Statistics – The Scale of the Problem

Report by the London School of Economics

HOW MENTAL ILLNESS LOSES OUT IN THE NHS

A precis of a report by The Centre for Economic Performance’s Mental Health Policy Group – June 2012

Figure 1: Morbidity among people under age 65

SUMMARY

There is one massive inequality within the NHS: the way it treats mental illness as compared with physical illness.
Here are six remarkable facts.
  • Among people under 65, nearly half of all ill health is mental illness (see Figure 1). In other words, nearly as much ill health is mental illness as all physical illnesses put together.
  • Mental illness is generally more debilitating than most chronic physical conditions. On average, a person with depression is at least 50% more disabled than someone with angina, arthritis, asthma or diabetes. Mental pain is as real as physical pain, and it is often more severe.
  • Yet only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions. It is a real scandal that we have 6,000,000 people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression. Yet three quarters of each group get no treatment. One main reason is clear: NHS commissioners have failed to commission properly the mental health services that NICE recommend. The purpose of this paper is to mend this injustice, by pressing for quite new priorities in commissioning. This might seem the worst possible moment to do this, but that is wrong for the following reason.
  • More expenditure on the most common mental disorders would almost certainly cost the NHS nothing. For mental illness often increases the scale of physical illness. It can make existing physical illness worse. And it can also cause physical symptoms which cannot be medically explained at all: a half of all NHS patients referred for first consultant appointments in the acute sector have “medically unexplained symptoms”. Altogether the extra physical healthcare caused by mental illness now costs the NHS at least £10 billion. Much of this money would be better spent on psychological therapies for those people who have mental health problems on top of their physical symptoms. When people with physical symptoms receive psychological therapy, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy. So while doing the right thing on mental illness, the NHS costs itself nothing. This applies much less to most other NHS expenditures.
  • This is mainly because the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3. In the government’s Improved Access to Psychological Therapy programme, outcomes are measured more carefully than in most of the NHS, and success rates are much higher than with very many physical conditions.
  • Effective mental health treatment can also generate other large savings to the government, for example by increasing employment or improving the behaviour of children. As one example, the Improved Access to Psychological Therapy programme has almost certainly paid for itself through reduced disability benefits and extra tax receipts. Likewise, when children are treated for conduct disorder, the costs are almost certainly repaid in full through savings in criminal justice, education and social services.

To conclude, mental illness accounts for a massive share of the total burden of disease. Even when we include the burden of premature death mental illness accounts for 23% of the total burden of disease. Yet, despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure. The under-treatment of people with crippling mental illnesses is the most glaring case of health inequality in our country.

The need for a rethink is urgent. At present mental health care is, if anything, being cut. It should be expanded. This is a matter of fairness, to remedy a gross inequality, and it is a matter of simple economics – the net cost to the NHS would be very small. When everyone praises early intervention, it is particularly shocking that the sharpest cuts today are those affecting children.

The NHS aims to save £20 billion on existing activities in order to finance new activities required by new needs, old unmet needs, and new technology. Nowhere is the case for extra spending more strong. In mental health there is massive unmet need and there are new treatments which are only beginning to be rolled out. We appeal to commissioners to think again.

INTRODUCTION

NHS commissioners have a weighty responsibility – to spend over £80 billion of our money in the best possible way. It is certainly not easy. There are massive needs for physical healthcare as well as mental healthcare. In preparing this report over the period of a year, we have tried to allow for both types of need. Throughout our report we have tried to work in a dispassionate way and it is only in our Summary that we have allowed ourselves to vent our passion.

The issue which we have set ourselves is this: Does the NHS give sufficient priority to mental health? To think about this, we have reviewed the following key issues:

  • the scale and severity of mental illness
  • the costs of mental illness to the NHS
  • the wider costs of mental illness to the government and to society
  • what treatments exist and how successful and cost-effective they are
  • the extent to which treatments are available in the NHS, and
  • the policy implications of our conclusions.

A major theme of our report will be the impact of mental illness on physical illness and the need to reflect this in NHS healthcare arrangements. Terminology in mental health is contentious and not used consistently. In this report we use the term ‘mental illness’ to include clinical depression and anxiety conditions, both of which are highly common and often highly disabling, as well as schizophrenia and bipolar disorder, which are less common. For children, we also include conduct disorder.

We use the term ‘illness’ deliberately in order to emphasise that conditions such as these should be taken as seriously as physical illnesses.The report does not cover dementia or drug and alcohol misuse – both of which are vitally important issues in their own right. Though some of the figures and statistics we present do include these conditions, we attempt in each case to be clear what is and what is not included.

THE SCALE AND SEVERITY OF ILLNESS

Even with our narrow coverage at least one third of all families (including parents and their children) include someone who is currently mentally ill.2 If we focus on individual adults, the figure is 17%, and for children it is 10% (see Table 1).

This compares with over a third of adults suffering from long-term physical conditions such as cardiovascular disease (including blood pressure), respiratory disease, musculo- skeletal problems or diabetes.3 But there is of course a substantial overlap between physical and mental illness, so that about a third of people with physical illness would also be diagnosed with mental illness.

Morbidity

So much for numbers of people. But, to look at the “burden of morbidity” which these numbers give rise to, we have to weight them by the severity of the illness – the reduced quality of life which it causes. The WHO get these weights from panels of clinicians.4 The weights take into account a variety of studies, such as that quoted earlier which showed that the degree of disability imposed by depression is 50% higher than that for angina, asthma, arthritis or diabetes.5 So let us see what happens when these weights are used in order to estimate the overall burden of “morbidity” imposed by each disease on people of all ages.

As Table 2 shows, mental illness accounts for nearly 40% of morbidity, compared with for example 2% due to diabetes. These are extraordinarily important figures and it is difficult to suppose that commissioners would not behave differently if they were aware of them.

From an economic point of view, it is particularly interesting to focus on morbidity among people of working age, since this has such an impact on the economy and thus on the public finances. Figure 2 shows morbidity at different ages. The units on the vertical axis measure ill-health by the average % reduction in the quality of life, spread over the whole population of each age group. As the graph shows, morbidity from physical illness rises steadily throughout life, whereas mental illness especially affects people aged 15-44. Taking together all ages up to 65, mental illness accounts for nearly as much morbidity as all physical illnesses put together.8 It is by far the most important illness for people of working age.

 

 

 

 

 

 

 

 

 

 

 

 

Table 1: Percentage suffering from mental illness (England)

 

 

 

 

 

 

 

 

 

 

 

 

Table 2: The burden of disease (UK)

 

 

 

 

 

 

 

 

 

 

 

Figure 2: Rates of morbidity in each age group (Equivalent life-years lost per 100 people)

This finding is consistent with many other key facts. For example, among people in work, mental illness accounts for nearly a half of all absenteeism. And among people out of work, mental illness again accounts for nearly half of all people on incapacity benefits.

The official figure here is 44% but many of those with inexplicable back pain, chest pain, abdominal pain and headache are also there because of mental illness.

Suffering

Another way of looking at the impact of mental illness is to ask, What proportion of suffering in the community is due to mental as opposed to physical illness? We can define those who are suffering as those who are least satisfied with their lives. We can then ask how far different factors explain whether a person falls into this category. We measure physical health by the number of physical problems a person reports at present. And, to avoid charges of tautology, we measure mental health by a person’s GHQ score six years earlier. Even so, we find that mental illness accounts for more suffering (as we have measured it) than physical illness does. (Table 3 overleaf.)

It is also striking that each type of illness explains more of the misery in our society than lack of income does. So we need a much wider concept of deprivation than is usually used in public debate. A person is deprived not only if he lacks income but if he lacks the other means to enjoy his life. And the biggest single source of deprivation is lack of mental health.

Mortality

However, healthcare is not only about the reduction of suffering: it is also about the preservation of life. The overall burden of disease includes not only suffering, but also

Table 3: Factors explaining low life satisfaction (adults. UK)

Most premature death is due to physical illness. So the share of physical illness is larger in the overall burden of disease (including premature death) than in the burden of morbidity. Even so, mental illness still accounts for nearly a quarter of the total burden of disease (see Table 2).

Moreover this does not reflect at all the indirect impact of mental illness on mortality.

Mental illness has the same effect on life-expectancy as smoking, and more than obesity.

Thus age-specific death rates for people with depression exceed those of other people by a factor of 1.52 – about the same as the impact of smoking and much higher than obesity.13

This occurs partly through effects on suicide and fatal accidents, and partly because mentally ill people smoke more. But it largely comes about through the way in which mental illness intensifies the effects of physical illness by, for example, intensifying inflammation and the production of stress hormones like cortisol, and by undermining the immune system.14 Thus, if we consider patients with cardiovascular disease of given severity, the rates of hospitalisation and death for those with mental health problems are up to three times higher than for others.15 Similar results are found for asthma, diabetes and COPD.

THE COSTS OF MENTAL ILLNESS TO THE NHS

We can now compare the share of mental health in the burden of disease (23%) with its present share in NHS expenditure (13%). As Table 4 shows, total expenditure on healthcare for mental illness amounts to some £14 billion a year.

As can be seen, the largest expenditure is on people with schizophrenia, bipolar disorder and personality disorder (the majority of the latter are in forensic care). The next big expenditure is on elderly patients, mainly with dementia – who also attract large social care expenditure from local authorities. Drug and alcohol services also cost over £1 billion. The 700,000 children with mental disorders get only £0.8 billion spent on CAMHS, while for the 6,000,000 adults with depression and anxiety disorders the main discrete service is Improved Access to Psychological Therapy, costing roughly £0.2 billion in 2010/11.16 Support from GPs costs some £1.9 billion.17

 

 

 

 

 

 

 

 

 

Table 4: NHS mental health expenditure (England, 2010/11)

Costs in physical healthcare

However these costs give a very incomplete account of the costs which mental illness imposes on the NHS. Nearly a third of all people with long-term physical conditions have a co-morbid mental health problem like depression or anxiety disorders.18 These mental health conditions raise the costs of physical health-care by at least 45% for a wide range of conditions including cardio-vascular disease, diabetes and COPD at each level of severity, costing at least £8 billion a year.

Moreover, a half of all patients referred for first consultant appointments in the acute sector have medically unexplained symptoms,19 such as back pain, chest pain and headache. These patients cost the NHS some £3 billion a year,20 and many of them should be treated for mental health problems. So, if we add in the £8 billion or more above, untreated mental illness is costing the NHS over £10 billion in physical healthcare costs.

THE WIDER COSTS OF MENTAL ILLNESS

An obvious question is ‘Could these costs be reduced by more and better treatment of mental illness?’ But, before answering this question, we should also consider the wider costs of mental illness. The most obvious cost is the loss of output resulting from people being unable to work – or to work to their full capacity. Mentally ill people are less likely to be in work than others, and, were it not so, total national employment would be 4% higher than it actually is.21 Similarly those who are in work are more likely to have days off – and, were this not so, hours worked in the economy would be 1% higher. On top of that is presenteeism: the fact that people who are ill have lower productivity as a result of their illness. Taking all these phenomena into account, the Centre for Mental Health estimates that mental illness reduces GDP by 4.1% or £52 billion a year.

From a policy point of view a more important figure is the cost of mental illness to the Exchequer. If we focus on non-employment, this costs the Exchequer £8 billion in benefits for the 1.3 million people on incapacity benefits. And the total non-NHS cost of adult mental illness to the Exchequer may be around £28 billion.22

In some ways child mental illness is even more disastrous. Some 50% of mentally ill adults were mentally ill before the age of 15.23 And 30% of all crime (costing society some £20 billion a year) is committed by people who had a clinically diagnosable conduct disorder in childhood or adolescence.24 In terms of cost to the government a child with conduct disorder at 10 subsequently costs the government roughly £100,000 more than other children.25 And none of these estimates includes the devastating cost of mental illness to the families affected.

There is another important issue: the social gradient of mental illness. As Figure 3 shows, rates of depression, anxiety and psychosis combined are much higher in the lower quintiles of incomes. Reducing health inequalities is now a duty on the government and it clearly requires a much more vigorous approach to mental illness.

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3: Rates of mental illness by income group (%)

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 4:

 

 

 

 

 

 

 

 

 

 

 

 

 

Annex B: Prevalence of adult mental health conditions and % in treatment, England 2007

In England the number of people with mental illness thus defined is about 7 million and the number of dwellings in England is 21 million. Thus, if each mentally ill person were the only one in their household, a third of households would include a mentally ill person. The assumption made is clearly extreme, but this is offset by the fact that most ill adults belong to more than one family (their own family and their parents’ family).

The Guardian 18/6/12

A report by the LSE suggests that only a quarter of those who need treatment are getting it.

The report claims that millions of pounds are being wasted by not addressing the real cause of many people’s health problems. Nearly half of all the ill-health suffered by people of working age has a psychological root and is profoundly disabling, says the report from a team of economists, psychologists, doctors and NHS managers, published by the London School of Economics.

Talking therapies such as cognitive behaviour therapy relieves anxiety and depression in 40% of those treated, says the Mental Heath Policy Group led by Lord Layard. But despite government funding to train more therapists, availability is patchy with some NHS commissioners not spending the money as intended, and services for children being cut in some areas. “It is a real scandal that we have 6 million people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression,” says the report. “Yet three quarters of each group get no treatment.”

Layard added: “Mental health is so central to the health of individuals and of society that it needs its own cabinet minister … The under-treatment of people suffering from mental illnesses is the most glaring case of health inequality in the NHS … Despite the existence of cost-effective treatments it receives only 13% of NHS expenditure. If local NHS commissioners want to improve their budgets, they should all be expanding their provision of psychological therapy.”

A third of families have a member suffering a mental illness, the authors found. The report says mental health problems account for nearly half of absenteeism at work and a similar proportion of people on incapacity benefits.

In 2008, Layard and others won the argument that treating anxiety and depression saved the NHS money. A programme called Improving Access to Psychological Therapy (IAPT) was set up to train thousands more therapists.

Official figures, however, show that too few people are getting treatment across the country. There were 6.1 million with treatable anxiety or depression in England but only 131,000, or 2.1%, entered talking therapy in the last quarter of 2011.

There are stark differences between primary care trusts. Walsall did best, with 6.4% of depressed and anxious people in talking therapy, followed by Swindon with 5.8% and Northumberland with 5.5%.

But Hillingdon, west London had only 0.1% in treatment – 17 out of 29,000. Barnet and Enfield, both in north London, had 0.3% and 0.4% respectively.

Layard said commissioners were wrong “if they think ‘why don’t we cut a bit of that [talking therapies]‘ when they are spending money on infinitely lower priority conditions. Depression is 50% more disabling than conditions like angina, arthritis, asthma or diabetes.” Even including those on medication, treatment only reaches a quarter of those in need.

Commissioners needed to understand that treating people with mental illness saves money, the report says. Layard pointed to a survey at two London hospitals which found that half the patients sent for an appointment with a consultant had physically inexplicable symptoms, such as chest and head pains for which there was no organic explanation. “These are people with somatic symptoms as a result of mental stress,” he said.

In the long term he said he would like to see psychologists and therapists working alongside physical medicine doctors in the acute sector, to help determine the real cause of people’s apparently inexplicable symptoms.

Dr Andrew McCulloch, chief executive of the Mental Health Foundation, said the report showed mental health remained a poor relation to physical health for the NHS. “The government has rightly committed to a parity of esteem between physical health and mental health in the health and social care bill, and surely they must now deliver on what they have promised.”

Dr Clare Gerada, the chair of the Royal College of GPs, applauded the efforts of Layard and his colleagues to increase the availability of talking therapies.

“We live in a stressful society and the number of patients with mental health problems presenting to GPs is on an upward spiral,” she said. “GPs face tremendous challenges in caring for patients with mental health problems in primary care and we welcome any development which will help us improve their care.”

The care services minister, Paul Burstow, said: “Mental ill-health costs £105bn per year and I have always been clear that it should be treated as seriously as physical health problems … the coalition government is investing £400m to make sure talking therapies are available to people of all ages who need them. This investment is already delivering remarkable results.”

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