Rehospitalization rates of chronically ill schizophrenic patients discharged on a regimen of risperidone, olanzapine, or conventional antipsychotics

ASHP Therapeutic Position Statement on the Use of Antipsychotic Medications in the Treatment of Adults with Schizophrenia and Schizoaffective Disorder

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What happens with schizophrenia patients after their discharge from hospital? Results on outcome and treatment from a "real-world" 2-year follow-up trial

Aim of the study was to examine the course of schizophrenia patients within 2 years after discharge. Within a multicenter study of the German Competence Network on Schizophrenia, patients suffering from a schizophrenia spectrum disorder were examined regarding their psychopathological improvement, tolerability, and the treatment regime applied during hospitalization and a 2-year follow-up period. Response, remission, the level of everyday functioning, and relapse were furthermore evaluated during the follow-up period using established definitions for these outcome domains. The psychopharmacological treatment was specifically evaluated in terms of a potential association with relapse. 149 patients were available for analysis, with 65% of the patients being in response, 52% in symptomatic remission, and 64% having a satisfiable everyday functioning 2 years after their discharge from hospital. Despite these favorable outcome rates, 63% of the patients suffered from a relapse within the 2-year follow-up period with 86% of these patients being rehospitalized. Discharge non-responder and non-remitter were twice as likely to relapse during follow-up. A significant decrease of side-effects was observed with negligible rates of extrapyramidal side-effects, sedation, and weight gain during follow-up. Patients receiving treatment with atypical antipsychotics were found to have the lowest risk to relapse (p < 0.0001). The results highlight the natural and unsteady course of schizophrenia in most patients underlining the need to develop more specific treatment strategies ensuring ongoing stability and preventing relapse.

Antipsychotic agents. Gradually improving treatment from the traditional oral neuroleptics to the first atypical depot

Relapse is one of the key factors in the long-term outcome of schizophrenia. The consequences of relapse are diverse and often unpredictable, and the time to recovery and degree of recovery worsen with each successive relapse. There is now overwhelming evidence that advances in antipsychotic drug treatment have led to significant reductions in the rate of relapse. This review charts the developments that have taken place in antipsychotic therapy from the introduction of depot formulations, through atypical agents, to the development of the first long-acting atypical antipsychotic. Depot formulations of conventional antipsychotics were developed in the 1960s and led to fewer relapses and episodes of hospitalization, compared with oral equivalents. Meta-analysis has confirmed that patients receiving depot antipsychotics experience significantly greater global improvement than those receiving the respective oral agents. Conventional antipsychotics are, however, associated with a range of potentially serious adverse events. The atypical antipsychotics were introduced in the 1990s and have significant advantages over conventional agents with regard to positive and negative symptoms. There is also evidence that atypical agents can reduce the risk of relapse. Importantly, atypical antipsychotics have an improved safety profile compared with older agents, particularly with regard to extrapyramidal symptoms. One disadvantage of atypical agents has been that they are only available in an oral form. The recent development of a long-acting injectable formulation of risperidone means that a new treatment option is available to physicians.

Mindfulness-Based Interventions for In-Patients With Schizophrenia Spectrum Disorders-A Qualitative Approach

In recent years, mindfulness-based interventions (MBI) have gained clinical relevance in the treatment of patients with schizophrenia spectrum disorders (SSDs). High symptom burden, long durations of hospitalization and high rehospitalization rates demonstrate the severity and cost-intensity of these disorders. MBIs have shown promising treatment outcomes in a small number of trials, primarily taking place in English-speaking countries. The current study aims to explore mechanisms and processes as well as adverse effects of MBIs on in-patients with SSDs in a German university hospital setting. A qualitative design based on inductive thematic analysis accompanied by quantitative assessments was chosen. A semi-structured interview guide was developed by psychiatrists and psychologists to assess patient experiences, perceptions, thoughts, and feelings during and after taking part in a MBI. Twenty-seven interviews were conducted between September 2017 and October 2018 with in-patients who are diagnosed with schizophrenia or schizoaffective disorder. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Montgomery Asberg Depression Rating Scale (MADRS), and Psychotic Symptom Rating Scales-Auditory Hallucination (PSYRATS-AH) were administered at baseline to collect clinical outcomes. Qualitative analysis revealed two domains: content and function. In the first domain related to content with the core elements "detachment and rumination", "presence and getting lost", "non-judgment and judgment", and effects with "emotions", "cognition", and "symptom changes". A second domain related to function was extracted, including the relevance of perception of context and transfer to everyday life. Overall, improvements concerning cognition, distress, and psychopathology were detected, while no adverse effects, such as increased psychotic symptoms, were revealed. As the first study of its kind, mechanisms, processes, and the safety of MBIs were explored and confirmed in a sample of German in-patients with SSDs. The results of this qualitative study are in line with recent findings on MBIs amongst patients with psychotic disorders from other countries. Results lay the ground for future research to focus on the systematic study of MBIs in large samples, its treatment processes, outcomes, and effectiveness for in-patients with SSDs.

Analysis of the Health Insurance Review and Assessment Service data from 2011 to 2015

Background

Schizophrenia is a recurrent, debilitating disease that is rarely curable. Rapid intervention after the first episode of schizophrenia has been shown to positively affect the prognosis. Unfortunately, basic data is scarce on first-episode schizophrenia in Korean patients making it difficult to create a comprehensive list of risk factors for relapse. This study aims to investigate the demographic characteristics and institutional factors of patients with first-episode schizophrenia in order to identify risk factors for relapse.

Methods

Data from the Health Insurance Review & Assessment Service (HIRA) was used for this study to represent the Korean patient population. To identify factors affecting relapse, we explored gender, age, geographic location, medical benefits, type of medical institution, type of medication used, medication adherence, and the severity of symptoms. Data analysis was performed using the Cox proportional hazard model.

Results

The number of patients diagnosed with first-episode schizophrenia in Korea over a 2-year period was 4567 of which 1265 (27.7%) patients experienced a relapse during the observational period. Factors affecting relapse included age, type of medical institution, type of medication used, medication adherence, and type of treatment (inpatient or outpatient) after the initial diagnosis, which varied depending upon the severity of symptoms.

Conclusions

It was found that environmental and institutional factors as well as the type of medical treatment were crucial in determining whether patients with first-episode schizophrenia subsequently relapsed. The results of this study can be utilized as source material for directing therapeutic interventions and improving mental health policies in the future.

Comparison of the effectiveness of depot antipsychotics in routine clinical practice

Aims and method

To compare effectiveness of long-acting injections in schizophrenia and related psychoses in Lanarkshire, Scotland, from 2002 to 2008. We retrospectively assigned Clinical Global Impression (CGI) scores and examined discontinuation and hospitalisation rates.

Results

Risperidone, zuclopenthixol and flupentixol were associated with CGI improvement in 72-74% of individuals. Zuclopenthixol was associated with lower rates of discontinuation as a result of inefficacy compared with risperidone (hazard ratio (HR) = 0.11, 95% CI 0.05-0.27) and flupenthixol (HR = 0.14, 95% CI 0.05-0.39), and lower rates of hospitalisation compared with risperidone (HR = 0.32, 95% CI 0.17-0.56) and flupentixol (HR = 0.34, 95% CI 0.16-0.71). ‘Very much improved’ or ‘much improved’ on the CGI was seen in risperidone (29%), zuclopenthixol (16%) and flupentixol (37%), P<0.001.

Clinical implications

No long-acting injection was clearly superior in all our outcome measures, supporting the continued need for a variety of long-acting depot antipsychotics to optimise the treatment of the range of patients seen in clinical practice.

Obsessive compulsive symptoms are associated with better functioning independently of cognition in schizophrenia

OBJECTIVES

Although the relationship of obsessive-compulsive symptoms (OCSs) with both cognition and social functioning (SF) has already been the focus of research in schizophrenia, the moderation of the relationship of OCSs with SF by cognition has not been explored to date. We investigated the association of OCSs with SF and its interaction with cognition in schizophrenia.

METHODS

We recruited 110 schizophrenia patients and assessed OCSs (Yale-Brown Scale), schizophrenia symptoms (Positive and Negative Syndrome Scale), SF (Strauss-Carpenter Scale) and cognition. 51 patients had one obsessive-compulsive symptom or more, whereas 59 patients had no obsessive compulsive-symptom, according to the Yale-Brown Scale. We mainly investigated: a) the predictive effect of OCSs on SF, controlling for cognition, illness duration and symptoms' severity and b) the moderating effect of cognition on the OCSs-SF relationship.

RESULTS

The mean score of OCSs for patients having at least one symptom was 13.43 (SD=8.32). Higher OCSs predicted increased SF (B=0.98, t=2.41, df=88, p=0.018). This relationship was driven by the association of compulsions with job functioning (B=0.074, t=2.029, df=88, p=0.046). Patients without OCSs demonstrated worse functioning compared with those having at least one obsessive-compulsive symptom (mean difference=2.496, t=3.732, df=88, p<0.001). We failed to find evidence that cognition moderates the effect of OCSs on SF.

CONCLUSION

There may be a beneficial effect of OCSs on SF in patients with schizophrenia which is independent of their cognitive performance.

Economic analysis of paliperidone long-acting injectable for chronic schizophrenia in Portugal

OBJECTIVE

Patients with chronic schizophrenia suffer a huge burden, as do their families/caregivers. Treating schizophrenia is costly for health systems. The European Medicines Agency has approved paliperidone palmitate (PP-LAI; Xeplion), an atypical antipsychotic depot; however, its pharmacoeconomic profile in Portugal is unknown. A cost-effectiveness analysis was conducted from the viewpoint of the Portuguese National Health Service.

METHODS

PP-LAI was compared with long acting injectables risperidone (RIS-LAI) and haloperidol (HAL-LAI) and oral drugs (olanzapine; oral-OLZ) adapting a 1-year decision tree to Portugal, guided by local experts. Clinical information and costs were obtained from literature sources and published lists. Outcomes included relapses (both requiring and not requiring hospitalization) and quality-adjusted life-years (QALYs). Costs were expressed in 2014 euros. Economic outcomes were incremental cost-effectiveness ratios (ICERs); including cost-utility (outcome = QALYs) and cost-effectiveness analyses (outcomes = relapse/hospitalization/emergency room (ER) visit avoided).

RESULTS

The base-case cost of oral-OLZ was 4447€ (20% drugs/20% medical/60% hospital); HAL-LAI cost 4474€ (13% drugs/13% medical/74% hospital); PP-LAI cost 5326€ (49% drugs/12% medical/39% hospital); RIS-LAI cost 6223€ (44% drugs/12% medical/44% hospital). Respective QALYs/hospitalizations/ER visits were oral-OLZ: 0.761/0.615/0.242; HAL-LAI: 0.758/0.623/0.250; PP-LAI: 0.823/0.288/0.122; RIS-LAI: 0.799/0.394/0.168. HAL-LAI was dominated by oral-OLZ and RIS-LAI by PP-LAI for all outcomes. The ICER of PP-LAI over oral-OLZ was 14,247€/QALY, well below NICE/Portuguese thresholds (≈24,800€/30,000€/QALY). ICERs were 1973€/relapse avoided and 2697€/hospitalization avoided. Analyses were robust against most variations in input values, as PP-LAI was cost-effective over oral-OLZ in >99% of 10,000 simulations.

CONCLUSION

In Portugal, PP-LAI dominated HAL-LAI and RIS-LAI and was cost-effective over oral-OLZ with respect to QALYs gained, relapses avoided, and hospitalizations avoided.

Correlates of readmission risk and readmission days in a large psychiatric hospital in Guangzhou, China

INTRODUCTION

For many patients with psychiatric disorders, the course of illness is characterized by frequent relapses, resulting to re-hospitalization and high costs. While the correlates of readmission have been extensively studied in developed countries, few studies have examined readmission in low- and middle-income countries where bed supply is limited.

METHODS

Using administrative data from the Guangzhou Psychiatric Hospital (GPH), we used Cox regression models to evaluate the relationship among age, gender, index length of stay (LOS), and the number of previous admissions to post-discharge readmission risk. Linear regression is used to evaluate predictors of total hospital days during the year after the index discharge.

RESULTS

Between April 1, 2010 and March 31, 2011, 2,525 patients were discharged with International Classification of Diseases, 10th Revision psychiatric diagnoses from GPH, with an average LOS of 64.2 (SD = 69.0), and 317 (12.4%) were readmitted in the following year. Survival analysis showed older age (P < 0.05), and the number of previous hospitalizations (P < 0.01) were significant predictors of the risk of readmission but not diagnosis or LOS. The number of previous admissions was the only predictor of total bed days of psychiatric care at GPH in the year following the initial discharge.

DISCUSSION

Shortened LOS was not associated with increased readmission risk or post-discharge hospital days. Rather, the number of past hospitalizations was the major predictor of both readmission risk and post-discharge hospital days of psychiatric care, and such patients deserve special attention. Lowering LOS may be justified, allowing funds to be redeployed to outpatient or community-based care.

Systematic review of long-acting injectables versus oral atypical antipsychotics on hospitalization in schizophrenia

OBJECTIVE

To assess the impact of long-acting injectables (LAIs) versus oral antipsychotics (OAs) on hospitalizations among patients with schizophrenia by conducting a systematic literature review of studies with different study designs and performing a meta-analysis.

METHODS

Using the PubMed database and major psychiatric conference proceedings, a systematic literature review for January 2000 to July 2013 was performed to identify English-language studies evaluating schizophrenia patients treated with atypical antipsychotics. Studies reporting hospitalization rates as a percentage of patients hospitalized or as the number of hospitalizations per person per year were selected. The primary meta-analysis assessed the percentage decrease in hospitalization rates before and after treatment initiation for matched time periods. The secondary meta-analysis assessed the absolute rate of hospitalization during follow-up. Pooled treatment-effect estimates were calculated using random-effects models. To account for differences in patient and study-level characteristics between studies, meta-regression analyses were used. Subset analyses further explored the heterogeneity across study designs.

RESULTS

Fifty-eight studies evaluating 25 arms (LAIs: 13 arms, 4516 patients; OAs: 12 arms, 23,516 patients) in the primary meta-analysis and 78 arms (LAIs: 12 arms, 4481 patients; OAs: 66 arms, 96,230 patients) in the secondary meta-analysis were identified. Reduction in hospitalization rates for LAIs was 20.7 percentage points higher than that of OAs (random-effects estimates: LAIs = 56.2% vs. OAs = 35.5%, P = 0.023). Controlling for patient and study characteristics, the adjusted percentage reduction in hospitalization rates for LAIs was 26.4 percentage points higher than for OAs (95% CI: 3.3-49.5, P = 0.027). As for the secondary meta-analysis, no significant difference between LAIs and OAs was observed (random-effects estimate: -8.6, 95% CI: -18.1-1.0, P = 0.077). Subset analyses across type of study yielded consistent results. Limitations of this analysis include the long observation period, which may not reflect current treatment patterns, the use of all-cause hospitalization, which may not be solely related to schizophrenia, and the fact that most studies in the LAI cohort evaluated risperidone.

CONCLUSION

The primary results of this meta-analysis, including studies with both interventional and non-interventional designs and using meta-regressions, suggest that LAIs are associated with higher reductions in hospitalization rates for schizophrenia patients compared to OAs.

Pharmacoeconomics of depot antipsychotics for treating chronic schizophrenia in Sweden

AIMS

To determine the cost-effectiveness of long-acting injectable (LAI) antipsychotics for chronic schizophrenia in Sweden.

METHODS

A 1-year decision tree was developed for Sweden using published data and expert opinion. Five treatment strategies lasting 1 year were compared: paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol decanoate (HAL-LAI) and olanzapine tablets (oral-OLZ). Patients intolerant/failing drugs switched to another depot; subsequent failures received clozapine. Resources and employment time lost (indirect costs) were costed in 2011 Swedish kroner (SEK), from standard government lists. The model calculated the average cost/patient and quality-adjusted life-years (QALYs), which were combined into incremental cost-effectiveness ratios. Multivariate and 1-way sensitivity analyses tested model stability.

RESULTS

PP-LAI followed by OLZ-LAI had the lowest cost/patient (189,696 SEK) and highest QALYs (0.817), dominating in the base case. OLZ-LAI followed by PP-LAI cost 229,775 SEK (0.812 QALY), RIS-LAI followed by HAL-LAI cost 221,062 SEK (0.804 QALY), HAL-LAI followed by oral-OLZ cost 243,411 SEK (0.776 QALY), and oral-OLZ followed by HAL-LAI cost 249,422 SEK (0.773 QALY). The greatest proportions of costs (52.5-83.8%) were for institutional care; indirect costs were minor (2.4-3.8%). RESULTS were sensitive to adherence and hospitalization rates, but not drug cost. PP-LAI followed by OLZ-LAI dominated OLZ-LAI followed by PP-LAI in 59.4% of simulations, RIS-LAI followed by HAL-LAI in 65.8%, HAL-LAI followed by oral-OLZ in 94.0% and oral-OLZ followed by HAL-LAI in 95.9%; PP-LAI followed by OLZ-LAI was dominated in 1.1% of the 40,000 iterations.

CONCLUSION

PP-LAI followed by OLZ-LAI was cost-effective in Sweden for chronic schizophrenia and cost-saving overall to the healthcare system.

Definitions and drivers of relapse in patients with schizophrenia: a systematic literature review

Relapse in patients with schizophrenia has devastating repercussions, including worsening symptoms, impaired functioning, cognitive deterioration and reduced quality of life. This progressive decline exacerbates the burden of illness on patients and their families. Relapse prevention is identified as a key therapeutic aim; however, the absence of widely accepted relapse definition criteria considerably hampers achieving this goal. We conducted a literature review in order to investigate the reporting of relapses and the validity of hospitalization as a proxy for relapse in patients with schizophrenia. The primary aim was to assess the range and validity of methods used to define relapse in observational or naturalistic settings. The secondary aim was to capture information on factors that predicted or influenced the risk of relapse. A structured search of the PubMed database identified articles that discussed relapse, and hospitalization as a proxy of relapse, in patients with schizophrenia. National and international guidelines were also reviewed. Of the 150 publications and guidelines identified, 87 defined relapse and 62% of these discussed hospitalization. Where hospitalization was discussed, this was as a proxy for, or a component of, relapse in the majority of cases. However, hospitalization duration and type varied and were not always well defined. Scales were used to define relapse in 53 instances; 10 different scales were used and multiple scales often appeared within the same definition. There were 95 references to factors that may drive relapse, including non-adherence to antipsychotic medication (21/95), stress/depression (11/95) and substance abuse (9/95). Twenty-five publications discussed the potential of antipsychotic therapy to reduce relapse rates-continuous antipsychotic therapy was associated with reduced frequency and duration of hospitalization. Non-pharmacological interventions, such as psychoeducation and cognitive behavioural therapy, were also commonly reported as factors that may reduce relapse. In conclusion, this review identified numerous factors used to define relapse. Hospitalization was the factor most frequently used and represents a useful proxy for relapse when reporting in a naturalistic setting. Several factors were reported to increase the risk of relapse, and observation of these may aid the identification of at-risk patients.

Time to rehospitalization in patients with schizophrenia discharged on first generation antipsychotics, non-clozapine second generation antipsychotics, or clozapine

Rehospitalization is an important outcome of drug effectiveness in schizophrenia. In this study, the hypothesis that clozapine and some second generation antipsychotics (SGA) were superior to first generation antipsychotics (FGA) in preventing rehospitalization of patients with schizophrenia discharged from a university hospital in Brazil was tested. A retrospective observational study was conducted designed to evaluate time to rehospitalization of patients with schizophrenia discharged on a regimen of oral FGA, depot FGA, risperidone, olanzapine and amisulpride, other SGA, or clozapine, during a three-year follow-up period. Risk factors associated with rehospitalization were examined. Of the 464 patients with schizophrenia discharged from hospital, 242 met criteria for study entry. Higher rehospitalization rates were observed in patients treated with depot FGA (30%), risperidone (30%) and other SGA groups (28.5%), respectively. Clozapine was significantly associated with lower rehospitalization risk compared with risperidone. The risk of rehospitalization in patients on olanzapine and amisulpride, and oral FGA, was similar to that of patients in use of clozapine. These results however, are limited by the heterogeneity of illness severity across the groups.

Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia

Prior authorization (PA) policies are increasingly being used to manage atypical antipsychotic (AA) Medicaid drug expenditures; however, some studies suggest that PAs may actually lead to higher rates of treatment discontinuation and hospitalization. A decision analytic model was developed to compare the cost of schizophrenia treatment from a Medicaid perspective when a PA policy for AA is in place with the cost of no PA, over a 1-year time horizon. Deterministic sensitivity analyses were conducted to assess the robustness of the model results when the parameters were varied. A second analysis was performed to assess the incremental impact of PA on hospitalization. The base case model calculates the mean yearly total medical cost for a patient with schizophrenia to be $12,967 (SD $798) under the PA arm and $12,996 (SD $925) with no PA. Results of the probabilistic sensitivity analysis suggest that PA is likely to produce modest cost savings 56% of the time. Analysis of the incremental impact of hospitalization on treatment cost showed that just a 0.5% increase in hospitalization rate in the PA arm will make the PA arm more costly. This analysis suggests that PA is likely to produce only modest cost savings approximately half the time. Sensitivity analyses show that small increases in hospitalizations will make PA the more costly option. Rigorous analysis of the PA policy for AAs is required to ensure that attempts to reduce pharmacy spending do not increase the risk for negative medical outcomes that would offset benefits.

The revolving door phenomenon in psychiatry: comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing country

INTRODUCTION

Deinstitutionalization has led to a dramatic reduction of inpatient beds and subsequent increase in pressure on available beds. Another consequence of deinstitutionalization has been the phenomenon of the revolving door patient; high-frequency users (HFUs) admitted to hospital repeatedly, remaining well for only short periods of time. The purpose of the study was to determine factors that contribute to HFU of inpatient psychiatric services by schizophrenia and schizo-affective disorder subjects in a developing country with a view to understanding this phenomenon better.

METHODS

Subjects were divided into HFU and low-frequency user (LFUs) groups for comparison with regard to selected variables.

RESULTS

HFUs had higher PANSS scores (p < 0.01), were more likely to admit to lifetime substance use (p = 0.01), be on mood stabilizers (p < 0.01) and also to have been crisis (premature) discharges (p < 0.01). LFUs were more likely to have been treated with depot medication (p < 0.01). Multivariate analysis showed crisis discharge (p = 0.03) and depot use (p = 0.03) to be the only remaining significant predictors of HFU versus LFU status.

DISCUSSION

Our findings suggest HFUs' characteristics to be similar across different settings, with under-utilization of depot antipsychotics and early discharge from hospital as particular contributors to high-frequency use of services in our sample.

CONCLUSION

Results seem to indicate that HFU-specific interventions are vital to addressing these issues.

Cost effectiveness of long-acting risperidone in Sweden

BACKGROUND

In Sweden, risperidone long-acting injectable (RLAI) is generally used in a population of schizophrenia patients who are at a high risk of being non-compliant. However, RLAI might also be suitable for use in the general schizophrenia population.

OBJECTIVES

To analyse the clinical and economic effects of RLAI in the Swedish treatment practice using a discrete-event simulation (DES) model. Treatment outcomes and direct costs were analysed for both the high-risk non-compliant patient population and the general schizophrenia population.

METHODS

An existing DES model was adapted to simulate the treatment of schizophrenia in Sweden. Model inputs were based on literature research and supplemented with expert opinion. In the high-risk non-compliant schizophrenia population, RLAI was compared with haloperidol LAI. The analysis was built upon differences in symptom reduction, time between relapses, compliance and adverse effect profile between the two drugs. Main outcomes were the predicted incremental (discounted) costs (€) and effects (QALYs). In the general schizophrenia population, RLAI was compared with oral olanzapine. This analysis was built upon differences in compliance and adverse effects between the drugs. Multivariate probabilistic sensitivity analyses (PSA) were carried out to assess the sensitivity of the results of the two analyses.

RESULTS

In the high-risk non-compliant patient population, RLAI was predicted to generate 0.103 QALYs per patient over 3 years while realizing cost savings of €5013 (year 2007 values) compared with haloperidol LAI. The main driver of the cost effectiveness of RLAI was the difference in Positive and Negative Syndrome Scale (PANSS) reduction between the two drugs, followed by the difference in adverse effects. The PSA showed that, in this setting, RLAI had a probability of 100% of being cost effective at a willingness-to-pay (WTP) threshold of €43,300 per QALY gained, compared with haloperidol LAI. The probability that RLAI combines additional effectiveness with cost savings compared with haloperidol LAI was estimated at 94%. When analysing RLAI in the general schizophrenia population, it was predicted to generate 0.043 QALYs and save €239 per patient over 5 years compared with olanzapine. Compliance was the main driver of the cost effectiveness of RLAI in this scenario. In the PSA it was shown that RLAI had a probability of 78% of being cost effective at a WTP threshold of €43,300 per QALY gained, compared with olanzapine. The estimated probability that RLAI combines additional effectiveness with cost savings was 50% and the probability that RLAI is less effective and more costly than olanzapine was negligible (0.2%).

CONCLUSIONS

Treatment with RLAI is suggested to result in improved QALYs combined with cost savings compared with haloperidol LAI among the Swedish, high-risk non-compliant schizophrenia patient population. In the general schizophrenia population, RLAI also resulted in positive incremental QALYs and cost savings, when compared with olanzapine. However, the estimates used in the model for compliance and symptom reduction need further validation through naturalistic-based studies with reasonable follow-up to more definitely establish the real-life differences between RLAI and the comparators in the considered patient populations and to further reduce the uncertainty of these parameters.

Long-term treatment with flupentixol results of a post-marketing surveillance study

Schizophrenia is one of the most expensive illnesses. Antipsychotics are an essential component of the acute and preventative treatment of this illness, and long-term treatment is necessary to decrease the risk of psychotic relapse. The efficacy and tolerability of flupentixol was evaluated in a post-marketing surveillance study (PMS) in schizophrenic patients receiving long-term treatment in routine clinical practice. Psychiatrists in office practice treated patients for approximately 10 weeks, with a subsequent follow-up period of up to 18 months. We here report on the follow-up period in 128 patients. The benefit for schizophrenic patients increased with the treatment duration of flupentixol as documented by the Clinical Global Impression (CGI). Subjective quality of life improved during the first study period, and this remained stable in the follow-up period. No increase in body weight was observed during the study. The relapse rate was much lower than in other studies. Anticholinergic medication was necessary for 22.7% of the patients at any time. More than 70% of the psychiatrists involved evaluated the treatment as very good or good. The results of this study suggest that flupentixol is a potent and safe antipsychotic for the long-term treatment of schizophrenia in routine clinical practice.

The CATIE and CUtLASS studies in schizophrenia: results and implications for clinicians

Numerous double-blind studies have compared second-generation antipsychotics (SGAs) with first-generation antipsychotics (FGAs), with most finding better efficacy and tolerability for SGAs. However, these 'efficacy trials' were generally short term and included only highly selected patients. Mostly because of weight gain and other metabolic effects of the SGAs, as well as their high acquisition price, the debate on the (cost) effectiveness of the SGAs led to two pragmatic clinical trials with no sponsorship by industry. Both trials had broad inclusion criteria and long follow-up, and tried to mimic clinical routine: CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) and CUtLASS (Cost Utility of the Latest Antipsychotic drugs in Schizophrenia Study). 1493 patients participated in CATIE, an 18-month, double-blind trial comparing the SGAs olanzapine, quetiapine, risperidone and ziprasidone with the FGA perphenazine. If efficacy or tolerability was insufficient, patients were re-randomized to a medication other than the one they previously received. Improvement of psychopathology and of quality of life was only moderate. Overall, 74% of patients discontinued study medication before 18 months, and the median time to discontinuation was 4.6 months. Aside from olanzapine (time to discontinuation 9.2 months), the other SGAs did not differ from each other or from perphenazine. Except for adverse effects as a reason for discontinuation, differences between the SGAs and the FGA were minimal. In CUtLASS, a 12-month open-label trial, 277 patients were randomized to receive an FGA or a SGA. Again, efficacy was rather similar between the two groups, with only limited improvement of psychopathology and quality of life. The authors of both trials concluded that SGAs do not markedly differ from FGAs regarding compliance, quality of life and effectiveness. The methodological problems of both trials have been discussed extensively. Patients had psychotic symptoms that were moderate in severity and were at least partially treatment resistant. The marginal improvement observed indicated that this population might not be appropriate to detect differences between FGAs and SGAs. Specific issues of CATIE include the exclusion of patients with tardive dyskinesia in the perphenazine arm and the high discontinuation rate. In CUtLASS, the concept of including 13 different FGAs and four SGAs in the respective classes was problematic. It is of interest that the most widely prescribed drug was sulpiride--of the FGAs, this is probably the 'most atypical' drug. Aside from the finding that the advantages of the SGAs are not as strong as early trials and marketing suggested or promised, the trials do not provide much helpful information regarding everyday practice. For tardive dyskinesia, no conclusions at all can be drawn. Similarly, methodological problems inhibited the detection of the other major advantage of the SGAs, i.e. the improved subjective well-being/quality of life while receiving these agents. It is well known that patients' and doctors' perspectives differ markedly, and the Quality of Life Scale (QLS), an expert-rated scale used in both trials, might not be sensitive enough to detect the subjective advantages reported by the majority of patients in other trials. CATIE and CUtLASS suggest that SGAs do not live up to all the previous expectations. However, even if most of these advantages are debatable, the lower risk of tardive dyskinesia and the better subjective effects should be strong enough reasons to favour these drugs. There is no single antipsychotic that is best for every schizophrenia patient, as individual responses differ markedly. For successfully individualized treatment, a multitude of antipsychotic options are needed.

The cost of relapse in schizophrenia and schizoaffective disorder

OBJECTIVE

The aim of this study was to quantify the costs and resource utilization associated with a relapse of schizophrenia or schizoaffective disorder.

METHODS

The study comprised a retrospective audit of data from 200 patients diagnosed with schizophrenia or schizoaffective disorder who were admitted to hospital for a relapse of their disorder in two mental health services in Australia between 1 June 2001 and 31 May 2002. Resource use and costing data were collected for 12 months before and 12 months after the hospitalization.

RESULTS

There was an increase in contacts per month and associated outpatient costs after the index admission which persisted for the full 12 month data collection period (total of AUD $637). There was also a total increase in hospital costs but this did not persist beyond the first 2 months of the follow-up period and is likely explained by the index admission.

CONCLUSIONS

Increased healthcare resource utilization and costs results from relapse in patients with schizophrenia or schizoaffective disorder. An increase in service use and costs persist for a considerable time period after an episode of relapse.

Novel Antipsychotics in the Long-term Treatment of Schizophrenia

Schizophrenia still has a poorer outcome than other affective disorders. One possible way to improve the long-term outcome of schizophrenic patients is to optimise long-term treatment with the aim of minimising the number of relapses and reducing residual symptoms. Atypical antipsychotics have various advantages over atypical neuroleptics. The first depot formulation of an atypical neuroleptic appears to be a further positive step to improve the possibilities of an optimal long-term treatment for schizophrenia.

The cost-effectiveness of atypicals in the UK

BACKGROUND

In 2002, the National Institute for Health and Clinical Excellence (NICE), recommended atypical antipsychotics over conventional ones for first-line schizophrenia treatment, based on their lower risk of extrapyramidal symptoms.

OBJECTIVE

To estimate the incremental cost-effectiveness of atypical relative to conventional antipsychotics for the treatment of schizophrenia in the UK.

METHODS

A discrete event simulation (DES) model was adopted to reflect the treatment of schizophrenia in the UK. The model estimates symptoms (using the Positive and Negative Symptom Score [PANSS]), psychiatrist visits, pharmacological treatment and treatment location, number and duration of psychotic relapses, level of compliance, quality-adjusted life-years (QALYs), and side effects over a 5-year time period. Probabilistic sensitivity analyses were carried out. Following NICE's "atypical" recommendation, the cost-effectiveness of atypical versus conventional antipsychotics was estimated in a scenario analysis, assuming both groups differ only in side-effect profile.

RESULTS

When comparing conventional and atypical antipsychotics, the model predicts that the latter would decrease 5-year costs by 1633 Pound per patient and result in a QALY gain of 0.101. The probabilistic sensitivity analysis suggests these results are robust. The sensitivity analyses indicate that incremental costs and effects are most sensitive to the differential efficacy of atypicals and conventionals, as measured by PANSS. When it is assumed that the only differences between atypicals and conventionals are found in side-effect profiles, the incremental cost-effectiveness ratio of the atypicals is 45,000 Pound per QALY gained.

CONCLUSION

According to this DES model for schizophrenia, atypical antipsychotics are cost-effective compared to the conventional antipsychotics. The assumptions used in the model need further validation through large naturalistic based studies with reasonable follow-up to determine the real-life differences between atypicals and conventional antipsychotics.

Two-year rehospitalization rates of patients with newly diagnosed or chronic schizophrenia on atypical or typical antipsychotic drugs: retrospective cohort study

AIM

To determine if atypical antipsychotic agents reduce the rehospitalization rates of patients with newly diagnosed or chronic schizophrenia in comparison with typical antipsychotic drugs.

METHODS

From January 1, 2003, to December 31, 2004, we retrospectively compared two-year rehospitalization rates of 135 patients with newly diagnosed schizophrenia and 398 patients with chronic schizophrenia (62% and 65% men, respectively), who were initially discharged from Vrapce Psychiatric Hospital, Zagreb, with the prescription of atypical (olanzapine, risperidone or clozapine) or typical (haloperidol or fluphenazine) antipsychotic treatment between January 1, 2002 and December 31, 2002. Time-to-readmission was determined with Kaplan-Meier formula for survival analysis.

RESULTS

In the two-year follow-up, 52 (39%) newly diagnosed patients and 197 (47%) patients with chronic schizophrenia were rehospitalized. No significant differences in time-to-rehospitalization were observed with respect to the type of medications in patients with newly diagnosed schizophrenia (P=0.378) or patients with chronic schizophrenia (P=0.531).

CONCLUSIONS

Rehospitalization rates of patients who were prescribed atypical antipsychotic drugs were similar to those of patients who were prescribed typical antipsychotic drugs for both the group with the first psychotic episode and group with chronic schizophrenia.

Predictors of the course of illness in outpatients with schizophrenia: a prospective three year study

The course of schizophrenia includes a combination of periods of remission and relapse. Previous studies focused on simple dichotomous outcomes and did not take into account the complexity of the course. Using data from a large 3-year follow-up study of schizophrenia, we described the different courses of schizophrenia. Of the 5950 patients with complete 3-year data, 38.7% never achieved remission (prolonged course), 15.7% achieved remission but relapsed and 45.7% achieved and maintained remission (persistent remission). Females, patients with better social functioning at baseline (living independently, in paid employment, socially active or having a spouse or partner) and with a shorter duration of illness had a more favourable course. Patients prescribed risperidone, quetiapine or depot typicals at the baseline visit were more likely to have a prolonged course than patients who started olanzapine. The results show that description of the long-term outcome of schizophrenia cannot be summarized with just one outcome variable.

A pharmacoeconomic analysis of atypical antipsychotics and haloperidol in first-episode schizophrenic patients in taiwan

The study prospectively examined the economic outcomes and co-medications among first-episode schizophrenic patients treated with monotherapy of second-generation antipsychotic agents (SGAs) continuously as compared with each other and with haloperidol. The sample included 3047 out of Taiwan's national sample of 29,341 first-episode schizophrenic patients, who were selected, based on International Classification of Disease, Ninth Revision code 295, from the National Health Insurance original claims data from 1999 to 2004. They were treated with only 1 of the following antipsychotic agents: haloperidol (n = 526), clozapine (n = 224), risperidone (n = 827), olanzapine (n = 824), zotepine (n = 286), or quetiapine (n = 360), without changing antipsychotics during the observation for at least 1 year (mean, 1.80 years; SD, 0.93 years) for each subject. Economic outcomes included clinic visits, prescription days, frequencies and duration of hospitalizations, and total and separate treatment costs (outpatient department- and hospital-related costs). Co-medications included use of anticholinergic, anxiolytic, hypnotic/sedative, and antidepressant agents. Patients treated with SGAs had lower number and shorter durations of hospitalizations than did haloperidol-treated patients, except for the clozapine group. Olanzapine was associated with the lowest hospitalization rates per year (mean, 1.63 vs 2.83). In terms of cost, haloperidol was more expensive in total hospitalization expenses (mean, US $3215 per year) and total treatment cost (mean, $3769 per year) than olanzapine, zotepine, or quetiapine. In general, there was no difference among the haloperidol and SGA groups in terms of rates of co-medications. The reduced number of hospitalizations and then lower total hospitalization costs seem to be more than the offset of high medication acquisition costs of SGAs.

Hospitalization rates before and after initiation of paliperidone ER in patients with schizophrenia: results from open-label extensions of the US double-blind trials

OBJECTIVE

To assess differences in the number of days hospitalized among schizophrenic patients receiving paliperidone extended-release (paliperidone ER) during the open-label extension (OLE) phases, compared to a similar time period prior to the screening for entry into the double-blind (DB) trials conducted in the United States.

METHODS

Mental health-related hospital days during the 52 weeks before entering the DB trials and during the OLE phases were compared. The mean number of hospital days per person per year in the pre- and post-periods was calculated and the statistical significance of pre-post differences was assessed using bootstrap resampling methods. Total person-years were also calculated for the pre- and post-periods to account for different lengths of observation.

RESULTS

Patients' (n=215) mean (+/-SD) age was 41.2 (+/-11.0) years; most were male (73.0%); and black (52.1 vs. 45.1% white). The mean (+/-SD) paliperidone ER treatment duration during the OLE phase was 167.0 (+/-145.0) days and the mean (+/-SD) daily dose was 10.5 (+/-2.0) mg. Overall, paliperidone ER patients spent an average (+/-SD) of 13.2 (+/-1.6) and 3.1 (+/-0.7) hospital days per person-year in the pre-and post-periods, respectively (mean +/-SD change 10.0+/-1.8, 95% CI 6.5, 13.4, p<0.001). Using the 2007 Federal Per Diem Base Rate (i.e., $595.09 per day), this reduction in hospital days would result in an average (+/-SD) cost savings of $5951 (+/-1071) per person per year.

CONCLUSIONS

Patients had significantly fewer hospital days in the OLE phase compared to the 1-year period prior to entering the DB trial. Paliperidone ER may play a role in reducing mental health-related hospital days and associated costs. Important study limitations include the lack of a control group, the pre-post design comparing historical data with data collected in the trials which could create a bias due to the mismatch in settings, and patients having more frequent contact with treating physicians and investigators during the trial period, which could favor the outcomes in the OLE phase. Further studies are needed to confirm these findings.

Modelling approaches: the case of schizophrenia

Schizophrenia is a chronic disease characterized by periods of relative stability interrupted by acute episodes (or relapses). The course of the disease may vary considerably between patients. Patient histories show considerable inter- and even intra-individual variability. We provide a critical assessment of the advantages and disadvantages of three modelling techniques that have been used in schizophrenia: decision trees, (cohort and micro-simulation) Markov models and discrete event simulation models. These modelling techniques are compared in terms of building time, data requirements, medico-scientific experience, simulation time, clinical representation, and their ability to deal with patient heterogeneity, the timing of events, prior events, patient interaction, interaction between co-variates and variability (first-order uncertainty). We note that, depending on the research question, the optimal modelling approach should be selected based on the expected differences between the comparators, the number of co-variates, the number of patient subgroups, the interactions between co-variates, and simulation time. Finally, it is argued that in case micro-simulation is required for the cost-effectiveness analysis of schizophrenia treatments, a discrete event simulation model is best suited to accurately capture all of the relevant interdependencies in this chronic, highly heterogeneous disease with limited long-term follow-up data.

Cost-effectiveness of antipsychotics for outpatients with chronic schizophrenia

AIMS

The aim of the present analysis was to evaluate the cost-effectiveness of alternative treatments for outpatients with chronic schizophrenia from the healthcare payer's perspective.

METHODS

Decision analysis was used to evaluate the cost-effectiveness of the following antipsychotic drugs: amisulpride, aripiprazole, haloperidol (oral formulation), haloperidol (depot formulation), olanzapine, quetiapine, risperidone (oral formulation), risperidone (depot formulation) and ziprazidone. Clinical and economic outcomes were modelled over 1-year time horizon. Effectiveness was measured as a percentage of patients in remission. Clinical parameters used in the model included compliance rates, rehospitalisation rates for compliant and non-compliant patients, duration and frequency of hospitalisation, and adverse event rates. One-way sensitivity analysis was performed to test the robustness of the model.

RESULTS

The most effective treatment was treatment with olanzapine where 64.1% of patients remained in remission. The least effective treatment was treatment with quetiapine where 32.7% of patients remained in remission. Overall costs ranged from 3,726.78 Euro for haloperidol to 8,157.03 Euro for risperidone in depot formulation. Inpatient costs represented the major part of costs for most of antipsychotic drugs. Typical antipsychotic drugs had substantially smaller outpatient costs (6.5%) compared with atypical antipsychotics (37.9%). In the base case scenario the non-dominated treatment strategies were haloperidol, haloperidol decanoate and olanzapine. Additionally, risperidone can also be considered to be part of the efficient frontier based on the sensitivity analysis results.

CONCLUSION

Among second-generation antipsychotics, which have a better safety profile than first-generation antipsychotics, olanzapine and risperidone showed to be the most cost-effective treatment strategies for outpatient treatment of chronic schizophrenia.

Rehospitalization rates of patients with schizophrenia discharged on haloperidol, risperidone or clozapine

OBJECTIVE:The purpose of this study was to evaluate the rehospitalization rates of patients discharged from the Institute of Psychiatry of the Hospital das Clínicas of the Universidade de São Paulo Medical School while being treated with haloperidol, risperidone or clozapine. METHOD: This is a naturalistic study designed to monitor rehospitalization rates for patients discharged on haloperidol (n = 43), risperidone (n = 22) or clozapine (n = 31). Time to readmission over the course of three years was measured by the product-limit (Kaplan-Meier) method. Risk factors associated with rehospitalizations were examined. RESULTS: At 36 months, remained in the community 74% of the haloperidol-treated patients, 59% of the risperidone-treated patients and 84% of the clozapine-treated patients. The haloperidol group showed a higher proportion of women, a late age of onset and shorter length of illness than the other groups, whereas the opposite was observed in the clozapine group. CONCLUSIONS: This study suggests that the rehospitalization rates of patients taking clozapine are lower than the rate for patients treated with haloperidol and risperidone. However confounding variables such as gender distribution and age of onset represent limitations that should be taken into account for the interpretation of the results.

Decision analysis model evaluating the cost-effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia

PURPOSE

To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale.

STUDY DESIGN AND METHODS

A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs.

RESULTS

Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs.

CONCLUSION

Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.

Hospitalization risks in the treatment of bipolar disorder: comparison of antipsychotic medications

OBJECTIVES

This study compared the relative risk for hospitalization of patients with bipolar and manic disorders receiving atypical and typical antipsychotics.

METHODS

This retrospective study was based on administrative claims data extracted from the PharMetrics database during 1999 through 2003. Comparisons were made among atypical antipsychotics (risperidone, olanzapine, quetiapine or ziprasidone), as well as between each of these versus a combined group of the leading typical antipsychotics. Relative risk for hospitalization was estimated with Cox proportional regression, which adjusted for differences in patient characteristics.

RESULTS

Risperidone and olanzapine demonstrated higher risks for hospitalization than quetiapine [hazard ratio (HR) 1.19, p < 0.05 for both], translating into higher annual mental health inpatient charges of $260 per patient. Risperidone and olanzapine also showed higher estimated risks than ziprasidone, which approached the p < 0.05 threshold. Differences between each of the atypicals and the combined typicals were not significant. Patients with putative rapid cycling had a threefold greater risk for hospitalization than other patients with bipolar disorder. In these patients, comparisons among atypical antipsychotics showed that risperidone had a significantly higher hospitalization risk than olanzapine (HR 3.31, p < 0.05), resulting in higher annual mental health inpatient charges of $4,930 per patient.

CONCLUSIONS

In the treatment of bipolar and manic disorders, risperidone and olanzapine were associated with a higher risk for hospitalization than quetiapine, and possibly ziprasidone. In the treatment of putative rapid cyclers, olanzapine was associated with a lower risk for hospitalization than risperidone.

Long-Acting Injectable Risperidone for the Treatment of Schizophrenia

Schizophrenia remains a severe disorder that is associated with a poor outcome in a large subgroup of patients. Major efforts should be made to improve treatment for all patients who have this debilitating disease. Second-generation antipsychotics were a major step forward in this respect; however, important unmet needs remain, such as a better solution for frequent noncompliance problems. Depot formulations are known to have advantages in this respect. However, for a long time, only depot formulations of conventional antipsychotics were available, with their high risk of extrapyramidal adverse effects. Therefore, there has been only very restricted use of depot antipsychotics, which mainly focused on patients with chronic disease who were difficult to treat and had a high risk of noncompliance. The situation may change with the advent of a depot formulation of an atypical antipsychotic. The first depot formulation of an atypical antipsychotic to be introduced to the market is long-acting injectable risperidone. On the basis of the pharmacokinetic properties of the depot formulation, a 2-week interval between administrations is recommended. The antipsychotic efficacy of long-acting risperidone was demonstrated in two 12-week, double-blind, randomised, phase III studies, one versus placebo and the other versus oral risperidone. These two studies, together with one open-label, long-term study over 12 months, belong to the core group of trials that were relevant for the licensing of long-acting risperidone. A relapse-prevention, control group study comparing the long-acting formulation versus oral risperidone was not performed because of the known principal methodological problems of such a comparison. Instead, as much clinical data as possible was collected from observational studies that investigated questions relevant for clinical practice, such as efficacy, safety and tolerability in different subgroups, and transition from pre-treatment with different kinds of antipsychotics to long-acting risperidone. On the basis of these data, it can be stated that the efficacy of the long-term formulation of risperidone is proven, and that the safety and tolerability are more or less comparable to those of oral risperidone. The local tolerability at the injection site is good. Because it is well known that noncompliance is a frequent feature of the treatment of schizophrenia, and considering the advantages of atypical antipsychotics, consideration of whether long-acting atypical antipsychotics should have a broader indication than is the case with the depot formulations of the classical antipsychotics is warranted.

Hospitalisation risks in the treatment of schizophrenia in a Medicaid population: comparison of antipsychotic medications

This study used administrative claims data to compare the relative risks for hospitalisation among patients with schizophrenia within a US Medicaid programme receiving atypical and typical antipsychotics. The newer atypical antipsychotics may be better tolerated among mentally ill patients receiving public assistance (Medicaid) who are less functional than other mentally ill populations. Risperidone, olanzapine, quetiapine and ziprasidone were compared with each other and to typical antipsychotics as a single category. Cox proportional hazard estimates, adjusted for differences in patient characteristics, showed numerically lower risks for each of the atypicals in comparison with the typicals, with that for quetiapine being statistically significant (HR: 0.672, p = 0.0413). There were no statistically significant differences among atypical pairs. This study provides evidence that risk for hospitalisation among Medicaid patients with schizophrenia may be lower with atypical antipsychotics, particularly quetiapine.

Hospitalization risks in the treatment of schizophrenia: comparison of antipsychotic medications

This study used administrative claims data to compare the relative risks for hospitalization among commercially insured patients with schizophrenia receiving atypical and typical antipsychotic drugs. Cox proportional hazard regression estimates, adjusted for differences in patient characteristics, suggested that among patients treated with the 4 atypical antipsychotic drugs, only olanzapine had a significantly higher risk for hospitalization than the typical antipsychotic drugs (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.20-2.75). In addition, risk for hospitalization with olanzapine was significantly higher than that for risperidone (HR, 1.34; 95% CI, 1.03-1.74) and numerically higher than that for quetiapine (HR, 1.40; 95% CI, 0.94-2.07). Overall, olanzapine was associated with a higher risk for hospitalization than the typical antipsychotic drugs and among the atypical antipsychotic drugs, risperidone and, potentially, quetiapine.

Comparison of time to rehospitalization among schizophrenic patients discharged on typical antipsychotics, clozapine or risperidone

BACKGROUND

The purpose of this study was to compare the time to rehospitalization of schizophrenic patients who were discharged from a psychiatric hospital while being treated with typical antipsychotics, clozapine or risperidone. We also assessed other possible predictors of time to rehospitalization.

METHODS

The study monitored the rehospitalization status of all the schizophrenic patients who were discharged from a psychiatric hospital between July 1, 2001 and June 30, 2002 while they were taking typical antipsychotics (n=272), clozapine (n=61) or risperidone (n=49). Rehospitalizations were tracked over a 2-year period using the Kaplan-Meier method. Risk factors associated with rehospitalization were examined by the Cox proportional hazards regression model.

RESULTS

No significant differences in time to rehospitalization were observed among the groups in the first or second year after discharge. Age at onset of schizophrenia was a risk factor for time to rehospitalization over the 1- and 2-year periods.

CONCLUSION

This study demonstrated that atypical antipsychotics did not lengthen the time to rehospitalization. The earlier the age at onset of schizophrenia, the shorter is the time to rehospitalization. Some other factors thought to impact rehospitalization need to be further assayed.

Medication decisions and clinical outcomes in the Canadian National Outcomes Measurement Study in Schizophrenia

OBJECTIVE

To evaluate over a 2-year period, patients from academic/non-academic centres, from each region of Canada, to determine whether location or other variables such as medication type, gender or income was associated with outcome as defined by non-hospitalization and persistence on original treatment.

METHOD

A total of 448 patients were recruited from academic and non-academic centres across all provinces of Canada and followed up for 2 years.

RESULTS

Patients from British Columbia had significantly lower rates of hospitalization than patients from other provinces. Male patients showed greater symptomatic improvement at 2 years from initial assessment compared to females. Patients on clozapine, risperidone and olanzapine were least likely to be hospitalized.

CONCLUSION

There were some regional differences noted in both utilization of types of antipsychotic medications and hospitalization rates. In this sample of stable out-patients over 70% who started on monotherapy with clozapine, risperidone, olanzapine and quetiapine remained on the same medication over the 2-year study period.

Resource utilization in a Canadian national study of people with schizophrenia and related psychotic disorders

OBJECTIVE

To determine how the use of the newer, so called atypical antipsychotic medications, effects the pharmacoeconomic treatment burden of schizophrenia and related conditions and to provide a clear comparison of the costs and risks associated with these atypical drugs.

METHOD

In this 2-year, open-label, prospective study, resource utilization (RU) data were collected on 160 patients with these conditions. A comparison between risks and costs was performed by combining the generalized CNOMSS data on both economic factors and risk assessments.

RESULTS

The main findings of the study were that the total adjusted 1- and 2-year costs were lowest for quetiapine. Drug acquisition costs were lowest for risperidone for both the 1- and 2-year cohorts. Clozapine use was predictably associated with the highest overall and medication costs at both 1 and 2 years.

CONCLUSION

Treatment with risperidone or quetiapine was associated with the lowest overall costs when compared with olanzapine or clozapine.

Risperidone: a review

When the risk of agranulocytosis associated with clozapine, the prototype of the second-generation neuroleptics, became apparent, its prescription was restricted to patients refractory to classical neuroleptics such as chlorpromazine and haloperidol. This stimulated the development of several novel second-generation antipsychotics with a clinical profile similar to that of clozapine. These novel antipsychotics, which include risperidone, olanzapine and others, are characterised by different pharmacological structures, and also to a certain degree by different pharmacological mechanisms. Following the increased research on the novel second-generation antipsychotics, it became apparent that they not only have the advantage of better extrapyramidal tolerability than the classical neuroleptics, but also have a broader efficacy spectrum (i.e., advantages in the treatment of negative and depressive symptoms and cognitive disturbances in the context of schizophrenia). Risperidone was specifically designed by Paul Janssen as a combined 5-HT2A and D2 receptor antagonist, thus following the pharmacological mechanism thought to be responsible for the antipsychotic effects of clozapine. After its advent in the 1990s as the first novel second-generation antipsychotic, risperidone achieved worldwide acceptance. The following review gives an overview of the huge clinical database available for risperidone in the field of schizophrenia.

Rehospitalization rates of patients with bipolar disorder discharged on a mood stabilizer versus a mood stabilizer plus an atypical or typical antipsychotic

One-year rehospitalization rates of patients with bipolar disorder discharged on a mood stabilizer alone, a mood stabilizer plus a typical antipsychotic, or a mood stabilizer plus an atypical antipsychotic were examined. Time to rehospitalization was measured by using the product-limit (Kaplan-Meier) formula. Twenty-three percent of patients on a mood stabilizer alone, 27% of patients on a mood stabilizer plus a typical antipsychotic, and 25% of patients on a mood stabilizer plus an atypical antipsychotic were rehospitalized within 1 year of discharge. There were no significant differences in rehospitalization rate or time to rehospitalization between groups. One-year rehospitalization rates for patients on a mood stabilizer plus olanzapine or risperidone were 25%. The number of previous psychiatric hospitalizations contributed to the risk of readmission. Risk factors and medication costs should be considered when designing the optimal treatment plan for an individual patient. Long-term prospective studies are needed to better delineate the effectiveness of different pharmacotherapeutic regimens on the long-term treatment outcomes in patients with bipolar disorder.

Strategies for improving adherence to second-generation antipsychotics in patients with schizophrenia by increasing ease of use

Despite the advances in the treatment of patients with schizophrenia that have occurred since the introduction of the second-generation (atypical) antipsychotic agents, a leading cause of suboptimal outcome is poor patient adherence to oral medication. Partial adherence can be attributed to a number of factors, including lack of insight, cognitive dysfunction, a complicated treatment regimen, drug-related side effects, patient attitude, lack of patient education, and cultural factors. A number of strategies, including psychosocial interventions, cognitive-behavioral techniques, strategies that minimize side effects, and pharmacological approaches that increase ease of medication use, can be employed to support adherence and improve long-term outcomes. This article focuses on strategies for increasing ease of use of antipsychotics in the treatment of patients with schizophrenia. These strategies include using monotherapy rather than polypharmacy, simplifying the medication regimen, and using a long-acting antipsychotic formulation. The goal of these strategies is to improve adherence and help prevent relapse by ensuring continuous antipsychotic coverage. Strategies that optimize ease of use of medication treatment for schizophrenia and thus improve adherence to treatment are likely to promote the attainment of new treatment goals and improved patient outcomes.

Simplifying psychotropic medication regimen into a single night dosage and reducing the dose for patients with chronic schizophrenia

RATIONALE

Taking psychotropic medications is frequently problematic from both consumers' and caregivers' perspective. Occasionally missed doses may lead to pervasive non-adherence with relapse a likely outcome.

OBJECTIVE

To evaluate the simple medication regimen, all psychotropics were given at night for patients with chronic schizophrenia, who had been taking them at least twice a day for more than 12 weeks before the entry.

METHODS

Switching of agents took place in two ways: converting only antipsychotic medications followed by other psychotropics, and changing all psychotropics simultaneously. Any psychotropics of little clinical significance were then cautiously minimized. Final evaluation was made 12 weeks after the competed dose consolidation. Patients finally rated their subjective impression on this intervention.

RESULTS

Twenty-five patients were recruited in each treatment arm (50 in total). After switching, 11 got better, 29 remained stable whereas seven got worse, according to the Global Improvement. Three were not assessable. Overall, there were no relevant changes in clinical ratings including adverse effects. However, the chlorpromazine equivalent dose of antipsychotics and the number of total psychotropics were significantly reduced from 957 to 722 mg/day (p<0.0001) and from 4.0 to 3.2 (p<0.0001), respectively. Dose deflation of psychotropics was feasible in 35 subjects (74.5%). Twenty-six (of 40 successful) patients indicated that they favored the night-time regimen mainly because it was less complicated. Sedation in the morning was identified as an important adverse event, which should be addressed by reducing the dose.

CONCLUSIONS

The procedure may be of value to counteract a recent trend of psychotropic polypharmacy in schizophrenia.

Risperidone: an open-label, observational study of the efficacy, tolerability, and prescribing behavior in acutely exacerbated patients with schizophrenia

OBJECTIVE

Efficacy of atypical antipsychotic in acute schizophrenic episodes is still in debate. This study evaluated treatment practices over 7 years of initial treatment with oral risperidone in acutely exacerbated patients with schizophrenia and in a subgroup of highly agitated, tense, and aggressive patients. Additionally, the study investigated the efficacy and tolerability of risperidone in routine clinical practice.

METHODS

In a prospective, multicenter, observational trial from 1996 to 2002, patients with schizophrenia experiencing acute symptom exacerbations were treated with risperidone within 24 hours of inpatient admission. Patients with a total score of > or =15 points on the agitation subscale of the Positive and Negative Syndrome Scale (PANSS) were defined as highly agitated. Efficacy measures were carried out with a modified PANSS, the Clinical Global Impression (CGI) and the Brief Psychiatric Rating Scale (BPRS).

RESULTS

A total of 1625 patients were evaluated. Despite prescription of decreasing risperidone dosages over 7 years, efficacy was maintained and tolerability improved significantly. Significant symptom relief occurred in all patients and was more pronounced in the subgroup of highly agitated patients (n = 256; P < 0.001 for PANSS, BPRS, and CGI). At Week 6, the mean daily dosage of risperidone was 4.8 mg in the highly agitated patients and 4.7 mg in the remaining patients, and more than 55% of all patients were receiving risperidone as monotherapy.

CONCLUSIONS

Prescribing patterns with risperidone in patients with acutely exacerbated schizophrenia, including highly agitated patients, changed with the experience gained with this compound. In routine clinical practice in this indication, risperidone was found to be effective and well tolerated.

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.

Reduction in hospital stay of chronic schizophrenic patients after long-term clozapine treatment

The present study aimed to elucidate the effectiveness of clozapine treatment in reducing the disabling period of chronically ill schizophrenic patients by investigating their rehospitalization status. Of 232 schizophrenic patients with a history of clozapine use who were recruited from the clinic at Seoul National University Hospital, 117 were selected who had been followed up for more than 1 year with respect to rehospitalization. To obtain information about the period before the clozapine change, a chart review of these 117 patients was conducted. The number and length of hospitalizations of the patients significantly decreased after clozapine treatment compared to the same period before clozapine treatment. The hospital days per year of the patients were also decreased significantly after clozapine introduction. By analysing 38 patients who were followed up for more than 5 years, it was suggested that the decrease in the number and length of hospitalizations was substantially sustained for up to 5 years after clozapine treatment. This study showed that the number and length of hospitalizations are significantly decreased by long-term clozapine treatment and that this effect can positively affect the social outcome of schizophrenic patients.

Analyse coût-efficacité des stratégies de prise en charge des patients schizophrènes : place d’un antipsychotique atypique sous forme injectable à libération prolongée

Schizophrenia is a disease affecting the young adults and amounts to approximately 300,000 people in France. The French public psychiatric sector takes care of approximately 150,000 adults schizophrenics: 50% benefit from ambulatory care, 50% are in partial or full-time hospitalization care. Schizophrenia represents the first diagnosis that psychiatric sectors take in charge. The costs associated with schizophrenia, mainly hospital costs, are important and were estimated at 2% of the total medical costs in France. In the French social welfare system, the social costs (pensions, allowances, managements of custody or guardianship by social workers) are also to be taken into account: it amounts to a third of the global direct cost. Schizophrenia also generates indirect costs (losses of productivity and premature deaths) which would be at least equal, or even more important, than direct medical costs. The non-compliance to the antipsychotic treatment is a major problem with people suffering from schizophrenia. Indeed the lack of compliance to the treatment, estimated at 20 to 40%, is a major handicap for schizophrenic patient stabilization. The poor level of compliance is due to many various causes: adverse effects that are considered unbearable, medicine viewed as persecutory, negation of the disease, nostalgia for the productive phases of the disease, lack of social support, complexity of the prescription, relapse itself. Compliance is thus influenced by the patient's clinical features, local provision of health care and the specific nature of the drug (adverse effects, pharmaceutical formulation). The atypical antipsychotics present fewer extrapyramidal side effects and reduce the cognitive deficits associated with the disease, which results in improved compliance. Long-acting injectable antipsychotics allow a better therapeutic compliance and thus better efficacy of the treatment. Several studies have shown a significant improvement in compliance related to the pharmaceutical formulation of antipsychotics. Hospitalization and relapse risks are lower in compliant than in non-compliant patients.

OBJECTIVES

The main objective of this pharmacoeconomic analysis is to evaluate the impact in terms of medical benefits and costs of the following strategies: 1. Risperidone long-acting injection: first long-acting injectable atypical antipsychotic; 2. Haloperidol depot: long-acting injectable conventional neuroleptic; 3. Olanzapine: atypical antipsychotic available commercially in oral formulation.

METHODS

The target population defined for the study are young schizophrenic patients treated for at least 1 year and whose disorder has not been diagnosed for longer than 5 years. The time horizon is 2 years. A cost-effectiveness analysis is performed. The perspective adopted is the French Health System. The main hypothesis of the model is that an increase in compliance linked to the use of long-acting injectable formulation could lead to an increased efficacy and a modification of the cost-effectiveness ratio. A decision tree was built. Six periods of follow-up are identified with a duration of 4-months per period. The tree contains 3 principal arms, each one corresponding to a specific treatment: risperidone LA injection, haloperidol decanoate and olanzapine. For each arm, at the chance node, two health states are identified: either the patient responds favourably to the treatment or does not respond favourably and requires a switch to another drug treatment. After a period of response, the patient can either remain in the same state or experiences a clinical deterioration. If the patient presents a clinical deterioration, he can either go back to a positive response state after a period of intensive follow-up or remain in an insufficient response state; in this case, a change of antipsychotic treatment is necessary. In the model, a patient should receive four different treatments before a long-term hospitalization takes put in place. According to the market authorization labelling, clozapine is proposed only as a 2nd or 3rd line therapeutic option, so when at least one or two successive neuroleptics have failed. The efficacy data used in the model are provided by clinical research recently published. These studies estimate the efficacy of oral risperidone, LA risperidone, olanzapine, and treatment by haloperidol. When available data in the literature were insufficient, the opinion of experts was sought. The effectiveness criteria is the rate of patients treated successfully: patients responding to the initial treatment with the possibility of experiencing one or two episodes of clinical deterioration but without requiring a switch to another drug during 2 years of follow-up. The base case is as follows: efficacy for oral risperidone is used for the LA risperidone strategy, increased by 10% within the first 4 months of follow-up; efficacy for oral haloperidol is used for haloperidol depot, increased by 5% within the first 4 months of follow-up; for olanzapine, observed data in clinical trials were applied. The hypotheses for long acting forms are rather conservative because the increase of efficacy which can be expected for the long-acting injectable formulations varies between 5% to more than 30% according to the literature data. The analysis of sensibility includes three scenarios: scenario 1: for LA risperidone, 5% of patients treated successfully improvement in regard to oral risperidone instead of 10% in the base case; scenario 2: for haloperidol depot, 10% of patients treated successfully improvement in regard of oral haloperidol instead of 5% in the base case; scenario 3: the results of an open trial conducted within the framework of the LA risperidone license are used, leading to an increase of up to 13,3% of the rate of successfully treated patients, compared to oral risperidone literature data. As for the side effects, only extrapyramidal symptoms were considered. Other side effects are described in the literature such as the obesity or the occurrence of a diabetes; these effects were not taken into account in the model, their impact on the cove-rage of schizophrenic patients and on resources utilisation being poorly known. Only direct medical costs were considered in the pharmaco-economic analysis. Two types of costs were identified: hospital costs and community care costs. The stays in overnight hospitalisation and day hospitalisation were derived from the Disease Related Groups (DRG) and valued from the data of the National Cost Study (Etude Nationale de Coûts; 1999). The DRGs corresponding to the diagnosis of schizophrenia are the DRG 627 (complete hospitalization) and DRG 819 (day hospitalisation). Ambulatory care: procedures and visits, were valued in euros in reference with the tariffs for reimbursement issued in the Naming General of the Professional Acts (NGAP) and published by the French National Health Insurance (Year 2001). Medication consumption was quantified by using the daily dosage specified in the the MAA and the French prescription database IMS-Dorema. The cost of medicines was valued from tariffs 2001 (SEMPEX). LA risperidone price being not fixed to date, the reserved hypothesis is a 141,62 Euro retail price. As schizophrenia is listed among the diseases reimbursed at a 100% rate by the Health insurance, out of pocket expenses by patient are not considered in the analysis. The cost for the extrapyramidal effects was attributed to all the strategies. This cost was calculated according to the rates of extrapyramidal effects occurrence collected in the literature. Globally, in the published studies, the incidence of the side effects for the patients treated by olanzapine or risperidone is similar. It was thus decided by the experts to use the same rate of occurrence for extrapyramidal effects for olanzapine and risperidone (20%). This rate is 40% for haloperidol decanoate, 10% for oral clozapine. For the cost estimation, the expenses for treating a schizophrenic patient for two years were taken into account.

RESULTS

The results show that in two years, LA risperidone is more effective than the two other antipsychotics. After 2 years, the rate of patients treated successfully is 82,7% for LA risperidone, 74,8% for olanzapine and 57,3% for haloperidol depot. The 2 year-cost per patient treated by LA risperidone is 14,055 Euro. This cost is 14,351 Euro and 17,203 Euro respectively for the strategies olanzapine and haloperidol depot. The cost-efficacy ratios per patient successfully treated are 16,995 Euro for the strategy LA risperidone, 19,186 Euro for olanzapine and 30,023 Euro for haloperidol depot. LA risperidone is a dominant strategy compared with both olanzapine and haloperidol depot. Scenario 1 shows that LA risperidone strategy remains the most effective. Indeed, this strategy allows a response increase of 3,5% regarding olanzapine strategy and of 21% regarding haloperidol depot strategy. Under the hypothesis tested in scenario 1, LA risperidone is a partial dominant strategy against olanzapine and a total dominant strategy against haloperidol depot. In scenario 2, as efficacy is improved for haloperidol decanoate (61,10%), a decrease of 1,763 Euro in the cost per patient treated is observed for this strategy. Cost per patient treated successfully and efficacy for LA risperidone and olanzapine are the same than in the base case. LA risperidone is a total dominant strategy against olanzapine and haloperidol decanoate. In scenario 3, the rate of patients treated successfully at 2 years is 88,6% for LA risperidone with a cost per patient of 12,347 Euro. LA risperidone is dominant against olanzapine and haloperidol depot.

DISCUSSION AND CONCLUSION

The schizophrenia is a relatively frequent disease. (ABSTRACT TRUNCATED)