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Table 6 Considerations of additional policy-relevant criteria

From: Cost-effectiveness of pharmacological and psychosocial interventions for schizophrenia

Criteria

Intervention package for schizophrenia

Level of evidence:

• We have relied heavily on evidence provided in Cochrane systematic reviews and used their inclusion criteria when adding more recent trials.

• There is sufficient data for drug interventions while few trials are available for psychosocial intervention. Most trials were conducted in Western countries and doubts remain about the applicability of these findings to Thailand. A number of further methodological problems were identified in this trial literature: the varying choice of comparator in the evaluation of psychosocial interventions; use of high doses of typicals as comparator in trials of newer generation drugs; potential publication bias; and short durations of follow-up

Equity:

• Generic risperidone is recommended as the first line drug treatment and should be included in the national essential drug list so that it can be prescribed equitably to all Thai patients.

• Lack of mental health resources and higher travel costs for patients and families may make family interventions less available or affordable in rural and remote areas. Poor households may have less access to this intervention.

Feasibility:

• Increased prescribing of clozapine in Thailand would be advisable only if health care units can maintain monthly blood testing. This would require additional support from the government to help patients and families with the travel cost.

• The availability of mental health resources psychiatric nurses or psychologists, training programs and accessibility of health care units are of concern.

• Maintaining the benefit of family interventions annually is possibly more difficult than doing it in the first year for a number of reasons: (a) the patients migrate to other areas; (b) the families have no time available during the program period; (c) lack of long term budget to support the program; and (d) the trained nurses change workplace or quit the careers.

Acceptability:

• The major effectiveness measurement of this study is symptom reduction based on clinical perspectives. In fact, the patient and families might have different views. This measurement by clinicians may be too limited from the point of view of patients and families who are interested in general wellbeing and productivity gains, for example. However, recent studies [58–60] found that psychiatric symptoms are the best independent predictors of these broader outcomes of schizophrenia (e.g. objective and subjective quality of life and social skill functions).

• Some policy makers and clinicians may be reluctant to use clozapine due to its rare but fatal side effect. Although a recent long-term follow-up study in Finland found a lower mortality rate among people with clozapine than those with other antipsychotics [61], less intensive monitoring for those on clozapine treatment in Thailand than Finland means these low mortality rates are unlikely to be achieved [47, 61].

• Self-stigma of people with schizophrenia and their families could be an obstacle to involvement in a psychosocial intervention program [48].

Sustainability:

• In order to maintain lifetime benefits due to family interventions, a long-term public funding is required from the government.