Title: Cost effective treatments and diagnostic approaches for people with schizophrenia within the NHS
Funder: Department of Health (England)

Abstract: 6. Details of proposed programme Background (1000 characters max):Schizophrenia an illness often starting in teenage years affects the ability to think perceive feel and move. With a lifetime prevalence of 1% one person in approximately every 25 households will either have or will develop this disabling illness. In terms of NHS economics schizophrenia costs are second only to stroke; outweighing those associated with heart disease or cancer (2007 - £2bn). Costs to social services voluntary sectors and the criminal justice system are also considerable (2007 - £4bn for unemployment alone). In times of austerity when the NHS is unlikely to be more generously funded prudent use of existing resources is crucial. This programme aims to review key treatments/approaches that are comparatively inexpensive and universally accessible. Inexpensive treatments/techniques for schizophrenia do exist. We are less clear if good diagnostic tests are available. This grant will help review diagnostic data and have the potential to offset introduction of unproven (and potentially expensive) techniques to the NHS.The Cochrane Schizophrenia Group (CSzG) has a record of excellence international impact contribution to teaching and research as well as practical consideration of NHS needs. For example all CSzG reviews are now being re-orientated to be in line with the NHS’ care pathway.1 Volunteer reviewers (largely NHS) continue to be the main workforce but some reviews are best supported by extraneous funding. Old treatments – key to cost effective treatment comparisons – are less attractive to a volunteer workforce. Also the needs of NICE have to be anticipated in a timely fashion and new [difficult] reviews on diagnosis should be undertaken to further reflect priorities and needs of the everyone in the NHS.1. Linking Cochrane and NHS Map of Medicine engaging end-users Project Ref: 10/4000/17 DoH Ref: 006/632Theme and scope of proposed programme (1000 characters max):The 20 new reviews and 20 updates cover four themes linked by cost efficient use of resources. Theme A: Benchmark comparisonsBenchmark treatments against which new expensive drugs are compared are often overlooked by reviewers when selecting a high-impact topic. These benchmarks are inexpensive. Theme B: Cost efficient deliverySimple brief psychosocial packages/approaches or drug techniques have been developed that have the potential to save the NHS much compared with their longer or more sophisticated counterparts.Theme C: DiagnosisCSzG requests support to undertake the first Cochrane reviews of diagnoses in mental health to direct effort to real world NHS needs set standards develop skills and avoid waste.Theme D: NICE updateNICE review of management of aggression due to serious mental illness will be updated 2012 and anticipating NICE need relevant reviews will be updated or produced.All reviews will be produced in line with the care pathway of the NHS (Map of Medicine). The diagnosis theme will involve contracting additional expertise and construction of a register of relevant studies.Proposed reviews to be undertaken and/or updated and how the choice is justified in terms of NHS priorities (2000 characters max):Effective treatment giving value for money underpins NHS priorities and has done for a long time. The Operating Framework for the NHS in England 2010/11 and its revision highlights the need for value for money a little less than every third page (15 times/52 pages) and the new government White paper increases this to 19 times in 56 pages. It clearly is a priority that the NHS does not forget the effects of inexpensive treatments in the face of heavy advertising from industry (Theme A) knows the value of brief rather than prolonged approaches (especially for expensive therapies) (Theme B) the value of expensive or inexpensive diagnostic tests (Theme C) and minimises duplication and has available up to date Cochrane reviews for NICE appraisals (Theme D). We will extract data of all economic outcome measures described in all new reviews with a view to also systematically analysing these data. Wherever possible we will use decision modelling to generate cost effectiveness ratios. With regards to the diagnostic reviews we will look at cost effectiveness or cost benefit ratios (if feasible) in completion of reviews which have a major economic component. (N=New U=Update)A-Benchmark comparisons (drugs)Chlorpromazine versus atypical antipsychotics (N)NChlorpromazine versus placebo (U)UFlupenthixol (oral) (N)NFlupenthixol decanoate (depot) (U)UFlupenthixol versus low-potency antipsychotic drugs (N)NFluphenazine (oral) versus atypical antipsychotics (N)NFluphenazine (oral) versus placebo (U)UFluphenazine decanoate and enanthate (depot) (U)UFluphenazine versus low-potency antipsychotic drugs (N)NHaloperidol versus low-potency antipsychotic drugs (N)NHaloperidol versus placebo (U)UPericyazine (U)UPerphenazine (U)UPerphenazine versus low-potency antipsychotic drugs (N)NPimozide (U)URisperidone (depot) (U)URisperidone versus placebo (U)USulpiride versus placebo (U)UTrifluoperazine versus low-potency antipsychotic drugs (N)NTrifluoperazine versus placebo (U)UZuclopenthixol (U)UB- Potentially cost efficient approachesFamily intervention (brief) (N)NUser-held personalised information (U)ULength of hospitalization (U)UIntermittent drug techniques (N)Cognitive behavoural therapy (brief) (N)NPsychoeducation (brief) (N)NSupportive therapy for schizophrenia (U)UC- DiagnosisFirst Rank symptoms (N)NUse of MRI (N)NBlood tests (N)NOperational criteria (N)NCT abnormalities (N)NAcute/chronic illness - operational criteria (N)NTreatment resistant illness - operational criteria (N)ND- NICE updateBenzodiazepines for psychosis-induced aggression (U)URisperidone for psychosis-induced aggression (N)NHaloperidol for psychosis-induced aggression (U)UOlanzapine IM/Velotab for psychosis-induced aggression (U)UZuclopenthixol acetate for psychosis-induced aggression (U)In addition in line with both NHS priorities and its already instigated pathways of care1 and the CSzG NIHR Cochrane-NHS Engagement Award Scheme2 we propose to ensure that all reviews are in line with NHS needs – both for commissioners clinicians as well as consumers of care. 1. http://www.mapofmedicine.com/2. Linking Cochrane and NHS Map of Medicine engaging end-users Project Ref: 10/4000/17 DoH Ref: 006/632Outline plan and timetable for undertaking reviews including how award would be used (eg. employment of new researchers) (2000 characters max):The CSzG has gone through considerable changes over the last three years. Now in Nottingham we have a stable team with experienced staff and can ensure timely identification and acquisition of studies and processing of reviews. Production of reviews did dip because of institutional move but we never ceased production and are now increasing back up to former levels. We are ready for a new challenge and diagnostic test reviews is certainly this. For this part of the programme we have been working with Karla Soares-Weiser (KSW) of Enhance Reviews. Karla has as wide experience as anyone in working in this area and a track record of timely cost-effective production of high grade reviews within Cochrane. Karla and the CSzG editorial base are already working together on NIHR funded work - communicating almost daily via Skype™. Regarding the ‘local’ RA post the CSzG has already had interest from people who have considerable experience in undertaking Cochrane reviews. We hope to have no lead-in time and to immediately embark on the programme. The CSzG has a track record with Rethink of a productive and innovative working relationship. We did not envisage that people who we already work with there would change (but please see section 16) – just that roles develop for the work of the CSzG and Rethink.


Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL;4.2 EVALUATION OF MARKERS AND TECHNOLOGIES;6.1 PHARMACEUTICALS
Health categories: MENTAL HEALTH