Costs and benefits of scaling psychosocial interventions during the perinatal period in England: A simulation modelling study.

BACKGROUND: Globally, guidance recommends the integration of mental health into maternal and child healthcare to address common maternal mental health problems during the perinatal period. However, implementing this in the real-world requires substantial resource allocations. OBJECTIVE: The aim of this study was to estimate the likely costs and consequences linked to scaling the delivery of treatment (in the form of psychosocial interventions) during the perinatal period. DESIGN: Simulation modelling. SETTING(S): England. METHODS: Costs and consequences were modelled for three scenarios of assumed provision of services, whereby one referred to the projected provision under current government plans, with no additional scaling up of treatment. The other two scenarios referred to additional scaling of treatment: in one scenario, this referred to the provision of treatment by midwives and health visitors trained in the routine enquiry about mental health and delivery of psychosocial interventions; in the other scenario this referred to an expanded provision by primary mental health services. For each scenario and in yearly intervals (covering a ten-year period, 2015 to 2024), unit cots and outcomes were assigned to the activities women were assumed to receive (routine enquiry, assessment, treatment, care coordination). All costs were in 2020 pounds sterling. Data sources for the modelling included: published findings from randomised controlled trials; national unit cost source; national statistics; and expert consultation. RESULTS: If the projected treatment gap was to be addressed, an estimated additional 111,154 (50,031) women would be accessing treatment in 2015 (2024). Estimated total costs (including cost offsets) in the scenario of projected provision under current government plans would be £73.5 million in 2015 and £95.2 million in 2024, whilst quality-adjusted life years gained would be 901 and 928 respectively. Addressing the treatment gap through provision by trained midwives and health visitors could mean additional costs of £7.3 million in 2015 but lower costs of £18.4 million in 2024. The additional quality-adjusted life years gained are estimated at 2096 in 2015 and 1418 in 2024. A scenario in which the treatment gap would be met by primary mental health services was likely to be more costly and delivered less health gains. CONCLUSIONS: Findings from this modelling study suggest that scaling the integration of mental health care into routinely delivered care for women during the perinatal period might be economically viable. REGISTRATION: N/A. TWEETABLE ABSTRACT: Integrating mental health into maternal and child healthcare might generate economic benefits new study by @a_annettemaria and @knappem @CPEC_LSE finds #increasing access to treatment for women with perinatal mental health problems.

Economic costs of perinatal depression and anxiety in a lower middle income country: Pakistan.

BACKGROUND: Women's mental health during the perinatal period is a major public health problem in Pakistan. Many challenges and competing priorities prevent progress to address the large treatment gap. Aim To quantify the long-term impacts of untreated perinatal depression and anxiety in economic terms, thus highlighting its overall burden based on country-specific evidence. METHODS: Cost estimates were generated for a hypothetical cohort of women giving birth in 2017, and their children. Women and children experiencing adverse events linked to perinatal mental health problems were modelled over 40 years. Costs assigned to adverse events included were those linked to losses in quantity and quality-of-life, productivity, and healthcare-related expenditure. Present values were derived using a discount rate of 3 %. Data were taken from published cohort studies, as well as from sources of population, economic and health indicators. RESULTS: The total costs were $16.5 billion for the cohort and $2680 per woman giving birth. The by far largest proportion referred to quality-of-life losses ($15.8 billion). Productivity losses and out-of-pocket expenditure made up only a small proportion of the costs, due to low wages and market prices. When the costs of maternal suicide were included, total costs increased to $16.6 billion. LIMITATIONS: Important evidence gaps prevented the inclusion of all cost consequences linked to perinatal mental health problems. CONCLUSIONS: Total national costs are much higher compared with those in other, higher middle-income countries, reflecting the excessive disease burden. This study is an important first step to inform resource allocations.

Exploring the return-on-investment for scaling screening and psychosocial treatment for women with common perinatal mental health problems in Malawi: Developing a cost-benefit-calculator tool.

This study sought to develop a user-friendly decision-making tool to explore country-specific estimates for costs and economic consequences of different options for scaling screening and psychosocial interventions for women with common perinatal mental health problems in Malawi. We developed a simple simulation model using a structure and parameter estimates that were established iteratively with experts, based on published trials, international databases and resources, statistical data, best practice guidance and intervention manuals. The model projects annual costs and returns to investment from 2022 to 2026. The study perspective is societal, including health expenditure and productivity losses. Outcomes in the form of health-related quality of life are measured in Disability Adjusted Life Years, which were converted into monetary values. Economic consequences include those that occur in the year in which the intervention takes place. Results suggest that the net benefit is relatively small at the beginning but increases over time as learning effects lead to a higher number of women being identified and receiving (cost­)effective treatment. For a scenario in which screening is first provided by health professionals (such as midwives) and a second screening and the intervention are provided by trained and supervised volunteers to equal proportions in group and individual sessions, as well as in clinic versus community setting, total costs in 2022 amount to US$ 0.66 million and health benefits to US$ 0.36 million. Costs increase to US$ 1.03 million and health benefits to US$ 0.93 million in 2026. Net benefits increase from US$ 35,000 in 2022 to US$ 0.52 million in 2026, and return-on-investment ratios from 1.05 to 1.45. Results from sensitivity analysis suggest that positive net benefit results are highly sensitive to an increase in staff salaries. This study demonstrates the feasibility of developing an economic decision-making tool that can be used by local policy makers and influencers to inform investments in maternal mental health.

Co-assessment of biomass and soil organic carbon stocks in a future reservoir area located in Southeast Asia.

An assessment of the organic carbon stock present in living or dead vegetation and in the soil on the 450 km2 of the future Nam Theun 2 hydroelectric reservoir in Lao People's Democratic Republic was made. Nine land cover types were defined on the studied area: dense, medium, light, degraded, and riparian forests; agricultural soil; swamps; water; and others (roads, construction sites, and so on). Their geographical distribution was assessed by remote sensing using two 2008 SPOT 5 images. The area is mainly covered by dense and light forests (59%), while agricultural soil and swamps account for 11% and 2%, respectively. For each of these cover types, except water, organic carbon density was measured in the five pools defined by the Intergovernmental Panel on Climate Change: aboveground biomass, litter, deadwood, belowground biomass, and soil organic carbon. The area-weighted mean carbon densities for these pools were estimated at 45.4, 2.0, 2.2, 3.4, and 62.2 tC/ha, respectively, i.e., a total of about 115±15 tC/ha for a soil thickness of 30 cm, corresponding to a total flooded organic carbon stock of 5.1±0.7 MtC. This value is much lower than the carbon density for some South American reservoirs for example where total organic carbon stocks range from 251 to 326 tC/ha. It can be mainly explained by (1) the higher biomass density of South American tropical primary rainforest than of forests in this study and (2) the high proportion of areas with low carbon density, such as agricultural or slash-and-burn zones, in the studied area.

British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017.

Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.

Visual function and patient experience after bilateral implantation of toric intraocular lenses.

PURPOSE: To evaluate the efficacy, stability, predictability, and patient-reported outcomes of bilateral toric intraocular lens (IOL) implantation in cases of cataract with preexisting astigmatism. SETTING: Fourteen universities, hospitals, or private practices, Canada. METHODS: Patients with cataracts and corneal astigmatism from 1.00 to 2.50 diopters (D) were included in a prospective study of bilateral AcrySof toric IOL implantation. Binocular uncorrected distance visual acuity (UDVA), manifest refraction, and IOL rotational stability were assessed 1 day and 1, 3, and 6 months postoperatively. Patients completed a questionnaire that assessed spectacle independence, visual disturbances, and satisfaction with vision (1 = completely unsatisfied; 10 = completely satisfied) preoperatively and 3 and 6 months postoperatively. RESULTS: The study included 117 patients (234 eyes). The binocular UDVA was 20/40 or better in 99% of patients and 20/20 or better in 63% of patients. The mean residual refractive astigmatism was 0.4 D +/- 0.4 (SD). The spherical equivalent was within +/-0.5 D of target in 77% of eyes. At last observation, IOL alignment was within +/-5 degrees in 91% of eyes and within +/-10 degrees in 99%. Sixty-nine percent of patients reported never using distance spectacles. The frequency and severity of halos and glare were significantly reduced from preoperatively to postoperatively. Satisfaction with vision was rated 7 or higher by 94% of patients. CONCLUSION: Bilateral implantation of toric IOLs yielded excellent and stable visual outcomes that patients rated as highly satisfactory. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

A national survey of psychiatric mother and baby units in England.

OBJECTIVE: This study identified all mother and baby units (MBUs) (defined in this study as inpatient psychiatric units where mothers and babies could be admitted that had at least four beds and were separate from other wards) in England and established the operating procedures of MBUs and the clinical characteristics of their inpatients. METHODS: A national cross-sectional survey of alternatives to standard acute inpatient care was conducted in England in 2005. Multiple methods, including telephone inquiries and consultation with relevant experts, were used to identify services. All MBUs identified were contacted and invited to participate in an interview with a researcher. RESULTS: Twenty-six facilities that accommodated mothers and babies were identified. Thirteen were excluded from the final analysis, because they did not fulfill the study's operationalized criteria for a MBU. Twelve of the 13 facilities with an MBU agreed to participate. Nationally, MBUs had fewer beds than needed and marked geographical variation. Ward size ranged between four and 12 beds, average occupancy was 78%, and the mean length of stay was 56 days. On admission, 45% of women were experiencing psychotic symptoms, and 18% were detained compulsorily. A significant proportion of MBUs did not offer psychological treatments (42%). CONCLUSIONS: The provision of MBUs in England is inequitable, and the clinical and operating characteristics of these services are highly variable. However, this study demonstrated that MBUs are serving women with severe mental illness. If services are to expand and develop in the future, more qualitative and quantitative studies are required to identify the most effective components of MBUs and examine for whom the MBUs are most helpful.