Demonstrating the economic burden of mental illness and the potential cost benefits of mental health promotion and prevention
I joined PSSRU at LSE to work on a European Union project on the economic impact for informal carers of looking after a family member with dementia. My colleague Martin Knapp had written a book on the economics of mental health in the early 1990s, and there had been some work on the impact of dementia on carers, but this field was still relatively under-developed at that time. It was only in the mid to late 1990s in England when people finally started to recognise the role and contribution made by family carers, often at great cost to their own health and finances.
The project (jointly with LSE Health and Social Care) brought three countries – England, Italy and Sweden – to look at the impact of dementia on carers and the value of their time. It was one of the first comparative cross-country pieces of work in this area. One of the things I learnt – which now seems like stating the obvious – was how the burden on carers differs greatly across countries because of the varying services and support available to families. For instance, in Italy there was very little perceived support for families, whereas in Sweden there was much greater acceptance of the role of the social support system and families were more willing and felt less guilty about sharing caring responsibilities with formal services. England was a mixed picture – some people had good support, others were stoic about the caring experience. I remember one man: he had fought in the Second World War, only had one leg and the impact of caring full-time for his wife was tough on him physically as well as emotionally, but there was no way he was going to stop caring for her whatever the situation. The caring bond is a powerful bond.
In all I spent around five years working on the economics of aspects of dementia (and I have returned to the topic from time to time since). Our work helped quantify the economic contribution of informal care and flagged up to service providers and governments how much we should value carers. We focused on looking at the amount of time people spent caring in order to circumvent the general scepticism about estimates of monetary value. That’s why to this day I know without thinking that there are 168 hours in the week, because this was often the amount of time people were providing care; it really is a 24/7 job.
In 2002, I helped establish the Mental Health Economics European Network (MHEEN), which nowadays brings together researchers from 32 countries to raise awareness of the economic costs of poor mental health, highlight the gaps in our knowledge across countries, develop analysis methods, and look at under-researched areas such as the impact of mental illness on employment and the workplace. This work provided an opportunity to become involved advising the European Commission on its mental health policy and in helping to develop the Commission’s Green Paper in 2005 on mental health promotion in Europe. That led to continuous involvement of myself, colleagues in PSSRU LSE and other European research centres in the policy meetings and working groups that contributed to the 2008 European Pact for Mental Health and Well-being. The Pact called for action in five areas of mental health: depression and suicide; youth and education; workplace settings; older people; and combatting stigma and social exclusion. I wrote background papers for the development of the Pact and to support its implementation in the years after publication. I remember writing a document for the German Ministries of Health and Labour on the value of mental health in the workplace that was presented at a high level conference in Berlin in 2011 to endorse and support the issue of mental health in the workplace. I continue to do this type of work, for example on the relationship between poor mental health and physical health costs.
Over the years, I’ve been involved in mental health economics work at different levels: European Union projects, World Health Organization initiatives and UK/England policy level. For example, some of our work was influential on the WHO Mental Health Declaration for Europe in 2005 in Helsinki, which set out priorities and actions on mental health in the WHO Europe region.
In 2011 in England, Martin Knapp, I and many colleagues at PSSRU LSE carried out a wide-ranging analysis for the Department of Health on the economics of mental health promotion and prevention initiatives. This work looked at the cost-effectiveness of more than a dozen interventions, from post-natal depression and anti-violent projects in schools, to workplace screening and suicide prevention. The study was commissioned by the Labour government and followed through by the Coalition. It has had a big impact in England, being heavily cited in the subsequent national Mental Health Strategy in 2011. The results have been used for various specific strategies such as suicide prevention and early intervention to reduce the risk of diabetes for people with depression. Some of the interventions we looked at on promoting the mental health of children have been influential in schools and pre-school care. I think we have helped to put more emphasis on actions that are genuinely about prevention, particularly where it is possible to identify cost savings for the Department of Health, for example interventions with mental health service users that reduce the risk of cardio-vascular disease. (If an intervention leads to cost savings for another department then there is the budgeting challenge of the health sector making the investment but other sectors reaping the cost benefit.) At a local level, some of the work now being carried out by local authorities and clinical commissioning groups has a strong focus on actions to prevent and promote better mental health and well-being. In such cases, the argument often used in favour of a programme is economic. There has also been interest in our findings at the European level and in the European parliament.
Another area that is not government related but where we are continuing to do a lot of work is in workplace mental health promotion. Companies can see the benefit of investment and interventions that help reduce the likelihood that people take time or work or reduce staff turnover, especially the larger firms with the resources to run these programmes. There has been recognition that early action is beneficial; there is a business case as well as a health case.
Overall, PSSRU has helped raise awareness in other countries of the importance of the economics of mental health as a discipline. When we started our mental health economics work we struggled in many countries to find people who had done research in this area. The situation has certainly now changed and I’m happy to say a lot of people we worked with back then are still active in the field and have built up strong mental health research centres in Europe. We have been part of a process that has opened up capacity to look at these issues in Europe as well as in the UK.
Interviewed by Teresa Poole
David McDaid joined the LSE branch of PSSRU in 1997 and since then his research activities have focused on mental health policy, with a particular interest in the economic impact of mental health. David splits his time between his role as Senior Research Fellow at PSSRU and similar posts at LSE Health and Social Care and the European Observatory on Health Systems and Policies. Here he explains how PSSRU has helped to raise the profile in England and across Europe of the economic impact of mental illness and the potential financial benefits of promotion and prevention interventions.