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Mental health expenditure accounts for just 2.1% of total domestic governmental health expenditure per capita. There is an economic, as well as moral, imperative to invest more in mental health given the long-term adverse impacts of mental disorders. This paper focuses on how economic evidence can be used to support the case for action on global mental health, focusing on refugees and people displaced due to conflict. Refugees present almost unique challenges as some policy makers may be reluctant to divert scarce resources away from the domestic population to these population groups. A rapid systematic scoping review was also undertaken to identify economic evaluations of mental health-related interventions for refugees and displaced people and to look at how this evidence base can be strengthened. Only 11 economic evaluations focused on the mental health of refugees, asylum seekers and other displaced people were identified. All but two of these intervention studies potentially could be cost-effective, but only five studies reported cost per quality-adjusted life year gained, a metric allowing the economic case for investment in refugee mental health to be compared with any other health-focused intervention. There is a need for more consistent collection of data on quality of life and the longer-term impacts of intervention. The perspective adopted in economic evaluations may also need broadening to include intersectoral benefits beyond health, as well as identifying complementary benefits to host communities. More use can be also made of modelling, drawing on existing evidence on the effectiveness and resource requirements of interventions delivered in comparable settings to expand the current evidence base. The budgetary impact of any proposed strategy should be considered; modelling could also be used to look at how implementation might be adapted to contain costs and take account of local contextual factors.
Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.
Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes.
We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359.
From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes.
There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.
Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units.
This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units.
We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies – of Interventions and Risk of Bias in Randomized Trials.
Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ2 = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI −261.24 to −67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43–0.68; P < 0.001).
Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.
Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.
A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.
Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.
Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.
Mental health problems early in life can negatively impact educational attainment, which in turn have negative long-term effects on health, social and economic opportunities. Our aims were to: (i) estimate the impacts of different types of psychiatric conditions on educational outcomes and (ii) to estimate the proportion of adverse educational outcomes which can be attributed to psychiatric conditions.
Participants (N = 2511) were from a school-based community cohort of Brazilian children and adolescents aged 6–14 years enriched for high family risk of psychiatric conditions. We examined the impact of fear- (panic, separation and social anxiety disorder, specific phobia, agoraphobia and anxiety conditions not otherwise specified), distress- (generalised anxiety disorder, major depressive disorder and depressive disorder not otherwise specified, bipolar, obsessive-compulsive, tic, eating and post-traumatic stress disorder) and externalising-related conditions (attention deficit and hyperactivity disorder, conduct and oppositional-defiant conditions) on grade repetition, dropout, age-grade distortion, literacy performance and bullying perpetration, 3 years later. Psychiatric conditions were ascertained by psychiatrists, using the Development and Well-Being Behaviour Assessment. Propensity score and inverse probability weighting were used to adjust for potential confounders, including comorbidity, and sample attrition. We calculated the population attributable risk percentages to estimate the proportion of adverse educational outcomes in the population which could be attributed to psychiatric conditions. Analyses were conducted separately for males and females.
Fear and distress conditions in males were associated with school dropout (odds ratio (OR) = 2.76; 95% confidence interval (CI) = 1.06, 7.22; p < 0.05) and grade repetition (OR = 2.76; 95% CI = 1.32, 5.78; p < 0.01), respectively. Externalising conditions were associated with grade repetition in males (OR = 1.66; 95% CI = 1.05, 2.64; p < 0.05) and females (OR = 2.03; 95% CI = 1.15, 3.58; p < 0.05), as well as age-grade distortion in males (OR = 1.66; 95% CI = 1.05, 2.62; p < 0.05) and females (OR = 2.88; 95% CI = 1.61, 5.14; p < 0.001). Externalising conditions were also associated with lower literacy levels (β = −0.23; 95% CI = −0.34, −0.12; p < 0.001) and bullying perpetration (OR = 3.12; 95% CI = 1.50, 6.51; p < 0.001) in females. If all externalising conditions were prevented or treated, we estimate that 5.0 and 4.8% of grade repetition would not have occurred in females and males, respectively, as well as 10.2 (females) and 5.3% (males) of age-grade distortion cases and 11.4% of female bullying perpetration.
The study provides evidence of the negative impact of psychiatric conditions on educational outcomes in a large Brazilian cohort. Externalising conditions had the broadest and most robust negative impacts on education and these were particularly harmful to females which are likely to limit future socio-economic opportunities.
The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England.
We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England.
There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40–49 years (30%) for men and 19–29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8−140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results.
The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.
Background: The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps.
Methods: The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps.
Results: The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities.
Conclusions: The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the “-omics” approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.
Developmental disabilities include limitations in function and activities resulting from disorders of the developing nervous system in conjunction with unaccommodating environments or absence of assistive technologies. This chapter discusses key principles and considerations in designing and implementing screening programs and epidemiologic studies of developmental disabilities. The epidemiologic studies in low- and middle-income countries were frequently conducted by foreign researchers and sometimes characterized as "helicopter epidemiology". One of the challenges of epidemiologic studies of disability is that case status is often based on information obtained from questionnaires or cognitive tests that are designed and validated for use in one language and culture, and may not be applicable for or capable of generating comparable data across cultures. It is likely that for the majority of the world's children with developmental disabilities, obtaining an accurate diagnosis, though an important step, comes with no guarantee that coordinated services and appropriate services will be available.
Aims – There is growing demand for economic analysis to support strategic decision-making for mental health but the availability of economic evidence, in particular on system performance remains limited. The Mental Health Economics European Network (MHEEN) was set up in 2002 with the broad objective of developing a base for mental health economics information and subsequent work in 17 countries. Methods – Data on financing, expenditure and costs, provision of services, workforce, employment and capacity for economic evaluation were collected through bespoke questionnaires developed iteratively by the Network. This was augmented by a literature review and analysis of international databases. Results – Findings on financing alone suggest that in many European countries mental health appears to be neglected while mechanisms for resource allocation are rarely linked to objective measure of population mental health needs. Numerous economic barriers and potential solutions were identified. Economic incentives may be one way of promoting change, although there is no one size fits all solution. Conclusions – There are significant benefits and synergies to be gained from the continuing development of networks such as MHEEN. In particular the analysis can be used to inform developments in Central and Eastern Europe. For instance there is much that can be learnt on both how the balance of care between institutional and non-institutional care has changed and on the role played by economic incentives in ensuring that resources were used to develop alternative community-based systems.
Declaration of Interest: none of the authors have received any financial support that presents a conflict of interest.
To provide an overview of the economic impact of poor mental health in the workplace and assess the extent to which economic evaluation has been used to further the case for investment in workplace based mental health programmes. Rapid scoping review of published and grey literature. The socio-economic costs of poor mental health in the workplace are substantial but conservative, as few studies have included productivity losses from work cutback, as well as absenteeism. While few economic evaluations of workplace based mental health interventions were identified, the available evidence base suggests that they have the potential to be highly cost effective. Much of this evidence may be from the US and be less applicable elsewhere; it may also have been solely published in company documents making assessment of methodological quality difficult. The potential economic case for workplace based mental health interventions appears good. More collaboration between policy makers and the private sector would help facilitate rigorous and transparent economic evaluations. A number of evaluations are planned. The challenge is to build on these initiatives, in order to address what remains a major gap in our knowledge on the economics of mental health.
Aims – This paper seeks to provide a methodology to assess the cost-effectiveness of anti-stigma campaigns for people with mental health problems. Methods – The costs of running a national campaign in Scotland were obtained and combined with the number of adults in the Scottish population and the estimated number of people with improved attitudes towards people with mental health problems. A decision model was constructed to estimate the economic impact of a campaign in terms of increased use of services by people with depression and increased work time. Results – If the campaign caused 10% of changed attitudes then it was estimated to cost £35 per one less person who felt that people with mental health problems were dangerous and £186 per one less person who felt the public needs protection from people with mental health problems. The decision model suggested extra economic benefits (employment gains minus service costs) as a result of an anti-stigma campaign compared to the absence of a campaign. Conclusions – Data on the economic impact of anti-stigma campaigns are scarce and evaluation is intrinsically difficult. We have demonstrated a method to conduct such analyses. The model proposed here should be tested further as data become available.
A system of devolved welfare governance, it is argued, increases participation in welfare services. However, limited empirical evidence has been reported on how it influences welfare reform. This paper draws upon evidence from the mental health system in Spain, where health care is devolved to the regional states (autonomous communities), to examine whether policy reform of neglected policy areas may be triggered through heightened policy awareness and better participation of interested stakeholders. We find that regional devolution has helped to scale up mental health in some of Spain's autonomous regions relative to support for other services. Evidence suggests that whilst fragmentation and certain historical legacies remain path dependent, regional devolution has indeed enhanced experimentation, reform and policy innovation in mental health care. However, the expansion of mental health care coverage has been constrained by the lack of a clear definition of public coverage, as well as the need to meet the demands of evidence-based policy in an era of cost-containment. Inequalities in access to mental health care remain; they are compounded by the stigma and discrimination experienced by people with mental health problems, which is a common challenge for all health systems in Europe.
During the period of austerity that we now face, the National Health Service (NHS), including mental health services, will have to make efficiency savings at a time when demand for services is likely to rise. It is critical to highlight that investment in evidence-based prevention, early intervention and treatment for mental disorders can have economic benefits that go far beyond the health sector. Many potential areas for efficiency savings, such as resources invested in management and administration, are relevant across the whole of the health system. The economic downturn may, however, also present a specific opportunity for radical innovation within the mental health system.
Mental health warrants a dedicated chapter within this book as it accounts for 14% of the global burden of disease. An estimated 450 million people worldwide are affected by mental health problems at any given time and one in five people will experience a psychiatric disorder (excluding dementia) within any given year (Horton 2007; WHO Regional Office for Europe 2003). Moreover, as we will indicate, assessment of the performance of mental health services presents challenges that may be unique within health care.
Within Europe, mental health problems account for approximately 20% of the total disability burden of ill health but often appear to be a lower policy priority than many other areas of health. This is despite the fact that nearly all countries readily admit that poor mental health has major impacts, not only on health but also on many other sectors of the economy (Taipale 2001).
The costs of poor mental health are conservatively estimated to account for 3%-4% of GDP in the European Union (EU) alone, yet none of these countries actually spends much more than 1% of GDP on mental health (Knapp et al. 2007). Differences in the boundaries between health and social care make cross-country comparisons difficult but health system funding for mental health in the EU ranges from almost 14% in England to much less than 4% in other countries including Bulgaria, the Czech Republic, Poland and Portugal.
Objectives: Many evaluations underestimate the utility associated with diagnostic interventions by failing to capture the nonclinical value of diagnostic information. This is a cause of bias in resource allocation decisions. A study was undertaken to investigate preferences for the assessment of cardiac risk, testing the suitability of conjoint analysis, a multiattribute preference elicitation method, in the field of clinical diagnosis.
Methods: Two conjoint analysis models focusing on selected characteristics of cardiac risk assessment in asymptomatic patients 40–50 years of age were applied to elicit preferences for cardiac risk assessment from samples of general practitioners and the general public in the United Kingdom and Italy. Both models were based on rankings of alternative scenarios, and the results were analyzed using multivariate analysis of variance and an ordered probit model.
Results: In both countries, members of the public attached at least three times more importance to prognostic value (relative to clinical value) than did general practitioners. Significantly different patterns were found in the two countries with regard to other characteristics of the assessment. Variation within samples was partly associated with personal characteristics.
Conclusions: Only a fraction of the value of cardiac risk assessment to individuals and physicians in this study was linked to health outcomes. The study confirmed the appropriateness and validity of conjoint analysis in the assessment of preferences for diagnostic interventions. A wider use of this technique might significantly strengthen the existing evidence-base for diagnostic interventions, leading to a more efficient use of health-care resources.