Resource utilization in mental illness - evaluation of an instrument for measuring direct costs of treatment for patients with severe mental illness (SMI).

PURPOSE: Serious mental illnesses (SMIs) exert a considerable financial burden on health-care systems. In this study, the resource utilization in mental illness (RUMI) tool was developed and employed to evaluate resource utilization in patients with SMI. MATERIALS AND METHODS: Data from 107 patients with SMI treated in four psychiatric outpatient clinics in Sweden were collected. The relationships between costs for physical and psychiatric care, social services, and the justice system, to self-reported health and quality of life, educational level, Global Assessment of Functioning (GAF), the Clinical Global Impressions scale score (CGI), and body mass index (BMI) were studied. RESULTS: Sixteen out of 107 patients accounted for 74% of the total costs. The mean and median cost for 6 months included in the survey for social services, family and social welfare and healthcare, psychiatric and physical treatment interventions, mean 8349 EUR, median 2599 EUR per patient (currency value for 2021). Education and psychosocial function (GAF) were both negatively correlated with costs for the social services (education, r=-0.207, p < 0.014; GAF, r=-0.258, p < 0.001). CGI was correlated with costs for physical and psychiatric healthcare (r = 0.161, p < 0.027), social services support (r = 0.245, p = 0.002) and total cost (r = 0.198, p = 0.007). BMI correlated with costs for psychiatric and physical health settings interventions (r = 0.155, p < 0.019) and for somatic and psychiatric medicines (r = 0.154, p < 0.019). CONCLUSION: The RUMI scale was acceptable and enabled estimation of resource utilization in a comparable manner across different care settings. Such comparable data have potential to provide a basis for budgeting and resource allocation.

Patients' perspectives on three-monthly administration of antipsychotic treatment with paliperidone palmitate - a qualitative interview study.

INTRODUCTION: Three-monthly dosage of paliperidone palmitate entails longer time to relapse after discontinuation, is similarly tolerable and safe compared to monthly injections of paliperidone palmitate and is beneficial for the caregivers. However, few studies have so far explored in depth the patients' experiences with paliperidone palmitate medication every three months, or with switching from monthly to three-monthly injections of paliperidone palmitate. MATERIAL AND METHODS: A qualitative study based on individual interviews with persons with schizophrenia who receive three-monthly paliperidone palmitate in Norway, Sweden and Denmark. Data was analysed according to qualitative content analysis. RESULTS: Twenty-four patients, 16 men and 8 women, took part in individual interviews. The patients' mental health care professionals mainly recommended the switch to three-monthly paliperidone palmitate, and few or no disadvantages were described. According to the patients, three-monthly paliperidone palmitate had several advantages, such as less frequent injections, less administration and planning and less focus on the illness. In addition, the participants described feeling more stability, being more physically and socially active, and that improvement processes were supported. For some, the use involved practical and economic challenges, and some worried whether the medicine 'wore off' before the next injection. According to the patients, switching to three-monthly paliperidone palmitate did not influence the frequency or content of patients' interaction with health care professionals. CONCLUSION: Switching from monthly to three-monthly injections with paliperidone palmitate seems to be experienced as advantageous for patients with schizophrenia.

Health and work disability outcomes in parents of patients with schizophrenia associated with antipsychotic exposure by the offspring.

This study aimed to identify if antipsychotic exposure in offspring is associated with psychiatric and non-psychiatric healthcare service use and work disability of their parents. This Swedish population-based cohort study was based on data comprising 10,883 individuals with schizophrenia, who had at least one identifiable parent in the nationwide registers, and their parents (N = 18,215). The register-based follow-up during 2006-2013 considered the level of antipsychotic exposure and persistence of use of the offspring, further categorized into first (FG) and second generation (SG) antipsychotics, and orals versus long-acting injections (LAIs). The main outcome measure was parental psychiatric healthcare service use, secondary outcomes were non-psychiatric healthcare use and long-term sickness absence. SG-LAI use was associated with a decreased risk (relative risks [RR] 0.81-0.85) of parental psychiatric healthcare use compared with not using SG-LAI, whereas oral antipsychotics were associated with an increased risk (RRs 1.10-1.29). Both FG- and SG-LAI use by the offspring were associated with a lower risk of long-term sickness absence (range of odds ratios 0.34-0.47) for the parents, compared with non-use of these drugs. The choice of antipsychotic treatment for the offspring may have an impact on work disability and healthcare service use of their parents.

"I live, I don't work, but I live a very normal life"-A qualitative interview study of Scandinavian user experiences of schizophrenia, antipsychotic medication, and personal recovery processes.

PURPOSE: To illuminate user experiences of schizophrenia, reasons for receiving antipsychotic medication, and encounters with mental health services. DESIGN AND METHODS: 24 semistructured qualitative research interviews with schizophrenia patients treated with 3-monthly paliperidone palmitate across Scandinavia were synthesized in qualitative content analysis. FINDINGS: Participants describe considerable challenges in everyday functioning. Simultaneously, they rate their current mental and physical well-being high and seem satisfied with their lives. These pathways indicate personal recovery. PRACTICE IMPLICATIONS: The participants emphasize the importance of trustful relations with healthcare professionals, therapeutic conversations, antipsychotic medication in a 3-monthly formulation, and support from relatives.

Outcome of a psychosocial health promotion intervention aimed at improving physical health and reducing alcohol use in patients with schizophrenia and psychotic disorders (MINT).

BACKGROUND: Life expectancy is reduced by 19 years in men and 17 in women with psychosis in Sweden, largely due to cardiovascular disease. AIM: Assess whether a psychosocial health promotion intervention improves cardiometabolic risk factors, quality of life, and severity of illness in patients with psychotic disorders more than treatment as usual. METHODS: A pragmatic intervention trial testing a manual-based multi-component health promotion intervention targeting patients with psychosis. The Swedish intervention was adapted from IMPaCT therapy, a health-promotion program based on motivational interviewing and cognitive behavioral therapy, designed to be incorporated into routine care. The intervention group consisted of 119 patients and the control group of 570 patients from specialized psychosis departments. Outcome variables were assessed 6 months before intervention during the run-in period, again at the start of intervention, and 12 months after the intervention began. The control group received treatment as usual. RESULTS: The intervention had no significant effect on any of the outcome variables. However, BMI, waist circumference, systolic BP, heart rate, HbA1c, general health, and Clinical Global Impressions Scale score improved significantly during the run-in period before the start of the active intervention (observer effect). The multi-component design meant that treatment effects could only be calculated for the intervention as a whole. CONCLUSION: The results of the intervention are similar to those of the U.K. IMPaCT study, in which the modular health-promotion intervention had little effect on cardiovascular risk indicators. However, in the current study, the run-in period had a positive effect on cardiometabolic risk factors.

Burden for Parents of Patients With Schizophrenia-A Nationwide Comparative Study of Parents of Offspring With Rheumatoid Arthritis, Multiple Sclerosis, Epilepsy, and Healthy Controls.

BACKGROUND: The study aimed to (1) compare the risk of health care use, adverse health status, and work productivity loss of parents of patients with schizophrenia to parents of patients with multiple sclerosis (MS), rheumatoid arthritis (RA), epilepsy, and healthy controls; and (2) evaluate such outcome measures while considering disease severity of schizophrenia. METHODS: Based on linkage of Swedish registers, at least one parent was included (n = 18215) of patients with schizophrenia (information 2006-2013, n = 10883). Similarly, parental information was linked to patients with MS, RA, epilepsy, and matched healthy controls, comprising 11292, 15516, 34715, and 18408 parents, respectively. Disease severity of schizophrenia was analyzed. Different regression models yielding odds ratios (OR), hazard ratios (HR), or relative risks (RR) with 95% confidence intervals (CI) were run. RESULTS: Psychiatric health care use, mainly due to anxiety and affective disorders, showed a strongly increasing trend for parents of patients with schizophrenia throughout the observation period. During the follow-up, these parents had an up to 2.7 times higher risk of specialized psychiatric health care and receipt of social welfare benefits than other parents. Parents of the moderately severely ill patients with schizophrenia had higher risk estimates for psychiatric health care (RR: 1.12; 95% CI: 1.07-1.17) compared with parents of least severely ill patients. CONCLUSIONS: Parents of patients with schizophrenia have a considerably higher risk of psychiatric health care and social welfare benefit receipt than other parents. Psychiatric health care use worsens over time and with increasing disease severity of the offspring.

Antipsychotics and mortality in a nationwide cohort of 29,823 patients with schizophrenia.

INTRODUCTION: It has remained controversial if antipsychotic treatment is associated with increased or decreased mortality among patients with schizophrenia, and if there are any clinically meaningful differences between specific agents and routes of administration. METHODS: We linked prospectively gathered nationwide register-based data during 2006-2013 to study all-cause mortality among all patients aged 16-64years with schizophrenia in Sweden (N=29,823 in total; N=4603 in the incident cohort). Multivariate Cox regression models were adjusted for clinical and sociodemographic covariates. Sensitivity analyses with the incident cohort were conducted to control for survival bias. RESULTS: During the mean follow-up of 5.7years, 2515 patients (8.4%) died. During the maximum follow-up (7.5years), the lowest cumulative mortality was observed for second generation (SG) long-acting injection (LAI) use (7.5%). Adjusted hazard ratios (aHRs) compared to SG LAI use were 1.37 (95%CI 1.01-1.86) for first generation (FG) LAIs, 1.52 (1.13-2.05) for SG orals, 1.83 (1.33-2.50) for FG orals, and 3.39 (2.53-4.56) for nonuse of antipsychotics. Concerning specific agents, the lowest mortality was observed for once-monthly paliperidone LAI (0.11, 0.03-0.43), oral aripiprazole (0.22, 0.15-0.34), and risperidone LAI (0.31, 0.23-0.43). In pairwise comparison, LAIs were associated with 33% lower mortality than equivalent orals (0.67, 0.56-0.80). The results with incident cohort were consistent with the primary analyses. CONCLUSIONS: Among patients with schizophrenia, LAI use is associated with an approximately 30% lower risk of death compared with oral agents. SG LAIs and oral aripiprazole are associated with the lowest mortality.

Real-World Effectiveness of Antipsychotic Treatments in a Nationwide Cohort of 29 823 Patients With Schizophrenia.

Importance: It has remained unclear whether there are clinically meaningful differences between antipsychotic treatments with regard to preventing relapse of schizophrenia, owing to the impossibility of including large unselected patient populations in randomized clinical trials, as well as residual confounding from selection biases in observational studies. Objective: To study the comparative real-world effectiveness of antipsychotic treatments for patients with schizophrenia. Design, Setting, and Participants: Prospectively gathered nationwide databases were linked to study the risk of rehospitalization and treatment failure from July 1, 2006, to December 31, 2013, among all patients in Sweden with a schizophrenia diagnosis who were 16 to 64 years of age in 2006 (29 823 patients in the total prevalent cohort; 4603 in the incident cohort of newly diagnosed patients). Within-individual analyses were used for primary analyses, in which each individual was used as his or her own control to eliminate selection bias. Traditional Cox proportional hazards multivariate regression was used for secondary analyses. Main Outcomes and Measures: Risk of rehospitalization and treatment failure (defined as psychiatric rehospitalization, suicide attempt, discontinuation or switch to other medication, or death). Results: There were 29 823 patients (12 822 women and 17 001 men; mean [SD] age, 44.9 [12.0] years). During follow-up, 13 042 of 29 823 patients (43.7%) were rehospitalized, and 20 225 of 28 189 patients (71.7%) experienced treatment failure. The risk of psychiatric rehospitalization was the lowest during monotherapy with once-monthly long-acting injectable paliperidone (hazard ratio [HR], 0.51; 95% CI, 0.41-0.64), long-acting injectable zuclopenthixol (HR, 0.53; 95% CI, 0.48-0.57), clozapine (HR, 0.53; 95% CI, 0.48-0.58), long-acting injectable perphenazine (HR, 0.58; 95% CI, 0.52-0.65), and long-acting injectable olanzapine (HR, 0.58; 95% CI, 0.44-0.77) compared with no use of antipsychotic medication. Oral flupentixol (HR, 0.92; 95% CI, 0.74-1.14), quetiapine (HR, 0.91; 95% CI, 0.83-1.00), and oral perphenazine (HR, 0.86; 95% CI, 0.77-0.97) were associated with the highest risk of rehospitalization. Long-acting injectable antipsychotic medications were associated with substantially lower risk of rehospitalization compared with equivalent oral formulations (HR, 0.78; 95% CI, 0.72-0.84 in the total cohort; HR, 0.68; 95% CI, 0.53-0.86 in the incident cohort). Clozapine (HR, 0.58; 95% CI, 0.53-0.63) and all long-acting injectable antipsychotic medications (HRs 0.65-0.80) were associated with the lowest rates of treatment failure compared with the most widely used medication, oral olanzapine. The results of several sensitivity analyses were consistent with those of the primary analyses. Conclusions and Relevance: Clozapine and long-acting injectable antipsychotic medications were the pharmacologic treatments with the highest rates of prevention of relapse in schizophrenia. The risk of rehospitalization is about 20% to 30% lower during long-acting injectable treatments compared with equivalent oral formulations.

Diabetes and glucose disturbances in patients with psychosis in Sweden.

OBJECTIVE: The objectives of this study were to (1) analyze the prevalence of diabetes, prediabetes, and antidiabetic medication in patients with psychosis compared with control subjects and (2) determine what factors in patients with psychosis were associated with antidiabetic medication. METHOD: We studied 977 patients with psychosis recruited from outpatient clinics in Stockholm County, Sweden, and they were compared with 3908 non-psychotic control subjects for fasting plasma glucose levels; prevalence of diabetes, prediabetes, antidiabetic treatment, and tobacco use; and blood pressure, weight, height, and waist circumference. Group differences were evaluated with analysis of variance and χ(2) test, and factors associated with antidiabetic treatment were evaluated with logistic regression. RESULTS: Diabetes was observed in 94 (10%) patients with psychosis, 2.7 times the prevalence observed in control subjects. Among patients with psychosis, 87 (10%) had prediabetes (fasting glucose, 6.1-6.9 mmol/L) compared with 149 (3.8%) control subjects. Most patients with psychosis (77%) who had prediabetes fulfilled criteria for metabolic syndrome. In patients with psychosis, both lipid-lowering medication and fasting glucose were significantly associated with antidiabetic treatment. There was no significant relation between antidiabetic treatment and lifestyle factors such as smoking or degree of psychiatric illness. CONCLUSIONS: The high prevalence of impaired fasting glucose and metabolic syndrome in patients with psychosis warrants further clinical research in preventing or delaying the onset of diabetes in these patients by pharmacotherapy and/or lifestyle intervention.

Galantamine versus risperidone treatment of neuropsychiatric symptoms in patients with probable dementia: an open randomized trial.

OBJECTIVE: To examine the effects of galantamine and risperidone on neuropsychiatric symptoms in dementia (NPSD) and global function. METHODS: Using a randomized, controlled and open-blind, one-center trial at an in- and outpatient clinic at a university hospital, we studied 100 adults with probable dementia and NPSD. Participants received galantamine (N = 50, target dose 24 mg) or risperidone (N = 50, target dose 1.5 mg) for 12 weeks. The primary outcome was effects on NPSD assessed by the Neuropsychiatric Inventory (NPI). Secondary measures included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating, Clinical Global Impression, and Simpson Angus scales. All tests were performed before and after treatment. RESULTS: Outcome measures were analyzed using analysis of covariance. Ninety-one patients (67% women, mean age 79 ± 7.5 years) with initial NPI score of 51.0 (± 25.8) and MMSE of 20.1 (± 4.6) completed the trial. Both galantamine and risperidone treatments resulted in improved NPSD symptoms and were equally effective in treating several NPI domains. However, risperidone showed a significant treatment advantage in the NPI domains irritation and agitation, F(1, 97) = 5.2, p = 0.02. Galantamine treatment also ameliorated cognitive functions where MMSE scores increased 2.8 points compared with baseline (95% confidence interval: 1.96-3.52). No treatment-related severe side effects occurred. CONCLUSIONS: These results support that galantamine, with its benign safety profile, can be used as first-line treatment of NPSD symptoms, unless symptoms of irritation and agitation are prominent, where risperidone is more efficient.

Dose and plasma concentration of galantamine in Alzheimer's disease - clinical application.

INTRODUCTION: Patients with Alzheimer's disease (AD) are currently treated with cholinesterase inhibitors, such as galantamine, without actual knowledge of its concentration in plasma. Our objective was to analyse potential relationships between galantamine concentration, galantamine dose, socio-demographic characteristics, body weight, body mass index (BMI), and treatment response. METHODS: Eighty-four patients with AD recruited from the Memory Clinic, Malmö, Sweden, and treated with galantamine were included in the study. Efficacy measures, including cognition (Mini-Mental State Examination (MMSE), Alzheimer's Disease Assessment Scale - cognitive subscale (ADAS-cog)) and instrumental activities of daily living (IADL), were evaluated at baseline, 2 months after treatment initiation (MMSE only) and semi-annually over 3 years. At these assessments, blood samples were obtained for the analysis of the galantamine concentration, and body weight, BMI, drug dose and time from drug intake were recorded. RESULTS: All patients had a measurable concentration of galantamine at all assessments. The mean plasma concentration of the drug exhibited a positive linear association with dose (r = 0.513, P < 0.001). The dose did not differ between sexes. Negative linear associations between the galantamine plasma concentration and BMI (r = -0.454, P = 0.001) or body weight (r = -0.310, P = 0.034) were found exclusively in the male group. When mixed-effects models were used, the dose of galantamine (P < 0.001), time from drug intake (P < 0.001), and BMI (P = 0.021) or weight (P = 0.002) were factors that predicted the concentration, whereas sex, age, and cognitive and functional changes were not. CONCLUSIONS: High compliance to galantamine treatment was found among all patients in this naturalistic AD study. The impact of BMI or body weight on the plasma concentration of galantamine was important only among males. No relationship was observed between concentration and short-term treatment response or progression rate in terms of cognitive and functional abilities.

The economic impact of galantamine vs placebo: an analysis based on functional capacity in a Swedish cohort study.

OBJECTIVE: To analyse the economic impact of galantamine, based on basic activities of daily living (ADL). METHODS: Data were derived from Swedish patients enrolled in a 6-month placebo-controlled trial of galantamine (GAL-INT-1; n=80), and from the Kungsholmen-Nordanstig Project, a longitudinal study of 919 elderly persons in Sweden. Basic ADL were assessed using the Katz' Index of Independence in Activities of Daily Living (ADL) (number of ADL lost [dependency in 0, 1-2, 3-4, or 5-6 ADL]). Costs were appraised based on regression analysis and on costs directly linked to ADL. Six-month costs for galantamine and placebo were calculated. RESULTS: In the regression analyses, each increase in a Katz stage was associated with an annual cost increase of SEK 81,415-83,683 (∼€8000). Results were similar using stage-specific costs. Overall, there was a small, non-significant numerical cost benefit for galantamine indicating cost neutrality. LIMITATIONS: The small number of Swedish patients in the GAL-INT-1 study, which was not powered for economic outcomes, limits the statistical power of the analysis. In addition, long-term outcomes are difficult to assess in persons with dementia because of practical and logistical problems. CONCLUSIONS: The benefits of galantamine in patients with AD can be achieved with no increase in cost. Combined with positive effects in terms of outcome, treatment with galantamine can be regarded as cost-effective using a cost-consequence approach.

Dementia management programme in a community setting and the use of psychotropic drugs in the elderly population.

BACKGROUND AND OBJECTIVE: The number of elderly persons in society is increasing, placing additional demands on the public health system. Extensive use of drugs is common in the elderly, and in patients with dementia this further increases their vulnerability. Since 1998 the municipality of Kalmar, Sweden, has worked with a dementia management programme that focuses on early intervention in order to identify the patient's help needs at an early stage. An important part of the programme aims at optimizing pharmacological treatment. The objective of the present study is to evaluate whether the dementia programme had a secondary effect on the use of psychotropic medication in the elderly population in general. DESIGN AND SETTING: A retrospective, drug utilization study analysing the use of selected drug categories by the elderly (75 years and older) in the Kalmar municipality compared with the whole of Sweden. RESULTS AND CONCLUSIONS: The results suggest that the dementia programme contributed to an improvement in psychotropic drug use in the elderly as a secondary effect. Furthermore, the implementation of this programme did not require allocation of extra funding.

The cost of diagnosing dementia in a community setting.

OBJECTIVES: In order to cope with the increasing number of individuals with dementia, it is crucial to develop the diagnostic capacity in primary care in cooperation with dementia specialists. Further, in order to establish prerequisites for care and planning it is important to identify the cost of dementia diagnosis. This study aims to evaluate the cost of establishing a dementia diagnosis. METHODS: This is a prospective, time- and resource utilization study for the identification of the total cost associated with diagnosing dementia (from start of the diagnostic process to time for established or rejected dementia diagnosis) both at the specialist and primary care level. RESULTS: Dementia evaluation in primary care took between 2 weeks and 2 months before reaching diagnosis. The average cost for all patients evaluated at the primary care level was 477 Euro (euro), whereas evaluations done on a specialist level reached a cost of 1115 euro. Thus, the costs per true diagnosed case consist of the cost for all dementia investigations divided by the number of finalized diagnoses. CONCLUSIONS: In this study the cost for diagnosing dementia per true diagnosed patient is 849 euro at the primary care level and 1334 euro at the specialist level. Based on this result we estimated that the cost of establishing a dementia diagnosis is 1% of the total cost of dementia.

A symptom self-rating scale for schizophrenia (4S): psychometric properties, reliability and validity.

The objective of the study was to validate a self-administrated symptom rating scale for use in patients with schizophrenia spectrum disorders by item analysis, exploration of factor structure, and analyses of reliability and validity. Data on 151 patients, initially treated by risperidone, obtained within the framework of a naturalistic Phase IV longitudinal study, were analysed by comparing patient and clinician ratings of symptoms, side-effects and global indices of illness. The Symptom Self-rating Scale for Schizophrenia (4S) is psychometrically adequate (item analysis, internal consistency, factor structure). Side-effect ratings were reliable. Symptom ratings displayed consistent associations with clinicians' ratings of corresponding symptom dimensions, suggesting construct validity. Patients had most difficulties assessing negative symptom items. Patients were well able to assess their own symptoms and drug side-effects. The factor structure of symptom ratings differs between patients and clinicians as well as how they construe global indices of illness. Clinicians focus on psychotic, patients on affective symptoms. Use of symptom self-ratings is one way to improve communication and thereby strengthen the therapeutic alliance and increase treatment adherence.

A Swedish programme for dementia diagnostics in primary healthcare.

OBJECTIVE: To meet diagnostic needs of dementia, a new care programme was implemented in the county of Kalmar, Sweden. The objective of the study was to analyse whether the programme could identify and diagnose the estimated number of new cases. METHODS: A long-term follow up study on all new patients referred to primary and specialist care between 1999 and 2005 for dementia evaluation. RESULTS; Based on epidemiological data, 153 new cases per year were expected. Using the programme, an average of 127 cases was identified in primary healthcare and 22 at specialist level. Although the number of false-negative cases is not known, it may be concluded that most of the new cases with dementia were identified. The proportion of cases identified doubled after implementing the programme. The programme was implemented within an unchanged budget. CONCLUSION: The programme may be of value for diagnosis and management of demented patients in primary healthcare.