Kings College London Centre for the Economics of Mental Health.
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Transcript of Kings College London Centre for the Economics of Mental Health.
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
6
Child and Adolescent Mental Health Services
Dr Sarah Byford
7
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
10
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
11
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
12
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
14
Learning Disabilities
Renee Romeo
15
• CEMH staff are also involved in learning disability research
• 2 studies explore cost alongside outcome:
− community living − health checks
16
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
17
=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
19
• 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
20
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
21
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
22
DISCUSSION
23
Forensic Mental Health and Personality
DisordersBarbara Barrett
24
Personality disorder
Criminaljustice &Forensic
mentalhealth
Eating disorders
Self-harm
Severe mental illness
25
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
26
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
27
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
28
(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
29
(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
30
(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
31
Common Mental Disorders
Dr Paul McCrone
32
Key questions
1. What do we mean by ‘common mental disorders’?
2. What are their economic implications?
3. How cost-effective is treatment?
33
What do we mean by ‘common mental disorders’?
34
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)
35
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)
37
How cost-effective is treatment?
38
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
39
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)
40
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)
41
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