The Economic Costs of Mental Health Ailments in Post-Conflict Bosnia and Herzegovina

1. The EconomicCosts of Mental Health Ailments in Post-Conflict Bosnia and Herzegovina Kinnon Scott, DECRG Mike Massagli, HPRT

2. Why Mental Health? • Within the next 20 years major depression is projected to become the second leading cause of disability (Murray and Lopez, 1996) • Efforts to address depression and Post Traumatic Stress Disorder (PTSD) in post-disaster or conflict areas based on assumption that effects are transitory • Research suggests that major depression and PTSD are prevalent and chronic among refugee populations (Mollica et al 1999, 2001; Mollica et al 1993: and Shrestha et al 1998).

3. Why Mental Health? • Prevalence among refugees is 40-70% (< 10% in non-post conflict countries) • Rates in the general population are unknown, expected to be somewhere between refugee rates and ‘normal’ rates • Impact of untreated mental health ailments on development, • Effectiveness of economic and social policies in this context

4. Bosnia and Herzegovina • Break up of the Former Republic of Yugoslavia • Civil war 1993-1995, three ‘ethnic’ groups, ending with Dayton Agreement • High rates of depression and PTSD among refugees of this war • Persistence of symptoms three years later (Mollica et al, 1999, 2001)

5. Bosnia and Herzegovina • Construction of a new state: • Transition Economy • Post–Conflict economy and society • Massive effort by international community to assist in creating a viable state: re-construction, policy reform, governance • Role of mental health ailments?

6. Goal • Determine the prevalence of depression symptoms in the general adult population in a post-conflict country • Assess the economic costs of untreated mental health ailments

7. Methodology • Nationally representative household survey: Living Standards Measurement Study Survey (LSMS) • Validation study • Community data collection

8. Living Standards Measurement Study Survey (LSMS) • Multi-topic Household Survey • ‘All’ aspects of welfare: • Monetary • Access to social services and infrastructure • Human capital • Economic activities • National coverage, representativeness

9. Sectoral Demographics Housing, utilities Education Consumption Food expenditures Home production Non-food expend. Housing Durable goods Health, ADLs Migration Anthropometric Income Non-farm Self-Empl. Agric. Activities Labor activities Other income Savings and credit Modules in LSMS Questionnaires

10. To include mental health questions? • Adequacy of Sample Size • Sensitivity of Questions • Validity

11. To include mental health questions? • Adequacy of the sample size • Sensitivity of questions • Validity

12. Sample size issue 5400 households Average household size is 3.5=> 3,780 people per domain Five domains of study (1080 hhlds per domain) 1/2 of population adult: 1390 adults per domain If rate of depression is 5% 70 adults per domain 556 40%

13. To include mental health questions? • Validity • Adequacy of the sample size • Sensitivity of questions • Non-clinical setting • Training issues • Interviewers have undergone same experience

14. Depression Index • Modified Hopkins Symptoms Checklist (HSCL-25) • 15 Questions to screen for depression • Each question scored from 1 (symptom is not bothersome) to 4 (extremely bothersome or common • Index is constructed by taking mean score over the 15 questions • Cut-off point 1.75, above which shows symptoms of depression

15. Examples of Questions

16. To include mental health questions? • Adequacy of the sample size • Sensitivity of questions • Non-clinical setting • Training issues • Interviewers have undergone same experience • Focus only on depression (proxies for trauma) • Validity

17. To include mental health questions? • Adequacy of the sample size • Sensitivity of questions • Validity

18. Validity • Questions adequate for context • Translation issue • HPRT work • Pilot test • Had to drop one question • Proxies for trauma • Migration- DP, Refugee, Permanent Resident • Status of housing ownership • Status of agricultural land • Cut-off point adequacy

19. Cut-off point • Independent study • 185 individuals sampled at primary health care facilities • Administered screening questions: Hopkins Symptom Checklist (HSCL-25) • Then interviewed by psychiatrist according to standard Structured Clinic Interview-DSM-IV (SCID). • Use the clinical work to determine the validity of the Checklist and determine the appropriate cut-off point for depression

20. Individuals’ behavior affected by conditions of community: Trauma Percentage of housing stock damaged Shift in ethnic majority Change in population Employment Pre-war major sources of employment Present sources of employment One company towns Unemployment Community Data

21. Community Data • Health • Presence of health care facilities • Services provided • Treatment for mental health ailments • Costs

22. The Research: Objectives • Estimate the prevalence of mental health symptoms consistent with depression among the adult (17 and older) population in Bosnia and Herzegovina and its relation to welfare; • Examine the effect of mental health ailments on labor market productivity; and • Examine the causal relationship between mental health symptoms and utilization of health care services

23. Conceptual Issues • Direction of causality: • Labor markets: observed outcomes in the labor market can be result of depression or cause of it. • Health care utilization. A depressed individual may overuse the health care system as mis-diagnosis of their ailment leads to repeated visits. But a serious concern about one’s health and a failure of repeated visits to health care professionals could lead to depression.

24. Identification problem • The presence of trauma events offers scope for identification. • Trauma is highly correlated with depression and is clearly causal- it is hard to imagine a reasonable case being made for depression causing trauma. • Past trauma does not have current effects on productivity independent of its effect on depression. • Use trauma as an instrumental variable for depression. • Trauma leading to physical disability : Either past (6 years) or can control for it with Physical Functioning scales

25. Prevalence • Preliminary results suggest 20 percent of adult population (3000 cases) have depression symptoms • Depression is higher among: • Poor • Women • Elderly • Republika Srpska

26. Depression and Poverty • Relative importance of depression on poverty • Where C is log of per adult equivalent consumption, DEP is depression score, and X is vector of household characteristcis and Z a vector of community characteristics

27. Labor Markets • Impact of depression on labor force participation • Using estimated depression

28. Health care • Role of depression in determining health care visits, controlling for the ability to pay, demographic characteristics and the health status of the individual (presence of chronic illness, acute illness or injury, and physical functioning • Use negative binomial model • Follow the model used by Trivedi (2002) in his work on Vietnam.

29. Health service use and depression Where X is a vector of variables affecting health care usage and B are the coefficients

30. Time table • Poverty and Welfare analysis by June 2004 • Health care will wait til can add panel data