Measuring the costs of schizophrenia. Implications for the post-institutional era in the US

Schizophrenia is a stress-related biomedical condition of the brain, characterised by unusual internal experiences, severe and often persistent functional disability and socially inappropriate behaviour. It is estimated that schizophrenia affects approximately 1% of all adults worldwide. Young adults are especially vulnerable. It is an illness with profound economic impact on patients, their families and society at large. Before the 1950s, most patients with schizophrenia were admitted to hospital for long inpatient stays. Keeping the patient in an institutional setting was all that psychiatry could offer, because there was little active treatment available. After World War II, and especially following the introduction of chlorpromazine in 1954, treatment was offered increasingly in outpatient settings. At present, more than 90% of individuals with schizophrenia will receive most healthcare services in outpatient facilities, supplemented by brief hospital treatment. The trend toward community-based care continues into the 1990s, supported in part by recent pharmacotherapeutic developments that are making a new generation of drug treatment options available. Clozapine, the most widely used of these new drugs, has been the subject of several studies that compared its costs with those of conventional drug treatments. These early studies suggest that further reductions in the cost of hospital treatment are possible in the near future. At the same time, despite the increasing availability of effective treatment in outpatient settings, the shift of resources from institutional to community care will not occur as quickly as some might wish. Delays in the transformation of care systems are caused by political interest groups and the sheer inertia of the infrastructure left over from the era of institutional care. These factors must be taken into account in estimating the cost of schizophrenia care during the next decade. The aim of this review is to provide a clinical picture of schizophrenia, emphasising features that contribute most to the cost of illness. We define and quantify the direct and indirect costs of the illness, discuss the cost implications of new pharmacotherapeutic and psychosocial treatments, and critique strategies for measuring the economic efficacy of these new treatments. The difficulties in measuring the costs of schizophrenia that are related to the transition from institutional to community-based systems of care in the US are also reviewed.