In previous editions of Invested, we explored the Economic impact of mental health and illness care, and why the impact is felt in sectors not included in traditional health care. In this edition, we are looking at what limitations exist in the mental health economic evidence and how they impact policy- and decision-makers.

While economic evidence provides valuable insights into the costs and benefits of mental health care interventions and initiatives, and despite there being an encouraging amount of progress in the field, gaps still exist. These gaps range from how specific areas of mental health treatment and care are funded, to how evidence is gathered globally and implemented into practice across health care, social care, and other interrelated sectors.[1]

More specifically there are six areas of limitations that need to be considered:[2][3][4]

1. Mental health is complicated: Measuring the outcomes of mental health care interventions can be challenging since they are complex and often difficult to quantify. Different studies on the economic cost of the same type of intervention or care can vary considerably due to frequently changing definitions of disorders. This then limits the accuracy of the economic evaluations as the evidence from those studies can be obsolete or inaccurate.
2. Bias: Even economic evaluations can be influenced by biases. Everything from the perspective of the researchers and funders, to the methodology used to evaluate outcomes, to the data sources used to estimate costs and benefits can be susceptible to bias.
3. Myopic policy- and decision-makers: Because many mental illnesses are chronic in nature, savings from better treatments might not be seen for several years. This makes it harder to demonstrate the economic case for prevention and persuade decision-makers working within shorter timelines (such as election cycles) to invest now despite the possibility for substantial gains in the future.
4. Patient context: Economic evaluations may not fully capture the context in which mental health interventions are delivered. The availability of resources, cultural and social contexts, and the preferences of patients and their families all play a role in how services are utilized. If a project makes sense from a purely economic standpoint but is not taken advantage of by the patient due to their socioeconomic or cultural components not being considered during implementation, then that program becomes both a wasted opportunity, and wasted funds.
5. Limited generalizability: Economic studies are often based on data from a specific population or context. Because of this, they may not be generalizable to other populations or settings. Age, gender, sexual orientation, ethnic background, and which mental illness a person is suffering from all play a role in what treatment is needed, and how that person engages with the system providing the care. This can limit the applicability of economic evidence to inform mental health policy and practice in other countries, cities, or even between neighbourhoods in the same city. 
6. Non-economic outcomes still matter: Economic evaluations naturally tend to focus on economic outcomes, such as cost-effectiveness or an initiative’s return on investment. But this may not fully capture the broader and less quantifiable (and less directly related to the health care sector) impacts of mental health treatments. A person’s quality of life, their social functioning, and overall well-being are all aspects of mental health care that represent the “indirect costs” discussed in last months issue of Invested.

The number of economic studies done in the health care sector continues to rise, with cost-effectiveness analyses seeming to be the most prevalent. However, more needs to be done with other types of analysis, such as cost-utility and cost-benefit, and within the peripheral sectors to provide a more complete picture. Despite these limitations, the last several years have seen vast improvements in economic methods and models allowing for more and more comprehensive and reliable data that gives us a clearer idea of the scale of the economic impact mental disorders has across sectors.[5] In support of this is the World Health Organization and the United Nations Development Program, which recently recommended return on investment analyses be standard procedure when making an investment case for mental health initiatives.[6]

While economic evidence can provide valuable information for decision-makers in mental health care, treatment results and socioeconomic contextual factors continue to be necessary evidence needed to inform policy and practice.

Stay tuned for future editions of Invested where we investigate current developments in the field of mental health economics, and the ROI of some of Canada’s mental health initiatives.

Bibliography

Evers, S., Salvador–Carulla, L., Halsteinli, V., McDaid, D., & Mheen Group. (2007). Implementing mental health economic evaluation evidence: building a bridge between theory and practice. Journal of Mental Health, 16(2), 223-241.

Knapp, M., Funk, M., Curran, C., Prince, M., Grigg, M., & McDaid, D. (2006). Economic barriers to better mental health practice and policy. Health policy and planning, 21(3), 157-170.

Knapp, M., & Wong, G. (2020). Economics and mental health: the current scenario. World Psychiatry, 19(1), 3-14.

Le, L. K. D., Esturas, A. C., Mihalopoulos, C., Chiotelis, O., Bucholc, J., Chatterton, M. L., & Engel, L. (2021). Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations. PLoS medicine, 18(5), e1003606.

Trautmann, S., Rehm, J., & Wittchen, H. U. (2016). The economic costs of mental disorders: Do our societies react appropriately to the burden of mental disorders?. EMBO reports, 17(9), 1245-1249.