Sir,Schizophrenia is a chronic debilitating disorder presenting with positive, negative, and cognitive symptoms.[1] These symptoms can lead to functional and social impairments with poor quality of life in persons with schizophrenia.[2] Antipsychotic medications are the first-line treatment for schizophrenia along with psychological and psychosocial interventions. The currently available antipsychotic medications have an impact on the positive symptoms, such as delusions and hallucinations with little or no effect on the negative (apathy, amotivation, and anhedonia) and cognitive (attention, memory, and problem-solving) deficits.[3]Antipsychotic medications are available in oral and long-acting depot preparations for the management of symptoms in schizophrenia. Even though many studies have shown that the efficacy of oral and long-acting depot antipsychotics is similar in the treatment of schizophrenia, the latter are sparingly used in the routine clinical practice worldwide and in India.[4] Various reasons could be attributed to the reluctance to use depot antipsychotics among the psychiatrists for the management of schizophrenia, such as assumptions that depot neuroleptics present an increased risk of major side effects as well as medicolegal problems.[5] The standard treatment for schizophrenia in Indian psychiatric settings has been oral antipsychotics. With the growing recognition of poor treatment compliance and cost, it is critical to investigate the role of depot neuroleptics in the community in India. At the same time, approaches to improve treatment compliance can facilitate better course management, reduce patient and service costs, and increase quality of life.[6]One of the most important aspects to consider while choosing antipsychotics should be cost-effectiveness. Little to no studies from India has examined the cost-effectiveness of the oral antipsychotics in comparison with the long-acting depot antipsychotics from India. Hence, the aim of this study was to compare the cost of treatment of oral and long-acting depot antipsychotic medications in persons with schizophrenia.The study was conducted in the Kattankulathur and Thiruporur blocks of Kanchipuram district in Tamil Nadu between December 1, 2006, and May 31, 2009. Institutional ethics committee approval was obtained before the start of the study. A total of 97 patients were recruited for the study from the community through the psychiatric clinic in the study site. Purposive sampling technique was used to recruit the study subjects. All the clients visiting the clinic were screened using the recruitment criteria, and the eligible subjects were approached for the consent to be recruited into the study. The recruitment of subjects into the study was based on the following recruitment criteria: (1) persons diagnosed with schizophrenia; (2) stable course of illness for the past 12 months; (3) either only on oral or long-acting depot antipsychotic medications during the study period of 12 months; and (4) willing to provide written informed consent.According to protocol, serial follow-up assessments using the Positive and Negative Symptom Scale, Indian Disability Evaluation and Assessment Scale, Abnormal and Involuntary Movement Scale, Simpson and Angus scale, and Global Assessment of Functioning were administered. The assessments were carried out at baseline and every 3–4 months. A total of three assessments were completed for each patient in the study.The total cost of providing depot (fluphenazine decanoate along with promethazine) or oral medications (first-generation antipsychotics – haloperidol and chlorpromazine in adequate doses along with trihexyphenidyl) to the subjects for a year was averaged for the number of subjects receiving these medications and calculated based on their cost.The results indicate that the mean cost of treatment of schizophrenia for a period of 1 year with oral antipsychotics was 1291.72 while the cost of long-acting depot antipsychotics was 972.68. A statistically significant difference (P = 0.01) was observed between the two groups with long-acting depot medications found to be cheaper than oral antipsychotics. Moreover, the functional outcome observed between the subjects on oral and long-acting depot antipsychotic medications was found to be similar with no statistically significant difference (P > 0.05).This study has shown that the use of oral neuroleptics was significantly more costly than the use of depot. Literature on cost-effectiveness comparisons between oral and depot antipsychotics was not found in the Indian context. However, the results similar to this paper have been reported in a study where the total mean costs per patient over 2 years were least in long-acting risperidone (€16,406), as compared to olanzapine (€17,074) and haloperidol (€21,779).[7]Similar outcomes of oral and depot groups and studies supporting depot-related compliance to medication emphasize that the depot neuroleptics use could be an effective method of ensuring compliance to treatment in the community.[8] Further, subjective reports from community workers indicate the ease of administration of depot neuroleptics, proving them to be a feasible mode of treatment, especially in remote villages. Antipsychotic noncompliance can increase risk of relapse and result in higher costs of treatment.[9] Depot-related higher treatment compliance rates could indicate the use of depot injections as a cost-effective strategy in low- and middle-income countries.The current study is not without any limitations. Major limitations of the study are: (1) the study was not registered with the Clinical Trials Registry - India; (2) small sample size; (3) only the cost of the medications was studied while the other cost associated as a travel was not included in the study.Cost plays an important role in influencing the discontinuation or nonadherence to medication in persons with schizophrenia. The results of this study highlight the importance of long-acting depot antipsychotic preparations in the long-term management of schizophrenia, especially in rural communities in India.
Financial support and sponsorship
This work was supported by the National Mental Health Program of the Government of India.