School-based socio-emotional learning programs to prevent depression, anxiety and suicide among adolescents: a global cost-effectiveness analysis.

AIMS: Preventing the occurrence of depression/anxiety and suicide during adolescence can lead to substantive health gains over the course of an individual person's life. This study set out to identify the expected population-level costs and health impacts of implementing universal and indicated school-based socio-emotional learning (SEL) programs in different country contexts. METHODS: A Markov model was developed to examine the effectiveness of delivering universal and indicated school-based SEL programs to prevent the onset of depression/anxiety and suicide deaths among adolescents. Intervention health impacts were measured in healthy life years gained (HLYGs) over a 100-year time horizon. Country-specific intervention costs were calculated and denominated in 2017 international dollars (2017 I$) under a health systems perspective. Cost-effectiveness findings were subsequently expressed in terms of I$ per HLYG. Analyses were conducted on a group of 20 countries from different regions and income levels, with final results aggregated and presented by country income group - that is, low and lower middle income countries (LLMICs) and upper middle and high-income countries (UMHICs). Uncertainty and sensitivity analyses were conducted to test model assumptions. RESULTS: Implementation costs ranged from an annual per capita investment of I$0.10 in LLMICs to I$0.16 in UMHICs for the universal SEL program and I$0.06 in LLMICs to I$0.09 in UMHICs for the indicated SEL program. The universal SEL program generated 100 HLYGs per 1 million population compared to 5 for the indicated SEL program in LLMICs. The cost per HLYG was I$958 in LLMICS and I$2,006 in UMHICs for the universal SEL program and I$11,123 in LLMICs and I$18,473 in UMHICs for the indicated SEL program. Cost-effectiveness findings were highly sensitive to variations around input parameter values involving the intervention effect sizes and the disability weight used to estimate HLYGs. CONCLUSIONS: The results of this analysis suggest that universal and indicated SEL programs require a low level of investment (in the range of I$0.05 to I$0.20 per head of population) but that universal SEL programs produce significantly greater health benefits at a population level and therefore better value for money (e.g., less than I$1,000 per HLYG in LLMICs). Despite producing fewer population-level health benefits, the implementation of indicated SEL programs may be justified as a means of reducing population inequalities that affect high-risk populations who would benefit from a more tailored intervention approach.

The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study.

BACKGROUND: Reducing suicides is a key Sustainable Development Goal target for improving global health. Highly hazardous pesticides are among the leading causes of death by suicide in low-income and middle-income countries. National bans of acutely toxic highly hazardous pesticides have led to substantial reductions in pesticide-attributable suicides across several countries. This study evaluated the cost-effectiveness of implementing national bans of highly hazardous pesticides to reduce the burden of pesticide suicides. METHODS: A Markov model was developed to examine the costs and health effects of implementing a national ban of highly hazardous pesticides to prevent suicides due to pesticide self-poisoning, compared with a null comparator. We used WHO cost-effectiveness and strategic planning (WHO-CHOICE) methods to estimate pesticide-attributable suicide rates for 100 years from 2017. Country-specific costs were obtained from the WHO-CHOICE database and denominated in 2017 international dollars (I$), discounted at a 3% annual rate, and health effects were measured in healthy life-years gained (HLYGs). We used a demographic projection model beginning with the country population in the baseline year (2017), split by 1-year age group and sex. Country-specific data on overall suicide rates were obtained for 2017 by age and sex from the Global Burden of Disease Study 2017 Data Resources. The analysis involved 14 countries spanning low-income to high-income settings, and cost-effectiveness ratios were analysed at the country-specific level and aggregated according to country income group and the proportion of suicides due to pesticides. FINDINGS: Banning highly hazardous pesticides across the 14 countries studied could result in about 28 000 (95% uncertainty interval [UI] 24 000-32 000) fewer suicide deaths each year at an annual cost of I$0·007 per capita (95% UI 0·006-0·008). In the population-standardised results for the base case analysis, national bans produced cost-effectiveness ratios of $94 per HLYG (95% UI 73-123) across low-income and lower-middle-income countries and $237 per HLYG (95% UI 191-303) across upper-middle-income and high-income countries. Bans were more cost-effective in countries where a high proportion of suicides are attributable to pesticide self-poisoning, reaching a cost-effectiveness ratio of $75 per HLYG (95% UI 58-99) in two countries with proportions of more than 30%. INTERPRETATION: National bans of highly hazardous pesticides are a potentially cost-effective and affordable intervention for reducing suicide deaths in countries with a high burden of suicides attributable to pesticides. However, our study findings are limited by imperfect data and assumptions that could be improved upon by future studies. FUNDING: WHO.

Potential strategies for sustainably financing mental health care in Uganda.

BACKGROUND: In spite of the pronounced adverse economic consequences of mental, neurological, and substance use disorders on households in most low- and middle-income countries, service coverage and financial protection for these families is very limited. The aim of this study was to generate potential strategies for sustainably financing mental health care in Uganda in an effort to move towards increased financial protection and service coverage for these families. METHODS: The process of identifying potential strategies for sustainably financing mental health care in Uganda was guided by an analytical framework developed by the Emerging Mental health systems in low and middle income countries (EMERALD project). Data were collected through a situational analysis (public health burden assessment, health system assessment, macro fiscal assessment) and eight key informant interviews with selected stakeholders from sectors including health, finance and civil society. The situational analysis provided contextualization for the strategies, and was complimented by views from key informant interviews. RESULTS: Findings indicate that the following strategies have the greatest potential for moving towards more equitable and sustainable mental health financing in the Uganda context: implementing National Health Insurance Scheme; shifting to Results Based Financing; decentralizing mental health services that can be provided at community level; and continued advocacy with decision makers with evidence through research. CONCLUSION: Although several options were identified for sustainably financing mental health care in Uganda, the National Health Insurance Scheme seemed the most viable option. However, for the scheme to be effective, there is need for scale up to community health facilities and implementation in a manner that explicitly includes community level facilities.

Scaling-up services for psychosis, depression and epilepsy in sub-Saharan Africa and South Asia: development and application of a mental health systems planning tool (OneHealth).

BACKGROUND: Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders. METHODS: A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries. RESULTS: Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06-0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36-1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14-1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy. CONCLUSIONS: This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.

Informing mental health policies and services in the EMR: cost-effective deployment of human resources to deliver integrated community-based care.

For EMR countries to deliver the expectations of the Global Mental Health Action Plan 2013-2020 & the ongoing move towards universal health coverage, all health & social care providers need to innovate and transform their services to provide evidence-based health care that is accessible, cost-effective & with the best patient outcomes. For the primary and community workforce, this includes general medical practitioners, practice & community nurses, community social workers, housing officers, lay health workers, nongovernmental organizations & civil society, including community spiritual leaders/healers. This paper brings together the current best evidence to support transformation & discusses key approaches to achieve this, including skill mix and/or task shifting and integrated care. The important factors that need to be in place to support skill mix/task shifting and good integrated care are outlined with reference to EMR countries.

Mental health surveillance and information systems.

Routine information systems for mental health in many Eastern Mediterranean Region countries are rudimentary or absent, making it difficult to understand the needs of local populations and to plan accordingly. Key components for mental health surveillance and information systems are: national commitment and leadership to ensure that relevant high quality information is collected and reported; a minimum data set of key mental health indicators; intersectoral collaboration with appropriate data sharing; routine data collection supplemented with periodic surveys; quality control and confidentiality; and technology and skills to support data collection, sharing and dissemination. Priority strategic interventions include: (1) periodically assessing and reporting the mental health resources and capacities available using standardized methodologies; (2) routine collection of information and reporting on service availability, coverage and continuity, for priority mental disorders disaggregated by age, sex and diagnosis; and (3) mandatory recording and reporting of suicides at the national level (using relevant ICD codes).

Informing mental health policies and services in the EMR:cost-effective deployment of human resources to deliver integrated community-based care

For EMR countries to deliver the expectations of the Global Mental Health Action Plan 2013-2020 and the ongoing move towards universal health coverage, all health and social care providers need to innovate and transform their services to provide evidence-based health care that is accessible, cost-effective and with the best patient outcomes. For the primary and community workforce, this includes general medical practitioners, practice and community nurses, community social workers, housing officers, lay health workers, nongovernmental organizations and civil society, including community spiritual leaders/healers. This paper brings together the current best evidence to support transformation and discusses key approaches to achieve this, including skill mix and/or task shifting and integrated care. The important factors that need to be in place to support skill mix/task shifting and good integrated care are outlined with reference to EMR countries

Pour que les pays de la Région de la Méditerranée orientale puissent répondre aux attentes créées par le Plan d'action mondial sur la santé mentale 2013-2020 et pour faciliter le mouvement continu vers la couverture sanitaire universelle, tous les acteurs de la prestation de soins socio-sanitaires doivent faire preuve d'innovation et transformer leurs services afin de fournir des soins de santé fondés sur des bases factuelles qui soient accessibles, d'un bon rapport coût-efficacité et procurent les meilleurs résultats pour les patients. Pour ce qui est des personnels aux niveaux primaires et communautaires, ceci concerne les médecins généralistes, les infirmières praticiennes, les infirmières communautaires, les travailleurs sociaux communautaires, les responsables des logements sociaux,les travailleurs de la santé non professionnels, les membres des organisations non gouvernementales et de la société civile, y compris les leaders et les guérisseurs spirituels communautaires.Le présent article rassemble les meilleures bases factuelles actuellement disponibles à l'appui de cette transformation et examine les approches principales à cet égard, y compris l'éventail des compétences et/ou la délégation des tâches et les soins intégrés.Les facteurs importants qui doivent être en place à l'appui de l'éventail des compétences/la délégation des tâches et de bons soins intégrés sont présentés dans le contexte des pays de la Région de la Méditerranée orientale

Scale up services for mental disorders: a call for action.

We call for the global health community, governments, donors, multilateral agencies, and other mental health stakeholders, such as professional bodies and consumer groups, to scale up the coverage of services for mental disorders in all countries, but especially in low-income and middle-income countries. We argue that a basic, evidence-based package of services for core mental disorders should be scaled up, and that protection of the human rights of people with mental disorders and their families should be strengthened. Three questions are critical to the scaling-up process. What resources are needed? How can progress towards these goals be monitored? What should be the priorities for mental health research? To address these questions, we first estimated that the amount needed to provide services on the necessary scale would be US$2 per person per year in low-income countries and $3-4 in lower middle-income countries, which is modest compared with the requirements for scaling-up of services for other major contributors to the global burden of disease. Second, we identified a series of core and secondary indicators to track the progress that countries make toward achievement of mental health goals; many of these indicators are already routinely monitored in many countries. Third, we did a priority-setting exercise to identify gaps in the evidence base in global mental health for four categories of mental disorders. We show that funding should be given to research that develops and assesses interventions that can be delivered by people who are not mental health professionals, and that assesses how health systems can scale up such interventions across all routine-care settings. We discuss strategies to overcome the five main barriers to scaling-up of services for mental disorders; one major strategy will be sustained advocacy by diverse stakeholders, especially to target multilateral agencies, donors, and governments. This Series has provided the evidence for advocacy. Now we need political will and solidarity, above all from the global health community, to translate this evidence into action. The time to act is now.

Cost-effectiveness of different clinical interventions for reducing the burden of schizophrenia in Spain.

OBJECTIVE: To estimate the cost-effectiveness of interventions for reducing the burden of schizophrenia in Spain. METHOD: The study examined the cost-effectiveness of seven different types of clinical interventions at the level of Spanish population: i) current situation; ii) older antipsychotics alone; iii) new antipsychotics alone (risperidone); iv) older antipsychotics plus psychosocial treatment; v) new antipsychotics plus psychosocial treatment; vi) older antipsychotics plus case management and psychosocial treatment; vii) new antipsychotics plus case management and psychosocial treatment. RESULTS: Interventions based on the combination of haloperidol with psychosocial treatment or psychosocial treatment plus case management proved to be the most efficient strategies. CONCLUSION: The relatively modest additional cost of concurrent psychosocial treatment has significant health gains, thereby making such a combined strategy for schizophrenia more cost-effective than pharmacology alone.

[Use of quality of life measures in mental health economics and care planning]. / Medida de la calidad de vida en el análisis económico de la atención a la salud mental.

Quality of life measurement is a key element in health economics and healthcare planning, particularly in chronic diseases associated to high morbidity and disability (i.e., mental disorders). This paper provides a critical review on the theoretical background of utility, on the methods for developing measures based on health preferences or values, and the composite indexes derived from them (DALY and QALY). Then the practical use in mental health is revised both in burden of disease studies and cost-utility analysis. There is an important requirement on the part of mental health researchers and policy makers alike to pay close attention to the underlying methods and construction of utility-based estimates of health outcome.

Community outreach for untreated schizophrenia in rural India: a follow-up study of symptoms, disability, family burden and costs.

BACKGROUND: In resource-poor countries, there remains an alarming treatment gap for people with schizophrenia, particularly those living in rural areas. Decentralization of mental health services, including community-based outreach programmes, represents one obvious strategy for bringing appropriate care to these communities. This study set out to assess the costs and effects of such a programme in rural Karnataka in India. METHOD: Eight rural communities were visited by an outreach team, who identified cases of drug-naive or currently untreated schizophrenia. Recruited cases were provided with appropriate psychotropic medication and psychosocial support, and after obtaining informed consent were assessed every 3 months over one and a half years on symptomatology, disability, family burden, resource use and costs. A repeated-measures analysis was carried out to test for significant change in these outcome measures over this period. RESULTS: A total of 100 cases of untreated schizophrenia were recruited, of whom 28% had never received antipsychotic medication and the remaining 72% had not been on medication for the past 6 months. Summary scores for psychotic symptoms, disability and family burden were all reduced significantly, with particular improvement observed at the first follow-up assessment. Increases in treatment and community outreach costs over the follow-up period were accompanied by reductions in the costs of informal-care sector visits and family care-giving time. CONCLUSIONS: Efforts to organize community-based care such as outreach services for people with schizophrenia living in more remote areas of resource-constrained countries can bring substantial benefits to patients and families alike.

Economic implications of shared care arrangements. A primary care based study of patients in an inner city sample.

BACKGROUND: Providing care for people with serious and enduring mental health problems has been prioritised in a number of countries. It has been recognised that good liaison between primary and secondary care services is required for care to be effective. However, little is known about the resource implications of different levels of 'shared care'. The aim of this study is to compare service use and costs of different levels of shared care between primary and secondary care services. METHOD: Service use data were collected at baseline and one year later for participants with severe mental illness and costs were calculated. Levels of shared care were categorised into low, medium and high tertiles. Comparisons were made between the groups using multivariate analysis to control for participant characteristics. RESULTS: Participants receiving a low level of shared care used residential care less and were less likely to have contacts with a psychiatrist or social worker than those receiving medium or high levels of shared care. Mean costs for a low level of shared care were significantly lower than for a medium level (a difference of pound 2606, 90% CI pound 452 to pound 4923), but not significantly lower than for a high level of shared care (difference of pound 1867, 90% CI- pound 287 to pound 3903). CONCLUSION: Different levels of shared care are associated with different patterns of service use, with greater resource consumption associated with a medium level of shared care. Further work is required to investigate the causal links between integrated care and service use and costs.

Health services research into postnatal depression: results from a preliminary cross-cultural study.

BACKGROUND: Little is known about the availability and uptake of health and welfare services by women with postnatal depression in different countries. AIMS: Within the context of a cross-cultural research study, to develop and test methods for undertaking quantitative health services research in postnatal depression. METHOD: Interviews with service planners and the collation of key health indicators were used to obtain a profile of service availability and provision. A service use questionnaire was developed and administered to a pilot sample in a number of European study centres. RESULTS: Marked differences in service access and use were observed between the centres, including postnatal nursing care and contacts with primary care services. Rates of use of specialist services were generally low. Common barriers to access to care included perceived service quality and responsiveness. On the basis of the pilot work, a postnatal depression version of the Service Receipt Inventory was revised and finalised. CONCLUSIONS: This preliminary study demonstrated the methodological feasibility of describing and quantifying service use, highlighted the varied and often limited use of care in this population, and indicated the need for an improved understanding of the resource needs and implications of postnatal depression.

Global "burden of disease"-study for psychiatric disorders.

The Global Burden of Disease (GBD) study was conducted to provide a set of summary health measures that would be comprehensive and make available information on disease and injury, including non-fatal health outcomes. The main objective of the GBD approach was to inform global priority setting for health research and to influence international health policy and planning. One of the summary measures used was the Disability Adjusted Life Year (DALY). DALYs are a common metric for fatal and non-fatal health outcomes and are based on years of life lost because of premature death (YLL) and years of life lived with disability (YLD). Thus DALYs = YLL + YLD or Burden = Mortality + Disability. Therefore, a DALY is one lost year of healthy life. The DALY methodology provides a way to link information on disease burden to cost-effectiveness analysis. This feature would assist comparative assessments. The WHO plans to refine this framework for assessing the outcomes of interventions and their related costs.

Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy.

BACKGROUND: There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue. AIM: To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue. DESIGN OF STUDY: A randomised controlled trial incorporating a cost-consequences analysis. SETTING: One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months. METHOD: An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale. RESULTS: Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score). CONCLUSIONS: Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.

The London Depression Intervention Trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs.

BACKGROUND: Relapse of depression is associated with a criticising attitude of the patient's partner. AIMS: To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner. METHOD: A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner. RESULTS: Drop-outs were 56.8% [corrected] from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments. CONCLUSIONS: For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.

Expenditure on mental health care by English health authorities: a potential cause of inequity.

BACKGROUND: The York resource allocation formula includes a calculation of the amount needed to purchase mental health services equitably in each health authority in England. However, the amount which is actually spent on services is at the discretion of the authority. AIMS: To compare expenditure on mental health services with allocation, and test the hypothesis that differences between them are to the disadvantage of services in deprived areas. METHOD: A comparison of routine expenditure and allocation data, and linear regression modelling of the ratio of expenditure to allocation. RESULTS: The ratio of expenditure to allocation varies widely. Relative underspending occurs more frequently in deprived areas, although not in the four inner-London health authorities. CONCLUSIONS: The intentions of the York formula are not achieved in practice. The implications of the formula for mental health should be made explicit to health authorities, and shortfalls in mental health expenditure relative to allocation should be justified at a local level.

Integration of mental health care into primary care. Demonstration cost-outcome study in India and Pakistan.

BACKGROUND: Targeting resources on cost-effective care strategies is important for the global mental health burden. AIMS: To demonstrate cost-outcome methods in the evaluation of mental health care programmes in low-income countries. METHOD: Four rural populations were screened for psychiatric morbidity. Individuals with a diagnosed common mental disorder were invited to seek treatment, and assessed prospectively on symptoms, disability, quality of life and resource use. RESULTS: Between 12% and 39% of the four screened populations had a diagnosable common mental disorder. In three of the four localities there were improvements over time in symptoms, disability and quality of life, while total economic costs were reduced. CONCLUSION: Economic analysis of mental health care in low-income countries is feasible and practicable. Our assessment of the cost-effectiveness of integrating mental health into primary care was confounded by the naturalistic study design and the low proportion of subjects using government primary health care services.

Client Socio-Demographic and Service Receipt Inventory--European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs.

BACKGROUND: Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required. AIMS: To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care. METHOD: Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods. RESULTS: Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory--European Version (CSSRI-EU). This was subsequently administered to 404 people with schizophrenia across five countries. CONCLUSION: The CSSRI-EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.