Applied Health Economics and Health Policy

, Volume 13, Issue 5, pp 493–506 | Cite as

A Cost-effectiveness Analysis of Antipsychotics for Treatment of Schizophrenia in Uganda

  • Solomon J. Lubinga
  • Byamah B. Mutamba
  • Angelo Nganizi
  • Joseph B. Babigumira
Original Research Article

Abstract

Background

Reductions in prices following the expiry of patents on second-generation antipsychotics means that they could be made available to patients with schizophrenia in low-income countries. In this study we examine the cost effectiveness of antipsychotics for schizophrenia in Uganda.

Methods

We developed a decision-analytic 10-state Markov model to represent the clinical and treatment course of schizophrenia and the experience of the average patient within the Uganda healthcare system. The model was run for a base population of 25-years-old patients attending Butabika National Referral Mental Hospital, in annual cycles over a lifetime horizon. Parameters were derived from a primary chart abstraction study, a local community pharmacy survey, published literature, and expert opinion where necessary. We computed mean disability-adjusted life-years (DALYs) and costs (in US$ 2012) for each antipsychotic, incremental cost, and DALYs averted as well as incremental cost-effectiveness ratios (ICERs).

Results

In the base-case analysis, mean DALYs were highest with chlorpromazine (27.608), followed by haloperidol (27.563), while olanzapine (27.552) and risperidone had the lowest DALYs (27.557). Expected costs were highest with quetiapine (US$4943), and lowest with risperidone (US$4424). Compared to chlorpromazine, haloperidol was a dominant option (i.e. it was less costly and more effective); and risperidone was dominant over both haloperidol and quetiapine. The ICER comparing olanzapine to risperidone was US$5868 per DALY averted.

Conclusion

When choosing between first-generation antipsychotics, clinicians should consider haloperidol as the first-line agent for schizophrenia. However, overall, risperidone is a cost-saving strategy; policymakers should consider its addition to essential medicines lists for treatment of schizophrenia in Uganda.

References

  1. 1.
    Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet. 2014;383(9929):1677–87. doi:10.1016/s0140-6736(13)62036-x.PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Jablensky A. The 100-year epidemiology of schizophrenia. Schizophr Res. 1997;28(2–3):111–25. doi:10.1016/S0920-9964(97)85354-6.CrossRefPubMedGoogle Scholar
  3. 3.
    Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197–223. doi:10.1016/s0140-6736(12)61689-4.CrossRefPubMedGoogle Scholar
  4. 4.
    Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86. doi:10.1016/s0140-6736(13)61611-6.CrossRefPubMedGoogle Scholar
  5. 5.
    Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64(10):1123–31. doi:10.1001/archpsyc.64.10.1123.CrossRefPubMedGoogle Scholar
  6. 6.
    Laursen TM, Nordentoft M, Mortensen PB. Excess early mortality in schizophrenia. Annu Rev Clin Psychol. 2014;10:425–48. doi:10.1146/annurev-clinpsy-032813-153657.CrossRefPubMedGoogle Scholar
  7. 7.
    Goeree R, Farahati F, Burke N, Blackhouse G, O’Reilly D, Pyne J, et al. The economic burden of schizophrenia in Canada in 2004. Curr Med Res Opin. 2005;21(12):2017–28. doi:10.1185/030079905x75087.CrossRefPubMedGoogle Scholar
  8. 8.
    Knapp M, Mangalore R, Simon J. The global costs of schizophrenia. Schizophr Bull. 2004;30(2):279–93.CrossRefPubMedGoogle Scholar
  9. 9.
    Awad AG, Voruganti LN. The burden of schizophrenia on caregivers: a review. Pharmacoeconomics. 2008;26(2):149–62.CrossRefPubMedGoogle Scholar
  10. 10.
    van Os J, Kapur S. Schizophrenia. Lancet. 2009;374(9690):635–45. doi:10.1016/s0140-6736(09)60995-8.CrossRefPubMedGoogle Scholar
  11. 11.
    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.CrossRefPubMedGoogle Scholar
  12. 12.
    Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet. 2009;373(9657):31–41. doi:10.1016/s0140-6736(08)61764-x.CrossRefPubMedGoogle Scholar
  13. 13.
    Rukat A, Musisi S, Strohle A, Mundt AP. Prescription patterns of psychotropic medications for the treatment of psychotic disorders in the largest mental health institutions of Uganda. J Clin Psychopharmacol. 2014;34(5):571–6. doi:10.1097/jcp.0000000000000166.CrossRefPubMedGoogle Scholar
  14. 14.
    Albright B. Three key antipsychotics lose patent protection. Behav Healthc. 2012;32(2):44–5.PubMedGoogle Scholar
  15. 15.
    Chisholm D, Gureje O, Saldivia S, Villalon Calderon M, Wickremasinghe R, Mendis N, et al. Schizophrenia treatment in the developing world: an interregional and multinational cost-effectiveness analysis. Bull World Health Organ. 2008;86(7):542–51. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647485/pdf/0042-9686_86_07-045377.pdf.
  16. 16.
    Chisholm D, Saxena S. Cost effectiveness of strategies to combat neuropsychiatric conditions in sub-Saharan Africa and South East Asia: mathematical modelling study. BMJ. 2012;344:e609. doi:10.1136/bmj.e609.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Sham PC, MacLean CJ, Kendler KS. A typological model of schizophrenia based on age at onset, sex and familial morbidity. Acta Psychiatr Scand. 1994;89(2):135–41.CrossRefPubMedGoogle Scholar
  18. 18.
    Hutubessy R, Chisholm D, Edejer TT. Generalized cost-effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc. 2003;1(1):8. doi:10.1186/1478-7547-1-8.PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
  20. 20.
    Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet. 2009;374(9690):620–7. doi:10.1016/s0140-6736(09)60742-x.CrossRefPubMedGoogle Scholar
  21. 21.
    De Hert M, Correll CU, Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophr Res. 2010;117(1):68–74. doi:10.1016/j.schres.2009.12.029.CrossRefPubMedGoogle Scholar
  22. 22.
    Tiihonen J, Wahlbeck K, Lonnqvist J, Klaukka T, Ioannidis JP, Volavka J, et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ. 2006;333(7561):224. doi:10.1136/bmj.38881.382755.2F.PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    National Collaborating Center for Mental Health (UK). Psychosis and schizophrenia in adults: treatment and management. London(UK): National Institute for Health and Clinical Excellence 2014. Report No.: NICE clinical guidelines, No. 178. Available from: http://www.ncbi.nlm.nih.gov/books/NBK248060/pdf/TOC.pdf. Accessed 12 Nov 2014.
  24. 24.
    Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353(12):1209–23. doi:10.1056/NEJMoa051688.CrossRefPubMedGoogle Scholar
  25. 25.
    Kahn RS, Fleischhacker WW, Boter H, Davidson M, Vergouwe Y, Keet IP, et al. Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. Lancet. 2008;371(9618):1085–97. doi:10.1016/s0140-6736(08)60486-9.CrossRefPubMedGoogle Scholar
  26. 26.
    Tardy M, Huhn M, Engel RR, Leucht S. Perphenazine versus low-potency first-generation antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev. 2014;10:CD009369. doi:10.1002/14651858.CD009369.pub2.
  27. 27.
    Lieberman JA, Phillips M, Gu H, Stroup S, Zhang P, Kong L, et al. Atypical and conventional antipsychotic drugs in treatment-naive first-episode schizophrenia: a 52-week randomized trial of clozapine vs chlorpromazine. Neuropsychopharmacology. 2003;28(5):995–1003. doi:10.1038/sj.npp.1300157.PubMedGoogle Scholar
  28. 28.
    Weiden PJ, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull. 1995;21(3):419–29. http://schizophreniabulletin.oxfordjournals.org/content/21/3/419.full.pdf.
  29. 29.
    World Health Organization. Life expectancy: life tables Uganda. WHO. 2011. http://apps.who.int/gho/data/view.main.61730. Accessed 12 Sept 2013.
  30. 30.
    Cause-specific mortality 2008: [database on the Internet]. World Health Organization. 2008. Available from: http://www.who.int/entity/gho/mortality_burden_disease/global_burden_disease_DTH7_2008.xls. Accessed 28 Sept 2013.
  31. 31.
    Dossenbach M, Treuer T, Kryzhanovskaya L, Saylan M, Dominguez S, Huang X. Olanzapine versus chlorpromazine in the treatment of schizophrenia: a pooled analysis of four 6-week, randomized, open-label studies in the Middle East and North Africa. J Clin Psychopharmacol. 2007;27(4):329–37. doi:10.1097/JCP.0b013e3180ca83b1.CrossRefPubMedGoogle Scholar
  32. 32.
    Dossenbach M, Arango-Davila C, Silva Ibarra H, Landa E, Aguilar J, Caro O, et al. Response and relapse in patients with schizophrenia treated with olanzapine, risperidone, quetiapine, or haloperidol: 12-month follow-up of the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study. J Clin Psychiatry. 2005;66(8):1021–30.CrossRefPubMedGoogle Scholar
  33. 33.
    Leucht S, Cipriani A, Spineli L, Mavridis D, Orey D, Richter F, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet. 2013;382(9896):951–62. doi:10.1016/s0140-6736(13)60733-3.CrossRefPubMedGoogle Scholar
  34. 34.
    Yood MU, DeLorenze G, Quesenberry CP Jr, Oliveria SA, Tsai AL, Willey VJ, et al. The incidence of diabetes in atypical antipsychotic users differs according to agent—results from a multisite epidemiologic study. Pharmacoepidemiol Drug Saf. 2009;18(9):791–9. doi:10.1002/pds.1781.CrossRefPubMedGoogle Scholar
  35. 35.
    Citrome LL, Jaffe AB. Relationship of atypical antipsychotics with development of diabetes mellitus. Ann Pharmacother. 2003;37(12):1849–57. doi:10.1345/aph.1D142.CrossRefPubMedGoogle Scholar
  36. 36.
    Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2129–43. doi:10.1016/s0140-6736(12)61680-8.CrossRefPubMedGoogle Scholar
  37. 37.
    Lenert LA, Sturley AP, Rapaport MH, Chavez S, Mohr PE, Rupnow M. Public preferences for health states with schizophrenia and a mapping function to estimate utilities from positive and negative symptom scale scores. Schizophr Res. 2004;71(1):155–65. doi:10.1016/j.schres.2003.10.010.CrossRefPubMedGoogle Scholar
  38. 38.
    WHO. Global Burden of Disease 2004 Update: disability weights for diseases and conditions. Available from: http://www.who.int/healthinfo/global_burden_disease/GBD2004_DisabilityWeights.pdf. Accessed 26 Feb 2015.
  39. 39.
    Nambuya AP, Otim MA, Whitehead H, Mulvany D, Kennedy R, Hadden DR. The presentation of newly-diagnosed diabetic patients in Uganda. Qjm. 1996;89(9):705–11. http://qjmed.oxfordjournals.org/content/qjmed/89/9/705.full.pdf.
  40. 40.
    Fox-Rushby JA, Hanson K. Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis. Health Policy Plan. 2001;16(3):326–31. http://heapol.oxfordjournals.org/content/16/3/326.full.pdf.
  41. 41.
    Matsiko CW, Kiwanuka J. A review of human resources for health in Uganda. Health Policy and Development. 2003;1(1):15–20. http://www.bioline.org.br/pdf?hp03006.
  42. 42.
    Management Sciences for Health. International drug price indicator guide 2013. Available from: http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=DMP&language=English. Accessed 28 Nov 2014.
  43. 43.
    National Medical Stores. Price indicator, October 2010. Available from: http://www.nms.go.ug/images/imported_files/CATALOG_OCT_2010.pdf. Accessed 13 Nov 2013.
  44. 44.
    Chale SS, Swai AB, Mujinja PG, McLarty DG. Must diabetes be a fatal disease in Africa? Study of costs of treatment. BMJ. 1992;304(6836):1215–8.PubMedCentralCrossRefPubMedGoogle Scholar
  45. 45.
    Ninci A, Ocakacon R. How much do lab tests cost? Analysis of Lacor Hospital laboratory services. Health Policy and Development 2004. Available from http://www.bioline.org.br/pdf?hp04027. Accessed 9 Sept 2013.
  46. 46.
    Adam T, Evans DB, Murray CJ. Econometric estimation of country-specific hospital costs. Cost Eff Resour Alloc. 2003;1(1):3. doi:10.1186/1478-7547-1-3.PubMedCentralCrossRefPubMedGoogle Scholar
  47. 47.
    Uganda Bureau of Statistics. Statistical abstract 2012. Available from: http://www.ubos.org/onlinefiles/uploads/ubos/pdf%20documents/2012StatisticalAbstract.pdf. Accessed 22 Aug 2013.
  48. 48.
    Uganda Bureau of Statistics. Consumer price index September 2013. Available from: http://www.ubos.org/onlinefiles/uploads/ubos/cpi/septcpi2013/FINAL%20CPI%20release%20Sept.pdf. Accessed 17 Jan 2014.
  49. 49.
    Bank of Uganda. Exchange rates. 2013. www.bou.or.ug/bou/collateral/interbank_forms/2013/Dec/Major_31Dec13.html. Accessed 13 Nov 2013.
  50. 50.
    Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA. 1996;276(15):1253–8. http://jama.jamanetwork.com/article.aspx?articleid=409634.
  51. 51.
    Phanthunane P, Vos T, Whiteford H, Bertram M. Cost-effectiveness of pharmacological and psychosocial interventions for schizophrenia. Cost Eff Resour Alloc. 2011;9:6. doi:10.1186/1478-7547-9-6.PubMedCentralCrossRefPubMedGoogle Scholar
  52. 52.
    Phanthunane P, Vos T, Whiteford H, Bertram M, Udomratn P. Schizophrenia in Thailand: prevalence and burden of disease. Popul Health Metr. 2010;8:24. doi:10.1186/1478-7954-8-24.PubMedCentralCrossRefPubMedGoogle Scholar
  53. 53.
    Phanthunane P, Whiteford H, Vos T, Bertram M. Economic burden of schizophrenia: empirical analyses from a survey in Thailand. J Ment Health Policy Econ. 2012;15(1):25–32.PubMedGoogle Scholar
  54. 54.
    Adams CE, Awad GA, Rathbone J, Thornley B, Soares-Weiser K. Chlorpromazine versus placebo for schizophrenia. Cochrane Database Syst Rev. 2014;1:Cd000284. doi:10.1002/14651858.CD000284.pub3.
  55. 55.
    Hagg S, Joelsson L, Mjorndal T, Spigset O, Oja G, Dahlqvist R. Prevalence of diabetes and impaired glucose tolerance in patients treated with clozapine compared with patients treated with conventional depot neuroleptic medications. J Clin Psychiatry. 1998;59(6):294–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Solomon J. Lubinga
    • 1
    • 2
  • Byamah B. Mutamba
    • 3
  • Angelo Nganizi
    • 4
  • Joseph B. Babigumira
    • 1
    • 2
  1. 1.Pharmaceutical Outcomes Research and Policy Program, Department of PharmacyUniversity of WashingtonSeattleUSA
  2. 2.Global Medicines Program, Department of Global HealthUniversity of WashingtonSeattleUSA
  3. 3.Butabika National Referral Hospital for Mental, Neurological and Substance Abuse DisordersKampalaUganda
  4. 4.Kadic HospitalKampalaUganda

Personalised recommendations