Health economics and mental health service planning

Meet the patient

A 34-year-old man with treatment-responsive psychosis has been in an emergency department for nineteen hours. The crisis team is full, the assertive outreach team has a six-month wait, and the nearest inpatient bed is two hundred kilometres away. He has been admitted four times this year, each admission costing the system more than a year of an outreach place would have.[3][14]

The economics question is not abstract. Why does the most expensive option — repeated crisis admission — keep being the only one the system funds?[3][14]

This topic is the answer, and it is the one place in the fellowship where the wards and the spreadsheet describe the same failure. Every number below maps to a patient whose care was decided by a budget line drawn without an evidence-based alternative.[3][10]

Etymology worth one viva line: economy, from Greek oikonomia — management of a household. The word asks who keeps the house, who pays for the heating, and what gets thrown out when the money runs short. Mental health systems are households too.[3][11]

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1. [1]Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010 Lancet, 2013.PMID 23993280
2. [2]Prince M, Patel V, Saxena S, et al. No health without mental health Lancet, 2007.PMID 17804063
3. [3]Saxena S, Thornicroft G, Knapp M, Whiteford H Resources for mental health: scarcity, inequity, and inefficiency Lancet, 2007.PMID 17804062
4. [4]Saraceno B, van Ommeren M, Batniji R, et al. Barriers to improvement of mental health services in low-income and middle-income countries Lancet, 2007.PMID 17804061
5. [5]Patel V, Araya R, Chatterjee S, et al. Treatment and prevention of mental disorders in low-income and middle-income countries Lancet, 2007.PMID 17804058
6. [6]Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development Lancet, 2018.PMID 30314863
7. [7]Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in 14 world regions Br J Psychiatry, 2004.PMID 15123502
8. [8]Andrews G, Sanderson K, Corry J, et al. Cost-effectiveness of current and optimal treatment for schizophrenia Br J Psychiatry, 2003.PMID 14594918
9. [9]Haby MM, Carter R, Mihalopoulos C, et al. Assessing Cost-Effectiveness--Mental Health: introduction to the study and methods Aust N Z J Psychiatry, 2004.PMID 15298579
10. [10]Vos T, Haby MM, Magnus A, et al. Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services Aust N Z J Psychiatry, 2005.PMID 16050924
11. [11]Carter R, Vos T, Moodie M, et al. Priority setting in health: origins, description and application of the Australian Assessing Cost-Effectiveness initiative Expert Rev Pharmacoecon Outcomes Res, 2008.PMID 20528370
12. [12]Kakuma R, Minas H, van Ginneken N, et al. Human resources for mental health care: current situation and strategies for action Lancet, 2011.PMID 22008420
13. [13]Greenberg PE, Fournier AA, Sisitsky T, et al. The economic burden of adults with major depressive disorder in the United States (2005 and 2010) J Clin Psychiatry, 2015.PMID 25742202
14. [14]Thornicroft G, Deb T, Henderson C Community mental health care worldwide: current status and further developments World Psychiatry, 2016.PMID 27717265