Estimating the economic costs of schizophrenia

Global economic burden of schizophrenia: a systematic review

BACKGROUND

Schizophrenia is one of the top 25 leading causes of disability worldwide in 2013. Despite its low prevalence, its health, social, and economic burden has been tremendous, not only for patients but also for families, caregivers, and the wider society. The magnitude of disease burden investigated in an economic burden study is an important source to policymakers in decision making. This study aims to systematically identify studies focusing on the economic burden of schizophrenia, describe the methods and data sources used, and summarize the findings of economic burden of schizophrenia.

METHODS

A systematic review was performed for economic burden studies in schizophrenia using four electronic databases (Medline, EMBASE, PsycINFO, and EconLit) from inception to August 31, 2014.

RESULTS

A total of 56 articles were included in this review. More than 80% of the studies were conducted in high-income countries. Most studies had undertaken a retrospective- and prevalence-based study design. The bottom-up approach was commonly employed to determine cost, while human capital method was used for indirect cost estimation. Database and literature were the most commonly used data sources in cost estimation in high-income countries, while chart review and interview were the main data sources in low and middle-income countries. Annual costs for the schizophrenia population in the country ranged from US$94 million to US$102 billion. Indirect costs contributed to 50%-85% of the total costs associated with schizophrenia. The economic burden of schizophrenia was estimated to range from 0.02% to 1.65% of the gross domestic product.

CONCLUSION

The enormous economic burden in schizophrenia is suggestive of the inadequate provision of health care services to these patients. An informed decision is achievable with the increasing recognition among public and policymakers that schizophrenia is burdensome. This results in better resource allocation and the development of policy-oriented research for this highly disabling yet under-recognized mental health disease.

Costs of psychosis in 2010: findings from the second Australian National Survey of Psychosis

OBJECTIVES

To estimate the annual costs of psychosis in Australia from societal and government perspectives and assess whether average costs per person differ by principal service provider at time of census.

METHODS

Costs of psychosis encompassing health sector costs, other sector costs, and productivity losses were assessed for 2010 using a prevalence-based, bottom-up approach. Resource use data were obtained from the second Australian National Survey of Psychosis and unit costs were from government and non-government organization (NGO) sources. Costs to society were assessed by principal service provider at census: public specialized mental health services (PSMHS) and NGOs during the census month (current clients), and PSMHS in the 11 months preceding census (recent clients), and any differences were ascertained.

RESULTS

The average annual costs of psychosis to society are estimated at $77,297 per affected individual, comprising $40,941 in lost productivity, $21,714 in health sector costs, and $14,642 in other sector costs. Health sector costs are 3.9-times higher than those for the average Australian. Psychosis costs Australian society $4.91 billion per annum, and the Australian government almost $3.52 billion per annum. There are significant differences between principal service providers for each cost category. Current PSMHS clients had the highest health sector costs overall, and the highest mental health ambulatory, inpatient, and antipsychotic medication costs specifically. NGO clients had the highest other sector costs overall and the highest NGO assistance, supported employment, and supported accommodation costs. Recent PSMHS clients had the lowest productivity losses for reduced participation and the highest costs for absenteeism and presenteeism.

CONCLUSIONS

The costs of psychosis are broad ranging and very high. Development and implementation of cost-effective prevention, treatment, and support strategies is critical to maximizing the efficiency of service delivery. A needs-based framework based on principal service provider and recency of contact may facilitate this process.

Exploration of the comorbidity of cannabis use disorders and mental health disorders among inpatients presenting to all hospitals in New South Wales, Australia

BACKGROUND

Cannabis is one of the most commonly used illegal psychoactive substances and its use often coexists with mental health disorders.

OBJECTIVES

This study explores the relationships between cannabis use disorders and some common mental health disorders.

METHODS

Admissions to all New South Wales (NSW) hospitals were analyzed. The data were extracted from the NSW Department of Health Inpatient Statistics Data Collection for the period 1 July 2006 to 30 June 2007. Readmissions within 28 days were excluded. Data extraction and analyses were performed by using the SAS program. Chi-square tests and odds ratio were used to examine the association between cannabis use disorder and mental health disorders.

RESULTS

Of the 1.8 million admissions, associations between cannabis use disorders and mental health disorders were strong (odds ratio = 7.8-10.7, p < .001). Inpatients (53.8%) who used cannabis had at least one identifiable mental disorder. Higher comorbidity rates were observed for females (39.6%) and for those aged between 30 and 49 years. Cannabis use disorder comorbid with the most common mental disorders were: anxiety disorder (3.4%), bipolar affective disorder (5.7%), major depressive disorder (10.9%), personality disorder (9.2%), schizophrenia (15.0%), and severe stress disorder (8.7%). Cannabis use disorder has strong associations with these mental health disorders (odds ratio 4.8-34.8). The average length of stay (ALOS) for cannabis use disorders was 9.0 days and the ALOS for the most common mental health disorders was 11.0 days.

CONCLUSIONS AND IMPLICATIONS

This study provides detailed information about the association between cannabis use disorders and mental health disorders and extends our understanding of comorbidity presentations in inpatient admissions.

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.

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.

A report on economic studies of Australian mental health issues

OBJECTIVE

To report on economic studies of Australian mental health issues.

CONCLUSION

Although the international literature on the economics of mental health issues is increasing, and although many Australian studies exist on one comorbid condition of mental illness, namely substance abuse, there are very few empirical studies by economists of Australia's mental health issues.

Comorbidity: cannabis and complexity

Cannabis is one of the most commonly used illicit drugs, and its effects have traditionally been seen as less harmful than outcomes associated with the highly prevalent use of alcohol and other illicit substances (e.g., cocaine and amphetamines), and injecting drugs. Consequently, less attention has been focused on developing and evaluating interventions in this area. However, current research supports the idea that cannabis does pose a number of acute and chronic health risks to the individual and to society. The authors review findings concerning the physiological and neurological effects of cannabis, prevalence of use, and studies concerning its possible role as a "gateway" drug. Diagnostic criteria for cannabis dependence and abuse are discussed, with a focus on whether a cannabis withdrawal syndrome exists and if so how it can be diagnosed. There is strong support for a link between cannabis and the development and exacerbation of psychosis and other mental health conditions (e.g., anxiety, depression). Further research is needed to determine the underlying neurochemical processes and their possible contribution to etiology, as well as the social factors that contribute to the increasing use of cannabis by young people. In addition there is a need for systematic evaluation using randomized controlled trials to determine effective prevention and treatment strategies. A number of public health programs that address cannabis use are reviewed along with available evidence for their effectiveness.

Testing hypotheses about the relationship between cannabis use and psychosis

AIM

To model the impact of rising rates of cannabis use on the incidence and prevalence of psychosis under four hypotheses about the relationship between cannabis use and psychosis.

METHODS

The study modelled the effects on the prevalence of schizophrenia over the lifespan of cannabis in eight birth cohorts: 1940-1944, 1945-1949, 1950-1954, 1955-1959, 1960-1964, 1965-1969, 1970-1974, 1975-1979. It derived predictions as to the number of cases of schizophrenia that would be observed in these birth cohorts, given the following four hypotheses: (1) that there is a causal relationship between cannabis use and schizophrenia; (2) that cannabis use precipitates schizophrenia in vulnerable persons; (3) that cannabis use exacerbates schizophrenia; and (4) that persons with schizophrenia are more liable to become regular cannabis users.

RESULTS

There was a steep rise in the prevalence of cannabis use in Australia over the past 30 years and a corresponding decrease in the age of initiation of cannabis use. There was no evidence of a significant increase in the incidence of schizophrenia over the past 30 years. Data on trends the age of onset of schizophrenia did not show a clear pattern. Cannabis use among persons with schizophrenia has consistently been found to be more common than in the general population.

CONCLUSIONS

Cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.

Costs of schizophrenia and other psychoses in urban Australia: findings from the Low Prevalence (Psychotic) Disorders Study

OBJECTIVE

To estimate the costs associated with the treatment and care of persons with psychosis in Australia based on data from the Low Prevalence Disorders Study (LPDS), and to identify areas where there is potential for more efficient use of existing health care resources.

METHOD

The LPDS was a one-month census-based survey of people with psychotic disorders in contact with mental health services, which was conducted in four metropolitan regions in 1997-1998. Mental health and service utilization data from 980 interviews were used to estimate the economic costs associated with psychotic disorders. A prevalence-based, 'bottom-up' approach was adopted to calculate the government and societal costs associated with psychosis, including treatment and non-treatment related costs.

RESULTS

Annual societal costs for the average patient with psychosis are of the order of 46,200 Australian dollars , comprising 27,500 Australian dollars in lost productivity, 13,800 Australian dollars in inpatient mental health care costs and 4900 Australian dollars in other mental health and community services costs. Psychosis costs the Australian government at least 1.45 billion Australian dollars per annum, while societal costs are at least 2.25 billion Australian dollars per annum (including 1.44 billion Australian dollars for schizophrenia). We also report relationships between societal costs and demographic factors, diagnosis, disability and participation in employment.

CONCLUSIONS

Current expenditure on psychosis in Australia is probably inefficient. There may be substantial opportunity costs in not delivering effective treatments in sufficient volume to people with psychotic disorders, not intervening early, and not improving access to rehabilitation and supported accommodation.

Financial cost of treating out-patients with schizophrenia in Nigeria

BACKGROUND

An assessment of the monetary costs of treating a group of Nigerian out-patients with schizophrenia, in comparison with insulin-dependent diabetics, was made.

METHOD

Fifty out-patients with schizophrenia (mean age 42.9) and 40 with diabetes (mean age 41.9), attending government hospitals in Lagos, were assessed at six-monthly intervals, for direct and indirect costs (US$ = 82 naira; minimum monthly wage = 500 naira).

RESULTS

Twenty (40%) of those with schizophrenia and eight (20%) of the diabetics had no income at all. The mean total cost of schizophrenia in six months (2941.4 naira) or US$ 35.9) was significantly less than that of diabetes (11,791 naira or US $143). The cost of antipsychotic drugs accounts for 52.8% of the cost of schizophrenia; insulin injections accounted for 92.8% of the total cost of diabetes. Patients with schizophrenia and their relatives suffered significantly more loss of working days. Cost of illness was not significantly correlated with age and duration of illness.

CONCLUSIONS

Because of drastic currency devaluation, and lack of disability benefits and nursing homes, the findings contrast with Western reports where cost of drugs constitutes 2-5%, and indirect costs constitute over 50% of the total cost of schizophrenia.

Neuropsychiatric rehabilitation for persistent mental illness

The benefits of new knowledge on the psychobiology and neuropsychology of serious mental illnesses have been slow to impact on psychiatric rehabilitation technology. A literature review reveals that, at least in the case of schizophrenia, enough is known about neurobiological deficits and their impact on neurocognitive functioning to justify a more informed approach to psychiatric rehabilitation. Essential elements for a program of research are presented and preliminary data are reported examining the prevalence of executive deficits, correlations between neuropsychological deficits and social adjustment, and the nature of socially stigmatizing neuromotor deficits and their reliable assessment. In addition, early experience with the remediation of executive deficits is described and suggestions are made for future developments in this area. The authors conclude that barriers to the integration of knowledge from biological psychiatry and psychiatric rehabilitation have been largely related to academic "cultural" isolation, and that active cross fertilization of ideas is clearly justified by the present state of knowledge.