Epidemiology and Burden​

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Epidemiology and Burden​

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Epidemiology and Burden​
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Global Impact of Schizophrenia​
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The World Health Organization identified schizophrenia as 1 of the 20 leading causes of disability in the world in 2004. The same report estimated that the worldwide prevalence was 26.3 million people in 20041​

Estimates of the lifetime prevalence of schizophrenia range from 0.18% to 1.16% depending on the reference.2,3 Interestingly, there is a large degree of variability in prevalence among studies3​

One report has shown that there may be a positive correlation between increased latitude and increased prevalence of schizophrenia4

  1. The global burden of disease: 2004 update. World Health Organization Web site. http://www.who.int/healthinfo/global_burden_disease/2004_report_update/e...
  2. Accessed March 7, 2013.​
  3. American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. ​
  4. McGrath J, Saha S, Chant D, Welham J. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76.​
  5. Saha S, Chant DC, Welham JL, McGrath JJ. The incidence and prevalence of schizophrenia varies with latitude. Acta Psychiatr Scand. 2006;114(1):36-39.​
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The morbid risk of schizophrenia increases in relation to the percentage of genes shared with an affected individual​
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The negative impact of schizophrenia on patients and their caregivers affects many aspects of life​
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Key message: Schizophrenia negatively impacts many different aspects of the lives of both patients and their caregivers (e.g. economic, physical health, social aspects) ​

Background​
A community survey that included 697 caregivers and 439 patients with schizophrenia identified the top 10 negative impacts of schizophrenia in descending order of frequency, as listed on this slide. ​

Patients and caregivers have varying and at times conflicting perspectives and expectations, which need to be reconciled to achieve balance.​

For example, critical issues caregivers ranked as significant in contributing to the disease burden included ‘non-compliance and treatment adherence issues’, ‘lack of motivation and self-care’, and ‘co-morbid substance abuse’​

Patients perceived different issues to be significant problems, such as ‘access to more effective and better tolerated medications’, ‘commitment to having to take medications indefinitely’ and ‘QOL and better functioning’ ​​

  1. Awad AG, Voruganti LN. Pharmacoeconomics. 2008;26(2):149–62.​
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Caregivers of patients with schizophrenia can experience negative changes in their own quality of life​
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Key message: Decreases in the quality of life of caregivers may be associated with the burden of being a caregiver, lack of social support, course of the disease, and problems with family relationships

Background2
Literature review of 37 studies (1998–2008) that assessed factors associated with the quality of life of caregivers of people with schizophrenia

A systematic search was carried out using the following electronic databases: MEDLINE via PubMed, Web of Science, and PsycINFO. The following keywords were used: “quality of life”, “burden”, “schizophrenia”, “families”, “caregivers”, and a combination of these

Despite differences between countries, studies carried out in different parts of the world show similar outcomes

Evidence suggest that physical, emotional, and economic distress negatively affect caregivers’ QoL as a result of a number of unfulfilled needs, such as restoration of patient functioning in family and social roles, economic burden, and lack of spare time, among other factors

Several studies stated that appearance of psychotic symptoms  or the course of the disease produce an important level of burden

Working life was also significantly affected. Caregivers often need to leave their jobs, modify their working hours, or change to another job. Moreover, in some cases, stress seemed to be associated with a triple shift: job, household duties, and patient care

Economic issues produce concern in caregivers because of expenses in different areas, e.g. drug therapy and treatment. There is a difference between developed and developing countries – in countries such as Chile, Nigeria, and India, caregivers expressed more concern in this dimension, likely caused by scarcity of community and health resources​​

  1. European Federation of Associations of Families of People with Mental Illness (EUFAMI). The Caring For Carers (C4C) Survey, 2014. 
  2. Caqueo-Urízar A et al. Health Qual Life Outcomes. 2009;7:84.
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Inability to function in everyday settings contributes to the high cost of schizophrenia​
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Key message: Inability of patients to function in everyday settings contributes to the high cost of schizophrenia (both direct costs from caring for patients, and indirect costs from lost employment). 

Background
Schizophrenia causes a high degree of disability. In the global burden of disease study, schizophrenia accounted for 1.1% of the total disability adjusted life years (DALYs) and 2.8% of years lived with disability (YLD)1

Annual cost of schizophrenia is over €110 billion per year in the EU and US alone (calculated total from France, Germany, Hungary, Norway, UK, US). 2.5% of national health expenditure in US represents both direct and indirect costs of schizophrenia2

Baseline data on more than 1,400 patients with a diagnosis of schizophrenia were collected before their entry into the Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) schizophrenia study. 72.9% of patients reported no employment activity. Overall employment of persons with schizophrenia seems to be impeded by clinical problems, including symptoms of schizophrenia and poorer neurocognitive and intrapsychic functioning3

 

  1. World Health Organization (WHO). The World Health Report 2001 - Mental Health: New Understanding, New Hope. 2001
  2. Knapp M, et al. Schizophr Bull 2004;30(2):279–293.
  3. Rosenheck R, et al. Am J Psychiatry 2006;163:411–417. 
  4. Harvey PD, Strassnig M. World Psychiatry 2012;11:73–79. 

Note on Knapp reference: please note that more recent figures for similar statistics are available and have been published. The Knapp reference was used for this slide as the most relevant and widely cited source.

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Schizophrenia One-Year Incidence Rates From Selected World Studies​
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Epidemiology of Schizophrenia in the United States​
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The 1-year prevalence of schizophrenia in the United States was estimated to be 1.1% of the adult population1​

37 Population-based studies from 25 countries that reported primary data on deaths in people with schizophrenia were examined2​

  • The median standardized mortality ratio (SMR) for all-cause mortality was 2.58​
  • The median SMR for suicide was 12.86​
  • The median SMRs for cardiovascular diseases, digestive diseases, infectious diseases, and respiratory diseases were 1.79, 2.38, 4.29, and 3.19, respectively ​

  1. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50(2):85-94.
  2. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64(10):1123-1131.
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Prevalence of Schizophrenia in Asia​
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Taiwan: A random population of subjects from the National Health Insurance database was used to identify members with ≥1 claim for a principal diagnosis of schizophrenia1​

China: A random population of subjects from Xinjin County were interviewed face to face to assess the prevalence of schizophrenia based on the Chinese Classification and Diagnostic Criteria of Mental Disorder (CCMD-2-R) and the International Classification of Diseases, 10th Revision (ICD-10)2​

Korea: A multistage, cluster sampling design was used to randomly select persons who were administered the Korean version of Composite International Diagnostic Interview 2.1 (K-CIDI 2.1) to diagnose mental disorders including schizophrenia3​

Micronesia: The Mental Health section of the Bureau of Health Services for the Trust Territory of the Pacific Islands surveyed the population of Micronesia for individuals with signs and symptoms of mental illness. Subjects were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II) criteria4​

Japan: Epidemiological studies of schizophrenia have been conducted from 1940 to 1978 in rural, urban, island, and small town settings5​

  1. Chien IC, Chou YJ, Lin CH, Bih SH, Chou P, Chang HJ. Prevalence and incidence of schizophrenia among national health insurance enrollees in Taiwan, 1996-2001. Psychiatry Clin Neurosci. 2004;58(6):611-618.​
  2. Ran MS, Xiang MZ, Li SX, et al. Prevalence and course of schizophrenia in a Chinese rural area. Aust N Z J Psychiatry. 2003;37(4):452-457.​
  3. Cho MJ, Kim JK, Jeon HJ, et al. Lifetime and 12-month prevalence of DSM-IV psychiatric disorders among Korean adults. J Nerv Ment Dis. 2007;195(3):203-210.​
  4. Dale PW. Prevalence of schizophrenia in the Pacific Island populations of Micronesia. J Psychiatr Res. 1981;16(2):103-111.​
  5. Nakane Y, Ohta Y, Radford MH. Epidemiological studies of schizophrenia in Japan. Schizophr Bull. 1992;18(1):75-84.​
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Epidemiology of Schizophrenia in Europe​
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Review as stated on slide​

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Epidemiology of Schizophrenia in Canada​
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Vanasse and colleagues examined the lifetime prevalence of patients with schizophrenia in Quebec from 1996 to 2006 using public health plan databases. Patients were identified with a hospital discharge or physician claim for schizophrenia1​

Goldner et al estimated the 1-year prevalence rates for schizophrenia from 1996 to 1999 using administrative health services data for residents of the Canadian province of British Columbia in the age range of 15 to 65 years. Patients were identified by a diagnostic code of 295 in at least 1 of 3 databases2​

Woogh examined the prevalence of schizophrenia over 10 years from 1986 to 1996 in Kingston, Ontario. Patients were identified based on demographic, diagnostic, and service use information for all psychiatric inpatients, outpatients, and emergency contacts at 3 hospitals3

  1. Vanasse A, Courteau J, Fleury MJ, Grégoire JP, Lesage A, Moisan J. Treatment prevalence and incidence of schizophrenia in Quebec using a population health services perspective: different algorithms, different estimates. Soc Psychiatry Psychiatr Epidemiol. 2012;47(4):533-543.​
  2. Goldner EM, Jones W, Waraich P. Using administrative data to analyze the prevalence and distribution of schizophrenic disorders. Psychiatr Serv. 2003;54(7):1017-1021.​
  3. Woogh C. Is schizophrenia on the decline in Canada? Can J Psychiatry. 2001;46(1):61-67.​
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Economic Burden of Schizophrenia​
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The burden of schizophrenia​
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Schizophrenia and Years Lived with Disease (YLD)​
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Schizophrenia is a chronic brain disorder that affects more than 21 million people worldwide.3,4 Schizophrenia is listed among the top ten leading causes of years lived with disability (YLDs) in men (ranked fifth) and women (ranked sixth), accounting for almost 3% of global YLDs.1

Schizophrenia has an impact on almost all aspects of a patients’ life.2

  1. World Health Organization (WHO). The Global Burden of Disease. 2004 Update. © World Health Organization 2008.​
  2. Lehman AF, Lieberman JA, Dixon LB, et al. Practice Guideline for the treatment of patients with schizophrenia. Second edition. American Psychiatric Association, 2004. © American Psychiatric Association, 2010. Accessed at http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/g..., October 2014. ​
  3. National Institute of Mental Health. Schizophrenia. NIH Publication No. 09-3517. Revised 2009.​
  4. World Health Organization (WHO). Mental Health: Schizophrenia. Accessed at http://www.who.int/mental_health/management/schizophrenia/en/, October 2014.
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Cost and Prevalence of Disorders of the Brain in Europe in 2010​
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Past Relapses Predicted an Increased Risk of Future Relapses and Higher Costs in the United States​
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In the US Schizophrenia Care and Assessment Program (US-SCAP) study, patients with a recent relapse demonstrated a relative relapse risk of 4.23 during the 1-year study (P<0.001) compared to patients who experienced no relapse in the previous 6 months1

Patients were 18 years of age or older and had been diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria2

Compared to patients who did not experience prior relapse, patients with prior relapse incurred significantly higher total annual direct mental health care costs during the 1-year study period, which were nearly 3 times higher for those who relapsed ($33,187) compared with those who did not ($11,771, P<0.01)2

  1. Ascher-Svanum H, Zhu B, Faries DE, et al. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry. 2010;10:2 [Additional file 3: Table S3. Logistic regression analyses of relapse predictors for the 1,557 participants and by relapse status].
  2. Ascher-Svanum H, Zhu B, Faries DE, et al. The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry. 2010;10:2.
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Direct Costs of Schizophrenia in the United States Were $47 Billion in 2002*†​
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Annual direct medical costs associated with schizophrenia were estimated based on administrative claims data—including a large private claims database and the California Medicaid program database—and compared with demographically/geographically matched control samples (1 case: 3 controls)​

Excess annual direct non–health care costs were estimated for law enforcement, homeless shelters, and research/training related to schizophrenia​

Excess annual indirect costs were estimated for 4 components of productivity loss: unemployment, reduced workplace productivity, premature mortality from suicide, and family caregiving using a human capital approach based on market wages​

All costs have been estimated in 2012 US dollars based on 2002 results using US Medical Care Category

  1. Wu EQ, Birnbaum HG, Shi L, et al. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatry. 2005;66(9):1122-1129.​
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Direct Costs of Schizophrenia in South Korea Were Approximately $540 Million in 2005​
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The total direct costs for treating schizophrenia in South Korea in 2005 were calculated from National Health Insurance and Medical Aid records. The treated prevalence of schizophrenia in South Korea in 2005 was 0.4% of the population1​

When adjusted for inflation, 2005 costs equals $652 million in 2013 dollars2

  1. Chang SM, Cho SJ, Jeon HJ, et al. Economic burden of schizophrenia in South Korea. J Korean Med Sci. 2008;23(2):167-175.​
  2. Consumer price index in South Korea. Trading Economics Web site. http://www.tradingeconomics.com/south-korea/consumer-price-index-2005--1... June 17, 2013.​
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Canadian Health Care and Non−Health Care Costs Reached $2 Billion (Canadian) in 2004​
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The financial burden of schizophrenia in Canada in 2004 was calculated using a prevalence-based cost-of-illness approach. Various sources were used for analysis including published scientific literature, and government reports and documents. When Canadian data sources for patient populations or health care systems data were not available, data from similar countries closely resembling Canada were used1​

When adjusted for inflation, 2004 total costs equals $2.4 billion (Canadian) in 20132​

  1. Goeree R, Farahati F, Burke N, et al. The economic burden of schizophrenia in Canada in 2004. Curr Med Res Opin. 2005;21(12):2017-2028.​
  2. Inflation calculator. Bank of Canada Web site. http://www.bankofcanada.ca/rates/related/inflation-calculator. Accessed June 17, 2013.​
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Costs of Treating Schizophrenia in France, Germany, ​ and the United Kingdom in 2000​
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The costs of medical care for patients with schizophrenia were calculated from the European Cohort Study of Schizophrenia (EuroSC). This was a naturalistic, 2-year, follow-up study in patients recruited from France (n=288), Germany (n=618), and the United Kingdom (n=302)

  1. Heider D, Bernert S, König HH, et al. Direct medical mental health care costs of schizophrenia in France, Germany and the United Kingdom–findings from the European Schizophrenia Cohort (EuroSC). Eur Psychiatry. 2009;24(4):216-224.​
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Lower Relapse Rates Can Be Expected to Result in Reduced Costs Associated With Schizophrenia​
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Patients were randomly selected from current psychiatric caseloads drawn from urban and suburban areas of Leicester, England​

Patients were included as participants if they had received a diagnosis of schizophrenia according to Diagnostic and Statistical Manual of Mental Diseases, 4th edition (DSM-IV) criteria and had no other psychosis, were aged 18 to 64 years, and had given their informed consent​

Relapse was identified retrospectively in this study as the reemergence or aggravation of psychotic symptoms for at least 7 days during the 6 months prior to the study​

In addition to instances of relapse identified by clinical staff, recorded changes in mental state were regarded as significant and amounting to relapse if there was a clearly documented assessment of a relapse. A change in management, as appropriate, might also have occurred, and not all relapses led to readmission. Relapse could thus be identified in cases of patients who had been admitted to a hospital in the past 6 months, who had consulted their psychiatrist and had had their medication changed for deterioration in their condition, or who had had an increase in intensive support at home from the community mental health team. A planned hospital admission was not classified as a relapse​

Patients who relapsed demonstrated significantly higher expenditures in inpatient care, outpatient psychiatric visits, and visits by psychiatrists​

Higher costs in day care center visits were seen in patients who did not relapse​

  1. Almond S, Knapp M, Francois C, Toumi M, Brugha T. Relapse in schizophrenia: costs, clinical outcomes and quality of life. Br J Psychiatry. 2004;184:346-351.​
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Multiple Components Contribute to the High Costs of Treating a Patient With Schizophrenia in the United States in 2008​
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Data were drawn from a large, multisite, 3-year, noninterventional study of patients with schizophrenia enrolled in the United States Schizophrenia Care and Assessment Program (US-SCAP), conducted between 1997 and 2003. Participants were treated in various mental health treatment systems, including Veterans Affairs (VA) hospitals, community mental health centers, community and state hospitals, and university health care service systems. Most patients in the study were covered by Medicare/Medicaid (81%), while those remaining were covered by the VA (6%), by private insurance (4%), or were uninsured (7%). Total costs over a 1-year period for mental health services and component costs (psychiatric hospitalizations, antipsychotic medications, other psychotropic medications, day treatment, emergency psychiatric services, psychosocial/rehabilitation group therapy, individual therapy, medication management, and case management) were calculated for 1557 patients with complete medical information. Patients were enrolled regardless of psychiatric or medical comorbidity, use of concomitant medications, or presence of behavioral problems​

  1. Zhu B, Ascher-Svanum H, Faries DE, Peng X, Salkever D, Slade EP. Costs of treating patients with schizophrenia who have illness-related crisis events. BMC Psychiatry. 2008;8:72. ​
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