mental health and economics martin knapp london school of economics and political science kings...
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Mental health and economics
Martin Knapp London School of Economics and Political Science
King’s College London, Institute of PsychiatryNIHR School for Social Care Research
Current activities:• Director of PSSRU• Director of LSE Health• Professor, health economics KCL• Director of NIHR SSCRCurrent 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
AMental health
0%
20%
40%
60%
80%
100%
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%
Years lost to disability (men) - globally
All Causes Total YLD (millions) % of total
1. Unipolar major depression 20.35 7.7
2. Hearing Loss, adult onset 14.96 5.6
3. Cataracts 12.16 4.6
4. Alcohol use 11.5 4.3
5. Cerebrovascular disease 7.58 3.1
6. Vision related disorders 7.23 2.7
7. Peri-natal conditions 7.03 2.7
8. Osteoarthritis 6.59 2.5
9. Chronic Obstructive Pulmonary Disorder
6.55 2.5
10. Schizophrenia 5.66 2.1
Disease Control Priority Project 2006,
All Causes Total YLD (millions) % of total
1. Unipolar major depression 31.26 11.0
2. Cataracts 16.49 5.8
3. Hearing Loss 15.03 5.3
4. Osteoarthritis 10.83 3.8
5. Vision related disorders 9.66 3.4
6. Alzheimers & other dementia 9.46 3.3
7. Cerebrovascular disease 6.98 2.5
8. Perinatal conditions 6.91 2.4
9. Schizophrenia 5.58 2.0
10. Bi-Polar Disorder 4.82 1.7
Disease Control Priority Project 2006,
Years lost to disability (women)
N of people by disorder, England 2007 & 2026
1.24
2.28
0.21
0.580.61
2.47
0.117
1.14
1.45
2.56
0.94
0.69
2.64
0.1220.24
1.23
0
1
2
3
DEP ANX SCH BPD EAT PER CHI DEM
Nu
mb
er
of
peop
le (
million
)
McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008
Current & projected future prevalence
Projected number of people with dementia in the UK: 2005-2029
0
200000
400000
600000
800000
1000000
1200000
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Nu
mb
er o
f p
eop
le
100 & over
95-99
90-94
85-89
80-84
75-79
70-74
65-69
Source: Knapp et al (2007) Dementia UK report
Characteristics of mental health …
o High prevalenceo Chronic courseo Genes / environmento Multiple needso Employment effectso Links to suicide / self-harmo Compulsory treatment / detentiono Stigma & discriminationo Family impactso Antisocial behaviour, crime o Mental well-being / happiness
o High prevalence high expenditureo Chronic course lifelong economic impactso Genes/environment complex causalityo Multiple needs wide-ranging costso Employment effects productivity losseso Links to suicide/self-harm fear/costs etco Compulsory treatment user choice?o Stigma & discrimination social exclusiono Family impacts often hidden; incentives?o Crime exaggerated societal reactions?o Mental well-being links to happiness
… with economic consequences
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, presenteeismf. Social inclusion – rights, opportunities, participation etcg. Equity – vicious cycle linking deprivation to morbidityh. Ageing and implications for not just dementia but also psychoses,
depressioni. Stigma and discrimination (at the root of many challenges?)
BEconomic questions
Interventions
Antidepressant medication
CBT
Primary care counselling
Interpersonal psychotherapy
Couple therapy
Example: Treatments for depression …
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 …
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.
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. C
osts
?
Question 1: What does it cost?
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. C
osts
?
Question 2: Will it pay for itself?
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. C
osts
?
Question 3: Is it worth it?
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. C
osts
?
4. Incentives ?Question 4: Can we change things?
4. Incentives?
BCosts
Many causes; widespread impacts
Health care
Social care
Housing
Education
Crim justice
Benefits
Employment
Vol sector
Income
Mortality
Genes
Family
Income
Emply’t
Resilience
Trauma
Phys env
Events
Chance
Long-term needs
…on many different budgets (England)
Health care
Social care
Housing
Education
Crim justice
NHS
LAsCLG
DfE
MoJ
Benefits
Employment
DWP
Firms
Vol sector
Income
CVOs
AllMortality
Indiv
Genes
Family
Income
Emply’t
Resilience
Trauma
Phys env
Events
Chance
Long-term needs
0
0.5
1
1.5
2
2.5
2002 20310
10
20
30
40
2002 2031
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
Depression – costs for adults in England, 2000
Day care0%
General practitioner
1%
Mortality61%
Out-patient2%
In-patient3%
Primary care medication
33%
Thomas & Morris Brit J Psychiatry 2003
Excluding ‘morbidity’ costs
Productivity90%
Mortality6%
Service costs4%
Total cost = £9 bn
Thomas & Morris Brit J Psychiatry 2003
Depression – costs for adults in England, 2000 - continued
0
20
40
60
Moderatedepression
Milddepression
OCD GAD Schizophrenia No psychiatricproblems
GB - employment and mental health
% in full-time work
GB 2000
GB - disability benefits, 2007
22%
40%
6%8%
18%
6%
Other Mental and Behavioural Disorders
Nervous System Circulatory and Respiratory System
Musculoskeletal System Injury, Poisoning, External Causes
Department of Work and Pensions, 2007
€ 3.9 billion per annum
Plus reduced tax receipts €14 billion
0
2000
4000
6000
8000
10000
No depression Subthreshold depression Major depression
0 1 2 3
Simon et al, Gen Hosp Psychiatry, 2005
0 0 01 1 122 233 3
Number of reported diabetes complications
Costs of health service use by diabetes patients, by depression
severity
Family costs45%
Education5%
Voluntary2%
Benefits43%
Social care0%
Health care5%
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: 547-533
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 26-28 …Research question: What services were used and
what costs incurred between aged 10 and 28?
0
20000
40000
60000
No problems Conductproblems
Conductdisorder
CriminaljusticeBenefits
Relationships
Social care
Health
Education
Costs in early adulthood linked to childhood antisocial behaviour
0
20000
40000
60000
No problems Conductproblems
Conductdisorder
CriminaljusticeBenefits
Relationships
Social care
Health
Education
Scott, Knapp, Henderson, Maughan (2001) Financial cost of social exclusion: follow-up study of antisocial children into adulthood. Brit Med J 323: 191-4.
Costs (£) from ages 10 to 28
CCost-offsets
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085
New economic evidence on
mental health promotion and mental illness
prevention
Check report for full details
Aim - model the costs and economic pay-offs of initiatives to prevent mental illness and promote mental well-being.
o Looked at evidence-based mental health interventions (incl. non-NHS) – must have well-established outcomes
o Looked at 15 different areas and interventions
o Used simple decision analytic modelling
o Close liaison with DH officials; consultation with experts
As far as the robust evidence base allows:
o Included promotion, primary, secondary prevention
o Looked at widest range of economic impacts
o Estimated impacts over long time periods
o If in doubt, we adopted conservative estimates
Our approach - 1
o Examined interventions from 2 perspectives:
- pay-offs to society as a whole and
- cash savings to the public sector
o And interested particularly in the timing of impacts and whether (or when) ‘cashable’
o Over 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
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
Debt counselling: the economic caseTarget General 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
Findings Complicated …! 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.
Medically unexplained symptoms: the economic case
Target Individuals 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
Findings Total 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.
Early detection of psychosis: the economic case
Target Young 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.
Findings In 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.
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 1.08 1.78 5.03 7.89
Health visitor interventions to reduce postnatal depression
0.40 - 0.40 0.80
Early intervention for depression in diabetes 0.19 0 0.14 0.33
Early intervention for medically unexplained symptoms 1.01 0 0.74 1.75
Early diagnosis and treatment of depression at work 0.51 - 4.52 5.03
Early detection of psychosis 2.62 0.79 6.85 10.27
Early intervention in psychosis 9.68 0.27 8.02 17.97
Screening for alcohol misuse 2.24 0.93 8.57 11.75
Suicide training courses provided to all GPs 0.08 0.05 43.86 43.99
Suicide prevention through bridge safety barriers 1.75 1.31 51.39 54.45
Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and emotional learning programmes
9.42 17.02 57.29 83.73
School-based interventions to reduce bullying 0 0 14.35 14.35
Workplace health promotion programmes - - 9.69 9.69
Addressing social determinants and consequences of mental disorder
Debt advice services 0.34 0.58 2.63 3.55
Befriending for older adults 0.44 - - 0.44
DCost-effectiveness
If the core clinical/care question is:
‘Does this intervention work?’
Then the economic question is:
‘Is it worth it?’
Cost-effectiveness
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
Possible CEA results
C2 > C1New treatment less effective and more costly
C2 < C1
E2 < E1 E2 > E1
New treatment less effective but less costly
New treatment more effective but also more costly
New treatment more effective and also less costly
C = costsE = effects1 = old treatment2 = new treatment
How are the outcomes traded-
off against the costs?
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?
Cost-effectiveness acceptability curve (CEAC)
Value of threshold ratio
Pro
bab
ilit
y o
f b
ein
g c
ost-
eff
ecti
ve
€10k
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0 €20k €30k €40k
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
Exam
ple
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 = £2190Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004
EIncentives
Providing information about what people do and the associated economic consequences
Rewarding/penalising decision-makers for ‘good/bad decisions’ or good/bad performance
Hence:
o Fee for service … the GP contract
o Payment by results (HRGs)
o Incentive-based contracts / salaries
o Provider competition within health / social care
o Financial rewards for patients (e.g. FIAT)
Using economic incentives
