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

Refining antipsychotic treatment strategies in schizophrenia: discovery of genetic biomarkers for enhanced drug response prediction

Schizophrenia (SCZ) is a severe mental disorder affecting around 1% of individuals worldwide. The variability in response to antipsychotic drugs (APDs) among SCZ patients presents a significant challenge for clinicians in determining the most effective medication. In this study, we investigated the biological markers and established a predictive model for APD response based on a large-scale genome-wide association study using 3269 Chinese schizophrenia patients. Each participant underwent an 8-week treatment regimen with one of five mono-APDs: olanzapine, risperidone, aripiprazole, quetiapine, or amisulpride. By dividing the response into ordinal groups of "high", "medium", and "low", we mitigated the bias of unclear treatment outcome and identified three novel significantly associated genetic loci in or near CDH12, WDR11, and ELAVL2. Additionally, we developed predictive models of response to each specific APDs, with accuracies ranging from 79.5% to 98.0%. In sum, we established an effective method to predict schizophrenia patients' response to APDs across three categories, integrating novel biomarkers to guide personalized medicine strategies.

How theories, models, and frameworks have been used to implement digital health interventions in services for people with severe mental health problems: a scoping review

BACKGROUND

Digital health interventions have the potential to improve the efficacy and accessibility of mental health services for people with severe mental health problems, but their integration into routine practice is a challenge. The real-world implementation of digital health interventions should be considered alongside digital intervention development. However, little is known about the quality of implementation research in this area, including the extent to which implementation science theories, models and frameworks are used. The aim of this review was to synthesise evidence regarding the application of theories, models and frameworks in research investigating the implementation of digital health interventions in services for people with severe mental health problems. Secondary aims were to consider the contexts within which studies had been undertaken and the degree of service user involvement in this research.

METHODS

A scoping review method was employed. Electronic databases were systematically searched for published papers in English and reference lists of included studies were hand searched. Included studies used an implementation science theory, model, or framework to understand, guide or evaluate the implementation of digital health interventions in services for people with severe mental health problems.

RESULTS

Twelve eligible studies were identified. Studies were primarily undertaken in community mental health services with staff participants and there was variation in the types of digital interventions that were investigated. Eight different implementation science theories, models, and frameworks were used and were mainly employed to guide qualitative analysis. Most studies were undertaken in the early exploratory stages of implementation projects and there was little evidence regarding factors affecting the longer-term sustainment of digital health interventions in practice. Only one study reported the inclusion of service users in the design of the implementation study.

CONCLUSIONS

The use of implementation theories, models, and frameworks in efforts to implement digital health interventions in routine care for people with severe mental health problems is limited. Researchers should consider integrating such approaches throughout the research process and ensure service users are involved in this work. Further research regarding implementation processes, and the reach and sustainment of digital health interventions in routine practice, is required.

The societal costs of avoidant personality disorder

The study aims to estimate the societal costs of avoidant personality disorder (AvPD). Cross-sectional data on AvPD patients during 2017-2020 were retrieved from the quality register of the Norwegian Network for Personality Disorders. Cost estimations were based on a bottom-up approach, using a structured interview covering the 6-month period prior to initial assessment. Unit costs were retrieved from public records. The human capital approach was used to calculate productivity losses. Diagnoses were determined according to DSM-5 by semi-structured diagnostic interviews (SCID-5-PD). Mean societal costs were €19,378 for the total group (N = 410). The subgroup with a single diagnosis (n = 270) incurred €18,818, whereas the subgroup with at least one comorbid PD (n = 140) incurred €20,458. The difference between the two subgroups was not statistically significant. The largest cost component was productivity loss (69%), whereas health service costs constituted 31%. The main contributors to societal costs from the health service cost components were inpatient treatment (18%) and individual outpatient treatment (11%). In conclusion, societal costs for AvPD patients were high, on the same level as borderline PD, schizotypal PD, and schizophrenia, and higher than anxiety disorders, depression, and rheumatoid arthritis. In the future, development of effective AvPD treatment programs enhancing personality functioning and workforce participation is important in order reduce the cost of illness.

A systematic review of passive data for remote monitoring in psychosis and schizophrenia

There is increasing use of digital tools to monitor people with psychosis and schizophrenia remotely, but using this type of data is challenging. This systematic review aimed to summarise how studies processed and analysed data collected through digital devices. In total, 203 articles collecting passive data through smartphones or wearable devices, from participants with psychosis or schizophrenia were included in the review. Accelerometers were the most common device (n = 115 studies), followed by smartphones (n = 46). The most commonly derived features were sleep duration (n = 50) and time spent sedentary (n = 41). Thirty studies assessed data quality and another 69 applied data quantity thresholds. Mixed effects models were used in 21 studies and time-series and machine-learning methods were used in 18 studies. Reporting of methods to process and analyse data was inconsistent, highlighting a need to improve the standardisation of methods and reporting in this area of research.

Review of community-based interventions for people with serious mental illness, focusing on learning instrumental activities of daily living and enhancing wellbeing

This review synthesises evidence on community-based interventions designed to support individuals with serious mental illness (SMI) in learning instrumental activities of daily living (IADLs). Given the increasing prevalence of SMI affecting over 500 million people worldwide, and associated functional impairments, effective interventions are critically needed. This review of thirty studies represented a range of global contexts and intervention types, which were categorised into simple IADLs (e.g. household chores), complex IADLs (e.g. financial management), and recreational IADLs (e.g. leisure activities). Findings demonstrated that community-based interventions significantly improved IADLs, promoting functional independence and overall well-being. Thematic analysis identified five key mechanisms for success: individualised goal-setting, structured programs with practical learning, engagement of support systems, integration into daily life, and use of innovative technologies. The review highlighted that personalised and practical IADL interventions, supported by robust community and technological resources, were most effective. When effective, interventions enhance practical skills of individuals while also contributing to emotional well-being, social connections, and personal fulfilment. Despite promising results, the review notes variability in study designs and outcomes, suggesting a need for consistent and long-term evaluations. Nonetheless, review insights offer valuable guidance for designing future interventions to better support autonomy and community integration of individuals with SMI.

Effects of mindfulness-based interventions (MBIs) on psychotic symptoms and psychological outcomes in patients with schizophrenia spectrum disorders: A systematic review and meta-analysis

OBJECTIVE

Mindfulness refers to the practice of consciously attending to the present moment without judgement. Although mindfulness-based intervention have been extensively researched. Less is known about the effect of this intervention on psychotic symptoms in patients with schizophrenia spectrum disorders. Thus, we synthesized the effects of mindfulness-based interventions (MBIs) on psychotic symptoms, global functioning, insight, and mindfulness in patients with schizophrenia spectrum disorders.

METHOD

Nine electronic databases were searched from inception to March 2024 including Academic Search Complete, CINAHL, Cochrane, Ovid APA InFo, ProQuest, PubMed, Scopus, Mindfulness Journal and Web of Science. We reviewed studies on outcomes for patients with schizophrenia spectrum disorders receiving mindfulness-based interventions. We only reviewed all experimental and quasi-trials studies written in English. A random-effects model was used to compute the effect size. We used Funnel plot, Q statistics, and I2 to test the heterogeneity across studies. Also, we examined moderators to explore sources of heterogeneity.

RESULTS

Across 24 included studies (N = 1,632), 796 schizophrenia patients participated in mindfulness interventions; 836 served as controls. Most schizophrenia patients were males (69 %, s = 7). Mean age ranged from 24.4 to 59.5 years. Overall, mindfulness-based interventions showed reduced psychotic symptoms (g = 0.70, 95 %CI 0.04, 1.36, I2 = 96 %), increased global functioning (g = 1.28, 95 %CI 0.50, 2.05), insight (g = 1.21, 95 %CI 0.88, 1.55) and mindfulness (g = 0.56, 95 %CI 0.15, 0.97) compared to control groups, but with substantial heterogeneity. With subgroup analysis, every one-year of mean age of patients with schizophrenia increased, psychotic symptom worsened (slope = -0.071, tau2 = 0.77, Qbetween = 166.3, p = .016). Additionally, for every day of MBIs practice increased, psychotic symptoms improved (Slope = 0.012, tau2 = 1.37, Qbetween = 251.6, p = .033), patients' functioning improved (slope = 0.013, tau2 = 0.69, Qbetween = 142.1, p = .017) and patients' insight improved (slope = 0.001, tau2 = 0.012, Qbetween = 8.6, p = .043). Providing MBIs as a mixed format (individual plus group intervention) had a greater effect (g = 1.538) on improving patients' insight than providing MBIs only to individuals (g = 0.889). Also, providing MBIs with a home assignment had a greater effect (g = 1.517) on improving patients' insight than providing MBIs without a home assignment (g = 0.787). No primary studies reported the adverse effects.

CONCLUSION

MBIs significantly improved psychotic symptoms, global functioning, insight, and mindfulness among patients with schizophrenia spectrum disorders, especially MBIs with home assignment. Clinicians and health providers should consider using MBIs as alternative complementary treatment for improving psychotic symptoms and increasing global functioning, insight and mindfulness.

The Real-world Effect of Long-acting Injectable Antipsychotics on Annual Medical Costs of Korean Schizophrenia Patients

Objective

Schizophrenia is a severe and chronic mental disorder that significantly impacts cognitive, social, and occupational functions, leading to substantial economic burdens. Long-acting injectable (LAI) antipsychotics have been introduced to improve treatment adherence and outcomes, yet their economic impact remains debated. We aim to analyze the impact of LAIs on the medical costs of Korean schizophrenia patients.

Methods

A retrospective analysis of 164 schizophrenia patients treated with LAI antipsychotics, paliperidone palmitate, and aripiprazole monohydrate at Korea University Guro Hospital between January 2017 and July 2022 was performed. Comparisons of inpatient department (IPD) and outpatient department (OPD) healthcare expenditures one year before and after LAI initiation were conducted.

Results

LAIs led to an increase in annual OPD costs (1,437.44 ± 1,127.60 to 4,015.42 ± 1,204.59; units: 1,000 KRW) but significantly reduced IPD admission associated costs (3,826.06 ± 5,500.63 to 698.06 ± 3,619.38; units: 1,000 KRW). After LAI administration, there was an overall reduction in total annual healthcare costs (5,263.49 ± 5,333.11 to 4,713.48 ± 3,625.89; units: 1,000 KRW), but it was not statistically significant.

Conclusion

Although the use of LAIs did not significantly lower the first-year medical costs of schizophrenia patients, they offer beneficial economic impacts over time by reducing hospitalization-associated costs. Future research should focus on long-term cost analyses and the impacts of newer LAI formulations.

Management of schizophrenia and comorbid substance use disorders: expert review and guidance

BACKGROUND

Schizophrenia and substance use disorders (SUDs) are often comorbid conditions that present clinical challenges due to their heterogeneity and the difficulties associated with poor physical health, low medication adherence, high relapse and hospitalization rates, and increased risk of mortality. This is often exacerbated by a fragmented health care system that treats addiction and mental illness separately, leading to delays in proper diagnosis and treatment.

MAIN TEXT

The aim of this narrative review, based on an extensive literature search and experts' clinical experience, is to synthesize evidence on the psychopathological and clinical characteristics of patients, the burden and management at the level of healthcare system, and possible gaps in the treatment of schizophrenia with comorbid SUD in order to understand and address the needs of patients. Treatment options, differences between antipsychotic medications, and the benefits of long-acting formulations and partial dopaminergic agonists are described. Partial dopamine agonists (aripiprazole, cariprazine, and brexpiprazole) have demonstrated good control of psychotic symptoms and SUDs with a favorable safety profile.

CONCLUSION

Pharmacological interventions should be accompanied by psychosocial support within an integrated and multidisciplinary approach that promotes shared decision-making and a good therapeutic alliance between the entire medical team and the patient.

Productivity costs of schizophrenia spectrum and other psychotic disorders by friction cost and human capital methods: The Northern Finland Birth Cohort 1966

PURPOSE

Psychotic disorders are associated with substantial productivity costs; however no previous studies have compared these between schizophrenia spectrum (SSD) and other psychotic disorders (OP). The human capital method (HCM) and the friction cost method (FCM) are the two most common approaches to assess productivity costs. The HCM focuses on employees' perspectives on the costs, whereas the FCM demonstrates employers' perspectives. Studies comparing these methods when estimating the productivity costs of psychoses are lacking.

METHODS

Utilizing the Northern Finland Birth Cohort 1966 with linkages to national registers, we compared the adjusted productivity costs of SSD (n = 216) and OP (n = 217). The productivity costs were estimated from ages 18 to 53 including projections to statutory retirement age using the FCM and HCM.

RESULTS

When estimated via the HCM, productivity losses were higher for SSD (€193,940) than for OP (€163,080). However, when assessed using the FCM, costs were significantly lower for SSD (€2,720) than for OP (€4,430). Productivity costs varied by sex and various clinical and occupational factors.

CONCLUSION

This study highlights how productivity costs vary by psychosis diagnosis. These differences should be noted when planning interventions. The low FCM estimates indicate the need of interventions before or during the early phases of psychoses. From a societal perspective, interventions are needed, particularly for those with highest HCM productivity losses, such as males with SSD. Besides psychiatric services, the roles of social services, employment agencies and occupational health care should be considered when helping individuals with psychoses to working life.

Real-World Effectiveness, Economic, and Humanistic Outcomes of Selected Oral Antipsychotics in Patients with Schizophrenia: A Systematic Review Evaluating Global Evidence

Background

Schizophrenia is a complex, chronic mental health disorder that confers a substantial disease burden globally. Oral antipsychotic treatments (OATs) are the mainstay for treating early and advanced stages of schizophrenia. Our systematic review aimed to synthesize literature describing real-world effectiveness, economic, and humanistic outcomes of OATs (asenapine, brexpiprazole, cariprazine, iloperidone, lumateperone, lurasidone, olanzapine/samidorphan, paliperidone, and quetiapine) for successful management of the disease.

Methods

PubMed, American Psychological Association PsycINFO (EBSCOhost), and Cumulative Index of Nursing and Allied Health Literature were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting real-world effectiveness, costs, humanistic, behavioral (eg, interpersonal relations, suicide ideation), medication adherence, and product-switching outcomes for selected OATs published in English from January 2010 to March 2022 were identified and evaluated qualitatively.

Results

We included 48 studies with different designs providing extensive evidence on schizophrenia. All studies were conducted in countries outside of the United States. In most studies, antipsychotic medications were more effective than placebo, suggesting their value in the management of schizophrenia. Sixteen studies measured the economic outcomes of OATs. Eight studies assessed humanistic outcomes, while one reported behavioral outcomes in three second-generation antipsychotics. Medication adherence was described in two studies, while five studies evaluated product switching. Non-adherence was commonly reported for OATs. Medication non-adherence and treatment discontinuation were predominant factors contributing to the economic burden of schizophrenia.

Conclusion

Our research showcased a significant knowledge gap across OATs spanning the humanistic and behavioral outcomes and medication adherence and switching, suggesting a need for robust evidence generation to help clinicians and payers make informed decisions regarding treatment opportunities and cost-effective strategies for patients with schizophrenia.

Neural stem/progenitor cells from olfactory neuroepithelium collected by nasal brushing as a cell model reflecting molecular and cellular dysfunctions in schizophrenia

OBJECTIVES

Neural stem/progenitor cells derived from olfactory neuroepithelium (hereafter olfactory neural stem/progenitor cells, ONSPCs) are emerging as a potential tool in the exploration of psychiatric disorders. The present study intended to assess whether ONSPCs could help discern individuals with schizophrenia (SZ) from non-schizophrenic (NS) subjects by exploring specific cellular and molecular features.

METHODS

ONSPCs were collected from 19 in-patients diagnosed with SZ and 31 NS individuals and propagated in basal medium. Mitochondrial ATP production, expression of β-catenin and cell proliferation, which are described to be altered in SZ, were examined in freshly isolated or newly thawed ONSPCs after a few culture passages.

RESULTS

SZ-ONSPCs exhibited a lower mitochondrial ATP production and insensitivity to agents capable of positively or negatively affecting β-catenin expression with respect to NS-ONSPCs. As to proliferation, it declined in SZ-ONSPCs as the number of culture passages increased compared to a steady level of growth shown by NS-ONSPCs.

CONCLUSIONS

The ease and safety of sample collection as well as the differences observed between NS- and SZ-ONSPCs, may lay the groundwork for a new approach to obtain biological material from a large number of living individuals and gain a better understanding of the mechanisms underlying SZ pathophysiology.

A systematic review of pharmacogenetic testing to guide antipsychotic treatment

Pharmacogenomics could optimize antipsychotic treatment by preventing adverse drug reactions, improving treatment efficacy or relieving the cost burden on the healthcare system. Here we conducted a systematic review to investigate whether pharmacogenetic testing in individuals undergoing antipsychotic treatment influences clinical or economic outcomes. On 12 January 2024, we searched MEDLINE, EMBASE, PsycINFO and Cochrane Centrale Register of Controlled Trials. The results were summarized using a narrative approach and summary tables. In total, 13 studies were eligible for inclusion in the systematic review. The current evidence base is either in favor of pharmacogenetics-guided prescribing or showed no difference between pharmacogenetics and treatment as usual for clinical and economic outcomes. In the future, we require randomized controlled trials with sufficient sample sizes that provide recommendations for patients who take antipsychotics based on a broad, multigene panel, with consistent and comparable clinical outcomes.

Cost-of-illness studies of inherited retinal diseases: a systematic review

BACKGROUND

While health care and societal costs are routinely modelled for most diseases, there is a paucity of comprehensive data and cost-of-illness (COI) studies for inherited retinal diseases (IRDs). This lack of data can lead to underfunding or misallocation of resources. A comprehensive understanding of the COI of IRDs would assist governmental and healthcare leaders in determining optimal resource allocation, prioritizing funding for research, treatment, and support services for these patients.

METHODS

Following PRISMA guidelines, a literature search was conducted using Medline, EMBASE and Cochrane databases, from database inception up to 30 Jun 2023, to identify COI studies related to IRD. Original studies in English, primarily including patients with IRDs, and whose main study objective was the estimation of the costs of IRDs and had sufficiently detailed methodology to assess study quality were eligible for inclusion. To enable comparison across countries and studies, all annual costs were standardized to US dollars, adjusted for inflation to reflect their current value and recalculated on a "per patient" basis wherever possible. The review protocol was registered in PROSPERO (registration number CRD42023452986).

RESULTS

A total of nine studies were included in the final stage of systematic review and they consistently demonstrated a significant disease burden associated with IRDs. In Singapore, the mean total cost per patient was roughly US$6926/year. In Japan, the mean total cost per patient was US$20,833/year. In the UK, the mean total cost per patient with IRD ranged from US$21,658 to US$36,549/year. In contrast, in the US, the mean total per-patient costs for IRDs ranged from about US$33,017 to US$186,051 per year. In Canada, these mean total per-patient costs varied between US$16,470 and US$275,045/year. Non-health costs constituted the overwhelming majority of costs as compared to healthcare costs; 87-98% of the total costs were due to non-health costs, which could be attributed to diminished quality of life, poverty, and increased informal caregiving needs for affected individuals.

CONCLUSION

IRDs impose a disproportionate societal burden outside health systems. It is vital for continued funding into IRD research, and governments should incorporate societal costs in the evaluation of cost-effectiveness for forthcoming IRD interventions, including genomic testing and targeted therapies.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.