Economic Cost of Schizophrenia in a Nigerian Teaching Hospital

An analysis of financial hardship faced by patients with First Episode Psychosis, and their families, in an Indian setting

BACKGROUND

The economic burden of psychotic disorders is not well documented in LMICs like India, due to several bottlenecks present in Indian healthcare system like lack of adequate resources, low budget for mental health services and inequity in accessibility of treatment. Hence, a large proportion of health expenditure is paid out of pocket by the households.

OBJECTIVE

To evaluate the direct and indirect costs incurred by patients with First Episode Psychosis and their families in a North Indian setting.

METHOD

Direct and Indirect costs were estimated for 87 patients diagnosed at AIIMS, New Delhi with first-episode psychosis (nonaffective) in the first- and sixth month following diagnosis, and the six months before diagnosis, using a bespoke questionnaire. Indirect costs were valued using the Human Capital Approach.

RESULTS

Mean total costs in month one were INR 7991 ($107.5). Indirect costs were 78.3% of this total. Productivity losses was a major component of the indirect cost. Transportation was a key component of direct costs. Costs fell substantially at six months (INR 2732, Indirect Costs 61%). Respondents incurred substantial costs pre-diagnosis, related to formal and informal care seeking and loss of income.

CONCLUSION

Families suffered substantial productivity loss. Care models and financial protection that address this could substantially reduce the financial burden of mental illness. Measures to address disruption to work and education during FEP are likely to have significant long-term benefits. Families also suffered prolonged income loss pre-diagnosis, highlighting the benefits of early and effective diagnosis.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19

BACKGROUND

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss.

METHODS

This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach.

RESULTS

On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs.

CONCLUSIONS

The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

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

BACKGROUND

Schizophrenia imposes a substantial economic burden on society. This updated systematic review aims to collate the latest societal cost of schizophrenia across countries by reviewing recent cost-of-illness (COI) studies.

METHODS

An electronic search was conducted across several databases (MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Health Management Information Consortium, and System for Information on Grey Literature) to identify COI studies published from 2016 to 2022. Two independent reviewers selected studies for inclusion. The cost components and estimates reported by included studies were descriptively summarised. All costs were converted to US dollars (2022 values). Study quality was assessed using a checklist adapted from Larg & Moss.

RESULTS

Twenty-four studies were included (5 from the update review and 19 from the original review), of which only two were conducted for low- and middle-income countries (LMICs). Widespread methodological heterogeneity among included studies was observed. The annual societal cost per person varied from US$819 in Nigeria to US$94,587 in Norway. Productivity losses accounted for 32-83% of the overall societal cost, whilst direct healthcare cost made up 11-87%. The reporting quality of included studies varied.

CONCLUSION

This review highlights the substantial economic burden of schizophrenia and a lack of COI studies for LMICs. Recommendations on future research, and good practices on improving the methodological and reporting quality of COI research for schizophrenia are provided.

Integrating mental health into primary care: evaluation of the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) pilot project

Background

The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project trains non-specialist and primary health care workers in Imo State, Nigeria. This project adapted the World Health Organization’s Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG), emphasizing stigma reduction among trainees. This convergent mixed-methods proof-of-concept study evaluates the HAPPINESS pilot project mhGAP-IG training’s impact on mental illness stigma among trainees and barriers, facilitators, and opportunities to consider for project improvement.

Methods

Trainees (n = 13) completed a 43-item questionnaire before and after their 5-day training to assess perceptions of mental disorders and attitudes towards people with mental illness. These responses were analyzed using paired-sample t-tests for four subscales of the questionnaire: acceptance of socializing with people with mental illness, normalizing activities and relationships with people with mental illness, supernatural causation of mental illness, and endorsement of a biopsychosocial approach to mental illness. Semi-structured key informant interviews (n = 11) with trainees, trainers, and local health officials who participated in or supported the HAPPINESS project were thematically analyzed to understand their experiences and perspectives of the project’s barriers, facilitators, and opportunities.

Results

Trainees showed significant improvements on socializing, normalizing, and supernatural causation subscales of the stigma questionnaire (p < 0.05). No significant effect was seen on the biopsychosocial subscale; however, evidence of biopsychosocial beliefs was found in interview responses. Key informant interviews revealed that the HAPPINESS project enhanced trainees’ diagnostic and treatment abilities, mental health awareness, and empathy towards patients. Misinformation, stigma, inadequate funding, and lack of road access to clinics were identified as barriers to mental health care integration into general care in Imo State. Respondents also suggested ways that the HAPPINESS project could be improved and expanded in the future.

Conclusions

This study adds to the limited evidence on the implementation of mhGAP-IG in Nigeria. Using mixed methods, it evaluates how mhGAP-IG can impact perceptions and knowledge of stigma among primary care trainees. It also highlights barriers, facilitators, and opportunities to consider for project growth. Future efforts should focus on clinical support, supervision, health outcomes, as well as scaling up and assessing the cost-effectiveness of the HAPPINESS project intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07703-1.

Medication Profile and Treatment Cost Estimation Among Outpatients with Schizophrenia, Bipolar Disorder, Depression, and Anxiety Disorders in Indonesia

PURPOSE

The present retrospective study aimed to determine the medication profile and estimate the treatment costs from medical records of new outpatients with schizophrenia, bipolar disorder, depression, and anxiety disorders from a healthcare perspective at a national referral hospital in Indonesia from 2016 to 2018.

METHODS

Medical records (including medical and administrative data) of 357 new outpatients with schizophrenia, bipolar disorder, depression, or anxiety disorders were collected from the hospital information system. The records of new outpatients with schizophrenia, bipolar disorder, depression, or anxiety disorders aged >18 years and had only received drugs for treatment were included. The medication profile was descriptively assessed, and estimated costs were calculated based on direct costs from a healthcare perspective.

RESULTS

Overall, 173 medical records were further analyzed. The main drugs administered to the new outpatients were atypical and typical antipsychotics for schizophrenia, atypical antipsychotics and mood stabilizers for bipolar disorder, antidepressants and atypical antipsychotics for depression, and antidepressants and benzodiazepines for anxiety disorders. The average annual treatment costs per patient were IDR 3,307,931 (USD 236) for schizophrenia, IDR 17,978,865 (USD 1,284) for bipolar disorder, IDR 1,601,850 (USD 114) for depression, and IDR 1,190,563 (USD 85) for anxiety disorders.

CONCLUSION

The most commonly prescribed drugs for schizophrenia were haloperidol and risperidone; for bipolar disorders, sodium divalproex and risperidone; for depression, fluoxetine and sertraline; and for anxiety disorders, sertraline and lorazepam. Considering the high prevalence and estimated treatment costs for mental disorders, special attention is required to prevent an increase in their prevalence in Indonesia.

Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane

BACKGROUND

Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa.

METHODS

Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment.

RESULTS

Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21).

CONCLUSION

Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.