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Mental health and economics Martin Knapp London School of Economics and Political Science Kings College London, Institute of Psychiatry NIHR School for.

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Presentation on theme: "Mental health and economics Martin Knapp London School of Economics and Political Science Kings College London, Institute of Psychiatry NIHR School for."— Presentation transcript:

1 Mental health and economics Martin Knapp London School of Economics and Political Science Kings College London, Institute of Psychiatry NIHR School for Social Care Research Current activities: Director of PSSRU Director of LSE Health Professor, health economics KCL Director of NIHR SSCR Current research areas: Depression, psychosis Dementia Stroke Telehealth/telecare Long-term (social) care Child mental health; wellbeing Genetic testing (economics of) Autism Intellectual disability Carers Community capital building Prevention Inequalities

2 A Mental health

3 Prevalence of mental health problems – working age population (UK) Severe mental illness (schizophrenia, bipolar disorder, serious depression) 1%-2% Symptoms (sleep problems, fatigue, worry, but no disorder 17% Common mental disorders: symptoms that reach threshold for diagnosis 17% Symptom-free 64%

4 Years lost to disability (men) - globally All CausesTotal YLD (millions)% of total 1. Unipolar major depression Hearing Loss, adult onset Cataracts Alcohol use Cerebrovascular disease Vision related disorders Peri-natal conditions Osteoarthritis Chronic Obstructive Pulmonary Disorder Schizophrenia Disease Control Priority Project 2006,

5 All CausesTotal YLD (millions)% of total 1. Unipolar major depression Cataracts Hearing Loss Osteoarthritis Vision related disorders Alzheimers & other dementia Cerebrovascular disease Perinatal conditions Schizophrenia Bi-Polar Disorder Disease Control Priority Project 2006, Years lost to disability (women)

6 N of people by disorder, England 2007 & 2026 McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, Kings Fund, 2008 Current & projected future prevalence

7 Projected number of people with dementia in the UK: Source: Knapp et al (2007) Dementia UK report

8 Characteristics of mental health … oHigh prevalence oChronic course oGenes / environment oMultiple needs oEmployment effects oLinks to suicide / self-harm oCompulsory treatment / detention oStigma & discrimination oFamily impacts oAntisocial behaviour, crime oMental well-being / happiness

9 oHigh prevalence high expenditure oChronic course lifelong economic impacts oGenes/environment complex causality oMultiple needs wide-ranging costs oEmployment effects productivity losses oLinks to suicide/self-harm fear/costs etc oCompulsory treatment user choice? oStigma & discrimination social exclusion oFamily impacts often hidden; incentives? oCrime exaggerated societal reactions? oMental well-being links to happiness … with economic consequences

10 Leading mental health policy themes a.Wider NHS and social care structures - financing; commissioning; competition … few MH-specific issues. b.Coordination - getting health and other systems to work together more effectively and efficiently c.Prevention of mental illness; and promotion of mental wellbeing. d.Early intervention – life-course perspectives etc e.Roles of hospitals (and other institutions) - appropriate housing support; community care f.Personalisation – responding to individual needs and preferences; hence personal budgets etc e.Employment, including welfare payments, absenteeism, presenteeism f.Social inclusion – rights, opportunities, participation etc g.Equity – vicious cycle linking deprivation to morbidity h.Ageing and implications for not just dementia but also psychoses, depression i.Stigma and discrimination (at the root of many challenges?)

11 B Economic questions

12 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Example: Treatments for depression …

13 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life … could lead to better outcomes …

14 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Cost savings Lower use of health and social care services Fewer out-of- pocket expenses Greater economic productivity Higher income Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life … and lower longer-term costs.

15 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Cost savings Lower use of health and social care services Fewer out-of- pocket expenses Greater economic productivity Higher income Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 1. Costs ? Question 1: What does it cost?

16 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Cost savings Lower use of health and social care services Fewer out-of- pocket expenses Greater economic productivity Higher income Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 2. Cost-offsets ? 1. Costs ? Question 2: Will it pay for itself?

17 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Cost savings Lower use of health and social care services Fewer out-of- pocket expenses Greater economic productivity Higher income Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 2. Cost-offsets ? 3. Cost-effectiveness ? 1. Costs ? Question 3: Is it worth it?

18 Interventions Antidepressant medication CBT Primary care counselling Interpersonal psychotherapy Couple therapy Cost savings Lower use of health and social care services Fewer out-of- pocket expenses Greater economic productivity Higher income Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 2. Cost-offsets ? 3. Cost-effectiveness ? 1. Costs ? 4. Incentives ? Question 4: Can we change things? 4. Incentives?

19 B Costs

20 Many causes; widespread impacts Health care Social care Housing Education Crim justice Benefits Employment Vol sector Income Mortality Genes Family Income Emplyt Resilience Trauma Phys env Events Chance Long- term needs

21 …on many different budgets (England) Health care 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 Emplyt Resilience Trauma Phys env Events Chance Long- term needs

22 Projected total LTC expenditure, at 2002 prices LTC expenditure as % of Gross Domestic Product Red – older people with cognitive impairment; Blue - not Expenditure projections for people with dementia 2002 to 2031 Comas-Herrera et al, IJGP 2007

23 Depression – costs for adults in England, 2000 Thomas & Morris Brit J Psychiatry 2003 Excluding morbidity costs

24 Total cost = £9 bn Thomas & Morris Brit J Psychiatry 2003 Depression – costs for adults in England, continued

25 GB - employment and mental health % in full-time work GB 2000

26 GB - disability benefits, 2007 Department of Work and Pensions, billion per annum Plus reduced tax receipts 14 billion

27 Simon et al, Gen Hosp Psychiatry, Number of reported diabetes complications Costs of health service use by diabetes patients, by depression severity

28 Total cost excluding benefits averaged £5,960 per child per year, at 2000/01 prices (benefits = £4307) Costs - young children with persistent antisocial behaviour Romeo, Knapp, Scott (2009). Children with antisocial behaviour. British J Psychiatry 188:

29 Evidence from the Inner London Longitudinal Study All 10-year olds in a London borough, 1970 (n=1689). Led by Michael Rutter at that time Teacher ratings, child questionnaires Intensively studied 50% of children with psychological problems and random 8% of others At age 10: No problems at school, no clinical diagnosis (65) Antisocial behaviour at school, only (61) Conduct disorder (16) Emotional problems at school, only (32) Emotional disorder (8) Followed up at age … Research question: What services were used and what costs incurred between aged 10 and 28?

30 Costs in early adulthood linked to childhood antisocial behaviour Scott, Knapp, Henderson, Maughan (2001) Financial cost of social exclusion: follow- up study of antisocial children into adulthood. Brit Med J 323: Costs (£) from ages 10 to 28

31 C Cost-offsets

32 New economic evidence on mental health promotion and mental illness prevention Check report for full details

33 Aim - model the costs and economic pay-offs of initiatives to prevent mental illness and promote mental well-being. oLooked at evidence-based mental health interventions (incl. non-NHS) – must have well-established outcomes oLooked at 15 different areas and interventions oUsed simple decision analytic modelling oClose liaison with DH officials; consultation with experts As far as the robust evidence base allows: oIncluded promotion, primary, secondary prevention oLooked at widest range of economic impacts oEstimated impacts over long time periods oIf in doubt, we adopted conservative estimates Our approach - 1

34 oExamined interventions from 2 perspectives: - pay-offs to society as a whole and - cash savings to the public sector oAnd interested particularly in the timing of impacts and whether (or when) cashable oOver and above the economic pay-offs there are health and QOL benefits to individual patients Important to note that … a.These are simple, partial and incomplete models b.Findings are not definitive: they provide a platform for discussion (hence publication on DH website and linked elsewhere) c.Interventions modelled are not necessarily the only ones that are economically attractive d.BUT every intervention has proven health/wellbeing benefits Our approach - 2

35 Prevalence of mental health problems 45% of people in debt have mental health problems compared with 14% not in debt Incidence of mental health problems Developing unmanageable debt is associated with an 8.4% risk of mental health problems compared to 6.3% for people without financial problems Specific conditions Alcoholism (2x), Drug Addition (4x), Suicidal ideation (2x) Source: Fitch et al, submitted; Meltzer, et al., 2010; Skapinakis et al., 2006; Debt: mental health challenges

36 Debt counselling: the economic case 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 £3.55 over 5 years. Knapp et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.

37 Medically unexplained symptoms: the economic case 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 McDaid et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.

38 Early detection of psychosis: the economic case TargetYoung people aged 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. FindingsIn short-term (Year 1) there is a net cost, but the total return on £1 investment over a 10-year period is £10.27 – 26% of this is to the NHS McCrone et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.

39 Economic pay-offs per £1 investment NHS Other public sector Non- public sector Total Early identification and intervention as soon as mental disorder arises Early intervention for conduct disorder Health visitor interventions to reduce postnatal depression Early intervention for depression in diabetes Early intervention for medically unexplained symptoms Early diagnosis and treatment of depression at work Early detection of psychosis Early intervention in psychosis Screening for alcohol misuse Suicide training courses provided to all GPs Suicide prevention through bridge safety barriers Promotion of mental health and prevention of mental disorder Prevention of conduct disorder through social and emotional learning programmes School-based interventions to reduce bullying Workplace health promotion programmes Addressing social determinants and consequences of mental disorder Debt advice services Befriending for older adults0.44--

40 D Cost- effectiveness

41 If the core clinical/care question is: Does this intervention work? Then the economic question is: Is it worth it? Cost-effectiveness

42 Symptoms of illness Extent of disability Needs (met, unmet) Social functioning Self-care abilities Employment, occupation, activities Behavioural characteristics Quality of life Normalised lifestyle Autonomy, choice, control Family well-being Carer impact Societal perceptions (e.g. safety) QALYs (quality-adjusted life years) Which outcome dimensions? Characteristics of a good outcome measure: Relevant! Reliable Valid Sensitive to change Succinct Acceptable to patient

43 Possible CEA results C 2 > C 1 New treatment less effective and more costly C 2 < C 1 E 2 < E 1 E 2 > E 1 New treatment less effective but less costly New treatment more effective but also more costly New treatment more effective and also less costly C = costs E = effects 1 = old treatment 2 = new treatment How are the outcomes traded- off against the costs?

44 If an intervention is more effective and also more costly, then calculate the cost per unit gain in effectiveness. Crunch question: Is it worth it? So we could: Attach a monetary value to the outcome gain Show decision-maker the cost-effectiveness of various ways to spend their money and get them to choose Show decision-maker the probability of cost- effectiveness at different WTP values … or ask them how much they are willing to pay? Set a threshold, rigidly or as a guide (cf. NICE) … … But then need a way to compare across different diagnostic groups) … and hence use of QALYs, DALYs Trade-offs … is it worth it?

45 Cost-effectiveness acceptability curve (CEAC) Value of threshold ratio Probability of being cost-effective 10k k30k40k

46 Computerised Cognitive Behavioural Therapy (CBT) for anxiety and depression Design n=274 primary care patients (aged 18-75) with depression and/or anxiety disorder; not currently receiving face-to- face psychological therapy. RCT Interventions Beating the Blues (BtB) – 8 sessions (50 mins each) of therapy on top of usual care vs. treatment as usual (TAU) alone (discussions with GP, referral to counsellor, practice nurse or MH professional, etc) Aim To compare effectiveness and cost- effectiveness of BtB and TAU Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004 Example

47 Beating the Blues: results Effectiveness BtB better than treatment as usual on clinical measures of symptoms (Beck Depression Inventory, Beck Anxiety Inventory) and functioning (Work and Social Adjustment Schedule) Cost BtB more costly than standard care (to NHS) So is it worth it? Cost per 1 incremental gain on Beck Depression Inventory = £21 Cost per additional depression-free day = £2.50 Cost per additional QALY = £2190 Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004

48 E Incentives

49 Providing information about what people do and the associated economic consequences Rewarding/penalising decision-makers for good/bad decisions or good/bad performance Hence: oFee for service … the GP contract oPayment by results (HRGs) oIncentive-based contracts / salaries oProvider competition within health / social care oFinancial rewards for patients (e.g. FIAT) Using economic incentives

50 Thank you


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