Schizophrenia costs and treatment cost-effectiveness

Healthcare use of young finnish adults with mental disorders - profiles and profile membership determinants

BACKGROUND

Comprehensive, timely, and integrated primary care services have been proposed as a response to the increased demand for mental health and substance use services especially among young people. However, little is known about the care utilization patterns of young people with mental and substance use disorders. Our aim was to characterize profiles of care use in young Finnish adults with mental or substance use disorders, and the potential factors associated with the service use profiles.

METHODS

Primary and specialized care visits of young adults (16-29 years) diagnosed with a psychiatric or a substance use disorder (n = 7714) were retrieved from the national health care register from years 2020 and 2021. K-Means clustering was used to detect different profiles based on the utilization of care services. Multinomial logistic regression was used to analyze the factors associated with different profiles of care use.

RESULTS

Five different profiles were identified: low care use (75%), and use of principally primary health care (11%), student health services (9%), psychiatric services (5%), or substance use services (1%). Female gender was associated with membership in the primary health care focused profiles (OR 2.58 and OR 1.99), and patients in the primary health care and student health services profiles were associated with a better continuity of care (OR 1.04 and OR 1.05). Substance use disorders were associated with psychiatric service use (OR: 2.51) and substance use services (OR: 58.91). Living in smaller municipalities was associated with lower service use when comparing to the largest city.

CONCLUSIONS

Young adults diagnosed with a psychiatric or a substance use disorder had remarkably different and heterogeneous care patterns. Most of the participants had low care utilization, indicating potential gaps in service use and care needs. Measures should be taken to ensure equal access to and availability of mental health services. The profiles that utilized the most services highlights the importance of integrated services and patient-oriented improvement of treatment.

Cross-culturally adapted psychological interventions for the treatment of depression and/or anxiety among young people: A scoping review

BACKGROUND

Mental health problems among young people are a major global public health challenge. Psychological interventions may improve mental health, yet most are developed in western cultures, and it is unclear whether they are applicable to other geographical settings and can be delivered successfully to diverse populations. We identified empirical studies focusing upon cross-culturally adapted psychological interventions and examined the cultural adaptation process used and the effectiveness of the interventions in the treatment of depression and/or anxiety disorders among young people (defined here as children and adolescents aged between 8-18 years).

METHOD

We conducted a scoping review aligning to the guidelines reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. Stakeholder engagement enabled us to discuss the findings of the review and obtain feedback.

RESULTS

We identified 17 studies of cross-culturally adapted psychological interventions that considered the appropriate language, metaphors, culturally appropriate terms, and cultural values of young people. Most studies (n = 11) adopted a randomised control trial (RCT) methodology. Six studies used the ecological validity and cultural sensitivity framework. Planned adaptation, cultural adaptation of content, and surface and deep structure level adaptations were used in other studies. Apart from one pilot study, all studies reported that culturally adapted interventions resulted in improvements in depression and/or anxiety symptoms in young people. The results suggest the potential effectiveness of cross-culturally adapted interventions within this context. Our stakeholder consultations demonstrated that engaging different community-level stakeholders in the adaptation process was highly recommended.

CONCLUSIONS

Whilst most included studies indicated improvements in depression and/or anxiety symptoms in young people following a cross-culturally adapted intervention, more work is needed in this area. In particular, focus should be placed upon identifying the dimensions of interventions that should be culturally adapted to make them acceptable, engaging and effective.

Schizophrenia induces abnormal frequency-dependent patterns of dynamic brain network reconfiguration during an auditory oddball task

OBJECTIVE

Schizophrenia is a psychiatric disorder that has been shown to disturb the dynamic top-down processing of sensory information. Various imaging techniques have revealed abnormalities in brain activity associated with this disorder, both locally and between cerebral regions. However, there is increasing interest in investigating dynamic network response to novel and relevant events at the network level during an attention-demanding task with high-temporal-resolution techniques. The aim of the work was: (i) to test the capacity of a novel algorithm to detect recurrent brain meta-states from auditory oddball task recordings; and (ii) to evaluate how the dynamic activation and behavior of the aforementioned meta-states were altered in schizophrenia, since it has been shown to impair top-down processing of sensory information.

APPROACH

A novel unsupervised method for the detection of brain meta-states based on recurrence plots and community detection algorithms, previously tested on resting-state data, was used on auditory oddball task recordings. Brain meta-states and several properties related to their activation during target trials in the task were extracted from electroencephalography (EEG) data from patients with schizophrenia and cognitively healthy controls.

MAIN RESULTS

The methodology successfully detected meta-states during an auditory oddball task, and they appeared to show both frequency-dependent time-locked and non-time-locked activity with respect to the stimulus onset. Moreover, patients with schizophrenia displayed higher network diversity, and showed more sluggish meta-state transitions, reflected in increased dwell times, less complex meta-state sequences, decreased meta-state space speed, and abnormal ratio of negative meta-state correlations.

SIGNIFICANCE

Abnormal cognition in schizophrenia is also reflected in decreased brain flexibility at the dynamic network level, which may hamper top-down processing, possibly indicating impaired decision-making linked to dysfunctional predictive coding. Moreover, the results showed the ability of the methodology to find meaningful and task-relevant changes in dynamic connectivity and pathology-related group differences.

Impact of Group Art Therapy Using Traditional Chinese Materials on Self-Efficacy and Social Function for Individuals Diagnosed With Schizophrenia

The purpose of this study was to examine the effect of group art therapy using traditional Chinese materials on improving the self-efficacy and social function of individuals diagnosed with schizophrenia. In China, little research has been conducted on patients to measure the effectiveness of group art therapy, especially using traditional Chinese materials. To address this research gap, 104 individuals diagnosed with schizophrenia were tested in a group art therapy program that included 30 treatment sessions and used a wide variety of materials, including traditional Chinese materials, such as Chinese calligraphy, traditional Chinese painting, Chinese embroidery, and Chinese beads. The effect of art therapy was analyzed using the General Self-Efficacy Scale (GSES) and Scale of Social Skills for Psychiatric Inpatients (SSPI). This study demonstrates that group art therapy using traditional Chinese materials can improve self-efficacy and social function, reducing social and life function problems, and promote the recovery of individuals diagnosed with schizophrenia.

School-based, two-arm, parallel, controlled trial of a culturally adapted resilience intervention to improve adolescent mental health in Vietnam: study protocol

INTRODUCTION

The Resourceful Adolescent Program (RAP) is an evidence-based resilience intervention for adolescents. Operating in a strength-focused paradigm, the programme uses an integration of cognitive behavioural therapy and interpersonal psychotherapy to improve coping skills and build resilience. This study aims to establish whether a culturally and linguistically adapted intervention informed by RAP principles is effective in increasing resilience, enhancing coping skills and preventing symptoms of depression and anxiety.

METHODS AND ANALYSIS

We will translate, back-translate and culturally adapt the RAP for adolescents and training materials for facilitators, and the adapted intervention will be called Happy House. A two-arm parallel controlled trial will be conducted in eight high schools in the north of Vietnam. In each of the selected schools, all students from four randomly selected grade 10 classes (an estimation of about 1204 students) will be invited to participate. The control group will receive the usual curriculum. The intervention group will receive six weekly 90 min school-based group sessions of Happy House in addition to the usual curriculum. The primary outcome, depressive symptoms, will be measured using a locally validated version of the Centre for Epidemiologic Studies Depression Scale Revised. Secondary outcomes are mental well-being, coping self-efficacy, school connectedness, anger management and health risk behaviours. Data will be collected at recruitment, and at two weeks and six months post intervention. Mixed-effect logistic regression for the main outcome and mixed-effect linear and logistic regression models for the secondary outcomes will be conducted to estimate the effects of the intervention on the outcomes.

ETHICS AND DISSEMINATION

This trial has been approved by Monash University Human Research Ethics Committee (No. 21455) and the Institutional Review Board of the Hanoi School of Public Health (488/2019/YTCC-HD3). Dissemination of findings will include peer-reviewed publications, international and national conferences, seminar and media presentations, national policy briefings in Vietnam, local language reports and lay language summaries for participants.

TRIAL REGISTRATION NUMBERS

Registered with the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12620000088943 (3/2/2020).WHO Universal Trial Number: U1111-1246-4079.

Cost-effectiveness analysis of olanzapine and risperidone in schizophrenic patients in the Indian healthcare settings of Andhra Pradesh, India

Objectives

The prevalence of schizophrenia in Andhra Pradesh, India is 279, and the crude disability-adjusted life year is 177 per 100 thousand people. It is one of the major mental health problems of the state. However, there is a dearth of information regarding the pharmacoeconomics of schizophrenia treatment. The purpose of this study was to evaluate the cost and effectiveness of the two most commonly used drugs olanzapine and risperidone for schizophrenia.

Methods

A prospective observational study was carried out in a tertiary care teaching hospital (Department of psychiatry) for a period of 1 year among 124 schizophrenia patients. The data were collected in a specially designed patient data form, and the cost and effectiveness of the treatment were evaluated. Then, the ICER for olanzapine 71 and risperidone 53 users were calculated. Sensitivity analysis was run creating a model to identify uncertainties and its effect on the results.

Key findings

The mean cost per patient for olanzapine was 89.96 USD, and risperidone was 85.56 USD for 8 weeks from the start of the treatment. The incremental effects and value of the treatment score with the Positive and Negative Syndrome Scale (PANSS) for olanzapine (27.33) were greater than that of risperidone (20.38). The cost (USD) per PANSS reduction for olanzapine was 3.29 and risperidone was 4.20. The overall incremental cost-effectiveness ratio (ICER) of olanzapine compared to risperidone was 0.63 USD/PANSS.

Conclusion

The results showed that olanzapine was a cost-effective drug and an alternative to risperidone in the Indian healthcare settings. With further revision and validation, the cost-effectiveness outcome of olanzapine and risperidone can be used to inform any comprehensive healthcare financing mechanism in Indian healthcare settings.

One-Year Outcome and Adherence to Pharmacological Guidelines in First-Episode Schizophrenia: Results From a Consecutive Cohort Study

BACKGROUND

Remission in schizophrenia is difficult to achieve. Antipsychotic drugs are critical in the treatment of schizophrenia. International guidelines for the pharmacological treatment of schizophrenia recommend a 3-step algorithm with clozapine being the third-line antipsychotic agent. This study investigated the 1-year outcome and the application of the guidelines for the pharmacological treatment of nonremitted first-episode schizophrenia (FES) patients during the first year of follow-up.

METHODS

A sample of 78 FES patients from the Norwegian TIPS (Early Treatment and Intervention in Psychosis) 2 study was assessed at the end of the first year of follow-up. The symptom remission criteria were those defined by the Remission in Schizophrenia Working Group. The adherence to the pharmacological guidelines was assessed by reading the medical files and by a digital search of the words "clozapine," "klozapin," and "Leponex" in the hospital electronic data system.

RESULTS

The majority (n = 53, 67.9%) of the patients included were nonremitted at the 1-year follow-up. The majority of the nonremitted patients received either none (7.5%), one (56.6%), or 2 types (15.1%) of antipsychotic drugs during the first year of follow-up. Only 2 (3.8%) received treatment with clozapine, and 3 (5.7%) in total were offered it.

CONCLUSIONS

For our FES sample, there was a low 1-year remission rate and a poor adherence to the pharmacological guidelines. Higher adherence to treatment guidelines with a more intensified antipsychotic treatment, which in some cases will include clozapine, will enhance the quality of treatment and may enhance the rates of remission for schizophrenia.

Exploring non-stationarity patterns in schizophrenia: neural reorganization abnormalities in the alpha band

OBJECTIVE

The aim of this paper was to characterize brain non-stationarity during an auditory oddball task in schizophrenia (SCH). The level of non-stationarity was measured in the baseline and response windows of relevant tones in SCH patients and healthy controls.

APPROACH

Event-related potentials were recorded from 28 SCH patients and 51 controls. Non-stationarity was estimated in the conventional electroencephalography frequency bands by means of Kullback-Leibler divergence (KLD). Relative power (RP) was also computed to assess a possible complementarity with KLD.

MAIN RESULTS

Results showed a widespread statistically significant increase in the level of non-stationarity from baseline to response in all frequency bands for both groups. Statistically significant differences in non-stationarity were found between SCH patients and controls in beta-2 and in the alpha band. SCH patients showed more non-stationarity in the left parieto-occipital region during the baseline window in the beta-2 band. A leave-one-out cross validation classification study with feature selection based on binary stepwise logistic regression to discriminate between SCH patients and controls provided a positive predictive value of 72.73% and negative predictive value of 78.95%.

SIGNIFICANCE

KLD can characterize transient neural reorganization during an attentional task in response to novelty and relevance. Our findings suggest anomalous reorganization of neural dynamics in SCH during an oddball task. The abnormal frequency-dependent modulation found in SCH patients during relevant tones is in agreement with the hypothesis of aberrant salience detection in SCH. The increase in non-stationarity in the alpha band during the active task supports the notion that this band is involved in top-down processing. The baseline differences in the beta-2 band suggest that hyperactivation of the default mode network during attention tasks may be related to SCH symptoms. Furthermore, the classification improved when features from both KLD and RP were used, supporting the idea that these measures can be complementary.

Long-term follow-up of clozapine prescribing

OBJECTIVE

Clozapine is uniquely effective for treatment-resistant schizophrenia, and so treatment continuation is essential. We aimed to identify factors associated with an increased likelihood of clozapine discontinuation in a cohort of patients in South East London.

METHODS

We gathered demographic and treatment information such as duration of illness and antipsychotic treatment history. t-tests, chi-square tests and binary logistic regression were used to compare patients who continued and discontinued clozapine during the study and to identify predictor variables for discontinuation.

RESULTS

Out of the study population of 133 patients, 48 discontinued clozapine at least once during the study period. The majority of these (75%) stopped treatment within the first 4 years of clozapine therapy. Age, ethnicity, diagnosis and antipsychotic treatment history were not predictive of the risk of clozapine discontinuation. However, male patients were more likely to stop taking clozapine (χ² = 6.81, p = 0.009). The odds of discontinuing clozapine were 2.15 times higher for male patients. The most common reason for discontinuation was patient refusal of treatment.

CONCLUSION

We found that patients who discontinue clozapine are more likely to be male, but no other demographic variable was found to predict treatment cessation. Discontinuation usually occurred due to patient refusal of treatment.

Long-Acting Injectable Antipsychotics in Schizophrenia: Literature Review and Practical Perspective, with a Focus on Aripiprazole Once-Monthly

INTRODUCTION

Prevention of relapse is a major challenge in schizophrenia, a disease characterized by poor adherence to antipsychotic medication leading to multiple rehospitalizations and a substantial burden-of-care.

METHODS

We narratively review published clinical data from the development of long-acting injectable (LAI) formulations of antipsychotic drugs and examine the comparative effectiveness of oral versus LAIs in schizophrenia, with a focus on the second-generation LAI antipsychotic aripiprazole. Evidence is presented from studies with naturalistic/pragmatic as well as explanatory trial designs, supported by the clinical experience of the authors.

RESULTS

LAI formulations of antipsychotic drugs offer advantages over oral medications and there is good evidence for their use as a first-choice treatment and in younger patients. Key phase III studies have shown aripiprazole once-monthly 400 mg (AOM 400) to be effective and well tolerated, with high rates of adherence and low rates of impending relapse. In a recent randomized trial with a "naturalistic" study design more representative of routine clinical practice, AOM 400 was well tolerated and had significantly greater effectiveness than paliperidone LAI overall and in younger patients aged ≤35 years.

CONCLUSION

Results across the "full spectrum" of efficacy in traditional clinical trials as well as those encompassing the concept of effectiveness in a more naturalistic setting of real-life clinical practice support the use of AOM 400 as a valid long-term treatment option in schizophrenia overall, as well as earlier in the treatment course, and not solely in situations of poor adherence or when oral antipsychotics have failed.

How gender affects the pharmacotherapeutic approach to treating psychosis - a systematic review

INTRODUCTION

The effectiveness, effective dosages and side effect profiles of antipsychotic medication differ significantly between the sexes. Areas covered: We present a systematic review of gender-differences in the treatment of psychosis focusing on randomized, controlled trials and meta-analyses. Expert opinion: Despite many years of research, the database on gender-differences affecting the pharmacotherapeutic approach to treating psychosis is insufficient. Currently, the US National Institute of Health encouraged the enrolment of female participants in federally supported phase III clinical trials to increase the data available of female patients. Emerging evidence points to a superior antipsychotic response in women, with men requiring higher dosages. In general, women metabolize drugs differently, resulting in side effects occuring more frequently when compared to men. In any case, women require electrocardiograms or bone density scans as well as diabetes and cardiovascular workups when treated with antipsychotics. Dose adjustments during the menstrual cycle (e.g. to raise antipsychotic doses premenstrually) should be considered. First-generation antipsychotics, drugs that are known to prolong QTc interval and increase prolactin levels should be avoided in postmenopausal female patients. Furthermore, the effects of antipsychotics during pregnancy and breastfeeding have been investigated insufficiently, and more research is urgently needed.

Fostering secure attachment in low- and middle-income countries: Suggestions for evidence-based interventions

Children struggling with the effects of trauma in low- and middle-income countries (LMIC) face a substantial mental health resource gap that limits their opportunities for positive psychosocial development. Multidisciplinary interventions working to close this gap may benefit from incorporating an empirically supported treatment (EST) into their approach that targets a universal mechanism implicated in resilience, like attachment. ESTs should be selected based on their level of empirical support and cultural adaptability, and then modified on the basis of qualitative evaluations conducted with the local population and stakeholders. This paper will provide an overview of attachment as a mechanism of resilience, a critical analysis of existing attachment-based ESTs, and recommendations for overcoming EST implementation barriers in LMIC.

A Role for Estrogen in Schizophrenia: Clinical and Preclinical Findings

Gender differences in schizophrenia have been extensively researched and it is being increasingly accepted that gonadal steroids are strongly attributed to this phenomenon. Of the various hormones implicated, the estrogen hypothesis has been the most widely researched one and it postulates that estrogen exerts a protective effect by buffering females against the development and severity of the illness. In this review, we comprehensively analyse studies that have investigated the effects of estrogen, in particular 17β-estradiol, in clinical, animal, and molecular research with relevance to schizophrenia. Specifically, we discuss the current evidence on estrogen dysfunction in schizophrenia patients and review the clinical findings on the use of estradiol as an adjunctive treatment in schizophrenia patients. Preclinical research that has used animal models and molecular probes to investigate estradiol's underlying protective mechanisms is also substantially discussed, with particular focus on estradiol's impact on the major neurotransmitter systems implicated in schizophrenia, namely, the dopamine, serotonin, and glutamate systems.

Understanding the direct and indirect costs of patients with schizophrenia

BACKGROUND

Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries.

OBJECTIVE

The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them.

RESULTS

Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives.

CONCLUSIONS

Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Understanding the direct and indirect costs of patients with schizophrenia

Background : Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries. Objective : The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them. Results : Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives. Conclusions : Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Clinical effectiveness and resource utilization of paliperidone ER for schizophrenia: Pharmacoepidemiologic International Longitudinal Antipsychotic Registry (PILAR)

OBJECTIVE

To document prescribing patterns in clinical practice and assess long-term outcomes related to initiation of paliperidone ER and other oral antipsychotics among patients with schizophrenia in a naturalistic setting.

RESEARCH DESIGN AND METHODS

An international, non-interventional, naturalistic study of adult patients (≥18 years) with schizophrenia. Patients were assigned to the relevant treatment group (paliperidone ER or 'all other oral antipsychotics') after switching to, or initiating, oral antipsychotic treatment. Retrospective 12 month data collection was followed by 12 month prospective data collection, with 3-monthly assessments. The primary endpoint was time to all-cause discontinuation of new medication. Secondary endpoints included Clinical Global Impression-Severity (CGI-S) score, Clinical Global Impression-Schizophrenia (CGI-SCH) score, Personal and Social Performance (PSP) score, health-related quality of life (HR-QoL) and quality of sleep, evaluation of healthcare resource utilization and patient's treatment satisfaction.

RESULTS

A total of 4051 patients were included in the intent-to-treat (ITT) analysis set. All-cause study discontinuation rates were comparable between the paliperidone ER group (16.8%) and the 'all other oral antipsychotics' group (15.5%). There was no difference in the time to discontinuation of newly initiated antipsychotic treatments between paliperidone ER and 'all other oral antipsychotics' groups. Paliperidone ER was associated with greater improvements from baseline to endpoint in both the PSP scale score (+14.2 vs +13.1, p = 0.041) and the physical component of quality of life (SF-12 Physical scores; +3.9 vs +2.9, p = 0.003) compared to 'all other oral antipsychotics'. Improvements in mean CGI-S score, CGI-SCH score, HR-QoL, quality of sleep and daytime drowsiness, as well as patients' treatment satisfaction were comparable between treatment groups. The incidence of adverse events was comparable between groups.

CONCLUSIONS

This study provides valuable data on the prescribing habits and treatment outcomes associated with use of paliperidone ER in everyday clinical practice, and supports previous findings of the favorable functional improvement and treatment satisfaction associated with paliperidone ER.

CLINICAL TRIAL REGISTRATION

NCT00696813; R076477SCH4015 (Register of German Association of Research-based Pharmaceutical Companies [VFA] http://www.vfa.de/de/arzneimittel-forschung/datenbanken-zu-arzneimitteln/nisdb).

Risperidone long-acting injection in the treatment of schizophrenia spectrum illnesses: A retrospective chart review of 19 patients in the Vancouver Community Mental Health Organization (Vancouver, Canada)

BACKGROUND

Schizophrenia is a chronic debilitating disease that affects ~110,000 Canadians (0.55% lifetime prevalence). Risperidone long-acting injection (RLAI) is the first injectable, long-acting, atypical antipsychotic drug marketed in Canada.

OBJECTIVE

The aim of this study was to assess the clinical effectiveness and hospitalization rates of patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder treated with RLAI in a community mental health care setting.

METHODS

Data were collected between August 1, 2006 and September 30, 2006 via a retrospective chart review of outpatients diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder who received treatment from 1 of the 8 mental health teams within the Vancouver Community Mental Health Organization (VCMHO) in Vancouver, British Columbia, Canada. Collected data included: frequency and duration of institutional care, discharge and relapse rates, demographic variables, diagnosis history, RLAI medication history, and history of other medications. The overall severity of symptoms before and after RLAI treatment and the improvement in symptoms during treatment were evaluated using the Clinical Global Impression Scales for severity (CGI-S)(1 = not ill to 7 = extremely ill) and improvement (CGI-I)(1 = very much improved to 7 = very much worse).

RESULTS

Forty-four patients were identified as having received RLAI. The charts of 19 patients (10 men, 9 women; mean [SD] age at time of chart audit, 36.7 [11.7] years; mean [SD] age at primary diagnosis, 23.6 [7.4] years; race: white, 10 [52.6%]; Asian, 6 [31.6%]; American Indian, 1 [5.3%]; black, 1 [5.3%]; other, 1 [5.3%]) were included in the analysis. The majority of patients (78%) had been treated with another antipsychotic drug prior to treatment with RLAI: risperidone (77%), quetiapine (47%), zuclopenthixol (43%), olanzapine (43%), and loxapine (17%). Mean (SD) CGI-S Scale score declined significantly from 5.29 (1.3) before treatment initiation to 3.05 (1.0) posttreatment (P < 0.001). Mean (SD) CGI-I Scale score was 2.58 (0.71) (P < 0.001); 94% of patients had a CGI-I score ≤3. Mean (SD) duration of hospitalization decreased significantly from 15.7 (19.7) days before treatment to 2.4 (6.0) days after treatment (P < 0.05). Mean (SD) number of hospializations also decreased significantly from 2.0 (1.8) before treatment to 0.5 (1.3) after treatment (P < 0.01).

CONCLUSIONS

The results of this pilot study suggest that use of the atypical-antipsychotic medication RLAI significantly decreased duration and rates of hospitalization, compared with baseline, in these VCMHO patients with schizophrenia spectrum illnesses.

Long-acting injectables and risk for rehospitalization among patients with schizophrenia in the home care program in Taiwan

We aimed at evaluating the relationship between medication and treatment effectiveness in a home care setting among patients with schizophrenia. Patients with schizophrenia hospitalized between 2004 and 2009 with a primary International Classification of Diseases, Ninth Revision, Clinical Modification code of 295 were identified from Psychiatric Inpatient Medical Claims Data released by the National Health Research Institute in Taiwan. Patients who joined the home care program after discharge and were prescribed long-acting injection (LAI) (the LAI group) or oral antipsychotic medications (the oral group) were included as study subjects. The final sample for the study included 810 participants in the LAI group and 945 in the oral group. Logistic regression was performed to examine the independent effect of LAI medication on the risk for rehospitalization within the 12-month observation window after controlling for patient and hospital characteristics and propensity score quintile adjustment. The unadjusted odds ratio for rehospitalization risk was 0.80 (confidence interval, 0.65-0.98) for the LAI group compared to the oral group. The adjusted odds ratio was further reduced to 0.78 (confidence interval, 0.63-0.97). Results remained unchanged when the propensity score quintiles were entered into the regression for further adjustment. In a home care setting, patients treated with long-acting antipsychotic agents are at a significantly lower risk for psychiatric rehospitalization than those treated with oral medication. Consequently, LAI home-based treatment for the prevention of schizophrenia relapse may lead to substantial clinical and economic benefits.

Cost analysis of risperidone long-acting injection in the treatment of schizophrenia and schizoaffective disorders in Hong Kong: an approach using generalised estimating equations

Schizophrenia is one of the most expensive psychiatric illnesses. This study compared retrospectively health-care resources consumed 12 months before and 24 months after risperidone long-acting injection (RLAI) treatment in Hong Kong. A mirror-image analysis was conducted using data (N=191) from three public hospitals in Hong Kong from 2003 to 2007. The main outcome measure was hospitalisation cost. Other secondary outcomes such as hospitalisation episodes, outpatient visits and adverse events were also compared. A predictive model was established using linear regression based on generalised estimating equations. Analysis showed that RLAI was associated with a reduction in hospitalisation cost by HK$10,001,390 (24.7%) (HK$40,418,694 vs. HK$30,417,303; P-value <0.05). Days of hospitalisation were reduced by 1538 days (10.1%) (15,271 vs. 13,733; P-value <0.05). The predictive model estimated that the hospitalisation cost of patients using RLAI was only 11.1% (3.1-3.93%, 95% confidence interval (CI)) compared to those receiving conventional antipsychotics combined with oral risperidone. Cost of hospitalisation was significantly reduced after RLAI therapy. However, results should be considered as indicative or suggestive only, due to potential channelling bias where certain drug regimens are preferentially prescribed to patients with particular conditions. The findings from our study may be useful in health-care decision making considering treatment options for schizophrenia in resource-limited settings.

Long-acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations

BACKGROUND

Current guidelines suggest specific criteria for oral or long-acting injectable antipsychotic drugs (LAIs). This review aims to describe the demographic and clinical characteristics of the ideal profile of the patient with schizophrenia treated with LAIs, through the analysis of nonrandomized studies.

METHODS

A systematic review of nonrandomized studies in English was performed attempting to analyze the factors related to the choice and use of LAIs in daily practice. The contents were outlined using the Cochrane methods for nonrandomized studies and the variables included demographic as well as clinical characteristics. The available literature did not allow any statistical analysis that could be used to identify the ideal profile of patients with schizophrenia to be treated with LAIs.

RESULTS

Eighty publications were selected and reviewed. Prevalence of LAI use ranged from 4.8% to 66%. The only demographic characteristics that were consistently assessed through retrieved studies were age (38.5 years in the 1970's, 35.8 years in the 1980's, 39.3 years in the 1990's, to 39.5 years in the 2000's) and gender (male > female).Efficacy was assessed through the use of various symptom scales and other indirect measurements; safety was assessed through extrapyramidal symptoms and the use of anticholinergic drugs, but these data were inconsistent and impossible to pool. Efficacy and safety results reported in the different studies yielded a good therapeutic profile with a maximum of 74% decrease in hospital admissions and the prevalence of extrapyramidal symptoms with LAIs consistently increased at 6, 12, 18, and 24 months (35.4%, 37.1%, 36.9%, and 41.3%, respectively).

CONCLUSIONS

This analysis of the available literature strongly suggests that further observational studies on patients with schizophrenia treated with LAIs are needed to systematically assess their demographic and clinical characteristics and the relationships between them and patient outcome.Besides the good efficacy and safety profile of LAIs, health care staff must also take into account the importance of establishing a therapeutic alliance with the patient and his/her relatives when selecting the most appropriate treatment. LAIs seem to be a good choice not only because of their good safety and efficacy profile, but also because they improve compliance, a key factor to improving adherence and to establishing a therapeutic alliance between patients with schizophrenia, their relatives, and their health care providers.

Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia

The current study aimed at exploring the relationship between self-stigma, readiness for change and psychosocial treatment adherence among individuals with schizophrenia. Between March 2007 and January 2008, 105 adults with schizophrenia were recruited for this cross-sectional study. Face-to-face interviews were conducted to assess participants' level of self-stigma, readiness for change, insight, and general self-efficacy. The corresponding case therapists reported participants' level of treatment adherence, psychopathology, and global functioning. Findings of stepwise multiple regression suggested that individuals with higher global functioning, better readiness for action, and lower level of self-stigma demonstrated better treatment participation. Individuals with lesser severity of psychiatric symptoms and female participants had better treatment attendance. The results of discriminant function analysis showed the combined score of self-stigma, stages of change, and global functioning measures correctly classified 76.2% participants into adherent/nonadherent group membership. Suggestions for further studies and development of self-stigma reduction program to facilitate recovery and treatment adherence were made.

Evaluation of health services use following the initiation of risperidone long-acting therapy among schizophrenia patients in the veterans health administration

WHAT IS KNOWN AND OBJECTIVE

The introduction of long-acting injection antipsychotic agents has been associated with better treatment persistence and better subsequent patient outcomes. However, limited empirical data are available on patient outcomes resulting from the initiation of long-acting injectable antipsychotic agents. In this study, we assessed patterns of health-care utilization following the initiation of risperidone long-acting therapy (RLAT), the first and only second generation long-acting injectable antipsychotic agent, in schizophrenia patients within the Veterans Health Administration.

METHODS

Patients were identified if they initiated RLAT between 1 October 2005 and 30 September 2006, were ≥ 18 years of age at the time of initiation, and had at least four injections following the initiation. Paired t-tests and McNemar tests were used to compare patterns of health services use during 12 months pre- and post-initiation.

RESULTS AND DISCUSSION

Among 924 eligible study subjects, about 94% were male with mean age of 51·1 years and as high as 60% had >3 and 29% had >5 comorbid conditions. The initiators of RLAT had an average of 17·3 (SD ± 9·7) injections within the 12 months following the initiation, with an average of 14 days between injections. Between the pre- and post-initiation periods, although the number of psychiatric-related outpatient visits increased from 24·6 to 39·1 (P < 0·001), the number of psychiatric hospitalizations decreased from 1·4 to 1·0 (P < 0·001) with an average length of stay reducing from 20 to 14 days (P < 0·001). The percentage of patients who experienced at least one or two psychiatric-related hospitalizations decreased from 68·9% to 45·7% (P < 0·001) and from 34·9% to 24·4% (P < 0·001), respectively.

WHAT IS NEW AND CONCLUSION

Despite the values of RLAT in treating patients with schizophrenia, RLAT is largely underutilized in routine clinical practice. This observation highlights the importance for future research to ascertain the cost-effectiveness of initiating RLAT, especially the extent to which medication adherence influences the prescription pattern of RLAT and subsequent costs of initiating RLAT.

At-risk mental state (ARMS) detection in a community service center for early attention to psychosis in Barcelona

AIM

To describe the strategy and some results in at-risk mental state (ARMS) patient detection as well as some of the ARMS clinical and socio-demographical characteristics. The subjects were selected among the patients visited by an Early Care Equipment for patients at high risk of psychoses, in Barcelona (Spain) during its first year in operation.

METHODS

Descriptive study of the community-team relations, selection criteria and intervention procedure. Description of patient's socio-demographic and symptomatic characteristics according to the different instruments used in detection and diagnoses, taking account of four principal origins of referrals: mental health services, primary care services, education services and social services.

RESULTS

Twenty of 55 referred people fulfilled the at-risk mental state criteria, showing an incidence of 2.4 cases per 10,000 inhabitants. They were mainly adolescent males referred from health, education and social services. Overall, negative symptoms were predominant symptoms and the more frequent specific symptoms were decrease of motivation and poor work and school performance, decreased ability to maintain or initiate social relationships, depressed mood and withdrawal.

CONCLUSIONS

It is possible to detect and to provide early treatment to patients with prodromal symptoms if the whole matrix of the community--including the social services--contributes to the process. The utilization of a screening instrument and a two-phase strategy--the second carried out by the specialized team--seems to be an appropriate approach for early psychosis and ARMS detection.

Relapse and long-acting injectable risperidone: a 1-year mirror image study with a national claims database in Taiwan

OBJECTIVES

The development of long-acting, injectable atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The study was designed to assess whether a risperidone long-acting injection (RLAI) is associated with reduced relapses and service utilization in the real world.

METHODS

The Psychiatric Inpatients Medical Claims dataset was used for the analysis. It is a longitudinal dataset that includes the National Health Insurance claims of service uses by a cohort of mentally ill patients. The inclusion criteria for this analysis were patients who: 1) had available information for at least 12 months after the first dose of RLAI; 2) had a primary diagnosis of schizophrenia; and 3) were regularly treated with RLAI for at least 1 year. Patients who accumulatively received at least 75-mg RLAI per 3-month period were considered to be undergoing regular treatment. Wilcoxon signed rank tests were performed to compare differences in numbers of acute admissions, hospital days, emergency room visits, and relapses between the pre- and post-RLAI periods in this 1-year mirror-image study.

RESULTS

In total, 108 patients were eligible for analysis. Significant reductions in the total annual numbers of acute hospital admissions by 55% (80 vs. 36, P = 0.0003), hospital days by 48% (4106 vs. 2126, P = 0.0021), and relapses by 54% (115 vs. 53, P = 0.0005) were observed. A reduction of emergency room visits was also observed, but did not reach statistical significance (55 vs. 25, P = 0.1255).

CONCLUSIONS

This 1-year mirror-image analysis with claims-based data demonstrated that RLAI treatment was associated with reductions in relapses and hospital service utilization.

An economic evaluation of aripiprazole vs olanzapine adapted to the Italian setting using outcomes of metabolic syndrome and risk for diabetes in patients with schizophrenia

OBJECTIVE

To evaluate the cost-effectiveness of aripiprazole and olanzapine in patients with schizophrenia.

METHODS

Data from a double-blind, randomized study demonstrating the efficacy of aripiprazole and olanzapine were used to observe new incidence of metabolic syndrome (26-week therapy) and to model the risk of developing diabetes over 5 years of therapy. Cumulative incidence of metabolic syndrome was compared using Kaplan-Meier estimates; diabetes risk was estimated using a validated, general population risk-prediction model. Economic assessment was conducted from the third-party payer perspective by evaluating pharmacotherapy costs of treating schizophrenia and medical costs associated with treating adverse metabolic effects in a hypothetical cohort of 1000 patients. Resource utilization and costs were derived from the underlying study and published data, using a 3% rate to discount costs and benefits.

RESULTS

For the patients switched from olanzapine to aripiprazole, treatment with aripiprazole was a dominant cost-saving strategy. Use of aripiprazole avoided 184 events of metabolic syndrome over 26 weeks of treatment, contributing to a real-world (RW) cost savings of euro2.53 per patient and a total savings of approximately euro465.52 over a 5-year period. For the same cohort, the risk-prediction model indicated that 34 occurrences of diabetes could be avoided over 5 years, corresponding to a RW cost savings of euro56.86 per patient and a total saving of approximately euro1,933.24. These savings reflect avoided costs in treating adverse metabolic events and comparable costs in the acquisition of aripiprazole.

CONCLUSIONS

Maintenance aripiprazole therapy offers medical and economic benefits over olanzapine, reflected by reduced incidence of metabolic syndrome and diabetes and associated lower costs.

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.

The functionality and economic costs of outpatients with schizophrenia in Taiwan

The aims of this study were to investigate the economic costs of outpatients with schizophrenia in Taiwan, and to survey factors that influence the costs. The direct costs were defined as the costs associated with psychiatric services and other medical treatment. The indirect costs were estimated using the Human Capital Method. Patients' characteristics, including sex, age, duration of education, duration of illness, frequency of hospitalization, type of antipsychotic medication, severity of extrapyramidal side effects caused by antipsychotic medication, and global functions, were used to estimate the costs. The average annual total cost was approximately US$16,576 per patient. The direct and indirect costs were 13% and 87% of the total costs, respectively. Among the direct costs, folk therapy ranked third, just behind prescription drugs and acute ward hospitalization. The productivity loss of both the patients and their caregivers was the major component of the indirect costs. The patient's age and global functions had a significantly negative relationship with the direct costs. The severity of extrapyramidal side effects, type of antipsychotic medication, and the patient's illness duration correlated positively with the indirect costs, while the patient's global function correlated negatively with the indirect costs. Overall, the indirect costs of treating schizophrenia were higher than the direct costs. Improving patients' functionality and decreasing caregivers' burden are essential to reducing costs.

Child and adolescent mental disorders: the magnitude of the problem across the globe

OBJECTIVE

Describe objectively the global gaps in policy, data gathering capacity, and resources to develop and implement services to support child mental health.

METHODS

Report on the World health Organization (WHO) child and adolescent mental health resources Atlas project. The Atlas project utilized key informants and was supplemented by studies that focused on policy. This report also draws on current epidemiological studies to provide a context for understanding the magnitude of the clinical problem.

RESULTS

Current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from a disabling mental illness; that suicide is the third leading cause of death among adolescents; and that up to 50% of all adult mental disorders have their onset in adolescence. While epidemiological data appears relatively uniform globally, the same is not true for policy and resources for care. The gaps in resources for child mental health can be categorized as follows: economic, manpower, training, services and policy. Key findings from the Atlas project include: lack of program development in low income countries; lack of any policy in low income countries and absent specific comprehensive policy in both low and high income countries; lack of data gathering capacity including that for country-level epidemiology and services outcomes; failure to provide social services in low income countries; lack of a continuum of care; and universal barriers to access. Further, the Atlas findings underscored the need for a critical analysis of the 'burden of disease' as it relates to the context of child and adolescent mental disorders, and the importance of defining the degree of 'impairment' of specific disorders in different cultures.

CONCLUSIONS

The recent finding of substantial gaps in resources for child mental health underscores the need for enhanced data gathering, refinement of the economic argument for care, and need for innovative training approaches.

Costs of schizophrenia during 5 years

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Factors affecting outcome in schizophrenia and their relevance for psychopharmacological treatment

A major focus of current treatment research in schizophrenia is the determinants of long-term outcome, including functional outcome and general medical well being, rather than just specific domains of psychopathology such as positive and negative symptoms, mood symptoms, and cognitive impairment. This focus does not negate the importance of the latter issues but sees them as factors contributing to long-term outcome to variable extents. A long-term treatment focus facilitates a more clinically relevant assessment of benefits versus risks of available treatments. For instance, atypical antipsychotic drugs as a group have clear advantages for several important domains of efficacy that may influence long-term outcome, but are also more expensive over the long term. Use of some agents may also result in deleterious physical health consequences as well as large additional costs over the long term owing to metabolic adverse effects. The present paper focuses on several key issues in schizophrenia which are important determinants of long-term outcome in schizophrenia, or influence choice of antipsychotic drugs, or both, including: (i) duration of untreated psychosis; (ii) impact of relapse on long-term outcome; (iii) limited efficacy for specific domains of psychopathology of current treatments; (iv) mortality owing to suicide; and (v) mortality owing to other causes (e.g. cardiovascular disease).

Economic consequences of alternative medication strategies in first episode non-affective psychosis

Background

Maintenance treatment appears to be successful in preventing relapses in first episode psychosis, but is also associated with side effects. Guided discontinuation strategy is a less intrusive intervention, but may lead to more relapses. In the current economic evaluation, costs and health outcomes of discontinuation strategy will be compared with the results of maintenance treatment in patients with remitted first episode psychosis.

Method

The study was designed as a randomised clinical trial. In total 128 patients were prospectively followed for 18 months after six months of stable remission. The economic evaluation was conducted from a societal perspective. Quality-adjusted life years (QALYs) were used as primary health outcome in the economic evaluation. Relapse rates were assessed in addition to various other secondary outcomes.

Results

There were no relevant differences in mean costs between groups during the study. Total costs were largely influenced by costs related to admissions to psychiatric hospitals. No differences between groups were found for QALY results.

Conclusions

There were no indications that either of the examined interventions is superior to the other in terms of costs or QALY results. Additional results indicated that the relapse rate in discontinuation strategy was twice as high, but without an increase in hospital admissions or negative consequences on other clinical outcomes. For a minority of remitted first episode patients, guided discontinuation strategy may offer a feasible alternative to maintenance treatment.

Long-acting risperidone injection: efficacy, safety, and cost-effectiveness of the first long-acting atypical antipsychotic

OBJECTIVE

To review the pharmacokinetics, efficacy, safety, and cost-effectiveness of long-acting risperidone.

METHODS

Studies published between January 2000 and October 2006 evaluating the pharmacokinetics, efficacy, safety, and cost-effectiveness of long-acting risperidone were reviewed, as identified from literature searches using Medline and EMBASE. Abstracts and posters on long-acting risperidone presented at key psychiatry congresses and available in the public domain during this time period were also reviewed.

RESULTS

The unique pharmacokinetic profile of long-acting risperidone is derived from the encapsulation of risperidone in a glycolide/lactide matrix in the form of microspheres such that after a single intramuscular injection, significant plasma levels of the drug are achieved after week 3. Steady state, after repeated administration at 2-week intervals, is achieved after 3 injection cycles. Short- and long-term studies have demonstrated that long-acting risperidone (25, 37.5, or 50 mg) is both efficacious and well tolerated in a wide variety of patients with schizophrenia and related psychoses. Most patients can be switched from other oral and long-acting antipsychotic agents without compromising efficacy and safety. Long-acting risperidone may also reduce overall healthcare costs by decreasing rates of relapse and hospitalization.

CONCLUSION

The assured delivery of an atypical antipsychotic medication with long-acting risperidone has important implications for patient compliance, maintenance of stability, consistency of treatment, and improving patient outcomes including the achievement of remission.

Cost-effectiveness of different clinical interventions for reducing the burden of schizophrenia in Spain

OBJECTIVE

To estimate the cost-effectiveness of interventions for reducing the burden of schizophrenia in Spain.

METHOD

The study examined the cost-effectiveness of seven different types of clinical interventions at the level of Spanish population: i) current situation; ii) older antipsychotics alone; iii) new antipsychotics alone (risperidone); iv) older antipsychotics plus psychosocial treatment; v) new antipsychotics plus psychosocial treatment; vi) older antipsychotics plus case management and psychosocial treatment; vii) new antipsychotics plus case management and psychosocial treatment.

RESULTS

Interventions based on the combination of haloperidol with psychosocial treatment or psychosocial treatment plus case management proved to be the most efficient strategies.

CONCLUSION

The relatively modest additional cost of concurrent psychosocial treatment has significant health gains, thereby making such a combined strategy for schizophrenia more cost-effective than pharmacology alone.

Anti-psychotics adherence among out-patients with schizophrenia in Hong Kong

OBJECTIVE

Adherence to antipsychotic treatment is an important aspect of long term management of schizophrenia and other related psychotic disorders. The evaluation of adherence is often difficult in clinical settings. This study compared patients self-reports and clinician judgment of adherence behavior and explored their relationship with attitudes toward taking medication.

METHODS

Clinician rated questionnaire and matching patient self rated questionnaires were administered to 508 consecutive outpatients and their clinicians in four hospital clinic sites in Hong Kong. Items in the questionnaires address adherence behaviors as well as attitudes toward medication. In addition, clinicians also estimate the presence of factors unfavorable to adherence such as substance abuse, cognitive impairments etc.

RESULTS

Non-adherence was reported in at least 26% of patients. Clinician's detection of non-adherence behaviors achieved relative high specificity (0.84) but has low sensitivity (0.33). A logistic regression analysis on patients' decision to stop medication revealed that significant predictors include patients' reported lack of perception from the benefits of medication, patients' reported negative feelings associated with regular medication and younger age.

CONCLUSION

Non-adherence is a widespread phenomenon affecting a significant proportion of outpatients under treatment. Clinicians have relatively low sensitivity in detecting which patients are non-adherent. Non-adherence behavior is predicted by level of awareness of illness, perceived benefits of medication, negative feelings toward medication and age.

A wellness class for inpatients with psychotic disorders

OBJECTIVE

The purpose of this project was to educate inpatients with psychotic disorders, many of whom were taking second-generation antipsychotics, about lifestyle changes they can make to combat weight gain.

METHOD

All inpatients on a Veterans Affairs acute inpatient schizophrenia treatment unit were invited to a 30-minute, didactic presentation given by a medical student and a psychology student under the supervision of the primary investigator. The topics covered included the health benefits of maintaining an ideal body weight by selecting foods according to the USDA Food Pyramid, determining adequate food portions, choosing healthy meals outside the home, and beginning and adhering to an exercise program. Subjects completed a 13-item quiz concerning their knowledge of food and nutrition before and after the presentation to determine its efficacy in teaching patients the material.

RESULTS

Fifty patients completed both the pre- and post-presentation tests. The mean percentage of correct answers on the pre-test was 85.6%, which rose to 89.3% on the post-test. This difference of 3.7% was statistically significant (t = 2.43, df = 49, p < 0.02), and the mean percent of improvement was 6.1%.

CONCLUSIONS

This study demonstrates that psychotic individuals are able to benefit from educational presentations about nutrition and a healthy lifestyle. A statistically significant improvement in test scores suggests that subjects gained an understanding of basic concepts related to food choices and fitness.

Pharmacoeconomic evaluation of schizophrenia in Taiwan: model comparison of long-acting risperidone versus olanzapine versus depot haloperidol based on estimated costs

Antipsychotics are the keystone in schizophrenia treatment. Although the benefits of the new generation of antipsychotics has been demonstrated over the last decade, the issues of patient compliance and higher purchasing price of atypical antipsychotics remain unresolved. Risperidone is the only atypical antipsychotic agent with long-acting formulation. Long-acting risperidone is a water-based injection and it has been associated with a low level of pain. The aim of the present study was to test whether an improvement in compliance with the use of a long-acting risperidone, compared with olanzapine and depot haloperidol, can increase the effectiveness and the cost-effectiveness indexes. An economic comparison model with decision tree, rather than a prospective design with real clinical drug trial, was applied. The unit cost for each medical procedure was obtained from the claimed-database of the Bureau of National Health Insurance in Taiwan. An executive committee simulated the incidence of extrapyramidal side-effects and proposed a therapeutic model for each strategy based on a literature review. The probabilities of treatment response of different agents and those of different mental health states were estimated by the executive committee and 10 senior psychiatrists who were randomly selected. Sensitivity analysis was performed for drug cost-effectiveness and compliance improvement for using long-acting risperidone. The results showed that long-acting risperidone is more cost-effective than either olanzapine or depot haloperidol for treating schizophrenia patients whose conditions are stable and whose illness duration ranges from 1 to 5 years. The comparison model with the Kaplan-Meier decision tree may serve as an alternative to prospectively designed studies for cost-effectiveness of atypical antipsychotics.

Size of burden of schizophrenia and psychotic disorders

Schizophrenia is a severe mental disorder characterised by fundamental disturbances in thinking, perception and emotions. More than 100 years of research have not been able to fully resolve the puzzle that schizophrenia represents. Even if schizophrenia is not a very frequent disease, it is among the most burdensome and costly illnesses worldwide. It usually starts in young adulthood. Life expectancy is reduced by approximately 10 years, mostly as a consequence of suicide. Even if the course of the illness today is considered more favourable than it was originally described, it is still only a minority of those affected, who fully recover. The cumulative lifetime risk for men and women is similar, although it is higher for men in the age group younger than 40 years. According to the Global Burden of Disease Study, schizophrenia causes a high degree of disability, which accounts for 1.1% of the total DALYs (disability-adjusted life years) and 2.8% of YLDs (years lived with disability). In the World Health Report [The WHO World Health Report: new understanding, new hope, 2001. Geneva], schizophrenia is listed as the 8th leading cause of DALYs worldwide in the age group 15-44 years. In addition to the direct burden, there is considerable burden on the relatives who care for the sufferers. The treatment goals for the moment are to identify the illness as early as possible, treat the symptoms, provide skills to patients and their families, maintain the improvement over a period of time, prevent relapses and reintegrate the ill persons into the community so that they can lead as normal a life as possible.

Assessment of compliance with antipsychotic treatment and resource utilization in a Medicaid population

BACKGROUND

Partial compliance with mental health medications has been associated with an increased risk of clinical worsening, relapse, and repeat hospitalization.

OBJECTIVE

The purpose of this study was to evaluate the effect of partial compliance of patients (diagnosed as having schizophrenia or bipolar disorder) with prescribed oral atypical and conventional antipsychotic agents and the corresponding impact on resource utilization.

METHODS

Patients receiving antipsychotic agents ina large Southeastern Medicaid program were grouped according to their level of compliance. Compliance was measured by the continuous, multiple interval medications available methodology. Patients were deemed partially compliant if compliance was <80%, compliant if compliance was 80% to 125%, and overly compliant if compliance was >125%. Medical costs were modeled as a function of compliance while controlling for background covariates. Logistic regression was used to model the probability of specific resource utilization.

RESULTS

A total of 7864 patients were included in this analysis. After controlling for background covariates, partially compliant patients were 49.0% (95% CI, 29.2%-71.7%) more likely than compliant patients to have an inpatient hospitalization and incurred 54.5% (P < 0.001) higher inpatient charges. Partially compliant patients were also 64% (P < 0.01) more likely than compliant patients to switch or augment therapy.

CONCLUSION

Partial compliance was associated with an increased risk of hospitalization and switching or augmentation of therapy when compared with being compliant.

Towards consensus in the long-term management of relapse prevention in schizophrenia

APPROACH TO DEVELOPING GUIDANCE: When developing guidance for the long-term management of schizophrenia, one approach is to adopt a proactive strategy that sets out clear treatment goals and strategies. This should involve a broad view being taken, embracing overall mental and physical well-being rather than simply the absence of illness. Although relapse prevention is an important goal of any long-term management strategy, there are other aspects that need to be considered, such as reintegration into society, regaining independence and quality of life.

CURRENT TREATMENT

To help achieve these goals, a range of interventions can be incorporated into long-term management strategies for schizophrenia, including pharmacological interventions, psychosocial therapies and alliance-building initiatives. The current UK National Institute for Clinical Excellence guidelines already recommend that continuous therapy should be practised using an atypical (second-generation) antipsychotic drug, whenever possible, in preference to older typical drugs. The launch of the first long-acting atypical antipsychotic is an interesting new advance that may benefit many patients with schizophrenia. Psychosocial interventions, particularly family-based therapies, as well as cognitive behavioural and compliance therapies, when used alongside antipsychotics, have been shown to reduce relapse rates dramatically and to assist in social reintegration. In addition, forging collaborative alliances with patients and their carers can help to demystify schizophrenia and empower patients to take responsibility for their illness.

CONSENSUS STATEMENT

This article outlines a consensus reached by a panel of leading UK healthcare professionals working with schizophrenia brought together to discuss long-term management strategies.

Oral risperidone with lorazepam versus oral zuclopenthixol with lorazepam in the treatment of acute psychosis in emergency psychiatry: a prospective, comparative, open-label study

Acutely psychotic patients presenting as psychiatric emergencies with aggression or agitation are often administered conventional antipsychotics intramuscularly. However, patients view intramuscular administration as coercive, and conventional antipsychotics are often associated with adverse events. In this open study, consecutive adult patients presenting with an acute exacerbation of schizophrenia or other psychotic disorder were assigned to oral risperidone 2-6 mg/day (n = 48) or oral zuclopenthixol 20-50 mg/day (n = 27) for 7-14 days. Lorazepam (either oral or intramuscular) was administered to both groups as needed. Patients were assessed regularly until day 14 or discharge. Mean Positive And Negative Syndrome Scale (PANSS) aggression scores (sum of item scores on excitement, poor impulse control, hostility and uncooperativeness) decreased steadily and similarly in both groups; the mean changes from baseline were statistically significant at days 10 and 14 and at study end-point. The mean decrease at study end-point in the PANSS component score for hostility was statistically significant in the risperidone group, but not in the zuclopenthixol group. Social Dysfunction and Aggression Scale aggression scores and Clinical Global Impression scores decreased significantly and similarly in both groups. Overall, 18.7% of patients showed minor extrapyramidal symptoms during the study, but only 16.7% of risperidone-treated patients, compared to 59.3% of zuclopenthixol-treated patients, received anti-parkinsonian medication (p < 0.001). Lorazepam was administered to all of the patients assigned to risperidone and to 89% of those assigned to zuclopenthixol. Oral risperidone plus lorazepam is a convenient, effective and well-tolerated alternative to conventional antipsychotics for the treatment of acute psychosis in emergency psychiatry.

Cost-effectiveness analysis of pharmacological treatments in schizophrenia: critical review of results and methodological issues

OBJECTIVE

To comprehensively review and critically appraise the results and the methodological issues in the cost-effectiveness literature on pharmacological treatments in schizophrenia.

METHODS

Relevant literature published in peer-reviewed journals was identified through a computer search in Medline from 1975 to 2002. Further studies were identified using reference lists and published review articles. Articles included in the review were required to evaluate both costs and clinical outcomes in the same study.

RESULTS

Seventeen articles met all inclusion criteria. Cost-effectiveness analysis (CEA) in schizophrenia spans three types of studies-randomized trial-based studies (six), retrospective cohort-based studies (six) and decision model-based studies (five). Comparing results from CEA across all types of studies in schizophrenia reveals a large ambiguity in the incremental evaluation of newer atypicals. For treatment-resistant patients, clozapine seems to produce cost saving and better outcomes compared to standard neuroleptics. However, there is tremendous uncertainty in the estimates of cost savings and clinical benefits that may prevent decision makers from making optimal policy decisions about insurance coverage and formulary design based on these results. For chronic schizophrenic patients, the results are even more ambiguous. For example, the studies based on trial settings find risperidone to cost more than haloperidol, while studies based on cohort design and decision models find risperidone to be either equivalent or lower in costs than haloperidol.

CONCLUSIONS

Further studies of cost-effectiveness need to be carried out with careful consideration of the limitations of published analyses. There are a variety of theoretical and methodological issues that are important to consider during the development of new decision models in this field.

Healthcare resource utilization during 1-year treatment with long-acting, injectable risperidone

BACKGROUND

Schizophrenia is associated with disproportionately high costs, mainly due to hospitalization rates. This study assessed healthcare resource use in patients with schizophrenia and schizoaffective disorder during treatment with long-acting risperidone.

METHODS

Patients (n = 397 [inpatients, 24%; outpatients, 76%]) receiving stable doses of an antipsychotic for >or=4 weeks were eligible to enter this 1-year, open-label study. Following a 2-week run-in period (oral risperidone 1-6 mg/day), patients received intramuscular long-acting risperidone (25 or 50 mg modal dose) every 2 weeks. Healthcare resource use in the previous 12 weeks was assessed at baseline and 12-weekly intervals.

RESULTS

Patients needing hospitalization decreased significantly and continuously from 38% during the 12 weeks before study entry to 12% during the last 12 weeks. Mean hospitalization length during the study was 30.5 days (outpatients, 4.9 days; inpatients, 110 days). This included 28 patients (7%) who remained in hospital throughout the study. During treatment, 71% of those hospitalized at baseline were discharged. Partial hospitalization decreased significantly from 7% of patients during the 12 weeks before treatment to 3% during the last 12 weeks. Outpatient consultations also decreased significantly from 70% of patients to 30% in the first 12 weeks of treatment and remained stable thereafter. Only 9% of patients required an emergency room visit; mostly for non-psychiatric conditions.

CONCLUSION

Healthcare resource use is significantly reduced in patients with stable schizophrenia or schizoaffective disorder receiving long-acting risperidone. It is highly likely that these reductions will decrease healthcare costs in patients receiving long-acting risperidone.

Treatment of schizophrenia: preventing the progression of disease

Atypical antipsychotic drugs offer a number of advantages compared with typical antipsychotic drugs during the acute treatment of psychotic episodes and maintenance treatment to prevent psychotic relapses in patients with schizophrenia. These advantages include superior efficacy, especially for negative symptoms and reduced extrapyramidal adverse effects. Clinicians, however, need to be vigilant regarding new adverse effects that may be more strongly associated with atypical than typical drugs, especially those related to weight gain. Despite increased pill costs for atypical antipsychotic drugs, the overall costs of providing care to patients with schizophrenia using these drugs do not appear to be substantially higher.

Cost-effectiveness of the HIT programme in patients with schizophrenia and persistent auditory hallucinations

OBJECTIVE

To examine the cost-effectiveness of Hallucination focused Integrative Treatment (HIT) in patients with schizophrenia and a history of persistent auditory hallucinations.

METHOD

Costs, in and outside the health care sector, and outcomes were registered prospectively during a period of 18 months for patients who received the HIT programme and for patients in the care as usual (CAU) condition. The Positive and Negative Syndrome Scale (PANSS) was used as main outcome measure in the cost-effectiveness analysis. Bootstrap analyses provided additional information on the skewly distributed costs.

RESULTS

Mean costs per patient in the HIT group (18,237 dollars) were lower than the mean costs per patient in the CAU group (21,436 dollars). Results of the PANSS were slightly in favour of the HIT group.

CONCLUSION

There appears to be no significant cost-effectiveness advantage of the HIT programme over CAU. Additional analyses indicated that future application of the HIT programme will, in most cases, lead to a reduction of (non) medical costs.

Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics

Recent studies suggest that the risk of relapse in patients with schizophrenia is approximately 3.5% per month. Predictors of more frequent relapses include poor compliance with antipsychotic drug treatment, severe residual psychopathology, poor insight into the illness and the need for treatment, comorbid substance abuse, and poor relationships between patients, families and care providers. Although conventional antipsychotic drugs, such as haloperidol and fluphenazine, are effective in preventing relapse, second generation antipsychotic drugs, such as clozapine, risperidone and olanzapine, appear to be superior in preventing relapse and improving the patient's quality of life. The development of adverse events can undermine treatment response and relapse prevention. Minimising adverse effects thus helps to improve treatment compliance and prevent relapse. Second generation antipsychotic drugs tend to have fewer adverse effects than conventional agents, especially pseudoparkinsonism and akathisia. The societal costs of treating patients with schizophrenia can be lessened by employing strategies that decrease relapse and the need for rehospitalisation, the most costly treatment alternative.

The cost-effectiveness of clozapine: a controlled, population-based, mirror-image study

A retrospective cohort study, with a mirror-image design, was used to measure inpatient service utilization in 63 consecutive patients started on clozapine from a geographical catchment area compared to a control group matched for previous inpatient service use. An intent-to-treat analysis, including those patients (n = 28) who discontinued clozapine during the study period, showed a significant reduction in number of admissions and total time spent in hospital in the 2 years following clozapine initiation compared to the previous 2 years and to the follow-up period in the control group. This translated into a reduction of 7,300 pounds in hospitalization costs per patient started on clozapine, over the 2-year period. In those patients who continued clozapine treatment for the whole of the 2-year period, there was a two-thirds reduction in number of admissions and total time spent in hospital compared to no change in the clozapine discontinuers. These findings suggest that clozapine is a clinically and cost-effective intervention for severe schizophrenia in routine clinical settings.