1. Martin Knapp & Paul McCrone PSSRU, London School of Economics King’s College London, Institute of Psychiatry Best Practice in Mental Health GP Led Commissioning 25 March 2011 Investing in Mental Health: the Economic Case

2. N of people by disorder, England 2007 & 2026 McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008 Current & projected future prevalence

3. Context: current & projected future costs Cost by disorder, England 2007 & 2026 McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008

4. Aim - model the costs and economic pay-offs of initiatives to prevent mental illness and promote mental well-being. oLook at evidence-based mental health interventions (incl. non-NHS) – must have well-established outcomes oLooked at 16 different areas and interventions oUse simple decision analytic modelling oClose liaison with DH officials; consultation with experts As far as the robust evidence base allows: oInclude promotion, primary & secondary prevention oLook at widest range of economic impacts oEstimate impacts over long time periods oIf in doubt, adopt conservative estimates Our approach

5. oExamine interventions from 2 perspectives: - pay-offs to society as a whole and - cash savings to the public sector oThe wider impacts are important, given the high ‘external’ costs of many MH problems … but are they considered? oOver and above the economic pay-offs estimated here there are health and QOL benefits to individuals (‘patients’ etc) Please be aware that … a.The findings are not definitive – they provide platform for discussion b.These are simple, partial and incomplete models c.The interventions modelled are not necessarily the only ones that are economically attractive Please note …

6. What economic case needs to be made? Costs are higher Costs are lower Outcomes are worse Outcomes are better

7. What economic case needs to be made? Costs are higher Costs are lower Outcomes are worse  A non- starter Outcomes are better

8. What economic case needs to be made? Costs are higher Costs are lower Outcomes are worse  A non- starter Outcomes are better A winner – but check the timing and spread of impacts

9. What economic case needs to be made? Costs are higher Costs are lower Outcomes are worse  A non- starter  A delight to penny-pinchers; a nightmare to everyone else Outcomes are better A winner – but check the timing and spread of impacts

10. What economic case needs to be made? Costs are higher Costs are lower Outcomes are worse  A non- starter  A delight to penny-pinchers; a nightmare to everyone else Outcomes are better ? ? Do the outcomes justify the higher costs? A winner – but check the timing and spread of impacts

11. Many causes; widespread impacts Mental health Health care Each of these links is evidence-based Social care Housing Education Crim justice NHS LAs CLG DfE MoJ Benefits Employment DWP Firms Vol sector Income CVOs All Mortality Indiv Genes Family Income Emply’t Resilience Trauma Phys env Events Chance

12. Parenting for conduct disorder TargetPrevalence of conduct disorder = 4.9% among children aged 5-10 Inter- vention Mix of individual and group-based parenting programmes at age 5; average cost = £1,177 per family Outcome evidence Based on data from 20 RCTs, effectiveness = 33% (but low take-up, high drop-out) Economic pay-offs Reduced use of NHS, social care and special education services and reduced crime, from age 5-30. Excluded: employment / earnings, social security, adulthood MH, mortality FindingsTotal return of £7.89 for every £1 invested, including savings in public expenditure of £2.86

13. Early intervention teams for psychosis TargetYoung people aged 15-35 in general population with first-episode psychosis. Estimated number per year = 6900. Inter- vention Multidisciplinary team intervention including medical and non-medical professionals. Emphasis on assertive approach to maintaining contact and heavy emphasis on vocational recovery. Outcome evidence Reduction in relapse rate (Craig et al, 2004), improvement in vocational recovery and quality of life (Garety et al, 2006). Economic pay-offs Reduction in: readmission rates, costs of homicide and suicide, and lost employment. FindingsAverage cost savings in the short-term of £5777 pa, medium-term £4774 pa and long-term £2600 pa. Return for £1 spent: £5.82 short term, £7.69 medium term, £4.47 long term.

14. Early detection of psychosis TargetYoung people aged 15-35 in general population with prodromal symptoms of psychosis. Estimated number per year = 15,763. Inter- vention Early detection service (based on OASIS in South London; Valmaggia et al 2009). Consists of psychological and pharmacological treatment. Outcome evidence Reduced rate of transition to full psychosis and reduced duration of untreated psychosis for those who do develop it. Economic pay-offs Reduction in inpatient costs and lost employment, reduction in homicide rate, reduction in suicide rate. FindingsShort-term cost increase of £2228 per person pa, medium term cost saving of £3022 pa and long-term saving of £2604 pa. Annual return for £1 spent: £5.87 short term, £7.42 medium term, £5.05 long term.

15. Workplace well-being programmes TargetWorking-age adult population accessed through their place of employment Inter- vention Multi-component health promoting programme, including a health risk appraisal and information and advice tailored to the employee’s readiness to change health-related behaviours. Cost = £80 per year employee per year Outcome evidence Quasi-experimental evaluation in UK company reported significantly reduced stress levels, reduced absenteeism and improved productivity (Mills et al 2007). Economic pay-offs Reductions in sickness absence and presenteeism; reduced costs of avoidable mental health problems to NHS FindingsTotal savings = £9.69 for every £1 invested

16. Medically unexplained symptoms TargetIndividuals with sub-threshold somatisation and clinical somatisation disorders in primary care (account for c. 25% of all primary care consulters) Inter- vention Referral to 10 sessions of cognitive behavioural therapy over 6-month period; cost = £400 Outcome evidence CBT shown effective in reviews; 35% of individuals report improvement in symptoms after 15-month follow-up (Allen et al 2006) Economic pay-offs Reduced NHS costs (GP consultations, prescriptions, A&E, outpatients, inpatients); reduced sickness absence from work FindingsTotal savings over 3 years = £1.75 per £1 invested for comprehensive programme; savings = £7.82 per £1 invested for targeted programme. Majority of savings accrue to NHS

17. Debt advice services TargetGeneral population without mental health problems who are at risk of unmanageable debt Inter- vention Debt advice services, provided on face-to-face, telephone or internet basis Outcome evidence Unmanageable debt increases risk of developing depression/anxiety disorders by 2% in general population. Face-to-face service alleviates 56% of unmanageable debt; telephone service alleviates 47%. Economic pay-offs Reductions in: health and social care service use; lost employment; legal system costs; costs to local economy FindingsComplicated …! Savings depend on who pays, mode of delivery, and amount of debt recovered. Telephone/web advice cost saving (most scenarios). Face-to-face advice most cost-effective. If 2/3 of service costs recovered from creditors, then total savings = £0.63 per £1 invested in first year; and £3.21 over 5 years.

18. Other interventions examined  Post-natal depression – health visitors (universal or targeted)  School-based social and emotional learning programmes  School-based anti-bullying initiative  Workplace screening for depression risk, then CBT  Debt counselling  Alcohol misuse - GP screen and advice  Suicide – population awareness scheme + CBT for people at risk  Suicide – ‘hotspots’ - e.g. safety barriers on bridges  Co-morbid diabetes and depression – collab. care  Medically unexplained symptoms – CBT  Older people – befriending schemes (various)  Dementia - physical exercise programmes  [previously done] Anti- stigma campaigns

19. NHS Other public sector Non- public sector Total Early identification and intervention as soon as mental disorder arises Early intervention for conduct disorder1.081.785.037.89 Health visitor interventions to reduce postnatal depression 0.40- 0.80 Early intervention for depression in diabetes0.1900.140.33 Early intervention for medically unexplained symptoms b 1.0100.741.75 Early diagnosis and treatment of depression at work 0.51-4.525.03 Early detection of psychosis2.620.796.8510.27 Early intervention in psychosis9.680.278.0217.97 Screening for alcohol misuse2.240.938.5711.75 Suicide training courses provided to all GPs0.080.0543.8643.99 Suicide prevention through bridge safety barriers 1.751.3151.3954.45 Promotion of mental health and prevention of mental disorder Prevention of conduct disorder through social and emotional learning programmes 9.4217.0257.2983.73 School-based interventions to reduce bullying0014.35 Workplace health promotion programmes--9.69 Addressing social determinants and consequences of mental disorder Debt advice services0.340.582.633.55 Befriending for older adults0.44-- Summary of findings

20. oVery conservative models  even so, many interventions look good value for money. oSome are self-financing from NHS perspective oSome are very low cost: a small shift in expenditure from treatment to prevention/promotion could generate efficiency gains oMany have broad pay-offs - both within public sector, and more widely (educational performance, employment/earnings, crime). oPay-offs may span many years; need to invest for the longer term oProcess parameters - targeting, take-up rates, drop-out rates – are important. It may be most cost-effective to increase take-up among high-risk groups, or improve ‘completion’ rates. oEach modelled intervention is evidence-based – each has been shown to be effective (to achieve good outcomes) … o… which means that there are health and QOL gains to individuals over and above the economic pay-offs here Conclusions

21. Rebeea’h Aslam 1 Florence Baingana 1 Annette Bauer 1 Jennifer Beecham 1,4 Eva-Maria Bonin 1 Sarah Byford 2 Adelina Comas 1 Sara Evans-Lacko 2 Chris Fitch 5 Nika Fuchkan 1 Derek King 1 Martin Knapp 1,2 Canny Kwok 1 Paul McCrone 2 David McDaid 1 Team; and further information Iris Molosankwe 2 Gerald Mullally 1 A-La Park 1 Michael Parsonage 3 Margaret Perkins 1 Andres Roman 1 Marya Saidi 1 Azuso Sato 1 Madeleine Stevens 1 Jamie Vela 1 1 PSSRU, LSE 2 KCL, IOP 3 Centre for Mental Health 4 PSSRU, Univ of Kent 5 Royal Coll. Psychiatrists Further details of work to date: Report published by the DH, Jan 2011 More work likely to be undertaken in 2011 Contact: m.knapp@lse.ac.uk paul.mccrone@kcl.ac.uk