Centre for the Economics of Mental Health King’s College London Centre for the Economics of Mental Health

Introduction Professor Martin Knapp

User needs and preferences A simplified mental health system Markets Funding Cost-of-illness User needs and preferences Cost-effectiveness evaluation

So why is economics relevant? Scarcity There 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

This session Sarah Byford – Child and Adolescent Mental Health Services Renee Romeo – Learning Disabilities Discussion Barbara Barrett – Forensic Mental Health and Personality Disorders Paul McCrone – Common Mental Disorders Ramon Sabes-Figuera – Non-Mental Health Research

Child and Adolescent Mental Health Services Dr Sarah Byford

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

CAMHS – recently completed Adolescents with anorexia nervosa Adolescents with depression Young people in the youth justice system Economic cost of autism in the UK Cost of young adults who deliberately poisoned themselves in childhood and adolescence

TOuCAN study – design Aim: 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

Specialist outpatient TOuCAN study – results Inpatient Specialist outpatient General outpatient MRAOS score 8.3 8.4 Inpatient days 73 55 89 Total cost £ 34531 26738 40794

TOuCAN study – results

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

CAMHS – current RCT of group therapy for adolescents who repeatedly harm themselves RCT of a pre-school communication treatment for autism RCT of multi-systemic therapy for children in need RCT of brief psychodynamic psychotherapy, cognitive behaviour therapy and treatment as usual in adolescents with moderate to severe depression

Learning Disabilities Renee Romeo

CEMH staff are also involved in learning disability research 2 studies explore cost alongside outcome: community living health checks 15

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 16

= Majority of lifestyle outcome measures Fully-staffed group home & Semi-independent living participants = Majority of lifestyle outcome measures Fully-staffed group home participants Fully-staffed group home participants

= Majority of lifestyle outcome measures Fully-staffed participants & Semi-independent living participants = Majority of lifestyle outcome measures 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 Fully-staffed participants Fully-staffed participants

Health checks 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 19

> > > = Health checks - lower cost to agencies and carers Mean Standard care One-year incidence of new health need detection 4.80 2.26 Met new health needs 3.56 Met health promotion needs 2.88 1.38 Met health monitoring needs 1.70 1.26 > Health checks - lower cost to agencies and carers > > = 20

> > > = Health checks - lower cost to agencies and carers Mean Standard care One-year incidence of new health need detection 4.80 2.26 Met new health needs 3.56 Met health promotion needs 2.88 1.38 Met health monitoring needs 1.70 1.26 > Health checks may potentially offer value for money relative to standard care for people with a learning disability Health checks - lower cost to agencies and carers > > = 21

DISCUSSION

Forensic Mental Health and Personality Disorders Barbara Barrett

Criminal justice & Forensic mental health Self- harm Severe mental illness Eating disorders Personality disorder Criminal justice & Forensic mental health

Personality disorder Self- harm Severe mental illness Eating disorders TROUBLED RCT of different psychological therapies in patients with both eating disorders and symptoms of borderline PD Self- harm Severe mental illness Eating disorders Personality disorder 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-harm Nidotherapy Nidotherapy v TAU for severe mental illness and PD in community mental health team

Criminal justice Unit costs in criminal justice Reforms of Scottish legal system Electronic monitoring and bail Fines enforcement teams Legal aid Evidence disclosure to defending teams Criminal justice

Criminal justice & Forensic mental health People with personality disorder in criminal justice system, in particular evaluations of the new PD services DSPD: IMPALOX, CODES, IDEA MSU: UPDATE Personality disorder Criminal justice & Forensic mental health

(1) Developmental work UNIT 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

(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

(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

Common Mental Disorders Dr Paul McCrone

Key questions What do we mean by ‘common mental disorders’? What are their economic implications? How cost-effective is treatment?

What do we mean by ‘common mental disorders’?

Estimated number of people with mental health problems in England in 2007 McCrone et al (2008)

What are their economic implications?

Estimated cost of depression and anxiety in 2007 and 2026 McCrone et al (2008)

How cost-effective is treatment?

Evidence from two studies Computer 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

Probability that cCBT is cost-effective McCrone et al (2004)

Probability that SSRIs are cost-effective Kendrick et al (2009)

Non Mental Health Research Ramon Sabes-Figuera

Background 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

Psychological and social factors Example: diabetes 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 Study in progress: Impact of psychological and social factors on costs Cost-effectiveness of psychological interventions to improve self-care skills, and therefore outcomes

Example: economic evaluation of arthritis self-management in primary care Cost Outcomes (QALYs) £1,442 0.580 self management programme (6 sessions) + education booklet osteoarthritis patients aged +50 -hips and/or knees -pain and/or disability Cost Outcomes (QALYs) £1,487 0.558 education booklet alone

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)

Other non-mental health areas we are working in Cancer therapy in different settings Coronary heart disease and depression in primary care Multiple Sclerosis MET with and without CBT to treat Type 1 Diabetes Antibiotic use in chest infection in stroke CBT for irritable bowel syndrome Longer-term stroke care

DISCUSSION