Reducing the Burden of Mental Disorders

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Reducing the Burden of Mental Disorders

• Professor Gavin Andrews
• UNSW at St Vincents Hospital, Sydney,
• for
• Trimbos, Utrecht, January 2006

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The purpose of medicine is to reduce the burden
of disease

• First, to research the etiology and
• develop effective treatments
• develop prevention strategies
• Then, ensure service delivery accuracy
• Then, ensure coverage and adherence
• And finally use E-health to maximize all these
• The free market doesnt do this well
• See World Health Report 2000 Geneva, WHO.

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The WHO Five Step Method
The Burden of a Health Problem
100
Unavertable with existing interventions
Combined efficacy of intervention mix
Averted with current mix of interventions and
population coverage
Avertable with existing but non-cost-effective
interventions
Avertable with improved efficiency
0
100
Effective coverage in population
Source The WHO Ad Hoc Committee on Investing in
Health Research Development (1996)
http//www.who.int/tdr/publications/publications/p
df/investing_report/investing1.pdf
4
Bobadilla World Bank

• No county in the world can supply all the health
  care its citizens would like
• We have to prioritize/ration health care
• prioritize what is given, who gets it..

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SETTING PRIORITIES for the provision of insurance
funded health care is more than cost effectiveness

• Q1 Does the rule of rescue apply?
• If yes then do it if no ask
• Q2 Is there an effective treatment?
• If no, then primary care only if yes ask
• Q3 Is effective treatment affordable?
• If yes then treat if no ask
• Q4 Are there equity or other societal demands
  that justify an unaffordable treatment?
• If yes then treat If no then primary care only
• 
  
  Gray and
  Andrews

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Background SurveyHow many have which disorder?

• Principal complaint, last four weeks
• Anxiety Disorders 5.1
• Affective Disorders 2.8
• Substance Use Disorders 2.0
• Schizophrenia 0.3
• All other disorders 3.4
• Any current disorder 13.6
• Source National surveys of adult mental health
  1997

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Background How many adults have a mental
disorder?

• 22 adults meet criteria for a mental disorder in
  past year, 13 currently
• Affective disorder 7
• Anxiety disorder 6
• Substance use disorder 8
• Schizophrenia 0.3
• Other disorders 8
• National Mental Health Survey 1997

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The pathways to care are not optimal
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Background Best Buys 1997
Mental Disorder in the past 12 months
Source Australian National Survey of Mental
Health Wellbeing
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Best Buys Current Treatment
Coverage Effective Burden Efficiency coverage
averted /YLD Depressive
Disorders 60 34 15 20 000 Anxiety
Disorders 35 20 13 15 000 Alcohol
Disorders 11 6 2 98 000 Schizophrenia 100 100 13 1
96 000 Total 40 23 13 30 000 Total cost 1800
Million Upper level of affordability is
78,000/YLD
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Best Buys Optimal Treatment
Coverage Effective Burden Efficiency coverage
averted /YLD Depressive
Disorders 60 60 23 11 000 Anxiety
Disorders 35 35 20 9 000 Alcohol
Disorders 11 11 5 53 000 Schizophrenia 100 100 22
107 000 Total 40 40 20 18 000 Total cost 1600
Million NB upper limit of affordability is
78,000/YLD
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The WHO Five Step Method
The Burden of a Health Problem
100
60 unavertable
Efficacy of intervention mix
13
7
20
0
100
Effective coverage in population
Source The WHO Ad Hoc Committee on Investing in
Health Research Development (1996)
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Summary

• Currently, at 40 coverage, we avert an eighth of
  the burden of mental disorders
• Optimal treatment at 40 coverage would avert one
  fifth of the burden and be more cost-effective
• Optimal treatment at a hypothetical 100 coverage
  would avert only four tenths of the burden
• This is a serious conclusion

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Advice on spending more money EBM with targeted
coverage is our most equitable resource allocation

• Coverage YLDs Total
  Efficiency
• averted cost
• M /YLD
• Affective Disorders 70 27 500
  11,000
• Anxiety Disorders 70 34 700
  9,000
• Alcohol Disorders 50 12 300
  46,000
• Schizophrenia 100 22 700
  108,000
• Total 67
  28 2100M 16,000
• Marginal cost is 4000/YLD gained

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Tolkien II (2004/6)

• Moving from best guess of Tolkien I to best
  information using
• National Survey of Mental Health Cost
  effectiveness of treatment Clinical guidelines
  databases
• Reference groups of experts to determine who
  does what, how often

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Tolkien II 14 disorders
Dysthymia N Cost
Depression N Cost
Bipolar N Cost
Panic/Agoraphobia N Cost
GAD N Cost
Social Phobia N Cost
OCD N Cost
Schizophrenia N Cost
PTSD N Cost
Subs Dependence N Cost
Substance Abuse N Cost
Somatoform N Cost
Eating Disorder N Cost
Personality Disorder N Cost
Total N Cost
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General Method for Tolkien II

• Prepare synopsis of each disorder
• Recruit expert psychiatrists, GPs, clinical
  psychologists
• Ask, sensible money no object, what would good
  treatment entail?
• Convert their recommendations into clinical
  pathways and costs

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Social Phobia Schizophrenia

• Population burden about 30,000 YLDs.
• Social phobia Prevalence 1.4, Coverage 20,
  43,000 seek treatment
• Schizophrenia Prevalence 0.3, Coverage 100,
  41,000 in treatment

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Social Phobia clinical pathway
20 SSRIs for 8 mths, 4 GP visits
None or MILD N18499
100 5 GP visits self-help
70 still meet criteria at week 8
50 6 Clin Psy sessions
30 SSRIs 8mths 4 GPvisits self-help
10 still meet criteria at week 8
1 Psych visit to change meds 6 Clin Psy
MODERATE N 11059
70 10 Clin Psy sessions
10 SSRIs for 12 mths 4 GP visits
20 still meet criteria at week 14
N 43,071
10 8 more Clin Psy sessions
80 SSRIs for 12 mths 4 GP visits
50 10 Clin Psy sessions
10 SSRIs 4 GP visits
SEVERE N 9207
40 still meet criteria at week 14
50 Group CBT (Clin Psy)
30 Psych review 8 more Clin Psy
20 dont start meds
TREATMENT RESISTANT N 4,307
100 5 GP 2 Psych visits
100 10 Clin Psy sessions
50 stop drug tmt 50 change
20
Social Phobia in Australia N in treatment
43,000 GP visits 260,000 Psychiatrist visits
12,000 Clinical Psychologist visits
286,000 Mental Health Team visits 0 Inpatient
days 0 Drug days 5,437,000 Cost 27,000,000
or 600/yr each
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Schizophrenia is brain damage Experts view of
optimal treatment

• Community Mental Health Team is the central
  agent
• Early intervention
• Multi-targeted approach
• Medical treatment
• Patient and family education
• Social and vocational recovery
• Inpatient admissions
• Long-term support in community

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Schizophrenia clinical pathway
N41,197 In Australia
23
Schizophrenia clinical pathway
CONTINUOUSLY SYMPTOMATIC Medication N17,571
20 Depot Risperidone 20 Multiple Drugs 60
Clozapine
100 medication
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Schizophrenia Accommodation needs in 100,000
population?

• PEC beds LOS 2days ?
• Acute unit LOS 20 days 2
• Rehab unit LOS 200 days 7
• Community accommodation
• Staffed 17
• Visited 35
• We need to accommodate 1 in 4
• See www.commonground.org Rosanne Haggerty

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Schizophrenia in Australia N in treatment
41,000 GP visits 278,000 Psychiatrist visits
8,000 Clinical Psychologist visits
20,000 Mental Health Team visits
1,084,000 Inpatient rehab days 537,000 Long
term accommodation days 3,207,000 Drug days
14,282,000 Cost 670,000,000 or 16,300/yr each
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Tolkien II How the components fit
Dysthymia N Cost
Depression N 390,000 Cost 536M 484M
Bipolar N69,000 Cost110M 61M
Panic/Agoraphobia N67,500 Cost59M 81M
GAD N 140,000 Cost 153M 112M
Social Phobia N 43,000 Cost 27M 44M
OCD N7300 Cost15M NA
Schizophrenia N41,000 Cost 670M 740M
PTSD N130,000 Cost 185M 158M
Subs Dependence N Cost
Substance Abuse N Cost
Somatoform N Cost
Eating Disorders N Cost
Borderline PD N7,700 Cost34M NA
Total N Cost
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Tasks to be done 2005/6

• Is the model affordable it probably is?
• What do we add for crisis intervention?
• Do we have enough GPs, psychiatrists,
  psychologists, mental health team staff
• Enough acute and rehab beds, community
  accommodation, NGOs?
• What new skills and roles are needed
• Can we enhance prevention and self help
  strategies

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How do you ensure that clinicians do what they
know to do?

• Tell them
• Walk the talk
• Pay them
• Fine them
• And tell their patients

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CLIMATE is a doctor prescribed, patient education
system

• Runs on a computer over the internet
• Measures symptoms at each session
• Teaches by using an illustrated recovery story
• Gives homework to instruct about self care
• Checks that the homework has been done at the
  beginning of each session
• Allows doctors to monitor progress

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What conditions are included?

• Anxiety CBT for generalized anxiety disorder,
  panic/agoraphobia, social phobia
• Depression CBT for teenage girl, single
  woman, married woman, widow, married man
• health information for
• asthma (2 modules) diabetes (2 modules)
• breast cancer heart failure
• osteoarthritis incontinence

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Panic Confronting fears
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Pete Son Mending Fences
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Its working 140 practitioners since January

• Doctors buy books of 12 coupons for 96.
• Each coupon contains a unique password that
  allows a patient to log on to www.climate.tv and
  complete a module in the clinic, at home, at the
  library...
• Patient/doctor confidentiality is maintained
• Patients pay 10 per module (3-6 sessions). This
  covers practitioner costs.
• Practice nurse can instruct and supervise

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Prevention smoking, alcohol

• Add alcohol smoking slides

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PREVENTION CLIMATE schools www.climate.tv/school

• Prevention programs for alcohol, anxiety and
  depression exist Andrews and Wilkinson MJA 2003
• They all need staff
• CLIMATE schools is computerized to fit into the
  health and personal development curriculum of
  years 8 9
• Anxiety, depression and alcohol modules exist,
  are being trialed, ready 2006

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New slides prevention of alcohol abuse

• Add slides

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New slides prevention of anxiety and depression

• Add slides

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Conclusion how to reduce the burden

• We need to integrate our services
• We need to be able to use other staff
• We need no more acute beds, but more step down
  beds schizophrenia is chronic
• We need to increase coverage from 40 to 70
• We need to make use of self-help services
• We need to promote prevention strategies
• We dont need more moneyyet, yet, yet
• But we will - because change costs money

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Reducing the burden

• Andrews, G. 1991 Tolkien Report. June 13 1991.
• ISBN 0 646 16530 5.
• Andrews G et al. 2004. Utilising survey data to
  inform public policy. British Journal of
  Psychiatry,
• 184, 526-533
• www.crufad.org/research/bestbuys
• www.crufad.org/research/t2.pdf
• www.climate.tv
• www.climate.tv/school