Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Wednesday, April 13, 2016

Investing in Mental Health

According to the NY Times, which does not lie, while mental health care is scarce in parts of the US, it's virtually non-existent in most of the world, with one mental health professional per 1 million people in developing countries.

This is the push behind the World Health Organization's (WHO's) goal to, "...move mental health to the forefront of the international development agenda," and the focus of a conference in Washington this week.

In support of this goal is a paper published yesterday in the Lancet Psychiatry, Scaling-up treatment of depression and anxiety: a global return on investment analysis, by Chisholm, et al. The study was funded by Grand Challenges Canada, which supports, "Bold Ideas with Big Impact in global health," and is, itself, funded by the Canadian government.

I was curious about the study, in particular, how they went about assessing something huge like economic impact of mental illness, and what interventions they think would be helpful. They used the OneHealth tool, which you can download here, to estimate the number of people with depression and anxiety disorders living in 36 large countries, constituting 80% of the world's population, and 80% of the global burden of depression and anxiety disorders. The countries were a mix of low-, middle-, and high-income. Incidentally, I didn't download the OneHealth tool even though it looks really interesting because it's designed for Windows, feh, and I would have to do funny things to my precious Mac to use it. But there's an introductory tutorial on YouTube, and boy does OneHealth have a lot of fascinating data for countries, and powerful functionality.

Quite reasonably, in my opinion, they excluded prevention as a type of treatment, because the evidence for it is weak, and not easily generalizable. Interventions included, "...basic psychosocial treatment for mild cases, and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases." The choice of intervention is based on WHO's Mental Health Gap Action Programme (mhGAP), where the recommended treatment for moderate to severe depression is:

Anxiety and mild depression are considered, "Other Significant Emotional or Medically Unexplained Complaints." In those cases, the recommended treatment is:

INT are advanced psychosocial interventions which take, "...more than a few hours of a health-care provider’s time to learn and typically more than a few hours to implement." They include Behavioral Activation, CBT, Contingency Management Therapy, Family Counseling or Therapy, Interpersonal Psychotherapy, Motivational Enhancement Therapy, Parent Skills Training, Problem-Solving Counseling or Therapy, Relaxation Training, and Social Skills Therapy.

I have to say I'm a little skeptical about how effective these interventions will be. However, their computations were based on the assumption that there would be only a 5% improvement in the ability to work, and productivity at work, as a result of treatment. So their expectations were modest-if someone would normally miss 20 days of work per year, how much money would it cost or save if that person only missed 19 days per year. At least, that's how I understand it.

They were looking for the total cost of scaling-up treatment, as well as effects on three categories:

Health Return = increased healthy life years gained as a result of treatment
Value of Health Returns = I don't really understand this
Economic Return = enhanced levels of productivity

One table I initially skimmed over but now realize is quite important is:

Current and target levels of scaled-up treatment coverage for depression and anxiety disorders (all interventions combined), by country income level 

It reflects the idea I pointed out above that their expectations are modest. Currently, 7% of people who need it get treatment in low-income countries. With the scaled-up program, that number will rise to 34%, which means that 2/3 of people who need treatment won't get it.

The article notes that, "...very few studies have assessed the extent to which effective depression treatments get people back into work." So that's an important question to try to answer. They looked at absenteeism, meaning days lost to work, and "presenteeism", meaning partial days of impaired activity while at work. I guess that includes things like staring off into space.

Let's review. They used this powerful, OneHealth tool to see how many people in the world suffer from depression and anxiety. And they also used the tool to determine the economic impact of these illnesses when they're treated, and when they're not treated. Then they figured out how many more people would need treatment in order to get a 5% increase in productivity. They estimated the cost of the additional treatment, and they estimated how much money would be saved (or made, depending on your perspective) by having that many more people back at work.

And this is what they found:

Costs and benefits of scaled up treatment of depression and anxiety disorders, 2016–30

The total investment is $91.5 billion for depression, plus $55.7 billion for anxiety, equals approximately $147 billion.

They claim that, "...scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period [2016-30]." I don't understand how they determined this, but they placed an economic value on these healthy life-years, the "Value of Health Returns".  For depression, it's $258 billion, and for anxiety, $52 billion, for a total of $310 billion.

In terms of economics, they got $230 billion for depression, and $170 billion for anxiety. That's a total of $400 billion.

To summarize, just looking at pure dollar amounts, over a 15 year period, you put in $147 billion, you get out $400 billion, yielding a total benefit to cost ratio of 2.3-3 : 1.

The discussion describes some limitations. For example, it notes that is a modest return on investment. By comparison, in another OneHealth model, the benefit to cost ratio for malaria was 28-40 : 1. But they also mention that they didn't include things like reduction in unemployment- and welfare-benefits in their analysis, so that could change the ratio.

Another limitation is that unlike the prevalence of of depression and anxiety, the prevalence of treated depression and anxiety is unknown. Meaning that even if you invest in and set up programs, they may not be implemented well. Also, treating more people, for example in remote locations, may drive up the cost of treatment.

Plus, the study didn't consider the negative effect of maternal depression on early child development, the health, social, and economic benefits of effective treatment of maternal depression on the cognitive and physical development of newborns, the monetary and non-monetary impact of effective treatment on family and other caregivers, and the effect of depression and its treatment on physical health outcomes.

To these considerations I would add my own concerns about the particular interventions the WHO recommends. However, I will concede that while the whole endeavor is about the bottom line, and may not make that much emotional difference to that many people, some people will be helped, and that's more than are helped now. And, more importantly, if things work out like they want them to, they will have demonstrated that helping more people actually saves money. I hope they're right.


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