King’s College LondonCentre for the

Economics of Mental Health

2

Introduction

Professor Martin Knapp

3

A simplified mental health system

User needs and preferences

FundingMarkets

Cost-of-illness

Cost-effectiveness

evaluation

4

So why is economics relevant?

ScarcityThere are not enough resources to meet every need or want …

… so we have to choose how to use those resources ‘appropriately’

… and ‘appropriate’ often means – among other things – efficiently

… which is the cue for economics

5

This session Sarah Byford – Child and Adolescent

Mental Health Services Renee Romeo – Learning DisabilitiesDiscussion Barbara Barrett – Forensic Mental Health

and Personality Disorders Paul McCrone – Common Mental Disorders Ramon Sabes-Figuera – Non-Mental

Health ResearchDiscussion

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Child and Adolescent Mental Health Services

Dr Sarah Byford

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Status of evaluation in CAMHS• CEMH systematic review over 25 years (1982 and 2006):

−UK clinical and economic evaluations−children and adolescents−non-pharmacological specialist mental health services

• 40 UK controlled, clinical studies including only 10 RCTs• 4 UK economic evaluations (3 undertaken by CEMH)• Internationally, less than 2% of all paediatric economic evaluations carried out between 1980 and 2006 focused on mental or behavioural disorders (n=31)• This compares to an estimated 30 adult mental health economic studies being published annually

8

CAMHS – recently completed1. Adolescents with anorexia nervosa

2. Adolescents with depression

3. Young people in the youth justice system

4. Economic cost of autism in the UK

5. Cost of young adults who deliberately poisoned themselves in childhood and adolescence

9

TOuCAN study – designAim: To explore the clinical and cost effectiveness of inpatient, specialist outpatient and general outpatient services for adolescents with anorexia nervosa

Design: Large population based randomised controlled trial (n=167) with 2-year follow-up

Location: North West Region

Outcome: Morgan-Russell Average Outcome Scale (MRAOS)

Perspective: Health, social services, education, voluntary and private sectors

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TOuCAN study – results

Inpatient Specialist outpatien

t

General outpatien

tMRAOS score

8.3 8.4 8.3

Inpatient days

73 55 89

Total cost £ 34531 26738 40794

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TOuCAN study – results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000

Decision makers' willingness to pay for a unit increase in MRAOS score at 2 years (£)

Pro

bab

ilit

y th

at s

trat

egy

is c

ost-

effe

ctiv

e

Specialist outpatient Inpatient General outpatient

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Findings from other studies• CBT + SSRI is not more effective or cost-effective than

SSRI alone in adolescents with persistent major depression• Young offenders in the community have higher levels of mental health need than those in secure facilities, yet access fewer mental health services• The costs of supporting children with ASDs are estimated to be £2.7 billion each year• Child and adolescent mental health problems predict significant costs in adulthood compared to general population controls, including greater reliance on social security benefits, supported accommodation and special education and greater criminal justice sector costs

13

CAMHS – current

1. RCT of group therapy for adolescents who repeatedly harm themselves

2. RCT of a pre-school communication treatment for autism

3. RCT of multi-systemic therapy for children in need

4. RCT of brief psychodynamic psychotherapy, cognitive behaviour therapy and treatment as usual in adolescents with moderate to severe depression

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Learning Disabilities

Renee Romeo

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• CEMH staff are also involved in learning disability research

• 2 studies explore cost alongside outcome:

− community living − health checks

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Community living: semi-independent living and fully staffed group homes

• Supported housing units adopted a fully-staffed group home model for all but the most independent people

• Staffing levels not catering to the adaptive abilities of residents

• Higher staff-user ratios less choice and independence

• Semi-independent living better outcomes at lower cost

• This study compared costs and quality-of-life outcomes of semi-independent (SI) living to otherwise similar fully-staffed (FS) group homes for adults

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=Fully-staffed group home & Semi-independent living participants

Majority of lifestyle outcome measures

Fully-staffed group home participants

Fully-staffed group home participants

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=Fully-staffed participants& Semi-independent living participants

Majority of lifestyle outcome measures

Fully-staffed participants

Fully-staffed participants

• Potential to reduce the costs of

provision for people with learning

disabilities with moderate to low

support needs

• On balance, semi-independent living

could offer certain cost-effective

lifestyle advantages provided that

sufficient attention is given to health

and financial well-being

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• People with learning disabilities have a range of physical and mental health needs, with higher prevalence than the general population

- So less likely to receive adequate health and social services

• Health checks recommended as way of identifying health needs

• Previous studies have not explored effectiveness of health checks and the associated service consequence and costs

• Costs and outcomes were assessed for:−50 people offered a health check intervention −50 people receiving standard care

Health checks

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Health Check(n = 50)

Mean

Standard care(n = 50)

Mean

One-year incidence of new

health need detection

4.80 2.26

Met new health needs 3.56 2.26

Met health promotion needs 2.88 1.38

Met health monitoring needs 1.70 1.26

>

>>=

Health checks - lower

cost to agencies and

carers

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Health Check(n = 50)

Mean

Standard care(n = 50)

Mean

One-year incidence of new

health need detection

4.80 2.26

Met new health needs 3.56 2.26

Met health promotion needs 2.88 1.38

Met health monitoring needs 1.70 1.26

>

>>=

Health checks - lower

cost to agencies and

carers

Health checks may potentially

offer value for money relative

to standard care for people

with a learning disability

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DISCUSSION

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Forensic Mental Health and Personality

DisordersBarbara Barrett

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Personality disorder

Criminaljustice &Forensic

mentalhealth

Eating disorders

Self-harm

Severe mental illness

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Personality disorder

Eating disorders

Self-harm

Severe mental illness

TROUBLED

- RCT of different psychological therapies in patients with both eating disorders and symptoms of borderline PD

POPMACT

-RCT of CBT v TAU for repeated deliberate self-harm

JOSHUA

- RCT of joint crisis plans v TAU for people with borderline PD and repeated deliberate self-harmNidotherapy

- Nidotherapy v TAU for severe mental illness and PD in community mental health team

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Criminaljustice

Unit costs in criminal justice

Reforms of Scottish legal system

-Electronic monitoring and bail

-Fines enforcement teams

-Legal aid

-Evidence disclosure to defending teams

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Personality disorder

Criminaljustice &Forensic

mentalhealth

People with personality disorder in criminal justice system, in particular evaluations of the new PD services

- DSPD: IMPALOX, CODES, IDEA

- MSU: UPDATE

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(1) Developmental workUNIT COSTS IN CRIMINAL JUSTICE

• Aim – to develop unit cost information to be used alongside outcome data from 3 large cohort studies

• Methods – scoping exercise, planning, collation of finance and budgetary data, time diary exercise

• Output – series of updatable unit costs

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(2) Prospective studies

• Randomised controlled trials

• Economic evaluation to produce cost-effectiveness and cost-utility analyses

• Service use data collected alongside clinical outcome measures at assessment follow-ups

• Linked to primary outcome measure

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(3) Modelling studies

• Use mathematical relationships to define the possible consequences that flow from a set of alternative options being evaluated• Structured way of thinking about how a decision taken now impacts on costs and outcomes in the future • Results are generated by modelling existing data on costs and outcomes

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Common Mental Disorders

Dr Paul McCrone

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Key questions

1. What do we mean by ‘common mental disorders’?

2. What are their economic implications?

3. How cost-effective is treatment?

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What do we mean by ‘common mental disorders’?

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Estimated number of people with mental health problems in England in 2007

1.2

2.3

0.2

1.1

0.1

2.5

0.6

0

1

2

3

Depression Anxiety Schizophrenia& related

Bipolar &related

Eatingdisorders

Personalitydisorders

Dementia

Nu

mb

er o

f p

eop

le (

mil

lio

n)

McCrone et al (2008)

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What are their economic implications?

36

Estimated cost of depression and anxiety in 2007 and 2026

0

2

4

6

8

10

12

14

Depression(2007)

Depression(2026)

Anxiety(2007)

Anxiety(2026)

Co

st (

£ b

illi

on

)

Service costs

Lost work costs

McCrone et al (2008)

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How cost-effective is treatment?

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Evidence from two studiesComputer aided CBT

(cCBT)

• RCT in primary care settings

• cCBT more effective in reducing depression (BDI) and anxiety (BAI) than usual care

• … but more expensive

SSRIs for mild/moderate

depression

• RCT in primary care settings

• SSRIs associated with reduction in depression (HDRS) and increase in QALYs

• … but more expensive

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Probability that cCBT is cost-effective

0

0.2

0.4

0.6

0.8

1

0 5 10 15 20 25 30 35 40 45 50

Societal value of day free of depression (£)

Pro

ba

bil

ity

McCrone et al (2004)

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Probability that SSRIs are cost-effective

0

0.2

0.4

0.6

0.8

1

050

00

1000

0

1500

0

2000

0

2500

0

3000

0

3500

0

4000

0

4500

0

5000

0

Societal value Quality Adjusted Life Year (£)

Pro

ba

bil

ity

12-week

26-week

Kendrick et al (2009)

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Non Mental Health Research

Ramon Sabes-Figuera

42

• Mental health interventions and treatments are the main focus of CEMH research

• Physical and mental health are strongly correlated and this may have an important impact on costs

• CEMH is also involved in projects to evaluate innovative interventions in non- mental health conditions

Background

43

Example: diabetes

Study in progress:

• Impact of psychological and social factors on costs

• Cost-effectiveness of psychological interventions to improve self-care skills, and therefore outcomes

Diabetes outcomes

Self care skills

Psychological and social factors

Cost of care Diabetes NIHR - non-pharmacological approaches to improving diabetes outcomes in

Type 2 diabetes

44

Example: economic evaluation of arthritis self-management in primary care

Cost Outcomes (QALYs)

£1,442 0.580

osteoarthritis patients aged +50-hips and/or knees -pain and/or disability

self management programme (6 sessions) + education booklet

education booklet alone

CostOutcomes (QALYs)

£1,487 0.558

45

Economic evaluation of arthritis self-management in primary care

…(the) study does not suggest cost effectiveness based on current policy (i.e. NICE) perspectives (BMJ 2009)

46

Other non-mental health areas we are working in

Coronary heart disease and depression in primary care

MET with and without CBT to treat Type 1 Diabetes

Cancer therapy in different settings

Multiple Sclerosis

CBT for irritable bowel syndrome

Antibiotic use in chest infection in stroke

Longer-term stroke care

47

DISCUSSION