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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 262-268

Cost-of-treatment of clinically stable severe mental lilnesses in India


1 Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication14-Sep-2017

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry and NDDTC, Room no 4096, 4th Floor, Teaching Block, AIIMS, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.214600

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  Abstract 


Background and Aims: The cost-of-treatment studies can help to make informed decisions while planning health-care services. This study is aimed to assess direct costs of outpatient treatment of four common chronic severe mental illnesses in a tertiary care hospital in South India. Methods: The patients with ICD-10 diagnoses of schizophrenia, unspecified nonorganic psychosis, bipolar disorder, and recurrent depression were recruited by purposive sampling from a government teaching hospital in South India. The total cost-of-treatment to the patient and the hospital was computed for each disorder as a percentage of the per-capita income of an individual patient. Results: The study comprised a total of 140 patients. The average monthly total cost-of-treatment was Indian Rupees (INR) 770 (95% confidence interval of 725 to 815), or approximately US$ 12.8. The monthly total cost-of-treatment was INR 720 for schizophrenia, INR 750 for unspecified nonorganic psychosis, INR 830 for bipolar disorder, and INR 790 for recurrent depression, with no significant differences between groups. On an average, 22.8% of total cost-of-treatment was borne by the patient, and the rest by the hospital. The patients spent a median of 12% of their per-capita income on treatment related to direct costs. Conclusions: Despite substantial government subsidies, patients do incur some expenses in treatment of chronic psychiatric illnesses. The attempts to reduce treatment and travel costs can facilitate psychiatric care to larger number of individuals.

Keywords: Bipolar disorder, cost of treatment, depression, psychosis, schizophrenia


How to cite this article:
Sarkar S, Mathan K, Sakey S, Shaik S, Subramanian K, Kattimani S. Cost-of-treatment of clinically stable severe mental lilnesses in India. Indian J Soc Psychiatry 2017;33:262-8

How to cite this URL:
Sarkar S, Mathan K, Sakey S, Shaik S, Subramanian K, Kattimani S. Cost-of-treatment of clinically stable severe mental lilnesses in India. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Jul 18];33:262-8. Available from: http://www.indjsp.org/text.asp?2017/33/3/262/214600




  Introduction Top


The cost-of-treatment is an important issue while making informed choices about provision of psychiatric treatment services.[1],[2] When the resources are limited, it becomes incumbent upon health-care providers to ensure access to care to as many individuals as possible. Hence, there is a need to find the costs associated with various treatment options. However, health care costs can be computed in a variety of ways.[3] The direct costs refer to costs incurred by the patients and other agencies for medications, hospital visits and hospitalization. The indirect costs involve intangible expenses like loss of income from work and societal costs. Though direct costs are tangible and can be clearly elucidated, indirect costs are relatively difficult to be uniformly applied, and vary across health systems.[4],[5]

Marked differences are present between developed and developing countries with respect to the structure of service provision, actual service utilization and the economic impact of psychiatric disorders.[6],[7] The studies about cost-of-treatment of psychiatric disorders are relatively fewer from India, an emerging and populous developing country.[8],[9],[10],[11] Further, no study has attempted to explicitly compare the cost-of-treatment to the financial background of the patient population. Hence, this study was conducted to assess the cost of treatment of four severe mental illnesses, which require long term psychotropic medication, and to compare it with the per-capita income of the patient.


  Materials and Methods Top


Setting of the study

The study was conducted in a multi-specialty governmental teaching hospital in South India, which provides both inpatient and outpatient psychiatric services. The patients are either referred from other centers/departments, or are self-referred. A diagnosis is made in accordance with ICD 10 after detailed assessment and discussion with consultant. Regular follow-ups are advised as a part of treatment of chronic psychiatric disorders. The family members usually accompany the patients to the clinic. The hospital primarily caters to patients from lower socio-economic strata. There is no consultation fee for seeking treatment at the centre, and many medications are provided free from the hospital pharmacy, typically for 3 weeks at a time.

Patient characteristics

The present study included outpatients with an ICD 10 diagnosis of schizophrenia (F20), unspecified nonorganic psychosis (psychosis NOS) (F29), bipolar affective disorder (BPAD) (F31), and recurrent depressive disorder (RDD) (F33), of more than 1 year duration and on stable doses of medication for last 3 months. In case, if the patient had a relapse in the last 1 year, but were on stable doses of medication in the last 3 months, they were included. The patients with a diagnosis of current substance dependence (apart from nicotine), mental retardation, or organic psychiatric disorders were excluded. The participants were recruited after obtaining informed consent and the study had Institutional Ethics Committee approval. The data collection was done between March 2014 to June 2014.

The information was gathered from the patients, their caregivers' medical records, and in a single sitting using a structured questionnaire. The data was obtained about the basic demographic details, diagnosis, duration of illness and treatment, current treatment regimen, per-capita family income, and amount spent per-month on travel related to treatment. In cases of irregular family income, the participant was asked to provide an estimate of the average monthly income for the year.

Cost estimation

The cost calculations were done in Indian Rupees (INR) per month, and rounded off to the nearest 10 (1 US Dollar was approximately equivalent to INR 60 at the time of the study). For the purposes of the study, the direct cost-of-treatment was sub-divided into cost to the patient and cost to the hospital. The cost to patient included money spent on travel and medication purchased from outside the hospital. Medications were prescribed from outside either because; the medications available from inside the hospital were intolerable or were proved ineffective. The cost to the hospital was computed by adding the cost of services and infrastructure (hospital consultation estimate) to the hospital pharmacy medication costs.

The costs of medication for each patient were calculated by obtaining the median current market costs of medication as per current drug review.[12] The monthly cost-of-treatment at the median prescribed dose was calculated for each of the medications for representation. A single strength of dosing was available for medications available in the hospital pharmacy to minimize prescription and dispensing errors. For bulk purchases, it is possible that hospital could obtain significant discounts. Hence, additional analyses were conducted with medication cost discounted at 25% and 50%. But still, drug review estimates were used and not the current hospital actual procurement costs, as hospital procurement costs may vary markedly from year to year based upon sealed competitive bidding. For providing an international perspective, the monthly costs of each medication in USA were also enumerated.[13]

The hospital consultation estimate was calculated by adding the cost of service (salaries in weighted proportion of the time spent in the outpatient services) and the cost of hospital infrastructure (approximate amount payable for renting the outpatient area, electricity charges, furniture and other incidentals). The total monthly expense per-month was divided by the number of distinct patients seen per-month to arrive at the hospital consultation estimate per-patient per-month. The hospital consultation estimate was based on simplistic assumption that all patients required roughly equal amount of time per month, irrespective of their diagnosis; though it is possible that different patients required different amount of consultation time. An alternate analysis was also conducted with an increase in the cost of hospital consultation estimate by 20% to account for possible inflated incidentals like procurement costs, possible investigations, differences in cost of medications at different outlets etc. The base year for the comparisons was 2014.

Statistical analysis

The demographic and clinical characteristics of the patients were descriptively represented across the different diagnostic groups. The costs of treatment (both to the patient and the hospital) were calculated for the diagnostic sub-groups. Non-parametric tests were used for comparison of clinical and cost characteristics due to skewed data.

Thereafter, proportion of the per-capita income spent by the patient towards treatment (travel and outside medication) was computed. This was done to assess the burden of the treatment on the patients and their families despite attending to a ‘free’ government hospital. The proportion was dichotomized on the cut-off of 100% of per-capita income (i.e. spending one person of the family's entire monthly expenses towards treatment).


  Results Top


Patient characteristics and medications

The study included 140 patients across 4 diagnostic groups (32 with schizophrenia, 52 with psychosis NOS, 40 with BPAD and 16 with RDD). The distribution of the patients in the different diagnostic groups is shown in [Table 1]. The mean monthly per-capita family income was INR 1680. The four groups differed from each other on duration of illness (p = 0.010), duration of treatment (p = 0.012), and number of pills taken per day (p = 0.002).
Table 1: Characteristics of the patients

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The psychotropic medications prescribed to entire set of patients are listed in [Table 2]. Only 16 out of 140 patients (11.4% of the sample) were prescribed medications from outside the hospital. Risperidone, fluoxetine and valproate were the most commonly prescribed antipsychotic, antidepressant and mood-stabilizer medications, respectively. Diazepam was the most commonly prescribed sedative-hypnotic. About 47.9% of the sample was on 3 or more medications, while none of the patients were prescribed 5 or more medications. For the total sample, antipsychotics contributed to 36.4% of total psychotropic medication cost, mood stabilizers to 21.3%, sedative-hypnotics to 15.9%, antidepressants to 11.8%, and other medications contributed to 14.6% of the total medication costs.
Table 2: Psychotropic medications being prescribed

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Treatment costs

On an average, the total monthly direct cost of treatment was INR 770 per patient (95% confidence interval of 725 to 815). The average monthly medication cost-per-patient was INR 390, out of which 87.9% was borne by the hospital pharmacy. The monthly hospital consultation estimate was calculated to be INR 260 per-patient per-month. The treatment costs for various disorders are depicted in [Table 3]. The hospital pharmacy medication costs differed significantly between the diagnostic groups, leading to difference in costs to the hospital (Kruskal Wallis χ2 = 9.303, p = 0.026 for both). The cost to the hospital was 29.6%, 24.1% and 1.8% higher for RDD, BPAD and schizophrenia group than patients with psychosis NOS. The costs of treatment are graphically depicted in [Figure 1].
Table 3: Cost of treatment for various disorders per patient per month

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Figure 1: BPAD Bipolar Affective Disorder, INR Indian Rupees, RDD Recurrent Depressive Disorder

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On an average, 22.8% of the costs were borne by the patient. The proportion of total cost of treatment borne by the hospital to the total cost was calculated to estimate the subsidy provided. The degree of subsidy ranged from 72.0% for treatment of psychosis NOS, 75.3% for the treatment of schizophrenia, 79.8% for BPAD, and 88.6% for the treatment of RDD (average subsidy of 77.2% for all the disorders combined).

Treatment costs as a proportion of per-capita income

Next, treatment costs were calculated as a percentage of per-capita income. This was done to find out the financial burden posed by the treatment on the income of the patient and their family. The patients currently spend a median of 12% (inter-quartile range [IQR] of 4% to 26.7%) of their per-capita income on treatment related expenses. However, it was seen that 4.0% of the sample spent more than 100% of the per-capita income on treatment related expenses.

That total treatment costs comprised a median of 71.1% (IQR of 31.7% to 133.2%) of the monthly per-capita income of patient. The total treatment costs surpassed the per-capita monthly income in 32.3% of the patients. The percentage of per-capita income spent on treatment is graphically represented in [Figure 1]. It did not significantly differ across the treatment groups (Kruskal Wallis χ2 = 3.192, p = 0.363).

Analysis with discounted medication costs and inflated hospital consultation estimate

An alternate analysis with discounted medication prices (at discount rates of 25% and 50%, respectively) brought down the monthly cost of treatment per patient to INR 690 and INR 600 (decrement of 10.9% and 21.8%, respectively in the monthly total costs of treatment). Similarly, an increase in the hospital consultation estimate by 20% increased the cost of monthly cost of treatment to INR 820, reflecting an increase of 6.7% in the cost of treatment per patient.

Discounting of prices of medication and escalation of hospital consultation estimate did not have an impact on the percentage of per-capita income spent by the patients. But discounting of 25% and 50% of medication costs, the cost to the hospital reduced the median total costs-of-treatment from 71.1% of per-capita income of the patient to 63.8% and 54.5% of the per-capita income (reduction of 7.3% and 16.6%, respectively). Similarly, escalation of hospital consultation estimate by 20% increased the median total cost-of-treatment as percentage of per-capita income to 75.0% (increase of 3.9%).


  Discussion Top


Patient and medication characteristics

The present analysis was conducted in a group of outpatient at a tertiary care hospital on relatively stable doses of medication. The study had a higher representation of patients with a diagnosis of psychosis NOS as compared to schizophrenia. Other prescription audits from India also suggest that patients with unspecified psychosis might outnumber schizophrenia,[14] probably because of restrictive diagnostic criteria of schizophrenia as per ICD 10. The mean monthly per-capita income of the sample was INR 1680 (annual per-capita income of approximately US$335). This was considerably lower than current per-capita GDP of India of US$1499,[15] suggesting that a large number of treatment seekers to this hospital belonged to lower socio-economic status. On an average, patients were prescribed 2 to 3 types of psychotropic medication. This is similar to office based prescriptions from elsewhere.[16]

The type of medications being commonly prescribed was based upon constraints of hospital supply and therapist preferences. Risperidone was the second-generation antipsychotic available free of cost from the hospital, and was the commonest prescribed antipsychotic according to the survey of prescription patterns among Indian psychiatrists.[17] The use of antidepressants fluoxetine and amitriptyline was not in line with the prescription pattern from other places of India,[18] and escitalopram seems to be most commonly prescribed antidepressant in the region. A larger proportion of patients rely on valproate as mood-stabilizer rather than lithium, due to physician preferences. Another study from north India has also found similar prescribing trends of valproate eclipsing lithium.[14]

It is interesting to note that the monthly medication costs were considerably lower in India as compared to USA. This was primarily so for the antipsychotics, especially the newer antipsychotics. Taking risperidone as an example, the cost of monthly supply of this medication in USA was 13.4 times that of India (4 times higher after correcting for purchasing power parity [PPP] of 2013).[19] The monthly cost of aripiprazole was about 85.2 times higher in USA after correcting for PPP. However, for some medications like fluoxetine and lithium, medication costs in the US were only 2.9 and 2.1 times higher, respectively (0.86 and 0.61 times after correcting for PPP), after matching the medications costs in India.

Costs of treatment

The present study suggests that direct monthly cost of treatment of a stable patient with severe psychiatric disorder at the centre was INR 770, roughly translating to US$ 12.8 per month or US$ 154 annually. The direct cost per patient was higher than two previous studies,[8],[9] probably accounted by inflation over time. However, it was interesting to see that monthly medication costs have not increased substantially over a period of time.[10] The present study takes into consideration the costs borne for the consultation, which is likely to vary from place to place and can be considerable.[11] The resources spent by the hospital and other service provider can be substantial and may be more than cost of medications.[9],[20],[21] In our study, the proportion of costs borne by healthcare provider was higher than a north Indian study,[8] probably because a larger proportion of patients got free medications from the hospital in the present sample.

The direct costs of treatment in this study was found to be lower than Europe;[1] other developed countries like Australia, Canada and USA;[22] and other developed Asian countries;[23],[24] though differences in ascertainment methodology may be remarked. The lower costs of treatment in the present setting might be ascribed to two factors. Firstly, the medication costs in India had been comparatively lower than certain other western countries due to policies of the Indian government,[25],[26] which made effective medications accessible to the Indian masses at affordable costs. Secondly, the cost of services in healthcare sector in India has been comparatively lower than Western countries.[27] However, it must be remarked that the monthly cost of treatment was found to be higher than reported from other developing countries like Nigeria and Sri Lanka.[28],[29]

On a macroeconomic level, the cost of treatment of patients who are maintaining well on psychotropic medication can be massive when computed for the entire Indian population. Taking conservative estimates, if 2% of the adult population has severe psychiatric illness requiring treatment,[30] of which only 25% are treated, and of them 20% (i.e. 5% of population with severe mental illness) at government hospitals, it would translate to 720,000 individuals. The direct governmental cost of treatment of these ‘well’ individuals would be approximately 665 crore INR.

Comparison to per-capita incomes

The patients spent a median of 12% of their per-capita income on treatment. But a small proportion (4.0%) spent more than 100% of their per-capita income on treatment. This suggests a potentially unsustainable financial scenario, predisposing to treatment non-adherence. It has been seen that high cost of treatment could be an important predictor of non-adherence in clinical population in India and elsewhere.[31],[32],[33] Also, it must be acknowledged that despite treatment at the hospital being ‘free', patients needed to incur some direct expenses, especially for travel and at times for medication. To reduce costs of treatment borne by the patient further, steps can be taken including giving free bus passes, providing medication for a longer time, and providing home based treatment.[34] Tele-psychiatry can also be attempted for delivering expert treatment services through the primary health care centers.

The study also further analyzed percentage of per-capita income, which would be used up if government subsidy did not exist. In the absence of subsidy, the median per-capita income spent on treatment would increase from 12% to 71.1% (increase of about 600%), which would be a great financial burden to the patients and their families. This would push the direct treatment spending of more than 30% of the patients above 100% of their per-capita income. Such an increase is likely to further lead to difficulty to continue medications, leading to relapses and further increase in the direct and indirect costs associated with the illness. Hence, government funding needs to be continued for the treatment services.

Strengths and limitations

The findings of the study should be interpreted in the light of strengths and limitations. The strengths of the study include comparison of four chronic and severe psychiatric disorders encountered in clinical psychiatric practice. The study estimated the proportion of per-capita income of the patient being spent on treatment, in an attempt to understand the burden of treatment costs on the patient and the family. Additional analyses were carried out by factoringin the effect of discounted medication prices and escalating consultation costs.

The limitations of the study include purposive sampling leading to selection bias, reliance on self-report for income and travel expenses, and estimation of medication prices based upon rates quoted in drug indices. Systematic scales were not used to measure severity of different disorders. Disability benefits, if received were not factored into the calculations. The results reflect findings from one government teaching hospital and generalization is constrained by varied staffing patterns, hospital policies, and clientele in different institutions. The present study did not include costs of treatment of other comorbid disorders, and costs incurred on nutraceuticals/ investigations. The study refrained from computing indirect costs encompassing cost of care giving, loss of income, cost of alternate treatments, and costs to law enforcement requirement ascribed to psychiatric illness. It was stratified by the socio-economic status, residence and other demographic characteristics, as data on these aspects could not be gathered accurately in the present set-up. Cost estimations may be carried in a variety of ways and the methods used in the present study represent one of the ways. Formal sample size estimation was not done for this study

Conclusions

To conclude, the present descriptive study suggests that monthly direct cost of outpatient treatment for psychiatric disorders in India is approximately INR 770, out of which 22.8% was spent by the patient on medications and travel expenses, and 77.2% was spent by the hospital. Clinical practice may be enriched by careful consideration of the cost of extraneous medications and frequency of visits, especially for patients belonging to lower socio-economic status. Further studies may delve into the cost of treatment of other psychiatric disorders like substance use disorders and comorbid disorders like diabetes. The studies assessing cost of treatment in different settings nationally or internationally using similar methodology can help in a better comparative analysis.


  Acknowledgements Top


Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]


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