1. Centre for the Economics of Mental Health
King’s College London
Centre for the
Economics of Mental Health

2. Introduction Professor Martin Knapp

3. User needs and preferences
A simplified mental health system
Markets
Funding
Cost-of-illness
User needs and preferences
Cost-effectiveness
evaluation

4. So why is economics relevant?
Scarcity
There are not enough resources to meet every need or want …
… so we have to choose how to use those resources ‘appropriately’
… and ‘appropriate’ often means – among other things – efficiently
… which is the cue for economics

5. This session
Sarah Byford – Child and Adolescent Mental Health Services
Renee Romeo – Learning Disabilities
Discussion
Barbara Barrett – Forensic Mental Health and Personality Disorders
Paul McCrone – Common Mental Disorders
Ramon Sabes-Figuera – Non-Mental Health Research

6. Child and Adolescent Mental Health Services
Dr Sarah Byford

7. Status of evaluation in CAMHS
CEMH systematic review over 25 years (1982 and 2006):
UK clinical and economic evaluations
children and adolescents
non-pharmacological specialist mental health services
40 UK controlled, clinical studies including only 10 RCTs
4 UK economic evaluations (3 undertaken by CEMH)
Internationally, less than 2% of all paediatric economic evaluations carried out between 1980 and 2006 focused on mental or behavioural disorders (n=31)
This compares to an estimated 30 adult mental health economic studies being published annually

8. CAMHS – recently completed
Adolescents with anorexia nervosa
Adolescents with depression
Young people in the youth justice system
Economic cost of autism in the UK
Cost of young adults who deliberately poisoned themselves in childhood and adolescence

9. TOuCAN study – design
Aim: To explore the clinical and cost effectiveness of inpatient, specialist outpatient and general outpatient services for adolescents with anorexia nervosa
Design: Large population based randomised controlled trial (n=167) with 2-year follow-up
Location: North West Region
Outcome: Morgan-Russell Average Outcome Scale (MRAOS)
Perspective: Health, social services, education, voluntary and private sectors

10. Specialist outpatient
TOuCAN study – results
Inpatient
Specialist outpatient
General outpatient
MRAOS score
8.3
8.4
Inpatient days 73 55 89
Total cost £
34531
26738
40794

11. TOuCAN study – results

12. Findings from other studies
CBT + SSRI is not more effective or cost-effective than SSRI alone in adolescents with persistent major depression
Young offenders in the community have higher levels of mental health need than those in secure facilities, yet access fewer mental health services
The costs of supporting children with ASDs are estimated to be £2.7 billion each year
Child and adolescent mental health problems predict significant costs in adulthood compared to general population controls, including greater reliance on social security benefits, supported accommodation and special education and greater criminal justice sector costs

13. CAMHS – current
RCT of group therapy for adolescents who repeatedly harm themselves
RCT of a pre-school communication treatment for autism
RCT of multi-systemic therapy for children in need
RCT of brief psychodynamic psychotherapy, cognitive behaviour therapy and treatment as usual in adolescents with moderate to severe depression

14. Learning Disabilities
Renee Romeo

15. CEMH staff are also involved in learning disability research
2 studies explore cost alongside outcome:
community living
health checks 15

16. Community living: semi-independent living and fully staffed group homes
Supported housing units adopted a fully-staffed group home model for all but the most independent people
Staffing levels not catering to the adaptive abilities of residents
Higher staff-user ratios  less choice and independence
Semi-independent living  better outcomes at lower cost
This study compared costs and quality-of-life outcomes of semi-independent (SI) living to otherwise similar fully-staffed (FS) group homes for adults 16

17. = Majority of lifestyle outcome measures Fully-staffed group home
& Semi-independent living participants =
Majority of lifestyle outcome measures
Fully-staffed group home participants
Fully-staffed group home participants

18. = Majority of lifestyle outcome measures
Fully-staffed participants
& Semi-independent living participants =
Majority of lifestyle outcome measures
Potential to reduce the costs of provision for people with learning disabilities with moderate to low support needs
On balance, semi-independent living could offer certain cost-effective lifestyle advantages provided that sufficient attention is given to health and financial well-being
Fully-staffed participants
Fully-staffed participants

19. Health checks
People with learning disabilities have a range of physical and mental health needs, with higher prevalence than the general population
- So less likely to receive adequate health and social services
Health checks recommended as way of identifying health needs
Previous studies have not explored effectiveness of health checks and the associated service consequence and costs
Costs and outcomes were assessed for:
50 people offered a health check intervention
50 people receiving standard care 19

20. > > > = Health checks - lower cost to agencies and carers
Mean
Standard care
One-year incidence of new health need detection
4.80
2.26
Met new health needs
3.56
Met health promotion needs
2.88
1.38
Met health monitoring needs
1.70
1.26
>
Health checks - lower cost to agencies and carers
>
> = 20

21. > > > = Health checks - lower cost to agencies and carers
Mean
Standard care
One-year incidence of new health need detection
4.80
2.26
Met new health needs
3.56
Met health promotion needs
2.88
1.38
Met health monitoring needs
1.70
1.26
>
Health checks may potentially offer value for money relative to standard care for people with a learning disability
Health checks - lower cost to agencies and carers
>
> = 21

22. DISCUSSION

23. Forensic Mental Health and Personality Disorders
Barbara Barrett

24. Criminal justice & Forensic mental health
Self- harm
Severe mental illness
Eating disorders
Personality disorder
Criminal justice & Forensic mental health

25. Personality disorder Self- harm Severe mental illness Eating disorders
TROUBLED
RCT of different psychological therapies in patients with both eating disorders and symptoms of borderline PD
Self- harm
Severe mental illness
Eating disorders
Personality disorder
POPMACT
RCT of CBT v TAU for repeated deliberate self-harm
JOSHUA
- RCT of joint crisis plans v TAU for people with borderline PD and repeated deliberate self-harm
Nidotherapy
Nidotherapy v TAU for severe mental illness and PD in community mental health team

26. Criminal justice Unit costs in criminal justice
Reforms of Scottish legal system
Electronic monitoring and bail
Fines enforcement teams
Legal aid
Evidence disclosure to defending teams
Criminal justice

27. Criminal justice & Forensic mental health
People with personality disorder in criminal justice system, in particular evaluations of the new PD services
DSPD: IMPALOX, CODES, IDEA
MSU: UPDATE
Personality disorder
Criminal justice & Forensic mental health

28. (1) Developmental work UNIT COSTS IN CRIMINAL JUSTICE
Aim – to develop unit cost information to be used alongside outcome data from 3 large cohort studies
Methods – scoping exercise, planning, collation of finance and budgetary data, time diary exercise
Output – series of updatable unit costs

29. (2) Prospective studies
Randomised controlled trials
Economic evaluation to produce cost-effectiveness and cost-utility analyses
Service use data collected alongside clinical outcome measures at assessment follow-ups
Linked to primary outcome measure

30. (3) Modelling studies
Use mathematical relationships to define the possible consequences that flow from a set of alternative options being evaluated
Structured way of thinking about how a decision taken now impacts on costs and outcomes in the future
Results are generated by modelling existing data on costs and outcomes

31. Common Mental Disorders
Dr Paul McCrone

32. Key questions What do we mean by ‘common mental disorders’?
What are their economic implications?
How cost-effective is treatment?

33. What do we mean by ‘common mental disorders’?

34. Estimated number of people with mental health problems in England in 2007
McCrone et al (2008)

35. What are their economic implications?

36. Estimated cost of depression and anxiety in 2007 and 2026
McCrone et al (2008)

37. How cost-effective is treatment?

38. Evidence from two studies
Computer aided CBT
(cCBT)
RCT in primary care settings
cCBT more effective in reducing depression (BDI) and anxiety (BAI) than usual care
… but more expensive
SSRIs for mild/moderate
depression
RCT in primary care settings
SSRIs associated with reduction in depression (HDRS) and increase in QALYs
… but more expensive

39. Probability that cCBT is cost-effective
McCrone et al (2004)

40. Probability that SSRIs are cost-effective
Kendrick et al (2009)

41. Non Mental Health Research
Ramon Sabes-Figuera

42. Background
Mental health interventions and treatments are the main focus of CEMH research
Physical and mental health are strongly correlated and this may have an important impact on costs
CEMH is also involved in projects to evaluate innovative interventions in non- mental health conditions

43. Psychological and social factors
Example: diabetes
Diabetes outcomes
Self care skills
Psychological and social factors
Cost of care
Diabetes NIHR - non-pharmacological approaches to improving diabetes outcomes in Type 2 diabetes
Study in progress:
Impact of psychological and social factors on costs
Cost-effectiveness of psychological interventions to improve self-care skills, and therefore outcomes

44. Example: economic evaluation of arthritis self-management in primary care
Cost
Outcomes (QALYs)
£1,442
0.580
self management programme (6 sessions) + education booklet
osteoarthritis patients aged +50
-hips and/or knees
-pain and/or disability
Cost
Outcomes (QALYs)
£1,487
0.558
education booklet alone

45. Economic evaluation of arthritis self-management in primary care
…(the) study does not suggest cost effectiveness based on current policy (i.e. NICE) perspectives (BMJ 2009)

46. Other non-mental health areas we are working in
Cancer therapy in different settings
Coronary heart disease and depression in primary care
Multiple Sclerosis
MET with and without CBT to treat Type 1 Diabetes
Antibiotic use in chest infection in stroke
CBT for irritable bowel syndrome
Longer-term stroke care

47. DISCUSSION