Understanding the direct and indirect costs of patients with schizophrenia

Why is schizophrenia such a costly disease?

Schizophrenia is a chronic psychiatric condition that affects around 1% of the population worldwide^1–4. It is one of the most stigmatizing diseases of all time^3,5. Schizophrenic disorders present with a wide range of symptoms, both positive and negative, leading to cognitive, social and functional impairment. Therefore most individuals with schizophrenia are considered disabled and claim benefits⁶. The debilitating nature of the disorder means that patients receive lifelong treatment, and a large proportion of them need to be admitted to a hospital inpatient unit on multiple occasions throughout their lifetime^1–3.

All of the above factors lead to the high costs associated not only with the treatment of schizophrenia but also related to social impairment^3,7. By these we mean the inability to work and also the way that schizophrenia affects the patients´ environment. The need to take care of and support schizophrenic relatives is a major reason for members of their families to take sick leave or even sacrifice their own career^3,8. All of this, plus the high expense associated with the newest antipsychotic drugs, makes the costs of schizophrenia management as high as 3% of the total healthcare budget of western countries¹.

The aim of this paper is to give a global view on the problem and to emphasize certain cost-inducing aspects of schizophrenia management by reviewing past research on the costs of schizophrenia management.

Understanding the direct and indirect costs of schizophrenia – the clue to the problem

Regardless of the authors’ origin, they all agree unanimously that the costs associated with the treatment and care of patients with schizophrenia can be divided into two important groups: direct and indirect costs^2–4,8,9. The direct costs of treating schizophrenia include cost of hospitalization (short- and long-term), outpatient follow-up, residential and day care, pharmaceutical interventions, laboratory testing and social security payments, whereas the indirect costs are mainly related to the loss of productivity^1,3,10,11. The age of onset of the disorder, usually in the late teens or early 20s, can preclude patients from even starting to work¹². Later on, most of the patients receive benefits for incapacity for work due to disability⁶. Nowadays, most schizophrenic patients receive a disability certificate and eventually do not work. Up to 80% of schizophrenic patients in the UK do not have paid employment³. In Italy and Spain, three out of four patients with schizophrenia are excluded from the job market^9,13. Thus, some authors consider the loss of productivity as accounting for the majority of the indirect costs⁴.

Speaking of indirect costs, it is also important to consider the indirect cost associated with caregivers to schizophrenic patients, who contribute with their time and in-kind services (Table 1). Therein lies the issue. The real number of people affected by schizophrenia is much bigger than just the number of the patients. According to some authors, direct and indirect costs are approximately equal¹⁴, whereas others suggest that indirect costs can outnumber the direct ones up to three or four times^11,15.

Some authors also distinguish a third group of costs, called “intangible costs”³. These are expenses of a non-financial nature. They try to accomplish the hard task of reflecting the patients´ quality of life, including side-effects of pharmaceutical interventions and stress and anxiety, both caused by the disease itself and also the treatment process. Although this group might have no direct financial impact, it is worth considering these factors as they probably affect the cooperation between patient and health providers^16,17. Furthermore, we can also take into account the intangible costs of the caregivers of schizophrenic patients³. Daily care of a schizophrenic relative can be a very challenging and exhausting experience^3,18. Social stigma and the lack of sympathy and understanding may lead to anxiety and depression in caregivers as well as sufferers⁵. This could damage the relationship between the caregiver and the caretaker, which may lead to an increased rate of patient deterioration and worse prognosis in the long-term¹⁸.

Data collection in relation to the aims of this article

The main part of data used in this article come from psychiatric wards in Spain, France, Sweden, Poland, United Kingdom and Ukraine (Table 2 and Table 3). Data from recent USA research have also been included for comparison purposes. Although some of the methods used for data collection vary, depending on the country and researchers, the general idea of this article is to get a global view on the subject. Thus, some estimations can be made and their legitimacy is consistent as shown by the similarities between the results.

Limitations of study and recommendations for future research

Collected data across different studies vary in terms of the number of patients included or hospitals involved across different investigations. An exact comparison between all papers is obviously not possible, but certain estimations can be made.

In some countries, like France and UK, the indirect costs outnumber the direct ones (Table 2)^4,15. On the other hand, results coming from Spain and USA suggest that both types of cost are equally important in total^12,14. To better understand this result we need to consider the differences across particular studies regarding design and methods used. For instance, the approach to calculate the cost of lost workforce varies between the countries, which could lead to some of the differences observed. In Spain, the official registries do not reflect the work force lost by people who have never even started a job – and this group of people accounts for a large proportion of schizophrenic patients since the onset of the disorder (and so the problems with getting or maintaining employment) may occur early in life, before young people begin their career¹⁴.

Therefore, it could be possible that the indirect costs are even higher in the countries who register its workforce in this way.

How to improve the situation?

Many authors raise the issue of patients´ adherence to prescribed therapy. An optimal control of schizophrenic symptoms is proven to lead to fewer numbers of hospitalizations and less need to use other approaches of formally organized patient care¹⁹. Although good adherence to treatment means no reduction in the budget for pharmaceutical interventions, this cost does not seem to represent a significant percentage when compared to total cost of the illness (drugs costs vs. total costs – see Table 2, Table 3). Good psychoeducational programs and building insight about the disease and its management makes patients feel more secure and thus more cooperative^1,3.

When the symptoms of schizophrenia remain under control, patients experience a smaller risk of mental impairment and social exclusion which extends to participation in work opportunities²⁰. So it is of crucial importance to investigate whether better control of symptoms could allow patients to get a chance to attain and keep a job, and how this fact could affect their quality of life. Moreover, we should consider how this could be used to lighten the burden of care that relatives and caregivers experience and thus reduce the indirect costs which make up a significant part of the costs of this illness.

Therefore, it is our suggestion that the future of schizophrenia treatment should address more carefully important elements of the financial aspects of the disease, such as cost-efficacy of treatment, including psychological therapies and psychoeducational approaches for both patients and their families. A wider view on the matter is needed.