By Dr David Laing Dawson and Marvin Ross
As family members of those with schizophrenia will tell you, the care that we as a society provide is bad and has been getting worse for a number of years. The growing numbers of homeless in our cities many of whom have untreated mental illnesses is an indicator. Another indicator is the increasing proportion of mentally ill in jails. We have closed expensive hospital and high support residential facilities, kicked patients out of hospitals before they are properly stabilized and lack sufficient community programs. A study done in 2014 found that the psychiatrists in practice see too few patients and are reluctant to accept new referrals.
The end result of that, according to Kathy Mochnacki, President of the Board of Directors of Home on the Hill Supportive Housing a family driven Charitable Organization in Ontario, is that her organization spends a great deal of time supporting families who are often in crisis because of the lack of adequate services in the community.
This is the reality that exists today that is not addressed by a recent study out of the University of Calgary entitled 10 Year Trends in Health Care Spending Among Patients with Schizophrenia in Alberta Canada. The researchers looked at the amount of money spent from 2008 to 2017 on patients for hospitalizations, emergency department visits, outpatient physician visits, and prescription medications.
What they did find is that per capita ER costs remained about the same although in absolute dollars, it increased from $10.5 million to $21.7 million. In patient hospitalizations was way down at $13,397 per capita to $6818 per capita ($216.8 million to $226.1 million in absolute spending). The big increase in spending was for drugs that went from $2246 per capita to $8046 or a 3.6 fold increase.
This huge drug increase was attributable to an increase in the use of injectable Abilify. Not surprisingly, research has determined that compliance on anti-psychotic medication is much better when given in once monthly injections rather than daily pills or capsules. And because of this the relapse rate is lower.
This is especially true for patients living in less than ideal circumstances: unstable housing, roommates, communal living, boarding houses, marijuana, alcohol and other drug use. (I have had patients ask to go on monthly injections for these reasons)
So it is also not surprising that more and more patients suffering from schizophrenia are being put on monthly injections rather than daily pills. Especially now that we have injections that last one month rather than one or two weeks.
Doctors don’t pay much attention to the cost of medication in Canada unless it is not covered by the Province or other insurance.
So we researched the cost of aripriprazole (Abilify) which in the injectable form is Abilify Maintena.
For comparison, in Alberta where the study was done, a month’s supply of Risperdone or Olanzapine in pill form would cost between $10 and $40.
Abilify (made by Bristol-Myers Squibb) in pill form would cost $100.
The cost of Abilify in injection form for a 30 day period is $450.
So that would be a ten fold increase over maintenance on Olanzapine, and probably a twenty fold increase over maintenance on an older antipsychotic like Perphenazine.
And there are other costs associated with monthly injections as opposed to a doctor’s appointment every 3 months.
Of course the drugs making the most profit for the pharmaceutical companies are promoted and touted, and whether they are better or not, they get far more advertising than older drugs. And older drugs like perphenazine (an effective anti-psychotic with few adverse effects when small dose is sufficient) are almost forgotten because nobody is making money on them.
Which means two things: 1. That expensive research study was entirely unnecessary.
We know the prevalence and incidence of schizophrenia. We know it varies study from study because of methodology and diagnostic changes. And we could have determined the rest by spending a little time with Google.
So more and more patients are being maintained on monthly injectables, as expected.
Abilify is or is becoming the most popular of these.
Abilify in injectable form costs 10 times per month more than comparable medication in daily pill form.
And 2. clearly the provinces and/or Canada have not done a good job negotiating pricing with Bristol-Myers Squibb.
And, according to Dr Richard O’Reilly, a psychiatrist in London, Ontario:
“We are spending more on costly drugs, which large research studies suggest are not more effective. The newer antipsychotics offer a different suite of side-effects i.e. metabolic rather than neurological. They are a useful alternative for some patients who are sensitive to neurological side effects, such as Parkinsonism and tardive dyskinesia. However, the fact that many effective older antipsychotic drugs have almost disappeared from use is an indication of the marketing skills of the pharmaceutical industry – targeting both clinicians and family groups to advocate for their patent-protected medications. The metabolic effects of many so-called “atypical antipsychotics” increase the risk of mortality and studies show that life expectancy of people who suffer from schizophrenia continues to be markedly reduced in comparison to the general population: in part due to high rates of adverse cardiovascular events. We have closed expensive hospitals and high support residential facilities and invested those savings in expensive new medications with marginal benefits. We should be using those savings to pay for professionals and systems that provide high quality care for people with schizophrenia and other severe mental illnesses in community settings. My impression is that the only the winners are the pharmaceutical companies.”
What is missing from this study is outcomes. Are these patients better off in 2017 compared to 2008? That is the key metric. The researchers did look at what they called material and social deprivation but how they derived those measures is inadequately described by using census data and postal codes as proxies. They did state that “a higher proportion of patients were classified as unstably housed, with a low of 5.0% in 2008 to a high of 5.8% in 2017”.
To reiterate, this study was totally unnecessary and did nothing to advance our knowledge or to help improve care to those who have been neglected for so long.