Part 3 of Prof. Dominic Hodgkin's workshop on topics in the economics of mental health care, presented to the Myers-JDC-Brookdale Institute on July 8, 2015.
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2015-07-08 Dominic Hodgkin Part 3 Economic Burden and Treatment Effectiveness
1. Mental illness: economic burden
and treatment effectiveness
Dominic Hodgkin
Professor
Institute for Behavioral Health
Heller School of Social Policy and Management
Brandeis University
Presentation for Myers-JDC-Brookdale Institute
Jerusalem, July 8, 2015
2. Outline of talk
• Introduction
• The burden of mental illness
– Disability burden
– Economic cost
• Effectiveness of treatment
• Conclusions
3. Burden
Concepts
• It’s worth distinguishing some different
ways the burden of an illness is measured:
• Disability burden: on individuals with
illness
– Focuses on morbidity and mortality
• Economic cost: to society
– Includes impact on others, lost productivity etc.
5. Burden
Disability burden
• The leading effort to measure disability
burden is the World Health Organization’s
Global Burden of Disease study
• They collect data around the world on
disease prevalence and causes of mortality
• Latest reports measure burden in 2010 1
• Including one on burden of mental illness 2
1. Murray 2014. 2. Whiteford, 2014
6. Burden
Measuring disability burden
• Disability Adjusted Life Years (DALYs)
measure has 2 components
• Years lost to death: compares mean age of
mean life expectancy with/without disease
• Years lived with disability: applies weights
that vary (0 to 1) with severity, e.g.
– Major depressive disorder has weight of 0.65
– Schizophrenia (acute state) has weight of 0.76
7. Burden
Disability burden results
• In 2010, mental and behavioral disorders
accounted for 185 million DALYs lost.
This was 7.4% of all DALYs. 1
• By disorder, the big contributors were:
– depression (40% of all mental DALYs)
– anxiety (15%)
– drug use disorders (11%)
– alcohol use disorders (10%)
1. Whiteford, 2014
8. Percent of DALYs explained by each
mental and substance use disorder in 2010
40%
15%
11%
10%
7%
17%
Depressive disorders
Anxiety disorders
Drug use disorders
Alcohol use disorders
Schizophrenia
Other
Source: Whiteford, 2014
9. Percent of ‘Years of Life Lost’ explained by
each disorder in 2010
42%
44%
7%
7%
Drug use disorders
Alcohol use disorders
Schizophrenia
Other
Source: Whiteford, 2014
10. Percent of ‘Years Lived with Disability’
explained by each disorder in 2010
43%
15%
9%
8%
7%
19%
Depressive disorders
Anxiety disorders
Drug use disorders
Alcohol use disorders
Schizophrenia
Other
Source: Whiteford, 2014
11. Burden
Mortality versus disability
• The impact of mental and substance use
disorders occurs largely as disability, not
mortality 1
• 23% of disability burden, 0.5% of mortality
– Suicide is not attributed to depression
• Different disorders affect mortality:
– The top 2 (with 86%) are alcohol and drug use
disorders, not depression and anxiety
1. Whiteford, 2014
12. Burden
Regional differences
• Results also analyzed for 22 regions
• Depressive disorders had the highest
proportion of total MH burden across all
regions
– Some disorders had big variation across regions
in the share of burden, e.g. eating disorders
– Others had much less variation
13. Burden
Ranking of mental disorders
• Mental and substance use disorders are
among the most disabling conditions 1
• Major depression ranked 12th worldwide
– 4th in Western Europe, 5th in North America
• Anxiety disorders ranked 26th worldwide
– 14th in Western Europe, 13th in North America
• But the absolute burden is high in poor
countries too
1. Murray 2012.
14. Burden
Implications
• Mental disorders are an important source of
disability worldwide
• They are not just a first-world problem:
high rates found in rich and poor countries
16. Economic cost
Cost of illness methods
• Cost of illness approach seeks to measure
effect on society
• Key questions:
– what adverse outcomes are associated with the
illness?
– what is the degree of causality between the
illness and these outcomes?
– what economic values ought to be assigned to
these consequences?
17. Economic cost
Cost of illness: key concepts
• Direct costs:
– Health care costs attributable to the illness
– Public and private spending on crime due to the illness
– Administrative costs of social welfare programs
• Indirect costs:
– Losses from premature death
– Value of lost output
• Include ‘opportunity costs’, not just cash
outlays
18. Economic cost
Cost of illness findings
• Economic burden of some key mental disorders
for the US, as estimated in cost of illness studies:
– Major depressive disorder: $80 billion, in 2010 1
– Bipolar disorder: $151 billion in 2009 2
– Excessive drinking: $224 billion, in 2006 3
• By comparison:
– Other studies estimated cost of cancer at $190 billion,
cardiovascular disease at $394 billion, lung disease
$132 billion 4
1. Greenberg, 2015. 2. Dilsaver, 2011. 3. Bouchery, 2011. 4. RTI, 2006
19. Components of the incremental economic
burden of major depressive disorder
21%
14%
12%
12%
41% Medical services
Pharmacy services
Suicide-related costs
Absenteeism
Presenteeism
Source: Greenberg, 2015
20. Components of the incremental economic
burden of excessive drinking
11%
2%
33%
29%
10%
6%
1%
8%
Health care
Absenteeism
Lost productivity--work
Lost productivity - mortality
Criminal justice
Motor vehicle crashes
Fire losses
Other
Source: Bouchery, 2011.
21. Economic cost
Comparing illnesses
• Different cost components matter for different
diseases
– Car crashes and crime are a big part of the economic
burden of excessive drinking (16%), but not for major
depression 1
– Suicide (12%) is an important cost driver for major
depressive disorder, but not for excessive drinking 2
– Lost productivity is important for both
1. Greenberg, 2015. 2. Bouchery, 2011.
22. Who bears the burden of excessive
drinking?
42%
42%
16%
Government
Heavy drinker & family
Others
Source: Bouchery, 2011.
23. Economic cost
Policy implications
• Does measuring the burden tell us how to
target treatment and prevention resources?
• No – we also need to know the
effectiveness of the alternative interventions
• But burden studies help identify problem
areas, get policymakers’ attention 1
1. Meara, 2005.
25. Effectiveness
Defining effectiveness
• Effectiveness is the intervention’s
performance
– relative to some alternative (e.g. placebo,
treatment as usual)
– on some pre-specified outcome (e.g. symptoms,
functioning)
• Often evaluated using randomized
controlled trials
26. Interventions
Example: Contingency management
• An incentive-based approach to treating
substance use disorders 1,2
• Patients treated in psychosocial or
methadone maintenance clinics are
rewarded for drug abstinence
• Possible rewards include retail vouchers,
raffle drawings, or cash
1. Stitzer 2006. 2. Higgins 2008
28. Interventions
Contingency management: an example study
• Setting:4 community-based SUD treatment clinics
• Intervention: 16 weeks of standard care with CM
followed by 16 weeks of standard care without
CM, or vice versa. Target: client attendance.
• CM = Weekly raffle drawings for prizes
– Each participant had 1 ticket for each week’s full
attendance
– Non-attendance resets client’s number of tickets
Ledgerwood et al., 2008
29. Interventions
Contingency management: evidence
• A meta-analysis of CM for substance use
disorders (n=47 studies) found: 1
– Substantial median effect size (d=0.47)
• They concluded that CM is “among the
more effective approaches to promoting
abstinence” during treatment of SUD
1. Prendergast, 2006
30. Effectiveness
Efficacy versus effectiveness
• Efficacy is the performance of an
intervention under ideal and controlled
circumstances
• Effectiveness is the intervention’s
performance under ‘real-world’ conditions
• The two can differ a lot
31. Effectiveness
Why effectiveness can fall short
• Clinicians in real practice may be less
motivated, trained than those in a study trial
• Trials often exclude many patients, creating
a less generalizable sample
• The intervention may not fit well with
existing delivery system, financing models
• Adherence may be low, depending on
tolerability of drugs, or time burden of visits
34. Effectiveness
Lynch example
• Lynch et al 1 compared 2 treatments for SSRI-
resistant depression in youth:
– Switch in antidepressant only
– ‘Combined treatment’: Switch in antidepressant PLUS
cognitive behavioral therapy (CBT)
• Data from TORDIA trial (24 weeks)
• Key outcome: depression-free days (DFD)
– Also converted DFD to quality-adjusted life years
(QALYs)
1. Lynch, 2011
35. Effectiveness
Lynch example: Findings
• Lynch et al compared combined treatment
to switch-only. Combined treatment was:
– more effective: 8.3 more depression-free days
– more costly: $1,633 more in cost per patient
– cost-effective, if willing to pay $188 per
depression-free day
• Suppose doubling the dose would add one
more DFD, but extra cost was $1500?
37. Budget impact
• Even interventions that are effective and
cost-effective may still be unaffordable
• Governments can’t pay for all cost-effective
interventions
– Especially in poorer countries: e.g. HIV meds
• So policymakers look at budget impact too 1
1. Cohen, 2008.
38. Ranking interventions by cost-effectiveness
40
$60,000
10
$50,000
Cases treated
Cost per HY
BA
50
C
$70,000
40. Conclusions
• Many studies have documented the substantial
burden of mental illness
• Effective interventions exist for many disorders
• But they compete for funding with other priorities
– So cost-effectiveness and budget impact matter
• Full discussion of an intervention’s value will
need to address those too
41. References (1)
• Bouchery, Ellen E., et al. "Economic costs of excessive alcohol consumption in the US,
2006." American journal of preventive medicine 41.5 (2011): 516-524.
• Dilsaver, Steven C. "An estimate of the minimum economic burden of bipolar I and II
disorders in the United States: 2009." Journal of affective disorders 129.1 (2011): 79-83.
• Cohen, J. P., Stolk, E., & Niezen, M. (2008). Role of budget impact in drug
reimbursement decisions. Journal of health politics, policy and law, 33(2), 225-247.
• Meara, E., & Frank, R. G. (2005). Spending on substance abuse treatment: how much is
enough?. Addiction, 100(9), 1240-1248.
• Greenberg, Paul E., et al. "The economic burden of adults with major depressive
disorder in the United States (2005 and 2010)." The Journal of clinical psychiatry 76.2
(2015): 155-162.
• Higgins ST, Silverman K, Heil SH. 2008. Contingency Management in Substance
Abuse Treatment. The Guilford Press: New York, NY.
• Ledgerwood, David M., et al. "Contingency Management for Attendance to Group
Substance Abuse Treatment Administered by Clinicians in Community Clinics."
Journal of Applied Behavior Analysis 41.4 (2008): 517-526.
42. References (2)
• Lynch, Frances L., et al. "Incremental cost-effectiveness of combined therapy vs
medication only for youth with selective serotonin reuptake inhibitor–resistant
depression: Treatment of SSRI-Resistant Depression in Adolescents Trial findings."
Archives of general psychiatry 68.3 (2011): 253-262.
• Murray, Christopher JL, et al. "Disability-adjusted life years (DALYs) for 291 diseases
and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of
Disease Study 2010." The lancet 380.9859 (2013): 2197-2223.
• Prendergast, Michael, et al. "Contingency management for treatment of substance use
disorders: A meta‐analysis." Addiction 101.11 (2006): 1546-1560.
• RTI International. Cost-of-Illness Summaries for Selected Conditions.
https://www.rti.org/files/COI_Summaries.pdf. 2006.
• Stitzer, M., & Petry, N. (2006). Contingency management for treatment of substance
abuse. Annu. Rev. Clin. Psychol., 2, 411-434.
• Whiteford, Harvey A., et al. "Global burden of disease attributable to mental and
substance use disorders: findings from the Global Burden of Disease Study 2010." The
Lancet 382.9904 (2013): 1575-1586.
