Psychosocial Health and Work Conference, Ljubljana, 9 October 2008 The economic dimensions of mental...

Psychosocial Health and Work Conference, Ljubljana, 9 October 2008

The economic dimensions of mental health

Dr Anita Patel

Senior Lecturer in Health Economics

Institute of Psychiatry, King’s College London

Psychosocial Health and Work ConferenceLjubljana, 9 October 2008

Outline

1. Adults of working age

2. Children & young people

3. Older people


Where does economics come in?

Mental health problems place a clinical and social burden on individuals, families and communities

All of these burdens have economic dimensions, which impact on all levels of society


Health care

Products

Human resources/services


Family burden

Time

Average weekly hours caring for person with schizophrenia:

Amsterdam 0.9

Leipzig 6.9

London 10.6

Verona 5.2

Lost work, leisure & education opportunities

Lost income

Out of pocket expenses

Family strain

Unpublished figures from the QUATRO Study (European Union QLG4-CT-2001-01734)


Economic costs of mental illness in England = £32 billion (43 billion Euros)

Informal care9%

Lost employment

34%Other costs

3%

Benefits24%

Health care12% Social care

6%

Criminal justice3%

Suicide – productivity

9%

Patel & Knapp, Mental Health Research Review, 1998


Costs of depression (adults), England, 2000

Day case0%

Outpatient care2%

Inpatient care3%Lost

productivity (suicide)

61%

Medications33%

GP consultations

1%

Thomas & Morris, British Journal of Psychiatry 2003; 183: 514


Costs of depression (adults), England, 2000

Lost productivity (morbidity)

90%

Lost productivity

(suicide)6%

Treatment costs

4%

Thomas & Morris, British Journal of Psychiatry 2003; 183: 514


The business costs of mental illness

Absenteeism (UK) Average employee

takes 7 ‘sick days’ per year...40% are for mental health problems

Cost to business =

£8.4 billion

(11.3 billion Euros)

Presenteeism (UK) Mental health

problems can make people less productive in the workplace

Cost to business =

£15.1 billion


Staff turnover (UK) Replacing staff who

leave because of mental ill-health

Cost to business =

£2.4 billion


Sainsbury Centre for Mental Health. Mental health at work: the business case. 2007


A caution about interpreting lost productivity costs

Many lost productivity estimates are calculated as:

Number of days absent x average daily wage

This (‘human capital’) approach could lead to over-estimates

Workers may compensate for short term absence (Jacob-Tacken et al, 2005) Workers may be replaced. So only need to calculate costs of the intervening

(‘friction’) period e.g. advertising, recruiting, training, low productivity in early phase

Lost productivity due to schizophrenia-related deaths (1996)

Human capital approach = Canadian $105 million Friction cost approach = Canadian $1.53

(Goeree et al, 1999)


Other large financial impacts

Early retirement – lost productivity

Disability pensions

Disability-related social security benefits

(Approximately 40% of people receiving Incapacity Benefit in UK is due to mental illness)

Lost tax income for government

Insurance payouts

Centre for Economic Performance, LSE, 2006


Economic burden of mental illness

We now know something about:

How large this burden is

How the burden is distributed across the economy

The potential savings from tackling some of the problems

But what can we do about it?


What can we do about it?

There are numerous examples of health care, social care, educational and vocational interventions that work

But we can’t pay for them all

Firstly, there are not enough professional, pharmaceutical and other resources to meet all assessed needs

Secondly, even if local, national & Europe-wide budgets were greatly increased, we still need to decide how to allocate these extra funds as effectively as possible

Thirdly, we need to consider equity, not only within mental health sphere but also outside of it…other health and welfare programmes may equally deserve more investment

Economic evaluation can help inform such decisions by considering costs as well as effectiveness

Example….


EQOLISE: evaluation of a supported employment scheme

Sample of 312 people

Adults with diagnosis of psychotic illness Minimum 2 years duration Living in community Not been in competitive employment in previous year Expressing desire to enter competitive employment

Randomised controlled trial

Individual placement and support (IPS) versus existing rehabilitation and vocational services

6 European cities: Zurich, London, Ulm, Sofia, Rimini, Groningen

Burns et al., Lancet 2007; 370:1146


EQOLISE: effectiveness

Employment rate 27% higher Average of 100 more days of work

0

20

40

60

80

100

120

140

% worked Mean days

IPS

Vocational services

Burns et al., Lancet 2007; 370:1146

IPS worked…

No significant differences between the two groups in other outcomes

But some association between working more and better social functioning, clinical and quality of life outcomes


EQOLISE: costs

Mean difference in health & social care costs (£) over 18 months

-10000

-7500

-5000

-2500

0

2500

5000

Burns et al., Report to EC 2006 (Project QLRT-2001-00683)

And it cost less…so IPS is cost-effective


A caution about interpreting international evidence

EQOLISE: effectiveness varied across the centres (socio-economic factors, such as GDP growth per capita and local unemployment rate, explained some of this variation)

Costs also varied across sites, with no cost savings in Groningen

This is not an unusual finding….


QUATRO: Another example of variations across study centres

Percentage of QUATRO study participants using each resource

Patel. Unit costs of health & social care, University of Kent, 2006.

Special accommodation

Inpatient services

Outpatient services

Community-based day services

Community-based professionals

Mental health medications

Criminal justice services

Informal care

Amsterdam Leipzig

London Verona

• Shape and size vary

• % using secondary care: 28 – 76%

• Average length of stay: 19 – 88 days

Need to account for local/national contextual factors when applying evidence to alternative settings


Outline



3. Older people


Children & young people

How many people are affected? 10-20% of European children and adolescents suffer from

mental health problems Suicide is one of the 3 most common causes of death Other family members are affected

With what consequences? Poor quality of life; damaged family relations Disrupted education; failure to fulfil potential Enduring problems into adulthood High costs to individuals, families, State & economy

See Jane-Llopis & Braddick, EC Consensus Paper, 2008


Children with persistent antisocial behaviour: costs in childhood (2000/01)

Health care5%

Social care0%

Benefits43%

Voluntary2%

Education5%

Family costs45%

Romeo, Knapp & Scott, Brit J Psychiatry 2006; 188: 547

Total annual cost per child excluding state benefits = £5960 per child (8046 Euros)

(benefits = £4307; 5814 Euros)


Children & young people

How many people are affected? 10-20% of European children and adolescents suffer from mental health problems Suicide is one of the 3 most common causes of death Other family members are affected

With what consequences? Poor quality of life; damaged family relations Disrupted education; failure to fulfil potential Enduring problems into adulthood High costs to individuals, families, State & economy individuals, families, State & economy

See Jane-Llopis & Braddick, EC Consensus Paper, 2008

What can we do about it? Parenting support Prevent bullying & violence Support in schools

Work with communities Tackle poverty Better treatment access

But we can’t do everything…so need cost-effectiveness evidence


Outline



3. Older people


Older people

How many people are affected? 5 million or more older Europeans have dementia 10-15% of people aged 65+ have depression Suicide rate is highest for older people

With what consequences? Again – devastating impacts on quality of life Heavy burdens falling to family carers But often these consequences remain hidden High costs to individuals, families, State & economy

Knapp, Prince et al, Alzheimer’s Society, 2007


Distribution of dementia costs (UK)

Accommodation41%

Social care15%

Health services8%

Informal care36%

Knapp, Prince et al, Alzheimer’s Society, 2007


Costs of mental illness (UK) - now

McCrone et al., King’s Fund, 2008

0

5

10

15

20

25

Depression Anxietydisorders

Schizophrenicdisorders

Bipolardisorder/related

Eatingdisorders

Personalitydisorder

Child/adolescentdisorders

Dementia

Cost (£ billions)

Lost earnings

Service cost

Total = £49 billion (66bn Euros)


Costs of mental illness (UK) - 2026

McCrone et al., King’s Fund, 2008

0

5

10

15

20

25

Depression Anxietydisorders

Schizophrenicdisorders

Bipolardisorder/related

Eatingdisorders

Personalitydisorder

Child/adolescentdisorders

Dementia

Cost (£ billions)

Additional cost in 2026 (2007 prices)

Lost earnings

Service cost

Total at 2007 prices = £ 61 billion (82bn Euros)

Total at 2026 prices = £88 billion (119bn Euros)


Older people

How many people are affected? 5 million or more older Europeans have dementia 10-15% of people aged 65+ have depression Suicide rate is highest for older people

With what consequences? Again – devastating impacts on quality of life Heavy burdens falling to family carers But often these consequences remain hidden High costs to individuals, families, State & economy

See Jane-Llopis & Gabilondo, EC Consensus Paper, 2008

What can we do about it? Better treatment access Better preventative efforts Support for carers

Social integration Choice and control

But we can’t do everything…so need cost-effectiveness evidence


Potential annual savings from selected interventions

Condition and interventions 2007 2026

Depression

Medication for those currently untreated £5 – 36 m £8 – 61 m

Medication + psychological therapy for those currently untreated £1 – 9 m £2 – 16 m

Anxiety disorders

Medication for those currently untreated £8 – 66 m £13 – 102 m

Medication + psychological therapy for those currently untreated £1 – 7 m £2 – 11 m

Schizophrenia

Expansion of crisis intervention teams £4 – 22 m £7 – 37 m

Expansion of early intervention services £0 m £13 – 65 m

Introduction of detection services £0 m Up to £19 m

Bipolar disorder

Expansion of crisis intervention teams £2 – 10 m £3 – 16 m

Expansion of early intervention services £0 m £8 – 31 m

Introduction of detection services £0 m Up to £4 m

Dementia

Reduction in prevalence among those aged 65-74 £0.2 – 0.6 bn £0.4 – 1.2 bn

Reduction in prevalence among those aged 65-84 £0.8 – 2.4 bn £1.7 – 5.2 bn

Range depends on how many more patients are treated andhow quickly new services are introduced


Conclusions

Mental health problems…

devastating - for individuals of all ages burdensome - for families challenging - for communities very expensive - for economies


MentalHealth care

MainstreamHealth care

Educationsystem

Social caresystem

Familycaregivers

Communitysupport

Criminaljustice

Housingprovision

Incomesupport

Mental health care

Sits among a complex array of support agents

Crosses multiple boundaries

Conclusions

Danger is that individual sectors may be reluctant to invest if benefits are felt elsewhere and/or much later, leading to low

overall investment

Employers

NEED FOR COORDINATED CROSS-AGENCY ACTION

WITH A VIEW TO THE LONG TERM


References

Burns, Catty, Becker, Drake, Fioritti, Knapp, Lauber, Rössler, Tomov, van Busschbach, White, Wiersma, EQOLISE Group. Lancet 2007; 370 (9593):1146-1152.

Burns, Becker, Catty, Fioritti, Knapp, Lauber, Rössler, Tomov, van Busschbach, White, Wiersma, EQOLISE Group. Final Report to European Commission, Project code QLRT-2001-00683, 2006.

Centre for Economic Performance, London School of Economics, 2006

Goeree, O’Brien, Blackhouse, Agro, Goering. Canadian Journal of Psychiatry 1999; 44: 455-463

Jacob-Tacken, Koopmanschap, Meerding, Severens. Health Eocnomics 2005; 14: 435-443

Jane-Llopis & Braddick, EC Consensus Paper, 2008

Jane-Llopis & Gabilondo, EC Consensus Paper, 2008

Knapp, Prince et al. Dementia UK. Alzheimer’s Society, 2007

McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith. Paying the price. The King’s Fund, 2008.

Patel. Unit costs of health & social care. University of Kent, 2006.

Patel & Knapp. Mental Health Research Review 1998; 5: 4-10.

Romeo, Knapp & Scott. British Journal of Psychiatry 2006; 188: 547

Sainsbury Centre for Mental Health. Mental health at work: the business case. 2007

Thomas & Morris. British Journal of Psychiatry 2003; 183: 514


Appendix A

EQOLISE outcome measures

Positive and Negative Syndrome Scale (PANSS) Global Assessment of Functioning (GAF) Hospital Anxiety and Depression Scale (HADS) Lancashire Quality of Life Profile - European Version

(LQoLP-EU) Rosenberg Self-Esteem Scale (RSE) Camberwell Assessment of Need (CAN-EU) Groningen Social Disability Schedule (GSDS) Helping Alliance Scale (HAS)

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