Assessing the value of antipsychotics for treating schizophrenia: the importance of evaluating and interpreting the clinical significance of individual service costs.

Schizophrenia is a serious and complex disorder, with treatment requiring a large number and wide range of health and social service resources. This paper addresses one challenge for assessing the direct costs of antipsychotic treatments - that of interpreting both cost and effectiveness implications of specific components of service use. Information collected on direct component costs has frequently been analysed and reported only in total. Results of several published studies provide evidence that the total direct medical costs associated with atypical antipsychotics appear to be at least equivalent to, and in some cases lower than, those associated with conventional agents. An important implication of this cost-equivalency finding is that treatment involving higher medication costs have led to offsets in certain medical service costs. Results from several studies demonstrate a shift of cost components, primarily from more expensive inpatient to less expensive outpatient care. Although the common inpatient versus outpatient dichotomy is useful, the complexities of schizophrenia and the heterogeneity of outpatient service provision are likely to warrant greater specificity. Published schizophrenia treatment guidelines can assist researchers to more fully understand and meaningfully interpret the possible relationship of antipsychotic effectiveness to the use of particular outpatient services. Because the disease requires comprehensive and continuous care, outpatient treatment costs may be better conceptualised as baseline or expectable costs necessary in the maintenance phase of treatment. Lack of expectable costs may represent poor patient outcomes and increased intangible costs. In contrast, reductions in acute outpatient service costs may provide important markers of treatment effectiveness. A small number of studies have examined the use of crisis services, but additional work is needed to differentiate treatments vis-à-vis the need for intensive (acute) interventions. The assessment and clinical interpretation of individual cost components may offer an important opportunity to build upon initial results focusing on total costs and tailor analyses to the complexities of the disorder and the treatment process. Research able to incorporate clinical acumen into cost analyses will enhance the ability of healthcare policy makers to make informed decisions regarding the value of different antipsychotic medications for the treatment of schizophrenia.