Despite the enormous burden that mental ill-health imposes on individuals, their families, society, health systems and the economy, mental health care remains a neglected area of health policy in too many countries. Mental disorders represent a considerable disease burden, and have a significant impact on the lives of the OECD population, and account for considerable direct and indirect costs. This report argues that even in those OECD countries with a long history of deinstitutionalisation, there is still a long way to go to make community-based mental health care that achieves good outcomes for people with severe mental illness a reality. The disproportionate focus on severe mental illness has meant that mild-to-moderate mental illnesses, which makes up the largest burden of disease, have remained overwhelmingly neglected. This book addresses the high cost of mental illness, weaknesses and innovative developments in the organisation of care, changes and future directions for the mental health workforce, the need to develop better indicators for mental health care and quality, and tools for better governance of the mental health system. The high burden of mental ill health and the accompanying costs in terms of reduced quality of life, loss of productivity, and premature mortality, mean that making mental health count for all OECD countries is a priority.
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Table of Contents
- Foreword 5
- Acknowledgements 6
- Table of Contents 7
- Acronyms and abbreviations 13
- Executive summary 17
- Assessment and recommendations 19
- Chapter 1. The cost of mental illness 33
- 1.1. Introduction 34
- 1.2. Getting a full picture of the costs of mental ill-health 35
- Figure 1.1. Components of cost of illness 36
- 1.3. Mental health accounts for a significant proportion of health spending in OECD countries 36
- Table 1.1. Total mental health expenditures by health care provider 38
- Figure 1.2. Mental health care expenditures, Canada, 2007-08 and France, 2007 39
- Figure 1.3. Expenditures related to mental health care as a percentage of total mental health care expenditures, Australia, 1992/93-2010/11 39
- Figure 1.4. Expenditures related to mental health care as a percentage of total mental health care expenditures, United States, 1986-2005 40
- Table 1.2. Expenditure on mental health care in municipal health services in Finland, 2000-10 40
- Figure 1.5. Distribution of direct services investment, England, 2002/03 to 2011/12 41
- Figure 1.6. Share of hospital inpatient expenditures by main diagnostic category, 2011 (or nearest year available) 42
- Figure 1.7. Share of acute inpatient expenditures by sub-category of mental illness 42
- Table 1.3. Share of major NCDs in total health expenditures, selected countries 43
- Table 1.4. Direct and indirect costs of mental illness: Results from selected studies 44
- Figure 1.8. Presenteeism has increased among all groups of the population 45
- Table 1.5. The cost of mental health: Absenteeism, presenteeism and unemployment 46
- Figure 1.9. Benefit recipiency rates are much higher with co-morbidity 48
- Figure 1.10. Significant increases in disability benefit claims are being driven by claims for mental ill-health 48
- 1.4. Measuring intangible costs, and estimating the human cost of mental ill-health 49
- Box 1.1. Using QALYs to assess the effectiveness of a specific health intervention 50
- 1.5. Conclusion 50
- Notes 51
- References 52
- Chapter 2. Securing better care for mild-to-moderate disorders 55
- 2.1. Introduction 56
- 2.2. The burden of mild-to-moderate mental disorders in OECD countries 57
- Figure 2.1. People with a mental disorder face a large poverty risk 60
- Figure 2.2. Around one in four young people have a mental disorder 61
- Figure 2.3. The opportunity to seek specialist treatment varies considerably across countries 62
- 2.3. How are OECD countries treating mild-to-moderate disorders? 62
- Figure 2.4. Antidepressants consumption, 2000 and 2011 (or nearest year available) 63
- Figure 2.5. Type of provider(s) consulted for mental health problems, selected EU countries, 2010 65
- Table 2.1. How are mental health problems dealt with in primary care? 66
- Table 2.2. Medications which primary care providers would typically adjust or prescribe 67
- 2.4. Strengthening primary care provision 68
- Box 2.1. Primary care-level incentives: The QOF 70
- Table 2.3. Are primary care physicians required or incentivised to comply with treatment guidelines or practice protocols established? 75
- Box 2.2. Consultation-liaison model between GPs and community mental health services in Italy 76
- Table 2.4. Links between primary care and specialist care for mental disorders 77
- Figure 2.6. Eight studies of the cost-effectiveness of the collaborative care model for depression 78
- Table 2.5. Availability and reimbursement of psychological therapies and cognitive behavioural therapy (CBT) 79
- 2.5. New interventions for mild-to-moderate disorders can represent good value for money 80
- Box 2.3. Developments in eMental health for mild-to-moderate disorders 82
- Box 2.4. Blended therapies: stepped care though guided peer support, group therapies, and individual evidence-based therapies, delivered online 84
- Box 2.5. Extensive roll-out of psychological therapies: The English IAPT experience 86
- Box 2.6. The Access to Allied Psychological Services (ATAPS) in Australia 88
- 2.6. Conclusion 91
- References 92
- Chapter 3. Advancing the organisation, payment and integration of care for people with severe mental illness 99
- 3.1. Introduction 100
- 3.2. The high burden of severe mental illness and co-morbidities with physical ill-health 100
- 3.3. Organisation and delivery of mental health care for people with SMI 105
- Table 3.1. Initiation of SMI pharmaceuticals by primary care practitioners in selected OECD countries 106
- Table 3.2. Adjustment of SMI medication by primary care practitioners 107
- Table 3.3. Formal or informal co-ordination between primary and specialist mental health care 108
- Table 3.4. Services that are routinely available as part of community mental health services, selected OECD countries 111
- Table 3.5. Availability of out-of-hours access to specialist care, selected OECD countries 112
- Figure 3.1. Psychiatric care beds per 100 000 population, 2011 114
- Figure 3.2. Psychiatric care beds per 100 000 population, selected OECD countries, 1991-2011 115
- Figure 3.3. Public psychiatric hospitals per 100 000 population in selected OECD countries, 2010 118
- Figure 3.4. Public day treatment facilities per 100 000 population, selected OECD countries 119
- Figure 3.5. Public community residential facilities per 100 000 population, selected OECD countries 119
- 3.4. Provider payment for treatment of SMI 120
- Table 3.6. How are specialist mental health services reimbursed for services provided? 121
- 3.5. Employment and vocational rehabilitation for people with SMI 127
- Box 3.1. Principles of supported employment (SE) 128
- 3.6. Conclusion 130
- Notes 131
- References 131
- Annex 3.A1. Definitions of mental health care facilities and community teams 137
- Chapter 4. Improving quality measurement and data collection for mental health 139
- 4.1. Introduction 140
- 4.2. The epidemiological burden of mental ill-health: Using surveys and mortality indicators to collect information on prevalence and need 140
- Table 4.1. Instruments used to measure prevalence of mental disorders in OECD countries 142
- 4.3. Filling gaps in the information to help drive improvements in the quality of mental health care 145
- Figure 4.1. Change in suicide rates, 2000 and 2011 (or nearest year available) 145
- Figure 4.2. Schizophrenia re-admissions to the same hospital, 2006 and 2011 (or nearest year available) 147
- Figure 4.3. Bipolar disorder re-admissions to the same hospital, 2006 and 2011 (or nearest year available) 147
- Figure 4.4. Inpatient suicides among patients diagnosed with schizophrenia or bipolar disorder, age(-sex) standardised rate per 100 patients, 2000, 2006 and 2011 (or nearest year available) 149
- Figure 4.5. Deaths after discharge from suicide among patients diagnosed with schizophrenia or bipolar disorder, age(-sex) standardised rate per 100 patients, 2000, 2006 and 2011 (or nearest year available) 150
- Figure 4.6. Excess mortality from schizophrenia, 2006 and 2011 (or nearest year available) 151
- Figure 4.7. Excess mortality from bipolar disorder, 2006 and 2011 (or nearest year available) 151
- 4.4. Quality and outcome measures for mental health care must improve in order to catch up with other disease areas 152
- Table 4.2. Primary care providers are required to keep a register of people with mental disorders 155
- Figure 4.8. People with a mental disorder face a considerable employment disadvantage 156
- 4.5. OECD HCQI work on measuring the quality of mental health care 156
- Table 4.3. Mental health quality indicators recommended by the HCQI Mental Health Panel 158
- Table 4.4. Recommended indicators ranked by availability 159
- 4.6. International initiatives to measure and benchmark quality and outcomes of mental health care 160
- Table 4.5. List of mental health indicators for inclusion in a comprehensive European health monitoring system 163
- 4.7. Using data to drive improvements: Developing mental health quality and outcome indicators, targets and standards 164
- Table 4.6. Development of mental health outcome indicators, targets and standards at a national or regional level, selected OECD countries 165
- Table 4.7. Mental health indicators in NHS Outcomes Framework 167
- Table 4.8. Mental health indicators in the CCG OIS 167
- Table 4.9. Depression and mental health indicators included in the Quality and Outcomes Framework 2013-14 168
- Table 4.10. Recommended and Additional Quality Indicators for use with mental health currencies in England 169
- Table 4.11. Items, structure and scoring of the HoNOS 169
- Table 4.12. Dutch indicators on outcome, safety and client satisfaction 170
- 4.8. Conclusion 174
- Notes 175
- References 175
- Chapter 5. Developing skilled workforces for high-performing mental health systems 179
- 5.1. Introduction 180
- 5.2. Composition of the mental health workforce in OECD countries 180
- Figure 5.1. Psychiatrists per 100 000 population, 2000 and 2011 (or nearest year available) 181
- Figure 5.2. Share of psychiatrists among all physicians, 2011 (or nearest year available) 182
- Figure 5.3. Mental health nurses per 100 000 population, 2000 and 2011 (or nearest year available) 183
- Figure 5.4. Psychologists per 100 000 population, 2000 and 2011 (or nearest year available) 183
- Table 5.1. Availability of mental health professionals in primary care settings 185
- 5.3. Education and accreditation of mental health professionals 186
- Table 5.2. Mix of new graduates mental health professionals per 100 000 population, 2011 (or most recent year available) 186
- Table 5.3. Professional accreditation bodies in selected OECD countries 187
- Table 5.4. Training requirements of mental health professionals in selected OECD countries 189
- 5.4. Continuous professional education and development 190
- 5.5. Shortages in mental health professions 191
- 5.6. Changing models of human resources in mental health care 195
- Table 5.5. Models of collaboration between psychiatric specialists and general practitioners (GPs) 196
- 5.7. Integration of service users and carers into the mental health workforce 199
- 5.8. Conclusion 203
- References 204
- Annex 5.A1. Definitions of mental health professional categories 207
- Chapter 6. Good governance for better mental health 209
- 6.1. Introduction 210
- 6.2. What are the key leadership challenges for mental health systems? 210
- 6.3. Who will lead efforts to address these challenges? Key stakeholders in mental health governance 213
- Box 6.1. European Federation of Associations of Families of People with Mental Illness (EUFAMI) 217
- 6.4. Influencing the functioning of the mental health system through mental health legislation 218
- Table 6.1. Mental health legal frameworks in OECD countries 219
- Table 6.2. Criteria for involuntary treatment orders in selected OECD countries 220
- 6.5. A high-level perspective for system-wide improvements: Setting strategic directions to plan and execute change in mental health 225
- Table 6.3. Areas covered by mental health strategy or plan in selected OECD countries 228
- 6.6. Identifying and addressing gaps in mental health systems using vertical programmes 229
- Table 6.4. Mental health programmes in OECD countries 231
- Box 6.2. See Me – a whole population stigma change campaign in Scotland 234
- Box 6.3. This is me – an innovative technology campaign targeting young people in Slovenia 235
- Box 6.4. The Anti Stigma Programme European Network (ASPEN) 236
- 6.7. Conclusion 237
- Notes 238
- References 238