This study found that a specialized model of early psychosis intervention with timely and assured care during the early illness period can improve positive symptoms and promote recovery as well as significantly reduce treatment costs over the extended critical period of the first few years of illness. This study is the first, to our knowledge, to conduct a long-term economic evaluation of an early psychosis program using patient-level data rather than economic modeling. The key finding is that the advantage of the early intervention model, both in terms of clinical outcomes and treatment costs, is maintained well beyond the period over which the intervention was provided. Differences on functional outcome measures were inconclusive because the study may have been underpowered to detect such effects. This study indicates that investment in specialized early psychosis interventions appears to provide excellent value for money and should be seriously considered as an additional stream of care within specialist mental health services. Indeed, such reform is being widely supported internationally and in parts of Australia, though investment remains insufficient in many locations.2
The first study of the EPPIC program11
found that the EPPIC subjects used less inpatient care but more community-based mental health care compared with the historical control within the first year of treatment. However, the current study shows that the reliance on all forms of care over the longer term is greatly reduced in the EPPIC cohort compared with the control group. This finding is unsurprising given that a better course of illness is observed in the EPPIC group. The advantage of the current study over the previous study is that the subjects were followed up over a largely overlapping time period, reducing the chances of confounding associated with historical matched controls treated over different time periods.
The results of the current study are in marked contrast to those in the Danish OPUS trial (a large multicenter randomized trial of integrated vs standard treatment for first-episode patients) that found that at 5-year follow-up, the gains demonstrated by the early intervention cohort at 2-year follow-up31
had largely disappeared.9
This suggested that a 2-year window of specialized intervention is insufficient to produce a sustained benefit. While the present data do paint a more positive picture, our clinical experience supports the need for more extended specialized early psychosis care for at least a subset of patients who do poorly if transferred to generic adult services within the first 5 years of illness. It may be that even greater cost savings are possible over the long term if high-quality specialized care is assured for the full “critical period” of the first 5 years of illness.32
Reasons for different results from the 2 studies may include differences in study design and in the delivery of the 2 early intervention services as well as broader differences within the Australian and Danish health-care systems.
However, the conclusions of the current study are tempered by some important caveats. Firstly, the sample size in this study is relatively small. Data were only available on 64% of the original cohort (as reported by Mihalopoulos and colleagues10
); however, while we are confident that this smaller cohort is representative of the original cohort, we acknowledge the original cohort (102) was still not very large. Future studies utilizing much larger sample sizes are required to validate this finding. The current study employed a limited costing perspective. Important other costs such as primary care or community-based specialist care (such as private psychiatrists) have not been included. Private inpatient service use has also not been included; as the EPPIC program services the Western metropolitan region of Melbourne that has a disadvantaged socioeconomic profile, inhabitants of this region are not likely to be high users of privately funded health services. An Australian study investigating the costs of treatment associated with psychotic disorders found that such private sector costs are very small in comparison to public mental health treatment costs.33
Conversely, the improved clinical course of the EPPIC patients may have other positive economic consequences not captured in the current evaluation, such as improved work force participation and hence productivity gains. Certainly, there is some suggestion that the EPPIC cohort was more likely to be in the paid work force, and possibly less reliant on welfare payments, compared with the control group. Prior research on the costs associated with psychotic disorders have found that productivity costs are associated with about 50% of the total societal costs, and transfer payments are associated with about 17% of the total costs.33
Therefore, the inclusion of such costs in the current evaluation would make the EPPIC program appear even more economically favorable. Even though such costs can be included in economic evaluations, they were outside the scope of the current study. Future research including a broader societal perspective is required to ensure that early psychosis interventions are truly cost-effective.
The total annual costs observed in the current study are somewhat lower than annual treatment costs associated with psychotic disorders (including first-episode psychosis) reported in previous studies.33–35
Importantly, the largest cost drivers in previous cost studies include productivity effects associated with lost work time, accounting for approximately 50% of total costs, and inpatient costs, accounting for approximately 30% of total costs or over 75% of mental health treatment costs.33,35
The EPPIC patients in the current study appeared to use about one-third the level of inpatient services as the control group. Similar to the current study, other studies investigating the treatment costs associated with early intervention services for first-episode psychosis have found such services to markedly reduce costs associated with inpatient treatment.10,36
Finally, the current study includes all first-episode patients, not only those with a diagnosis of schizophrenia or schizophreniform psychosis and captures those patients who did not require ongoing treatment; therefore, it is unsurprising that the observed costs are lower than those observed in other studies such as Carr et al,33
which included only patients with psychotic disorders in active treatment, and Guest and Cookson34
that focused on the costs of schizophrenia. In fact, we found the costs for patients displaying a continuous course of illness in the control group to be comparable to the costs reported by Carr et al.33
We have assumed that the data sources used to extract the resource use information contained complete records of the variables of interest. Inpatient episode data are likely to be virtually complete, as there are rigorous systems and protocols in place to ensure that services capture and record this information. The patient files are also assumed to include all clinically significant public mental health sector contact information and medication data; however, it is conceivable that some information was not recorded in the files, as systems and protocols for the documentation of this information are less rigorous. The consequence of any potential loss of data due to inadequate documentation is that the cost estimates derived from this study should be viewed as conservative. Fortunately, however, there is no reason to believe that rates of undocumented resource use would be systematically different across the 2 comparison groups.
Although the clinical outcome assessments for the intervention and control groups were conducted by different members of the research team, and raters were not blind to group membership, the findings in favor of the EPPIC model are unlikely to have been affected by rater bias. The control group rater trained and monitored the EPPIC raters, thus ensuring consistency over time. The claim of consistency is also supported by the excellent levels of interrater reliability as measured in the larger EPPIC long-term follow-up study (ICCs of .91 and higher for the primary outcome measures).
A final limitation is that we were unable to apply the duration criterion of the remission criteria17
as follow-up data regarding symptomatology were collected cross-sectionally. This may have reduced the stringency of the criteria and led to an overestimate of remission among the sample.
In conclusion, this study indicates that early intervention in psychosis may not only improve the clinical course of psychotic disorders but also make such disorders less costly to treat compared with more traditional forms of care.