Alison Andrew, Martin Knapp, Paul McCrone, Michael Parsonage, Marija Trachtenberg.

Effective Interventions in schizophrenia: the economic case. Discussion paper [or working paper, etc.]

Original citation: Andrew, Alison and Knapp, Martin and McCrone, Paul and Parsonage, Michael and Trachtenberg, Marija (2012) Effective Interventions in schizophrenia: the economic case. Personal Social Services Research Unit, London School of Economics and Political Science, London,UK This version available at: http://eprints.lse.ac.uk/47406 Originally available from Personal Social Services Research Centre Available in LSE Research Online: November 2012 © 2012 The Authors LSE has developed LSE Research Online so that users may access research output of the School. Copyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in LSE Research Online to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain. You may freely distribute the URL (http://eprints.lse.ac.uk) of the LSE Research Online website.

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EFFECTIVE INTERVENTIONS IN SCHIZOPHRENIATHE ECONOMIC CASE

A report prepared for the Schizophrenia Commission

November 2012

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THE AUTHORS FOREWORD

EXECUTIVE SUMMARY

CURRENT COSTS OF SCHIZOPHRENIA INPATIENTTIME DISRUPTED/LOSSOFEMPLOYMENT DISRUPTEDEDUCATION HOMELESSNESS PHYSICALHEALTHPROBLEMS SUBSTANCEMISUSE CONTACTWITHTHECRIMINALJUSTICESYSTEM FAMILYIMPACT

EVALUATING VARIOUS INTERVENTIONS EARLYINTERVENTION INDIVIDUALPLACEMENTANDSUPPORTSCHEMES FAMILYTHERAPY CRIMINALJUSTICESYSTEMDIVERSION PHYSICALHEALTH SUBSTANCEMISUSE HOMELESSNESS-TARGETEDINTERVENTIONS/SUPPORTEDHOUSING CRISISTEAMS PEER-SUPPORTWORKERS ADVANCEDTREATMENTDIRECTIVES COGNITIVEBEHAVIOURTHERAPY

CONCLUSIONS

REFERENCES

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AUTHORS Alison AndrewMartin KnappPaul McCroneMichael ParsonageMarija Trachtenberg

CONTENTS

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THE AUTHORS

AlisonAndrewisastudentofeconomicsattheUniversityofCambridge,withaspecialinterestinhealtheconomics.ShehaspreviouslyinternedattheWorldHealthOrganisationandisDirectorforPolicyatTheWilberforceSociety,theUK’sfirststudent-runthinktank.ShewasaResearchAssistantinPSSRUattheLondonSchoolofEconomicsin2012.

MartinKnappisProfessorofSocialPolicyandDirectorofthePersonalSocialServicesResearchUnit(PSSRU)attheLondonSchoolofEconomicsandPoliticalScience.HeisalsoProfessorofHealthEconomicsatKing’sCollegeLondon,basedintheInstituteofPsychiatry.HeisDirectoroftheNIHRSchoolforSocialCareResearch.

PaulMcCroneisProfessorofHealthEconomics,andDirectoroftheCentrefortheEconomicsofMentalandPhysicalHealth,attheInstituteofPsychiatry(King’sCollegeLondon).

MichaelParsonageisChiefEconomistandSeniorPolicyAdviserattheCentreforMentalHealthandalsoaVisitingSeniorFellowattheLondonSchoolofEconomicsandPoliticalScience.

MarijaTrachtenbergrecentlycompletedaMastersattheLondonSchoolofEconomicsspecializinginhealtheconomics.ShehasworkedforbothpublicandprivatesectorswiththeCentreforMentalHealthaswellasUnitedHealthGroup.

Alison Andrew

Martin Knapp

Paul McCrone

Michael Parsonage

Marija Trachtenberg

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FOREWORD

ThisreporthasbeenproducedtosupporttheworkoftheSchizophreniaCommissionduringitsyear-longinquiryintothecare,treatmentandoutcomesforpeoplewithschizophreniaandpsychosis.Thisillnessishighlydistressing,witha15-20yearmortalitygapcomparedtothegeneralpopulation.Thehumancostsareimmense,butsotooarethefinancialcosts.Forexample,thecostofschizophreniatoEnglishsocietyis£11.8billionperyear.

Bringingtheinformationtogetherforthisreporthasbeenchallenging.Althoughbuildingonresearchthatsomeofus(Michael,Paul,myself)haveundertakenoveraperiodofmanyyears,ithasbeenhugelyinfluencedbytheothertwoauthors:byMarija’sMScworkonpeersupportandparticularlybyAlison’s‘summerjob’atLSE,whenshesearchedenergetically,analysedexpertlyandsummarisedresultsclearlyacrossawidespanoftopics.

Itwillbeclearfromthereportthatthereareareaswherewestillknowlittleaboutthecostsofdeliveringservicesandevenlessaboutthelonger-termeconomicimpacts.Nevertheless,thereisrobustevidencearoundsomeinterventions,makingastrongeconomiccaseforchange.WehopethattheworkoftheSchizophreniaCommissioncandriveforwardsomeofthechangesrequiredtoimprovequalityofcareandqualityoflives.

WearegratefultomembersoftheSchizophreniaCommissionfortheirsupport,especiallytoLizMeekandRobinMurrayforcomments,andweareparticularlygratefultoVanessaPinfoldforherenthusiasmthroughouttheprocessofpullingthistogether.WewouldalsoliketothankPaulRowlandsandMikeAkroydfromDerbyshireHealthcareNHSFoundationTrust,andSophiaWinterbourne(LSE)foraccesstoveryusefulinformation.

TheworkforthisreportwasfundedbythePersonalSocialServicesResearchUnitattheLSE.TheauthorshavenoconflictsofinteresttodeclareexceptthatIamaVicePresidentoftheBritishAssociationofCounsellingandPsychotherapy.

PROFESSOR MARTIN KNAPPPSSRU,LondonSchoolofEconomicsandPoliticalScienceInstituteofPsychiatry,King’sCollegeLondon

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Thisreportdescribesthemaincostsassociatedwithschizophreniaandassessestheeconomiccaseforabroadrangeofeffectiveinterventionsthat,ifmademorewidelyavailable,couldleadtobetteroutcomesandpotentiallyreducecosts.

EXECUTIVE SUMMARY

CURRENT COSTS OF SCHIZOPHRENIA

Schizophreniahasverysignificanteconomicconsequences.Costsfallonmanydifferentpartsofsociety,especiallyonindividualswithschizophreniaandtheirfamilies.Overall,thetotalsocietalcostinEnglandisestimatedat£11.8billionperyearandthecosttothepublicsectorat£7.2billion.Thisequatestoanaverageannualcosttosocietyof£60,000andtothepublicsectorof£36,000perpersonwithschizophrenia.

Thesecostsariseinmanydifferentways.Somedirectcostsofschizophreniaappearbothascoststosocietyandtothepublicsector:examplesarein-patienthospitalcostsandsupportfromcommunitymentalhealthteams.Othercosts,suchasthoseassociatedwithunpaidcarebyfamilyorfriends,areveryrealcostsforsocietybutdonothaveadirectimpactonpublicspending.Lostpotentialoutputduetohigherunemploymentratesandprematuremortalityforpeoplewithschizophreniarepresenthugecostsforsocietyandalsotranslateintoindirectcostsforthepublicsectorviathelossoftaxrevenue.Weidentifyeightkeycostdriversassociatedwithschizophrenia:inpatienttime;disrupted/lossofemployment;disruptededucation;homelessness;physicalhealthproblems;substancemisuse;contactwiththecriminaljusticesystem;andtheimpactonthefamily.

Inourworkwefoundmanyareaswheretheavailabilityandqualityofeconomicevidenceweredisappointing,bothintermsofaccuratelyestimatingthetruecostsassociatedwithschizophreniaandinbeingabletodrawfirmconclusions.Weidentifiedaparticularlackofevidencerelatingtocostsincurredthroughdisruptededucationalopportunities,homelessnessandcontactwiththecriminaljusticesystem.

Duetothenatureofschizophrenia,manyrelatedcostsarenon-retrievable.OurworkfocusedonareasofthecurrentcareandtreatmentsysteminEnglandthatcouldpotentiallybemademorecost-effective.

EVALUATING VARIOUS INTERVENTIONS

Thereareawiderangeofinterventionsthatarerelevantforthecareandtreatmentofpeoplewithschizophrenia.Inthisworkwehavelookedat:earlyinterventions;IndividualPlacementandSupportschemes;familytherapy;diversionfromthecriminaljusticesystem;physicalhealth;substancemisuse;targetinghomelessnessandsupportedhousing;crisisteams;theroleofpeer-supportworkers;advancedtreatmentdirectives;andcognitivebehaviourtherapy.

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Whenassessingthevariousinterventions,wewerehamperedbythelackofrobusteconomicevidencerelatingtosomeofthem,inparticularphysicalhealthinterventions,advancedtreatmentdirectivesandcriminaljusticeinterventions.

Thereisneverthelessstrongevidencethatseveralinterventionsnotcurrentlyinwidespreadusecouldreducetheoverallcostofschizophreniawhileimprovinghealthandqualityoflifeoutcomesforpeoplewiththeillnessandfortheirfamilies.Oneinterventionforwhichthereisstrongcost-effectivenessevidence,butwhichisnotavailabletomanypeople,isIndividualPlacementandSupport,whichaimstohelppeoplewithschizophreniafindcompetitiveemployment.Wealsofoundgoodevidencethatfamilytherapy,currentlyofferedtoveryfewpeoplewithschizophrenia,wascost-effective.Inotherareas–suchasphysicalhealth,substancemisuse,peer-support,advancedtreatmentdirectivesandinterventionstotacklehomelessness–wefoundsomeevidenceofcost-effectivenessbutnotenoughtodrawfirmconclusions.

Theevidenceweidentifiedcamedownstronglyinsupportofearlyinterventionservicesthat,althoughcurrentlyinwidespreaduse,mightbeunderthreatinaneraofausterity.Thereisalsoevidencethatotherinterventionswhicharealreadyinplace,suchascrisisteams,couldbeutilisedmoreeffectively.

Inmanycases,economicadvantagesmighttakemanyyearstobefullyrealised.Forexample,interventionstoimprovethephysicalhealthofpeoplewithschizophreniacanbeeffectiveandcost-effective,butwithimpactsthatshowthemselvesoverquitealongperiod.Thefulleconomicconsequencesofearlyinterventionserviceswillalsonotbeseenimmediately;andthe(sofarunmeasured)

consequencesofdisruptededucationwouldcertainlyhavelong-termeconomicconsequences.Whencostsandbenefitsoccuroverlongtimeperiodsitcanbedifficulttoobtainaccurateestimatesoftheeconomicimpactsofinterventions,sincethedataarerarelyavailable.Itmayalsobeparticularlydifficultinthecurrenteraofausteritytoarguesuccessfullyforinterventionswheresavingsonlybecomeapparentoverrelativelylongtimescales.

Costsandsavingsrelatingtointerventionsdonotalwaysariseinthesameareaofpublicspending.Oneconsequentchallengeislikelytobeaneedfornegotiationtoagreejointcoursesofactionacrossgovernmentdepartments,localcouncilbudgetareasormorewidely.Agoodexamplewouldbeinterventionstotacklehomelessnesswhichcanoriginateinanumberofdifferentsectors,andhavepay-offssimilarlyacrossawiderangeofbudgets.

Itisalsothecasethatmanyinterventionscancostmorethantheysave.Heredecision-makerswillneedtoaskwhethertheimprovedoutcomesthataregeneratejustifythecoststhatwillbeincurred.

CONCLUSIONS

Itwasnotourintentionwiththisreporttorecommendaparticular‘package’ofidealinterventions,rathertoofferasummaryofevidenceoncostsandcost-effectivenessasaplatformfordiscussion.OurreviewhasestablishedthatthereareareasofthecurrentsystemforthecareandtreatmentofpeoplewithschizophreniainEnglandthatcouldbemademorecost-effective.Thereisrobustevidencearoundsomeinterventionswhichsuggestsastrongeconomiccaseforchange.

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CURRENT COSTS OF SCHIZOPHRENIA

1. Estimates made from uprating cost estimates by Mangalore and Knapp (2007) to 2010/11 prices (using price indices specific to each cost area), uprating estimated number of people with schizophrenia in England to the recent estimate by NICE of 197,000 (www.nice.org.uk/usingguidance/commissioningguides/schizophrenia) and using an 18% average indirect tax and an 18% average income tax on all earnings. Figures reported here do not include the more intangible costs of the pain and suffering incurred by individuals with schizophrenia and their loved ones.

Schizophreniahasverysignificanteconomicconsequences;thecostsimpactonmanydifferentpartsofsociety,especiallyonindividualswithschizophreniaandtheirfamilies.Overall,schizophreniaisestimatedtocostEnglishsociety£11.8billionperyearandthepublicsector£7.2billion.1Thisamountstoanaverageannualcosttosocietyof£60,000andtothepublicsectorof£36,000perpersonwithschizophrenia.

Figure 1: Annual costs of schizophrenia to society and the public sector (£,2010/11 prices, per person with schizophrenia)

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Figure1showshowthesecostestimatesbreakdown.Somedirectcostsofschizophrenia,suchasin-patienthospitalcostsandsupportfromcommunitymentalhealthteams,arecommoncomponentsofboththecosttothepublicsectorandthecosttosociety.Othercosts,suchasunpaidcare,donotcostthepublicsectordirectlybutarestillveryrealcostsforsociety.Lostpotentialoutputduetoelevatedunemploymentratesandprematuremortalityforpeoplewithschizophreniatranslateintohugecostsforsocietyandalsotranslateintocostsforthepublicsectorviathelossoftaxrevenue.

Evidently,schizophreniaishugelyexpensivebothtothepublicpurseandsocietyatlarge.Duetothenatureoftheconditionmanyofthesecostsarenon-retrievable–notreatmentortherapywillbeabletogeteveryserviceuserintofull-timeemploymentforexample,andexpensivetreatmentsandmedicationsmayalwaysberequired.Inthisreport,however,wecontendthatthereareareasofthecurrentsystemforthecareandtreatmentofpeoplewithschizophreniainEnglandthatcouldbemademorecost-effective.Thepurposeofthereportistosummarisethemaineconomicimpactsofschizophrenia,andthentoconsiderarangeofinterventions(usingthattermbroadly)that,ifmademorewidelyavailable,couldleadtobetteroutcomesandlowercosts.Itisnotourintentiontorecommendaparticular‘package’ofidealinterventions,rathertoofferasummaryofevidenceoncostsandcost-effectivenessasaplatformfordiscussion.

ThereareanumberofimportantelementsintheoverallcostsofschizophreniasummarisedinFigure1,anditishelpfultofocusonsomeofthekeycost ‘drivers’.Infact,wecanidentifyeightkeycostdriversassociatedwithschizophrenia:areas,eventsorexperiencesthataccountfororhelptoexplainsignificantproportionsofthecostassociatedwithschizophrenia.Byconsideringeachofthesedriverswecansubsequentlyfocusoninterventionsthatmayhavethepotentialtoreducetheeconomicimpactofthesedriverswhilemaintainingorimprovingthehealthandwell-beingofindividualswithschizophreniaandtheirfamilies.

Mostoftheevidencethatwesummariseinthisreportrelatestopeoplewithschizophrenia,althoughsometimesthestudiesthatwediscusslookedatawidergroupofpeople,suchaspeoplewiththediagnosisofschizophreniaandotherpsychoticillnesses,orpeoplewithseriousorseverementalillnesses.Wehaveendeavouredtobeclearaboutthegroupsofpeoplecoveredaswediscusstheevidence.Werecognisethatthetermschizophreniaandpsychosisinclinicalservicesareusedinterchangeablybutmostresearchusestheterm‘schizophrenia’.

INPATIENT TIME

Mostindividualswithschizophreniahaveatleastoneinpatientstay,withahighprobabilityofreadmission(Allardyce&Os2010).Inpatienttimeaccountsforaverysignificantproportionofthecostsassociatedwithschizophrenia,roughly38%ofallhealth,socialcareandinstitutionalcostsassociatedwiththecondition,androughly21%ofallpublicsectorcosts.2TheaveragecostofanightinamentalhealthinpatientbedinEnglandis£321(Curtis2011).HospitalEpisodeStatistics(HESonline2011)showthatthemedianlengthofadmissionis38days,translatingintoanestimatedcostof£12,198peradmission.3Typically,compulsory(orformal)admissionsundertheMentalHealthActarelongerthanthis,andthustranslateintohighercoststhanvoluntaryadmissions.Duetotheveryhighcostsassociatedwithinpatientservices,interventionsthatreducetheprobabilityofadmissionorreducetheexpectedlengthofstaycantranslateintoverysignificantcostsavings,althoughthisshouldnotbeattheexpenseofpoorerhealth,qualityoflifeorotheroutcomes.

Formanypeoplewithschizophrenia,aninpatientadmissionisanecessaryandperhapsimportantturningpointinthecourseoftheirillness,butinotherinstancesadmissioncouldbeavoidedifmoreandbetterinterventionswereavailableoutsidetheinpatientsetting.Likewise,intermsofreducingthelengthofadmission,arecentCochranereview(althoughtheincludedstudiesweredated)foundnoevidenceofadverseoutcomesfromshorter

2. Calculated from Mangalore and Knapp (2007).3. Mean length of stay is 130 days. Data are heavily skewed due to a small proportion of individuals who are admitted to

long-stay units.

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hospitalstaysandsomeevidenceofbenefits(Alwanetal.2010).RecentworkbytheAuditCommission(2010)foundlargevariationsininpatientusebetweendifferentPrimaryCareTrusts;specificallyitfoundafive-foldvariationinadmissionratesforpsychosis,12-foldvariationinpsychosisbeddaysanda14-foldvariationinlengthofstay.4Thereportestimatedthatifalltrustsachievedthemedianrateofbeddaysthenthiswouldreducetotalbeduseby15%,resultinginaneconomicbenefitof£221million5tomentalhealthservices.

DISRUPTED / LOSS OF EMPLOYMENT

Whilsttheemploymentrateforalladultsaged16-64yearsinEnglandiscurrently71%6,recentestimatesplacetheemploymentrateforpeoplewithschizophreniaasbetween5and15%7(Marwaha&Johnson2004).EvidencesummarisedinFigure2suggeststhattheemploymentrateforpeoplewithschizophreniahasfallensignificantlyoverthepasthalfcentury–atimeframeoverwhichtheemploymentrateforthepopulationasawholehasrisen.ThereisanoticeablelackofmorerecentstatisticsreportingtheemploymentrateforpeoplewithschizophreniaintheUK.

4. All rates weighted for need.5. Updated to reflect current prices using the Pay and Prices Index in Curtis (2011).6. Source: www.ons.gov.uk/ons/about-ons/who-we-are/services/unpublished-data/social-survey-data/aps/index.html7. Estimates between 1990 and 2004.

Figure 2: Reported employment rates in 15 studies of people with schizophrenia in the UK; circle areas represent sample size. Data taken from Marwaha and Johnson (2004)

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Theexceptionallylowemploymentrateforpeoplewithschizophreniarepresentsahugelossofproductivecapacity.Assuminganemploymentrateof7%forpeoplewithschizophrenia(theweightedaverageofallstudiessince1995)andanemploymentrateof71%inthegeneralpopulation,thenschizophreniacauses–orisassociatedwith–a64-percentagepointdecreaseintheprobabilityofbeingcompetitivelyemployed.Usinganestimateofgrossannualmedianearningsof£21,3008thisisequivalenttoanexpectedlossofproductivecapacityof£13,600peryearperindividual(2011/12pricelevels).Theuseofmeangrossannualearnings9(£26,900)givesanestimatedlossofproductivecapacityof£17,200perindividual,whichcanbescaleduptogiveanexpectedlosstotheEnglisheconomyof£3.4billioneachyear.

Thelowemploymentratehasknock-oneffectsonthefinancesofthepublicsectorthroughlossesintaxrevenueandpaymentsofsocialsecuritybenefits.Assumingan18%averagedirecttaxrate(incometax)andan18%averageindirecttaxrate(VAT),10thistranslatesinto£715millionoftaxrevenueforgone(or£5500perserviceuser)perannum.

Lowratesofemploymentalsotranslateintohigherdependenceonsocialsecuritybenefits.UpdatingtheevidencepresentedbyMangaloreandKnapp(2007)tocurrentpricesgivesanestimatedreceiptofbenefitsof£5500perserviceuserperyear(assumingthat77.6%ofeconomicallyinactivepeoplewithschizophreniaareinreceiptofbenefits).If,intheabsenceofotherinformation,weassumethatthesameproportionofthegeneralpopulationwhoareeconomicallyinactiveareinreceiptofbenefitstothesamevalue,wefindanaveragebenefitreceiptforthegeneralpopulationofaround£1900.(Thisislikelytobeanover-estimatesincemostmembersofthegeneralpopulationwouldnotbeentitledtoincapacitybenefit.)Theseestimatessuggestanexcessof£3600ispaidinbenefitsperserviceuserperyear,oratotalof£470millionperyear.

Ofcoursethecounterfactualusedintheabovescenarioisunrealistic–eventhemosteffectiveinterventionsinschizophreniadonotproduceemploymentratesandwageratesonaparwiththeaverageforthegeneralpopulation–sotheabovesuggestedlossesintermsoftaxrevenueandbenefitscouldneverbefullyrecovered.However,thereareverysignificantsavingsthatcouldbemadeiftheemploymentrateforpeoplewithschizophreniacouldbeimproved.Theeconomicgainstosocietyresultingfromacautiousscenariowhere50%ofpeoplewithschizophreniawereemployedatanaverageof20hoursaweekattheNationalMinimumWagewouldbeintheorderof£350million,includingasavingofaround£120milliontothepublicfinances.

Thereisnoevidencetosuggestthatincreasingemploymentratesforpeoplewithschizophrenialeadstodetrimentaloutcomes.Indeedthereisevidencethattheconverseistrue,thatsuccessfulgainofcompetitiveemploymentbyindividualswhowantit(andthevastmajoritydo)leadstoimprovedclinicaloutcomes(Kilianetal.2012).Thisimprovementinclinicalstatecangenerateknock-onsavingselsewhere,forexampleinhealthservicecosts.

DISRUPTED EDUCATION

Schizophreniamostoftendevelopsinlateadolescenceorearlyadulthood–yearsthatarekeyfordevelopingskillsandknowledgethatwillprovidebenefitandincreaseearningspotentialthroughoutlife.Thedebilitatingnatureofthecondition,particularlyinthefirstfewyearsafteronset,oftenforcespeoplewithschizophreniatoleaveeducationortrainingearlierthantheywouldotherwisehavedone.Surprisinglyfewstudieshaveaddressedthecostsofmissededucationalandtrainingopportunitiesduetothecondition.

ArecentreportforthedepartmentofBusiness,InnovationandSkillsfoundthatthemarginalreturntoanundergraduatedegreewas27.4%(whencomparedtohavingtwoormoreGCEAlevels)(LondonEconomics2011b).

8. Taken from the annual survey of hours and earnings (ASHE), 2011. Source: www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-235202

9. Taken from the annual survey of hours and earnings (ASHE), 2011. Source: www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-235202

10. The use of an indirect tax rate in this estimation accounts for the tax revenue forgone due to reduced consumer spending as a result of the fall in earnings. Rate taken from Adam and colleagues (2012).

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Thistranslatedintoalifetimenetbenefittotheindividualof£108,000(currentprices,discountedat3.5%perannum)andtotheexchequerof£89,000.Thus,foreveryyoungpersonwhohastoforgoauniversityeducationbecauseofschizophreniatheresultwouldbealostnetbenefitof£197,000tosociety.

Likewise,formanyyoungpeoplethedevelopmentofschizophreniameanstheymissvocationaleducationandtrainingopportunities.Forexample,ifayoungpersonenrolledforaBTEClevel2qualificationcouldnotcompletethisqualificationbecauseofdevelopingschizophrenia,thisisestimatedtoresultinforgoinga12%wagegain,resultinginaforgonenetbenefittosocietyofbetween£54,000and£104,000overalifetime(LondonEconomics2011a).

HOMELESSNESS

Arecentnaturalisticstudyfoundthat33%ofasampleofpeoplewithschizophreniadrawnfromLondonandLeicesterhadbeenhomelessatsomestageand13%hadbeenroofless.Thiscomparedtofiguresof9%and6%forFrance,and8%and3%forGermany(Bebbingtonetal.2005).WhilstthesefiguresmaynotberepresentativeoftheUKmorewidely,sincelargeconurbationssuchasLondonandLeicesterwillhavehigherratesofhomelessnessashomelesspeoplefromotherareastendtodrifttolargecities,theydosuggestmajorfailingsinthecurrentsystemsthatleavelargeproportionsofpeoplewithschizophreniahighlyvulnerabletoviolence,theft,substancemisuseandfurtherdeterioratingmentalandphysicalhealth.

Homelessnessrepresentsahugewasteofpotentialinoursociety.Unemploymentisbothacauseandconsequenceofhomelessness.Thehomelessarefivetimeslesslikelytobeemployedthanthepopulationasawhole(CrisisUK2012)andbeinghomelesscreatesverysignificantbarrierstosubsequentlyre-enteringemployment.Formanypeople,beinghomelessmeanshavingnofixedaddressformailingsandnotbeingabletoopenamainstreambankaccount,makingithardertofindwork(Stansbury&Phakey2011).

Homelessnessalsohassignificantdirectcoststotheexchequer.Estimatesofthe(gross)annualcostsofhomelessnesstothepublicsectorliebetween£24,000and£30,000perhomelessperson(DepartmentforCommunitiesandLocalGovernment2012).Itisnoteasytoattributecostsspecificallytohomelessnessasmanycostlyphenomena,suchassubstancemisuse,criminalbehaviourandpoorhealth,arebothcausesandresultsofhomelessness.However,itisclearthathomelessnessisnotonlyanappallingexperienceforanindividual,butthatitalsohaswide-rangingeconomicconsequencesforthemandsociety.

PHYSICAL HEALTH PROBLEMS

Itisnowwidelyrecognisedthatschizophreniaincreasestheprobabilityofpoorphysicalhealth(Leucht,etal.,2007).Asaresult,thereisasignificantmortalitygapbetweenpeoplewithschizophreniaandthegeneralpopulation:arecentsystematicreviewestimatedthattheage-adjustedall-causemortalityrateamongstpeoplewithschizophreniawas2.58timeshigherthanforthegeneralpopulation(Sahaetal.2007).Aproportionofthiselevatedmortalityrateisduetoanincreasedriskofsuicide,butindividualswithschizophreniawerefoundtohaveincreasedmortalityratesinmostmajor‘causeofdeath’categories.

Schizophreniaincreasesriskfactorsformanyphysicalhealthproblems.Analysisoftheclinicalrecordsof1.7millionpeoplefoundthat61%ofpeoplewithschizophreniasmokedcomparedto33%ofpeoplewithoutschizophrenia,andthat33%ofpeoplewithschizophreniawereobesecomparedto21%ofpeoplewithout(Hippisley-Cox&Pringle2005).Manyantipsychoticmedications(particularlysecondgenerationones)areassociatedwithweightgain(Connolly2005).Combined,thesefactorsmeanthatpeoplewithschizophreniafaceahigherriskofdevelopingmanyphysicalhealthproblems.

Untilfairlyrecentlythephysicalhealthofpeoplewithschizophreniahasnotbeenapolicyprioritydespitethisverysubstantialphysicalhealthinequality:individualswithschizophreniaaresignificantlylesslikelytohavehadarecentcervicalsmear,arecentbloodpressurerecording,arecentcholesteroltestorbeonaspirinasaprophylaxisforstroke

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(Hippisley-Cox&Pringle2005).Therearealsoeconomicargumentstobemade:physicalhealthproblemstranslateintoadditionalhealthserviceexpenditure,lostproductivityandincreasedrelianceonsocialcareservices,resultinginsignificanteconomiclosses.

SUBSTANCE MISUSE

Quiteahighproportionofindividualswithschizophreniaaresubstancemisusers.DatafromtheEuropeanSchizophreniaCohortidentifiedanoverallsubstancedependencein42%ofparticipantsinLondonand28.3%inLeicester,placingthetwoUKcitiesfirstandthirdoutofeightEuropeancitieslookedatinthatstudy(Carràetal.2012).Thatstudyalsoestimatedaprevalencerateforalcoholmisuseof26.1%comparedto11.9%inthegeneralpopulation,andaprevalencerateforthemisuseofallothersubstancesof17.8%comparedto7%forthegeneralpopulation.Sincethedataaretakenfromurbanareas,figuresmaybesomewhathigherthanforthecountryasawhole(Carràetal.2009),butitisclearthatthereisastrongassociationbetweenschizophreniaandsubstancemisuse.

Inadditiontothepersonalcoststhatsubstanceabusecancause,therearealsowidereconomicconsequences.Thereisevidencethatindividualswithadualdiagnosisofschizophreniaandsubstancemisuseincurhigherserviceusecosts.Turkingtonandcolleagues(2009)foundthatpersistentsubstancemisuseincreasedtheprobabilityofrelapse,suggestingadditionaladmissionsandservicecosts.McCroneandcolleagues(2000)foundthatinasamplefromSouthLondon,‘core’costs(mentalhealthservicecosts,emergencycliniccostsanddaycarecosts)overasix-monthperiodwere£1913higherforthedualdiagnosisgroupthanforotherpatients(95%CI:£309to£3865),non-accommodationcostswere£1910higher(95%CI:£281to£3820)andtotalcosts(includingsupportedaccommodation)were£1469higher(95%CI:-£954to£4292).Whilstthereareproblems

ofself-selectionintothesubstancemisusestate-perhapsindividualswithmoreseverepsychosis,whowouldincurmorecostsanyway,aremorelikelytobesubstancesmisusersandthustheabovecostsmaynotrepresentthetruemarginaldifferenceincostsduetosubstancemisuse–thereisstrongevidencethatsubstancemisuseisassociatedwithhigherservicecostsinschizophreniacare.

Anothercostthatmaybeassociatedwithsubstanceabuseforpeoplewithschizophreniaisbecauseofcrime.InalargelongitudinalstudyinSweden(80025people,ofwhich8003hadadiagnosisofschizophrenia)Fazelandcolleagues(2009)showedthattheelevatedriskofsomeonewithschizophreniacommittingaviolentcrimecanbealmostentirelyaccountedforbyhighlevelsofsubstanceabuseinthisgroup.

Itwasfoundthatindividualswithschizophreniaandsubstance-useco-morbidityhadariskofcommittingaviolentcrimethatwas4.4timesgreater(95%CI:3.9to5.0)thanforthegeneralpopulation,whereasindividualswhohadschizophreniabutdidnotabusesubstanceshadanelevatedriskofjust1.2greater(95%CI:1.1to1.4).Similarfindingswerefoundinarecentsystematicreview(Fazeletal.2009).GiventheHomeOffice(2005)estimatesthatviolentcrimecauseseconomicandsocialcoststotalling£44.6billion11inEnglandandWaleseachyear,elevatedviolentcrimeduetothisco-morbiditybetweenschizophreniaandsubstancemisuseisclearlyverycostly.

Othercostsmayalsobeincurredasaresultofadualdiagnosiswithsubstancemisuse.Itislikelythatsubstancemisusereducesemploymentopportunities,resultinginwastedeconomicpotentialandlossestotheexchequerintaxrevenueforgone.

11. Uprated to reflect current prices using the GDP deflator (ONS). 12. Source: www.justice.gov.uk/downloads/statistics/mojstats/spcr-full-tables-paper-5-2-prisoners-backgrounds-

reconviction-a.xls

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CONTACT WITH THE CRIMINAL JUSTICE SYSTEM

Peoplewithschizophreniaareover-representedinthecriminaljusticesystem.Themostrecent(althoughnowquitedated)estimatesarethataround8%oftheprisonpopulationhaspsychosis,with2%qualifyingforaformaldiagnosisofschizophrenia(Singletonetal.1998).Thiscomparestofiguresofbetween0.2%to0.5%forthegeneralhouseholdpopulation(Singletonetal.2000;Sahaetal.2005;Mangaloreetal.2007).

Questionsareincreasinglybeingaskedabouttheappropriatenessofprisonsentencesformanyofthesepeople–frombothmoralandeffectivenessperspectives.Itisalsoclearthatprisonmaybeaneconomicallyinefficientinterventionformanywithschizophreniaorothermentalhealthproblems.Thecostofaprisonplaceforoneyearisestimatedtobe£40,000(MinistryofJustice2011b)andyetitisremarkablyineffectiveatpreventingreoffending;resultsfromtheSurveyingPrisonerCrimeReductionsurvey12foundthat54.2%ofprisonerswhohadbeentreatedforamentalhealth/emotionalproblemintheyearbeforecustodyhadbeenreconvictedwithinoneyearofrelease(at51.7%thereconvictionratewasalsoveryhighforprisonerswithoutsuchproblems).

ManypeoplewithschizophreniawhohavecommittedcrimesendupinsecurecareprovidedorfundedbytheNHS.Theseunitsaredifferentfromprisonsbecauseoftheiremphasisoncareandtreatmentasopposedtopunishment.Thereareanumberofroutesbywhichanindividualcanbeadmittedtosecurecare:theycanbereferredfromprison,onarestrictedorunrestrictedhospitalorderfromcourtasanalternativetoprison,ordirectlyfromcommunitytreatment.Securementalhealthbedsaredividedintohigh,mediumandlowsecure,aswellasspecialisedmediumsecureunitsforwomen.Nearly97%ofpeopletransferredonrestrictionordersfromprisongointohighormediumsecurebeds,whereaslowsecurebedsaremainlyusedforpeopledetaineddirectlyfromthecommunityundertheMentalHealthAct,orpeople‘stepped-down’frommoresecurebeds(Rutherford&Duggan2007).

Secureunitsrepresentaveryexpensiveelementofmentalhealthcare:secureandhigh-dependencyservicesaccountedfor19%ofdirectinvestmentinmentalhealthservicesin2010/11,withinvestmenttotallingover£1billion(MentalHealthStrategies2011).Inadditiontohighunitcosts,totalcostsaresohighpartlybecausestaysaretypicallyverylong,with27%ofpeopledetainedremaininginforensicservicesforover10years(Rutherford&Duggan2007).

FAMILY IMPACT

Manyrelativesandotherunpaidcarersofpeoplewithschizophreniawillgiveupemploymentortaketimeoffworkinordertoprovidecareandsupport.UsingresultsfromtheUK-SCAPstudy,MangaloreandKnapp(2007)estimatedthat4.8%ofcarershadterminatedemploymentand15.5%tookameanof12.5daysoffworkperyearspecificallyasaresultofbeingacarer.Thistranslatesintoameanannualeconomiclossof£517(2011/12prices)perindividualwithschizophrenialivinginthehouseholdpopulation.

Inadditiontothelossofproductivityasaresultofbeingacarer,itisalsopossibletoputaneconomicvalueontheunpaidcarethattheseindividuals(whoareusuallyfamilymembers)providetopeoplewithschizophrenia,ontheassumptionthatiftheydidnotprovidesuchcaresomeoneelsewouldhaveto.IfsuchcareandsupportisvaluedathowmuchitwouldcosttheNHStoprovidesimilarcare(thesalaryofanassistantnurseornursingauxiliary)thenbasedontheassumptionthattheunpaidcarerprovidesameanof5.6hourssupportperday,thiscomestoanaverageof£34,000perpersonwithschizophreniabeinglookedafterbyafamilyorothercarer.Roughly31%ofpeoplewithschizophreniaarelivinginprivatehouseholds(Mangalore&Knapp2007b),sothiscouldtranslateintoanaggregatecosttosocietyofasmuchas£1.24billionperyear.

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Havingdiscussedsomeofthekeycostdriversinrelationtoschizophrenia,wenowmoveontolookattheeconomicconsequencesofavarietyofinterventions.TheextensiveevidencecollectedbytheSchizophreniaCommissionfromawiderangeofpeoplewithexpertiseaboutand/orexperienceofpsychosisguidesthescopeandnatureofinterventionsdiscussedhere.Ingatheringandcollatingeconomicevidenceoneachoftheseinterventionswehavetriedtobeasbalancedandfairaspossible.

differentcircumstances.Interventionsarenotindependentfromoneanotherinthattheoutcomesofonemaybepositivelyornegativelyimpactedbyotherinterventionsthatanindividualisreceivingorhaspreviouslyreceived.Forexample,itwouldperhapsbeunrealistictoassumethesamereductionininpatientuseasaresultofaspecifictalkingtherapy,suchascognitivebehaviouraltherapy(CBT),whentheindividualalreadyreceivesothertypesofpsychologically-informedinterventionsaswhenhe/shereceivesCBTalone.Becauseofthisinterdependence,thecostestimatesreportedhereareincertainlynotadditive.WediscussthisfurtherinSection3.

Anotherpointtobearinmindistheoftenelusivenatureofthesocalled‘standardcare’or‘treatmentasusual’againstwhichinterventionsaretypicallycompared.Oftentrialsgivelimitedinformationaboutthenatureofsuchstandardservicestowhichtheyarecomparingtheinterventioninquestion,yetsincestandardpracticesofcarevarytremendouslyacrossthecountry(letalonebetweencountriesandovertime),thisleadstoseriousquestionsaboutextrapolatingeconomicevidencefromonecontexttoanother.Ifaparticularinterventionsaved£Xperpatientinonelocalitywhencomparedtostandardcareinthatarea,itis

EVALUATING VARIOUS INTERVENTIONS

However,duetotimeconstraints,asystematicreviewineachcasewascertainlynotpossible.Instead,asastartingpointforeachintervention,wecontactedresearchersintheareatoidentifythemostsignificantexistingeconomicevidence,includingextantreviews.Thisinformationwassupplementedwithextensive,albeitnotsystematic,literaturesearchingforeachinterventioninturn.

Wheretheeconomicevidenceforinterventionswasconsideredtobestrongwehaveattemptedtodrawconclusionsfortheeconomicimplicationsoftheseinterventionsonthreedifferentlevels–fortheNHS,forthepublicpursemoregenerally,andforsocietyasawhole.Forthoseinterventionswheretheeconomicevidenceisnotstrongenoughtodrawfirmconclusions,keyevidencehasbeensummarisedandareasforfutureworkhighlighted.

Attentionmustbedrawntothefactthattheseinterventionsareneithermutuallyexclusivenorindependent.Schizophreniaisacomplexconditionandmostindividualswiththeconditioncanbenefitfromacombinationofinterventions,andofcourse,theyandtheirfamilieswouldhavepreferencesaboutwhichinterventionsareappropriatein

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notnecessarilythecasethatthesamesavingof£Xwillbeobtainedinanotherlocalityifthestandardcarepracticedinthisareaisdifferent.Havingsaidthat,withoutextensiveinformationabouttheroutinepracticeofdifferentmentalhealthservicesthereisoftenlittleoptionbuttoassumeasimilarstandardcareandthusthatanycostsorbenefitswillbegeneralisable.

Someoftheinterventionsdiscussedbelow,suchasEarlyInterventionandCrisisTeamsarealreadywidelyinplace,atleastinname;andfortheseouranalysisattemptstoevaluatetheeconomicevidenceformaintainingthem.Otherinterventionsdiscussedhere,suchasIndividualPlacementandSupport,HomelessnessInterventionsandPeerSupportareasyetnotwidelyavailable;hereweattempttoevaluatetheevidenceformakingsuchinterventionsmore widely available.

Allcostsinthisreporthavebeenupratedforinflationto2010/11pricelevelsusinganappropriatepriceindex.Allfuturecostimplicationshavebeendiscountedbacktothepresentatarateof3.5%perannum.

EARLY INTERVENTION

Someearlyinterventionservices(EIS)inpsychosisaimatearlydetectionofpeoplewithprodromalsymptomsofpsychosis(orthosewhosepsychosishasnotalreadybeenadequatelydetectedandtreated),butmostearlyinterventionteamsareworkingwithpeoplewhoseillnesshasbeendiagnosed.Treatmentintheearlyinterventionstageideallyinvolvesacombinationof‘pharmacological,psychological,social,occupationalandeducationalinterventions’(NationalInstituteforHealthandClinicalExcellence2009).Therationaleforinterveningearlyinpsychosisisbasedonevidencethatsuggestsanassociationbetweenthedurationofuntreatedpsychosisandoverallprognosis(Marshalletal.2005).

EarlyinterventionserviceswereformallyintroducedintotheNHSin2001/2002asoutlinedinThe Mental Health Policy Implementation Guide(DepartmentofHealth2001).Sincethen,earlyinterventionteamshavebeenintroducedquitewidelyacrossEngland(Shiers&Smith2010)althoughthereremaininequalitiesinaccess(IRIS2011).

ClinicalevidencesuggestsEarlyInterventioninPsychosiscanhavepositiveeffects.Arecentsystematicreviewandmeta-analysissuggestedthatspecialisedFirstEpisodePsychosisprogrammescansignificantlyreducetheriskofrelapsewhencomparedtousualtreatment(Alvarez-Jiménezetal.2011).ArecentCochranereviewwaslesspositive,findingfewsignificantresultsinfavourofEIS(Marshall&Rathbone2011).However,theusefulnessoftheCochranemethodologyinevaluatingservicemodelssuchasEarlyInterventionhasbeenquestioned.McGorry(2012)claimsthatmanywell-designedstudiesevaluatingtheeffectivenessofEISwereexcludedfromtheCochranereview.HedisputestherelevanceofmanyoftheCochranefindingssince‘thereviewfocusedlargelyontrialscomparingthe“componentinterventions”ofEIPservices.…SuchinterventionsweretypicallystudiedagainstthebackdropoftherangeofcareprovidedwithinstreamedEIPservices.Itisnotsurprisingthatsomeoftheseindividualtrialswere“ineffective”giventhatthecontrolgroupsinthesetrialsweretherecipientsofanalreadycomprehensivemodelofcare.’

Inadditiontopatientoutcomestherehasbeenattentiongiventopotentialcostsavingsthattheuseofearlyinterventionservicesmayoffer–inboththeimmediateandlongerterm.Thefirststudiesthataimedtotacklethisissuewererelativelynarrowinscope–focusinglargelyondirectcoststomentalhealthservices.Morerecently,however,workhasbeendonetotakeamorecomprehensivelookattheeconomicconsequencesofEarlyInterventionservices.RecentstudieshaveconsideredtheimplicationsofEISformoreofthecostdriversdiscussedinSection1,includingcriminaljusticecostsandlostemploymentcosts(McCroneetal.2010).

InarecenteconomicevaluationofEIS,McCroneandcolleagues(2010)usedadecisionmodellingapproach,derivingprobabilitiesfromtheliterature,toestimatethecostconsequencesofEarlyInterventionServices.TheresultswerestronglyinfavourofEIS.ThisreportupdatesthecostsreportedbyMcCroneetal.(2010)sotheyreflectcurrentcostsandprices,andalsoaddsinanexpectedincreaseintaxrevenue.BelowweoutlinethekeymechanismsthroughwhichEarlyInterventionServicesmayleadtocostsavings.

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Mental Health Service UseSinceEarlyInterventionServiceshavebeenshowntohaveclinicalbenefitsitisperhapsunsurprisingthattheirintroductionwouldreduceserviceuse,inparticularhigh-costinpatienttime.Indeed,usingdatafromtheLambethEarlyOnset(LEO)team,routinedatafromWorcestershireandNorthumberlandEIServicesandtheHealthcareCommissiontheauthors(McCrone,Knapp,etal.2009)estimatedthatEarlyInterventionServicesreducetheprobabilityofaformaladmission(compulsoryadmissionundertheMentalHealthAct)from44%to23%inthefirst2monthsofpsychosisandfrom13%to6%ineach2-monthperiodthereafter.Thistranslatesintoverysizeablecostsavingsforthementalhealthservices:itisestimatedthat,at2010/11prices,theintroductionofanEarlyInterventionServicesaves£5,493perserviceuserinthefirstyearofpsychosisand£15,742duringthefirstthreeyears(costsdiscountedat3.5%peryear).

Suicide and Homicide CostsEarlyInterventionServiceshavebeenshowntobeeffectiveinreducingtheriskofbothsuicideandhomicide.Associatedcostsavingsfromthereductionofsuiciderisk(throughcoststotheNHSandthelostproductivityofthedeceased)areestimatedat£481inthefirstyearofpsychosis.Theassociatedcostsavingsfromthereductioninhomicideriskaresmall(just£28overthreeyears)becauseoftheverylowstartingprobabilitythataserviceuserwillcommithomicide,yetEarlyInterventionServicesdosignificantlyreducethisrisk.However,weneedtobecautiouswiththesefiguresonsuicideand(especially)onhomicidegiventhelimiteddatathatwereavailableasabasisfortheeconomiccalculation.

EarningsEarlyInterventionServiceshaveapositiveimpactontheretentionandgainofcompetitiveemployment.McCroneetal.(2010)estimatethat12%ofstandardcarepatientswillbeinemployment,comparedto35%ofpeoplesupportedbyEIS.Ifahumancapitalapproachisassumed,valuingemploymentattheminimumwagerate,theresultwouldbeagaininearningsof£4299evenwhenassumingthatnoemploymentoccursinthefirstyearforeithergroup.

Thisincreaseinemploymentrate,whenviewedfromasocietalperspective,increasesproductionintheeconomyasawholeand,whenviewedfromapublicsectorperspective,increasestaxrevenue.Inthisreportitisassumedthattheonlynetbenefitintermsoftaxrevenuecomesfromthemeanindirecttaxrateof18%(Adametal.2012);sincethesizeoftheearningsweareconsideringisrelativelymodest,weassumenoincometaxispaid,whichmakestheestimatesofcostsavingstothepublicsectorconservative.

Net Cost SavingsWhenwesumtheseindividualcoststogethertofindthenetsavingsaccruedbytheintroductionofEISwefindthefollowingresults:

� TheintroductionofEarlyInterventionServicesisestimatedtosavetheNationalHealthService£5536perserviceuserinthefirstyearofpsychosis.Thisrisestoatotalof£15862inthefirstthreeyears.

� Intermsofthepublicpurseviewedasawhole,theintroductionofEISisestimatedtohaveanetbenefitof£5545inthefirstyearofpsychosis,risingto£16663overthefirstthreeyears.ThesefiguresincludecostsaccruedtotheNHS,criminaljusticesystemandextrataxrevenuegained.

� TakingasocietalviewofthenetbenefitsofEISbyincludingallincreasedproductionthatoccursasaresult(notonlythatwhichissubsequentlycollectedbygovernmentintaxes)givesafigureof£6015savedinthefirstyearofpsychosisand£21512savedoverthethree-yearperiod.

Thereareothercoststhathavenotbeenintegratedintothismodelthatwould,itseemslikely,increasethepotentialsavingsofEIservices.Oneisthecostincurredbyfamiliesandcarersthroughreducingtheirownemploymentandprovidingunpaidcareandsupport.ItisexpectedthatthroughtheclinicalbenefitsassociatedwithEI,thiscostincurredbyfamilieswouldbereduced.

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CaveatsTheaboveestimatesofcostsavingsfromimplementationofEISareobtainedusingonespecificsetofmodelparameters:aspecificsetofprobabilitiesofadmissionunderstandardcareandEIS,andaspecificsetofcostsofadmissionandcommunitycare.EstimatedcostsavingsfromtheimplementationofEISwillvaryfromlocalitytolocalitydependingonprioradmissionrates,thefidelityofEIStoevidence-basedmodels,thenatureandqualityof‘standardcare’servicesandthequalityandcostofinpatientcare.TheabovemodelislargelyestimatedusingparameterstakenfromLondon-basedstudies,soresultsmaynotbeimmediatelytransferabletootherareasofthecountry,whereservicemodelsandpopulationscouldbedifferent.However,EISinverydifferentpartsofthecountryhavebeensuccessfulinreducingadmissions.Forexample,followingtheimplementationoftheNorth

EastDerbyshireEarlyInterventionservice,thepercentageofpeoplewithschizophreniawithafirstepisodeofpsychosis(whocameintocontactwithregularservicesandthespecialistEISrespectively)thatwereadmittedtohospitalwithinthefirstyearfellfrom62%tolessthan31%(Rowlands2012;Phillipsonetal.2012).13

WhenconsideringtheeconomicconsequencesofEarlyInterventionitisalsoimportanttobearinmindthatschizophreniaisalifelongconditionandthebenefitsofthespecialisedmodelthatEISprovidesmaynotbesustainedaftertheserviceuserisnolongereligiblefortheservice.Intwomajorstudies,significantbenefitsofEISwerenolongerseenatafive-yearfollow-up(Gafooretal.2010;Bertelsenetal.2008).This,though,maybebecauseoftheservicesthatrecipientsofEIweredischargedtoratherthantodeficienciesinEIitself.

13. It must be noted that the eligible populations for the two services are different, mainly in that NE Derbyshire EIS only deals with people under the age of 35. Thus, whilst this figure is indicative of the success of EIS in bringing about fewer inpatient admissions it must not be interpreted as a precise estimate of the impact of the service.

Figure 3: Cost savings accrued through the introduction of Early Intervention Services (2010/2011 £)

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INDIVIDUAL PLACEMENT AND SUPPORT SCHEMES

Mostpeoplewithschizophreniaandotherseverementalhealthissueswanttowork(Grove1999;Mueseretal.2001;Marwaha2005).However,onlybetween5and15%areactuallyinemployment,representingahugewasteofpotentialaswellasdenyingpeopleopportunitiesforsocialinclusion,meaningfuldaytimeactivityandasenseofpersonalidentityandachievement.IndividualPlacementandSupport(IPS)isatypeofsupportedemploymentaimedathelpingthosewithseverementalhealthproblemstogainpaidcompetitiveemployment.IPSservicesareverydifferenttothekindsofvocationalrehabilitationservicesconventionallyavailable(andtheservicesthatstillexistinmanypartsofEngland)inthatIPSservicesaimtoplacepeoplewithschizophreniaincompetitiveemploymentassoonaspossibleandthenprovideadditionalsupportandtraining.Incontrast,standardvocationalschemeslargelytaketheapproachthataconsiderableamountoftrainingisneededbeforepeoplewithschizophreniaarereadytobegincompetitiveemployment.

Suchtrainingpriortoobtainingcompetitiveemploymentishighlyexpensiveandhasoftenbeensomewhatineffectiveinhelpingpeoplewithschizophreniagaincompetitiveemployment(SainsburyCentreforMentalHealth2009a;Crowtheretal.2010).ThereisnowasubstantialbodyofevidencefromacrosstheworldthatIPSissignificantlymoreeffectiveathelpingpeoplewithschizophreniatogaincompetitiveemploymentthanstandardvocationalservices(Crowtheretal.2010)

ThedetailedcharacteristicsofeffectiveIPSschemesarereportedelsewhere(Beckeretal.2008).Belowarelistedthekeyconceptsofhigh-fidelityIPSschemes(copiedfromtheSainsburyCentreforMentalHealth’sreport(2009a):

� Competitiveemploymentistheprimarygoal

� Everyonewhowantsitiseligibleforemploymentsupport

� Jobsearchisconsistentwithindividualpreferences

� Jobsearchisrapid:beginningwithinonemonth

� Employmentspecialistsandclinicalteamsworkandarelocatedtogether

� Supportistime-unlimitedandisindividualisedtoboththeemployedandtheemployee

� Welfarebenefitscounsellingsupportsthepersonthroughthetransitionfrombenefitstowork

PerhapsthemostobviouspublicsectorcostsavingthatwemightexpecttoaccompanytheimplementationofIPSservicesistheadditionaltaxrevenuereceivedandthesocialsecuritybenefitpaymentssaved.However,moreimportantislikelytobethereductioninservicecostsresultingfromtheimprovementinmentalhealththatcompetitiveemployment(ortheactivesearchforit)canbring.IPSserviceshaveconsistentlybeenshowntohaveverypositiveoutcomesintermsofclinicalmeasures.Meta-analysishasshownthatIPSschemessignificantlyimprovesymptomsofthoughtdisturbance(p=0.069),anergia(p=0.094)anddepression(p=0.022)andimprovetotalsymptoms(p=0.009)14(Campbelletal.2011).

InadditiontothebetterdocumentedshortertermeffectsofIPSservicesonmentalwellbeingthereisalsoemergingevidencethatthereareverysignificantlong-termbenefitsassociatedwiththegainofstablecompetitiveemploymentwhichcorrespondtosignificanteconomicsavings(SainsburyCentreforMentalHealth2009).

MuchoftheevidenceontheeconomicconsequencesofIPSschemesissomewhatlimited,withmanystudiesfocusingprimarilyonsavingsintermsofincreasedearningsandnotconsideringbroadercostconsequences.

14. All symptoms measured using the Brief Psychiatric Rating Scale (BPRS)

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Mental Health Service UseThemostrecentlypublishedeconomicevaluationofIPSwasbasedonarandomisedcontrolledtrialcarriedoutinsixEuropeancities;thisisEQOLISEstudy(Burnsetal.2007;Knappetal.2012).Thisstudyrandomised312participants(around80%hadschizophrenia,othershadbipolarorotherseverementalhealthproblems)toeitherIPSservicesorstandardvocationalservicesandfollowedthemfor18months.InaccordancewithotherstudiesofIPS,largelyoriginatingfromtheUSA,IPSprovedmuchmoreeffectivethanstandardvocationalservices,bothintermsofgainingcompetitiveemploymentandintermsofclinicaloutcomes(Burnsetal.2007;Burnsetal.2009;Kilianetal.2012)

TheeconomicanalysisoftheEQOLISEstudyshowedencouragingresultsforIPSintermsofserviceuseandassociatedcosts(Knappetal.2012).ItwasfoundthatIPSgeneratedsignificantsavingsininpatientcosts,asavingof£4,400overthe18-monthfollow-upperiod,althoughmostofthissavingoccurredinthefirstsixmonths.Effectsonotherareasofmentalhealthservicecostsweresmaller:IPSwasfoundtoincreaseoutpatientserviceand

communityservicecostsbyatotalofaround£1,000overthe18months,whilsteffectsonotherareasweremixed.Totalmentalhealthservicecosts(excludinginterventioncosts)were£4,000lowerfortheIPSgroupcomparedtothevocationalservicesgroupoverthe18-monthperiod.

EarningsEarningsforIPSandstandardcarewereestimatedfromtheEQOLISEstudyusingahumancapitalapproach.DatafromtheEQOLISEstudyrevealthathoursworkedincreasedoverthe18-monthperiodforboththeIPSandthecomparisongroups,butIPSparticipantsworkedmoreineachandeveryperiodwiththedifferencebetweenthegroupsincreasing(seeFigure4).Reassuringly,theestimatedhoursworkedfromtheEQOLISEstudywereverysimilartothoseestimatedinarecentmeta-analysisoffourhigh-qualityRCTsconductedintheUSA(Campbelletal.2011)whichtogetherincluded681participants.Itwas,however,decidedtousedataonlyfromtheEQOLISEstudysinceUKlabourmarketsaremoresimilartoEuropethantheUSA.

15. This is an underestimate since a minimum wage rate was assumed for all participants whereas in reality some would be earning significantly more. Thus the actual benefit accrued to the exchequer is likely to be more than the figure estimated here.

Figure 4: Hours worked by IPS and standard Vocational Services participants (adapted from Burns et al 2007)

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Thisincreaseinearningstranslatesdirectlyintosocietalbenefitof£1700over18months(conservatively,employmentwasvaluedatthenationalminimumwageof£6.08perhour).Forpresentpurpose,tocreateanestimateofthebenefitaccruingtotheExchequerasaresultofthisincreaseinearnings,anaverageindirecttaxof18%canbeused,resultinginanincreasedrevenueof£300over18monthsfortheExchequer.

SincetheestimatedaverageearningsresultingfromIPSarerelativelysmall–onlyeightofthe312EQOLISEparticipantswereestimatedtohaveannualearningsabovethelowerthresholdforincometax(£8105)15–noincreasedrevenueduetoincometaxesornationalinsurancecontributionswereestimated.

Other Economic ImpactsAnalysisofthecostimplicationsofIPSpresentedinthisreportcoversonlycostsandbenefitsrelatedtomentalhealthserviceuseandearnings.WehavenotattemptedtoestimatethecostconsequencesofanyeffectthatIPSmighthaveonphysicalhealth,criminaljusticecontactsorhousingbecause,althoughitispossiblethattheseeffectsmightresult,thereisinsufficientrobustevidenceonthem.Arecentmeta-analysisofIPSservicesintheUSAsuggestedthatIPScouldpossiblyreducehomelessnessandsubstanceabuseandhencegeneratefurthersavings,althoughtheresultsofthemet-analysiswerepositivebutnotstatisticallysignificant.Additionally,inthepresentreportwehaveassumednoreductioninbenefitreceiptresultingfromIPS,whereasinrealityitislikelythatbenefitreceiptwouldfallwiththeincreaseinthecompetitiveemploymentrate.

Figure 5: Estimated cost savings per service user following the introduction of an IPS service

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Net SavingsInterventioncostsweretakenfromtheLondonsiteoftheEQOLISEstudy.Inreality,intervention‘costs’whenIPSwascomparedtostandardvocationalserviceswereactuallynegativesinceIPSwassignificantlycheapertoprovidethanthesestandardservices.Whilstthismaynotrepresentarealisticcostsavingformentalhealthservicesthatcurrentlyofferlittleornovocationalservices,suchasituationmayresultinlargersavingsinotherareasasaresultofanevengreaterdifferentialintheemploymentrate.

PuttingtogetherthesevariouscostcomponentswearriveatestimatednetsavingsperserviceuserofimplementinganIPSservice:

� TheintroductionofIndividualPlacementandSupportServicesisestimatedtosavetheNationalHealthService£5193peruseroftheserviceoveran18monthperiod.

� ItisestimatedthattheintroductionofIPSserviceswouldsavethepublicsectorasawhole£5501peruserover18monthsthroughreducedhealthservicecostsandincreasedtaxrevenue.

� TakingasocietalviewthenetbenefitsofIPSareestimatedtobe£6906peruserover18monthswhichincludestheincreaseintotalproduction,notjustthecomponentcollectedintaxrevenuebythegovernment.

ThesenetsavingsarerepresentedinFigure5.

Figure5representsestimatedcostsavingsperserviceuserengagingwithanIndividualPlacementandSupportservice.TheEQOLISEstudy,onwhichthecalculationsinthisreportarebased,studiedonlypeoplewithschizophreniawhowishedtofindcompetitiveemployment(Burnsetal.2007)andtherefore,sinceIPSwouldnotbesuitableforallpeoplewithschizophrenia,itisdifficulttocalculateaggregatesavingsthatmightflowfromthenationalroll-outofIPSservices.

CaveatsManypeoplehaveexpresseddoubtsabouttheapplicabilityofIPS,aservicemodeldevelopedintheUSA,toaUKcontext(Heslinetal.2011).TheyarguethatthedifferingstructureofsocialsecurityandthelabourmarketsmeansthatIPSwouldbelesseffectiveintheUKduetoalessernecessitytofindworkinordertosurviveintheUSA.Thisargumentisslightlymisleading,sinceitdoesnottakeintoaccountthattherearealsomajoreconomicdisincentivestoregainingemploymentintheUSA–peoplewilloftenlosetheirentitlementtoprogrammeslikeMedicaidwhentheybecomeemployed.

Therearelegitimateargumentstobemadeaboutthedifferingincentivestoworkacrossnations,buttheoverarchingpremiseandmotivationofanIPSapproachisthatthemajorityofindividualswithschizophreniawanttofindcompetitiveemployment.Thisisoftennotonly(orperhapsatall)foreconomicreasons,andgainingsuchcompetitiveemploymentisclinicallybeneficial.However,someresultsdosuggestthattheworkincentivesintheUKaresuchastodiscouragethepursuitofcompetitiveemploymentforindividualswithschizophrenia.IntheEQOLISEstudy,Burnsandcolleagues(2007)foundthatLondonwasatthehighestriskoutofthesixEuropeancentresofhavingabenefittrapdespitetherebeingmeasuresinplacetoreducethedisincentivesforwork(SainsburyCentreforMentalHealth2004).CurrentreformstosocialsecurityentitlementsinEnglandmight,ofcourse,reduceanyfinancialdisincentivetowork.

FAMILY THERAPY

Familytherapyreferstoarangeofpsychosocialinterventionsforpeoplewhohaveasignificantemotionalconnectiontosomeonewithschizophrenia,herereferredtoforsimplicityas‘thefamily’.Thetherapytypicallyinvolvesprovidinginformationaboutschizophrenia,searchingformethodsofsupportinganindividualwithschizophreniaandresolvingpracticalproblems.Interventionsareaimedatreducingthelevelofexpressedemotionwithinthefamily,sinceexpressedemotionhaslongbeenrecognisedasarobustpredictorofrelapse(Butzlaff&Hooley2012).

16. Uprated to reflect current prices using the GDP deflator, ONS.

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Althoughfamilytherapyhasbeenanacceptedinterventioninschizophreniatreatmentforalongtime,relativelyfewstudieshaveformallyattemptedtoassessitseconomicimpact(Mihalopoulosetal.2004;Knapp2000;Leffetal.2001;Goldstein1996;McFarlaneetal.1995;Tarrieretal.1991;Libermanetal.1987).Inthisreport,webaseoureconomicanalysisoffamilytherapyprimarilyonarecentdecisionmodelbytheauthorsofthisreport(tobepublishedseparately).ThismodelusestheestimatedriskratiosassociatedwiththeprobabilityofrelapsewithfamilytherapyderivedfromarecentCochranesystematicreview(Pharoahetal.2010)toupdateprobabilitiesofrelapseunderstandardcaretoestimatethetotalserviceusecostsunderfamilytherapyandstandardcare.

Themodelestimatesacostsaving(netofinterventioncost)of£1,004overathree-yearperiod,meaningthatfamilyinterventionwouldbeseentobesuperiortostandardcareinthatitisassociatedwithbothbetterclinicaloutcomesandlowercosts.Insensitivityanalysisthisresultheldusingavarietyofdifferentadmissioncosts.

CRIMINAL JUSTICE SYSTEM DIVERSIONManypeopleinthecriminaljusticesystemhavecomplexmentalhealthneedswhicharepoorlyrecognisedandinadequatelymanaged.Largenumbersendupinprison:ahigh-costinterventionwhichisinappropriateasasettingformentalhealthcareandineffectiveinreducingsubsequentoffending.Theoverallsizeoftheprisonpopulationhasmorethandoubledinthelast20yearsandoneprisonerintenhasaseverementalillnesssuchasschizophrenia.

Diversionseekstoensurethatpeoplewithmentalhealthproblemswhocomeintocontactwiththecriminaljusticesystemareidentifiedanddirectedtowardsappropriatementalhealthcare,particularlyasanalternativetoimprisonment.Diversioncanbewithinoroutsidethejusticesystemandneednotreplacesanctionsforanyoffenceapersonhascommitted.

Forsomeoffenderswithseverementalillness,themostappropriatealternativetoprisonisplacementinanNHSsecureunit.Theseunitsare,however,intendedonlyforthosewhohavecommittedseriousoffencesandthegreatmajorityofprisonerswithseverementalillnessareonshortsentencesandhavenotcommittedseriousenoughcrimestowarranttransfertoasecurehospital.

Aboutthree-quartersofallpeoplesenttoprisoneachyearreceivesentencesoflessthan12monthsandparticularlyforthoseinthisgroupwithseverementalillnessthereisastrongcost-effectivenesscasefortheuseofsuspendedsentencesorcommunityordersinsteadofimprisonment,togetherwithanappropriatepackageofcommunity-basedmentalhealthsupport.

Intermsofcostsacommunitysentenceisfarcheapertoprovidethanaprisonsentence.FiguresfromtheNationalAuditOffice(Accenture2007)suggestthatonaverageacommunitysentencecostsbetween£720and£4,10016dependingonitstype.EventheMentalHealthTreatmentRequirement,whichisthemostexpensiveofthetwelvecommunityorders,costsonlyroughly10%ofthecostoftheaverageprisonsentence(MinistryofJustice2011b).

Intermsofeffectivenesstooitappearsthatcommunitysentencesdominateprisonintheoutcomestheyachieve–bothclinicallyandinreducingreoffending.Peoplewithschizophreniacangetmuchbettermentalhealthcareinthecommunitythaninprison:prisonisaverypoortherapeuticenvironmentwhich,ifanything,islikelytoexacerbateamentalhealthproblem.Sincethepeopleforwhomcommunityordersaredesignedareonshortprisonsentences(typicallylessthanoneyear)theyareunlikelytobeenrolledon,orbenefitfrom,behaviouralprogrammesaimedatreducingre-offending.Withaprisonsentencetheyarealsonotrequiredtoseeaprobationofficerafterreleasewhichmeanstheygetlittleornosupportoncebackinthecommunity,incontrasttowhatwouldhappeniftheywereonacommunitysentence.Partlybecauseofthesefactorsre-offendingratesaresignificantlyhigheronalike-for-likebasiscomparingpeopleonashortprisonsentenceandthoseonacommunitysentence.Indeed,

17. The reports make detailed recommendations as to how MHTRs could be better implemented.

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usingamatchedpairstechnique,theMinistryofJusticeestimatedthatCommunityOrders(ofalltypes)resultinan8percentagepointdecreaseinre-offendingrateswhencomparedwithcustodialsentencesoflessthanoneyear(MinistryofJustice2011a).

Itistobenotedthatthereisnostrongargumentforprisonsentencesovercommunityordersonpublicsafetygroundsgiventhatthetypeofoffencesinvolvedarerelativelyminor.

TheMentalHealthTreatmentRequirement(MHTR)isoneofthetwelverequirementsthatmagistratesandjudgescanplaceonindividualswhoreceiveaCommunityOrderoraSuspendedSentenceOrder.Therequirementmeansthattheindividualisthenrequiredtoreceivementalhealthtreatmentforadefinedperiodoftime.Despiteitsintroductionin2005,recentdatafromtheMinistryofJusticeshowaverylowuptakeoftherequirement.Whilst43%ofpeopleservingcommunitysentenceshavesomesortofmentalhealthproblem(Solomon&Silvestri2008),only0.3%aregivenaMentalHealthTreatmentRequirement.BarrierstomorewidespreaduseofMHTRsincludedifficultiesinobtainingpsychiatricassessments,ineffectiveidentificationofmentalhealth

problemsinthecriminaljusticesystem,alackofawarenessoftherequirementswithinthecriminaljusticesystemworkforceandalackofcommunicationandtrustbetweenhealthservicesandthecriminaljusticesystem(Khanometal.2009;Seymouretal.2008).17

Itis,however,importanttoemphasisethatthecasefordiversionforpeoplewithschizophreniadoesnotstandorfalldependingonwhetherornottheygetanMHTR.IfanMHTRisdeemedtobeunsuitable,perhapsbecauseofaninappropriatenessofprovidingtreatmentonacompulsorybasis,thecost-effectivenesscaseforthediversionofpeoplewithschizophreniaoutofprisonandintothecommunitystillstands.

PHYSICAL HEALTH

AsdiscussedinSection1.5,thephysicalhealthofindividualswithschizophreniaandtheassociatedeconomicconsequenceshavelongbeenoverlooked.Interventionsforschizophreniaarerarelyanalysedfromaphysicalhealthperspective;thein-depthcost-consequenceanalysisoftheantipsychotic

Figure 6: Mean Differences in change in body weight between the treatment and control groups. End of treatment results include follow up, up to 6 months (95% CI in parentheses). Source: Faulkner et al. (2010)

Cognitive/BehaviouralIntervention

PharmacologicalIntervention

PreventingWeightGain

Mediumterm:

-3.38kg(-4.81kgto-1.96kg)

Endoftreatment:

-4.87kg(-7.11kgto-2.64kg)

Endoftreatment:

-1.16kg(-1.90kgto-0.41kg)

TreatingWeightGain

Mediumterm:

-1.69kg(-2.77kgto-0.61kg)

Endoftreatment:

-3.85kg(-4.25kgto-3.44kg)

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medicationaripiprazolewhichtookintoaccountrisksofdiabetesandcardio-vasculardiseaseundertakenbyBarnettandcolleagues(2009)isarareexception.Itisimportantthatphysicalhealthimplicationsofalltreatmentsberoutinelyconsideredinanalysesthatinformpolicydecisions.Belowwediscussevidenceoninterventionsthatarespecificallydesignedtotargetthephysicalhealthofindividualswithschizophrenia.

Interventions to reduce weight Respondingtohigherthanusuallevelsofoverweightandobesityamongstindividualswithschizophrenia,arangeofinterventionshavebeendevisedwhichaimtoreduceweight(eitherpreventweightgainortreatweightgain).Suchinterventionscanfallintothebroadcategoriesofcognitive-behaviouralinterventionsthatworkthroughchanginglifestylechoicesandpharmacologicalinterventions.

ArecentCochranereview(Faulkneretal.2010)ofsuchinterventionsfoundthatbothtypesofinterventions(withinwhichtherearemanydifferentspecificinterventions)wereeffectivebothatpreventingandtreatingweightgainintheshorttomediumterm.Figure6offersasummary.

Evenwhenthereissignificantweightreductionintheshortrunitisverydifficulttodrawconclusionsabouttheeconomicimpactofsuchinterventions.Thereislittleevidencewithwhichtodeterminewhetherornotanyreductioninweightissustainedintothelongerrun.Sincemanyoftheseinterventionsaredesignedtobeadministeredintheearlystagesofschizophrenia,theparticipants’riskofsufferingamajorphysicalhealthevent(suchasaheartattackorstroke)issmallintheshortterm,andsoevenifareductionofweightoccursthismaybeoflittleimportanceinincreasingoveralllifeexpectancyifweightreductionisnotsustained.Thus,tofullyunderstandtheeconomicconsequencesofinterventionsthataimtoreduceweightinpeoplewithschizophrenia,moreresearchisneededlookingattheextenttowhichweightlossissustained.18

Exercise TherapyExercisetherapyisaninterventionthatissometimesusedwiththeaimofincreasingmentalandphysicalwellbeing.ClinicaloutcomesreportedinarecentCochranereview(Gorczynski&Faulkner2011)weregenerallypositive,recordingsignificantimprovementsinmeasuresofmentalhealthandphysicalfitness.However,thelimitednumberofstudiesaddressingExerciseTherapyasatreatmentinschizophreniaandthelackofevidenceastohowchangesinphysicalfitnesstranslateintoeconomicconsequencesmeansthatnomoreanalysisispossiblehere.

Smoking CessationAsdiscussedinSection1.5,schizophreniaisassociatedwithalmostadoublingoftheriskoftobaccouse,whichinturnhasmanyadverseaffectsonphysicalhealth.Inresponse,avarietyofinterventionshavebeenconceptualisedinordertohelppeoplewithschizophreniastopsmoking,manyofwhicharebasedoninterventionsthathavepreviouslybeenshowntobeeffectiveforthepopulationasawhole.InarecentCochranereview,Tsoiandcolleagues(2010)foundevidencetosuggestthattheantidepressantbupropioncouldbeeffectiveathelpingpeopletoquit.However,toolittleevidencewasfoundinourreviewtodrawanymeaningfulconclusionsabouttheeffectsofothertreatmentssuchasnicotinereplacementtherapyandpsychosocialinterventions.

Intermsofcost-effectivenessevidence,littleanalysishasspecificallyaddressedthequestionofwhetherinterventionsdesignedtohelppeoplewithschizophreniatostopsmoking.OnerecentanalysisusedaMarkovmodeltoconsidertheeconomicimplicationsoften-weekinterventionofbupropionandco-interventions(grouptherapyeitheraloneorwincombinationwithnicotinereplacementtherapy)andcomparedthistoco-interventionsonly.Themodelestimatedthattheincrementalcost-effectivenessratioofthecombinedinterventionwas£385perQALY,wellbelowNICE’srecommendedthresholdforcosteffectiveness.Themodelpredictedthattherewasa95%chancethatthecombinedinterventionwasmorecost-effectivethantheco-interventionsonly(Winterbourne2012).

18. Current research in PSSRU at the LSE is looking at the economic case for weight loss/avoidance interventions for people in the early stage of their psychosis.

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SUBSTANCE MISUSE

AsdiscussedinSection1.8,substancemisuseamongstpeoplewithschizophreniahassignificantadverseeconomicconsequences,inpartthroughinflatingNHScostsandcriminaljusticesystemcosts.Thecomplexneedsofthispopulationareincreasinglybeingrecognised;NICEhasrecentlypublishedaguidelineonassessingandmanaging‘psychosiswithco-existingsubstancemisuse’.ClinicalpracticerecommendationsbyNICEaddressmanybroadareastoequipmentalhealthandsubstancemisuseservicestoworkeffectivelywithpeoplewhofallundertheremitofbothservices.Here,wesummarisetheavailableeconomicevidenceonpsychologicalandpsychosocialinterventionsthathavebeenspecificallydesignedforapopulationwithco-existingschizophreniaandsubstancemisuse.

Avarietyofpsychologicalandpsychosocialinterventionsarerecommendedforpeoplewithoneofschizophreniaorsubstancemisuse,butsomeevidencesuggeststhatindividualswithadualdiagnosiscanbeexcludedfromtheseinterventions(inparticular,manydonotreceiveanytreatmentforsubstancemisuse)(DepartmentofHealth2006).Thereforepsychologicalandpsychosocialinterventionshavebeendesignedspecificallyforthispopulationwithadualdiagnosis;theseinterventionsgenerallyinvolvesomecombinationofCBTandmotivationalinterviewing.

Theclinicaloutcomesrecordedbymeta-analysesinarecentCochranereview(Clearyetal.2010)andbyNICE(2011)aremixed,withsomeevidenceofsignificantimprovementsinsubstancemisuseandmentalhealth,althoughmanymeasuresshowednosignificantdifference.Samplesizesweregenerallysmall,aswerethenumberofrelevantstudiesavailable.

OnerandomisedtrialhasattemptedtostudytheeconomicconsequencesofaninterventionthatcombinedCBT,familyinterventionandmotivationalinterviewing(Haddock2003).Awiderangeofcostswastakenintoaccount,includinghealthservicecosts,travelcosts,productivitylossesandout-of-pocketexpenditures.Netofinterventioncosts(the

interventioncost£281319overan18monthperiod)itwasfoundthatmeantotalcostswere£1627lower(p=0.25)fortheinterventiongroupthanforthecontrolgroup(95%CI:£9012lessto£5759more).Netofinterventioncosts,meancostsincurredbythehealthservicewere£1554lowerfortheinterventiongroup.Theauthorsestimatedthattherewasa69.3%chancethattheinterventionwascost-saving(awillingnesstopayofzero).Ifthefavourableclinicalresultsproducedbytheinterventionweregivenvalue,theprobabilityoftheinterventionbeingcost-effectivewouldincrease.Whilstthisstudyshowssomepromisingresultsforsuchinterventions,thesmallsamplesizeandlackofothersimilartrialsmeancautionmustbeapplied.

HOMELESSNESS- TARGETED INTERVENTIONS / SUPPORTED HOUSING

AsdiscussedinSection1.4,peoplewithschizophreniaintheUKarehighlyvulnerabletobecominghomeless,withmajorimplicationsfortheirmentalandphysicalwell-being,andfordirectservicecosts,aswellasrepresentingahugewasteofeconomicpotential.Inrecognitionofthisproblemavarietyofdifferentinterventionshavebeenconceptualisedwhichaimtoreducetheincidenceofhomelessnessamongstpeoplewithseverementalillness.

Critical Time InterventionsACriticalTimeIntervention(CTI)is‘anindividual-levelinterventiondesignedtoreducetheriskofhomelessnessandotheradverseoutcomesinadultswithmentalillnessfollowingdischargefrominstitutionstocommunityliving’(Hermanetal.,2007).Suchinterventionstypicallylastaround9monthsandconsistofthreephases–thetransitionphase,thetry-outphaseandthetransferofcarephase.ACTIworkeroverseesthewholeinterventionandperformskeyrolesincludinghomevisits,co-ordinatingcare-givers(meetingwith,givingadvicetoandmediatingconflicts)anddevelopingplansforlong-termgoals(Hermanetal.,2007).

19. Updated to reflect current prices using PSSRU’s Pay and Prices Index. 20. Figure converted from US$ using PPP rates in 1992 and then uprated for inflation using the GDP deflator.

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Arandomisedcontrolledtrialtoexaminetheeffectivenessandcost-effectivenessofCTIwascarriedoutwithasampleof96mendischargedfromashelterinNewYorkCitybetween1991and1993.ThisstudyshowedtheCTIgroupexperiencedsignificantlyfewernightsofhomelessnessascomparedtothecontrolgroup(p=0.003)andsignificantlyfewerperiodsofextendedhomelessness(over54nights)(p=0.45)(Susseretal.1997).Are-analysisofthedataalsosuggestedasignificantreductioninchronichomelessness(Lennonetal.,2005).Acost-effectivenessanalysisofthesametrialrevealedthatmeancosts(includinginterventioncosts,mentalhealthcare,otherhealthcare,acuteservices,substanceabuseservices,housingservices,criminaljusticeandpublictransfers)werebroadlysimilaracrossthetwogroups:costsincurredbytheCTIgroupwere1.4%higherthanthoseincurredbythecontrols.

Thecostoftheinterventionwasalmostoffsetbyareductioninserviceuse(inparticularinacuteservices,supportedhousing,shelterservices).Theauthorsconcludedthatawillingnesstopayofmorethan£14720pernon-homelessnightmadeCTIacost-effectiveintervention.ThissuggestsCTIcouldpossiblybeacost-effectiveinterventionintheUKtoo,althoughmoreworkwouldneedtobedonetoseehowsuchinterventionscouldbeadaptedtoaUKcontext.

ArecentRCThascomparedoutcomesfollowingdischargefromapsychiatrichospitalinNewYorkCityofagroupreceivinga9-monthCTIserviceinadditiontousualcareandacontrolgroupreceivingonlyusualcare.ThisstudyestimatedthattheCTIserviceledtoafive-folddecreaseintheriskofhomelessness(Oddsratio:0.22,95%CI:0.06,0.88)(Hermanetal.2011).WhilstthisstudymakesnomentionofserviceuseorthecostsofprovidingCTI,suchadramaticreductioninhomelessnesssuggeststhisisanimportantinterventiontoconsider.

Althoughnodataareyetavailable,astudyledbytheUniversityofManchesteriscurrentlyevaluatingCTIforpeoplewithmentalhealthproblemsreleasedfromprison,

Assertive Community TreatmentAssertiveCommunityTreatment(ACT)referstoanoutpatientservicemodelgroundedonamobileteamdeliveringpsychiatriccareandcasemanagementtopeoplewithschizophreniawhomakeintensiveuseofinpatientservices.Theapproachwasnotdesignedspecificallytoaddresstheissueofhomelessnessamongstpeoplewithseverementalillness,althoughithasbeensuggestedthatACTmaybeaneffectiveinterventiontotackletheissue.

Wolffandcolleagues(1997)conductedacost-effectivenessanalysisofanRCTexaminingtheeffectofprovidingthreeformsofcasemanagementtoindividualswithseverementalillnesswhowereeitherhomelessoratriskofhomelessnessfromSt.Louis.WhilstACTservicesdidnotsignificantlyreducetheincidenceofhomelessnesstheauthorsdidfindthattherewasnosignificantdifferenceintotalcostsincurred(areductioninserviceuselargelyoffsethigherinterventioncostsofACT)andanimprovementinsymptomsandsatisfaction,indicatingACTmaybeacost-effectiveinterventionfordeliveringmentalhealthservicestothehomeless.AnotherRCTstudyingtheoutcomesofprovidingACTtohomelesspeoplewithseverementalillness,thistimeinBaltimore,foundpositive,butlargelyinsignificant,effectsonhousingoutcomes(Lehmanetal.1997).ThisstudysuggestednetsavingsfromtheimplementationofanACTservice:meancostpercase(netofinterventioncosts)wasfoundtobe24%lowerfortheACTgroupthanthecontrol.WhilstthesetwostudiesdoprovidesupportingevidenceforthepremisethatACTisacost-effectiveinterventionforhomelesspeoplewithseverementalillness,Rosenheck(2000)hasquestionedthegeneralizabilityoffindingssincebothstudieshadpatientswhoincurredmuchhighercosts(atbaseline)thantheUSnationalaverageandthusitmaybeeasiertoprovecost-effectivenessorcost-neutrality.

Arecentlarge-scale(non-randomised)studyofACTintheUSAsuggestedthatACTdidnotsignificantly(inthematchedsample)reducedhomelessnessyetcausedanetincreaseincosts,thusquestioningwhetherthisisthemosteffectivewaywithwhichtodealwiththeproblemofhomelessnessamongstpeoplewithschizophrenia(Sladeetal.2012).

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TheabovestudieswereallconducedintheUSAandthefirsttwoarenowquitedated,meaningquestionsmustbeaskedabouttherelevanceofthesefindingsfortheUKtoday.ThemostrecentRCTstudyinghigh-fidelityACTintheUKfoundnoreductioninserviceuseforACTserviceusers-indeedtotalin-patientdayswerehigher(butinsignificant)fortheACTgroupthanforthecommunitymentalhealthteamgroup(Killaspyetal.2009).Whilstthestudydidnotreportonhomelessnessdirectly,itraisesquestionsabouttheaddedbenefitthatACTservicesbringaboveandbeyondCommunityMentalHealthTeamsinaUKcontext,notleastbecausemany‘standard’communityservicesnowembodytheprinciplesofassertiveoutreach(Burnsetal2001).

Outreach ProgrammesOutreachprogrammesaimtoimproveoutcomesforhomelesspeoplewithmentalillnessbyengagingwithhomelesspeoplewhoareunwillingtofindhelpontheirownandprovidinghelptosuchgroups.

TheonlyoutreachprogrammeevaluatedwithanexperimentaldesignistheNewYorkChoicesprogramme.Thisconsistedoffourmainelements:(1)outreachandengagement,(2)invitationtotheChoicesCentre,(3)respitehousing,and(4)in-communityandon-siterehabilitationservices(Shernetal.2000).Byusingavailableserviceusedata,Rosenheck(2000)estimatedthattheserviceincreasedcosts,boththroughtheadditionalinterventioncostsandthroughincreasedserviceusecostsasmorepeoplewerebroughtintoservices.

Similarly,byestimatingthecostimplicationsfromserviceutilisationdata,Rosenheck(2000)estimatedthattheAccesstoCommunityCareandEffectiveSupportiveServicesProgram(Lam&Rosenheck1999)wasacost-increasinginterventionbutwaseffectiveinimprovingaccesstohousingandimprovingsymptoms.Likewise,anobservationalstudyoftheDepartmentforVeteran’sAffairsveteran’sprogramshowedhealthcarecosts(bothinpatientandoutpatient)increasedsignificantlywithoutreachcontact,withanobservedincreaseinhealthcarecostsof13%.Whenthecostsoftheinterventionarealsoadded,the

observedincreaseincostsintheyearafterfirstoutreachcontactwas36%(Rosenhecketal.1993).

Bythedefinitionofoutreach,theseprogrammesveryoftenbringpeopleintocontactwithserviceswhomaynototherwisehavebeenso,andthusmaywellincreaseserviceusecostsaswellasimprovingoutcomes.Thisdoesnotmeantheseprogrammesarenotcost-effective,buttheircosteffectivenessliesinthebalanceoftheextracoststheyincur,theimprovementinoutcomesandthevaluesocietyplacesonthoseimprovements.

Supported HousingSupportedhousingforpeoplewithschizophreniaisseenasacrucialcomponentofcareforthosewhomaynotbeabletoliveindependentlyinthecommunity(Lelliottetal.1996;Priebeetal.2009).High-qualitysupportedhousinginterventionsmayreducethenumberofpeoplewithschizophreniawhobecomehomeless(Macpherson2004).Surprisinglyveryfewhigh-qualitystudieshaveattemptedtoaddresstheimplicationsofsupportedhousingforpeoplewithschizophrenia(orseverementalillnessingeneral).Indeed,arecentCochranereviewonthesubjectfoundthatnostudiesmettheirinclusioncriteria(Chilversetal.2010).

Studieshaveaddressedtheissuebutgiventheirmethodologicalweaknessesresultsmustbeinterpretedwithcaution.OnestudyinBoston,MassachusettsrandomisedparticipantstoeitherEvolvingConsumerHouseholds(wherepeoplewithschizophrenialivedingroupsand,intheearlystages,hadmuchsupportfromprogrammeworkers)orIndependentLivingapartments.Housingandclinicaloutcomeswerenotsignificantlydifferentbetweenthetwogroups,butcostsfortheEvolvingConsumerHouseholdsgroupweremuchgreaterduetotheadditionalhousingcosts(Dickeyetal.1997;Rosenheck2000).AnobservationalstudyoftheDepartmentforVeteran’sAffairsHomelessChronicallyMentallyIllVeteransPrograminwhichhomelesspeoplewithmentalillnessweregiventime-limitedtreatmentinahalfwayhousesuggestedthatresidentialtreatmentledtosuperioroutcomes

21. Uprated to reflect current prices using PSSRU’s Pay and Prices Index22. Uprated to reflect current prices using PSSRU’s Pay and Prices Index.23. All costs uprated to reflect current prices using PSSRU’s Pay and Prices Index.

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butincreasedcosts:meancostsfortheresidentialtreatmentgroupwere53%higherthanforthecasemanagementgroup(Liptonetal.1988;Rosenheck2000).

Theevidenceonthecost-effectivenessofsupportedhousinginterventionsinthecontextoftacklinghomelessnessismixed.Thereisaneedforrobuststudiesinthisarea.

CRISIS TEAMS

CrisisResolutionHomeTreatment(CRHT)teamswereestablishedintheNHSfollowingtheirrecommendationintheNationalServiceFrameworkin1999(DepartmentofHealth1999).Theaimoftheseteamsistoprovideintensivetreatmentandsupportinthecommunitytothoseundergoingaseverementalhealthcrisisthatwouldotherwiseresultinadmissiontoaninpatientunit.EffectiveCRHTteamsreduceinpatientusage,boththroughreducingtheprobabilitythatanadmissionwouldoccur(actingasasocalled“gatekeeper”)andbyallowingforearlierdischarge.

StudiessuggestsavingscanbemadefromCRHTteamswhentheyareimplementedwithhighfidelity.Aprospectivenon-randomisedstudycomparedservicecostsofpatientsbeforeandaftertheimplementationofaCRHTteaminSouthIslington(McCroneetal.2009).ItwasfoundthatmeancostsforthecohortfollowingtheimplementationoftheCrisisResolutionteamwere£173821lowerthanbeforetheservice,althoughthisdifferencewasnotstatisticallysignificant.AsubsequenteconomicevaluationalongsidearandomisedcontrolledtrialexaminingtheeffectsofaCrisisResolutionTeaminNorthIslingtonfoundthatmeantotalserviceusecostswere£252022(90%CI:£969to£4054)lowerforthoserandomisedintotheCRTgroup(McCroneetal.2009a).

However,studieslookingattheeffectsoftheimplementationofCRHTteamsastheyhavebeenimplementedandareworkinginpracticehavebeenslightlymoremixed.Aninitialanalysisshowedapositiveeffectoninpatientadmissionswithadmissionsfallingbyanaverageof10%(95%CI:1.7%to18.1%)moreinthe34areaswhichhadhadCRHTteamsinplaceforthepasttwoyearsandby23%(95%CI:7.1%to38.4%)moreinthe12areas

whichoperated24hoursaday,comparedwiththe130areaswithoutCRHTteams(Gloveretal.2006).However,reanalysisofthesameadmissiondatareachedadifferentconclusion.Thereanalysisusedadifference-in-differencemodelandcontrolledforconfoundingvariablessuchasdeprivation,substancemisuse,age,gender,populationdensity,region,lengthofstayandfidelityofservices.TheCRHTindicatorvariablewasnotsignificant.ThisanalysisledtheauthorstotheconclusionthattheimplementationofaCRHT per se didnotdecreaseadmissionrates(Jacobs&Barrenho2011).However,thisperhapsreflectsthefactthatwhileinpatientuseforthosereceivingCHRTinputfalls,beduseforanareamaybemaintainedduetotheexistenceofexcessdemand.

EarlierworkbytheNationalAuditOffice(2007)suggestedthatwhileCRHTteamswerehavingapositiveimpactoninpatientbeduse,teamswereoftennotutilisedtotheirfullpotential.Thesurveyof500admissionstheycarriedoutsuggestedthatonlyhalf(asopposedtoall)ofadmissionshadbeenassessedbyaCRHTteamandthat20%ofadmissionscouldhavebeensuitableforCRHTinstead.EconomicanalysisfortheNAO,usingadecisionmodellingframework,estimatedasavingof£69023percrisisepisodewithfullutilisationofaCRHTteamversuswhennosuchservicewasavailable.Thiseconomicanalysisconcludedthatatleast£13.7millioncouldbesavedeachyearifteamsinwhichabelow-averageproportionofcasesinvolvedCRHTinvolvementcouldincreaseinvolvementtotheaveragerateof53%.Theyestimatedpotentialsavingsof£59millionayeariftheinvolvementratewas90%forallteams.

LikewiseareportbytheHealthcareCommission(2008)suggestedthatCRHTteamswerenotasfullyutilisedasintended.Duringasix-monthstudyperiod,CRHTswereinvolvedinonly61%ofalmost40,000admissionstoacutewards,withverysubstantialvariationsacrossthecountry(ratesrangedfrom9%to100%).Likewise,only25%ofalmost40,000dischargesfromacutewardsoccurredearlywithCRHTsupport(ratesrangedfrom0%to70%).ThisevidencesuggeststhatthereducedinpatientbedusefollowingtheintroductionofCRHTteamsisnotasgreatasitcouldbe,whichinturnsuggeststhatfurthercostsavingscouldbemadeiffullerusewasmadeofCRHTteams.

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PEER-SUPPORT WORKERS

Soloman(2004)definespeersupportas‘socialemotionalsupport,frequentlycoupledwithinstrumentalsupport,thatismutuallyofferedorprovidedbypersonshavingamentalhealthconditiontootherssharingasimilarmentalhealthconditiontobringaboutadesiredsocialorpersonalchange.’Suchsupportmaybedeliveredvoluntarilyorbefinanciallyremunerated.Itcantakedifferentforms:self-helpgroups,internetsupportgroups,peer-deliveredservices,peer-runoroperatedservicesandpeeremployees(Solomon2004).Generallyanimportantdistinctionisthattheseservicesareunlikemutualsupportbecausepeer-supportworkersreceivetrainingandsupervision(Repper2011).Whilstsomeoftheseserviceslikeself-helpgroupshavelongformedapart,albeitoftenaninformalpart,ofrecoveryfrommentalillnessintheNationalHealthService,othersarerelativelynewandhaveyettobecomemainstreamcomponentsofcare.

Peer-supportworkersare,atthesimplestlevel,peoplewhohaveexperiencedlivingwithadiagnosisofseverementalillnessandhavebeenabletorecover.RecoveryemergedasapsychiatricconceptintheEnglish-speakingworldinthe1970sandhaslargelyovertakentheprevioustraditionalmedicalmodelintheUS(Davidson2005).Itdefinesthehealthoutcomeasoverallwellbeingbeyondsymptommanagement.Ofcentralimportanceinthe‘recovery’approachistheverydifferentexpectationthatpatientscanleadnormallives,secureemployment,furthereducationandtraining,andindependenthousing.Peer-supportworkersarethosethatare‘furtheralongtheirroadtorecovery‘(Deegan1996;Repper&Carter2011;Davidsonetal.2006).Peer-supportworkersarethoughttobenefitpatientsbysharingtheirexperience,provideanempatheticandreciprocalrelationship,andarebetterabletoprovidehopeandencouragement,whichincombinationprovidepatientswithempowerment,confidence,andincreasedself-esteemthatfacilitatestherecoveryprocess(Kleinetal.1998;Forchuketal.2005;Davidsonetal.2006;Lawn2007;Riveraetal.2007;Repper&Carter2011).

Theevidencebaseonpeer-supportworkerslargelycomesfromtheUSandasrecentlyas2003itbecameafederallyreimbursedservice(ThePresident’sNewFreedomCommissiononMentalHealth2003).InaforthcomingreportfromtheCentreforMentalHealth,itwasfoundthatpeer-supportworkersareacost-effectivecomponentofservicedelivery.

Theevidencebaseonpeer-supportworkersstaffedinadjunctpositionsisgrowingandfairlyextensive,althoughisalsoheterogeneouswithrespecttothefunctionsandservicemodelsinwhichtheyareemployed.IntheforthcomingreportfromtheCentreforMentalHealth,theauthorsidentifiedsevenstudiesofgooddesign,amajorityofwhichwereeitherrandomizedorobservationalstudies,withonestudyrelyingonexpertopinionfortheestimationofhospitaldayssaved.Generallyitwasfoundthatonepeer-supportworkercouldsaveasignificantnumberofhospitaldaysperindividualperyearandtheevidencebaseseemsverypositiveinthisregard.TheestimatesusedbytheCentreforMentalHealthareconservative,reflectingminimumsavings,althoughthestudiesthemselveshavereportedgreaterreductions.TheCentreforMentalHealth,usingUKcosts,foundthatthereisanalmostcertainlikelihoodthatpeer-supportworkers,ifemployedandpaidascommunitysupportworkers,wouldgeneratenetcostsavings.Acrosstheeightstudies,thetotalsamplesizeforthecontrolandinterventiongroupswascloseto1,000each(CentreforMentalHealth,forthcoming).Intheseincludedstudies,healthbenefitswereeitherthesameas,ifnotbetterthanforindividualswithoutpeersupport.

Analternativemodelforpeersupportiswhenworkersareemployedinexistingcasemanagerroles.Here,threestudiesfoundnoworsenedoutcomesandpeer-supportworkerscouldfunctioninthesamewayascasemanagerswithnoexperienceofseverementalillness(Solomon&Draine1995;Clarkeetal.2000;Schmidtetal.2008).Thestudiesfoundnostatisticallysignificantdifferencebetweenindividualsinrelationtohealthorserviceuseoutcomesattheendofthestudy.Whileitwasexpectedthatpatientswouldexperienceimprovedoutcomes,atleastinserviceuse,

24. Uprated to reflect current prices using the Pay and Prices Index reported in the PSSRU unit costs volume.

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Schmidt(2008)hypothesizesthismaybeduetopeer-supportworkersadoptingtheprofessionalculturetofitinandthusdownplaytheirmedicalhistoryandrelylessontheirpersonalexperience.Thesestudieswererandomizedcontroltrialswithsamplesizesoflessthan50ineachgroup;Clarkeetal(2000)replicatedthesamestudydesignasSolomonandDraine(1995),comparinganinterventionteamfullystaffedwithpeer-supportworkersascasemanagersandthecontrolteamstaffedwithcasemanagerswithnopersonalexperienceofasevermentalillnessdiagnosis.ThestudybySchmidt(2008)maybelimitedinitsabilitytodetectdifferencesbecausetheinterventionwasstaffedbyonlyonepeer-supportworkerasacasemanagerinateamofsixwiththeanalysisongroupdifferences,limitingtheabilitytodetectanydifferencesiftherewereany.

Itis,however,difficulttodrawfirmconclusionsfromjustthreestudiesfocusingonthecost-effectivenessintermsofhospitalization,andfurtherresearchinthisareaisclearlyneeded.

Itisalsoworthnotingthatthebenefitsofemployingpeer-supportworkersincludenotjustbenefitsrelatingtothepeopletheysupport,butalsobenefitstotheworkersthemselvesintermsofbeingingainfulemploymentandalltheassociatedrewardsthatthisbrings.

Inconclusion,furtherresearchwouldhelptogeneratestrongerconclusionsabouttheeconomicimplicationsofpeer-supportworkers.Weareawareofanumberofongoingprojectsinvolvingpeersupport(Williams2011;MentalHealthFoundation2012)anditishopedthatthesewillcontributehelpfullytotheevidencebase.However,themostrecentworkbytheCentreforMentalHealthreachesasimilarconclusiontopreviousliteraturereviews(Davidsonetal.1999;Simpson&House2002;Doughty&Tse2011;Repper&Carter2011;Wright-Berrymanetal.2011;Davidsonetal.2012)thattheresultsarepromisingandthattherearehealthbenefits.TheCentre’srecentwork,however,placesmoreconfidencethanpreviousreviewsintheassertionthattherearesignificantreductionsinhospitaldays,giventheenhancedevidencebasenowavailable.

ADVANCED TREATMENT DIRECTIVES

AdvancedTreatmentDirectivesaredocumentsdrawnuptoexpressapatientorserviceuser’spreferencesconcerningtreatmentoptionsandotherarrangementsintheeventoftheindividuallosingthecapacitytomakethatdecisioninthefuture.ThepreferencesexpressedinsuchdocumentscanbeoverriddenusingtheMentalHealthAct,buttheNICEguidelines(2009)statethat‘healthcareprofessionalsshouldendeavourtohonouradvancedecisionsandstatementswhereverpossible’.Suchdirectiveshavestrongethicalappealastheygivepeoplewithschizophreniaarighttoself-determination(includingtherighttorefusetreatment)attimeswhentheymaylackcapacity.Inaddition,therearehopesthatsuchdirectivescoulddecreasetheuseofcoercionandinvoluntaryadmissionduringperiodsofrelapse,possiblyresultinginreducedserviceuse.

ArecentCochranesystematicreviewofAdvancedTreatmentDirectivesfoundjusttwopublishedstudiesthatmetitsinclusioncriteria(moststudiesonthesubjectwerenon-randomisedandthereforeexcluded).ThefirstincludedstudywasanRCTexaminingtheeffectsofmakingalow-intensityAdvancedTreatmentDirectiveinterventionwherepeoplewithschizophreniawereencouragedtofillinabookletcontainingsevenpreferencestatements(e.g.‘IfIdoseemtobebecomingillagainIwouldlike…’and‘IfIhavetobeadmittedtohospitalagainIwouldlike…’).Thestudyinvestigatedtheeffectsoftheinterventiononcompulsoryre-admissionratesfor156individualsabouttobedischargedfromtwopsychiatricinpatientunitsinLondon(Papageorgiouetal.2002).Thestudyfoundnosignificantdifferencesinvoluntaryorinvoluntaryreadmissionintheone-yearfollow-upperiod.

Thesecondstudywasasingle-blindRCTmeasuringtheeffectsofajointcrisisplanthatwas‘formulatedbythepatient,carecoordinator,psychiatristandtheprojectworkerandcontainedcontactinformation,detailsofmentalandphysicalillnesses,treatments,indicatorsforrelapse,andadvancestatementsofpreferencesforcareintheeventoffuturerelapse’(Hendersonetal.2004).ThisstudywasalsocarriedoutintheUK.Itfoundthat

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compulsoryadmissionsweresignificantly(p=0.028)lowerfortheinterventiongroupthanforthecontrolgroup,withariskratioof0.48(95%CI:0.25to0.95).Inotherwords,thestudyestimatedthattheinterventionreducedcompulsoryadmissionsbymorethanonehalf.Aneconomicevaluationofthestudyestimatedthattheservicecostsincurredbytheinterventiongroupwere£121024lower,althoughthisdifferencewasnotstatisticallysignificant(95%CI:-£3109to£5529).Theauthorsconcludedthattherewasagreaterthan78%chancethattheJointCrisisPlansaremorecost-effectivethanstandardserviceinformation(Floodetal.2007).

Jankovic(2010)suggestedtheobserveddifferencesinoutcomesbetweenthesetwostudiescouldbeduetothefactthatPapageorgiuoandcolleagues’studylookedonlyatpeopleabouttobedischargedwhohadbeenundergoingtreatmentundersections2,3or4oftheMentalHealthAct,whereasHendersonandcolleagueslookedatabroadergroupofpeople–anyonewithanoperationaldiagnosisofpsychoticillnessornon-psychoticbipolardisorderwhohadexperiencedhospitaladmissionwithintheprevioustwoyears.Additionally,theinterventionswereverydifferent,onebeingalow-intensitybookletnotsupportedbytheserviceuser’smentalhealthteam,whilsttheotherinterventionfullyinvolvedmanystakeholders.

Thereseemstobesomepositiveevidencethat,aswellasincreasingself-determinationofserviceusers,AdvanceDirectivesmayresultinlowerserviceuseandservicecosts.Moreevidenceis,however,neededbeforeafirmconclusioncouldbedrawnonthisissue.TwostudyprotocolshavebeenidentifieddescribingRCTscurrentlyinprogressexaminingtheeffectsofAdvancedDirectivesonserviceuseandcosts(Thornicroftetal.2010;Ruchlewskaetal.2009).ThesestudiesaretakingplaceintheUKandtheNetherlandsrespectively.TheresultsandanalysisofthesestudieswillhopefullyallowmoreconclusiveinferencestobemadeontheeconomicimplicationsofAdvanceDirectives.

COGNITIVE BEHAVIOUR THERAPY

CognitiveBehaviourTherapy(CBT)isashort-termtalkingtherapytypicallycomprisingofbetweenfiveandtwentyweeklysessionswithhomeworkbetweensessions.Asitsnamewouldsuggest,CBTfocusesonthinkingpatternsandbehaviour,oftenbreakingdownproblemsintosmallcomponentssothatstraightforwardinterventionscanbeidentifiedtoaddresstheseproblems.CBTsessionsoftencompriseofdiscussionswiththetherapistaboutnegativebeliefsandbehaviouralexperimentsinwhichbeliefsaretestedthrough

25. This and other costs quoted in this paragraph were uprated to reflect current prices using the Pay and Prices Index in the PSSRU volume.

26. Uprated to reflect current prices.

Figure 7: Re-hospitalisation rates with CBT from Jones and colleagues (2012)

Rehospitalisation Pooledsamplesize EstimatedRiskRatio95%Confidence

interval

Shortterm 136 0.36 0.11to1.13

Mediumterm 132 0.59 0.27to1.30

Longterm 294 0.86 0.61to1.20

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behaviouralchanges.TheelementsofCBTthataredifferentfromotherpsychologicaltherapiesarethehighlystructurednatureofthetherapy,thefocuspredominantlyonthehere-and-nowanditspracticalnature.CBThasbeenshowntobebeneficialinthetreatmentofawiderangeofmentalhealthconditionsincludingdepressionandanxietydisorders.MorerecentlyithasbeenrecognisedthatCBTmayalsobebeneficialforindividualswithschizophreniabyhelpingthemcopewithunhelpfulthoughtsandbehaviours.CBTisformallyrecommendedbyNICEyetinpracticethetherapyisnotavailableinEnglandforthemajorityofpeoplewithschizophrenia.

Byhelpingpeoplewithschizophreniatoaddressnegativethoughtsandbehaviours,CBTmaybehelpfulinreducingrelapsethusreducingserviceusage.Inaddition,CBTmayequipindividualswithcopingmechanismstoreturntoemployment,thusprovidingadditionaleconomicbenefits.

Service UseArecentCochranesystematicreview(Jonesetal.2012)comparedCBTwithotherpsychosocialtreatments(both‘active’and‘non-active’therapies).Ameta-analysisofrelevantstudiesthatmettheinclusioncriteriaestimatedthatCBTreduced(butnotsignificantly)readmissionratesintheshort,mediumandlongrun.AsshowninFigure7,theestimatedeffectsizewasfairlylarge,butresultswerenotstatisticallysignificantduetoalargevarianceandrelativelysmallpooledsamplesize.MoreevidenceisneededbeforeafirmerconclusioncouldbedrawnastohowCBTimpactsonadmissionratesvis-à-visotherpsychologicaltherapies.

However,sincemanypeoplewithschizophreniadonothaveaccesstoanykindofpsychologicaltherapy,thequestionofwhichpsychologicaltherapymaybeseenaslessrelevant.Formentalhealthserviceswhodonot,asyet,offeranyformofpsychologicaltherapy,amorerelevantquestionforeconomicevaluationiswhatarethecostsandbenefitsofofferingCBToranotherpsychologicaltherapyascomparedtoofferingnosuchservice.Anotherpsychologicaltherapythathasbeenevaluated

forpeoplewithschizophreniaiscognitiveremediationtherapy,forwhichthereissomeencouragingevidenceonbotheffectivenessandcost-effectiveness(Wykesetal.2007,Pateletal.2010).Anearlierstudyevaluatedwhatwascalled‘compliance(oradherence)therapy’forpeoplewhowereleavinganinpatientsettingtoreturntothecommunity(Healeyetal.1998).Itfoundcost-effectivenessadvantagesfortheintervention,whichincludedmotivationalinterviewing,butasubsequentmulti-siteEuropeanstudydidnotreplicatethefindingsofeffectivenessorcost-effectiveness(Pateletal.2012).

SimpleeconomicmodellingbyNICEinvolvedameta-analysisoffiveRCTs(themostrecentbeing2003)toobtainarelativeriskratioofhospitalisationof0.74forCBTplusstandardcarecomparedtostandardcarealone(95%CI:0.61to0.94).ThisanalysisestimatedthatafullcourseofCBT,involving16individuallydeliveredsessionswithaclinicalpsychologist,eachofonehourinduration,cost£1184.25However,thereductioninhospitalisationratesimpliedbythemeta-analysisledNICEtoestimateareductioninhospitalisationcostof£2277,resultinginanetsavingduetoCBTof£989.Intheirsensitivityanalysis,varyingrehospitalisationratestotheboundsofthe95%confidenceinterval,theestimatednetcostofprovidingCBTrangedbetween-£1124(anetsaving)and£829.However,morerecentcontrolledtrialssuggestthattheeffectivenessofCBTonreducingrelapseandhospitalisationratesmaybelowerthanthatassumedusedinNICE’smodelling.TheRCTsidentifiedbyarecentreview(Lynchetal.2010)foundnosignificantdifferenceinrelapseratesbetweenCBTandcontrolgroups(Bechdolfetal.2004;Tarrieretal.2004;Valmaggiaetal.2005;Barrowcloughetal.2006;Garetyetal.2008),althoughsomeofthesetrialsweretestinggroupCBTwhichmayaffectfidelityandoutcomes.

OtherstudieshaveattemptedtoanalysethecostimplicationsofCBTdirectlybyrecordingserviceuseandcalculatingassociatedcosts.EconomicoutcomeswererecordedinanRCTofCBTforacuteschizophreniainNorthWales(Startupetal.2005).Positiveclinicaloutcomes

27. Converted into pounds sterling using PPP exchange rate as reported by OECD iLibrary. 28. Converted into pounds sterling using PPP exchange rate as reported by OECD iLibrary.

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werereported,withtheCBTgroupscoringsignificantlyhigherthanthecontrolgrouponpositivesymptoms,negativesymptomsandsocialfunctionataone-yearfollow-up,andsignificantlyhigheronnegativesymptomsandsocialfunctioningatthetwo-yearfollow-up.(Theyalsoappearedtoscorehigheronpositivesymptomsatthetwo-yearfollow-up,butthedifferencewasnotstatisticallysignificant.)TheeconomicevaluationofthetrialshowedthatthemeancostofprovidingCBTwas£914,26butthiscostwasoffsetbyareductioninserviceuse.Meantotalcostsoverthetwo-yearperiodwereslightlylowerfortheCBTgroupbutthedifferencewasnotsignificant(p=0.94).ThistrialprovidespositiveevidencefortheclaimthatCBTisacost-effectivetreatmentforschizophrenia,providingsuperiorclinicaloutcomesforthesamecost.

AmorerecentRCTinvestigatingcostsassociatedwithCBTintheNetherlands(VanDerGaagetal.2011)foundthatCBTwasassociatedwithbetterclinicaloutcomesthantreatmentasusual(183daysofnormalsocialfunctioningvs.106,p<0.05)buthighercosts:theCBTgrouphadmeantotalcostsof£286027higherthanthecomparisongroupoveran18-monthperiod,althoughthisdifferencewasnotsignificant.Theauthorscalculatedacostof£3928peradditionaldayofnormalfunctioninggained,whichsuggestedthatCBTforschizophreniacouldbeacost-effectiveinterventioninschizophreniaifsocietyiswillingtopaythisprice.

EmploymentIfCBTdoesimproveoutcomesandpreventrelapseinschizophrenia,thismayleadtoincreasesinemployment,inturnleadingtoadditionalbenefits,bothtotheExchequerandtosociety.However,fewstudiescouldbeidentifiedthatincludedemploymentasameasuredoutcome.Gumleyandcolleagues(2003)foundemploymentincreased2.1timesmorefrombaselineintheCBTgroupthaninthetreatmentasnormalgroupbutthiswasnotsignificantatconventionallevels.

Anotherstudy(Lysakeretal.2005)investigatedtheuseof‘enhancedcognitive–behaviouraltherapyforvocationalrehabilitationinschizophrenia.’Fiftyparticipantswereoffered6-monthworkplacements,andwererandomisedtoreceiveeitherstandardvocationalservicesoraprogrammebasedonCBTtechniquestotargetbeliefsthatmightaffectvocationalfunctioning.Resultswereencouraging:comparedtostandardvocationalservicesgroup,theCBTgroupworkedformoreweeks(p=0.02)andmorehours(p=0.06).CautionmustbeexercisedinapplyingtheseconclusionstohowstandardCBTmightaffectemploymentoutcomessincethisCBTprogrammewasdesignedspecificallytohelpitsparticipantsinaworkenvironment,andthereforetheeffectmaybelargerthanformoretypicalCBTcourses.However,thisstudydoessuggestthattheremaybeadditionaleconomicbenefitstoCBT(inadditiontoanyreductioninserviceuse)throughanincreaseinpaidemployment(andthusanincreaseintaxrevenueandareductioninbenefitsdependence).

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Inthisreportwehavedescribedboththemaincostsassociatedwithschizophreniaandtheeconomicimplicationsofavarietyofinterventions.Theinterventionsconsideredincludesomethatarecurrentlywidelyusedinpractice,aswellassomethathaveyettobefullyexploredorappliedintheUK,andarenot,generallyspeaking,incorporatedintomainstreamcare,supportandtreatmentarrangements.Inconcludingweofferafewbriefcomments.

CONCLUSIONS

First,wehavefoundmanyareaswhereboththeavailabilityandqualityofeconomicevidencearedisappointing.Thishaslimitedourabilitytosayverymuchaboutthelikelyeconomicconsequencesofsomepromising-lookinginterventions,andinsomeothercasesithasmeantthatwecanonlysetoutsuchconsequencesoverrelativelyshorttimeperiods.Schizophreniaisanillnesswithpotentiallylifelongimplicationsforindividualsandfamilies,anditwouldbehelpfuliftheassociatedeconomicimpactsofboththeillnessandinterventionsthatmightbeaccessedcouldbemorereliablyprojected.

Whatisclearfromtheevidencethatwewereabletocollateinthisreportisthatschizophreniahasverysignificanteconomicconsequencesforsociety.Whilstsomeofthecostsestimatedinpreviousstudiesareunavoidable,giventhenatureofschizophrenia–because,formostpeople,theillnesswillneedtreatmentofsomekindforsomeperiodoftime–thereisneverthelessstrongevidencethatseveralinterventionsthatarenotcurrentlyinwidespreadusecouldreducetheoverallcostofschizophreniawhileimprovehealthandqualityoflifeoutcomesforpeoplewiththeillnessandfortheirfamilies.

Buttherearechallengesingettingtherightresponsestothisevidence.Onechallengeisobviouslythegeneraleconomicclimate,particularlyinviewoftheausteritymeasuresbeingimplementedacrosspublicandnon-publicsectorsalike.Itishardlyagreattimetobeproposingadditionalpublicexpenditureunlesssavingscanbeexpected.Moreover,thosesavingswillneedtobesecuredinrelativelyshorttimescales,whereassomeoftheevidenceinsupportofinterventionsdiscussedinthisreportsuggeststhattheeconomicadvantagesmighttakeanumberofmanyyearstobefullyrealised.

Alinkedchallengeisthatmanyinterventionsrequireexpenditurebyonepartofthepublicsector(andoftenthiswillbetheNHS),whilemanyofthepayoffsintermsofsavings,improvedproductivityandsooncouldwellbeseeninotherpartsofthepublicsectororelsewhere.Oneconsequenceandchallengeislikelytobeaneedfornegotiationtoagreejointcoursesofactionacrossgovernmentdepartments,localcouncilbudgetareasormorewidely.Withoutsuchcoordination,itcouldhardtoaddresswhatareclearlypressingissuesforindividuals,familiesandcommunities.

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Someinterventionswillnotproducesavingsthataresufficienttocoverthefullcostoftheinitialinvestmentorthecontinuedsupportofindividualswithschizophrenia.Inotherwords,thoseinterventionscouldcostmorethantheysave.Thisisabsolutelynoreasonfornotexploringthoseoptionsfurther,becausethevastmajorityofinterventionsin,forexample,thehealthfieldorthecriminaljusticesystemalsodonotgeneratesavingsthatexceedexpenditures.Thecrucialquestioniswhetherthereturnstothoseexpendituresarejustified,andthatmeansmakingcomparisonsofcostsandoutcomesbetweeninterventions,notjustforpeoplewithschizophreniabutforpeoplewithotherhealthneeds,andindeedincomparisontootherareasofpublicexpenditure.

Thereis,finally,alsothequestionofinequalities,whichwehavebarelytouchedoninthisreport.Becauseofthedevastatingimpactofanillnesslikeschizophrenia,peoplewiththeconditionoftenfindthemselvesinpersonaleconomicdifficulties.Manypeoplewithschizophreniaaresociallyisolatedorinotherwayssociallyaswellaseconomicallyexcluded.Interventionsthathavethepotentialtoimprovetheirqualityoflifeshouldbeconsiderednotjustongroundsofefficiency(i.e.whetherthehealthorqualityoflifegainsjustifythecosts),butalsoonthegroundsofequity.Inotherwords,dothoseinterventionshelptobreakdownotherwiseentrenchedpositionsofsocialexclusion,creatingbetterlifechances?

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The authors can be contacted through: Personal Social Services Research UnitLondon School of Economics and Political ScienceHoughton StreetLondon, WC2A 2AE Email: pssru@lse.ac.ukTel: +44 (0)20 7955 6238Fax: +44 (0)20 7955 6131Twitter: @PSSRU_LSEwww.pssru.ac.uk

To read more about the work of the Schizophrenia Commission, go to www.schizophreniacommission.org.uk

This report should be referenced as: Andrews A, Knapp M, McCrone P, Parsonage M, Trachtenberg M (2012) Effective interventions in schizophrenia the economic case: A report prepared for the Schizophrenia Commission. London: Rethink Mental Illness.

The Schizophrenia Commission is an independent group set up and funded by Rethink Mental Illness (Registered charity number 271028).

For further information on Rethink Mental Illness telephone: 0300 5000 927, email: info@rethink.org, website: www.rethink.org