With the findings of the Australian National Survey of Mental Health and Wellbeing (AIHW, 2013) concluding that 45 per cent of Australians will experience a high prevalence mental health disorder in their lifetime, it is vital that government policies and funding for both the prevention and treatment of mental health disorders is informed by the best available evidence. The evidence for the effectiveness of psychological interventions in treating mental health disorders, based on numerous high quality studies and meta-analyses, is now compelling. This has been recognised by the Australian Government through the establishment over the past decade of a range of programs delivering psychological services to address high prevalence mental health disorders, including the Better Access and Access to Allied Health Services (ATAPS) initiatives, the KidsMatter suite of programs to address the mental health of children in primary school and early childhood centres, and the headspace youth mental health initiative. Evaluations of these programs have been positive and, notwithstanding some recent funding cuts, the level of Government support to address the high rate of mental illness has to date been encouraging.
The high rate of common mental health disorders in the community presents a challenge for governments and the health system, and highlights the need for not just effective interventions but also those that have demonstrative cost-effectiveness, that is, interventions providing good value for money. The provision of services that are both effective and cost-effective should be the focus of all government mental health policy and funding commitments.
This article discusses the evidence for the cost-effectiveness of psychological interventions for high prevalence disorders from both an international and local perspective. To assist in understanding measurement techniques in this complex area, the boxed information provides a brief description of cost-benefit analyses and how cost-effectiveness is measured.
Cost-effectiveness of psychological interventions: International perspectives
Internationally, over some decades researchers have been investigating the cost benefits of psychology interventions for a range of mental health disorders, including depression, anxiety disorders, psychotic disorders and child attention and conduct disorders. The health care cost savings of psychological interventions for psychological problems and other health conditions were demonstrated to be in the range of 20-30 per cent in a meta-analysis of 91 studies published across three decades, with 90 per cent of the studies determining that a medical cost-offset was made (Chiles, Lambert & Hatch, 1999). Similarly, cognitive behaviour therapy (CBT) for mental health disorders, whether provided alone or in combination with medication, demonstrated a cost off-set by reducing demand on health care services in a 2006 review of 22 studies (Myhr & Payne, 2006). This review was conducted to inform policy funding in Canada and concluded that CBT is cost-effective and is likely to improve health outcomes and result in cost savings.
In the United Kingdom cost-effectiveness studies have largely been commissioned by the National Health Service to inform funding decisions. These studies are generally of high quality, having been conducted alongside clinical trials and using the quality-adjusted life years (QALY) as the metric for analysis. Investigations have provided support for the cost-effectiveness of psychological interventions, particularly CBT (e.g., Tyrer et al. 2014; Wiles et al. 2014).
Cost-effectiveness: The Australian perspective
Assessing Cost Effectiveness (ACE) studies
In Australia there has been considerable interest and research in this area, with the most well-known studies being those frequently referred to as the ACE (Assessing Cost Effectiveness) studies. These studies use economic modelling techniques expressed as disability-adjusted life year (DALYs), most commonly against a $50,000 per DALY value-for-money threshold. The team behind the ACE studies has been investigating the cost-effectiveness of psychological interventions for mental health problems for over a decade with numerous publications. The ACE studies have investigated psychological interventions (mostly psychologist-administered CBT or components of CBT) for the prevention and treatment of mental health disorders in both adults and children and have demonstrated cost-effectiveness, with some studies showing psychological treatment to be more cost-effective than standard medical treatments. Studies have reported cost savings ranging between $9,000/DALY to $23,000/DALY (e.g., Haby et al., 2004; Heuzenroeder et al., 2004; Mihalopoulos & Vos, 2013; Mihalopoulos et al., 2012; Vos et al., 2005).
Rapid review for the Mental Health Commission of New South Wales
Most recently, a ‘rapid review’ was conducted by Doran (2013) on behalf of the Mental Health Commission of New South Wales to inform State Government policy. A rapid review is a review of the literature undertaken over a short period of time and often with some urgency to inform government planning, as opposed to a comprehensive systematic review. The rapid review included psychological and non-psychological interventions, was limited to studies published between 2000 and 2013 and included only studies conducted in Australia, New Zealand, the UK or Canada on the basis that these countries have comparable health care systems.
A total of 50 studies were included, of which a third were conducted in Australia, including the ACE studies. Doran (2013) evaluated the quality of the studies in his rapid review using the Drummond checklist (an approach for evaluating the quality of economic articles; Drummond, & Jefferson, 1996) and found that 78 per cent of studies, including all of the ACE studies, received the highest rating of ‘good quality’.
Although the ACE studies were identified as being of high quality and provide strong support for the cost-effectiveness of psychological interventions, this was not specifically referred to in the final report. Instead, the focus was on limitations of the studies. On this basis – although identifying the majority of studies as being of high quality and demonstrating cost-effectiveness – the report concludes that the evidence is insufficient. An evaluation of rapid reviews by Cameron et al. (2007) found that they are generally limited in focus, have stringent inclusion criteria and limited peer review. Conclusions drawn from this NSW rapid review therefore can only be considered tentatively.
Better Access evaluation
Investigation of cost-effectiveness of psychological interventions was conducted as part of the Australian Government’s 2011 evaluation (Pirkis et al., 2011) of the Better Access initiative, which enables Medicare-funded access to psychological interventions for high prevalence mental health disorders. While a comprehensive cost-analysis was out of the scope of the evaluation, the investigation did compare consumer outcomes and the cost of care (including psychologist and GP billing under the Medicare Benefits Schedule) with a recognised standard cost for optimal treatment of anxiety and depression. The cost of a package of care was found to be significantly less than previous estimates and deemed to be value for money in terms of Medicare Benefits Schedule costs to government. On this basis, it was concluded that psychological interventions provided by psychologists under the Better Access initiative were a cost-effective way of delivering health care, supporting much of the research in this area to date.
Concluding comments
There are good quality studies both in Australia and internationally indicating that psychological interventions for mental health disorders are cost-effective. Although costs should not be the only driver of health care planning, the current evidence for cost-effectiveness of psychological interventions, particularly for treating high prevalence disorders, is substantial and growing. This forms a sound basis for Government investment to provide broader community access to psychological interventions, and alongside this to provide support for clinical trials to build on the already established evidence. This would not only work towards meeting the high level of need in the community but would constitute sound, evidence-based economic planning.
| Measuring value for money: Understanding cost-benefit analysis |
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Measurement approaches for determining cost-benefit can vary, but there are some principles that underlie most methods. In measuring the cost-benefit of a particular intervention, a monetary figure based on a standard amount is often set as a threshold for determining any cost-benefit (e.g., if the cost is over $30,000 per person this may not be acceptable).
Measurement approaches consider both direct costs (e.g., primary and secondary consultation) and indirect costs (e.g., lost productivity through work absenteeism due to illness or attending treatment, unemployment).
In addition, in establishing whether an intervention can be considered to be cost-effective, researchers take account of a range of societal factors and assign a value that indicates, given the outcome, the person’s likely future contribution or expense to society. An example of how this is done is to consider whether the treatment extends a person’s life (e.g., increasing opportunity for productivity) and also whether it improves the quality of life, for example, through the reduction of symptoms (and reduction of dependence on health services).
Common approaches to evaluating cost-effectiveness
(Doran, 2013; Hunsley, 2003)
- Cost-benefit analysis measures the extent to which an intervention yields a socially desirable outcome (e.g., return to work). Costs and benefits are expressed in monetary terms and can be compared. If the benefit is higher than the cost of a treatment then there would be a financial basis for implementing the treatment.
- Cost-effectiveness analysis is used to determine if two treatment options (e.g., medication and CBT) have the same costs, which of these has the greater benefit, or if two treatment options have the same benefit, which costs less. The value used to determine benefit is linked to symptom or diagnostic indicators (e.g., number of days free of symptoms).
- Cost-utility analysis is similar to cost-effectiveness analysis except that the treatment impact is converted to a standard value such as well years of life. Typically studies use one of two options as a standard metric for specifying health outcomes, which are calculated with reference to a normative comparison and are the inverse of each other: the quality-adjusted life years (QALY – the number of years of life that an individual would be expected to be symptom or disability free) or the disability-adjusted life year (DALY – the number of years lost due to premature mortality or years of disability).
- Medical cost-off-set reflects a reduction in the use of general medical services as a result of a psychological intervention. Where the savings exceed the cost of actually providing the psychological intervention this is referred to as a Total Offset.
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