Psychosocial treatments for schizophrenia

The direct health and social care costs for schizophrenia in England in 1992-1993 amounted to £810 million, and the overall cost of illness was approximately £2.6 billion, even without including carer costs.(23) These high costs are recurrent: schizophrenia is an early-onset chronic incurable illness which can severely damage the quality of life of sufferers and families. It also raises societal concerns, for example about public safety. Not surprisingly, therefore, much policy and practice attention has been devoted to ways of changing the nature or quality of support and treatment for people with schizophrenia so as to improve cost-effectiveness. Among the principal concerns today are the heavy demands on inpatient services (one NHS bed in 20 was occupied by a schizophrenia patient in England in 1992-1993), about the inappropriateness of currently available care regimes for some patient groups (particularly black and ethnic minority groups), and about the higher prices of the atypical antipsychotic agents.

A lot of attention has been focused on new and established pharmacotherapies and psychosocial therapies. This section focuses on the latter (but see, for example, Knapp et al.(24) on drug treatments for schizophrenia, and a number of Cochrane and other systematic reviews currently in progress). Some psychological interventions have been shown to be effective in patients with schizophrenia although there are relatively few prospective, controlled trials. (25,26 and2Z) Even fewer have an economics component. Nevertheless, there is robust evidence emerging from these few studies to suggest that psychosocial therapies can be cost-effective in the treatment of schizophrenia.

One psychosocial intervention which has been evaluated from an economics perspective is 'compliance therapy', aimed at improving patient compliance or adherence with medication regimes. Patients were initially invited to discuss their attitude towards their illness, and subsequently the drawbacks and advantages of drug treatment. Patients counselled in this way were five times more likely than a control group to take their medication without prompting. (28) Over an 18-month follow-up period, albeit with a slightly reduced sample, the 'compliance therapy' group had better global functioning, insight, compliance, and attitudes to their medication, (29) yet costs were no more than with standard counselling.(30) The 'compliance therapy' intervention was thus cost-effective.

Family interventions aim to reduce the impact of family stress and conflict often seen in households with high levels of expressed emotion. A systematic review by the Cochrane Schizophrenia Group concluded that family interventions reduce relapse and readmission rates, improve compliance and may also reduce costs. (3D Three economic studies with economic components were deemed to be of sufficiently good design to be included in the review, although two of them measured only health-care costs,(3 ,33) which is somewhat narrow for this kind of intervention for schizophrenia patients, and sample sizes were quite small. The third study gathered evidence from China'34) and was built on wider cost measures, reaching the same conclusion that family interventions can reduce costs while maintaining or improving outcomes. All were cost-consequences analyses.

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