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Summary
Schizophrenia is a chronic mental disorder that causes functional impairment in
work, interpersonal relationships, and self-care. Both the direct and indirect costs
of this disease are signicant. Managed care can implement various interventions to
improve patient outcomes and manage costs.
Key Points
Schizophrenia is a costly disease both from a direct and indirect cost perspec-
tive.
Medication nonadherence has a signicant impact on costs.
The costs of schizophrenia treatment can be managed by using available resourc-
es more effectively.
Strong evidence for effectiveness exists for antipsychotic medications, family edu-
cation, community atreatment teams, supported employment and housing, psycho-
social remedial therapies, and case management.
Managed care can improve outcomes in patients with schizophrenia by utilizing
community treatment teams, case management, disease management programs,
schizophrenia treatment algorithms, provider partnerships, specialty mental and
behavioral health organizations, and Community Mental Health Centers.
SCHIZOPHRENIA IS A PERSISTENT, OFTEN without the disease, these patients have a decreased
chronic, and usually serious mental disorder affect- life expectancy of about 25 years. This has actually
ing a variety of aspects of behavior, thinking, and worsened over the past 20 years. All of the symp-
emotion. Patients with delusions or hallucinations toms of schizophrenia cause functional impairment
may be described as psychotic. Thinking may be in work, interpersonal relationships, and self-care
disconnected and illogical. Peculiar behaviors may (Exhibit 1).1
be associated with social withdrawal and disinterest. The diagnostic criteria for schizophrenia are list-
While the word for schizophrenia is less than 100 ed in Exhibit 2.2 The differential diagnosis includes
years old, Kraepelin concretely identied the disease schizoid personality, schizophreniform disorder,
in 1887. Bleuler coined the term we know today schizotypal personality, bipolar disorder, and Asperg-
based on the Greek words schizo (split) and phrene ers Syndrome. Bipolar disorder is frequently misdi-
(mind), and also was the rst to describe symptoms agnosed as schizophrenia and the other way around.
in terms of positive and negative. Evidence that Exhibit 3 shows the progression of the course of
schizophrenia is biologically based has accumulated schizophrenia.3 Like bipolar disorder and major de-
in the past 20 years; genetic advancements offer even pression, there is a kindling model with schizophre-
more promise of understanding this illness. nia, which suggests that the more episodes one has
About 1 percent of the population develops this the harder treatment is and the more brain damage
disorder. There are both positive and negative symp- that occurs. Current practice is to treat schizophrenia
toms. Positive symptoms are those such as hearing early and for life to limit deterioration of function.
voices and negative symptoms include lack of mo- The direct and indirect costs of treating schizo-
tivation. There also are cognitive decits, disorga- phrenia are signicant. Inpatient costs have de-
nization, and mood symptoms. About 10 percent of creased since 1991 while outpatient expenses have
patients with schizophrenia commit suicide during increased (Exhibit 4).4 This particular direct cost
the course of their illness. Compared with someone analysis used a direct cost offset to take out the av-
Positive Negative
Symptoms Functional Impairments Symptoms
Work
Interpersonal Relationships
Self-Care
Cognitive Mood
Deficits Symptoms
Disorganization
erage cost of regular housing. The bulk of indirect agents, using expert consensus guidelines, holding
costs come from unemployment (Exhibit 5).4 providers accountable for improving patient out-
Medication nonadherence, which is a common comes, facilitating measurement-based clinical de-
problem in schizophrenia treatment, has a signicant cision making, and utilizing case management and
impact on costs. The degree of medication adher- disease management programs.
ence varies over the course of an individuals illness. There are a number of antispychotics available for
Overall, about 50 percent of patients are not compli- use (Exhibit 6). Some of these are available in in-
ant with their medications. Only 20 to 30 percent of jectable long acting formulations (depot). The goal
patients will relapse within one year with consistent of using long acting agents is to improve adherence
use of medication whereas 60 to 80 percent will re- and prevent relapse. The long acting agents are in-
lapse without medication consistency.5,6 Because of jected every two weeks [uphenazine (Prolixin) and
the increased relapse rate, medication nonadherence risperidone (Risperdal)] or four weeks [haloperidol
increases the risk of hospitalization. In one study of (Haldol)]. These were widely used in the past but
acute care inpatient admissions and hospital days have not been commonly used in the past 10 years
for Medicaid schizophrenia patients attributable to because of the introduction of the atypical agents. A
nonadherence, 10,686 acute care hospital admissions meta-analysis of six studies showed signicantly low-
occurred due to gaps in treatment. This resulted in er relapse rates in patients taking depot versus oral
121,838 inpatient days and an approximate cost of antipsychotics (P<0.0002).9 Encouraging the use of
$106 million.7 The nancial burden of relapse was depot agents is one strategy that managed care can
estimated at $300 million per year in 1995.8 Ex- use to improve adherence rates and contain costs.
trapolating to 2008 dollars the total cost is greater Refractory symptoms are a common occurrence
than $420 million. with schizophrenia. A poor treatment response oc-
Components of schizophrenia treatment that have curs in 30 percent of patients. An incomplete treat-
strong evidence for effectiveness are antipsychotic ment response occurs in an additional 30 percent
medications, family education, community treat- or more. Clozapine is the treatment of choice for
ment teams, supported employment and housing, treatment-resistant schizophrenia. Use of clozapine
psychosocial remedial therapies (organized peer produces a consistent 30 percent response rate in
support network, clubhouses, etc.), and case man- severely ill, treatment-resistant patients versus four
agement. The costs of schizophrenia treatment can percent with chlorpromazine.10
be managed by using available resources more ef- The adverse effects of the antipsychotic agents
fectively. This includes using protocols for proper have to be balanced against their efcacy. As a class,
administration and timing of psychotherapeutic the rst generation antipsychotics (FGAs) have the
A. Characteristic Symptoms: Two (or more) of the following, each present for a signicant portion of time during a
1-month period (or less if successfully treated):
(1) Delusions
(2) Hallucinations
(3) Disorganized speech (e.g., frequent derailment or incoherence)
(4) Grossly disorganized or catatonic behavior
(5) Negative Symptoms, i.e., Affect Flattening, Alogia or Avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the persons
behavior or thoughts, or two or more voices conversing with each other.
B. Social/occupational dysfunction: For a signicant portion of the time since the onset of the disturbance, one
or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level
achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of inter-
personal, academic, or occupational achievement).
C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at
least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and
may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Fea-
tures have been ruled out because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently
with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total
duration has been brief relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autism or another Pervasive Develop-
mental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also
present for at least a month (or less if successfully treated).
potential to cause sedation, dizziness, anticholiner- When the SGAs rst were introduced, many
gic effects, extrapyramidal symptoms, agranulocy- practitioners considered it almost malpractice not to
tosis, cardiovascular events, and depression. All of use them over the FGAs because of the reduced in-
them have at least one boxed warning in the FDA cidence of long-term adverse effects such as tardive
approved package labeling. The second-generation dyskinesia and benet for negative symptoms. This
antipsychotics (SGAs) have a wide variety of differ- assumption has been turned around by the ndings
ent side effects. These also have at least one boxed from one large, well-designed trial (CATIE).12 This
warning in the package labeling. As a class, most study compared several SGAs (olanzapine, quetiap-
of the SGAs all cause signicant weight gain and ine, risperidone, ziprasidone) with perphenazine, a
metabolic syndrome. Ziprasidone (Geodon) and FGA, over 18 months. The medications were simi-
aripiprazole (Abilify) are the two SGAs that do larly effective. Fewer people discontinued olanzap-
not appear to cause these problems. ine but it caused signicantly more weight gain and
After evaluating the available evidence, the metabolic problems. Perphenazine did not cause
Schizophrenia Patient Outcomes Research Team more EPS than the other medications and was just as
recommended SGAs (other than clozapine) as rst effective as three of the four medications. There was
choice medications.11 These recommendations do no advantage of the newer mediations on negative
note that weight gain and metabolic effects of the symptoms or cognitive functioning and perphen-
SGAs may alter the choice in an individual patient azine was the most cost effective. Unfortunately,
and are more expensive. The recommendations with a relatively short-term study, the difference in
made no clear statement of preference of SGAs rates of tardive dyskinesias was not answered.
over FGAs in acute or maintenance treatment. Because of the CATIE trial and a similar study
Clozapine is recommended for treatment-refrac- from the United Kingdom, the World Psychiatric
tory positive symptoms, hostility, and suicidality. Association did a comparison of all the available
Long-acting injectable antipsychotics are recom- trials.13 This analysis stated that antipsychotic treat-
mended for individuals who do not adhere to oral ment needs to be individually tailored to promote
medication regimens. optimal recovery. It noted that medications are very
Good
Prevention
Recovery
Function
Re a b l e
St
s id
Pr
od
Stable
ua
Premorbid ro Progression
l/
Relapsing
m
al
Poor
15 20 30 40 50 60 70
Age (Years)
Homeless Shelter
Research and Training Drugs
$291 $6,397
$5,043
Law Enforcement $ 2,637
$6,951
$7,967
heterogeneous with substantial differences in side to patients. The team adapts itself and the environ-
effect proles. SGAs were found to be inconsistently ment to patients needs. An example would be pro-
more efcacious than FGAs with a lower likelihood viding services where the patient lives rather than
to cause EPS but associated with more metabolic expecting them to show up for appointments. ACT
events. Consistent with other evidence, clozapine programs have reduced hospitalizations for severely
was found to be most efcacious in treatment-resis- mentally ill patients by approximately 40 percent.14
tant schizophrenia. Unfortunately, the ACT model is difcult to repli-
Numerous strategies can be used to improve the cate successfully.
outcomes in patients with schizophrenia. One of In one evaluation of schizophrenics with substance
these is assertive community treatment (ACT). abuse receiving ACT versus standard case manage-
This uses a 24/7 community-based treatment and ment (SCM), both groups showed signicant reduc-
rehabilitation model. Multidisciplinary teams pro- tions in substance use over time.15 ACT and SCM
vide ongoing continuous service, assertive out- were not signicantly different in cost-effectiveness
reach, and support services. Care teams have small, over three years. SCM was more effective than ACT
manageable caseloads and provide all key services in the rst two years, but ACT became more ef-
Caregiver
$7,899
Paliperidone (Invega)**
*Depot version available
**Depot version in development
cient during the nal year. The SCM program costs practice behavior through clinician and staff educa-
were about one-half of ACT costs, but subjects in tion and to improve cost effectiveness of treatment.
the SCM group used more mental health center ser- Interventions that may be utilized by disease man-
vices. Standard case management can be replicated agement programs include evidence-based practice
easier over a wide area and group of patients. guidelines, case management, self-management edu-
High-risk, high cost patients with schizophrenia cation, patient risk stratication, patient satisfaction
should be identied and placed in intensive case surveys, outcomes tracking and reporting, specialized
management programs or ACT. Case managers can software, computerized data warehouse, automated
ensure patients are receiving evidence-based treat- decision support tools, and callback systems.
ment and can assist with provider-to-provider com- Schizophrenia treatment algorithms also can be
munication, transportation, and other needs. used to improve cost effectiveness and patient out-
Disease management programs are another way comes. These algorithms can be developed with in-
to improve patient outcomes. These programs have put from mental health experts, literature reviews,
many potential goals such as to build and strengthen and data from consensus conferences. The goals of a
support systems, support physician-patient relation- treatment algorithm include increased effectiveness of
ships, increase medication adherence, reduce hospital- drug therapy to reduce symptoms and improve func-
izations and length of stay, improve patient function tion, and enhanced quality of clinical decision-mak-
and quality of life, and empower the patient and fam- ing and practice. One example is the Texas Medica-
ily with education. They also can be used to improve tion Algorithm Project. Clinician and patient/family