The Economic Burden of Schizophrenia

RESEARCH UPDATE

CASE VIGNETTE

“Mr Jobs” is a 50-year-old Caucasian male with a history of chronic schizophrenia as well as HIV. The local University Emergency Department (ED) is his essentially his only source of medical care. He is nonadherent with any medications and follow-up. In the past year, he has presented to the ED over 100 times, often for physical complaints, but also for worsening psychosis and suicidal ideation. He sometimes leaves the ED prior to being seen by a physician, and often states, “I just want to stay inside for a little while,” particularly when it gets cold. When seen by the ED psychiatry team, he has repeatedly been given information on local resources, including indigent medical/mental health care and homeless shelters, which he declines. He is frequently observed on the sidewalks outside the ED walking and smoking. The manager of a restaurant outside the ED has been bringing the patient food and drinks daily. University security has requested that local police arrest Mr Jobs for loitering/vagrancy, which they have refused. What is the economic burden of Mr Jobs’ care?

Schizophrenia is a chronic, severe, disabling mental health disorder that is associated with significantly increased morbidity and premature mortality. Schizophrenia is also associated with a significant economic burden. In the early 2000s, the annual cost of schizophrenia in the US was estimated to be greater than those for all cancers combined.¹ These costs include direct health (eg, outpatient, inpatient, emergency department, and pharmacy) and non-health care (eg, law enforcement and homeless shelters), and indirect (eg, unemployment and premature mortality) costs. A more recent study estimated the annual US societal cost of schizophrenia in 2013 as about $156 billion.² However, this estimated does not reflect recent health care system reforms and treatment advances.

The Current Study

Kadakia and colleagues updated the previous studies, estimating the total societal economic burden of schizophrenia in the US in 2019.³ The authors assumed a lifetime prevalence of schizophrenia of 1.19%, and performed sensitivity analyses using a prevalence of 0.72%.⁴ Excess costs were defined as the difference in costs between the population with and a similar population without schizophrenia. The total economic burden was estimated as the sum of excess direct health and non-health care costs, and excess indirect costs, after subtracting direct cost offsets.

Direct health care costs for insured patients were estimated retrospectively using a matched cohort design of patients with and without schizophrenia. Insurance claims data were obtained from the IBM Watson Health MarketScan databases. Patients were required to have continuous health plan enrollment for ≥ 12 months. Patients with and without schizophrenia were exactly matched 1:3 on age, sex, race, region of residence, health plan type, and year of index date. Methods for estimated excess direct non-health and indirect costs are extensively detailed in the study.³

The authors estimated 3.9 million individuals with schizophrenia in the US in 2019. The excess economic burden of schizophrenia was estimated at $343.2 billion (or almost $88,000 per person with schizophrenia. Excess direct health care costs were $62.3 billion; excess direct non-health care costs were $35.0 billion); and excess indirect costs were $251.9 billion. The greatest contributor to excess indirect costs were those associated with caregiving ($112.3 billion or $29,000 per person), which constituted about one-third of the total costs.

Direct health care costs were estimated based on a sample of 131,125 patients with schizophrenia. The largest contributors to excess direct health care costs were inpatient care ($30.2 billion), outpatient care ($12.9 billion), and pharmacy ($12.1 billion). In terms of excess direct non-health care costs, the largest contributor was law enforcement ($26.1 billion). Excess indirect costs accounted for almost 75% of the total economic burden of schizophrenia. In the sensitivity analysis, using the 0.72% lifetime prevalence estimate, the excess economic burden of schizophrenia was $215.1 billion.

Study Conclusions

The authors concluded that the economic burden of schizophrenia in the US in 2019 was $343.2 billion, suggesting that this burden doubled between 2013 and 2019, after adjusting for inflation. The authors noted that the dramatic increase in indirect costs was drive by a 20-fold increase in the estimate of premature mortality costs and a doubling of caregiving costs, compared to the previous analysis.⁴ They also noted that their findings were broadly similar to the estimated $281.6 billion in 202 by the Schizophrenia & Psychosis Action Alliance.⁵ Primary study limitations include the use of a prevalence-based approach, and the inclusion of both schizophrenia and schizoaffective disorders in the estimation of direct health care costs.

The Bottom Line

The estimated societal burden of schizophrenia in the US in 2019 was $343.2 billion, which represents a doubling since 2013. This tremendous burden highlights the need for effective treatment strategies and options.

Dr Miller is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric TimesTM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

References

1. Thaker GK, Carpenter WT Jr. Advances in schizophrenia. Nat Med. 2001;7(6):667-671.

2. Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. J Clin Psychiatry. 2016;77(6):764-771.

3. Kadakia A, Catillon M, Fan Q, et al. The economic burden of schizophrenia in the United States. J Clin Psychiatry. 2022;83(6):22m14458.

4. McGrath J, Saha S, Chant D, Welham J. Schizophrenia; a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76.

5. Societal costs of schizophrenia & related disorders. Schizophrenia & Psychosis Action Alliance. July 2021. Accessed November 10, 2022. https://sczaction.org/wp-content/uploads/2021/11/571-012_WhitePaper_Report_FINAL_updated_11.09.21.pdf