1. Welcome and Conference Introduction

2. Reforming the health care system from a mental health and economic perspective: a few thoughts Eric Latimer, Ph.D. Research Scientist Douglas Institute Associate Professor/Associate Member Departments of Psychiatry/ Epidemiology, Biostatistics and Occupational Health CHSP Annual conference March 21 2012

3. Outline 1 Three aspects of a health care system 2 The importance of mental illness 3 Learning from other countries: Evidence-based practices (EBPs) 4 Too much spending on meds, not enough on EBPs 5 What to do?

4. Taxes Insurance premiums Out-of-pocket payments CSSSs MDs Hospitals Meds Other providers Community orgs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO- SOCIAL SERVICES) FINANCING ALLOCATION DELIVERY $ Three aspects of a health care system* * Note that this graph does not reflect all possible sources of funds or providers

5. Tax revenues Private insurers Out-of-pocket CSSSs MDs Hospitals Meds Other providers Community orgs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO- SOCIAL SERVICES) FINANCING ALLOCATION DELIVERY $ Three aspects of a health care system

6. Tax revenues Private insurers Out-of-pocket CSSSs MDs Hospitals Meds Other providers Community orgs Care and social services provided to patients (PHYSICAL & MENTAL HEALTH, + PSYCHO- SOCIAL SERVICES) FINANCING ALLOCATION DELIVERY $ Three aspects of a health care system

7. Why care about the granularity of services for a specific group of conditions in considering health policy? Specificities of different health conditions For a system overall to be effective and cost- effective, attention must be paid to each component part – Whole greater than sum of its parts

8. Unipolar depressive disorder 3rd most important cause of global of disease overall 4.3% of all DALYs Source : WHO, hwww.who.int/healthinfo/global_burden_disease/en/index.html

9. Alcohol use disorder in 17th place; self-inflicted injuries in 20th 1.6% 1.3%

10. Leading causes of disease burden for women aged 15–44 years, high-income countries, and low- and middle-income countries, 2004: Schizophrenia, bipolar disorder (and PTSD) rise in importance Source : WHO, hwww.who.int/healthinfo/global_burden_disease/en/index.html

11. Lim et al. (2008) estimate total economic burden of mental illness in Canada at $50.8 billion in 2003 Source: Lim et al. (2008), A new population-based measure of the burden of mental illness in Canada, Chronic diseases in Canada, 28(3).

12. Using more comprehensive methods Jacobs et al. (2010) arrive at a higher figure for direct medical costs than Lim et al. (2008)… Source: Lim et al. (2008), A new population-based measure of the burden of mental illness in Canada, Chronic diseases in Canada, 28(3).

13. …namely, $14.3 billion… or about 7.2% of total health expenditures Inpatient Physicians Community and social Pharma- ceuticals Public income supports Other services

14. Of this, people with severe mental illness, though fewer (2-3% vs. perhaps 20% overall*) account for a large share Cost CategoryEstimated Cost – Schizophrenia alone (billion CAN $) Direct (HC & more)2.02 Productivity losses4.83 Total6.85 Source: Goeree et al., The Economic Burden of Schizophrenia in Canada in 2004, Curr Med Res Opin. 2005;21(12):2017-2028 * Variable depending on what is counted

15. To sum up… Large relative disability burden of mental illness, especially considering adults at key productive ages Significant costs of treating mental illness

16. Learning from other countries: Evidence-based practices for people with severe mental illness Normally defined on the basis of 2 or more successful RCTs Lists vary according to interpretation of evidence Model fidelity becomes an issue – higher fidelity, better outcomes – Concerns with implementation Typically involve organization of professionals around pursuit of a goal for clients – overall support of people with SMI, employment, housing, optimal use of medications, limit harm from substance abuse…

17. Evidence-based practices for people with severe mental illness: Examples Assertive Community Treatment Early Intervention Services for Psychosis Family Psychoeducation Integrated Tx for dual disorders (MI + substance abuse) Supported employment Housing First Illness Management and Recovery

18. Common characteristics of EBPs Aim for community integration and social inclusion Break down the silos: Close integration between treatment and rehabilitation (e.g., alcohol, employment, housing) Draw out and build on client goals and strengths as well as resources in natural environments Real-time adjustability to changes in patient needs …as may be seen, commonalities (e.g. breaking down silos) but also specificities compared to other forms of care

19. Learning from other countries: Implementing EBPs "Spray and pray" does not work – Coaching essential Technical assistance centers – CNESM in Québec – Monitoring fidelity and outcomes

20. Now for a concern related to allocation

21. Contrast: Lack of funding for EBPs, essentially unlimited funding for medications Closed funding envelopes for psychosocial care in regions perceived as being disproportionately rich (e.g., Montreal) – Result: Difficult to fund even transitions from less to more effective services Physicians can prescribe whatever they want, including off-label, with very few constraints

22. Potential savings from psychiatric drugs Possibility of increasing efficiency via more sparing use of psychotropic medications – 2.8 billion $ on psychotropic meds in Canada 2007/2008 – About 629 million $ on antipsychotics in 2007 Data suggest large variation in propensity to prescribe high doses of antipsychotics across prescribers, to patients with schizophrenia

23. Large variability in % patients with schizophrenia on high doses of antipsychotics, Québec, 2004 Source: Latimer E, Wynant W, Naidu A, Clark R, Malla A, Moodie E, Tamblyn R. Manuscript in preparation

24. Potential savings from psychotropic medications (2) Studies assembled by Whitaker (2010) suggest overconsumption of psychiatric medications, leading in a significant number of cases to chronicisation (very costly and not supportive of recovery!) Non-optimality of barely constraining expenditures on meds while severely constraining expenditures on psychosocial services

25. One way of viewing the problem… A mechanism for trading-off relative benefits of spending on one type of program or service vs another seems needed CSSSs were supposed to have responsibility for the population on their territory; but currently they cannot. – Hospitals, MDs, medication spending, not under their control

26. A British-style way forward? A single authority (CSSS?) could keep track of overall outcomes for a population, and purchase services (physicians, hospitals) and medications for this population Introduce incentives for increasing process quality, effectiveness and cost-effectiveness – Requires measuring them! Such an approach should increase access to well-implemented EBPs for people with severe mental illness – among other benefits

27. More realistically… …however, probably politically impossible in Québec! In its absence, prospect of slow incremental change, mostly through persuasion, and collaborative arrangements

28. Thank you for your attention eric.latimer@mcgill.ca