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Summary
Clozapine is an atypical antipsychotic drug used to treat the 10-25% of patients who suffer from schizophrenia who are treatment resistant or intolerant to standard antipsychotic drug treatment. A major issue associated with treatment is the high cost of the drug compared to standard antipsychotic drug treatment. Research carried out to date has suggested that despite the high cost of clozapine, it is overall a cost-effective treatment. This contention is based on the findings described elsewhere that clozapine treatment is associated with a dramatic decrease in psychiatric inpatient stay.
There are many ethical difficulties associated with a prospective double-blind controlled trial of clozapine treatment. We have therefore reported on a retrospective audit. A retrospective analysis was carried out by the examination of computerised patient records to determine if clozapine treatment had been associated with a reduction in psychiatric inpatient stay. Also examined was whether clozapine treatment had been associated with an overall shift from intensive therapeutic ward usage.
For example, patients are moved from intensive care and acute wards to wards with less intensive therapeutic input such as continuing care and rehabilitation wards. The inpatient stay details for 76 patients prescribed clozapine since early 1991 were examined before and after clozapine treatment commenced. The main problem with this retrospective analysis is that without any control group observed over the same time period, it is very difficult to assess how much of the decrease in bed usage is related to either the natural history of the disease and/or to changes in bed use over time associated with changes in mental health service provision and the development of community facilities.
Psychiatric inpatient stay decreased by a statistically non-significant average of 13.2 days (6%) in the first year of treatment (p=0.7692), a non-significant average of 34 days (15%) in the second year of treatment (p=0.0669), a significant average of 38.4 days (17%) in the third year of treatment (p=0.0007) and again by a significant average of 51.2 days (22%) in the fourth year of treatment (p=0.0011).
The average cost per inpatient bed-day for the main psychiatric hospital in the Health Board's area is £90.86 (based on 100% occupancy rate, 1994/95 prices). The reduction in bed days identified was equivalent to a saving of £1,200 per patient in the first year of treatment, £3,090 per patient in the second year, £3,490 per patient in the third year and £4,652 per patient in the fourth year. The average annual cost of clozapine per patient is approximately £2,500.
Clozapine treatment was also associated with a shift from intensive care and acute ward inpatient usage to continuing care and rehabilitative ward usage. In the year prior to clozapine treatment intensive care and acute ward stay accounted for 72.7% of total inpatient stay. In the first year of treatment this proportion decreased to 63.7%, in the second year to 39.5%, in the third year to 31.8% and in the fourth year to 24.6%. This represented potential savings of £500,000 per annum.
Overall, the data generated from this study indicated that clozapine treatment is associated with both a reduction in psychiatric bed usage and a shift to less therapeutically intensive care wards. However, the decrease identified is not as dramatic as the reduction quoted elsewhere in the literature. These findings provide useful costing information to support the view that clozapine is a cost-saving or cost-neutral treatment in terms of the provision of psychiatric services in the UK. However, the costs associated with the increased use of community services by the study group were not identified in this review. In order to establish whether or not clozapine is cost saving overall compared to standard antipsychotic treatment it would have been necessary to identify all costs, including the whole range of community costs, before and after treatment commenced.