Relapse, hospitalization, and healthcare-related costs are major drivers of the economic burden associated with schizophrenia.^1,2 Read the article below to learn more about the cost implications and benefits of antipsychotic (AP) therapy in schizophrenia.

Long-term management of schizophrenia has substantial financial implications

Schizophrenia is a chronic and debilitating mental health disorder that affects 0.6–1.9% of people in the United States (US).³ Despite having a relatively low prevalence,³ schizophrenia is characterized by episodes of relapse that place financial burden on the patient, their families, and healthcare systems.^1,4 Its long and fluctuating disease course means that schizophrenia is one of the costliest of all mental illnesses.^1,4 Relapse prevention remains a primary goal in schizophrenia management since numerous episodes of relapse have been linked to longer time to remission and higher inpatient costs.^1,5 Patients who experience relapse can incur up to four times more healthcare costs compared with those who do not.⁶ In 2013 alone, the overall US disease-related cost was $156 billion, with an estimated $44,773 spent on each patient per year.^2,6 A significant proportion of these direct costs are related to inpatient hospitalizations for both first episode psychosis and subsequent relapses (ranging from 15% to 58%),⁷ emergency room and outpatient visits, and prescribed medications.²

Hospitalization and related healthcare costs have risen considerably in recent years

A recent US study of 6,122,284 schizophrenia cases showed that hospitalizations rose by 59% from 2005 to 2014.⁸ This may be explained by an increase in schizophrenia cases over a similar period, with one systematic review finding that global cases rose from 13.1 million in 1990 to 20.9 million cases in 2016.⁹ Alternatively, this may be in part due to patients with mental health disorders having better access to healthcare since the approval of the Affordable Care Act in 2010.⁸ Conversely, patients with schizophrenia may be experiencing more severe symptoms requiring hospitalization due to inadequate treatment or nonadherence to AP medication.⁸ Possible reasons for nonadherence to AP medication include medication side effects, polypharmacy, treatment ineffectiveness, lack of finance, poor access to mental health facilities, poor insight into the disorder, and poor social support.⁸

AP medication adherence has been linked to lower overall inpatient costs

Schizophrenia is typically treated with AP medication in either oral or long-acting injectable (LAI) formulations.¹⁰ AP medication can be prescribed as short-term treatment for acute psychosis or long-term for disease management and relapse prevention.¹⁰ In addition, long-term continual treatment can help to reduce disease progression, promote recovery, and reduce rehospitalization rates.^11,12 Poor adherence to AP medication is the most common cause of relapse and is associated with a higher risk of rehospitalization and increased hospitalization costs.^5,7 From 1998–2000, the average annual hospitalization costs due to AP nonadherence in the US were $3413, compared with $1025 among patients who adhered to their prescribed medication.⁷ Oral AP medication is an affordable treatment option with higher utilization rates in the US than LAIs.^1,13 However, nonadherence to oral APs is a major cause of relapse and LAIs offer an effective treatment option that helps improve adherence to AP medication.⁵ Because of this, LAIs have been associated with substantially lower schizophrenia-related inpatient costs and reduced frequency and length of hospitalizations, compared with oral APs.¹ These findings suggest that despite being priced generally higher than oral AP medication, LAIs may improve patient outcomes and therefore decrease the financial burden of schizophrenia on society in the long-run.¹

The economic impact of criminal activity and psychiatric hospitalizations among patients with schizophrenia is substantial 

Individuals with serious mental health disorders such as schizophrenia are disproportionately represented in the US criminal justice system.¹⁴ Law enforcement encounters and judicial system costs were an estimated $2.3 billion in 2020; since people living with schizophrenia are more likely to have contact with law enforcement.¹⁵ When compared with people with schizophrenia, the rate of incarceration amongst the general population has been estimated as 5% (percentage based on the ratio of incarceration in both populations).¹⁵ This is substantially lower than the proportion of people living with schizophrenia who interact with law enforcement and the judicial system annually (46%).¹⁵ A survey conducted by the US Bureau of Justice Statistics estimated that more than half of the state prisoners and jail inmates reported symptoms or had a history of mental health disorders.¹⁴ Recidivism is common among individuals with serious mental illness and places added strain on the criminal justice system.¹⁴ A recent study in the US assessed the cost burden of relapse and reoffending among patients with schizophrenia who were recently released from incarceration.¹⁴ Of 34,500 individuals released from incarceration in Florida, a total of 5307 were recorded to have schizophrenia.¹⁴ It was estimated that over 3 years, this population would experience 2877 psychiatric hospitalizations, costing $25,616,442 and 2573 criminal infractions, costing $21,145,992.¹⁴ Importantly, a 20% increase in the proportion of patients receiving AP medication reduced total cumulative costs across the 3 years by $1,871,100 ($353 per patient).¹⁴ Provision and management of appropriate and effective treatment can help patients successfully transition from incarceration back into society and may also reduce medical and criminal justice system costs.¹⁴

Another key population significantly impacted by mental health disorders, including schizophrenia, are US veterans.¹⁶ The prevalence of schizophrenia is reportedly 3.1% among veterans, more than two times higher than the general population,^3,16 with approximately 60,000 diagnosed between 2006–2011 and average yearly healthcare costs of $31,297 attributed to this population.¹ A recent study assessed the economic outcomes of 20,389 veterans from 2014–2017, finding that schizophrenia-related outpatient costs were $3693 and pharmacy-related costs for AP medication were $844.¹⁶ The patient journey of veterans with schizophrenia should be examined to improve prescription and adherence to treatment and ease clinical and economic strain.¹⁶

Despite adequate treatment, patients may still require additional social and economic support

The National Alliance on Mental Illness conducted a survey of 250 patients with schizophrenia.¹⁷ Only 29% of patients reported receiving vocational rehabilitation services, 20% job placement assistance, and 17% public housing, all of which are key support systems that foster independence.¹⁷ The survey further demonstrated that even when patients received treatment, many still utilized the following services:¹⁷

– Social security disability income (56%)

– Medicare (51%)

– Medicaid (45%)

– Food stamps (40%)

– Social security income (34%)

Schizophrenia also has a significant impact beyond the patient, affecting the financial lives of caregivers.¹⁸ The cost to caregivers was estimated at a staggering $104.5 billion in 2020.¹⁵ Caregivers may also be less productive at work while providing financial support for patients living with schizophrenia.¹⁵ Work productivity loss and excess healthcare cost were an estimated $4300 and $6000, respectively.¹⁵ Patients are heavily reliant on family and friends for financial support, transportation, and housing, and are sometimes less likely to engage in job searches.¹⁷ Many patients with schizophrenia live with their parents or have their siblings or spouse as their primary caregivers.¹⁸ 

Provision of effective treatment options and initiatives to aid AP medication compliance is important to encourage independence among patients living with schizophrenia and may subsequently ease the financial strain on healthcare systems and society as a whole.¹⁴ 

References

1. Baser O, Xie L, Pesa J, Durkin M. Healthcare utilization and costs of Veterans Health Administration patients with schizophrenia treated with paliperidone palmitate long-acting injection or oral atypical antipsychotics. J Med Econ 2015;18:356–65.
2. Barbosa WB, de Oliveira Costa J, Lovato Pires de Lemos L, et al. Costs in the treatment of schizophrenia in adults receiving atypical antipsychotics: an 11-year cohort in Brazil. Appl Health Econ Health Policy 2018;16:697–709.
3. Patel KR, Cherian J, Gohil K, Atkinsonet D. Schizophrenia: overview and treatment options. P T 2014;39:638–45.
4. Biagi E, Capuzzi E, Colmegna F, et al. Long-acting injectable antipsychotics in schizophrenia: literature review and practical perspective, with a focus on aripiprazole once-monthly. Adv Ther 2017;34:1036–48.
5. Kaplan G, Casoy J, Zummo J. Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Prefer Adherence 2013;7:1171–80.
6. Yan T, Greene M, Chang E, et al. Health care cost in patients with schizophrenia treated with brexpiprazole versus other oral atypical antipsychotic therapy. Clin Ther 2020;42:77–93.
7. Sun SX, Liu GG, Christensen DB, Fu AZ. Review and analysis of hospitalization costs associated with antipsychotic nonadherence in the treatment of schizophrenia in the United States. Curr Med Res Opin 2007;23:2305–12.
8. Chen E, Bazargan-Hejazi S, Ani C, et al. Schizophrenia hospitalization in the US 2005–2014: examination of trends in demographics, length of stay, and cost. Medicine 2021;100:e25206.
9. Charlson FJ, Ferrari AJ, Santomauro DF, et al. Global epidemiology and burden of schizophrenia: findings from the global burden of disease study 2016. Schizophrenia Bull 2018;44:1195–203.
10. Jin H, Tappenden P, Robinson S, Achilla E, Aceituno D, Byford S. Systematic review of the methods of health economic models assessing antipsychotic medication for schizophrenia. PLoS One 2020;15:e0234996.
11. Lin HC, Lee HC. The association between timely outpatient visits and the likelihood of rehospitalization for schizophrenia patients. Am J Orthopsychiatry 2008;78:494–7.
12. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev 2011:CD004718.
13. Kane J, Mychaskiw MA, Lim S, et al. Prevalence of oral and long-acting injectable antipsychotic use among patients with schizophrenia in the United States: an analysis of a commercial claims database. Presented at: 34th European College of Neuropsychopharmacology (ECNP) Congress; October 2–5, 2021; Lisbon, Portugal. P.0760.
14. Lin I, Muser E, Munsell M, Benson C, Menzin J. Economic impact of psychiatric relapse and recidivism among adults with schizophrenia recently released from incarceration: a Markov model analysis. J Med Econ 2015;18:219–29.
15. Schizophrenia and psychosis action alliance. 2021. Societal costs of schizophrenia and related disorders. Available at: https://sczaction.org/insight-initiative/societal-costs/. Accessed September 2022.
16. Patel C, Huang A, Wang L, Paliwal Y, Joshi K. Patient journey of veterans with schizophrenia: an analysis of treatment patterns, healthcare resource utilization and costs. Adv Ther 2022. doi: 10.1007/s12325-021-01997-z. Online ahead of print.
17. National Alliance on Mental Illness (NAMI). Schizophrenia: public attitudes, personal needs. 2008. Available at: https://www.nami.org/Support-Education/Publications-Reports/Survey-Reports/SchizophreniaSurvey. Accessed September 2022.
18. Millier A, Schmidt U, Angermeyer MC, et al. Humanistic burden in schizophrenia: a literature review. J Psychiatr Res 2014;54:85–93.

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