Annette Bauer

Lifetime costs of perinatal anxiety and depression

BACKGROUND Anxiety and depression are common among women during pregnancy and the year after birth. The consequences, both for the women themselves and for their children, can be considerable and last for many years. This study focuses on the economic consequences, aiming to estimate the total costs and health-related quality of life losses over the lifetime of mothers and their children. METHOD A pathway or decision modelling approach was employed, based on data from previous studies. Systematic and pragmatic literature reviews were conducted to identify evidence of impacts of perinatal anxiety and depression on mothers and their children. RESULTS The present value of total lifetime costs of perinatal depression (anxiety) was £75,728 (£34,811) per woman with condition. If prevalence estimates were applied the respective cost of perinatal anxiety and depression combined was about £8500 per woman giving birth; for the United Kingdom, the aggregated costs were £6.6 billion. The majority of the costs related to adverse impacts on children and almost a fifth were borne by the public sector. LIMITATIONS The method was exploratory in nature, based on a diverse range of literature and encountered important data gaps. CONCLUSIONS Findings suggest the need to allocate more resources to support women with perinatal mental illness. More research is required to understand the type of interventions that can reduce long-term negative effects for both mothers and offspring.

Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis

BACKGROUND Studies of the association between income inequality and mental health have shown mixed results, probably due to methodological heterogeneity. By dealing with such heterogeneity through a systematic review and meta-analysis, we examine the association between income inequality, mental health problems, use of mental health services, and resilience (defined as the ability to cope with adversity). METHODS We searched the Global Health, PsychARTICLES, PsycINFO, Social Policy and Practice, Embase and MEDLINE databases up to July 6, 2016, for quantitative studies of the association of income inequality with prevalence or incidence of mental disorders or mental health problems, use of mental health services, and resilience. Eligible studies used standardised instruments at the individual level, and income inequality at the aggregated, contextual, and ecological level. We extracted study characteristics, sampling, exposure, outcomes, statistical modelling, and parameters from articles. Because several studies did not provide enough statistical information to be included in a meta-analysis, we did a narrative synthesis to summarise results with studies categorised as showing either a positive association, mixed results, or no association. The primary outcome in the random-effects meta-analysis was mental health-related morbidity, defined as the prevalence or incidence of any mental health problem. This study is registered with PROSPERO, number CRD42016036377. FINDINGS Our search identified 15 615 non-duplicate references, of which 113 were deemed potentially relevant and were assessed for eligibility, leading to the inclusion of 27 studies in the qualitative synthesis. Nine articles found a positive association between income inequality and the prevalence or incidence of mental health problems; ten articles found mixed results, with positive association in some subgroups and non-significant or negative association in other subgroups; and eight articles found no association between income inequality and mental health problems. Of the nine articles included in our meta-analysis, one reported a positive association between income inequality and mental health problems, six reported mixed results, and two reported no association. Pooled Cohens d effect sizes for the association between income inequality and any mental disorder or mental health problems were 0·06 (95% CI 0·01-0·11) for any mental disorder, and 0·12 (0·05-0·20) for depressive disorders. Our meta-regression analysis showed that none of the factors considered (sample size, contextual level at which income inequality was assessed, quality assessment, type of instruments, and individual income as control variable) explained heterogeneity between studies (I2 89·3%; p<0·0001). Only one study investigated the association between income inequality and resilience; it found greater income inequality was associated with higher prevalence of depression only among individuals with low income. The only study of the role of income inequality as a determinant of the use of mental health services reported no association. INTERPRETATION Income inequality negatively affects mental health but the effect sizes are small and there is marked heterogeneity among studies. If this association is causal and growing income inequality does lead to an increase in the prevalence of mental health problems, then its reduction could result in a significant improvement in population wellbeing. FUNDING None.

Economic and ethical implications of improving access to health care for older people with intellectual disabilities in England: a cost-effectiveness modelling study of health checks

Abstract Background An increasing number of people with intellectual disabilities are reaching old age. Knowledge has emerged internationally about the complex and largely unmet health needs of this specific ageing population, and associated costs. Annual health checks, incentivised but not mandatory for primary care in England, seek to reduce health inequities for this population. However, their cost-effectiveness is unknown. Our study aimed to address this evidence gap. Methods We developed a decision analytical Markov model to compare a strategy in which older people with intellectual disabilities received annual health checks with standard care. The model, developed to inform a guideline for the National Institute for Health and Care Excellence (NICE), followed hypothetical cohorts of 1000 people in England from when they were 40 years old until they died. Outcome measure was cost per quality-adjusted life-year (QALY) gained. We calculated incremental cost-effectiveness ratios (ICER). Costs were assessed from a health provider perspective and expressed in 2016 British pounds. Costs and QALYs were discounted at 3·5%. We carried out probabilistic sensitivity analysis. Data from published studies as well as expert opinions informed parameters. Findings Annual health checks led to a mean QALY gain of 0·072 (95% CI 0·069–0·113) and mean incremental costs of £4911 (4897–5133). For a threshold of £30 000, annual health checks were not cost effective (mean ICER £89 200, 95% CI 86 252 to 136 769). Costs of intervention needed to reduce from £258 to under £100 per year for annual health checks to be cost effective. Interpretation Although our findings need to be considered with caution since the model was based on assumptions to overcome evidence gaps, they suggest that providing cost-effective annual health checks is difficult. This immediately raises ethical questions about equitable access to health checks and health itself. Additional resources are needed if health systems are to contribute to a fairer society. Funding NICE.

Circles of Support and personalization Exploring the economic case

Circles of Support aim to enable people with learning disabilities (and others) to live full lives as part of their communities. As part of a wider study of the economic case for community capacity building conducted from 2012 to 2014, we conducted a mixed methods study of five Circles in North West England. Members of these Circles were supporting adults with moderate to profound learning disabilities and provided accounts of success in enabling the core member to live more independent lives with improved social care outcomes within cost envelopes that appeared to be less than more traditional types of support. The Circles also reported success in harnessing community resources to promote social inclusion and improve well-being. This very small-scale study can only offer tentative evidence but does appear to justify more rigorous research into the potential of Circles to secure cost-effective means of providing support to people with learning disabilities than the alternative, which in most cases would have been a long-term residential care placement.