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ECONOMIC evaluations are increasingly used in health care to ensure resources are allocated towards best practice, cost-effective services.
All medicines considered for listing on the Pharmaceutical Benefits Scheme (PBS), for example, are subject to a rigorous assessment of their cost-effectiveness to identify value for money. An affordable cost-effectiveness ratio is a key piece of evidence used in recommendations to list or not.
In order to inform the development of a strategic plan, the Mental Health Commission of NSW, an independent body which helps drive reform to benefit people who experience mental illness and their families and carers, commissioned a review of the evidence on the costs and benefits of mental health interventions.
The review found that Australia operates in an information vacuum when it comes to developing cost-effective mental health programs and that much more research is needed.
Over the past decade, only 17 studies in Australia had been conducted into the costs and benefits of mental health interventions. Pharmacological treatments, such as dexamphetamine and methylphenidate interventions to treat childhood attention deficit hyperactivity disorder, were the most common type of intervention studied followed by psychosocial interventions.
The majority of these studies were conducted from a health sector perspective and were completed using secondary data (ie, data reported in the literature as opposed to primary data collected alongside a clinical trial) to model potential cost-effectiveness.
The Australian evidence relies heavily on work done using the Assessing Cost-Effectiveness (ACE) methods — ACE Mental Health and ACE-Prevention. These evaluations were research driven, policy oriented with costs and outcomes modelled on realistic expectations of how interventions would be implemented under routine health service conditions in Australia.
Although the ACE methods are world-class, the data underpinning the analysis is far from ideal, which impacts on the potential policy relevance of the results.
We know there are cost-effective treatment options that are currently underused in Australia — cognitive behaviour therapy for depression and anxiety, family interventions for schizophrenia, screening children for symptoms of depression with subsequent provision of psychological therapy, parenting intervention for childhood anxiety prevention, screening for minor depression in adults for the prevention of depression.
We also know that one size doesn’t fit all. Not all patients respond to any one treatment and patients (and their doctors) have their own preferences for treatment, which will inevitably impact on its effectiveness.
The return on our mental health investment over the past decade has not been matched with the evidence policymakers require to improve decision making. The cost of operating the mental health service system in Australia is in excess of $5 billion each year — equivalent to 7.5% of all government health spending.
Another $4.63 billion is spent providing additional support services for people with mental illness, including income support, housing assistance, community and domiciliary care, employment and training opportunities.
Australia is not alone in operating in an information vacuum. The WHO observed that no country to date has been able to clearly link mental health strategic policy or investment decisions to a credible, consistent and evidence-based assessment of what interventions actually work best and at what cost.
We need to do more and to think more broadly than the health services sector.
Priorities should include more effective strategies to detect and treat children susceptible to a mental disorder and employment programs to better re-engage those not in the labour force due to mental illness or even those in employment who are under mental stress. The opportunity cost of lost productivity due to mental health conditions far exceeds the cost of medical treatment.
We need to better evaluate the best buys by incorporating economics into health services research, just as the Australian Government does with PBS-listed medicines.
We also need to tap into better linked data to investigate patterns and/or trends in mental health disorders and the subsequent impact of policy changes. Further, we need to improve collaboration across sectors.
Mental health is not just a health problem solved in clinical practice — it is a complex multisectoral problem that requires input from housing, employment, education and justice.
Professor Christopher Doran is a health research economist at the Hunter Medical Research Institute, NSW, and author of the review commissioned by the NSW Mental Health Commission.
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This is an excellent piece however mental health programs should not be held to a higher standard of proof to justify funding than in the rest of health care. There is wastage everywhere in health particularly in the final months of life in older people with chronic medical diseases, and, while there other considerations, this is demonstrably and highly non-cost-effective. The other major issue Prof Doran doesn’t highlight but I am sure would concede is that mental health is proportinately underfunded (7.5% only of the health expenditure or even less on some figures – while it is at least 13% of the disease burden and 35% in 15 – 44 year olds in the prime of life). However this is no excuse for wasting money on ineffective treatments. I am just arguing that the whole of health care should be more exposed to this principle (it is not the only consideration though – values are also critical) and that it not be used to actually reduce the mental healtjh spend, which is a risk. We need the opposite – a great increase in scale and scope – but based very much on best buys, as we have argued based partly on our own health econmic studies. Patrick McGorry, Orygen Youth Health Research Centre & University of Melbourne.