Mental health and economics

1. 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 Mental health and economics Martin Knapp London School of Economics and Political Science King’s College London, Institute of Psychiatry NIHR School for Social Care Research

2. A Mental health

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

4. Years lost to disability (men) - globally Disease Control Priority Project 2006,

5. Years lost to disability (women) Disease Control Priority Project 2006,

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

7. Projected number of people with dementia in the UK: 2005-2029 Source: Knapp et al (2007) Dementia UK report

8. Characteristics of mental health … • High prevalence • Chronic course • Genes / environment • Multiple needs • Employment effects • Links to suicide / self-harm • Compulsory treatment / detention • Stigma & discrimination • Family impacts • Antisocial behaviour, crime • Mental well-being / happiness

9. … with economic consequences • High prevalence  high expenditure • Chronic course  lifelong economic impacts • Genes/environment  complex causality • Multiple needs  wide-ranging costs • Employment effects  productivity losses • Links to suicide/self-harm  fear/costs etc • Compulsory treatment  user choice? • Stigma & discrimination  social exclusion • Family impacts  often hidden; incentives? • Crime  exaggerated societal reactions? • Mental well-being links to happiness

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

11. B Economic questions

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

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

14. … and lower longer-term costs. Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 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

15. Question 1: What does it cost? Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 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 1. Costs ?

16. Question 2: Will it pay for itself? Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 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 1. Costs ? 2. Cost-offsets ?

17. Question 3: Is it worth it? Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 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 1. Costs ? 3. Cost-effectiveness ? 2. Cost-offsets ?

18. Question 4: Can we change things? 4. Incentives ? 4. Incentives? Outcomes Symptom alleviation Interpersonal functioning Social functioning Employment Quality of life 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 1. Costs ? 3. Cost-effectiveness ? 2. Cost-offsets ?

19. B Costs

20. Many causes; widespread impacts Genes Health care Social care Family Housing Income Long-term needs Emply’t Education Crim justice Resilience Trauma Benefits Phys env Employment Events Vol sector Chance Income Mortality

21. …on many different budgets (England) Genes Health care NHS Social care Family LAs CLG Housing Income Long-term needs Emply’t Education DfE Crim justice MoJ Resilience Trauma Benefits DWP Phys env Employment Firms Events Vol sector CVOs Chance Income Indiv Mortality All

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

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

24. Depression – costs for adults in England, 2000 - continued Total cost = £9 bn Thomas & Morris Brit J Psychiatry 2003

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

26. GB - disability benefits, 2007 € 3.9 billion per annum Plus reduced tax receipts €14 billion Department of Work and Pensions, 2007

27. Costs of health service use by diabetes patients, by depression severity Number of reported diabetes complications 0 1 2 0 3 0 1 2 3 1 2 3 Simon et al, Gen Hosp Psychiatry, 2005

28. Costs - young children with persistent antisocial behaviour Total cost excluding benefits averaged £5,960 per child per year, at 2000/01 prices (benefits = £4307) Romeo, Knapp, Scott (2009). Children with antisocial behaviour. British J Psychiatry188: 547-533

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 26-28 … 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 Costs (£) from ages 10 to 28 Scott, Knapp, Henderson, Maughan (2001) Financial cost of social exclusion: follow-up study of antisocial children into adulthood. Brit Med J323: 191-4.

31. C Cost-offsets

32. New economic evidence on mental health promotion and mental illness prevention Check report for full details http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085

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

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

35. Debt: mental health challenges 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 Specificconditions • Alcoholism (2x), Drug Addition (4x), Suicidal ideation (2x) Source:Fitch et al, submitted; Meltzer, et al., 2010;Skapinakis et al., 2006;

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

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

38. Early detection of psychosis: the economic case McCrone et al (2011) in Knapp et al Mental Health Promotion…, Dept of Health.

40. D Cost-effectiveness

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

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. C = costs E = effects 1 = old treatment 2 = new treatment Possible CEA results C2 > C1 New treatment less effective and more costly How are the outcomes traded-off against the costs? New treatment more effective but also more costly E2 < E1 E2 > E1 New treatment less effective but less costly New treatment more effective and also less costly C2 < C1

44. Trade-offs … is it worth it? 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

45. Cost-effectiveness acceptability curve (CEAC) 1.0 0.9 0.8 0.7 0.6 0.5 Probability of being cost-effective 0.4 0.3 0.2 0.1 0 €10k €20k €30k €40k Value of threshold ratio

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 Example Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004

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. Using economic incentives Providing information about what people do and the associated economic consequences Rewarding/penalising decision-makers for ‘good/bad decisions’ or good/bad performance Hence: • Fee for service … the GP contract • Payment by results (HRGs) • Incentive-based contracts / salaries • Provider competition within health / social care • Financial rewards for patients (e.g. FIAT)

50. Thank you m.knapp@lse.ac.uk martin.knapp@kcl.ac.uk