Measuring the costs of schizophrenia. Implications for the post-institutional era in the US

Medication non-adherence and associated factors among peoples with schizophrenia: multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Schizophrenia is a serious and debilitating psychiatric disorder that is linked to marked social and occupational impairment. Despite the vital relevance of medication, non-adherence with recommended pharmacological treatments has been identified as a worldwide problem and is perhaps the most difficult component of treating schizophrenia. There are limited studies conducted on magnitude and potential factors of medication non-adherence among peoples with schizophrenia in Ethiopia.

OBJECTIVES

This study aimed to assess medication non-adherence and associated factors among peoples with schizophrenia at comprehensive specialized hospitals in Northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 387 peoples with schizophrenia at selected hospitals in the Northwest of Ethiopia from June to August 2022. Study participants were enrolled using systematic random sampling. Medication non-adherence was measured using Medication Adherence Rating Scale (MARS). Data entry and analysis were done using Epi-data version 4.6.0 and SPSS version 24, respectively. A multivariable logistic regression model was fitted to identify factors associated with medication non-adherence. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant.

RESULTS

The prevalence of medication non-adherence was 51.2% (95% CI: 46.3, 56.3). Duration of treatment for more than ten years (AOR = 3.76, 95% CI: 1.43, 9.89), substance use (AOR = 1.92, 95% CI: 1.17, 3.13), antipsychotic polypharmacy, (AOR = 2.01, 95% CI: 1.11, 3.63) and extra-pyramidal side effect (AOR = 2.48, 95% CI: 1.24, 4.94) were significantly associated with medication non-adherence.

CONCLUSION

In this study, half of the participants were found to be medication non-adherent. Respondents with a longer duration of treatment, substance users, those on antipsychotic polypharmacy, and those who develop extra-pyramidal side effect need prompt screening and critical follow-up to improve medication adherence.

Adherence to Antipsychotic Drugs by Medication Possession Ratio for Schizophrenia and Similar Psychotic Disorders in the Republic of Korea: A Retrospective Cohort Study

Objective

Pharmacotherapy is considered as an essential element in the treatment of psychotic disorders including schizophrenia. Discontinuation of antipsychotic drugs increases medical use and economic burden. Therefore, maintenance of medication is essential to reduce the social burden caused by schizophrenia and schizophrenia similar psychosis (SSP), and hence, it is important to investigate the rate at which pharmacotherapy is maintained. Therefore, this study aimed to examine the current status of drug compliance using national health insurance data.

Methods

This was a retrospective cohort study, which analyzed data from the nationwide insurance claims database. A total of 343,134 patients who were newly diagnosed with schizophrenia and SSP during 2011−2015. The adherence to antipsychotic drugs was assessed by medication possession ratio (MPR) and the risk factors of poor adherence were defined as MPR < 40%.

Results

The average of the MPRs was 45.8%, and the proportion of patients with less than 40% of MPR was 50.8%. It was found that female patients, the experience of “general hospital outpatient,” “psychiatric hospital admission,” “general hospital admission,” and patients receiving “health insurance” showed high risk of having statistically significant low MPR (< 40%).

Conclusion

In this study, the drug adherence of schizophrenia and SSP patients currently under treatment, as estimated by MPR, was very low. However, it was also found that the MPR was high among patients receiving medical aid, with less medical expenses. Thus, it is possible to consider an institutional mechanism in which schizophrenia and SSP patients can be treated with less economic burden.

Interventions to Improve Medication Adherence in Patients with Schizophrenia or Bipolar Disorders: A Systematic Review and Meta-Analysis

Adherence to prescribed medication regimes improves outcomes for patients with severe mental illness such as schizophrenia or bipolar disorders. The aim of this systematic review and meta-analysis was to compare the effectiveness among interventions to improve medication adherence in patients with schizophrenia or bipolar disorders. Literature published in the last decade was searched for interventions studies to improve adherence in patients with schizophrenia or a bipolar disorder. Interventions were categorised on the basis of type, and the context and effectiveness of the interventions were described. Two review authors independently extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. The GRADEPro (McMaster University, 2020, Ontario, Canada) was used for assessing the quality of the evidence. Twenty-three publications met the selection criteria. Different types of interventions aiming to improve adherence were tested: educational, behavioural, family-based, technological, or a combination of previous types. Meta-analysis could be performed for 10 interventions. When considered separately by subgroups on the basis of intervention type, no significant differences were found in adherence among interventions (p = 0.29; I2 = 19.9%). This review concluded that successful interventions used a combination of behavioural and educational approaches that seem easy to implement in daily practice.

Attitude towards Antipsychotic Medications in Patients Diagnosed with Schizophrenia: A Cross-Sectional Study at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Poor attitude towards antipsychotic drugs is high, and it is a factor for non-adherence to treatment. This increases the risk of relapse, associated healthcare utilization, and costs. This study aimed to assess attitude towards antipsychotic medication among patients with schizophrenia.

OBJECTIVES

The aim of this institution based cross-sectional study was to assess attitude towards antipsychotic medications and associated factors among patients with schizophrenia who attend the outpatient clinics at Amanuel Mental Specialized Hospital, 2018.

METHODS

In a cross-sectional study, 393 schizophrenic patients from Amanuel Mental Specialized Hospital were recruited by a systematic random sampling technique. Drug Attitude Inventory (DAI-10) was used to assess attitude, experience, and belief about antipsychotics. Glasgow antipsychotic side effect scale modified version, positive and negative syndrome scale, and Birch wood's insight scale for psychosis were the instruments used to assess the associated factors. Simple and multiple linear regression analysis models were fitted, and the adjusted unstandardized beta (β) coefficient at 95% confidence interval was used.

RESULTS

The mean score of attitude towards antipsychotic medications was 6.51 with standard deviation (SD) of 2.22. In multiple linear regression, positive symptoms (β= -0.07, 95% CI: (-0.09, -0.05)), negative symptoms (β= -0.04, 95% CI: (-0.06,-0.02)), shorter (≤5 years) duration of illness (β= -0.39, 95% CI: (-0.63, -0.15)), first generation antipsychotics (β = -0.35, 95% CI: (-0.55,-0.14)), having sedation (β= -0.28, 95% CI: (-0.52, -0.02)), and extra-pyramidal side effects (β= -0.34, 95% CI: (-0.59,-0.09)) were factors negatively associated with attitude towards antipsychotic medication treatment. Insight to illness (β= 0.24, 95% CI: (0.20, 0.27) was a factor positively associated with attitude towards antipsychotic medications.

CONCLUSION

The result suggests that the mean score of participants' attitude towards antipsychotic medications was good. Prevention of side effects particularly due to first generation antipsychotics is necessary.

A Patient-Centered Antipsychotic Medication Adherence Intervention: Results From a Randomized Controlled Trial

The purpose of this study was to develop and test a patient-centered and sustainable antipsychotic medication adherence intervention. The study design was a randomized controlled trial. Data from 61 patients diagnosed with schizophrenia or schizoaffective disorder were analyzed. The intervention included a checklist of barriers, facilitators, and motivators (BFM) for taking antipsychotic medications. The results of the checklist were summarized and a note was placed in the electronic medical record (EMR) and a hard copy was given to the patient. However, less than half of the BFM progress notes were placed in the EMR before the clinician visit as planned. The intervention significantly improved adherence at 6 months but not at 12 months and the intervention's effect on total Positive and Negative Syndrome Scale scores was not statistically significant. The BFM intervention is promising, but future studies are needed to improve the integration of the BFM intervention into typical clinic workflow.

Olanzapine: Psychopharmacology, Clinical Efficacy, and Adverse Effects

Olanzapine is an atypical antipsychotic that has a pharmacological profile similar that of clozapine. It is biotransformed by hepatic enzymes and can be dosed on a once-daily basis. In large, double-blind, placebo-controlled trials, olanzapine was shown to be efficacious in the treatment of schizophrenia relative to placebo. Many trials showed superior efficacy to haloperidol, especially against negative symptoms. Olanzapine is FDA-approved for the treatment of psychotic disorders, though data suggest possible use in depression, bipolar disorder, psychogenic polydipsia, and developmental disabilities. Olanzap-ine appears to be well-tolerated. Commonly reported adverse effects include orthostatic hypotension, sedation, hepatic transaminase elevations, weight gain, headache, agitation, dizziness, and constipation. The incidence of extrapyramidal symptoms and tardive dyskinesia is low. Few drug interactions have been reported. The recommended starting dose is 10 mg once daily. One trial indicated that the higher cost of this agent might be offset by a reduction in overall hospitalization costs.

Acceptance and Commitment Therapy for Inpatients with Psychosis (the REACH Study): Protocol for Treatment Development and Pilot Testing

Patients with schizophrenia-spectrum disorders frequently require treatment at inpatient hospitals during periods of acute illness for crisis management and stabilization. Acceptance and Commitment Therapy (ACT), a "third wave" cognitive-behavioral intervention that employs innovative mindfulness-based strategies, has shown initial efficacy in randomized controlled trials for improving acute and post-discharge outcomes in patients with psychosis when studied in acute-care psychiatric hospitals in the U.S. However, the intervention has not been widely adopted in its current form because of its use of an individual-only format and delivery by doctoral-level research therapists with extensive prior experience using ACT. The aim of the Researching the Effectiveness of Acceptance-based Coping during Hospitalization (REACH) Study is to adapt a promising acute-care psychosocial treatment for inpatients with psychosis, and to pilot test its effectiveness in a routine inpatient setting. More specifically, we describe our plans to: (a) further develop and refine the treatment and training protocols, (b) conduct an open trial and make further modifications based on the experience gained, and

Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

OBJECTIVE

The purpose of the study was to examine whether individuals with diagnoses of schizophrenia were differentially adherent to their statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) medications compared to individuals without psychiatric illness.

METHOD

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of schizophrenia or schizoaffective disorder receiving two or more medication dispensings of a statin or an ACEI/ARB in 2011 (N=710) were identified and matched on age, sex and Medicare status to controls with no documented mental illness and two or more medication dispensings of a statin in 2011 (N=710). Medication adherence, and sociodemographic and clinical characteristics of the study population were assessed.

RESULTS

Multivariable models indicated that having a schizophrenia diagnosis was associated with increased odds of statin medication adherence; the odds ratio suggested a small effect. After adjustment for medication regimen, schizophrenia no longer showed an association with statin adherence. Having a schizophrenia diagnosis was not associated with ACEI/ARB medication adherence.

CONCLUSIONS

Compared to patients without any psychiatric illness, individuals with schizophrenia were marginally more likely to be adherent to their statin medications. Given that patterns of adherence to cardioprotective medications may be different from patterns of adherence to antipsychotic medications, improving adherence to the former may require unique intervention strategies.

A comparison of treatment adherence in individuals with a first episode of psychosis and inpatients with psychosis

In predicting treatment compliance in individuals with severe mental illness, research has focused on variables such as substance abuse, personality, history of child abuse, and symptomatology, although these relationships have not been investigated in great detail in individuals at the onset of mental illness. To better understand these correlates of treatment compliance, two samples were examined: a sample of 117 individuals presenting with a first episode of psychosis and a more chronic forensic sample of 65 participants recruited from a psychiatric hospital. These samples were investigated for service engagement in terms of violence history, substance abuse, symptom severity, psychopathic traits and history of childhood abuse. Linear regressions performed for the first episode sample revealed that childhood physical abuse was the strongest predictor of poor service engagement, followed by problems with alcohol, a history of physical violence, any history of violence and higher psychopathic traits. Linear regression revealed for the forensic group that a lower level of service engagement was most strongly predicted by a history of childhood abuse and a higher score on the Brief Psychiatric Rating Scale (BPRS). Results are presented in light of the existing literature and clinical implications are discussed.

Attitudes toward Medication and Reasons for Non-Compliance in Patients with Schizophrenia

BACKGROUND

Non-compliance for the medication is an important area of concern in schizophrenia as it contributes to relapse and re-hospitalization of the patients. One of the ways to improve the drug compliance is to know crucial factors responsible for poor drug compliance and hence that proper strategies may be planned to improve patient's drug compliance.

AIM

The aim of the following study is to find out the attitudes of patients toward medication and reasons for drug non-compliance in schizophrenia and its association with clinical and socio-demographic variables.

MATERIALS AND METHODS

The study was conducted on follow-up patients with schizophrenia for the duration of 5 months. Their socio-demographic details were noted and illness related variables were evaluated using Positive and Negative Syndrome scale (PANSS). Patient's attitudes toward medication and the reasons for treatment non-compliance were assessed using the standardized tools, which consist of Drug Attitude Inventory-10 scale and Rating of Medication Influences scale respectively.

RESULTS

Nearly 41.9% of our study sample were non-compliant to medication. A significant association has been found between non-compliance and younger age group, unemployment, early age of onset, high positive PANSS score and poorer insight into the illness. The significant reasons for non-compliance in our study were Denial of illness, financial burden, less access to treatment facilities, Side-effects of the medication, Feeling that the medication was unnecessary and Substance abuse.

CONCLUSIONS

Findings suggest that there is a need to provide adequate information about mental illness and medications prescribed, to enhance medication compliance and to develop community mental health care facilities.

Development of a Patient-Centered Antipsychotic Medication Adherence Intervention

OBJECTIVE

A substantial gap exists between patients and their mental health providers about patient's perceived barriers, facilitators, and motivators (BFMs) for taking antipsychotic medications. This article describes how we used an intervention mapping (IM) framework coupled with qualitative and quantitative item-selection methods to develop an intervention to bridge this gap with the goal of improving antipsychotic medication adherence.

METHODS

IM is a stepwise method for developing and implementing health interventions. A previous study conducted in-depth qualitative interviews with patients diagnosed with schizophrenia and identified 477 BFMs associated with antipsychotic medication adherence. This article reports the results of using a variety of qualitative and quantitative item reduction and intervention development methods to transform the qualitative BFM data into a viable checklist and intervention.

RESULTS

The final BFM checklist included 76 items (28 barriers, 30 facilitators, and 18 motivators). An electronic and hard copy of the adherence progress note included a summary of current adherence, top three patient-identified barriers and top three facilitators and motivators, clarifying questions, and actionable adherence tips to address barriers during a typical clinical encounter.

DISCUSSION

The IM approach supplemented with qualitative and quantitative methods provided a useful framework for developing a practical and potentially sustainable antipsychotic medication adherence intervention. A similar approach to intervention development may be useful in other clinical situations where a substantial gap exists between patients and providers regarding medication adherence or other health behaviors.

Compliance, persistence, costs and quality of life in young patients treated with antipsychotic drugs: results from the COMETA study

BACKGROUND

Little data is available on the real-world socio-economic burden and outcomes in schizophrenia. This study aimed to assess persistence, compliance, costs and Health-Related Quality-of-Life (HRQoL) in young patients undergoing antipsychotic treatment according to clinical practice.

METHODS

A naturalistic, longitudinal, multicentre cohort study was conducted: we involved 637 patients aged 18-40 years, with schizophrenia or schizophreniform disorder diagnosed ≤10 years before, enrolled in 86 Italian Mental Health Centres and followed-up for 1 year. Comparisons were conducted between naïve (i.e., patients visiting the centre for the first time and starting a new treatment regimen) and non naïve patients.

RESULTS

At enrolment, 84% of patients were taking atypical drugs, 3.7% typical, 10% a combination of the two classes, and 2% were untreated. During follow-up, 23% of patients switched at least once to a different class of treatment, a combination or no treatment. The mean Drug-Attitude-Inventory score was 43.4, with 94.3% of the patients considered compliant by the clinicians. On average, medical costs at baseline were 390.93€/patient-month, mostly for drug treatment (29.5%), psychotherapy (29.2%), and hospitalizations (27.1%). Patients and caregivers lost 3.5 days/patient-month of productivity. During follow-up, attitude toward treatment remained fairly similar, medical costs were generally stable, while productivity, clinical statusand HRQoL significantly improved. While no significantly different overall direct costs trends were found between naïve and non naïve patients, naïve patients showed generally a significant mean higher improvement of clinical outcomes, HRQoL and indirect costs, compared to the others.

CONCLUSIONS

Our results suggest how tailoring the treatment strategy according to the complex and specific patient needs make it possible to achieve benefits and to allocate more efficiently resources. This study can also provide information on the most relevant items to be considered when conducting cost-effectiveness studies comparing specific alternatives for the treatment of target patients.

Adherence to medication for the treatment of psychosis: rates and risk factors in an Ethiopian population

Background

Medication-taking behavior, specifically non-adherence, is significantly associated with treatment outcome and is a major cause of relapse in the treatment of psychotic disorders. Non-adherence can be multifactorial; however, the rates and associated risk factors in an Ethiopian population have not yet been elucidated. The principal aim of this study was to evaluate adherence rates to antipsychotic medications, and secondarily to identify potential factors associated with non-adherence, among psychotic patients at tertiary care teaching hospital in Southwest Ethiopia.

Methods

A cross-sectional study was conducted over a 2-month period in 2009 (January 15^th to March 20^th) at the Jimma University Specialized Hospital. Adherence was computed using both a compliant fill rate method and self-reporting via a structured patient interview (focusing on how often regular medication doses were missed altogether, and whether they missed taking their doses on time). Data were analyzed using SPSS for windows version 16.0, and chi-square and Pearsons r tests were used to determine the statistical significance of the association of variables with adherence.

Result

Three hundred thirty six patients were included in the study. A total of 75.6% were diagnosed with schizophrenia, while the others were diagnosed with other psychotic disorders. Most (88.1%) patients were taking only antipsychotics, while the remainder took more than one medication. Based upon the compliant fill rate, 57.5% of prescription fills were considered compliant, but only 19.6% of participants had compliant fills for all of their prescriptions. In contrast, on the basis of patients self-report, 52.1% of patients reported that they had never missed a medication dose, 32.0% sometimes missed their daily doses, 22.0% only missed taking their dose at the specific scheduled time, and 5.9% missed both taking their dose at the specific scheduled time and sometimes missed their daily doses. The most common reasons provided for missing medication doses were: forgetfulness (36.2%); being busy (21.0%); and a lack of sufficient information about the medication (10.0%). Pill burden, medication side-effects, social drug use, and duration of maintenance therapy each had a statistically significant association with medication adherence (P ≤ 0.05).

Conclusion

The observed rate of antipsychotic medication adherence in this study was low, and depending upon the definition used to determine adherence, it is either consistent or low compared to previous reports, which highlights its pervasive and problematic nature. Adherence must therefore be considered when planning treatment strategies with antipsychotic medications, particularly in countries such as Ethiopia.

Adherence to treatment and therapeutic strategies in schizophrenic patients: the ADHERE study

AIM

To assess the degree of compliance and adherence to treatment during the follow-up of schizophrenic outpatients after a new therapeutic strategy had been initiated.

METHODS

A multicenter, retrospective, prospective, observational study of 1,848 outpatients with schizophrenia or schizoaffective disorders (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) was conducted. Patients were treated either with oral or injectable conventional or second generation antipsychotics, and were followed up for 3 months at mental health centers. Patient compliance with the pharmacological treatment was assessed by the use of questionnaires, scales, medication accountability, and the Medication Event Monitoring System. Patients were considered compliant if they reported a high compliance rate (> or = 80%).

RESULTS

At baseline only 29% of patients on oral medication were compliant compared with 79% of patients on injectable medication (injection counting) (OR= 9.11; 95% CI 6.02-13.77; P<.0001). At the 3 month visit, 84% of patients had changed their treatment and in these, the compliance rate of those on injectable medication was 94% versus 87% of patients taking oral medication (OR= 2.47; 95% CI 1.21-5.05; P=.022).

CONCLUSION

The use of long-acting injectable antipsychotics, which improves compliance rates and patient follow-up, should facilitate the management of Spanish patients with schizophrenia in mental health centers.

Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia

This study examined the medication compliance of people with schizophrenia in relation to their self-stigma, insight, attitude towards medication, and socio-demographic status via a cross-sectional observational design. Eighty-six Chinese adults with schizophrenia were recruited from the psychiatric hospitals and community settings for this study. The findings suggested that stereotype agreement of self-stigmatization and attitude towards medication were moderately correlated with medication compliance. Poor insight and living alone were found to be significant predictors of medication compliance based on regression analysis. Insight was identified to be the strongest predictor on compliance which accounted for 68.35% of the total variance. Although self-stigma is only moderately linked with medication compliance, its effects on medication-induced stigma cannot be ignored.

Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency

OBJECTIVES

The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications.

METHODS

Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status.

RESULTS

Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients.

CONCLUSIONS

Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review

OBJECTIVE

Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.

METHODS

MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.

RESULTS

In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.

CONCLUSIONS

Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

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.

Review and analysis of hospitalization costs associated with antipsychotic nonadherence in the treatment of schizophrenia in the United States

OBJECTIVE

To review the literature addressing the economic outcomes of nonadherence in the treatment of schizophrenia, and to utilize the review results to provide an update on the economic impact of hospitalizations among schizophrenia patients related to antipsychotic nonadherence.

METHODS

A structured search of EMBASE, Ovid MEDLINE, PubMed and PsycINFO for years 1995-2007 was conducted to identify published English-language articles addressing the economic impact of antipsychotic nonadherence in schizophrenia. The following key words were used in the search: compliance, noncompliance, adherence, nonadherence, relapse, economic, cost, and schizophrenia. A bibliographic search of retrieved articles was performed to identify additional studies. For a study to be included, the date of publication had to be from 1/1/1995 to 6/1/2007, and the impact of nonadherence had to be measured in terms of direct healthcare costs or inpatient days. Subsequently, an estimate of incremental hospitalization costs related to antipsychotic non adherence was extrapolated at the US national level based on the reviewed studies (nonadherence rate and hospitalization rate) and the National Inpatient Sample of Healthcare Cost and Utilization Project (average daily hospitalization costs).

RESULTS

Seven studies were identified and reviewed based on the study design, measurement of medication nonadherence, study setting, and cost outcome results. Despite the varied adherence measures across studies, all articles reviewed showed that antipsychotic nonadherence was related to an increase in hospitalization rate, hospital days or hospital costs. We also estimated that the national rehospitalization costs related to antipsychotic nonadherence was $1479 million, ranging from $1392 million to $1826 million in the US in 2005.

LIMITATIONS

The estimate of rehospitalization costs was restricted to schizophrenia patients from the Medicaid program. Additionally, the studies we reviewed did not capture the newer antipsychotic drugs (ziprasidone, aripiprazole and paliperidone). Thus, the nonadherence rates or rehospitalization rates might have changed after these new drugs came to the market, which could limit our cost estimation.

CONCLUSIONS

Poor adherence to antipsychotic medications was consistently associated with higher risk of relapse and rehospitalization and higher hospitalization costs. To reduce the cost of hospitalizations among schizophrenia patients, it seems clear that efforts to increase medication adherence should be undertaken.

Cost-Effectiveness Analysis of Schizophrenia Relapse Prevention

OBJECTIVE

The aim of this study was to estimate the cost-effectiveness of schizophrenia relapse prevention in Spain using data from the ZEUS (Ziprasidone-Extended-Use-in-Schizophrenia) study.

METHODS

Treatment of schizophrenia was modeled over 1 year using a retrospective deterministic model from the Spanish National Health System (NHS) perspective (year 2005). The primary outcome was the probability of relapse occurring within a 52-week period of treatment with daily doses of ziprasidone 40-160mg versus placebo. Data were obtained from a randomised, double-blind clinical trial (n = 218 patients). Antipsychotic cost, concomitant medications to treat adverse events (for example extrapyramidal symptoms) and medical costs associated with adverse events were derived from the clinical trial results and a Spanish health cost database. The average cost of a relapse admitted to hospital in Spain (3421 euro) was obtained from a retrospective study.

RESULTS

The probability of psychosis relapse was 0.77 with placebo, and 0.43, 0.35, 0.36 and 0.38 with ziprasidone daily doses of 40, 80, 160mg and average dose, respectively (p < 0.01 vs placebo in all cases). The average annual incremental cost per relapse avoided was 186 euro for the average dose, ranging from a saving of 557 euro (80 mg/day) to an incremental cost of 1015 euro (160 mg/day), and was lower in all cases than the minimum cost of a relapse (2830 euro).

CONCLUSIONS

According to this evaluation, psychosis relapse prevention with ziprasidone is cost effective compared with no treatment from the Spanish NHS perspective. Ziprasidone therapy avoids a considerable number of relapses at a reasonable cost, producing cost savings.

Pharmacoeconomics of long-acting risperidone: results and validity of cost-effectiveness models

Relapse is the primary cost driver in schizophrenia and is closely related to levels of adherence (compliance) with therapy. Both atypical antipsychotic agents and depot preparations have been shown to be useful in improving therapeutic adherence compared with oral conventional antipsychotic agents. Long-acting risperidone is a new formulation of an atypical antipsychotic agent that combines the pharmacological advantages of the atypical drugs with those of its mode of administration. The likelihood of improved compliance compared with existing treatment regimens implies that the higher acquisition costs would be offset by reduced rates of relapse. Economic models, which represent the health and economic outcomes of patients or populations under a variety of scenarios, are used to evaluate the economic implications of schizophrenia treatment. These models need to reflect clinical reality while simultaneously remaining as simple as possible. The assumptions and results need to be made transparent; data quality must be described explicitly; areas of uncertainty must be comprehensively explored through sensitivity analysis; and individual models must be validated, for example by comparing them with others in the therapeutic area. In this article, cost-effectiveness models of long-acting risperidone developed for different countries are discussed in terms of design, data sources and robustness, and the implications of the results for the treatment of schizophrenia are also reviewed. A discrete event simulation (DES) model that was developed using UK cost and treatment assumptions, in order to provide a 'proof of concept', is described. Country-specific models forthe United States, Canada, Germany, the Netherlands, France, Belgium, Italy and Portugal, using either DES or decision analytical structures, are then discussed. Comprehensive sensitivity analyses were conducted to assess the robustness of the results. In each case, long-acting risperidone produced additional clinical benefit and cost savings compared with other treatment strategies, despite significant variations in cost effectiveness and therapeutic approaches. In particular, improved adherence arising through the use of long-acting risperidone provides a cost-effective strategy for treating patients with schizophrenia, irrespective of the country analysed. The information generated in this analysis therefore provides one potential method for improving resource allocation and reducing the health burden related to schizophrenia.

Economic consequences of the adverse reactions related with antipsychotics: an economic model comparing tolerability of ziprasidone, olanzapine, risperidone, and haloperidol in Spain

Frequency of adverse reactions (ARs) related with antipsychotics usage is high. Along with clinical implications, economic impact might be important. The purpose of this study was to model the economic consequences of ARs related with ziprasidone, olanzapine, risperidone, and haloperidol in Spain, by means of a cost-effectiveness model developed using a Markov modeling approach. The model simulated treatment of a cohort of 1000 schizophrenics for 12 months, initiating treatment with one of four antipsychotic drugs; haloperidol, risperidone, olanzapine and ziprasidone. Conditional probabilities of developing any of four adverse events were calculated. Treatment was modified (decrease dose, switch medication) according to incidence of ARs and physician judgments, obtained from a local cross-sectional study and clinical trials previously published. The analysis was conducted in year 2002 from a third party payer perspective. Results are shown as annual cost per month with psychotic symptoms controlled and included univariate sensitivity analysis. The therapeutic strategy starting with ziprasidone showed the lower costs and the greater number of months with symptoms controlled in most scenarios evaluated versus the other options considered, although the differences were weak: 9.6, 9.3, 9.5 and 9.5 controlled months per patient in base scenario, with annual cost per patient per month with symptoms controlled of 1035 Euros, 1084 Euros, 1087 Euros and 1090 Euros for ziprasidone, haloperidol, risperidone and olanzapine, respectively. Results were robust to one-way sensitivity analysis. Despite the unlike drug prices of antipsychotics, a considerable economic impact due to adverse reactions was seen in our setting. These results should be taken into account by health decision makers and clinicians in the management of patients with schizophrenia.

Use of antipsychotic medications among HIV-infected individuals with schizophrenia

Persons with schizophrenia face elevated risk of infection with HIV. While HIV therapy is demanding, patients diagnosed with both conditions also require appropriate and consistent management of their psychiatric illness, for the same reasons that generally apply to persons with schizophrenia and because untreated psychiatric illness can interfere with full participation in HIV care. This study examines the correlates of use of and persistence on antipsychotic medications among HIV-infected individuals with schizophrenia, using merged New Jersey HIV/AIDS surveillance data and paid Medicaid claims. Persistence was defined as at least 2 months of medication use in a quarter. We identified 350 individuals who were dually diagnosed with HIV and schizophrenia. Overall, 81% of these beneficiaries had at least one claim for an antipsychotic medication at some point between 1992 and 1998. Multivariate techniques were used, including simple logistic regressions on use and robust longitudinal regressions that controlled for repeated observations on the same individual and treatment gaps. Among users of antipsychotic medications, persistence was very low at 37%. Racial/ethnic minorities were less likely to receive atypical antipsychotic medications. Use of atypical antipsychotics was associated with higher persistence. Our study confirmed past findings of racial disparities in the receipt of atypical antipsychotic medications. Findings suggest that use of atypical medications may benefit individuals dually diagnosed with HIV and serious mental illness.

Assessing the value of antipsychotics for treating schizophrenia: the importance of evaluating and interpreting the clinical significance of individual service costs

Schizophrenia is a serious and complex disorder, with treatment requiring a large number and wide range of health and social service resources. This paper addresses one challenge for assessing the direct costs of antipsychotic treatments - that of interpreting both cost and effectiveness implications of specific components of service use. Information collected on direct component costs has frequently been analysed and reported only in total. Results of several published studies provide evidence that the total direct medical costs associated with atypical antipsychotics appear to be at least equivalent to, and in some cases lower than, those associated with conventional agents. An important implication of this cost-equivalency finding is that treatment involving higher medication costs have led to offsets in certain medical service costs. Results from several studies demonstrate a shift of cost components, primarily from more expensive inpatient to less expensive outpatient care. Although the common inpatient versus outpatient dichotomy is useful, the complexities of schizophrenia and the heterogeneity of outpatient service provision are likely to warrant greater specificity. Published schizophrenia treatment guidelines can assist researchers to more fully understand and meaningfully interpret the possible relationship of antipsychotic effectiveness to the use of particular outpatient services. Because the disease requires comprehensive and continuous care, outpatient treatment costs may be better conceptualised as baseline or expectable costs necessary in the maintenance phase of treatment. Lack of expectable costs may represent poor patient outcomes and increased intangible costs. In contrast, reductions in acute outpatient service costs may provide important markers of treatment effectiveness. A small number of studies have examined the use of crisis services, but additional work is needed to differentiate treatments vis-à-vis the need for intensive (acute) interventions. The assessment and clinical interpretation of individual cost components may offer an important opportunity to build upon initial results focusing on total costs and tailor analyses to the complexities of the disorder and the treatment process. Research able to incorporate clinical acumen into cost analyses will enhance the ability of healthcare policy makers to make informed decisions regarding the value of different antipsychotic medications for the treatment of schizophrenia.

Interventions to improve antipsychotic medication adherence: review of recent literature

Antipsychotic nonadherence is an important barrier to the successful treatment of schizophrenia and can lead to clinical and economic burdens. Interventions capable of significantly improving medication adherence in patients with schizophrenia would be beneficial in maximizing treatment outcomes with antipsychotics. This article reviews recent literature reporting interventions designed to improve antipsychotic adherence in patients with schizophrenia. We searched the Medline, Healthstar, and PsycInfo electronic databases for articles published since 1980 on interventions to improve medication adherence in schizophrenia. Twenty-one studies met our selection criteria. In this review, educational, behavioral, affective, or a combination of these approaches to improve adherence were examined. A total of 23 interventions were tested, as 2 studies investigated more than 1 intervention. While study design and adherence measures varied across the trials reviewed, medication adherence was noted to moderately improve with 15 of the 23 interventions tested. Interventions of a purely educational nature were the least successful at improving antipsychotic adherence. The greatest improvement in adherence was seen with interventions employing combinations of educational, behavioral, and affective strategies with which improvements in adherence were noted in 8 out of 12 studies, with additional secondary gains such as: reduced relapse, decreased hospitalization, decreased psychopathology, improved social function, gains in medication knowledge, and improved insight into the need for treatment. Longer interventions and an alliance with therapists also appeared important for successful outcomes. The continuing development and study of successful interventions to improve medication adherence are necessary to maximize the usefulness of pharmacologic treatment of schizophrenia.

Adherence to antipsychotic and nonpsychiatric medications in middle-aged and older patients with psychotic disorders

OBJECTIVE

The prevalence and consequences of nonadherence to antipsychotic medications in schizophrenia and related psychotic disorders have been well described; however, little is known about adherence to medications for nonpsychiatric conditions in patients with psychotic disorders. We wished to determine medication adherence in nondemented middle-aged and older Veterans Affairs outpatients with schizophrenia or other psychotic disorders who had been prescribed oral medications for hypertension, hyperlipidemia, or diabetes.

METHODS

Medication adherence was assessed by review of medication fill records for 76 patients aged 40 years and older who had been prescribed an oral antipsychotic in addition to an oral agent for hypertension (N = 60), hyperlipidemia (N = 28), or diabetes (N = 24). Up to 12 months of therapy was reviewed, and a compliant fill rate (the number of adherent fills in proportion to the total number of prescription fills) and cumulative mean gap ratio (the number of days when medication was unavailable in relation to the total number of days) were calculated for each medication.

RESULTS

The 12-month mean compliant fill rates for antipsychotics, antihypertensives, antihyperlipidemics, and antidiabetics ranged from 52% to 64%. Nonpsychiatric medication adherence rates were similar in patients on typical vs. atypical antipsychotics and did not correlate significantly with antipsychotic adherence rates.

CONCLUSIONS

Nonadherence rates were found to be equally problematic for both antipsychotic and nonpsychiatric medications in middle-aged and older patients with psychotic disorders. Interventions to improve adherence to both antipsychotic and nonpsychiatric medications are needed.

Risperidone olanzapine drug outcomes studies in schizophrenia (RODOS): health economic results of an international naturalistic study

We report the health economic data from the Risperidone Olanzapine Drug Outcomes studies in Schizophrenia (RODOS) programme. Details of the efficacy and tolerability data from RODOS are available in a companion paper. The population analysed during RODOS consisted of 1901 patients with diagnoses of schizophrenia or schizoaffective disorder. The mean +/- SD daily dose of olanzapine treatment was 14.5 +/- 5.1 mg compared to 5.3 +/- 2.6 mg for risperidone. Use of concomitant neuroleptics (risperidone, 65%; olanzapine, 62%; P = 0.2) and other concomitant drugs (risperidone, 76%; olanzapine, 73%; P = 0.2) was similar in both groups. The mean +/- SD total costs of all inpatient drugs was significantly (P < 0.001) higher for olanzapine (US$ 297.5 +/- 305.1) than risperidone (US$159.9 +/- 183.3). Although this difference in the average total costs in part reflects the longer treatment duration for olanzapine compared to risperidone (34 days versus 31 days), the cost difference remained when looking at costs on a daily basis. The mean +/- SD daily cost of all inpatient drugs was also significantly (P < 0.001) higher for olanzapine (US$7.7 +/- 4.0) than for risperidone (US$ 4.6 +/- 2.9). These findings were very consistent across all nine countries. The results from RODOS suggest that treatment costs are significantly higher with olanzapine than with risperidone without any clinical benefit to offset this.

Designing naturalistic prospective studies of economic and effectiveness outcomes associated with novel antipsychotic therapies

The cornerstone of recent pharmacoeconomic work in schizophrenia is the hypothesis that the improved efficacy of novel antipsychotic medications will lead to a reduction in medical services utilization, thereby reducing direct medical costs associated with treatment. Creating the most valid design to prospectively examine the effectiveness and costs of competing pharmacotherapies requires a dialectic of opposing research paradigms. The final protocol must represent a series of decisions that strike a careful balance between being scientifically sound (internal validity) and generalizable to the real world of clinical treatment (external validity). The results must be useful to decision-makers in determining to what extent reductions in healthcare expenditures can offset higher drug acquisition costs within their type of treatment environment. This article is a review of several methodological challenges in the design of medical effectiveness trials, including whether to blind the study, definition of the patient population, degree of physician discretion in treatment, and how to collect and analyze data for patients who discontinue their originally assigned medication. The article also provides a discussion of how clinical practices can inform decisions made to meet these challenges. The issues are illustrated through a prospective study designed to evaluate the cost-effectiveness of the newer antipsychotics in general and olanzapine in particular. Cost-effectiveness studies of novel antipsychotic medications, particularly those with naturalistic designs, will increase in importance as the use of these second-generation agents continues to expand.

Medical-claims databases in the design of a health-outcomes comparison of quetiapine ('Seroquel') and usual-care antipsychotic medication

Treating schizophrenia is expensive. Preventing rehospitalization of patients with schizophrenia provides an attractive opportunity for cost savings, especially for patients with 'revolving-door' or multiple-episode schizophrenia. Reducing the occurrence of extrapyramidal symptoms and other adverse events associated with standard antipsychotic agents may increase compliance and reduce the rate of rehospitalization of patients with schizophrenia. Quetiapine ('Seroquel', ICI 204,636, Zeneca Pharmaceuticals) is a new dibenzothiazepine antipsychotic agent with a low propensity for extrapyramidal symptoms. We describe here a unique methodology to compare quetiapine with usual-care medications in real-world treatment settings. The trial objective is to determine if therapy with this new atypical antipsychotic agent can reduce the rate of rehospitalization and, therefore, treatment costs. Using two secondary medical-claims databases, we defined the minimal threshold for revolving-door status as 1.0 admission per year; this definition allows our trial to focus on the subpopulation of schizophrenic patients with the greatest potential for cost savings by either the new atypical antipsychotic quetiapine or usual-care therapy. We describe here the approach used in our trial.

Economic evaluation of zuclopenthixol acetate compared with injectable haloperidol in schizophrenic patients with acute psychosis

Zuclopenthixol acetate is a rapid-acting, injectable neuroleptic drug with a duration of action that allows for administration once every 2 to 3 days, in contrast to injectable haloperidol, which may require administration more than once daily. To assess the place of zuclopenthixol acetate in the treatment of acute episodes of schizophrenia, a cost-consequence analysis was performed comparing this new medication with short-acting, injectable haloperidol. The perspective of the Quebec health care system was adopted. The study population comprised patients diagnosed with schizophrenia who experienced an acute episode of psychosis and who were treated with intramuscular (i.m.) haloperidol. The study assessed patients for 9 days after the start of treatment. The literature was the principal source of comparative data about the clinical outcomes of the two treatments. The total cost associated with zuclopenthixol acetate i.m. or haloperidol i.m. was modeled using a decision tree built around the number of i.m. injections required to achieve stabilization. To establish costs, expert panels were consulted and patients' files were reviewed for a sample of schizophrenic patients who had been hospitalized in a large psychiatric or general hospital subsequent to a visit to the emergency department and had received a short-acting i.m. neuroleptic drug. Only a direct medical records costs were considered. Because zuclopenthixol acetate was not on the market at the time of the study, the file review did not allow for a direct estimate of its related costs but did provide an account of haloperidol use. The literature shows that zuclopenthixol acetate is similar to haloperidol with respect to the control of psychotic episodes; however, zuclopenthixol acetate is associated with increased sedation and a lower incidence of extrapyramidal symptoms. Using the base-case estimate for the number of injections required for stabilization, the incremental cost of zuclopenthixol acetate 50 mg over haloperidol was $25.00 (1995 Canadian dollars) per patient at the psychiatric hospital and $21.00 per patient at the general hospital. The results were sensitive to the estimate of the number of injections and the number of minutes of nursing care required by agitated patients. Zuclopenthixol acetate resulted in cost savings over haloperidol if it permits a reduction of 25% in minutes of nursing care or if 85% of patients require 2 injections or less (45% requiring 1 injection and 40% requiring 2). However, whichever drug is used, the cost of the injectable neuroleptic represents a small fraction of the cost of care for acutely psychotic patients.

Olanzapine. A review of its pharmacological properties and therapeutic efficacy in the management of schizophrenia and related psychoses

Olanzapine is a thienobenzodiazepine derivative which displays efficacy in patients with schizophrenia and related psychoses. It has structural and pharmacological properties resembling those of the atypical antipsychotic clozapine and an improved tolerability profile compared with the classical antipsychotic haloperidol. In several large, well controlled trials in patients with schizophrenia or related psychoses, olanzapine generally 5 to 20 mg/day was at least as effective as haloperidol (5 to 20mg) and more so than placebo, as assessed by overall rating scales for psychoses. Olanzapine improved negative symptoms to a greater extent than haloperidol in 2 of 3 comparative trials, including the largest trial. Efficacy of olanzapine has a rapid onset (within 1 to 2 weeks). Its clinical benefits appear to be maintained for treatment periods of up to 1 year, as shown by analysis of the extension phase of several trials demonstrating decreased probability of hospitalisation over this period compared with haloperidol. Preliminary data suggest the drug may also improve quality of life. Olanzapine was associated with significantly fewer adverse movement disorders (e.g. akathisia, dystonia, hypertonia, extrapyramidal symptoms) than haloperidol. There have been no reports of agranulocytosis (as occurs with clozapine) or any other haemotoxicity attributed to olanzapine, and the drug has shown minimal effect on prolactin levels. Transient increases in levels of hepatic transaminases seem to be clinically important. The only events recorded more frequently during olanzapine than during haloperidol therapy were weight gain, dry mouth and increased appetite. Although the antipsychotic activity of olanzapine has been well demonstrated. Its efficacy in refractory schizophrenia and its place relative to other atypical antipsychotics remain to be determined. Nevertheless, if the long term tolerability profile of olanzapine is confirmed, the drug should provide a valuable therapeutic alternative in the management of schizophrenia and related psychoses.

The cost of mental health services. Prospects for future research

The setting of priorities in mental health care evaluation requires considering future trends in mental health services. Three areas of change are mentioned in this paper: the development of services, the increase of the burden of illness, and reform processes in health care systems. Economic evaluation of mental health services has to consider the different roles of the agents acting in mental health care, policy-makers, companies, researchers and care professionals, and patients and their relatives.

Despite the increasing work done, most mental health care interventions have either not been evaluated or have been ill evaluated. There is a sense of paucity of measurement that has to be enriched with more and better evaluative research. Some unresolved methodological issues are commented on in this paper. In particular, direct costs outside the health care sector, indirect costs and quality of life measurement are briefly analysed.