Does the mental health system provide effective coverage to people with schizophrenic disorder? A self-controlled case series study in Italy

Abstract

Purpose: To measure indicators of timeliness and continuity of treatments on patients with schizophrenic disorder in 'real-life' practice, and to validate them through their relationship with relapse occurrences.

Methods: The target population was from four Italian regions overall covering 22 million beneficiaries of the NHS (37% of the entire Italian population). The cohort included 12,054 patients newly taken into care for schizophrenic disorder between January 2015 and June 2016. The self-controlled case series (SCCS) design was used to estimate the incidence rate ratio of relapse occurrences according to mental healthcare coverage.

Results: Poor timeliness (82% and 33% of cohort members had not yet started treatment with psychosocial interventions and antipsychotic drug therapy within the first year after they were taken into care) and continuity (27% and 23% of patients were persistent with psychosocial interventions, and antipsychotic drug therapy within the first 2 years after starting the specific treatment) were observed. According to SCCS design, 4794 relapses occurred during 9430 PY (with incidence rate of 50.8 every 100 PY). Compared with periods not covered by mental healthcare, those covered by psychosocial intervention alone, antipsychotic drugs alone and by psychosocial intervention and antipsychotic drugs together were, respectively, associated with relapse rate reductions of 28% (95% CI 4-46%), 24% (17-30%) and 44% (32-53%).

Conclusion: Healthcare administrative data may contribute to monitor and to assess the effectiveness of a mental health system. Persistent use of both psychosocial intervention and antipsychotic drugs reduces risk of severe relapse.

Keywords: Effective coverage; Healthcare utilization database; Mental healthcare; Real-world; Schizophrenic disorder; Self-controlled case series.

Fig. 1

Timeliness of starting psychosocial intervention and antipsychotic drug therapy in three regions (Lombardy, Emilia Romagna, and Lazio) and one province (Palermo), and in the whole Italian sample. Italy, QUADIM-MAP projects, Italy, 2013–2018. The observation started from the index date and ended on the date of starting therapy; the cumulative proportion of cohort members who started therapy during the first year after they were taken into care was calculated through the Kaplan–Meier estimator

Fig. 2

Probability of continuing any outpatient care, psychosocial intervention, and antipsychotic drug therapy in three regions (Lombardy, Emilia Romagna, and Lazio) and one province (Palermo), and in the whole Italian sample. Italy, QUADIM-MAP projects, Italy, 2013–2018. Cohort members who started therapy within the first year after they were taken into care were included; the observation started from the date of starting therapy and ended at the occurrence of the first episode of treatment discontinuation; the actuarial life-table method was used for calculating month-by-month probability of continuing therapy (i.e., of not experiencing discontinuation) once it started

Fig. 3

Summarized self-controlled case series estimates of the incidence rate ratio of emergency mental health-related hospital admissions associated with any outpatient care and antipsychotic drug therapy (left box) and psychosocial intervention and antipsychotic drug therapy (right box). Italy, QUADIM-MAP projects, Italy, 2013–2018. Self-controlled case series incidence rate ratio, and 95% confidence interval, estimated with conditional Poisson regression contrasting within-patient relapse incidence during time windows of coverage and no coverage with mental health care. Estimates were obtained through the design shown in supplementary Figure S1, third scenario