The researchers conducted a systematic review on the costs of all mental disorders, as well as intentional self-harm and suicide, in the World Bank South Asia Region.
The systematic review found profound economic impacts within and beyond health care systems.
Mental disorders – including alcohol use disorder – represent a considerable economic burden, but existing estimates are conservative as they do not consider long-term impacts or the full range of conditions.

Author

David McDaid (email: d.mcdaid@lse.ac.uk), Aishwarya Lakshmi Vidyasagaran, Muhammed Nasir, Simon Walker, Judy Wright, Krishna Prasad Muliyala, Sreekanth Thekkumkara, Rumana Huque, Mehreen Riaz Faisal, Saumit Benkalkar, Mohammod Akbar Kabir, Claire Russell, Najma Siddiqi

Citation

McDaid D, Vidyasagaran AL, Nasir M, Walker S, Wright J, Muliyala KP, Thekkumkara S, Huque R, Faisal MR, Benkalkar S, Kabir MA, Russell C, Siddiqi N. Understanding the costs and economic impact of mental disorders in South Asia: A systematic review. Asian J Psychiatr. 2024 Sep 16;102:104239. doi: 10.1016/j.ajp.2024.104239. Epub ahead of print. PMID: 39332059.


Source
Asian Journal of Psychiatry Volume 102 , December 2024, 104239
Release date
16/09/2024

Understanding the costs and economic impact of mental disorders in South Asia: A systematic review

Systematic review

Highlights

  • Governmental health expenditure on mental health in South Asia remains low.
  • Economic evidence can be used to support greater investment in mental health.
  • Profound economic impacts to government and families of depression and psychosis.
  • Critical to generate evidence for all mental disorders in all South Asian countries.
  • Modelling can be used to estimate longer term impacts of all mental disorders.

The World Bank South Asia Region

Eight countries are part of the World Bank South Asia:

  • Afghanistan,
  • Bangladesh,
  • Bhutan,
  • India,
  • Maldives,
  • Nepal,
  • Pakistan, and
  • Sri Lanka.

Costs due to mental disorders

These costs are only the tip of the iceberg.”

McDaid D, Vidyasagaran AL, Nasir M, Walker S, Wright J, Muliyala KP, Thekkumkara S, Huque R, Faisal MR, Benkalkar S, Kabir MA, Russell C, Siddiqi N. Understanding the costs and economic impact of mental disorders in South Asia: A systematic review. Asian J Psychiatr. 2024 Sep 16;102:104239. doi: 10.1016/j.ajp.2024.104239. Epub ahead of print. PMID: 39332059.

Figure 2 shows the mean monthly cost for all studies which included specific estimates of both direct and indirect costs. In total there are 33 different cost estimates, with some studies looking at costs across multiple countries, conditions or settings.

While figure 2 illustrates the variability in results across conditions and countries, making comparison challenging, some patterns can be observed:

First, in just eight of these 33 estimates did direct costs outweigh indirect costs. The estimate of costs of suicide in India, at $1387 per month was the highest of all studies, with indirect costs accounting for 82 % of all costs. Regarding depression, in only one study, looking at the costs of perinatal depression in Pakistan did indirect costs account for a minority of costs (28 %). Similarly, in only one study of the costs of psychosis and related disorders were indirect costs a minority, at 47 % of total costs for individuals with treatment resistant schizophrenia in India. In this case medical care costs may be expected to be higher.

Figure 2 also indicates that the highest estimates of cost for both depression and psychosis were from Pakistan, although it should be stressed that these estimates are from one specific private hospital setting, and costs are likely to differ in public hospital settings in Pakistan. Another observation related to that analysis in Pakistan, where a common approach was used to estimate costs, was the very similar levels of monthly cost for individuals being treated for psychosis and for depression, $880.77 and $805.17 respectively.

Future studies, using comparable methodology across mental disorders are needed to explore these differences in cost further. A final observation from Figure 2 is what it does not show, and that is the lack of studies outside of India and Pakistan, with one exception from Sri Lanka, that have looked at both the direct and indirect costs of mental disorders.

The high contribution in most studies of indirect costs, mainly due to exclusion from employment and other productive activities, also highlights the risk of families incurring catastrophic costs.

These costs are only the tip of the iceberg. Only one study in this systematic review looked at costs beyond one year. However, poor mental health can have very long-lasting impacts affecting employment and social functioning over decades, as well as having intergenerational effects. Poor mental health can also have a substantial adverse impact on human capital acquisition, reducing lifetime opportunities.

Human capital, vital to continuing economic development in South Asia, would be strengthened through earlier intervention to protect mental health. Arguments for this investment will be strengthened further if longer-term adverse impacts on productivity and the wider economy of not taking action are considered. One way of doing this would be to conduct more economic modelling studies that estimate the potential long-term economic impacts of mental health conditions..

This systematic review also indicates a need for well-designed studies on the economic impact of the broad range of mental health conditions. Beyond depressive and psychotic disorders, knowledge of economic impacts of many highly prevalent conditions such as anxiety disorders and dementia, as well as conditions associated with high levels of disability burden, notably eating disorders, appear very limited in South Asia. A lack of information on these issues again means that the true potential of investing in effective actions for better mental health may not be understood.

Another critical issue that multiple papers did address is the level of out-of-pocket expenditure associated with poor mental health. While publicly funded health service coverage is increasing, such as through the Indian Ayushman Bharat Yojana health insurance scheme for some inpatient care costs for low-income people, it would be helpful to distinguish consistently between public-purse costs and family costs when reporting results. This could help clarify risk of incurring catastrophic health care costs associated with mental health problems. The cost impact of changing the way people access services, such as through digital/telephone services, can also be explored.

Context regarding alcohol

Trends in total alcohol per capita consumption (APC) showed a marked increase in APC in South-East Asia since 2000. 

APC among alcohol consumers is highest in the African, European and South-East Asia regions.

The prevalence of current alcohol users increased by 25.9% (from 8.9% to 11.2% of persons aged 15–19 years) in the South-East Asia region.

There has been an increase in the prevalence of alcohol use disorders in the South-East Asia region since 2010. The prevalence of AUDs increased in the South-East Asia Region (5.3% relative increase). 

The proportions of deaths attributable to alcohol consumption was highest among people aged 30–34 years in the European and South-East Asia regions. 

Key findings regarding alcohol use disorders

Seven studies in Table 3 report costs of alcohol use disorder, six in India, three in Nepal and one in Sri Lanka. Three were randomised controlled trials, two observational and two modelling studies. Four of these studies included productivity losses in their estimate of costs.

Productivity losses made up 76 % and 61 %, respectively of total costs of men with harmful alcohol use in the control arm of a RCT in India over 3 and 12 months.

In another randomised controlled trial for men with alcohol addiction in India 59.5 % of monthly costs were for productivity losses.

An economic modelling study for individuals admitted to hospital for alcohol use disorder in Sri Lanka reported that productivity losses due to absenteeism accounted for just 10 % of mean monthly costs of $1275. However the net present value of productivity losses due to premature mortality in hospital was separately estimated $194,014.

The remaining three studies were narrow in scope. One modelling study estimated the average cost of scaling up access to primary care for alcohol use disorder in India and Nepal at $0.49 and $0.25 respectively. Subsequently, using observational data, monthly programme costs, plus travel expenses and waiting-time costs were estimated as $1.46 and $2.34 respectively, with another observational study indicating that out-of-pocket costs for community health expenditure were higher in both countries.

Table 3. Cost of alcohol use disorders (AUD) in South Asian Countries.

Study ID, Rating, Specific mental health condition covered & study designCountries, Study setting & PopulationCost duration/
Original Currency/
Price year
Description of cost incurredMean cost per case
(PPP $Int 2022)
Monthly cost per case
(PPP $Int 2022)
Chisholm et al. (2016); 67 %
AUD
Modelling study
India and Nepal, Community
People with depression, estimate: Sehore, India=7525; Chitwan, Nepal=3006
12 months
USD
2008
Direct primary medicalIndia$5·95$0·49
Nepal$3·08$0·25
Chisholm et al. (2020); 75 %
AUD
Prospective longitudinal observational study
India and Nepal, Community, Hospital
India: N=205; Male=204 (99·5 %); Ages 16–25=24 (11·7 %), 26–35=60 (29·3 %), 36–50=82 (40·0 %), 51+=39 (19·0 %)
Nepal: N=170; Male=144 (84·7 %); Ages 16–25=4 (2·4 %), 26–35=46 (27·1 %), 36–50=77 (45·3 %), 51+=43 (25·3 %)
3 months
USD
2015
Direct secondary medical and non-medical (travel costs/waiting time)India$4·39$1·46
Nepal$7·03$2·34
Lund et al. (2019); 83 %
AUD
Retrospective Cross-sectional observational study
India and Nepal, Community
Households in Sehore, India having people with psychosis=253; Male=99·5 %; Mean age=41·2; Chitwan, Nepal=186; Male=84·9 %; Mean age=40·6
1 month
USD
2015
Direct primary and secondary medical (OOP)India$3·74$3·74
Nepal$2·63$2·63
Nadkarni et al. (2017a); 100 %
AUD (Harmful drinking)
RCT
India, Community, Hospital
N=189 men in enhanced usual care group; Mean age=41·7
3 months
USD
2015
Direct primary and secondary$44·46$14·82
Indirect (productivity losses for individuals and families)$137·98$45·99
Nadkarni et al. (2017b); 100 %
AUD (Harmful drinking)
RCT
India, Community, Hospital
N=189 men in enhanced usual care group; Mean age=41·7
12 months
USD
2015
Direct primary and secondary$312·19$26·01
Indirect (productivity losses for individuals and families)$494·48$41·21
Nadkarni et al. (2019); 100 %
AUD (Alcohol dependence)
RCT
India, Community, Hospital
N=66 men in enhanced usual care group; Mean age=39·7
12 months
USD
2015
Direct primary and secondary$364·48$30·37
Indirect (productivity losses for individuals and families)$535·96$44·66
Ranaweera et al. (2018); 75 %
AUD
Modelling study
Sri Lanka, Community, Hospital
Model assumes 7391 live hospital discharges per annum for AUD (7032 male and 359 female) and 256 deaths (248 male, 8 female)
12 months (for direct medical costs and absenteeism for 7391 individuals and carers and lifetime for premature mortality for 256 people
SLR
2015
Direct secondary$13,792$1149·36
Indirect: Absenteeism$765·78$125·64
Premature mortality$194,013·98N/A
Key: Alcohol Use Disorder (AUD), Indian Rupees (INR), Sri Lankan Rupees, (SLR), United States Dollar (USD), Not Applicable (NA), Out-of-Pocket Payments (OOP)

Meaning and implications

There is existing and consistent evidence on the profound and potentially avoidable costs of mental health conditions that can inform policy and practice in South Asia. These estimates are probably conservative; data on longer term impacts, as well as for many more conditions including anxiety, eating disorders and dementia are needed. It is also important to assess costs for more countries.

Despite limitations in the evidence, this review highlights some profound impacts within and beyond health care systems linked with poor mental health. This information can be used to help inform policy and practice; it can also be combined with updated estimates of the prevalence and incidence of mental health conditions in South Asia, as well as other data on the enduring impacts of poor mental health, to model potential long term benefits to society if some of these issues could be avoided through prevention, earlier intervention, and better management.

Abstract

Mental disorders remain the most significant contributor to years lived with disability in South Asia, yet governmental health expenditure on mental health in South Asia remains very low with limited strategic policy development. To strengthen the case for action it is important to better understand the profound economic costs associated with poor mental health.

The researchers conducted a systematic review on the costs of all mental disorders, as well as intentional self-harm and suicide, in the World Bank South Asia Region. The scientists searched ten global and South Asian databases as well as grey literature sources were searched.

72 studies were identified, including 38 meeting high quality criteria for good reporting of costs. Of these, 27 covered India, five Pakistan, four Nepal and three Bangladesh and Sri Lanka. Most studies focused on depressive disorders (15), psychoses (14) and harmful alcohol use (7); knowledge of economic impacts for other conditions was limited.

The systematic review found profound economic impacts within and beyond health care systems.

In 15 of 18 studies which included productivity losses to individuals and/or carers, these costs more than outweighed costs of health care.

Mental disorders represent a considerable economic burden, but existing estimates are conservative as they do not consider long-term impacts or the full range of conditions. Modelling studies could be employed covering longer time periods and more conditions. Clear distinctions should be reported between out-of-pocket and health system costs, as well as between mental health service-specific and physical health-related costs.


Source Website: Science Direct