Martin Knapp

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
• Kings 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
All Causes Total YLD (millions) of total
1. Unipolar major depression 20.35 7.7
2. Hearing Loss, adult onset 14.96 5.6
3. Cataracts 12.16 4.6
4. Alcohol use 11.5 4.3
5. Cerebrovascular disease 7.58 3.1
6. Vision related disorders 7.23 2.7
7. Peri-natal conditions 7.03 2.7
8. Osteoarthritis 6.59 2.5
9. Chronic Obstructive Pulmonary Disorder 6.55 2.5
10. Schizophrenia 5.66 2.1
Disease Control Priority Project 2006,
5
Years lost to disability (women)
All Causes Total YLD (millions) of total
1. Unipolar major depression 31.26 11.0
2. Cataracts 16.49 5.8
3. Hearing Loss 15.03 5.3
4. Osteoarthritis 10.83 3.8
5. Vision related disorders 9.66 3.4
6. Alzheimers other dementia 9.46 3.3
7. Cerebrovascular disease 6.98 2.5
8. Perinatal conditions 6.91 2.4
9. Schizophrenia 5.58 2.0
10. Bi-Polar Disorder 4.82 1.7
Disease Control Priority Project 2006,
6
N of people by disorder, England 2007 2026
Current projected future prevalence
McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith,
Paying the Price, Kings 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

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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 Primar
y 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 Primar
y 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 Primar
y 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 Primar
y 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 Primar
y 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 Primar
y 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 Primar
y 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
Health care
Genes
Social care
Family
Housing
Income
Long-term needs
Education
Emplyt
Crim justice
Resilience
Benefits
Trauma
Employment
Phys env
Vol sector
Events
Income
Chance
Mortality
21
on many different budgets (England)
Health care
NHS
Genes
Social care
Family
LAs CLG
Housing
Income
Long-term needs
Education
DfE
Emplyt
Crim justice
MoJ
Resilience
Benefits
DWP
Trauma
Employment
Firms
Phys env
Vol sector
CVOs
Events
Income
Indiv
Chance
All
Mortality
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
0
1
2
0
1
1
2
2
3
3
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 Psychiatry 188
547-533
29
Evidence from the Inner London Longitudinal Study

• All 10-year olds in a London borough, 1970
  (n1689). 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?

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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 J
323 191-4.
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_1260
85
33
Our approach - 1

• 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

34
Our approach - 2

• 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

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
• Specific conditions
• 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
Target General population without mental health problems who are at risk of unmanageable debt
Inter-vention Debt advice services, provided on face-to-face, telephone or internet basis
Outcome evidence Unmanageable debt increases risk of developing depression/anxiety disorders by 2 in general population. Face-to-face service alleviates 56 of unmanageable debt telephone service alleviates 47.
Economic pay-offs Reductions in health and social care service use lost employment legal system costs costs to local economy
Findings Complicated ! Savings depend on who pays, mode of delivery, and amount of debt recovered. Telephone/web advice cost saving (most scenarios). Face-to-face advice most cost-effective. If 2/3 of service costs recovered from creditors, then total savings 0.63 per 1 invested in first year and 3.55 over 5 years.
Knapp et al (2011) in Knapp et al Mental Health
Promotion, Dept of Health.
37
Medically unexplained symptoms the economic case
Target Individuals with sub-threshold somatisation and clinical somatisation disorders in primary care (account for c. 25 of all primary care consulters)
Inter-vention Referral to 10 sessions of cognitive behavioural therapy over 6-month period cost 400
Outcome evidence CBT shown effective in reviews 35 of individuals report improvement in symptoms after 15-month follow-up (Allen et al 2006)
Economic pay-offs Reduced NHS costs (GP consultations, prescriptions, AE, outpatients, inpatients) reduced sickness absence from work
Findings Total savings over 3 years 1.75 per 1 invested for comprehensive programme savings 7.82 per 1 invested for targeted programme. Majority of savings accrue to NHS
McDaid et al (2011) in Knapp et al Mental Health
Promotion, Dept of Health.
38
Early detection of psychosis the economic case
Target Young people aged 15-35 in general population with prodromal symptoms of psychosis. Estimated number per year 15,763.
Inter-vention Early detection service (based on OASIS in South London Valmaggia et al 2009). Consists of psychological and pharmacological treatment.
Outcome evidence Reduced rate of transition to full psychosis and reduced duration of untreated psychosis for those who do develop it.
Economic pay-offs Reduction in inpatient costs and lost employment, reduction in homicide rate, reduction in suicide rate.
Findings In short-term (Year 1) there is a net cost, but the total return on 1 investment over a 10-year period is 10.27 26 of this is to the NHS
McCrone et al (2011) in Knapp et al Mental Health
Promotion, Dept of Health.
39
Economic pay-offs per 1 investment NHS Other public sector Non-public sector Total
Early identification and intervention as soon as mental disorder arises Early identification and intervention as soon as mental disorder arises Early identification and intervention as soon as mental disorder arises Early identification and intervention as soon as mental disorder arises Early identification and intervention as soon as mental disorder arises
Early intervention for conduct disorder 1.08 1.78 5.03 7.89
Health visitor interventions to reduce postnatal depression 0.40 - 0.40 0.80
Early intervention for depression in diabetes 0.19 0 0.14 0.33
Early intervention for medically unexplained symptoms 1.01 0 0.74 1.75
Early diagnosis and treatment of depression at work 0.51 - 4.52 5.03
Early detection of psychosis 2.62 0.79 6.85 10.27
Early intervention in psychosis 9.68 0.27 8.02 17.97
Screening for alcohol misuse 2.24 0.93 8.57 11.75
Suicide training courses provided to all GPs 0.08 0.05 43.86 43.99
Suicide prevention through bridge safety barriers 1.75 1.31 51.39 54.45
Promotion of mental health and prevention of mental disorder Promotion of mental health and prevention of mental disorder Promotion of mental health and prevention of mental disorder Promotion of mental health and prevention of mental disorder Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and emotional learning programmes 9.42 17.02 57.29 83.73
School-based interventions to reduce bullying 0 0 14.35 14.35
Workplace health promotion programmes - - 9.69 9.69
Addressing social determinants and consequences of mental disorder Addressing social determinants and consequences of mental disorder Addressing social determinants and consequences of mental disorder Addressing social determinants and consequences of mental disorder Addressing social determinants and consequences of mental disorder
Debt advice services 0.34 0.58 2.63 3.55
Befriending for older adults 0.44 - - 0.44
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
Which outcome dimensions?

• 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)

• Characteristics of a good outcome measure
• Relevant!
• Reliable
• Valid
• Sensitive to change
• Succinct
• Acceptable to patient

43
Possible CEA results
C costs E effects 1 old treatment 2 new
treatment
C2 gt 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 lt E1
E2 gt E1
New treatment less effective but less costly
New treatment more effective and also less costly
C2 lt 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 n274 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_at_lse.ac.uk
• martin.knapp_at_kcl.ac.uk