Pharmacopsychiatry 2003; 36(1): 18-26
DOI: 10.1055/s-2003-38089
Original Paper
© Georg Thieme Verlag Stuttgart · New York

Are the Second-generation Antipsychotics Cost-effective? A Critical Review on the Background of Different Health Systems

J. Hamann1 , S. Leucht1 , W. Kissling1
  • 1Klinik für Psychiatrie und Psychotherapie der Technischen Universität München
Further Information

Publication History

Received: 23.10.2001 Revised: 16.4.2002

Accepted: 2.5.2002

Publication Date:
21 March 2003 (online)

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

81675 München

Phone: +49-(0)89-4140-4282

Fax: +48-(0)89-4140-4898

Email: j.hamann@lrz.tum.de