Costs of treating patients with schizophrenia who have illness-related crisis events

Factors Associated with Family Retention or Involvement in Treatment of Persons with Severe Mental Illness: A Scoping Review

Objective

A scoping review was conducted to detect the factors that affect family retention (FR) or involvement (FI) in the treatment of persons with severe mental illness (PwSMI) and to understand the gaps in this research area.

Design

We included studies that described factors associated with FR/FI in the treatment of persons with PwSMI. English language articles available in full text, published until June 2022, were included. The literature search was carried out in four major electronic databases, such as PubMed, Scopus, ProQuest, and EBSCOhost, for 6 months from January 2022 to June 2022, which yielded 5442 articles, of which six (four primary studies and two secondary studies) were considered for the final scoping review as per the inclusion criteria.

Results

Five major categories of factors were identified: (a) family level, (b) professional level, (c) mental health system level, (d) related to characteristics of the patient and illness, and (e) related to the external environment. Most studies described barriers to FI, while only a few elaborated on facilitators for FI/FR. Systemic and family-level factors were the major contributors to the barrier to FI and FR in the treatment of people with PwSMI.

Conclusion

There is a dearth of literature in the field of FR/FI in the treatment of people with schizophrenia. More research is required so that holistic interventions can be designed and provided.

Socioeconomic burden of schizophrenia: a targeted literature review of types of costs and associated drivers across 10 countries

AIMS

Schizophrenia has the highest median societal cost per patient of all mental disorders. This review summarizes the different costs/cost drivers (cost components) associated with schizophrenia in 10 countries, including all cost types and stakeholder perspectives, and highlights aspects of disease associated with greatest costs.

MATERIALS AND METHODS

Targeted literature review based on a search of published research from 2006 to 2021 in the United States (US), United Kingdom (UK), France, Germany, Italy, Spain, Canada, Japan, Brazil, and China.

RESULTS

Sixty-four published articles (primary studies and literature reviews) were included. Comprehensive data were available on costs in schizophrenia overall, with very limited data for individual countries except the US. Most data is related to direct and not indirect costs, with extremely scarce data for several key cost components (adverse events, suicide, long-term care). Total schizophrenia-related per person per year (PPPY) costs were $2,004-94,229, with considerable variability among countries. Indirect costs were the main cost driver (50-90% of all costs), ranging from $1,852 to $62,431 PPPY. However, indirect costs are not collected systematically or incorporated in health technology assessments. Total schizophrenia-related PPPY direct costs were $4,394-31,798, with inpatient cost as the main cost driver (∼20-99% of direct costs). Intangible costs were not reported. Despite limited evidence, total schizophrenia-related costs were higher in patients with than without negative symptoms, largely due to increased costs of medication and medical visits.

LIMITATIONS

As this was not a systematic review, prioritization of studies may have resulted in exclusion of potentially relevant data. All costs were converted to USD but not corrected for inflation or subjected to a gross domestic product deflator.

CONCLUSIONS

Direct costs are most commonly reported in schizophrenia. The substantial underreporting of indirect and intangible costs undervalues the true economic burden of schizophrenia from a payer, patient, and societal perspective.

Evaluation of major treatment failure in patients with recent-onset schizophrenia or schizophreniform disorder: A post hoc analysis from the Disease Recovery Evaluation and Modification (DREaM) study

OBJECTIVE

A post hoc analysis of the Disease Recovery Evaluation and Modification (DREaM) study was conducted to evaluate time to first major treatment failure (ie, arrest/incarceration or psychiatric hospitalization) in participants with recent-onset schizophrenia or schizophreniform disorder treated with paliperidone palmitate (PP) versus oral antipsychotics (OAPs).

METHODS

DREaM was an open-label, delayed-start, randomized, multipart trial consisting of: Part I, 2-month oral run-in; Part II, 9-month disease progression phase (PP or OAP); and Part III, 9 months of additional treatment (PP/PP; OAP re-randomized: OAP/OAP or OAP/PP). PP/PP and OAP/OAP comprised the 18-month extended disease progression (EDP) analysis.

RESULTS

In Part II (PP, n = 78; OAP, n = 157), similar proportions of participants experienced a major treatment failure across groups (PP: 12.8 %; OAP: 13.4 %); no difference in time to first major treatment failure was identified (P = 0.918). Significant differences favoring PP emerged after 9 months; in Part III, no participants in the PP/PP group, 3.5 % of participants in the OAP/PP group, and 15.9 % in the OAP/OAP group experienced a major treatment failure (P = 0.002). In the EDP analysis, 10.2 % (PP/PP) and 25.4 % (OAP/OAP) of participants experienced a major treatment failure (P = 0.045; number needed to treat = 6). Safety results were similar between groups and consistent with the known safety profile of PP in adults with schizophrenia.

CONCLUSIONS

Initiation of PP during the early stages of schizophrenia spectrum disorders significantly delayed time to hospitalization and arrest/incarceration, outcomes with important personal and economic consequences, compared with OAP during this 18-month study.

CLINICALTRIALS

gov identifier: NCT02431702.

NMR Metabolomics in Serum Fingerprinting of Schizophrenia Patients in a Serbian Cohort

Schizophrenia is a widespread mental disorder that leads to significant functional impairments and premature death. The state of the art indicates gaps in the understanding and diagnosis of this disease, but also the need for personalized and precise approaches to patients through customized medical treatment and reliable monitoring of treatment response. In order to fulfill existing gaps, the establishment of a universal set of disorder biomarkers is a necessary step. Metabolomic investigations of serum samples of Serbian patients with schizophrenia (51) and healthy controls (39), based on NMR analyses associated with chemometrics, led to the identification of 26 metabolites/biomarkers for this disorder. Principal component analysis (PCA) and orthogonal partial least squares discriminant analysis (OPLS-DA) models with prediction accuracies of 0.9718 and higher were accomplished during chemometric analysis. The established biomarker set includes aspartate/aspartic acid, lysine, 2-hydroxybutyric acid, and acylglycerols, which are identified for the first time in schizophrenia serum samples by NMR experiments. The other 22 identified metabolites in the Serbian samples are in accordance with the previously established NMR-based serum biomarker sets of Brazilian and/or Chinese patient samples. Thirteen metabolites (lactate/lactic acid, threonine, leucine, isoleucine, valine, glutamine, asparagine, alanine, gamma-aminobutyric acid, choline, glucose, glycine and tyrosine) that are common for three different ethnic and geographic origins (Serbia, Brazil and China) could be a good start point for the setup of a universal NMR serum biomarker set for schizophrenia.

Second-generation LAI are associated to favorable outcome in a cohort of incident patients diagnosed with schizophrenia

OBJECTIVE

Investigate the associations of long-acting injectable (LAI) second generation antipsychotic drugs with number of relapses, psychiatric admissions, days hospitalized, intentional self-harm events, and costs linked to hospitalizations in incident patients diagnosed with schizophrenia.

METHOD

A nationwide, population-based, retrospective study utilizing mirror-image models before and after initiation of LAI SGA.

RESULTS

10,509 patients were included as study population, with analyses being conducted on 2223 patients in a six-month period, 1383 in a 12-month period, 713 in a 24-month period. After initiation of LAI antipsychotics, patients experienced a reduction in number of relapses with an incidence rate ratio (IRR) of 0.60 for the first six months, IRR 0.64 for the first 12 months and IRR 0.64 for the first 24 months following initiation of LAI, all P < 0.001. The number of psychiatric admissions was reduced in a similar manner with respective IRR of 0.59, 0.60 and 0.64, all P < 0.001. Psychiatric bed-days were reduced with 58, 100 and 164 days for the respective periods after LAI initiation, all P < 0.001. In a Cox regression model in patients initiated on LAI, higher age at diagnosis, hazard rate ratio (HR) 0.99, 95%CI(0.98-0.99), P < 0.001, and a later calendar year of diagnosis, HR 0.99, 95%CI(0.98-1.00), P < 0.05, were associated with a lower risk of relapse, whereas mainly psychiatric comorbidity, HR 1.07, 95% CI (1.04-1.11), P < 0.001, and cardiovascular disease, HR 1.12, 95%CI(1.01-1.26), P < 0.05, were associated with relapse.

CONCLUSION

Even though the design does not allow inferences regarding causality, these population-based findings support the use of second generation LAI antipsychotics.

Targeted cognitive training improves auditory and verbal outcomes among treatment refractory schizophrenia patients mandated to residential care

Computerized targeted cognitive training (TCT) of auditory processing has been shown to improve verbal learning in several clinical trials of schizophrenia outpatients. Less is known, however, about the effectiveness of this promising intervention in more chronic, treatment-refractory patients who are treated in non-academic settings. This study aimed to determine whether TCT improves auditory processing, verbal learning, and clinical symptoms in SZ patients mandated to receive care at a locked residential rehabilitation center. Secondarily, potential factors that moderate TCT's effectiveness including age, symptom severity, antipsychotic medication load, and duration of illness were examined. Schizophrenia patients were randomized to treatment as usual (TAU; n = 22) or TAU augmented with TCT (TAU + TCT; n = 24). Outcomes included a measure of auditory perception (Word-In-Noise test, WIN), verbal learning domain scores from the MATRICS Consensus Cognitive Battery (MCCB), and clinical symptoms (Scale for the Assessment of Positive Symptoms, SAPS; Scale for the Assessment of Negative Symptoms, SANS). TCT produced significant improvements in auditory perception (d = 0.67) and verbal learning (d = 0.65); exploratory analyses revealed a statistically significant reduction in auditory hallucinations (d = -0.64). TCT's effects were only weakly, and mostly non-significantly, moderated by age, clinical symptoms, medication, and illness duration. These findings indicate that even highly symptomatic, functionally disabled patients with chronic illness benefit from this emerging treatment. Ongoing studies will examine the predictive utility of neurophysiological biomarkers and other characteristics assessed at baseline.

Do comprehensive, coordinated, recovery-oriented services alter the pattern of use of treatment services? Mental health treatment study impacts on SSDI beneficiaries' use of inpatient, emergency, and crisis services

Current arrangements for financing and delivering behavioral health services to U.S. working-age adults with severe and persistent mental disorders (SPMD) have major inadequacies in funding for and access to critical elements of a recovery-oriented, comprehensive, and coordinated package of community-based treatment and rehabilitation services. This study presents results from a nation-wide 2-year randomized trial, involving 2,238 SSDI beneficiaries with SPMD, of a comprehensive intervention including evidence-based treatment and employment services. Estimates of impacts of the MHTS service intervention package, from a variety of regression specifications, showed clearly significant treatment group reductions in four outcomes (hospital stays and days, ER visits for mental health problems, and psychiatric crisis visits); these estimates suggest annual inpatient hospital treatment cost savings in excess of approximately $900 to 1,400. Negative estimated MHTS effects on three other utilization outcomes (hospital stays and days for mental health problems, overall ER visits) generally did not achieve statistical significance. Possible study implications for cost offsets from further expansions/replications of the MHTS intervention model are considered within the context of health reform.

Healthcare utilization and costs of Veterans Health Administration patients with schizophrenia treated with paliperidone palmitate long-acting injection or oral atypical antipsychotics

OBJECTIVE

This study aimed to compare real world healthcare costs and resource utilization between patients with schizophrenia treated with paliperidone palmitate long-acting injection (PP) and oral atypical antipsychotics (OAT).

METHODS

Patients (18-64 years) were selected from the Veterans Health Administration dataset (1 July 2007-31 May 2012). Patients with 2+ claims for PP or 2+ claims for the same OAT comprised the two study cohorts with the first prescription date designated as the index date. Participation in the VA healthcare system for 24 months pre- and 12 months post-index, schizophrenia diagnosis (International Classification of Disease 9th Revision Clinical Modification [ICD-9-CM] code 295.1x-6x, 295.8x-9x) and ≥1 claim for an antipsychotic medication during the baseline period were required. Propensity scores and Mahalanobis metric distances with calipers were used to create two matched cohorts. All-cause healthcare utilization and costs for the 12-month follow-up period were compared between matched cohorts.

RESULTS

The matching process produced two cohorts of 335 patients with similar baseline characteristics. During the 12-month follow-up period, patients in the PP cohort had lower mean inpatient costs (18,560 vs $31,505, p = 0.002), lower frequency of hospitalization (34% vs 53%, p < 0.001) and fewer average inpatient days (13.24 vs 24.18, p = 0.002) vs matched OAT patients. While mean pharmacy costs were higher for the PP cohort ($10,063 vs $4167, p < 0.001), mean total healthcare costs were not significantly different ($45,529 vs $52,569, p = 0.128).

CONCLUSION

VA patients, diagnosed with schizophrenia and treated with PP, had lower inpatient costs and admission rates compared to a matched cohort of OAT patients. Total healthcare costs were not significantly different.

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.

Does Treatment Adherence Therapy reduce expense of healthcare use in patients with psychotic disorders? Cost-minimization analysis in a randomized controlled trial

BACKGROUND

Adherence interventions in psychotic disorders have produced mixed results. Even when an intervention improved adherence, benefits to patients were unclear. Treatment Adherence Therapy (TAT) also improved adherence relative to Treatment As Usual (TAU), but it had no effects on symptoms or quality of life. TAT may or may not reduce healthcare costs.

AIM

To determine whether TAT reduces the use of healthcare resources, and thus healthcare costs.

METHOD

Randomized controlled trial of TAT versus TAU with 98 patients. Interviews were conducted at baseline (T0), six months later, when TAT had been completed (T1) and at six-month follow-up (T2). We have used admission data and part of the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). We compared total costs in the TAT group with those in the control group with the help of multivariate analysis of covariance.

RESULTS

TAT did not significantly minimize total costs. In the TAT group, the mean one-year health-treatment cost per patient (including TAT sessions) was € 23 003.64 (SD=19 317.95), whereas in the TAU group it was € 22 489.88 (SD=25 224.57) (F(1)=.652, p=.42). However, there were two significant differences at item-level, both with higher costs for the TAU group: psychiatric nurse contacts and legal proceedings for court-ordered admissions.

CONCLUSIONS

Because TAT did not reduce total healthcare costs, it did not contribute to cost-minimization. Its benefits are therefore questionable. No other adherence intervention has included analysis of cost-effectiveness or cost-minimization.

How do clinical trial participants compare to other patients with schizophrenia?

OBJECTIVE

Patients with schizophrenia enrolled in a trial of long-acting injectable risperidone at multiple sites of the Veterans Health Administration (VHA). We considered if the trial participants were representative of the targeted group of high-utilization patients with poor adherence to anti-psychotics.

METHODS

Participants' characteristics, health services utilization, and cost in the year prior to randomization were compared to a randomly selected time-matched cohort of 10,000 other patients with schizophrenia who were not in the trial.

RESULTS

There were few differences in the characteristics, utilization, or cost between trial participants and non-participants who met the key trial inclusion criterion of a history of psychiatric hospitalization in the prior 24 months. Trial participants were more likely to be African-American (45.5% vs. 35.1%, p<.001) and were less likely to have had a medical-surgical hospitalization in the study year (8.2% vs. 19.2% p<.001). Compared to non-participants who did not meet the inclusion criterion, trial participants were more likely to have a psychiatric condition in addition to schizophrenia (81.0% vs. 51.3%, p<.001), more likely to have a substance abuse disorder (46.3% vs. 13.9% p<.001), and less likely to be adherent with their anti-psychotic medication (21.3% vs. 37.9%, p<.001). They also incurred more than three times the annual cost ($42,563 vs. $12,270, p<.001).

CONCLUSIONS

Trial participants appeared to be representative of the 23.3% of VHA patients with schizophrenia who met the key trial inclusion criterion, suggesting that trial findings will be relevant to the broader group of high risk patients.

Effectiveness of injectable risperidone long-acting therapy for schizophrenia: data from the US, Spain, Australia, and Belgium

BACKGROUND

Because wide variations in mental health care utilization exist throughout the world, determining long-term effectiveness of psychotropic medications in a real-world setting would be beneficial to physicians and patients. The purpose of this analysis was to describe the effectiveness of injectable risperidone long-acting therapy (RLAT) for schizophrenia across countries.

METHODS

This was a pragmatic analysis of data from two prospective observational studies conducted in the US (Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation [SOURCE]; ClinicalTrials.gov registration number for the SOURCE study: NCT00246194) and Spain, Australia, and Belgium (electronic Schizophrenia Treatment Adherence Registry [eSTAR]). Two separate analyses were performed to assess clinical improvement during the study and estimate psychiatric hospitalization rates before and after RLAT initiation. Clinical improvement was evaluated using the Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, and change from baseline was evaluated using paired t tests. Psychiatric hospitalization rates were analyzed using incidence densities, and the bootstrap resampling method was used to examine differences between the pre-baseline and post-baseline periods.

RESULTS

The initial sample comprised 3,069 patients (US, n = 532; Spain, n = 1,345; Australia, n = 784; and Belgium, n = 408). In all, 24 months of study participation, completed by 39.3% (n = 209), 62.7% (n = 843), 45.8% (n = 359), and 64.2% (n = 262) of patients from the US, Spain, Australia, and Belgium, respectively, were included in the clinical analysis. Improvements compared with baseline were observed on both clinical assessments across countries (P < 0.001 at all post-baseline visits). The mean improvement was approximately 1 point on the CGI-S and 15 points on the GAF. A total of 435 (81.8%), 1,339 (99.6%), 734 (93.6%), and 393 (96.3%) patients from the US, Spain, Australia, and Belgium, respectively, had ≥1 post-baseline visit and were included in the analysis of psychiatric hospitalization rates. Hospitalization rates decreased significantly in all countries regardless of hospitalization status at RLAT initiation (P < 0.0001) and decreased significantly in the US and Spain (P < 0.0001) when the analysis was limited to outpatients only.

CONCLUSIONS

RLAT in patients with schizophrenia was associated with improvements in clinical and functional outcomes and decreased hospitalization rates in the US, Spain, Australia, and Belgium, despite differences in health care delivery systems.