According to analyses by the World Health Organization (WHO), wide variations exist in mental health care delivery systems across the world; for example, only 68% of countries have a mental health care policy . Countries differ with respect to the primary method of financing mental health care (that is, out-of-pocket payment, tax-based, social insurance, private insurance, or external grants) and available funds allocated for mental health care . Schizophrenia is a particularly debilitating mental illness with high human and societal costs. Patients and their families cope with symptom fluctuations, poor social and occupational functioning, and the periodic need for psychiatric hospitalization due to relapse [2, 3]. For society, schizophrenia is one of the most expensive mental illnesses to treat, with psychiatric hospitalization being a key driver of costs .
Continuous antipsychotic therapy is recommended to limit disease severity. However, with oral antipsychotic medication, non-adherence is present in approximately half of patients . Partial adherence (taking some but not all medication as prescribed) is even more prevalent, occurring in approximately 9 out of 10 patients . The impact of poor medication adherence is substantial and includes increased symptom levels; a greater risk for violence, arrest, and poor functioning; higher rates of substance abuse and alcohol-related problems; increased risk of psychiatric hospitalization and increased hospital costs [6–10]. A recent (2005) estimate of US costs due to medication non-adherence in patients with schizophrenia was $1.479 billion . Additionally, each relapse episode predisposes the patient to further episodes, whereas fewer episodes are associated with better long-term outcomes .
Long-acting formulations can improve adherence by ensuring medication delivery between injections. Compared with oral medications, depot formulations offer better control over dose adjustments, more predictable and consistent plasma drug concentrations, and lower rates of patient relapse [13, 14]. Risperidone long-acting therapy (RLAT) is the first such treatment to combine a long-acting injectable formulation with the efficacy of a second-generation antipsychotic. The short-term and long-term efficacy and safety of RLAT in patients with schizophrenia have been demonstrated in randomized controlled studies [15–18], and one open-label study (N = 397) found that the annual rehospitalization rate decreased from 38% to 12% in those receiving RLAT (P < 0.001) .
The objective of this pragmatic analysis was to examine the long-term effectiveness of RLAT in real-world clinical practice in different countries. Data for this analysis were from two 2-year RLAT observational studies: the Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation (SOURCE) study, conducted in the US, and the electronic Schizophrenia Treatment Adherence Registry (eSTAR), conducted in Spain, Australia, and Belgium.
The health care systems in these countries vary considerably. The US spends 6% of its total health budget on mental health care . The primary sources of financing are private insurance, tax-based insurance, and out-of-pocket expenditures paid by the patient or family. When private insurance benefits are exhausted, patients move to the public sector, where Medicaid and Social Security Disability Insurance provide a safety net . Spain does not have a specific budget allocation for mental health care services, so details about mental health care expenditures in that country are not available. The Spanish health care system provides universal access to medical and mental health care services for all of its citizens . Australia has a national health care system with universal access for all citizens. It spends 10% of its total health budget on mental health care, and the primary source of mental health care financing is tax based . Belgium spends 6% of its total health budget on mental health care services, which are a part of the primary health care system. The primary source of mental health care financing is through social insurance .