Early, Intensive Treatment for Psychosis Justifies Cost

Megan Brooks

February 08, 2016

The added cost of providing comprehensive, multidisciplinary, team-based care for first-episode psychosis (FEP) is worth it in terms of the clinical benefits achieved, conclude the authors of a new cost analysis.

"This study provides rigorous evidence that the health benefits exceed the additional costs of the intervention," lead author Robert Rosenheck, MD, professor of psychiatry and public health, Yale University Medical School, New Haven, Connecticut, told Medscape Medical News.

The researchers used data from the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP), an initiative sponsored by the National Institute of Mental Health (NIMH).

They evaluated the cost-effectiveness of the NAVIGATE (NAV) program for FEP, which includes four core interventions: personalized medication management (assisted by the COMPASS web-based decision support system), family psychoeducation, resilience-focused individual therapy, and supported employment and education.

In the RAISE-ETP study, 223 patients with FEP were randomly assigned to NAV, and 183 similar patients were assigned to standard community care. As previously reported by Medscape Medical News, patients in the NAV program experienced greater improvement in quality of life and psychopathology and were more involved in work and school than their peers who received standard community care. They also remained in treatment longer.

"But the question remained: What are the cost implications of providing early, intensive treatment, and, critically, what is the cost-effectiveness?" Dr Rosenheck said. "Our study shows that NAV costs a total of about 27% more over 2 years, but the benefits justify that increased cost."

The study was published online January 31 in the Schizophrenia Bulletin.

Benefits Exceed Costs

The researchers used three strategies to evaluate the cost-effectiveness and cost in relation to benefit of NAV compared with usual community care.

The first approach, which used mixed linear models, found greater effectiveness for NAV as well as greater total costs than community care, with 26% of the increased costs due to increased outpatient service costs, 36% to greater medication costs, and 9% to additional training for clinicians and other staff. "The increase in medication costs was presumably driven by guidance from the COMPASS decision support system that encouraged the use of second generation antipsychotics with favorable metabolic side effect profiles and also long acting antipsychotic formulations for adherence enhancement, despite their greater cost," they note.

The second analytic approach, bootstrap analysis of incremental cost-effectiveness ratio, supported the greater benefits and cost of NAV. The greatest cost-effectiveness was seen among patients with low duration of untreated psychosis (DUP) and when generic drug prices were used (as is likely to be the case in the future), the investigators say.

The third approach, using Net Health Benefits (NHB), gave a 0.95 probability that NAV was more cost-effective than community care when the Quality of Life Scale standard deviation (QLS-SD) is valued at $40,000, they report. Among low-DUP patients, the analysis gave a 0.94 probability that NAV was more cost-effective, at only $20,000/QLS-SD, wheras among high-DUP patients, there was a 0.31 probability, at $20,000, and a 0.64 probability that NAV was cost-effective at $50,000 compared with community care.

"Thus in all 3 analyses, NAV was both more effective and more costly than [community care], with considerably greater cost-effectiveness among low-DUP clients than among high-DUP clients, and when generic drug prices were used for antipsychotics," Dr Rosenheck and colleagues report.

"When converted to monetized quality-adjusted life years, NAV benefits exceeded costs, especially at future generic drug prices," they conclude.

Bold Innovation

"This study provides an important piece of scientific information which supports the dissemination of this intervention," said Dr Rosenheck. "As a clinician, the moment when someone comes down with schizophrenia is a horrible moment for that person and their family. Suddenly their mind is not working correctly, and on complete humanitarian grounds, we should provide that person and their family with as much support as we can early on."

But this would call for a change in current clinical practice. "Essentially, what we've had for 20 or 30 years is assertive community treatment where we provide very intensive services to the sickest people, those most disabled for a long time. The bold innovation here is now we aren't waiting to see who does the worst. We are saying, let's give everybody this intensive treatment early on, which has shown improvements in quality of life, and the piece we've now added is that it appears to be cost-effective," he said.

"The take-home message of this sophisticated research is that health service costs are, not surprisingly, somewhat higher when the mental health system provides the full range of services these young people need at a very vulnerable time in their lives," Robert Heinssen, PhD, director of the Division of Services and Intervention Research at the NIMH, said in a news release. "But these additional expenses have now been shown to be worth the investment in improving individuals' health and functioning."

Important Analysis

Scott Krakower, DO, assistant unit chief in psychiatry, Zucker Hillside Hospital, Glen Oaks, New York, told Medscape Medical News that this is a "unique" and "important" analysis.

"Schizophrenia is a devastating illness, and the economic impact of this disorder is quite great," he said. Early aggressive psychosis treatment is "designed to provide a better quality of life and prevent worsening or deterioration as patients get older," Dr Krakower explained. He was not involved in the analysis.

He said that having an integrated care model for schizophrenia that utilizes a variety of psychosocial interventions is "really important for the future and a good way to tackle schizophrenia. This is a multidimensional illness, and you really need a complete care coordinated team to make sure these patients get the true care they need to prevent them from getting worse.

"Without early treatment," Dr Krakower said, "the amount of money being spent later on taking care of people with this disorder is well up into the billions. Ideally, we'd like to have more funding for studies like these, but unfortunately, I think other disorders get more funding than schizophrenia."

The study was supported by the American Recovery and Reinvestment Act and the NIMH. Several authors have disclosed financial relationships with pharmaceutical companies, all of which are listed with the original article. Dr Krakower has disclosed no relevant financial relationships.

Schizophr Bull. Published online January 31, 2016. Abstract

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