What is the approximate cost of treatment for a person with schizophrenia?

1. Testimony to the Social Security Administration Hearing on Compassionate Benefits for Schizophrenia John S. Brekke, Ph.D. Frances Larson Professor of Social Work Research Associate Dean of Research School of Social Work University of Southern California November 18, 2009

2. What is the approximate cost of treatment for a person with schizophrenia? In terms of psychosocial interventions, cost will depend on the nature (intensity and training required) of the intervention, but it can vary from about $5,000 per year for Supported Employment, to over $18,000 per year for Assertive Community Treatment. Some shorter term interventions such as Multi-family Group Psychoeducation will be less expensive.

3. What do we know about the life expectancy of people with schizophrenia? The average life expectancy of individuals with schizophrenia is 61 years (57 years for men and 65 for women) whereas the corresponding figure is 76 years (72 years for men and 80 years for women) for the general population. Thus, patients with schizophrenia have approximately a 20% reduced life expectancy compared with the general population. (Amaddeo et al., 1995; Hennekens et al., 2005; Lawrence et al., 2000)

4. Life Expectancy • Among SZ patients, mortality rates are higher than in the general population for diseases of the circulatory, digestive, endocrine, nervous, and respiratory systems, cancer, as well as for suicide and for undetermined death. (Hennekens et al., 2005) • Suicide rates among SZ patients are 10 – 20 times the rate in the general population. (Amaddeo et al., 1995; Lawrence et al., 2000; Palmer et al., 2005)

5. Psychiatric Comorbidities • Substance Abuse – 47% (Buckley, 2006; Merikangas et al., 2007; Regier et al., 1990) • Anxiety - Panic Attacks – 15% - Panic Disorder – 25% (Grant et al., 2006; Katerndahl & Realini, 1993; Robins & Regier, 1991) - Posttraumatic Stress Disorder – 29% (Kessler et al., 1995) - Obsessive-Compulsive Disorder – 23% (Lucka et al., 2002; Poyurovksy et al., 2008; Shioiri et al., 2007) • Depression – 50% (Buckley, 2006)

6. Medical Comorbidities Estimated that more than 40% - 56% of patients with schizophrenia have a clinically significant medical illness (Keyser et al., 2008; Mitchell & Malone, 2006) Prevalence of Alcohol Use Disorder for persons with schizophrenia is 3.3 times greater compared to the general population (Green & Brown, 2006 ; Regier et al., 1990) Alcohol use disorders are also associated with medical morbidity (Liskow et al., 2000; De Alba et al., 2004)

7. Medical Comorbidities • Increased rates of several chronic medical conditions: • Cardiovascular disease (McCreadie, 2003) • Coronary artery disease (Davidson, 2002; Enger et al., 2004) • Chronic obstructive pulmonary disease (Himelhoch et al., 2004) • HIV (Cournos & McKinnon, 1997; Stoskopf et al., 2001) • Hepatitis C (Rosenberg et al., 2003) • Diabetes(Bushe & Holt, 2004; Dixon et al., 2000; Goff et al., 2005; Muir-Cochrane, 2006) • Obesity (Goff et al., 2005; Lieberman et al., 2005; Newcomer, 2005)

8. Medical problems may be related to a variety of factors: • Cognitive and behavioral impairments • Adverse effects of the medications used in treatment (Goldman, 1999; Sokal et al., 2004) • Advanced age, female gender, depression and neurocognitive impairment are all associated with an increased burden of comorbid medical illness in schizophrenia (Chwastiak et al., 2006) • Combined “dual neglect” of chronic medical conditions by both patients and health care providers (Meyer & Nasrallah, 2003; Nasrallah et al., 2006)

9. How does substance abuse affect individuals with schizophrenia? Does it increase with severity of the disease? Substance use complicates the course of illness and the treatment of persons with schizophrenia: • Reduces effectiveness of medications • Increases medication noncompliance • More likely to relapse • Less likely to respond well to treatment • Increases the use of crisis-oriented services • More likely to require hospitalizations • Worsens symptoms, undermines functioning, and interferes with social relationships (CAMH, 2004; Drake, 2006; Green & Sherwood, 2006; Petrakis, 2007)

10. Social problems associated with substance use in persons with schizophrenia Legal entanglement Housing instability Unemployment Poor money management (Petrakis, 2007)

11. How does homelessness affect individuals with schizophrenia? About 25-30% of the homeless population is made up of those with serious mental illness, mainly schizophrenia 15-20% of individuals diagnosed with schizophrenia are homeless at any one time This is compared to .0025% of US population that is homeless at any one time. Homelessness among those with schizophrenia devastates every aspect of their lives: health, work, mental health, economic.

12. How does homelessness affect individuals with schizophrenia? Most individuals with schizophrenia who are homeless lack: Basic health care Income Social support networks Housing options Individuals with schizophrenia who are homeless have been found to have elevated rates of victimization (Hiday et al., 1999) They also have mortality rates that are 3-4 times higher than the expected rate (Babidge et al., 2001)

13. What behaviors are likely to indicate that an individual will be unable to perform sustained work in the economy? Very few people with schizophrenia perform sustained work in the economy, generally less than 10% of those in treatment work in competitive employment, although over 60% express a desire to work (Bond, Drake et al., 2008)

14. Factors related to low employment Macro Factors: - Poverty - Societal and cultural factors: social exclusion and stigma - Disability policies - Human Resource policies - SSA policies and procedures

15. Factors related to low employment Individual level factors: - Motivational challenges - Cognitive impairments - Interpersonal deficits - Symptoms: particularly negative symptoms, although positive and depressive symptoms can interfere as well - Internalized stigma - Fear of losing benefits: fiscal and medical

16. Are there “scales of severity” or other known measures that can help us assess the impact of schizophrenia? How are these tests administered? Are they costly? Are they used widely? Symptoms: 1) Brief Psychiatric Rating Scale: trained rater 2) Schedule for Assessment of Positive and Negative Symptoms: trained rater 3) Brief Symptom Inventory: self administered 4) Colorado Symptom Index: self administered

17. Scales Cont’d Psychosocial Functioning: The Validation of Everyday Real-World Outcomes (VALERO) project (Leifker, Patterson et al., 2009) has made recommendations on a range of functional measures that target everyday living skills, social, and work functioning. Combination of rater and self-administration. Subjective domains: Measures of quality and satisfaction with life as well as core recovery domains are also available (Brekke et al., 2009; Bromley and Brekke, in press). Mostly self-administered.

18. The scales are widely used in research protocols but not widely used in usual care practice settings. Their cost is largely related to the amount of training needed, and scoring issues. These costs can be reduced with video training methods and the use of software for scoring. Start up and maintenance costs can be notable for smaller agencies.