Study Describes Unmet Needs in Schizophrenia, Schizoaffective Disorder Management

Christopher Crowe

Credit: Carelon Research

New research is calling attention to the burden of schizophrenia and schizoaffective disorder, providing new evidence highlighting various unmet needs for patients with these conditions.¹

Leveraging data from the Healthcare Integrated Research Database (HIRD), the study found patients with schizophrenia or schizoaffective disorder had high levels of comorbidities and healthcare resource utilization, frequently incurring elevated costs but receiving suboptimal treatment that they often discontinued, leading to relapse.¹

A subtype of schizophrenia, which affects about 22 in every 1000 people, schizoaffective disorder is estimated to affect about 3 in every 1000 people but is among the most frequently misdiagnosed psychiatric disorders in clinical practice. Given the complexity of both conditions, they often pose notable challenges for patients and health systems leading to substantial health and economic burdens.^2,3

“It is known that schizophrenia and schizoaffective disorder are more common among Medicaid enrollees relative to the general population, but there is a paucity of studies exploring how unmet needs for these patients may differ from those for commercial and Medicare enrollees,” Christopher Crowe, PhD, a lead analyst at Carelon Research, and colleagues wrote.¹ “If such comparisons were available, efforts could be made to develop more cost-effective, payor-specific strategies to improve care.”

To identify unmet needs relating to schizophrenia and schizoaffective disorder by payor type, investigators conducted a retrospective, observational cohort study using data from the HIRD, a geographically diverse longitudinal database of closed administrative medical and pharmacy claims. Patients were eligible for inclusion in the present study if they had ≥1 inpatient/ER claim or ≥2 outpatient claims between 30 and 183 days apart with a diagnosis of schizophrenia or schizoaffective disorder between January 1, 2014, and August 31, 2020.¹

Additionally, for inclusion, patients were required to be 12–94 years of age with ≥12 months of continuous medical and pharmacy health plan enrollment both before and after the index date. They also could not have a neurocognitive disorder or a diagnosis of schizophrenia or schizoaffective disorder before the index date. In total, investigators identified 4974 commercially insured, 1660 Medicare, and 4858 Medicaid patients 12–94 years of age with newly diagnosed schizophrenia or schizoaffective disorder.¹

For each payor type, investigators stratified patients based on the number of relapses they experienced during follow-up, defined as either an ER visit claim with any diagnosis of a psychiatric condition or an inpatient hospitalization claim with a primary diagnosis of schizophrenia or schizoaffective disorder. In total, 25% of commercial patients, 29% of Medicare patients, and 37% of Medicaid patients experienced relapse.¹

Investigators noted the daily antipsychotic pill burden was consistently higher among patients with more relapses (P <.001). Additionally, patients across all strata were more likely to have a fill for an atypical antipsychotic compared to other types of antipsychotics, and treatment with atypical antipsychotics was more common among patients with more relapses (P <.001).¹

Upon analysis, patients who were adherent to typical and atypical antipsychotics tended to have fewer relapses, regardless of payor type (P ≤.002). However, the proportion of patients who discontinued use of an atypical antipsychotic within 12 months of their index diagnosis differed by payor type and was most common among Medicaid patients (65%).¹

Access to psychotherapy also varied by payor type, with the number of patients who had ≥ 1 post-index psychotherapy visit accounting for 65%, 37%, and 46% of commercial, Medicare, and Medicaid patients, respectively. However, among those who had ≥ 1 visit, regular utilization of psychotherapy was rare.¹

Across all payor types, investigators noted post-index inpatient hospitalizations, ER visits, outpatient visits, and prescription fills increased with relapse frequency. They also pointed out the impact of schizophrenia or schizoaffective disorder on healthcare costs was greatest for commercial patients and lowest for Medicare patients. Relative to baseline, average unadjusted all-cause costs during follow-up increased by 105% for commercial patients, 66% for Medicare patients, and 77% for Medicaid patients.¹

Upon analysis, regardless of payor type, the strongest predictor of relapse was the index diagnosis location. Specifically, patients first diagnosed in an inpatient or ER setting had greater odds of relapse than those diagnosed in an outpatient setting (commercial odds ratio [OR], 5.95; 95% CI, 5.32–6.66; Medicare OR, 5.93; 95% CI, 4.90–7.18; Medicaid OR, 4.13; 95% CI, 3.76–4.54).¹

Although baseline comorbidities also predicted relapse, the strongest predictors varied by payor type. For commercial patients, post-traumatic stress disorder was the strongest predictor (OR, 1.59; 95% CI, 1.24–2.05). For Medicare patients, it was asthma (OR, 1.73; 95% CI, 1.40–2.14), and for Medicaid patients, it was substance use disorder excluding alcohol use disorder and nicotine dependence (OR, 1.32; 95% CI, 1.20–1.46).¹

Investigators acknowledged multiple limitations to these findings, including the potential for administrative coding errors, non-compliance with prescribed medications, and lack of access to medical care; the possibility that the true onset of disease occurred prior to the first recorded claim for schizophrenia or schizoaffective disorder; the lack of consideration of relapse events that occurred outside of inpatient or ER settings; and overlap with the COVID-19 pandemic that could have skewed healthcare resource utilization results.¹

“This study provides a robust, in-depth assessment of patients with incident schizophrenia or schizoaffective disorder across three different payor types in the US,” investigators concluded.¹ “Based on this assessment, the high burden of schizophrenia and schizoaffective disorder and the unmet needs for patients with these conditions in the US are evident.”

References

1. ^{Crowe CL, Xiang P, Smith JL, et al. Real-world healthcare resource utilization, costs, and predictors of relapse among US patients with incident schizophrenia or schizoaffective disorder. Schizophr. https://doi.org/10.1038/s41537-024-00509-6}
2. ^{Cleveland Clinic. Schizophrenia vs. Schizoaffective Disorder: What’s the Difference?. July 17, 2023. Accessed October 9, 2024. https://health.clevelandclinic.org/schizoaffective-disorder-vs-schizophrenia}
3. ^{Wy TJP, Saadabadi A. Schizoaffective Disorder. StatPearls. March 27, 2023. Accessed October 9, 2024. https://www.ncbi.nlm.nih.gov/books/NBK541012/}