Global economic burden of schizophrenia: a systematic review

Figures & data

Figure 1 Flow diagram of the selection process to identify studies to be included.

Table 1 Methodological characteristics of the included studies

Author	Country	Perspective	Cost (currency, year)	Study design	Study approach	General cost estimation method	Indirect cost estimation method	Setting	Study period/duration	Sample size (n)
Africa
Amoo and Ogunlesi^Citation81	Nigeria	NR	NGN 2005a	P	PB	Bottom-up	NR	Aro Neuropsychiatric Hospital and the Federal Medical Centre, Abeokuta	6 months	57
Suleiman et al^Citation82	Nigeria	NR	NGN 1997a USD 1997a	P	PB	Bottom-up	NA	Yaba Psychiatric Hospital	6 months	50
Asia Pacific
Carr et al^Citation70	Australia	Payer societal	AUD 2000	P	PB	Bottom-up	Human capital	Four metropolitan Australian Capital Territory, Queensland, Victoria, Western Australia	1997–1998	980
Fitzgerald et al^Citation80	Australia	NR	AUD 2007a	P	PB	Bottom-up	Human capital	As part of the Australian SCAP	3 years	347
Hall et al^Citation72	Australia	NR	USD 1975	R	IB	Top-down and bottom-up	Human capital	New South Wales	1974–1977	NR
Langley-Hawthorne^Citation79	Australia	NR	AUD 1997a	Markov model	IB	Bottom-up	Human capital	National	NA	NR
Zhai et al^Citation78	People’s Republic of China	NR	USD 2013a	P	PB	Bottom-up	Human capital	Two centers in North and South China	2010	356
Grover et al^Citation71	India	NR	INR 2005a	P	PB	Bottom-up	Human capital	Departments of psychiatry and endocrinology of a tertiary hospital	NR	50
Pahuja et al^Citation75	India	NR	INR 2011a	P	PB	Bottom-up	NA	A tertiary care hospital in Kerala, India	6 months	25
Sado et al^Citation77	Japan	Societal	JPY 2008 USD 2008	CS	PB	Top-down	Human capital	National	2008	NR
Chang et al^Citation11	South Korea	Societal	USD 2005	R	PB	Top-down	Human capital	National	2005	161,058
de Silva et al^Citation69	Sri Lanka	NR	LKR 2012a	P	PB	Bottom-up	Human capital	Outpatient psychiatry clinic of the National Hospital of Sri Lanka	2 months	91
Lang and Su^Citation73	Taiwan	NR	USD 1999	R	PB	Top-down	NA	National	NR	52,432
Lee et al^Citation74	Taiwan	Societal	USD 1999	P	PB	Bottom-up	Human capital	Psychiatric outpatient clinics in three cities: Tainan, Chiayi, Changhua	August 1999–May 2000	74
Phanthunane et al^Citation76	Thailand	Societal	THB 2008	P	PB	Bottom-up	Human capital	Nine hospitals	September to November 2008	429
Europe
De Hert et al^Citation30	Belgium	NR	USD 1994	P	PB	Bottom-up	NA	Four psychiatrists’ agendas and six hospital wards	1994	108
Mangalore and Knapp^Citation42	England	Societal	GBP 2007a EUR 2007a USD 2007a	R	PB	Bottom-up	Human capital	As part of UK SCAP	NR	600
Rouillon^Citation44	France	Payer	USD 1992	CS	PB	Bottom-up	NA	National	November 1992	477
Sarlon et al^Citation48	France	NR	EUR 2007	P	PB	Top-down and bottom-up	Human capital	Three integrated areas in northern, central, and southern France	2 years	288
Heider et al^Citation38	France Germany UK	Payer	EUR 2000	P	PB	Top-down and bottom-up	NA	Three centers in France, four centers in Germany, and two centers in the UK	1998–2002	1,208
Frey^Citation33	Germany	Societal payer	EUR 2008	R	PB	Bottom-up	Friction cost	National	2005–2008	8,224
Salize and Rossler^Citation47	Germany	NR	USD 1994	P	PB	Bottom-up	NA	Two hospitals	1 year	66
Zeidler et al^Citation51	Germany	Payer	EUR 2006	R	PB	Bottom-up	NA	One insurance scheme	2004–2006	9,946
Behan et al^Citation52	Ireland	NR	EUR 2006	R	PB	Top-down and bottom-up	Human capital	National	2006	10,126
Garattini^Citation34	Italy	Payer	EUR 1997	R	PB	Bottom-up	NA	14 CMHCs	September to December 1998	702
Garattini et al^Citation35	Italy	Payer	USD 1998	P	PB	Bottom-up	NA	14 CMHCs	1 year	643
Tarricone et al^Citation49	Italy	NR	ITL 1995	R	PB	Bottom-up	Human capital	10 CMHCs	1995	100
Evers and Ament^Citation53	the Netherlands	Societal	ANG 1989	R	PB	Top-down	Human capital	National	1989	NR
Knapp et al^Citation40	the Netherlands Denmark UK Italy Spain	NR	GBP 2002a	R	PB	Bottom-up	NA	NR	3 months	404
Rund and Ruud^Citation45	Norway	NR	NOK 1994 USD 1994	P	PB	Bottom-up	NA	All treatment units serving six catchment areas	4 weeks	412
Saldivia Borquez et al^Citation29	Spain	NR	EUR 1999	NR	PB	Bottom-up	NA	Granada Province	1999	NR
Haro et al^Citation37	Spain	NR	USD 1994	P	PB	Top-down and bottom-up	Human capital	Three areas: Burlada, Cantabria, the Eixample	NR	112
Oliva-Moreno et al^Citation43	Spain	Payer	EUR 2002	R	PB	Top-down	NA	National	2002	NR
Vazquez-Polo et al^Citation50	Spain	Societal payer	EUR 1997	Markov Chain Monte Carlo simulation	PB	Bottom-up	NR	Four areas: Catalonia, Andalusia, Madrid, Navarre	3-year follow-up from 1997 (1998–2000)	356
Salize et al^Citation46	Spain the Netherlands UK Sweden Germany Switzerland	NR	EUR 2004	P	PB	Bottom-up	NA	Community psychiatric services	12 months	507
Ekman et al^Citation32	Sweden	Societal	EUR 2009	R	PB	Top-down and bottom-up	Human capital	National	2006–2008	2,161
Hertzman^Citation39	Sweden	NR	SEK 1975	NR	PB	Top-down	Human capital	National	1975	NR
Lindstrom et al^Citation41	Sweden	NR	SEK 2005 EUR 2005	P	PB	Bottom-up	Human capital	NR	5 years	225
Davies and Drummond^Citation31	UK	NR	GBP 1990/1991	NR	PB/IB	Top-down	Human capital	National	NR	185,400
Guest and Cookson^Citation36	UK	Societal payer	GBP 1997	Discrete event model	IB	Top-down	Human capital	National	5 years	7,500
America
Leitao et al^Citation66	Brazil	NR	USD 1998	Decision tree model	PB	Bottom-up	NA	Sao Paulo	1998	120
Goeree et al^Citation60	Canada	Societal	CAD 2004	R	PB	Top-down	Friction cost	National	2004	234,305
Rubio-Stipec et al^Citation65	Puerto Rico	Societal	USD 1994a	CS	PB	Top-down	Human capital	National	NR	NR
Bartels et al^Citation54	US	NR	USD 1999	R	PB	Bottom-up	NA	New Hampshire	January 1–December 31, 1999	9,844
Crown et al^Citation55	US	NR	USD 2001a	R	PB	Bottom-up	NA	National	1991–1993	665
Cuffel et al^Citation56	US	NR	USD 1986	R	PB	Top-down	NA	San Diego	1986 and 1990	15,403; 16,206
Desai et al^Citation57	US	Societal	USD 2008	R	PB	Bottom-up	Human capital	National	2005–2008	348
Dixon et al^Citation58	US	Payer	USD 2001a	R	PB	Bottom-up	NA	National	1991	12,440
Feldman et al^Citation59	US	NR	USD 2010	R	PB	Top-down	NA	National	2003–2008	36,852
Gunderson and Mosher^Citation68	US	Societal	USD 1975a	R	PB	Bottom-up	Human capital	National	1968, 1971, 1973	NR
Leslie and Rosenheck^Citation61	US	NR	USD 1993	R	PB	Bottom-up	NA	National	1993–1995	3,456; 3,759
Martin and Miller^Citation62	US	NR	USD 1998a	R	PB	Bottom-up	NA	Georgia	January 1, 1991–December 31, 1993	6,443
McDonald et al^Citation63	US	NR	USD 2005a	CS	PB	Bottom-up	NA	National	2001–2002	571,000
Miller and Martin^Citation64	US	NR	USD 1995	R	PB	Bottom-up	NA	Georgia	1990–1997	16,227
Wu et al^Citation10	US	Societal	USD 2002	R	PB	Top-down and bottom-up	Human capital	National	2000–2003	NR
Wyatt et al^Citation67	US	NR	USD 1995a	NR	PB	Bottom-up	NR	National	1991	NA

Note:

a If no price-year was reported in a study, the year of publication was referred as the year of pricing.

Abbreviations: ANG, Dutch guilder; AUD, Australian dollar; CAD, Canadian dollar; CMHC, community mental health center; CS, cross-sectional; EUR, Euro; GBP, British pound; IB, incidence-based; INR, Indian rupee; ITL, Italian lira; JPY, Japanese yen; LKR, Sri Lankan rupee; NA, not applicable; NGN, Nigerian naira; NOK, Norwegian krone; NR, not reported or insufficient information; P, prospective; PB, prevalence-based; R, retrospective; SCAP, schizophrenia care and assessment program; SEK, Swedish krona; THB, Thai baht; USD, US dollar.

Table 2 Direct medical cost components and data sources used in cost estimation

Author	Cost components									Data source for utilization data
	Hospital inpatient	Outpatient	Emergency care	Professional feesa	Pharmacyb	Laboratory	Day unit	Community-based carec	Others	Database	Interview	Chart	Literature
Africa
Amoo and Ogunlesi^Citation81	−	−	−	+	+	+	−	−	Registration fees, feeding/bedding		√
Suleiman et al^Citation82	−	+	−	+	+	−	−	−	–		√
Asia Pacific
Carr et al^Citation70	+	+	+	+	+	−	−	+	Out-of-pocket expenditure				√
Fitzgerald et al^Citation80	+	+	+	−	+	−	−	+	–	√
Hall et al^Citation72	−	−	−	−	−	−	−	−	Unspecified			√	√
Langley-Hawthorne^Citation79	+	+	−	+	+	−	−	+	–			√
Zhai et al^Citation78	−	−	−	−	+	−	−	−	Unspecified		√
Grover et al^Citation71	−	−	−	+	+	−	−	−	Infrastructure Out-of-pocket expenditure		√	√
Pahuja et al^Citation75	+	−	−	+	+	+	−	−	–			√
Sado et al^Citation77	+	+	−	−	−	−	−	−	–				√
Chang et al^Citation11	+	+	−	−	+	−	−	+	–	√			√
de Silva et al^Citation69	−	−	−	+	+	−	−	−	Alternative treatment		√
Lang and Su^Citation73	−	−	−	−	+	−	−	+	–	√
Lee et al^Citation74	+	+	+	−	+	−	−	+	Alternative treatment		√
Phanthunane et al^Citation76	+	+	−	−	+	−	−	−	Nonmedication therapy		√	√
Europe
De Hert et al^Citation30	+	−	−	+	+	−	−	−	–		√	√
Mangalore and Knapp^Citation42	+	−	+	+	+	−	+	+	–	√
Rouillon^Citation44	+	−	−	+	+	−	−	−	Intermediate facilities		√		√
Sarlon et al^Citation48	+	−	−	+	+	−	+	+	–	√	√
Heider et al^Citation38	+	−	−	+	+	−	+	−	–	√	√
Frey^Citation33	−	−	+	−	+	+	−	+	Out-of-pocket expenditure	√
Salize and Rossler^Citation47	+	+	−	−	+	−	−	−	–			√
Zeidler et al^Citation51	+	+	−	−	+	−	−	−	Unspecified	√
Behan et al^Citation52	+	+	+	+	+	−	+	+	–	√			√
Garattini^Citation34	+	+	−	−	+	+	+	+	–		√
Garattini et al^Citation35	+	+	−	−	+	+	+	+	–		√
Tarricone et al^Citation49	+	−	−	+	+	+	−	+	Out-of-pocket expenditure		√
Evers and Ament^Citation53	+	+	−	+	+	−	+	−	–				√
Knapp et al^Citation40	+	+	−	−	−	−	+	+	–		√
Rund and Ruud^Citation45	+	+	−	−	−	−	+	+	–		√
Saldivia Borquez et al^Citation29	+	+	−	+	+	−	−	−	Infrastructure	NR	NR	NR	NR
Haro et al^Citation37	+	+	−	−	−	+	−	+	–	√	√	√
Oliva-Moreno et al^Citation43	+	+	+	−	+	−	+	+	–	√		√	√
Vazquez-Polo et al^Citation50	+	−	+	+	+	−	−	−	Alternative treatment		√
Salize et al^Citation46	+	+	−	−	+	−	+	+	–			√
Ekman et al^Citation32	+	+	−	−	+	−	−	+	–	√			√
Hertzman^Citation39	+	+	−	−	+	−	−	−	–				√
Lindstrom et al^Citation41	+	−	−	−	+	−	−	−	–	NR	NR	NR	NR
Davies and Drunmmond^Citation31	−	+	−	−	+	−	−	+	–				√
Guest and Cookson^Citation36	+	−	+	+	+	−	+	+	–		√		√
America
Leitao et al^Citation66	+	+	−	−	−	−	−	+	–	√	√	√	√
Goeree et al^Citation60	+	−	+	+	+	−	−	+	–	√			√
Rubio-Stipec et al^Citation65	−	−	−	−	−	−	−	−	Unspecified				√
Bartels et al^Citation54	+	+	−	+	+	−	−	+	Insurance-related	√
Crown et al^Citation55	+	+	−	−	+	−	−	−	–	√
Cuffel et al^Citation56	+	+	−	−	+	−	+	+	–	√
Desai et al^Citation57	+	+	+	−	+	−	−	+	–	√
Dixon et al^Citation58	−	−	−	−	−	−	−	−	–	√
Feldman et al^Citation59	+	+	−	+	+	−	−	+	–	√
Gunderson and Mosher^Citation68	+	+	−	+	−	−	+	+	Construction	√			√
Leslie and Rosenheck^Citation61	+	+	−	−	−	−	−	−	–	√
Martin and Miller^Citation62	+	+	−	+	−	+	+	+	–	√
McDonald et al^Citation63	+	−	+	−	+	−	−	+	–	√
Miller and Martin^Citation64	+	−	−	+	+	−	−	+	–	√
Wu et al^Citation10	+	+	−	+	+	−	−	+	–	√
Wyatt et al^Citation67	+	−	−	−	+	−	−	+	Substance abuse	√	√	√	√

Notes:

a Includes physician, psychiatrist, psychologist, and other health care provider fee.

b Includes medical equipment.

c Includes nursing home, long-term institutional, and rehabilitation care. + included; − not included; √ data source used.

Abbreviation: NR, not reported or insufficient information.

Table 3 Direct nonmedical cost components and data sources used in cost estimation

Author	Cost component					Data sources for utilization data
	Homeless shelter	Social service/voluntary and NGO sector	Travel, food, and lodging	Suicide-related	Others	Database	Interview	Chart	Literature
Africa
Amoo and Ogunlesi^Citation81	−	−	+	−	Pocket money for patients and nurses		√
Suleiman et al^Citation82	−	−	+	−	–		√
Asia Pacific
Carr et al^Citation70	+	+	−	−	–				√
Langley-Hawthorne^Citation79	+	−	−	−	–				√
Zhai et al^Citation78	−	−	−	−	Unspecified		√
Grover et al^Citation71	−	−	+	−	–		√
Sado et al^Citation77	−	+	−	−	–				√
Chang et al^Citation11	+	−	+	−	–				√
de Silva et al^Citation69	−	−	+	−	–		√
Lee et al^Citation74	+	+	+	−	Community resources		√
Phanthunane et al^Citation76	−	−	+	−	–		√
Europe
De Hert et al^Citation30	+	−	−	−	–		√
Mangalore and Knapp^Citation42	+	+	−	−	–	√			√
Rouillon^Citation44	−	+	−	−	–		√		√
Frey^Citation33	−	−	+	−	Housekeeping, administrative, hospital investments	√
Salize and Rossler^Citation47	+	−	−	−	–			√
Behan et al^Citation52	+	+	−	−	–				√
Evers and Ament^Citation53	+	−	−	−	–				√
Knapp et al^Citation40	+	−	−	−	–		√
Vazquez-Polo et al^Citation50	+	+	−	−	–		√
Salize et al^Citation46	+	−	−	−	–			√
Lindstrom et al^Citation41	+	−	−	−	–	NR	NR	NR	NR
Guest and Cookson^Citation36	+	−	−	−	–		√		√
America
Goeree et al^Citation60	+	−	−	+	–				√
Gunderson and Mosher^Citation68	−	−	−	−	Research				√
Martin and Miller^Citation62	−	−	+	−	–	√
Wu et al^Citation10	+	−	−	−	Research and training				√
Wyatt et al^Citation67	+	−	−	+	–		√		√

Notes: + included; − not included; √ data source used.

Abbreviations: NGO, non-governmental organization; NR, not reported or insufficient information.

Table 4 Indirect cost components and data sources used in cost estimation

Author	Cost component										Data sources for utilization data
	Absenteeism	Presenteeism	Unemployment	Morbiditya	Premature mortality	Income assistance	Legal costs	Law enforcementb	Informal care	Others	Database	Interview	Chart	Literature
Africa
Amoo and	−	−	+	−	−	−	−	−	+	–		√
Ogunlesi^Citation81
Suleiman et al^Citation82	−	−	−	−	−	−	−	+	+	Accident and damages, unspecified productivity loss		√
Asia Pacific
Carr et al^Citation70	−	−	−	+	−	+	+	−	+	Tax foregone, unspecified productivity loss				√
Fitzgerald et al^Citation80	−	−	−	−	−	+	+	−	−	Tax foregone, unspecified productivity loss	√	√		√
Hall et al^Citation72	−	−	−	−	−	−	−	−	−	Unspecified productivity loss				√
Langley-Hawthorne^Citation79	−	−	+	−	−	+	−	−	−	–				√
Zhai et al^Citation78	+	−	−	+	+	−	−	−	+	Accident and damages		√
Grover et al^Citation71	+	−	−	−	−	−	−	−	+	Unspecified productivity loss		√
Sado et al^Citation77	−	−	+	+	+	−	−	−	−	–		√		√
Chang et al^Citation11	−	+	+	−	+	−	−	+	+	–				√
de Silva et al^Citation69	+	−	+	−	−	−	−	−	+	Unspecified productivity loss		√
Lee et al^Citation74	−	−	−	−	−	−	−	−	+	–		√
Phanthunane et al^Citation76	+	+	−	−	−	−	−	−	+	–		√
Europe
Mangalore and Knapp^Citation42	+	−	+	−	+	−	−	+	+	–	√			√
Sarlon et al^Citation48	+	−	+	−	−	−	−	−	−	–		√
Frey^Citation33	+	−	−	+	+	−	−	−	+	–	√			√
Behan et al^Citation52	+	−	+	−	+	−	−	+	+	–	√			√
Tarricone et al^Citation49	+	−	−	−	−	−	−	−	+	–		√
Evers and Ament^Citation53	+	−	−	+	−	−	−	−	−	–				√
Haro et al^Citation37	−	−	−	−	−	−	−	−	+	Unspecified productivity loss	NR	NR	NR	NR
Oliva-Moreno et al^Citation43	−	−	−	−	−	−	−	−	+	–				√
Ekman et al^Citation32	+	−	−	+	−	−	−	−	−	–				√
Hertzman^Citation39	−	−	−	+	+	−	−	−	−	Short-term illness				√
Lindstrom et al^Citation41	−	−	−	−	−	−	−	−	−	Unspecified productivity loss	NR	NR	NR	NR
Davies and Drummond^Citation31	−	−	+	−	−	−	−	−	−	Unspecified productivity loss	NR	NR	NR	NR
Guest and Cookson^Citation36	+	−	+	−	+	−	−	+	+	–		√		√
America
Goeree et al^Citation60	−	−	−	+	+	+	−	+	−	–				√
Rubio-Stipec et al^Citation65				−	−	−	−	−	−	Unspecified productivity loss				√
Desai et al^Citation57	+	+	−	−	+	−	−	−	+	–	√	√		√
Gunderson and Mosher^Citation68	−	−	−	−	−	+	−	−	−	Unspecified productivity loss				√
Wu et al^Citation10	+	+	+	−	+	−	−	+	+	–				√
Wyatt et al^Citation67	−	−	−	−	+	+	+	−	+	Unspecified productivity loss		√

Notes:

a Includes permanent disability and early retirement.

b Includes incarceration, crime, and police contact. + included; − not included; √ data source used.

Abbreviation: NR, not reported or insufficient information.

Table 5 Annual cost estimate of direct and indirect costs and total cost as % of GDP (USD 2013) in national studies

Author	Country	Cost estimates (USD 2013, millions)				Cost contribution to total cost (%)			Total cost as % GDP (USD 2013)
		Direct medical cost	Direct nonmedical cost	Indirect cost	Total	Direct medical cost	Direct nonmedical cost	Indirect cost
Asia Pacific
Sado et al^Citation77	Japan	7,247	33	18,950	26,230	28	<0.1	72	0.52
Chang et al^Citation11	South Korea	519	36	3,204	3,759	14	1	85	0.31
Europe
Behan et al^Citation52	Ireland	172	13	488	673	25	2	73	0.30
Frey^Citation33	Germany	10,635	354	8,978	19,967	53	2	45	0.56
Evers and Ament^Citation53	the Netherlands	774	50	70	894	87	6	8	0.11
Olivia-Moreno et al^Citation43	Spain	1,882	NA	1,669	3,552	53	NA	47	0.26
Ekman et al^Citation32	Sweden	29	NA	94	123	24	NA	76	0.02
Hertzman^Citation39	Sweden	3,712	NA	5,422	9,134	41	NA	59	1.65
Guest and Cookson^Citation36	UK	154	49	199	403	38	12	50	0.02
America
Goeree et al^Citation60	Canada	2,111	102	5,287	7,500	28	<0.1	72	0.41
Rubio-Stipec et al^Citation65	Puerto Rico	31	NA	63	94	33	NA	67	0.09
Desai et al^Citation57	US	4,742	NA	20,710	25,452	19	NA	81	0.15
Wu et al^Citation10	US	29,279	12,014	41,714	83,007	35	14	50	0.50
Wyatt et al^Citation67	US	27,745	4,054	70,597	102,396	27	4	69	0.61
Gunderson and Mosher^Citation68	US	12,078	57	48,200	60,335	20	<0.1	80	0.36

Abbreviations: GDP, gross domestic product; NA, not applicable; USD, US dollar.

Table 6 Annual cost estimate of direct and indirect costs in LMIC

Author	Country	Cost estimates (USD 2013)				Cost contribution to total cost (%)
		Direct medical cost	Direct nonmedical cost	Indirect cost	Total	Direct medical cost	Direct nonmedical cost	Indirect cost
Amoo and Ogunlesi^Citation81	Nigeria	9,882a	NR	3,604	13,486	73a	NR	27
Suleiman et al^Citation82	Nigeria	2,951	80	430	3,461	85	2	12
Zhai et al^Citation78	People’s Republic of China	257,980	44,237	515,297	817,514	32	5	63
Grover et al^Citation71	India	1,814	718	4,310	6,842	27	10	63
de Silva et al^Citation69	Sri Lanka	25,075	186	111,574	136,834	18	0.1	82
Phanthunane et al^Citation76	Thailand	6,661,900	521,900	17,613,000	24,796,800	27	2	71

Note:

a Includes direct nonmedical cost.

Abbreviations: USD, US dollar; NR, not reported or insufficient information; LMIC, low- and middle-income countries.

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