ABSTRACTS
November 11 Seminar on Mental Health
th
Cost-effectiveness of interventions for reducing the
burden of neuropsychiatric disorders
Dan Chisholm 1,2 and Harvey Whiteford 3
on behalf of Disease Control Priorities II mental health chapter authors and
WHO-CHOICE
1
Department of Health System Financing, Expenditure and Resource Allocation, WHO Geneva
Department of Mental Health and Substance Abuse, WHO Geneva
2
3
Queensland Centre for Mental Health Research, The University of Queensland, Australia
Mental disorders, including substance abuse, affect cognition, emotion and
behavioral control, and substantially interfere both with the ability of children to learn
and with the ability of adults to function in their families, at work, and in their broader
society. In 2001 it was estimated they contributed 12% of the world disease burden
and 31% of all years lived with disability.
This paper estimates the burden attributed to six major neuropsychiatric conditions
(schizophrenia, bipolar disorder, depression, panic disorder, epilepsy and hazardous
alcohol use) that could be averted with the introduction of proven, efficacious
treatments and the expected cost and cost-effectiveness of such interventions. An
analysis at the level of six low- and middle-income geographical World Bank regions
is provided. Using the criteria of the WHO Commission for Macroeconomics and
Health, the results indicate that interventions for common mental disorders
(depression and panic disorder), epilepsy and heavy alcohol use can be considered
very cost-effective (each DALY averted costs less than one year of average per
capita income). An application of this work in defining a mental health care package
for Nigeria is presented.
Efficiency is only one of many criteria that shape the allocation of resources.
Interventions that successfully reduce disability in schizophrenia, whilst relatively
costly, can be expected to have significant other consequences including reduced
family burden and also meet the objective of protecting particularly vulnerable
members of the population.
Six Country Costs and Effectiveness Study of Mental Health Interventions for
Conflict Affected Populations
Joop de Jong, Director, TPO
The current lack of mental health economic evaluative studies in low-income
countries is a significant stumbling block to the investment of resources in mental
health by governments and international agencies. Research has indicated that
formal psychological treatment is generally effective in the West, but the use of
western style treatment in low-income countries is still controversial. Moreover, the
potential effectiveness of therapy for coping with mass atrocities is largely unknown.
This presentation consists of two parts. The first part presents several challenges
and core characteristics of a public mental health approach to psychosocial and
mental health problems in post-conflict areas. The second part presents data on a
six-country cost-effectiveness study that was co-funded by the World bank. The
study used an observational naturalistic design and this presentation will focus on
psychosocial and mental health interventions in Cambodia, Uganda and Burundi. For
each country, data will show whether patients improve in terms of distress,
psychiatric symptomatology, and functioning/ disability after receiving individual
counseling, psychotropics or group therapy.
This study is relevant for community mental health care programs for several
reasons. First, in view of the scarcity of mental health professionals in low and
middle income countries and in post-conflict areas, it is noteworthy that local trained
counselors are able to provide services that are helpful and cost-effective. Second,
these findings are important from a public health perspective because there is
ongoing disparity in service provision around the globe despite ongoing claims for
equity. Third, this study shows that it is feasible to develop community services in
peripheral areas affected by conflict and to do outcome research in rural areas in
low-income countries.
Joop de Jong MD, PhD is Professor of Mental Health and Culture at the Vrije
Universiteit in Amsterdam and adjunct Professor of Psychiatry at Boston University.
He is the founder and director of the Transcultural Psychosocial Organization (TPO),
a relief organization specialized in mental health and psychosocial care of
traumatized, (post-) conflict populations in Algeria, Burundi, Congo, Ethiopia, Eritrea,
Namibia, Mozambique, Cambodia, India, Sri Lanka, Gaza, Nepal, Indonesia, Sudan,
Surinam, Uganda, and Afghanistan.
Costs and Cost-effectiveness Analysis of mental health and psychosocial
interventions in Burundi
Joop de Jong, Director, TPO
A history of cyclic tribal wars between Hutu and Tutsi factions in Burundi created
hundreds of thousands of refugees and saw the death of 300,000 people as a result
of low intensity civil warfare. This paper describes a treatment outcome study on
mental health interventions provided by TPO Burundi. The study uses a naturalistic
effectiveness design with high external validity enabling the assessment of the public
mental health benefits of the interventions. The aims of this paper are (1) to assess
the effectiveness of individual psychosocial and psychiatric care and (2) to estimate
the costs and financial benefits of these interventions. The overall hypothesis of this
research project, co-funded by the World Bank, is that mental health service delivery
results in improvement in terms of psychopathology and disability in comparison to a
control group.
Joop de Jong MD, PhD is Professor of Mental Health and Culture at the Vrije
Universiteit in Amsterdam and adjunct Professor of Psychiatry at Boston University.
He is the founder and director of the Transcultural Psychosocial Organization (TPO),
a relief organization specialized in mental health and psychosocial care of
traumatized, (post-) conflict populations in Algeria, Burundi, Congo, Ethiopia, Eritrea,
Namibia, Mozambique, Cambodia, India, Sri Lanka, Gaza, Nepal, Indonesia, Sudan,
Surinam, Uganda, and Afghanistan.
Measuring Mental Health in Post Conflict Societies:
An Assessment of the Bosnia and Herzegovina Experiment
Kinnon Scott, Senior Economist, DECRG, The World Bank.
Major depression is presently the fourth leading cause of the global burden of
disease and, within the next 20 years is projected to become the second leading
cause of disability. In post-conflict countries, work with refugees has highlighted the
negative effect of mass violence on mental health as well as the apparent, long-term
nature of the effect. The increased levels of depression, among other ailments, is
hypothesized to affect reconstruction and development activities. In an effort to
quantify the overall incidence of depression in a post-conflict country and to be able
to investigate the linkages among depression and socio-economic outcomes in the
country, a series of depression screening questions were added to a national Living
Standards Measurement Study Survey in Bosnia and Herzegovina in 2001. The
paper first describes the methodology used in measuring adult depression in the
context of a national, multi-topic household survey. It then provides an assessment
of the feasibility of such a data collection exercise both in terms of survey
methodology and clinical validation of the resulting data.
Kinnon Scott is a Senior Economist with the Development Economics Group of the
World Bank and has worked mainly in the Europe and Central Asia as well as the
Latin America and Carribean Regions.
Mental Health and Socio-Economic Outcomes in Burundi
Florence Baingana a, Andrew Dabalena, Menahem Prywesa, Essimi Menyeb,
Michael Rosholmc,
a The
World Bank, Washington DC, USA
Monetary Fund, Washington DC, USA
c Department of Economics, University of Aarhus, Denmark
b International
Abstract
Earlier studies demonstrated the linkage between conflict and poor mental health ,
as well as the linkage between poor mental health and dysfunction. However, there
have not been, to our knowledge, any population-wide studies of the linkages
between mental health and socio-economic outcomes in poor, conflict-affected
countries. This paper presents the analysis of data from a survey of 5,599
respondents aged 10 years and older conducted country-wide in Burundi over 199899.
We estimate statistically significant relationships between indicators of poor mental
health and several social and economic outcomes. Most importantly, a worsening of
mental health is associated with a decline in employment and with a decline in
school enrolment of the subject’s children. We find no relationship between mental
health and poverty, once adjustments are made for demographic and regional
influences.
We argue that poor mental health diminishes people’s participation in work and
investment in their children’s education through dysfunction resulting from psychiatric
trauma and depression. Economic theory holds that investment in human capital,
such as in education, will depend in part on expectations about the return on the
investment. Combining the psychological and economic theory with our statistical
findings suggests that poor mental health is one of the causes of low enrollment of
children in primary education.
These results suggest that mental health programs could be one of the means for
promoting participation in labor and increased investments in education.