republic of China. The aims of this study were to quantify health care resource utilization and to estimate the direct medical costs for patients with schizophrenia in Tianjin, People's Republic of China.

METHODS

Data were obtained from the Tianjin Urban Employee Basic Medical Insurance (UEBMI) database. Adult patients with ≥1 diagnosis of schizophrenia and 12-month continuous enrollment after the first schizophrenia diagnosis between 2008 and 2009 were included. Both schizophrenia-related, psychiatric-related, and all-cause related resource utilization and direct medical costs were estimated.

RESULTS

A total of 2,125 patients were included with a mean age of 52.3 years, and 50.7% of the patients were female. The annual mean all-cause costs were $2,863 per patient with psychiatric-related and schizophrenia-related costs accounting for 84.1% and 62.0% respectively. The schizophrenia-related costs for hospitalized patients were eleven times greater than that of patients who were not hospitalized. For schizophrenia-related health services, 60.8% of patients experienced at least one hospitalization with a mean (median) length of stay of 112.1 (71) days and a mean cost of $1,904 per admission; 59.0% of patients experienced at least one outpatient visit with a mean (median) number of visits of 6.2 (4) and a mean cost of $42 per visit during the 12-month follow-up period. Non-medication treatment costs were the most important element (45.7%) of schizophrenia-related costs, followed by laboratory and diagnostic costs (19.9%), medication costs (15.4%), and bed fees (13.3%).

CONCLUSION

The costs related to the treatment of patients with schizophrenia were considerable in Tianjin, People's Republic of China, driven mainly by schizophrenia-related hospitalizations. Efforts focusing on community-based treatment programs and appropriate choice of drug treatment have the potential to reduce the use of inpatient services and may lead to better clinical and economic outcomes in the management of patients with schizophrenia in People's Republic of China.

Development of forensic mental health services in Japan: working towards the reintegration of offenders with mental disorders

Background

Until the recent enactment of the Medical Treatment and Supervision Act (MTSA) in 2005, neither legislations nor facilities for mentally disordered offenders were available in Japan. The aim of the country’s forensic mental health services, based on this new law, is to improve the social reintegration of mentally disordered offenders. In order to provide optimal psychiatric care to these individuals, specialised court proceedings, treatment facilities, and concrete guidelines have been established. The aim of this study was to review the current status of the new system and to clarify future challenges for improving services.

Methods

The authors collected official statistics regarding the new system published separately by the Ministry of Health, Labour and Welfare, the Ministry of Justice, and the Supreme Court of Japan. We aggregated the data and examined the system’s current implementation status, nationwide.

Results

There were 2,750 requests for enrolment in the MTSA system between its initiation in 2005 and 31 December 2012. Of those requests, 2,724 cases had been concluded in court. In 63.1% of the cases, an inpatient treatment order had been made; 82.4% of those inpatients were diagnosed with schizophrenia. By the end of March 2012, two patients completing treatment under the MTSA had re-committed a serious offense. While overall designated inpatient and outpatient treatment facilities have reached national targets in terms of resources and beds available, a regional gap in MTSA designated facilities remains and the number of patients under inpatient treatment order is on the increase.

Conclusions

Overall, the MTSA system has been running smoothly without encountering any serious problems. However, several concerns have emerged, such as the accumulation of patients under inpatient treatment order and insufficient regional resources. To more successfully promote the reintegration of mentally disordered offenders, improvements in outpatient treatment and welfare services are crucial. In order to install effective measures to help improve the system, a nationwide database of patients being treated under order of the MTSA should be properly built and maintained.

Schizophrenia--time to commit to policy change

Care and outcomes for people with schizophrenia have improved in recent years, but further progress is needed to help more individuals achieve an independent and fulfilled life. This report sets out the current need, informs policy makers and all relevant stakeholders who influence care quality, and supports their commitment to creating a better future. The authors recommend the following policy actions, based on research evidence, stakeholder consultation, and examples of best practice worldwide. (1) Provide an evidence-based, integrated care package for people with schizophrenia that addresses their mental and physical health needs. (2) Provide support for people with schizophrenia to enter and to remain in their community, and develop mechanisms to help guide them through the complex benefit and employment systems. (3) Provide concrete support, information, and educational programs to families and carers on how to enhance care for an individual living with schizophrenia in a manner that entails minimal disruption to their lives. (4) All stakeholders, including organizations that support people living with schizophrenia, should be consulted to regularly revise, update, and improve policy on the management of schizophrenia. (5) Provide support, which is proportionate to the impact of the disease, for research and development of new treatments. (6) Establish adequately funded, ongoing, and regular awareness-raising campaigns that form an integral part of routine plans of action. Implementation of the above recommendations will require engagement by every stakeholder, but with commitment from all, change can be achieved.

Predictors of repeated sick leave in the workplace because of mental disorders

INTRODUCTION

Mental disorders create a considerable burden to society. Previous studies have shown that productivity loss constitutes the largest proportion of the total societal burden. For depression and anxiety disorders, in particular, more than half of the associated productivity loss occurs in the workplace. Many previous studies have clarified the risk factors for the relapse/recurrence of mental disorders in health care settings. However, the risk factors for repeated sick leave among mental disorders prevalent in the workplace have not yet been adequately evaluated.

OBJECTIVE

The objective of this study was to investigate which variables could predict repeated sick leave for workers with a history of sick leave because of mental disorders.

METHODS

Data regarding 194 subjects employed at a manufacturing company were obtained. Mental disorders were defined as disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The duration between the return to work (RTW) and the repeated sick leave was regarded as a dependent variable. The subjects' age at the RTW, sex, age at the time of employment, job tenure, diagnosis, number of previous sick leave days, duration of most recent sick leave, and employee rank were examined as explanatory variables. Univariate analyses using a log-rank test and a multivariate analysis using the Cox proportional hazard model were conducted.

RESULTS

The results of the univariate analyses showed that the number of previous sick-leave episodes was a significant predictor of repeated sick leave. A multivariate analysis revealed that age at RTW and the number of previous sick-leave episodes were significant variables.

CONCLUSION

Age and the number of previous sick-leave episodes appeared to be predictors of repeated sick leave. Therefore, effective intervention to prevent repeated sick leave for those with high risk is quite crucial. Analyses including various work-related factors with subjects from multiple companies should be conducted in future studies.

Cost of anxiety disorders in Japan in 2008: a prevalence-based approach

BACKGROUND

The societal burden caused by anxiety disorders has likely been underestimated, while those for schizophrenia and depression have received more attention. Anxiety disorders represent a significant illness category that occurs at a high prevalence and poses a considerable burden. However, the cost of anxiety disorders in Japan has not yet been well researched. The goal of the present study was to estimate the total cost of anxiety disorders in Japan and to clarify the characteristics of this burden.

METHOD

A prevalence-based approach was adopted to measure the total cost of anxiety disorders. Anxiety disorders were defined as diagnosis code F40.0-F41.9 according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. The cost was comprised of the following components: medical treatment costs and social service costs as direct costs, and morbidity and mortality costs as indirect costs. Data were collected from publicly available statistics.

RESULTS

The total cost of anxiety disorders in Japan in 2008 was JPY 2.4 trillion (US$ 20.5 billion at the current exchange rate of US $1 = JPY 116.8). The direct cost was JPY 50 billion. The morbidity cost was JPY 2.1 trillion, while the mortality cost was JPY 0.24 trillion.

CONCLUSIONS

The social burden caused by anxiety disorders in Japan is tremendous and is similar to that of other mental disorders. Productivity loss in the workplace represents the largest portion of all the cost components. Because the medical examination rate is quite low, the improvement of healthcare access might contribute to cost mitigation.