Abstract
Background: Despite clinical advantages over conventional compounds, second-generation antipsychotics
are prescribed less frequently in some European countries than in the United States
because of their higher acquisition price and the current cost-containment strategies
of many European health systems. This has been criticized on the grounds that the
higher acquisition costs of the new antipsychotics might be more than outweighed by
savings in other fields, e. g., through a reduction in rehospitalizations or indirect
costs. Method: In order to create an empirical basis for this discussion, a review of the results
of pharmacoeconomic studies (mostly cost-effectiveness studies) comparing second-generation
with conventional antipsychotics was undertaken.
Results: Of the 35 studies identified, most report at least cost-neutrality of the new antipsychotics
(in many cases clozapine) that is due to reductions in hospitalization costs. These
results cannot be generalized, however, because of methodological shortcomings such
as small patient samples and study designs with low validity, and especially because
of a lack of studies performed outside the U.S.. It is shown that results from studies
in the U.S. cannot be generalized to other health systems in Europe or in developing
countries. Furthermore, only a few findings on newer second-generation antipsychotics
other than clozapine are reported, and no study investigated indirect costs, which
play a major role because of the early onset and chronicity of schizophrenia.
Conclusion: Until now, there has been no sufficient evidence for the superior cost-effectiveness
of atypical antipsychotics in European countries. Considering the importance of this
topic for health politics, more cost-effectiveness studies in European countries are
urgently needed.
But even if economic superiority of the second-generation antipsychotics cannot be
demonstrated in such studies, their use is nevertheless indicated with respect to
patient’s well-being.
References
- 1
Aitchison K J, Kerwin R W.
Cost-effectiveness of clozapine. A UK clinic-based study.
Br J Psychiatry.
1997;
171
125-130
- 2
Albright P S, Livingstone S, Keegan D L, Ingham M, Shrikhande S, Le Lorier J.
Reduction of healthcare resource utilisation and costs following the use of risperidone
for patients with schizophrenia previously treated with standard antipsychotic therapy:
a retrospective analysis using the Saskatchewan health linkable databases.
Clin Drug Invest.
1996;
11 (5)
289-299
- 3
Blieden N, Flinders S, Hawkins K, Reid M, Alphs L D, Arfken C L.
Health status and health care costs for publicly funded patients with schizophrenia
started on clozapine.
Psychiatr Serv.
1998;
49 (12)
1590-1593
- 4
Bret P, Jolivel C, Bret M C, Veylit S, Martin C, Garcia P.
Etude medico-economique du Leponex (clozapine) au centre hospitalier Charles Perrens
de Bordeaux.
Encephale.
1998;
24 (4)
365-377
- 5
Carter C, Stevens M, Durkin M.
Effects of risperidone therapy on the use of mental health care resources in Salt
Lake County, Utah.
Clin Ther.
1998;
20 (2)
352-363
- 6
Coley K C, Carter C S, DaPos S V, Maxwell R, Wilson J W, Branch R A.
Effectiveness of antipsychotic therapy in a naturalistic setting: a comparison between
risperidone, perphenazine, and haloperidol.
J Clin Psychiatry.
1999;
60 (12)
850-856
- 7
Drew L R, Hodgson D M, Griffiths K M.
Clozapine in community practice: a 3-year follow-up study in the Australian Capital
Territory.
Aust N Z J Psychiatry.
1999;
33 (5)
667-675
- 8
Edgell E T, Andersen S W, Johnstone B M, Dulisse B, Revicki D, Breier A.
Olanzapine versus risperidone. A prospective comparison of clinical and economic outcomes
in schizophrenia.
Pharmacoeconomics.
2000;
18 (6)
567-579
- 9
Essock S M, Frisman L K, Covell N H, Hargreaves W A.
Cost-effectiveness of clozapine compared with conventional antipsychotic medication
for patients in state hospitals.
Arch Gen Psychiatry.
2000;
57 (10)
987-994
- 10
Finley P R, Sommer B R, Corbitt J L, Brunson G H, Lum B L.
Risperidone: clinical outcome predictors and cost-effectiveness in a naturalistic
setting.
Psychopharmacol Bull.
1998;
34 (1)
75-81
- 11
Foster R H, Goa K L.
Risperidone. A pharmacoeconomic review of its use in schizophrenia.
Pharmacoeconomics.
1998;
14 (1)
97-133
- 12
Foster R H, Goa K L.
Olanzapine. A pharmacoeconomic review of its use in schizophrenia.
Pharmacoeconomics.
1999;
15 (6)
611-640
- 13
Galvin P M, Knezek L D, Rush A J, Toprac M G, Johnson B.
Clinical and economic impact of newer versus older antipsychotic medications in a
community mental health center.
Clin Ther.
1999;
21 (6)
1105-1116
- 14
Geddes J, Freemantle N, Harrison P, Bebbington P.
Atypical antipsychotics in the treatment of schizophrenia: systematic overview and
meta-regression analysis.
BMJ.
2000;
321 (7273)
1371-1376
- 15
Geronimi-Ferret D, Lesay M, Barges-Bertocchio M H, Cornet-Bonnefont M, Robert H.
Evaluation medico-economique du traitement par la clozapine versus les traitements
neuroleptiques anterieurs.
Encephale.
1997;
23 Spec No 4
24-31
- 16
Ghaemi S N, Ziegler D M, Peachey T J, Goodwin F K.
Cost-effectiveness of clozapine therapy for severe psychosis.
Psychiatr Serv.
1998;
49 (6)
829-831
- 17
Gury C, Dechelette N, Gayral P.
Leponex: lŽexperience du pharmacien hospitalier.
Encephale.
1996;
22 Spec No 6
28-32
- 18
Hamilton S H, Revicki D A, Edgell E T, Genduso L A, Tollefson G.
Clinical and economic outcomes of olanzapine compared with haloperidol for schizophrenia.
Results from a randomised clinical trial.
Pharmacoeconomics.
1999;
15 (5)
469-480
- 19
Hammond C M, Pierson J F, Grande T P, Munetz M R, Wilson D R, Pathak D S.
Economic evaluation of risperidone in an outpatient population.
Ann Pharmacother.
1999;
33 (11)
1160-1166
- 20
Honigfeld G, Patin J.
A two-year clinical and economic follow-up of patients on clozapine.
Hosp Community Psychiatry.
1990;
41 (8)
882-885
- 21
Jonsson D, Walinder J.
Cost-effectiveness of clozapine treatment in therapy-refractory schizophrenia.
Acta Psychiatr Scand.
1995;
92 (3)
199-201
- 22
Kissling W, Hoffler J, Seemann U, Muller P, Ruther E, Trenckmann U. et al .
Die direkten und indirekten Kosten der Schizophrenie.
Fortschr Neurol Psychiatr.
1999;
67 (1)
29-36
- 23
Le Pen C, Lilliu H, Allicar M P, Olivier V, Gregor K J.
[Economic comparison of olanzapine versus haloperidol in treatment of schizophrenia
in France].
Encephale.
1999;
25 (4)
281-286
- 24
Leucht S, Pitschel-Walz G, Abraham D, Kissling W.
Efficacy and extrapyramidal side-effects of the new antipsychotics olanzapine, quetiapine,
risperidone, and sertindole compared to conventional antipsychotics and placebo. A
meta-analysis of randomized controlled trials.
Schizophr Res.
1999;
35 (1)
51-68
- 25 Leucht S, Pitschel-Walz G, Kissling W. Meta-analysis of amisulpride - a selective
dopamine receptor with an ”atypical” profile. European Neuropsychpharmacology 2000
[10 (suppl. 3)], 326. Ref Type: Abstract.
- 26
Lewis M, McCrone P, Frangou S.
Service use and costs of treating schizophrenia with atypical antipsychotics.
J Clin Psychiatry.
2001;
62 (10)
749-756
- 27 Lohse M J, Müller-Oerlinghausen B. Psychopharmaka. In: Schwabe U, Paffrath D, editors
Arzneiverordnungs-Report 2001 Berlin, Heidelberg: Springer; 2001: 597-629
- 28
Luchins D J, Hanrahan P, Shinderman M, Lagios L, Fichtner C G.
Initiating clozapine treatment in the outpatient clinic: service utilization and cost
trends.
Psychiatr Serv.
1998;
49 (8)
1034-1038
- 29
Lynch J, Morrison J, Graves N, Meddis D, Drummond M F, Hellewell J S.
The health economic implications of treatment with quetiapine: an audit of long-term
treatment for patients with chronic schizophrenia.
Eur Psychiatry.
2001;
16 (5)
307-312
- 30
Meltzer H Y, Cola P, Way L, Thompson P A, Bastani B, Davies M A. et al .
Cost effectiveness of clozapine in neuroleptic-resistant schizophrenia.
Am J Psychiatry.
1993;
150 (11)
1630-1638
- 31
Moore D B, Kelly D L, Sherr J D, Love R C, Conley R R.
Rehospitalization rates for depot antipsychotics and pharmacoeconomic implications:
comparison with risperidone.
Am J Health Syst Pharm.
1998;
55 (24 Suppl 4)
17-19
- 32
Neumann P J.
Methods of cost-effectiveness analysis in the evaluation of new antipsychotics: implications
for schizophrenia treatment.
J Clin Psychiatry.
1999;
60 Suppl 3
9-14
- 33
Nightengale B S, Crumly J M, Liao J, Lawrence B J, Jacobs E W.
Economic outcomes of antipsychotic agents in a Medicaid population: traditional agents
vs. risperidone.
Psychopharmacol Bull.
1998;
34 (3)
373-382
- 34
Nightengale B S, Garrett L, Waugh S, Lawrence B J, Andrus J.
Economic outcomes associated with the use of risperidone in a naturalistic group practice
setting.
Am J Manag Care.
1998;
4 (3)
360-366
- 35
Percudani M, Fattore G, Galletta J, Mita P L, Contini A, Altamura A C.
Health care costs of therapy-refractory schizophrenic patients treated with clozapine:
a study in a community psychiatric service in Italy.
Acta Psychiatr Scand.
1999;
99 (4)
274-280
- 36
Reid W H, Mason M, Toprac M.
Savings in hospital bed-days related to treatment with clozapine.
Hosp Community Psychiatry.
1994;
45 (3)
261-264
- 37
Reid W H, Mason M.
Psychiatric hospital utilization in patients treated with clozapine for up to 4.5
years in a state mental health care system.
J Clin Psychiatry.
1998;
59 (4)
189-194
- 38
Revicki D A, Luce B R, Weschler J M, Brown R E, Adler M A.
Cost-effectiveness of clozapine for treatment-resistant schizophrenic patients.
Hosp Community Psychiatry.
1990;
41 (8)
850-854
- 39
Revicki D A.
Pharmacoeconomic studies of atypical antipsychotic drugs for the treatment of schizophrenia.
Schizophr Res.
1999;
35 Suppl
101-109
- 40
Revicki D A.
Cost effectiveness of the newer atypical antipsychotics: a review of the pharmacoeconomic
research evidence.
Curr Opin Investig Drugs.
2001;
2 (1)
110-117
- 41 Rice D P, Miller L G. The economic burden of schizophrenia: conceptual and methodological
issues, and cost estimates. In: Moscarelli M, et al., editors
Handbook of Mental Health Economics and Health Policy. Volume I, Schizophrenia. Chichester; John Wiley and Sons 1996: 321-334
- 42
Rosenheck R, Cramer J, Xu W, Thomas J, Henderson W, Frisman L. et al .
A comparison of clozapine and haloperidol in hospitalized patients with refractory
schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine
in Refractory Schizophrenia.
N Engl J Med.
1997;
337 (12)
809-815
- 43
Rosenheck R, Cramer J, Allan E, Erdos J, Frisman L K, Xu W. et al .
Cost-effectiveness of clozapine in patients with high and low levels of hospital use.
Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory
Schizophrenia.
Arch Gen Psychiatry.
1999;
56 (6)
565-572
- 44
Sacristan J A, Gomez J C, Martin C, Garcia-Bernardo E, Peralta V, Alvarez E. et al
.
Pharmacoeconomic assessment of olanzapine in the treatment of refractory schizophrenia
based on a pilot clinical study.
Clinical Drug Investigation.
1998;
15 (1)
29-35
- 45
Sarfati Y, Olivier V, Bouhassira M.
Utilisation des nouveaux antipsychotiques dans les traitement de la schizophrenie.
Encephale.
1999;
25 (6)
658-666
- 46
Schiller M, Hargreaves W A.
Clozapine’s cost effectiveness.
Am J Psychiatry.
1995;
152 (1)
151-152
- 47
Shermock K, Sadik M, Kozma C, Sesti A, Reeder C.
Risperidone, Haloperidol and Clozapine in the South Carolina Medicaid Program. A comparative
analysis of utilisation and expenditure.
Dis Manage Health Outcomes.
2001;
9 (4)
203-213
- 48
Souetre E, Martin P, Lecanu J P, Alexandre L, Lozet H, Gauthier J M. et al .
Evaluation medico-economiquedes neuroleptiques dans la schizophrenie. Amisulpride
versus haloperidol.
Encephale.
1992;
18 (3)
263-269
- 49
Thompson D.
Cost of switching from neuroleptics to risperidone and clozapine. A pilot study of
the San Diego County Mental Health Services.
Clin Drug Invest.
1997;
14 (5)
428-433
- 50
Tollefson G D, Beasley C M, Tran P V, Street J S, Krueger J A, Tamura R N. et al
.
Olanzapine versus haloperidol in the treatment of schizophrenia and schizoaffective
and schizophreniform disorders: results of an international collaborative trial.
Am J Psychiatry.
1997;
154 (4)
457-465
- 51
Tunis S L, Johnstone B M, Gibson P J, Loosbrock D L, Dulisse B K.
Changes in perceived health and functioning as a cost-effectiveness measure for olanzapine
versus haloperidol treatment of schizophrenia.
J Clin Psychiatry.
1999;
60 Suppl 19
38-45
- 52
Tunis S L, Johnstone B M, Kinon B J, Barber B L, Browne R A.
Designing naturalistic prospective studies of economic and effectiveness outcomes
associated with novel antipsychotic therapies.
Value in Health.
2000;
3 (3)
232-242
- 53
Viale G, Mechling L, Maislin G, Durkin M, Engelhart L, Lawrence B J.
Impact of risperidone on the use of mental health care resources.
Psychiatr Serv.
1997;
48 (9)
1153-1159
- 54 Wahlbeck K, Cheine M, Essali M A. Clozapine versus typical neuroleptic medication
for schizophrenia. Cochrane Database Syst Rev 2000 2: CD000059
- 55
Woods S W, Stolar M, Sernyak M J, Charney D S.
Consistency of atypical antipsychotic superiority to placebo in recent clinical trials.
Biol Psychiatry.
2001;
49 (1)
64-70
Dr. Johannes Hamann
Klinik für Psychiatrie und Psychotherapie der Technischen Universität München
Möhlstraße 26
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Telefon: +49-(0)89-4140-4282
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