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Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness

Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness Global Health Action SPECIAL ISSUE: EPIDEMIOLOGICAL TRANSITIONS  BEYOND OMRAN’S THEORY Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness 1 2,3 4 5 Helen Jack , Ryan G. Wagner , Inge Petersen , Rita Thom , 1,2 1,2 2,3,6 Charles R. Newton , Alan Stein , Kathleen Kahn , 2,3,6 2,5 Stephen Tollman and Karen J. Hofman * 1 2 Department of Psychiatry, University of Oxford, Oxford, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umea˚ Centre for Global Health Research, Umea˚ University, Umea˚ , Sweden; School of Applied Human Sciences, University of KwaZulu Natal, Durban, South Africa; PRICELESS SA (Priority Cost Effective Lessons in System Strengthening South Africa), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scaling- up mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes. Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions. Design: Narrative overview methodology. Results and conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context. Keywords: mental health; South Africa; economics; health planning; policy; costs and cost analysis Responsible Editors: Nawi Ng, Umea˚ University, Sweden; Barthe´le´my Kuate Defo, University of Montreal, Canada. *Correspondence to: Karen J. Hofman, PRICELESS and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Room 231, 27 St Andrews Road, Parktown, Johannesburg 2193, South Africa, Email: Karen.Hofman@wits.ac.za This paper is part of the Special Issue: Epidemiological Transitions  Beyond Omran’s Theory. More papers from this issue can be found at http://www.globalhealthaction.net Received: 25 November 2013; Revised: 20 December 2013; Accepted: 21 December 2013; Published: 15 May 2014 ental, neurological, and substance use (MNS) is expected to continue, in part due to the ongoing disorders accounted for 10% of the global epidemiological transition from communicable to non- Mburden of disease (GBD) in 2010 (1), yet on communicable diseases (NCDs) (3) and co-morbidity be- average, mental health accounts for less than 1% of tween MNS disorders, HIV, and other chronic health national health budgets in Africa and South East Asia conditions (46). (2). In South Africa, as in many low- or middle-income In 2011, faced with this growing burden, South Africa’s countries (LMICs), the burden of mental disorders has Ministry of Health publically committed to increasing grown over the past 20 years (19902010) (1). This rise by 30% the number of people screened and treated for Global Health Action 2014.# 2014 Helen Jack et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License 1 (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,transform,and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Helen Jack et al. mental disorders by 2030, and to reducing by 20% per facing South Africa’s mental health system, this review capita alcohol consumption by 2020 (5, 7, 8). Health summarizes current understanding and highlights key budgets and system designs, however, do not currently knowledge gaps. Findings may inform future research reflect these new commitments. For example, the District and the design of mental health policy and interven- Specialist Teams introduced under the proposed national tions in South Africa, other nations in sub-Saharan health insurance provide key specialty services to supple- Africa, and settings with a high prevalence of conditions, ment primary health care at the district-level, but the including HIV, that may be co-morbid with mental teams do not include mental health providers (9). Better disorders. understanding of cost-effective, context-specific interven- tions or packages of interventions for treatment and Prevalence and epidemiological burden prevention of MNS disorders may contribute to achiev- of MNS disorders in South Africa ing South Africa’s ambitious mental health targets. Globally, the World Health Organization (WHO) esti- Economic data is one of several relevant factors, in- mates that 30.8% of all years lived with disability (YLDs) cluding burden of disease and equity, that policymakers are due to neuropsychiatric disorders, primarily uni- and donors consider as they set priorities and make polar depression (11.9%), alcohol use disorder (3.1%), spending choices in resource-limited settings. Economic schizophrenia (4.8%), and bipolar mood disorder (4.4%) data provides an ‘external frame’ that can be used to (18). Three MNS disorders (unipolar depressive disorders, make comparisons between competing priorities or in- self-inflicted injuries, and alcohol use disorders) are terventions and justify investment in programs (10, 11). among the top 20 causes of disability-adjusted life years Cost-effectiveness analyses (CEAs), which compare inter- (DALYs) lost globally (18, 19), and MNS disorders ventions to determine those likely to yield the most im- account for a larger percentage of lost DALYs than provements in health per dollar (12), have achieved notable cardiovascular disease or cancer. successes as an advocacy tool for system improvements The South African Stress and Health (SASH) Study, (13, 14). conducted between 2002 and 2004, provides the only Despite the importance of economic information in nationally representative data on the prevalence of com- advocating for and designing policy change, there are mon mental disorders (20, 21). Other prevalence studies no reviews of costs related to MNS disorders and cost- examine specific populations and disorders (22, 23), but effectiveness of their treatment in South Africa, and few do not provide the national representativeness of the reviews that examine costing aspects of MNS disorders SASH (24). Table 1 shows that lifetime prevalence of in any LMICs (2). Compiling the disparate information common mental disorders was 30.3%, and prevalence in on costs and cost-effectiveness at a country-level could the 12 months prior to the survey was 16.5%. facilitate identification of key needs, interventions, and SASH, part of the WHO World Mental Health Survey knowledge gaps. A health system approach, which goes Initiative, is a cross-national effort to collect country- beyond single disorders or interventions, is necessary specific epidemiological data on mental disorders using a because MNS disorders often occur together and may be single assessment tool and data collection methodology. co-morbid with other health conditions, and a holistic It includes seven LMICs: China, Columbia, Lebanon, view can inform the design of treatment packages (15). Mexico, Nigeria, South Africa, and Ukraine. Lifetime Mental health care in South Africa differs from that prevalence rates of select types of MNS disorders are in other LMICs, making a South Africa-specific review shown in Table 1 (25). Examining all countries surveyed, necessary. Although South Africa’s gross national income the highest lifetime prevalence of these disorders is in the US and New Zealand (47.4 and 39.3%, respectively) (GNI) bears greater similarity to other middle-income countries than to the rest of sub-Saharan Africa, find- while the lowest is in Nigeria and China (12.0 and 13.2%, ings on MNS disorders from middle-income nations, respectively). South Africa has more than twice the including those in Latin American or South East Asia, lifetime prevalence of mental and substance use disorders cannot be generalized to South Africa. South Africa than Nigeria (12.0%), the only other African country has a unique post-apartheid socioeconomic and cultural surveyed (21, 26), and a greater lifetime prevalence than context of inequality, with one of the highest Gini co- all LMICs except Columbia and Ukraine. However, these efficients globally (a statistical measure of income comparisons must be interpreted cautiously because inequality in a population) (16), and particular disparities researchers acknowledge that prevalence may be under- between rural and urban areas. It also has a complex reported in Nigeria and China due to stigma and lack of disease burden characterized by high HIV prevalence public familiarity with surveys (27); prevalence of im- and a growing burden of non-communicable chronic pulse control disorders are measured in all LMICs except conditions (17). South Africa, potentially altering the overall prevalence Given the paucity of economic assessments of mental estimate (25); and the manifestations of mental disorders health in sub-Saharan Africa and the specific challenges and their diagnostic criteria may vary between cultural 2 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap contexts, making any single diagnostic instrument poten- tially unfit to capture the range of ways mental disorders may be expressed (28). In this review, we have chosen to focus our epidemiological examination only on data from the WHO World Mental Health Survey to ensure uni- form data collection methodology and consistency in defi- nitions of mental disorders. Overall, there are less epidemiological data on mental disorders than on other disorders in LMICs and few panel data available to examine change in their prevalence or burden over time (29). The SASH data suggest that the high prevalence of common mental disorders may be caused by exposure to stress and trauma during apartheid and the on- going period of racial tension and inequality following apartheid (21). The SASH data shows that 74.8% of South Africans have experienced at least one traumatic event, most commonly trauma related to someone close to them (for example, death of a friend or family member), witnessing a traumatic event, or being the victim of criminal or intimate partner violence (20). These traumas and other life stressors, such as economic hardship and relationship problems, were associated with increased 12-month and lifetime prevalence of common mental disorders (30). In 2000, neuropsychiatric disorders (including mental and nervous system disorders) ranked third in their contribution to South Africa’s national burden of disease. Table 2 shows the contributions of individual MNS disorders to that burden (31). YLD data was not directly collected for the country and, consequently, DALY and YLD estimates must be interpreted cautiously. Suicide, the only MNS disorder in the top 20 leading causes of YLLs, ranked thirteenth (1.3%). Suicide causes 5,5147,582 deaths per year (17), with the number of suicide deaths of people aged under 35 and over 65 increasing between 1968 and 1990 (32). MNS disorders are commonly co-morbid with HIV, and the conditions are mutually reinforcing (6, 24, 33). Considerable research has focused on the high prevalence of common mental disorders in HIV-positive patients (3336), with one study reporting that 35% of HIV patients in South Africa (n100) meet the criteria for major depressive disorder, 6% for bipolar mood disorder, and 21% for generalized anxiety disorder (33), far higher than prevalence estimates for the general population (24, 33). Among patients with severe mental illness admitted to a psychiatric hospital (n206), 29.1% were HIV positive, nearly triple the general population pre- valence (37). These co-morbidity data may not reflect the current situation, as they were collected before the rollout of ARVs and at the tertiary health care level where people with the most advanced HIV-related disease present for treatment; those who did not go to the hospital or who visited primary care clinics were not included. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 3 (page number not for citation purpose) Table 1. Prevalence of select categories of MNS disorders in South Africa and other LMICs countries included in the WHO World Mental Health Survey Initiative Lifetime prevalence 12-month prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence MNS disorder (South Africa) (%) (South Africa) (%) (China) (%) (Columbia) (%) (Lebanon) (%) (Mexico) (%) (Nigeria) (%) (Ukraine) (%) Anxiety 15.8 8.1 4.8 25.3 16.7 14.3 6.5 10.9 disorders Substance use 13.3 5.8 4.9 9.6 2.2 7.8 3.7 15.0 disorders Mood disorders 9.8 4.9 3.6 14.6 12.6 9.2 3.3 15.8 Any disorder 30.3 16.5 13.2 39.1 25.8 26.1 12.0 36.1 Sources: Williams et al. [20], Herman et al. [24], Kessler et al. [25]. Helen Jack et al. Table 2. Contributions of MNS disorders to South Africa’s South Africa has historically been reliant on psychiatric burden of disease hospitals, with little attention to mental health in primary care (19, 48, 49). Currently, care for psychiatric disorders, Ranking in epilepsy and other neurological disorders often occurs Percentage of contribution to in silos, even at the same health facility, and also varies burden of disease burden of disease from urban to rural areas. For example, epilepsy may be MNS disorder (South Africa) (South Africa) treated by mental health care providers in rural areas, but by physical health care providers in urban areas. Sub- Unipolar depressive 5.8 2 stance use disorders are also treated in both the health disorders sector and in social development. While the policy is to Alcohol use 2.8 6 develop comprehensive care at a primary care level, this is Bipolar mood disorder 2.1 9 not yet fully realized. Importantly, in South Africa, many Schizophrenia 2.1 11 people use traditional medicines for MNS disorders, Drug use 1.6 14 often before or instead of seeking conventional medical Foetal alcohol syndrome 1.1 16 treatment (50, 51). Obsessive compulsive 1.0 18 With respect to human resources, there is a substantial disorder mental health workforce shortage, with 1.2 psychiatrists Panic disorder 1.0 19 and 7.5 psychiatric nurses per 100,000 people, nearly 10 times less than many high-income countries. South Source: Norman et al. [31]. Africa’s mental health professionals are concentrated in urban locations, with some rural provinces having one Depression and other mental disorders are of parti- or no psychiatrist, leading to great disparities in care cular concern in patients with HIV because they can lead (19, 48). to suboptimal treatment adherence, and consequently, lower CD4 counts, increased viral load, and a greater chance of developing drug-resistant strains of HIV that Review methods require more costly second-line anti-retroviral therapy For this narrative overview, we searched Google Scholar (38). A diagnosis of HIV also complicates treatment of and MEDLINE (using PubMed and Ovid) for articles MNS disorders because of interactions between antire- written in English on the economic burden of MNS troviral drugs and other medications. Phenobarbital, disorders and for costing data on mental health inter- for example, a common treatment for epilepsy in sub- ventions in South Africa and other sub-Saharan African Saharan Africa, substantially reduces the half-life of countries. The narrative overview strategy was selected some anti-retrovirals, lowering their therapeutic efficacy because it facilitates outlining an area of research that has (39). previously not been widely discussed and highlights key There has been little published research on co- theoretical or empirical gaps in the existing knowledge, morbidities between MNS disorders and other chronic dis- yet does not fulfil the methodological criteria of a eases, yet existing data from South Africa and elsewhere systematic review (52). To ensure that results provided a in sub-Saharan Africa suggests association between sufficient and broad overview of the existing knowledge, mental disorders and diabetes, stroke, and epilepsy we used a deductive approach, generating the paper’s (4045). headings (direct costs, indirect costs, CEAs) then search- ing for studies that fit those categories. We broadened the Service delivery infrastructure search criteria (from South Africa to sub-Saharan Africa) In 2005, South Africa devoted 2.7% of its health budget if there was little literature from South Africa, a strategy to mental health care (19), more than twice that of that would not be appropriate for a systematic review, but Ghana, Uganda, and many other low- to middle-income was called for in this case because the amount of countries (46), but less than high-income nations, such as economic data available from South Africa and whether the UK, which uses 10.8% of its health budget on mental data from elsewhere in sub-Saharan Africa is general- health. Brazil and India, South Africa’s middle-income izable varies widely between different economic themes peers, spend 2.38 and 0.06% of their health budgets (i.e. direct costs, indirect costs, cost-effectiveness). We on mental health, respectively (47). Mental health care screened the search results for relevant, methodologically budget data in the WHO’s Mental Health Atlas was rigorous studies and conducted a forward search of the updated in 2011, but did not include new South African references of many of the relevant results to identify budget data. Consequently, 2005 data, the most recent additional studies. Table 3 displays a summary of all of available, is given here for South Africa. the studies included in the narrative overview. As in many LMICs, the mental health system in Language in South Africa’s mental health policy South Africa is fragmented. Mental health care in focuses on mental health and substance use disorders 4 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap Table 3. Summary of articles included in the narrative overview Economic information Number of Themes Study setting available studies (total: 18) (number of study in parentheses) (number of study in parentheses) Direct costs 5 Private sector chronic care (2), public sector South Africa (5) workforce costs (2), community interventions (1) Indirect costs 4 Income loss from depression (1), severe mental Ghana (1), Kenya (1), Nigeria (1), disorders (1), hospital stay for mental disorder (1), and South Africa (1) and psychological distress (1) Cost-effectiveness 9 Cost-effectiveness of interventions for depression (1), Low- and middle- income epilepsy (1), bipolar mood disorder (1), heavy alcohol regions, including sub-Saharan use (2), schizophrenia (1), and many mental disorders Africa (7), Nigeria (1), Uganda (1) (2); cost-effectiveness of group psychotherapy (1) (53), but we broadened the definition to MNS disorders management (primarily tests, scans, and doctor visits) to include patients with neurological disorders, such as for 1 year ranged from R875 (USD$88) for an individual epilepsy, who are often treated in mental health care with bipolar mood disorder to R1200 (USD$120) for facilities alongside those with mood disorders, anxiety, an outpatient with schizophrenia or epilepsy. Medica- schizophrenia, and substance use disorders. Neurological tion costs, on average, are much higher, ranging from and substance use disorders are also often co-morbid R4362 (USD$436) for patients with epilepsy to R7287 with mental disorders and share many of the same co- (USD$729) for those with schizophrenia and R7512 morbidities as mental disorders, such as HIV and other (USD$751) for those with bipolar mood disorder (55). NCDs. Because the mental health system addresses MNS Additionally, based on data from a private sector phar- disorders and these disorders are interlinked, an eco- maceutical group, in 2008, prescriptions for Alzheimer’s nomic analysis would not be complete without attention disease cost an average of R2659 (USD$266) per patient to the full burden on the system. per year (n588 patients) (56). Public sector workforce expenditures in LMICs ac- Results count for a substantial portion of health care costs (57), and likely a larger portion of mental health care costs Economic burden of MNS disorders because mental health services, particularly those with Economic costs due to mental illness are typically divided adequate capacity for psychosocial care, rely less on laboratory tests or tools and more on trained workers into direct and indirect costs (12, 54). Individuals, govern- ments, health insurers or other institutions pay direct than other forms of healthcare (2). The estimated work- costs, usually the costs of medical care and services. force cost of providing integrated adult mental health Indirect costs include funds spent or lost as a result of the services for a limited number of priority mental disorders condition, including lost productivity for patients and care- using a task-shifting approach (dedicating and support- givers, unemployment and disability benefits, and legal, ing counsellors and community health workers to work penal, or other costs related to a crime. While distinguish- in mental health rather than hiring more expensive ing direct from indirect costs is useful, there is no defined specialist health mental workers) in primary health care reference case for measuring costs and classifying them in South Africa was £28,457 per 100,000 population as direct or indirect. As a result, there is considerable (approximately USD$44,200 or USD$0.44 per person in methodological variation between studies. the population served by the primary health care facility). The staffing costs of scaling-up integrated primary men- tal health care, and employing a task-shifting approach Direct costs was cheaper than alternative staffing models to provide Two studies have explored the direct costs of private, comparable care coverage, although the exact cost differ- outpatient chronic disease care in South Africa. One examined the costs of caring for patients who have private ence was not specified (58). The staffing costs associated health insurance with chronic disease benefits and have with implementing inpatient and outpatient child and been diagnosed with schizophrenia, epilepsy, or bipolar adolescent mental health care ranged from $5.99 per individual in the population to provide care for 1530% mood disorder (n210,664 health insurance beneficiaries receiving treatment for at least one chronic condition* of children and adolescents with mental disorders to no specific data on number receiving treatment for other $21.50 for care for 100% of children and adolescents chronic mental disorders). In 2001, outpatient medical with mental disorders (59). A randomized control trial Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 5 (page number not for citation purpose) Helen Jack et al. in South Africa examined the effects of home-visits for also provide good value for money in terms of DALYs recently discharged psychiatric patients (n51) that averted. aimed to prepare the family for home care and assessed Several studies examine the cost-effectiveness of inter- ventions for depression (67), epilepsy (68), bipolar mood health status and care over a 1-year period. This inter- disorder (69), heavy alcohol use (70, 71), and schizophre- vention reduced re-admission by 31.5% and the number nia (72) in low-income regions, including sub-Saharan of days spent in hospital in a year by 55.6%, producing Africa. Using the same methodology, a single study com- a cost saving of R786 (approximately USD$79) per pared the cost-effectiveness of interventions to address patient (60). all of these disorders in sub-Saharan Africa. By estimat- ing staffing, drug, and patient care costs (inpatient stay, Indirect costs laboratory tests, outpatient visits, medications), the re- Indirect costs, i.e. costs to families and households, may searchers found that national or regional alcohol control contribute to the total economic burden of mental illness policies (USD$117 per DALY averted by increasing more than direct costs (54). Only one study has assessed taxation by 50%) and treatment for epilepsy or depres- indirect costs in South Africa, but several have examined sion in primary care (epilepsy: USD$265 per DALY these costs elsewhere in sub-Saharan Africa. averted; depression: USD$858 per DALY averted using In terms of productivity, the presence of severe depres- newer anti-depressants) were most cost-effective, while sion or anxiety was associated with a reduction in personal inpatient care for schizophrenia using newer psychotropic income of USD$4798 per adult per year in South Africa, drugs (USD$11,072 per DALY averted) was least cost- resulting in a national loss of USD$3.6 billion annually effective. Treating schizophrenia (USD$2,748 per DALY (61). In contrast, a Nigerian study found the annual averted) and bipolar affective disorder (USD$2,551 per impact of a severe mental disorder on productivity was DALY averted) in the community using older psycho- USD$463 per patient, totalling USD$166.2 million an- tropic drugs paired with psychosocial care was more nually (62). The disparity in these costs may be due to cost-effective than inpatient treatment (schizophrenia: differences in purchasing power parity (PPP) between USD$6,816 and bipolar affective disorder: USD$4,874 countries and different measurements of productivity. per DALYaverted). In general, treatments administered in Examining the indirect costs of the institutional care community and primary care settings were more cost- system, a Kenyan study estimated lost productivity over effective than those in hospitals. There were substantial the course of a hospital stay for patients and their families, differences in cost-effectiveness between sub-Saharan showing that one psychiatric hospital admission resulted African and South East Asian regions, underscoring the in a USD$453 productivity loss (63). Conversely, house- importance of context-specific cost-effectiveness data (73). hold survey data from Ghana examined the general Within sub-Saharan Africa, the only country-specific population, many of whom lack access to mental health cost-effective analysis for a range of interventions was treatment, and showed that psychological distress, conducted in Nigeria and found approximate corres- measured using the Kessler 10 Psychological Distress pondence with the regional data in the rank order of Scale (64), was associated with unemployment and lost cost-effectiveness of interventions, but differences in the work time in both formal and informal sectors. Indivi- cost-effectiveness ratios for each intervention (26, 73). duals with moderate or severe psychological distress A CEA of group psychotherapy for individuals with had reductions in productivity of 11.1 and 24.4%, res- depression in Uganda found that the therapeutic inter- pectively. From these estimates, the researchers calculated vention cost $1,150 per quality-adjusted life year added. that psychological distress in Ghana is associated with The authors concluded that this intervention was cost- an approximately 6.8% GDP loss, or USD$2.7 million effective because it cost less than Uganda’s per capita annually (65). GDP (74), the level that the WHO Commission on Despite research indicating that common mental dis- Macroeconomics and Health suggests as the upper limit orders co-occur with HIV in South Africa (3537), no for ‘highly cost-effective’ interventions (75). However, studies specify the direct or indirect costs that stem from the study’s authors acknowledged that that there is no the impact that MNS disorders have on other chronic universally recognized definition of ‘cost-effectiveness’ or conditions, including diabetes, and stroke. criteria for what makes an intervention cost-effective in any given context. CEAs of mental health interventions Existing research suggests that standard treatments, in- Discussion cluding psychotropic medications and various forms of This narrative overview examines available costing data psychotherapy, are effective in LMICs (66), and pre- on MNS disorders and the cost-effectiveness of treat- liminary cost-effectiveness data suggests that they may ments, with a focus on South Africa and data relevant 6 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap to South Africa. In the public sector, there is data on co-morbid conditions or poor lifestyle and self-care (6). workforce expenses at a population level for delivery For instance, individuals receiving public mental health of specific packages of care (55). In the private sector, services in the US died 1330 years sooner than people in there is information on the costs of medication and the general population, although the causes of death were medical management for three severe and chronic mental similar to those of the general population (76). Premature disorders (5860). Only one South African study inves- mortality in people with mental disorders is not well tigated income reduction associated with depression and understood in LMICs. anxiety (61), and few other studies estimate indirect costs While DALY measurements, in theory, illustrate dis- elsewhere in sub-Saharan Africa (62, 63, 65). There are ability YLD and premature mortality (YLL) more ef- some region-level data on the cost-effectiveness of inter- fectively, consideration must be given to how the DALY ventions for the treatment and prevention of MNS dis- is constructed and measured. DALY estimations in orders in sub-Saharan Africa, but no data specific to South Africa use disability weights that are not context- South Africa, even though existing analyses suggest specific. Disability weighting for YLD calculations varies variation in costs and cost-effectiveness between coun- widely by context depending on the impact of a given tries and regions. condition on a person’s lifestyle. In order to develop more accurate burden measures, disability weights should be empirically assessed in South Africa and other LMICs, What we can conclude from what we know rather than based on regional data or data from different The data in this review suggests that indirect costs from countries. foregone income due to MNS disorders are substantial Even DALYs cannot fully capture the societal costs of (6163, 65), and there are cost-effective interventions for mental disorders because they do not take into account addressing them (73). The most cost-effective interven- the indirect costs, such as lost productivity of patients tions incorporate mental health care into primary care and carers, household resources spent caring for a sick or community services without the use of specialized family member, travel costs for hospital visits, or the nega- workers (5860, 73). Such integration may be particularly apt in South Africa because of the high and grow- tive impact on patients’ children who may not receive ing prevalence of MNS disorders co-morbid with HIV adequate attention and care. Indirect costs are particu- and likely, with other chronic conditions (3, 17, 3537). larly high for MNS disorders and must be examined Integrated interventions could improve coverage of a alongside disease burden to fully illustrate their effects population that is at high risk for mental disorders and on patients, their families, and the broader society (77). already presenting for care, which would maximize the Furthermore, most direct and indirect cost studies con- impact and cost-effectiveness of interventions and im- ducted in sub-Saharan Africa examine mental disorders prove overall health outcomes by increasing adherence broadly, with few studies differentiating the costs due to to chronic disease treatment regimes. particular conditions and none specifically examining Prevention interventions that address alcohol consump- costs of neurological and substance use disorders. More tion by raising taxes, limiting advertising, or reducing disorder-specific cost data are needed to inform decisions alcohol availability by restricting hours of sale or increas- about priority setting and investment. ing the drinking age have been shown to be highly cost- Second, although use of traditional medicine for men- effective interventions for reducing DALYs lost due to tal disorders is common in South Africa (50, 51), there MNS disorders in LMICs (71, 73). The low cost of these are no data on the prevalence of use, motivations for interventions suggests that other prevention programs, use, costs, or effectiveness of these treatments. A better such as campaigns to reduce prevalence of risk factors for understanding of why people use traditional medicines mental disorders (such as child abuse and sexual violence), and the health effects of a range of traditional practices may also prove cost-effective. would provide insight into beliefs about mental health, how traditional healing could complement or be inte- Knowledge gaps grated with conventional medicine, and whether any This review reveals four linked knowledge gaps and of these practices put patients at risk. Additionally, associated methodological challenges. existing research on traditional treatments for other First, there is inadequate research on the health and health conditions suggests that the costs for traditional financial burdens of MNS disorders in South Africa medicine are high in South Africa, often as high as and other LMICs. In terms of health burden, much of those for conventional medical care, and are typically the existing research examines prevalence; this likely borne by the poorest segment of the population (78), yet underrepresents the burden of MNS disorders because there is no cost data available on traditional interven- of underreporting due to stigma and because much of the tions for MNS disorders. Complete, accurate data on burden is due to disability and premature mortality from traditional medicines and their costs would provide a Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 7 (page number not for citation purpose) Helen Jack et al. more thorough picture of mental health care and could and defines the future research agenda*appropriate provide a basis for cost-effective, integrated interven- goals for a narrative overview (52). Although the authors tions that operate in tandem with existing traditional defined the section headings prior to conducting the practices. search, they took precautions to ensure the presentation Third, effective strategies for integrating mental health of findings was as unbiased as possible, confining their services into other parts of South Africa’s health system commentary and interpretation to the discussion section must be designed and tested. Interventions to incorpo- and did not generate their arguments until results were rate mental health into primary care and into care for drafted. The grey literature was not searched, and the people living with HIV have shown promise for use in authors did not approach the Ministry of Health to get LMICs (7981), but must be tested in South Africa. additional unpublished data. Finally, costing data was Few interventions that integrate attention to MNS converted to a single currency, but was not adjusted to disorders into treatment programs for other chronic account for inflation to preserve the integrity of the diseases (82) or blend conventional treatment of MNS original data. disorders with traditional medicines have been imple- mented and tested in a LMIC. Before interventions can Conclusion be implemented on a national scale, they must be tested This narrative overview examines the epidemiological in South Africa and the effectiveness data used to guide context of MNS disorders in South Africa and reviews scale-up. what is known about their costs and the cost-effectiveness Fourth, in concert with evaluation of the effectiveness of their treatments. Existing data suggests that providing of interventions, there is a need for more data on cost- mental health services in the context of other health effectiveness and the economic impact of a range of interventions and prevention efforts aimed at limiting interventions and intervention packages. At present, alcohol consumption may be most cost-effective. Further cost-effectiveness research primarily examines specific research on the costs related to MNS disorders is greatly treatments, rather than care packages, such as coordi- needed to develop an evidence base to support effective nated treatment for patients with co-morbid conditions, and efficient implementation and advocacy. prevention efforts integrated with primary health care, Building political will is critical for the implementa- or cooperation with traditional healers. Future cost- tion of more integrated models of mental health care. effectiveness studies will need to examine a broader Economic data will be one key factor in making a per- selection of integrated interventions. suasive case and assisting policymakers to make more National or provincial cost-effectiveness data may informed choices about the importance of investment differ substantially from global or regional findings in mental health care and inclusion of mental health in and could be important for bringing about changes in the basket of options for the proposed national health funding priorities (26, 73). For instance, regional cost- insurance. While this review has put forward a set of effectiveness data do not fully account for inefficiencies in South Africa’s fragile health system, such as high potential priorities for researchers to address, further absenteeism and unfilled posts. Furthermore, there is a analysis must be conducted in tandem with conversations need to examine the broader societal benefits, such as with policymakers able to introduce changes based on gains in productivity and employment and reduction the findings. in costs to other parts of the economy, for instance, policing and crime, child protection, or social work Main findings services. Cost-effectiveness data can inform choices on resource allocation, and information on economic gains . South Africa faces a growing burden of mental, will help with advocacy for mental health services. These neurological, and substance use (MNS) disor- types of economic data are particularly important given ders, which are often co-morbid with HIV and the context of South Africa’s planned implementation other chronic diseases. A considerable mental health treatment gap exists, with significant care of a national health insurance. shortages in rural areas. . Indirect costs, primarily from foregone income Limitations due to MNS disorders, are substantial in sub- The analysis and findings in this review must be acknowl- Saharan Africa. edged in light of several limitations. A narrative overview . The most cost-effective treatment interventions was selected rather than a systematic review because there in sub-Saharan Africa incorporate mental health is little economic research related to MNS disorders in care into community-based services. Taxation of sub-Saharan Africa. As a result, there is great need for an alcohol is a ‘‘best buy’’ for prevention. introduction to the topic that challenges current thinking, 8 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap 3. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3: e442. Key messages for action 4. Beyenburg S, Mitchell AJ, Schmidt D, Elger CE, Reuber M. . Four policy-relevant knowledge gaps are identi- Anxiety in patients with epilepsy: systematic review and sug- gestions for clinical management. Epilepsy Behav 2005; 7: 16171. fied in South Africa: 5. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool k Epidemiological and economic burdens of Karim SS, Coovadia HM. Health in South Africa: changes and MNS disorders must be fully understood challenges since 2009. Lancet 2012; 380: 202943. to inform spending decisions 6. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370: 85977. k More data on the use, costs, and effective- 7. Ramokgopa G. A milestone for mental health in South Africa. ness of traditional therapies for MNS Afr J Psychiatry 2012; 15: 379. disorders are necessary to develop inter- 8. Summit PitNMH. The Ekurhuleni declaration on mental ventions that combine traditional and health*2012. Afr J Psychiatry 2012; 15: 3813. biomedical care 9. National health insurance in South Africa. In: DoHSA, ed. k Effective strategies for integrating mental 2011, p. 159. Available from: http://us-cdn.creamermedia.co.za/ assets/articles/attachments/34471_nhi.pdf [cited 18 July 2013]. health services into primary care must be 10. Tomlinson M, Lund C. Why does mental health not get the designed and tested attention it deserves. PLoS Med 2012; 9: e1001178. k Context specific data on the cost-effective- 11. Shiffman J, Smith S. Generation of political priority for global ness of integrated intervention models of health initiatives: a framework and case study of maternal cares is essential for advocacy and spending mortality. Lancet 2007; 370: 13709. 12. Drummond MF, Sculpher MJ, Torrence GW, O’Brien BJ, choices Stoddort GL. Methods for the economic evaluation of . Economic data is critical for advocacy, to health care programmes. Oxford, UK: Oxford University Press; develop integrated models of mental health care and will inform choices between competing 13. Disease control priorities related to mental, neurological, spending priorities. developmental and substance abuse disorders. Geneva: World Health Organization; 2006. Available from: http://whqlibdoc. who.int/publications/2006/924156332x_eng.pdf [cited 18 July 2013]. Authors’ contributions 14. Clark DM. Implementing NICE guidelines for the psychologi- KH, AS, RW, and HJ developed the concept for the cal treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry 2011; 23: 31827. paper. HJ and RW conducted the literature review. HJ 15. Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT. drafted the manuscript with assistance from RW and KH. Grand challenges in global mental health: integration in RT, IP, CN, AS, KH, RW, ST and KK reviewed and research, policy, and practice. PLoS Med 2013; 10: e1001434. provided comments on the manuscript. 16. World Bank (2013). GINI index. Available from: http://data. worldbank.org/ondicators/si.pov.gini [cited 15 October 2013]. 17. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Ethical issues Bradshaw D. The burden of non-communicable diseases in There are no ethical concerns with this paper and ethical South Africa. Lancet 2009; 374: 93447. review board approval was not required as no human 18. World health report 2001: mental health: new understanding, subjects were involved. new hope. Geneva, Switzerland: World Health Organization; 19. World Health Organization. Mental health atlas: 2005. World Acknowledgements Health Organization. Available from: http://www.who.int/mental_ Thanks to Patrizia Favini and Alex K Smith for their assistance in health/evidence/mhatlas05/en/ [cited 16 July 2013]. the preparation of this manuscript. 20. Williams SL, Williams DR, Stein DJ, Seedat S, Jackson PB, Moomal H. Multiple traumatic events and psychological distress: the South Africa stress and health study. J Trauma Conflict of interests and funding Stress 2007; 20: 84555. 21. Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SG, None of the authors declare any conflict of interest with the Kessler RC, et al. Lifetime prevalence of psychiatric disorders in material in this paper. South Africa. Br J Psychiatr 2008; 192: 11217. 22. Kleintjes S, Flisher A, Fick M, Railoun A, Lund C, Molteno C, References et al. The prevalence of mental disorders among children, adolescents and adults in the Western Cape, South Africa. Afr J 1. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Psychiatry 2006; 9: 15760. Michaud C, et al. Disability-adjusted life years (DALYs) for 291 23. Havenaar JM, Geerlings MI, Vivian L, Collinson M, Robertson diseases and injuries in 21 regions, 19902010: a systematic B. Common mental health problems in historically disadvan- analysis for the Global Burden of Disease Study 2010. Lancet taged urban and rural communities in South Africa: prevalence 2013; 380: 2197223. and risk factors. Soc Psychiatr Psychiatr Epidemiol 2008; 43: 2. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources 20915. for mental health: scarcity, inequity, and inefficiency. Lancet 24. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, 2007; 370: 87889. Williams DR. The South African Stress and Health (SASH) Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 9 (page number not for citation purpose) Helen Jack et al. study: 12-month and lifetime prevalence of common mental 44. Nubukpo P, Cle´ment J, Houinato D, Radji A, Grunitzky E, disorders. S Afr Med J 2009; 99: 33944. Avode´ G, et al. Psychosocial issues in people with epilepsy in 25. Kessler R, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Togo and Benin (West Africa) II: quality of life measured using Ormel J, et al. Special articles. The global burden of mental the QOLIE-31 scale. Epilepsy Behav 2004; 5: 72834. disorders: an update from the WHO World Mental Health 45. Mbewe EK, Uys LR, Nkwanyana NM, Birbeck GL. A primary healthcare screening tool to identify depression and anxiety (WMH) surveys. Epidemiol Psychiatr Sci 2009; 18: 23. disorders among people with epilepsy in Zambia. Epilepsy 26. Gureje O, Chisholm D, Kola L, Lasebikan V, Saxena S. Cost- Behav 2013; 27: 296300. effectiveness of an essential mental health intervention package 46. Flisher AJ, Lund C, Funk M, Banda M, Bhana A, Doku V, in Nigeria. World Psychiatr 2007; 6: 428. et al. Mental health policy development and implementation in 27. Kessler RC, Angermeyer M, Anthony JC, de Graaf R, four African countries. J Health Psychol 2007; 12: 50516. Demyttenaere K, Gasquet I, et al. Lifetime prevalence and 47. World Health Organisation (2011). Mental health atlas 2011. age-of-onset distributions of mental disorders in the World Available from: http://www.who.int/mental_health/publications/ Health Organization’s World Mental Health Survey Initiative. mental_health_atlas_2011/en/ [cited 16 July 2013]. World Psychiatr 2007; 6: 168. 48. Lund C, Kleintjes S, Kakuma R, Flisher AJ. Public sector 28. Lynskey MT, Strang J. The global burden of drug use and mental health systems in South Africa: inter-provincial com- mental disorders. Lancet 2013; 382: 15402. parisons and policy implications. Soc Psychiatr Psychiatr 29. Baxter AJ, Patton G, Scott KM, Degenhardt L, Whiteford HA. Epidemiol 2010; 45: 393404. Global epidemiology of mental disorders: what are we missing? 49. Petersen I, Lund C. Mental health service delivery in PLoS One 2013; 8: e65514. South Africa from 2000 to 2010: one step forward, one step 30. Seedat S, Stein DJ, Jackson PB, Heeringa SG, Williams DR, back. S Afr Med J 2011; 101: 7517. Myer L. Life stress and mental disorders in the South African 50. Sorsdahl K, Flisher A, Wilson Z, Stein D. Explanatory models stress and health study. S Afr Med J 2009; 99: 37582. of mental disorders and treatment practices among traditional 31. Norman R, Bradshaw D, Schneider M, Pieterse D, Groenewald healers in Mpumulanga, South Africa. Afr J Psychiatry 2010; P. Revised burden of disease estimates for the comparative risk 13: 28490. factor assessment, South Africa 2000. Cape Town: Medical 51. Sorsdahl K, Stein DJ, Flisher AJ. Traditional healer attitudes Research Council; 2006. and beliefs regarding referral of the mentally ill to Western 32. Flisher AJ, Liang H, Laubscher R, Lombard CF. Suicide doctors in South Africa. Transcult Psychiatr 2010; 47: 591609. trends in South Africa, 196890. Scand J Publ Health 2004; 52. Green BN, Johnson CD, Adams A. Writing narrative literature 32: 41118. reviews for peer-reviewed journals: secrets of the trade. Journal 33. Els C, Boshoff W, Scott C, Strydom W, Joubert G, Van der Ryst of Chiropractic Medicine 2006; 5: 10117. E. Psychiatric co-morbidity in South African HIV/AIDS 53. South African Department of Health (2012). Mental health patients. S Afr Med J  Cape Town Medical Association of policy framework for South Africa and strategic plan 2014 South Africa 1999; 89: 9924. 2020 (final draft) Pretoria. In: DOHS SA, ed. Government 34. Olley BO, Seedat S, Stein DJ. Persistence of psychiatric Printer; 2012, pp. 148. disorders in a cohort of HIV/AIDS patients in South Africa: 54. Hu TW. Perspectives: an international review of the national a 6-month follow-up study. J Psychosom Res 2006; 61: 47984. cost estimates of mental illness, 19902003. J Ment Health Pol 35. Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Econ 2006; 9: 3. Common mental disorders among HIV-infected individuals in 55. McLeod H, Rothberg A, Pels L, Eekhout S, Mubangizi DB, South Africa: prevalence, predictors, and validation of brief psy- Fish T. The costing of the proposed chronic disease list benefits chiatric rating scales. AIDS Patient Care STDs 2008; 22: 14758. in South African Medical Schemes in 2001. Centre for Actuarial 36. Freeman M, Nkomo N, Kafaar Z, Kelly K. Factors associated Research, University of Cape Town; 2002. Available from: http:// with prevalence of mental disorder in people living with HIV/ www.commerce.uct.ac.za/Research_Units/CARE/RESEARCH/ AIDS in South Africa. AIDS Care 2007; 19: 12019. Papers/Chronic Disease List Report.pdf [cited 18 July 2013]. 37. Singh D, Berkman A, Bresnahan M. Seroprevalence and HIV- 56. Truter I. Prescribing of drugs for Alzheimer’s disease: a South associated factors among adults with severe mental illness: a African database analysis. Int Psychogeriatr 2010; 22: 264. vulnerable population. S Afr Med J 2009; 99: 5237. 57. Provinces spend 46% of combined capital budgets. Available 38. Cook JA, Cohen MH, Burke J, Grey D, Anastos K, Kirstein L, from: http://www.sanews.gov.za/south-africa/provinces-spend-46- et al. Effects of depressive symptoms and mental health quality combined-capital-budgets [cited 19 July 2013]. of life on use of highly active antiretroviral therapy among 58. Petersen I, Lund C, Bhana A, Flisher AJ. A task shifting ap- HIV-seropositive women. J Acquir Immune Defic Syndr 2002; proach to primary mental health care for adults in South Africa: 30: 4019. human resource requirements and costs for rural settings. 39. Epilepsy and HIV*a dangerous combination. Lancet Neurol Health Pol Plann 2012; 27: 4251. 2007; 6: 747. 59. Lund C, Boyce G, Flisher AJ, Kafaar Z, Dawes A. Scaling up 40. Lin EH, Korff MV. Mental disorders among persons with child and adolescent mental health services in South Africa: diabetes*results from the World Mental Health Surveys. J human resource requirements and costs. J Child Psychol Psychosom Res 2008; 65: 57180. Psychiatry 2009; 50: 112130. 41. James BO, Omoaregba JO, Eze G, Morakinyo O. Depression 60. Gillis L, Koch A, Joyi M. The value and cost-effectiveness of among patients with diabetes mellitus in a Nigerian teaching a home-visiting programme for psychiatric patients. S Afr Med hospital. S Afr J Psychiatr 2010; 16: 614. J 1990; 77: 309. 42. Issa BA, Yussuf AD, Baiyewu O. The association between 61. Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental psychiatric disorders and quality of life of patient with diabetes illness and lost income among adult South Africans. Soc mellitus. Iranian J Psychiatr 2007; 2: 304. Psychiatr Psychiatr Epidemiol 2013; 48: 84551. 43. Oladiji J, Akinbo S, Aina O, Aiyejusunle C. Risk factors of 62. Esan OB, Kola L, Gureje O. Mental disorders and earnings: post-stroke depression among stroke survivors in Lagos, results from the Nigerian National Survey of Mental Health and Nigeria. Afr J Psychiatr 2009; 12: 4751. Well-being (NSMHW). J Ment Health Pol Econ 2012; 15: 77. 10 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap 63. Kirigia J, Sambo L. Cost of mental and behavioural disorders in 73. Chisholm D, Saxena S. Cost effectiveness of strategies to com- Kenya. Ann Gen Psychiatr 2003; 2: 7. bat neuropsychiatric conditions in sub-Saharan Africa and 64. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, South East Asia: mathematical modelling study. BMJ 2012; Normand S-LT, et al. Short screening scales to monitor popu- 344: e609. lation prevalences and trends in non-specific psychological 74. Siskind D, Baingana F, Kim J. Cost-effectiveness of group distress. Psychol Med 2002; 32: 95976. psychotherapy for depression in Uganda. J Ment Health Policy 65. Canavan ME, Sipsma HL, Adhvaryu A, Ofori-Atta A, Jack H, Econ 2008; 11: 127. Udry C, et al. Psychological distress in Ghana: associations with 75. Choosing interventions that are cost effective. Available from: employment and lost productivity. Int J Ment Health Syst 2013; http://www.who.int/choice/costs/CER_thresholds/en/ [cited 1 7: 9. October 2013]. 66. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva 76. Colton CW, Manderscheid RW. Congruencies in increased M, et al. Treatment and prevention of mental disorders in mortality rates, years of potential life lost, and causes of death low-income and middle-income countries. Lancet 2007; 370: among public mental health clients in eight states. Prev Chronic 9911005. Dis 2006; 3: A42. 67. Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S. 77. Hyman SE. The diagnosis of mental disorders: the problem of Reducing the global burden of depression Population-level reification. Annu Rev Clin Psychol 2010; 6: 15579. analysis of intervention cost-effectiveness in 14 world regions. 78. Nxumalo N, Alaba O, Harris B, Chersich M, Goudge J. The British Journal of Psychiatry 2004; 184: 393403. Utilization of traditional healers in South Africa and costs to 68. Chisholm D. Cost-effectiveness of first-line antiepileptic drug patients: findings from a national household survey. J Publ treatments in the developing world: a population-level analysis. Health Pol 2011; 32(Suppl 1): S12436. Epilepsia 2005; 46: 7519. 79. Blank MB, Hanrahan NP, Fishbein M, Wu ES, Tennille JA, Ten 69. Chisholm D, van Ommeren M, Ayuso-Mateos JL, Saxena S. Have TR, et al. A randomized trial of a nursing intervention for Cost-effectiveness of clinical interventions for reducing the HIV disease management among persons with serious mental global burden of bipolar disorder. The British Journal of illness. Psychiatr Serv 2011; 62: 131824. Psychiatry 2005; 187: 55967. 80. Crepaz N, Passin WF, Herbst JH, Rama SM, Malow RM, 70. Chisholm D, Rehm J, Van Ommeren M, Monteiro M. Reducing Purcell DW, et al. Meta-analysis of cognitive-behavioral inter- the global burden of hazardous alcohol use: a comparative ventions on HIV-positive persons’ mental health and immune costeffectiveness analysis. J Stud Alcohol Drugs 2004; 65: 782. functioning. Health Psychol 2008; 27: 414. 71. Anderson P, Chisholm D, Fuhr DC. Effectiveness and costef- 81. Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, fectiveness of policies and programmes to reduce the harm Wissow L. Grand challenges: improving HIV treatment out- caused by alcohol. Lancet 2009; 373: 223446. comes by integrating interventions for co-morbid mental illness. 72. Chisholm D, Gureje O, Saldivia S, Villalo´n Caldero´n M, PLoS Med 2013; 10: e1001447. Wickremasinghe R, Mendis N, et al. Schizophrenia treatment 82. Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, Rabadan- in the developing world: an interregional and multinational Diehl C, et al. Grand challenges: integrating mental health care cost-effectiveness analysis. Bull World Health Organ 2008; 86: into the non-communicable disease agenda. PLoS Med 2013; 54251. 10: e1001443. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 11 (page number not for citation purpose) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Global Health Action Taylor & Francis

Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness

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Abstract

Global Health Action SPECIAL ISSUE: EPIDEMIOLOGICAL TRANSITIONS  BEYOND OMRAN’S THEORY Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness 1 2,3 4 5 Helen Jack , Ryan G. Wagner , Inge Petersen , Rita Thom , 1,2 1,2 2,3,6 Charles R. Newton , Alan Stein , Kathleen Kahn , 2,3,6 2,5 Stephen Tollman and Karen J. Hofman * 1 2 Department of Psychiatry, University of Oxford, Oxford, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umea˚ Centre for Global Health Research, Umea˚ University, Umea˚ , Sweden; School of Applied Human Sciences, University of KwaZulu Natal, Durban, South Africa; PRICELESS SA (Priority Cost Effective Lessons in System Strengthening South Africa), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scaling- up mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes. Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions. Design: Narrative overview methodology. Results and conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context. Keywords: mental health; South Africa; economics; health planning; policy; costs and cost analysis Responsible Editors: Nawi Ng, Umea˚ University, Sweden; Barthe´le´my Kuate Defo, University of Montreal, Canada. *Correspondence to: Karen J. Hofman, PRICELESS and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Room 231, 27 St Andrews Road, Parktown, Johannesburg 2193, South Africa, Email: Karen.Hofman@wits.ac.za This paper is part of the Special Issue: Epidemiological Transitions  Beyond Omran’s Theory. More papers from this issue can be found at http://www.globalhealthaction.net Received: 25 November 2013; Revised: 20 December 2013; Accepted: 21 December 2013; Published: 15 May 2014 ental, neurological, and substance use (MNS) is expected to continue, in part due to the ongoing disorders accounted for 10% of the global epidemiological transition from communicable to non- Mburden of disease (GBD) in 2010 (1), yet on communicable diseases (NCDs) (3) and co-morbidity be- average, mental health accounts for less than 1% of tween MNS disorders, HIV, and other chronic health national health budgets in Africa and South East Asia conditions (46). (2). In South Africa, as in many low- or middle-income In 2011, faced with this growing burden, South Africa’s countries (LMICs), the burden of mental disorders has Ministry of Health publically committed to increasing grown over the past 20 years (19902010) (1). This rise by 30% the number of people screened and treated for Global Health Action 2014.# 2014 Helen Jack et al. This is an Open Access article distributed under the terms of the Creative Commons CC-BY 4.0 License 1 (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix,transform,and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Helen Jack et al. mental disorders by 2030, and to reducing by 20% per facing South Africa’s mental health system, this review capita alcohol consumption by 2020 (5, 7, 8). Health summarizes current understanding and highlights key budgets and system designs, however, do not currently knowledge gaps. Findings may inform future research reflect these new commitments. For example, the District and the design of mental health policy and interven- Specialist Teams introduced under the proposed national tions in South Africa, other nations in sub-Saharan health insurance provide key specialty services to supple- Africa, and settings with a high prevalence of conditions, ment primary health care at the district-level, but the including HIV, that may be co-morbid with mental teams do not include mental health providers (9). Better disorders. understanding of cost-effective, context-specific interven- tions or packages of interventions for treatment and Prevalence and epidemiological burden prevention of MNS disorders may contribute to achiev- of MNS disorders in South Africa ing South Africa’s ambitious mental health targets. Globally, the World Health Organization (WHO) esti- Economic data is one of several relevant factors, in- mates that 30.8% of all years lived with disability (YLDs) cluding burden of disease and equity, that policymakers are due to neuropsychiatric disorders, primarily uni- and donors consider as they set priorities and make polar depression (11.9%), alcohol use disorder (3.1%), spending choices in resource-limited settings. Economic schizophrenia (4.8%), and bipolar mood disorder (4.4%) data provides an ‘external frame’ that can be used to (18). Three MNS disorders (unipolar depressive disorders, make comparisons between competing priorities or in- self-inflicted injuries, and alcohol use disorders) are terventions and justify investment in programs (10, 11). among the top 20 causes of disability-adjusted life years Cost-effectiveness analyses (CEAs), which compare inter- (DALYs) lost globally (18, 19), and MNS disorders ventions to determine those likely to yield the most im- account for a larger percentage of lost DALYs than provements in health per dollar (12), have achieved notable cardiovascular disease or cancer. successes as an advocacy tool for system improvements The South African Stress and Health (SASH) Study, (13, 14). conducted between 2002 and 2004, provides the only Despite the importance of economic information in nationally representative data on the prevalence of com- advocating for and designing policy change, there are mon mental disorders (20, 21). Other prevalence studies no reviews of costs related to MNS disorders and cost- examine specific populations and disorders (22, 23), but effectiveness of their treatment in South Africa, and few do not provide the national representativeness of the reviews that examine costing aspects of MNS disorders SASH (24). Table 1 shows that lifetime prevalence of in any LMICs (2). Compiling the disparate information common mental disorders was 30.3%, and prevalence in on costs and cost-effectiveness at a country-level could the 12 months prior to the survey was 16.5%. facilitate identification of key needs, interventions, and SASH, part of the WHO World Mental Health Survey knowledge gaps. A health system approach, which goes Initiative, is a cross-national effort to collect country- beyond single disorders or interventions, is necessary specific epidemiological data on mental disorders using a because MNS disorders often occur together and may be single assessment tool and data collection methodology. co-morbid with other health conditions, and a holistic It includes seven LMICs: China, Columbia, Lebanon, view can inform the design of treatment packages (15). Mexico, Nigeria, South Africa, and Ukraine. Lifetime Mental health care in South Africa differs from that prevalence rates of select types of MNS disorders are in other LMICs, making a South Africa-specific review shown in Table 1 (25). Examining all countries surveyed, necessary. Although South Africa’s gross national income the highest lifetime prevalence of these disorders is in the US and New Zealand (47.4 and 39.3%, respectively) (GNI) bears greater similarity to other middle-income countries than to the rest of sub-Saharan Africa, find- while the lowest is in Nigeria and China (12.0 and 13.2%, ings on MNS disorders from middle-income nations, respectively). South Africa has more than twice the including those in Latin American or South East Asia, lifetime prevalence of mental and substance use disorders cannot be generalized to South Africa. South Africa than Nigeria (12.0%), the only other African country has a unique post-apartheid socioeconomic and cultural surveyed (21, 26), and a greater lifetime prevalence than context of inequality, with one of the highest Gini co- all LMICs except Columbia and Ukraine. However, these efficients globally (a statistical measure of income comparisons must be interpreted cautiously because inequality in a population) (16), and particular disparities researchers acknowledge that prevalence may be under- between rural and urban areas. It also has a complex reported in Nigeria and China due to stigma and lack of disease burden characterized by high HIV prevalence public familiarity with surveys (27); prevalence of im- and a growing burden of non-communicable chronic pulse control disorders are measured in all LMICs except conditions (17). South Africa, potentially altering the overall prevalence Given the paucity of economic assessments of mental estimate (25); and the manifestations of mental disorders health in sub-Saharan Africa and the specific challenges and their diagnostic criteria may vary between cultural 2 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap contexts, making any single diagnostic instrument poten- tially unfit to capture the range of ways mental disorders may be expressed (28). In this review, we have chosen to focus our epidemiological examination only on data from the WHO World Mental Health Survey to ensure uni- form data collection methodology and consistency in defi- nitions of mental disorders. Overall, there are less epidemiological data on mental disorders than on other disorders in LMICs and few panel data available to examine change in their prevalence or burden over time (29). The SASH data suggest that the high prevalence of common mental disorders may be caused by exposure to stress and trauma during apartheid and the on- going period of racial tension and inequality following apartheid (21). The SASH data shows that 74.8% of South Africans have experienced at least one traumatic event, most commonly trauma related to someone close to them (for example, death of a friend or family member), witnessing a traumatic event, or being the victim of criminal or intimate partner violence (20). These traumas and other life stressors, such as economic hardship and relationship problems, were associated with increased 12-month and lifetime prevalence of common mental disorders (30). In 2000, neuropsychiatric disorders (including mental and nervous system disorders) ranked third in their contribution to South Africa’s national burden of disease. Table 2 shows the contributions of individual MNS disorders to that burden (31). YLD data was not directly collected for the country and, consequently, DALY and YLD estimates must be interpreted cautiously. Suicide, the only MNS disorder in the top 20 leading causes of YLLs, ranked thirteenth (1.3%). Suicide causes 5,5147,582 deaths per year (17), with the number of suicide deaths of people aged under 35 and over 65 increasing between 1968 and 1990 (32). MNS disorders are commonly co-morbid with HIV, and the conditions are mutually reinforcing (6, 24, 33). Considerable research has focused on the high prevalence of common mental disorders in HIV-positive patients (3336), with one study reporting that 35% of HIV patients in South Africa (n100) meet the criteria for major depressive disorder, 6% for bipolar mood disorder, and 21% for generalized anxiety disorder (33), far higher than prevalence estimates for the general population (24, 33). Among patients with severe mental illness admitted to a psychiatric hospital (n206), 29.1% were HIV positive, nearly triple the general population pre- valence (37). These co-morbidity data may not reflect the current situation, as they were collected before the rollout of ARVs and at the tertiary health care level where people with the most advanced HIV-related disease present for treatment; those who did not go to the hospital or who visited primary care clinics were not included. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 3 (page number not for citation purpose) Table 1. Prevalence of select categories of MNS disorders in South Africa and other LMICs countries included in the WHO World Mental Health Survey Initiative Lifetime prevalence 12-month prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence Lifetime prevalence MNS disorder (South Africa) (%) (South Africa) (%) (China) (%) (Columbia) (%) (Lebanon) (%) (Mexico) (%) (Nigeria) (%) (Ukraine) (%) Anxiety 15.8 8.1 4.8 25.3 16.7 14.3 6.5 10.9 disorders Substance use 13.3 5.8 4.9 9.6 2.2 7.8 3.7 15.0 disorders Mood disorders 9.8 4.9 3.6 14.6 12.6 9.2 3.3 15.8 Any disorder 30.3 16.5 13.2 39.1 25.8 26.1 12.0 36.1 Sources: Williams et al. [20], Herman et al. [24], Kessler et al. [25]. Helen Jack et al. Table 2. Contributions of MNS disorders to South Africa’s South Africa has historically been reliant on psychiatric burden of disease hospitals, with little attention to mental health in primary care (19, 48, 49). Currently, care for psychiatric disorders, Ranking in epilepsy and other neurological disorders often occurs Percentage of contribution to in silos, even at the same health facility, and also varies burden of disease burden of disease from urban to rural areas. For example, epilepsy may be MNS disorder (South Africa) (South Africa) treated by mental health care providers in rural areas, but by physical health care providers in urban areas. Sub- Unipolar depressive 5.8 2 stance use disorders are also treated in both the health disorders sector and in social development. While the policy is to Alcohol use 2.8 6 develop comprehensive care at a primary care level, this is Bipolar mood disorder 2.1 9 not yet fully realized. Importantly, in South Africa, many Schizophrenia 2.1 11 people use traditional medicines for MNS disorders, Drug use 1.6 14 often before or instead of seeking conventional medical Foetal alcohol syndrome 1.1 16 treatment (50, 51). Obsessive compulsive 1.0 18 With respect to human resources, there is a substantial disorder mental health workforce shortage, with 1.2 psychiatrists Panic disorder 1.0 19 and 7.5 psychiatric nurses per 100,000 people, nearly 10 times less than many high-income countries. South Source: Norman et al. [31]. Africa’s mental health professionals are concentrated in urban locations, with some rural provinces having one Depression and other mental disorders are of parti- or no psychiatrist, leading to great disparities in care cular concern in patients with HIV because they can lead (19, 48). to suboptimal treatment adherence, and consequently, lower CD4 counts, increased viral load, and a greater chance of developing drug-resistant strains of HIV that Review methods require more costly second-line anti-retroviral therapy For this narrative overview, we searched Google Scholar (38). A diagnosis of HIV also complicates treatment of and MEDLINE (using PubMed and Ovid) for articles MNS disorders because of interactions between antire- written in English on the economic burden of MNS troviral drugs and other medications. Phenobarbital, disorders and for costing data on mental health inter- for example, a common treatment for epilepsy in sub- ventions in South Africa and other sub-Saharan African Saharan Africa, substantially reduces the half-life of countries. The narrative overview strategy was selected some anti-retrovirals, lowering their therapeutic efficacy because it facilitates outlining an area of research that has (39). previously not been widely discussed and highlights key There has been little published research on co- theoretical or empirical gaps in the existing knowledge, morbidities between MNS disorders and other chronic dis- yet does not fulfil the methodological criteria of a eases, yet existing data from South Africa and elsewhere systematic review (52). To ensure that results provided a in sub-Saharan Africa suggests association between sufficient and broad overview of the existing knowledge, mental disorders and diabetes, stroke, and epilepsy we used a deductive approach, generating the paper’s (4045). headings (direct costs, indirect costs, CEAs) then search- ing for studies that fit those categories. We broadened the Service delivery infrastructure search criteria (from South Africa to sub-Saharan Africa) In 2005, South Africa devoted 2.7% of its health budget if there was little literature from South Africa, a strategy to mental health care (19), more than twice that of that would not be appropriate for a systematic review, but Ghana, Uganda, and many other low- to middle-income was called for in this case because the amount of countries (46), but less than high-income nations, such as economic data available from South Africa and whether the UK, which uses 10.8% of its health budget on mental data from elsewhere in sub-Saharan Africa is general- health. Brazil and India, South Africa’s middle-income izable varies widely between different economic themes peers, spend 2.38 and 0.06% of their health budgets (i.e. direct costs, indirect costs, cost-effectiveness). We on mental health, respectively (47). Mental health care screened the search results for relevant, methodologically budget data in the WHO’s Mental Health Atlas was rigorous studies and conducted a forward search of the updated in 2011, but did not include new South African references of many of the relevant results to identify budget data. Consequently, 2005 data, the most recent additional studies. Table 3 displays a summary of all of available, is given here for South Africa. the studies included in the narrative overview. As in many LMICs, the mental health system in Language in South Africa’s mental health policy South Africa is fragmented. Mental health care in focuses on mental health and substance use disorders 4 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap Table 3. Summary of articles included in the narrative overview Economic information Number of Themes Study setting available studies (total: 18) (number of study in parentheses) (number of study in parentheses) Direct costs 5 Private sector chronic care (2), public sector South Africa (5) workforce costs (2), community interventions (1) Indirect costs 4 Income loss from depression (1), severe mental Ghana (1), Kenya (1), Nigeria (1), disorders (1), hospital stay for mental disorder (1), and South Africa (1) and psychological distress (1) Cost-effectiveness 9 Cost-effectiveness of interventions for depression (1), Low- and middle- income epilepsy (1), bipolar mood disorder (1), heavy alcohol regions, including sub-Saharan use (2), schizophrenia (1), and many mental disorders Africa (7), Nigeria (1), Uganda (1) (2); cost-effectiveness of group psychotherapy (1) (53), but we broadened the definition to MNS disorders management (primarily tests, scans, and doctor visits) to include patients with neurological disorders, such as for 1 year ranged from R875 (USD$88) for an individual epilepsy, who are often treated in mental health care with bipolar mood disorder to R1200 (USD$120) for facilities alongside those with mood disorders, anxiety, an outpatient with schizophrenia or epilepsy. Medica- schizophrenia, and substance use disorders. Neurological tion costs, on average, are much higher, ranging from and substance use disorders are also often co-morbid R4362 (USD$436) for patients with epilepsy to R7287 with mental disorders and share many of the same co- (USD$729) for those with schizophrenia and R7512 morbidities as mental disorders, such as HIV and other (USD$751) for those with bipolar mood disorder (55). NCDs. Because the mental health system addresses MNS Additionally, based on data from a private sector phar- disorders and these disorders are interlinked, an eco- maceutical group, in 2008, prescriptions for Alzheimer’s nomic analysis would not be complete without attention disease cost an average of R2659 (USD$266) per patient to the full burden on the system. per year (n588 patients) (56). Public sector workforce expenditures in LMICs ac- Results count for a substantial portion of health care costs (57), and likely a larger portion of mental health care costs Economic burden of MNS disorders because mental health services, particularly those with Economic costs due to mental illness are typically divided adequate capacity for psychosocial care, rely less on laboratory tests or tools and more on trained workers into direct and indirect costs (12, 54). Individuals, govern- ments, health insurers or other institutions pay direct than other forms of healthcare (2). The estimated work- costs, usually the costs of medical care and services. force cost of providing integrated adult mental health Indirect costs include funds spent or lost as a result of the services for a limited number of priority mental disorders condition, including lost productivity for patients and care- using a task-shifting approach (dedicating and support- givers, unemployment and disability benefits, and legal, ing counsellors and community health workers to work penal, or other costs related to a crime. While distinguish- in mental health rather than hiring more expensive ing direct from indirect costs is useful, there is no defined specialist health mental workers) in primary health care reference case for measuring costs and classifying them in South Africa was £28,457 per 100,000 population as direct or indirect. As a result, there is considerable (approximately USD$44,200 or USD$0.44 per person in methodological variation between studies. the population served by the primary health care facility). The staffing costs of scaling-up integrated primary men- tal health care, and employing a task-shifting approach Direct costs was cheaper than alternative staffing models to provide Two studies have explored the direct costs of private, comparable care coverage, although the exact cost differ- outpatient chronic disease care in South Africa. One examined the costs of caring for patients who have private ence was not specified (58). The staffing costs associated health insurance with chronic disease benefits and have with implementing inpatient and outpatient child and been diagnosed with schizophrenia, epilepsy, or bipolar adolescent mental health care ranged from $5.99 per individual in the population to provide care for 1530% mood disorder (n210,664 health insurance beneficiaries receiving treatment for at least one chronic condition* of children and adolescents with mental disorders to no specific data on number receiving treatment for other $21.50 for care for 100% of children and adolescents chronic mental disorders). In 2001, outpatient medical with mental disorders (59). A randomized control trial Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 5 (page number not for citation purpose) Helen Jack et al. in South Africa examined the effects of home-visits for also provide good value for money in terms of DALYs recently discharged psychiatric patients (n51) that averted. aimed to prepare the family for home care and assessed Several studies examine the cost-effectiveness of inter- ventions for depression (67), epilepsy (68), bipolar mood health status and care over a 1-year period. This inter- disorder (69), heavy alcohol use (70, 71), and schizophre- vention reduced re-admission by 31.5% and the number nia (72) in low-income regions, including sub-Saharan of days spent in hospital in a year by 55.6%, producing Africa. Using the same methodology, a single study com- a cost saving of R786 (approximately USD$79) per pared the cost-effectiveness of interventions to address patient (60). all of these disorders in sub-Saharan Africa. By estimat- ing staffing, drug, and patient care costs (inpatient stay, Indirect costs laboratory tests, outpatient visits, medications), the re- Indirect costs, i.e. costs to families and households, may searchers found that national or regional alcohol control contribute to the total economic burden of mental illness policies (USD$117 per DALY averted by increasing more than direct costs (54). Only one study has assessed taxation by 50%) and treatment for epilepsy or depres- indirect costs in South Africa, but several have examined sion in primary care (epilepsy: USD$265 per DALY these costs elsewhere in sub-Saharan Africa. averted; depression: USD$858 per DALY averted using In terms of productivity, the presence of severe depres- newer anti-depressants) were most cost-effective, while sion or anxiety was associated with a reduction in personal inpatient care for schizophrenia using newer psychotropic income of USD$4798 per adult per year in South Africa, drugs (USD$11,072 per DALY averted) was least cost- resulting in a national loss of USD$3.6 billion annually effective. Treating schizophrenia (USD$2,748 per DALY (61). In contrast, a Nigerian study found the annual averted) and bipolar affective disorder (USD$2,551 per impact of a severe mental disorder on productivity was DALY averted) in the community using older psycho- USD$463 per patient, totalling USD$166.2 million an- tropic drugs paired with psychosocial care was more nually (62). The disparity in these costs may be due to cost-effective than inpatient treatment (schizophrenia: differences in purchasing power parity (PPP) between USD$6,816 and bipolar affective disorder: USD$4,874 countries and different measurements of productivity. per DALYaverted). In general, treatments administered in Examining the indirect costs of the institutional care community and primary care settings were more cost- system, a Kenyan study estimated lost productivity over effective than those in hospitals. There were substantial the course of a hospital stay for patients and their families, differences in cost-effectiveness between sub-Saharan showing that one psychiatric hospital admission resulted African and South East Asian regions, underscoring the in a USD$453 productivity loss (63). Conversely, house- importance of context-specific cost-effectiveness data (73). hold survey data from Ghana examined the general Within sub-Saharan Africa, the only country-specific population, many of whom lack access to mental health cost-effective analysis for a range of interventions was treatment, and showed that psychological distress, conducted in Nigeria and found approximate corres- measured using the Kessler 10 Psychological Distress pondence with the regional data in the rank order of Scale (64), was associated with unemployment and lost cost-effectiveness of interventions, but differences in the work time in both formal and informal sectors. Indivi- cost-effectiveness ratios for each intervention (26, 73). duals with moderate or severe psychological distress A CEA of group psychotherapy for individuals with had reductions in productivity of 11.1 and 24.4%, res- depression in Uganda found that the therapeutic inter- pectively. From these estimates, the researchers calculated vention cost $1,150 per quality-adjusted life year added. that psychological distress in Ghana is associated with The authors concluded that this intervention was cost- an approximately 6.8% GDP loss, or USD$2.7 million effective because it cost less than Uganda’s per capita annually (65). GDP (74), the level that the WHO Commission on Despite research indicating that common mental dis- Macroeconomics and Health suggests as the upper limit orders co-occur with HIV in South Africa (3537), no for ‘highly cost-effective’ interventions (75). However, studies specify the direct or indirect costs that stem from the study’s authors acknowledged that that there is no the impact that MNS disorders have on other chronic universally recognized definition of ‘cost-effectiveness’ or conditions, including diabetes, and stroke. criteria for what makes an intervention cost-effective in any given context. CEAs of mental health interventions Existing research suggests that standard treatments, in- Discussion cluding psychotropic medications and various forms of This narrative overview examines available costing data psychotherapy, are effective in LMICs (66), and pre- on MNS disorders and the cost-effectiveness of treat- liminary cost-effectiveness data suggests that they may ments, with a focus on South Africa and data relevant 6 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap to South Africa. In the public sector, there is data on co-morbid conditions or poor lifestyle and self-care (6). workforce expenses at a population level for delivery For instance, individuals receiving public mental health of specific packages of care (55). In the private sector, services in the US died 1330 years sooner than people in there is information on the costs of medication and the general population, although the causes of death were medical management for three severe and chronic mental similar to those of the general population (76). Premature disorders (5860). Only one South African study inves- mortality in people with mental disorders is not well tigated income reduction associated with depression and understood in LMICs. anxiety (61), and few other studies estimate indirect costs While DALY measurements, in theory, illustrate dis- elsewhere in sub-Saharan Africa (62, 63, 65). There are ability YLD and premature mortality (YLL) more ef- some region-level data on the cost-effectiveness of inter- fectively, consideration must be given to how the DALY ventions for the treatment and prevention of MNS dis- is constructed and measured. DALY estimations in orders in sub-Saharan Africa, but no data specific to South Africa use disability weights that are not context- South Africa, even though existing analyses suggest specific. Disability weighting for YLD calculations varies variation in costs and cost-effectiveness between coun- widely by context depending on the impact of a given tries and regions. condition on a person’s lifestyle. In order to develop more accurate burden measures, disability weights should be empirically assessed in South Africa and other LMICs, What we can conclude from what we know rather than based on regional data or data from different The data in this review suggests that indirect costs from countries. foregone income due to MNS disorders are substantial Even DALYs cannot fully capture the societal costs of (6163, 65), and there are cost-effective interventions for mental disorders because they do not take into account addressing them (73). The most cost-effective interven- the indirect costs, such as lost productivity of patients tions incorporate mental health care into primary care and carers, household resources spent caring for a sick or community services without the use of specialized family member, travel costs for hospital visits, or the nega- workers (5860, 73). Such integration may be particularly apt in South Africa because of the high and grow- tive impact on patients’ children who may not receive ing prevalence of MNS disorders co-morbid with HIV adequate attention and care. Indirect costs are particu- and likely, with other chronic conditions (3, 17, 3537). larly high for MNS disorders and must be examined Integrated interventions could improve coverage of a alongside disease burden to fully illustrate their effects population that is at high risk for mental disorders and on patients, their families, and the broader society (77). already presenting for care, which would maximize the Furthermore, most direct and indirect cost studies con- impact and cost-effectiveness of interventions and im- ducted in sub-Saharan Africa examine mental disorders prove overall health outcomes by increasing adherence broadly, with few studies differentiating the costs due to to chronic disease treatment regimes. particular conditions and none specifically examining Prevention interventions that address alcohol consump- costs of neurological and substance use disorders. More tion by raising taxes, limiting advertising, or reducing disorder-specific cost data are needed to inform decisions alcohol availability by restricting hours of sale or increas- about priority setting and investment. ing the drinking age have been shown to be highly cost- Second, although use of traditional medicine for men- effective interventions for reducing DALYs lost due to tal disorders is common in South Africa (50, 51), there MNS disorders in LMICs (71, 73). The low cost of these are no data on the prevalence of use, motivations for interventions suggests that other prevention programs, use, costs, or effectiveness of these treatments. A better such as campaigns to reduce prevalence of risk factors for understanding of why people use traditional medicines mental disorders (such as child abuse and sexual violence), and the health effects of a range of traditional practices may also prove cost-effective. would provide insight into beliefs about mental health, how traditional healing could complement or be inte- Knowledge gaps grated with conventional medicine, and whether any This review reveals four linked knowledge gaps and of these practices put patients at risk. Additionally, associated methodological challenges. existing research on traditional treatments for other First, there is inadequate research on the health and health conditions suggests that the costs for traditional financial burdens of MNS disorders in South Africa medicine are high in South Africa, often as high as and other LMICs. In terms of health burden, much of those for conventional medical care, and are typically the existing research examines prevalence; this likely borne by the poorest segment of the population (78), yet underrepresents the burden of MNS disorders because there is no cost data available on traditional interven- of underreporting due to stigma and because much of the tions for MNS disorders. Complete, accurate data on burden is due to disability and premature mortality from traditional medicines and their costs would provide a Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 7 (page number not for citation purpose) Helen Jack et al. more thorough picture of mental health care and could and defines the future research agenda*appropriate provide a basis for cost-effective, integrated interven- goals for a narrative overview (52). Although the authors tions that operate in tandem with existing traditional defined the section headings prior to conducting the practices. search, they took precautions to ensure the presentation Third, effective strategies for integrating mental health of findings was as unbiased as possible, confining their services into other parts of South Africa’s health system commentary and interpretation to the discussion section must be designed and tested. Interventions to incorpo- and did not generate their arguments until results were rate mental health into primary care and into care for drafted. The grey literature was not searched, and the people living with HIV have shown promise for use in authors did not approach the Ministry of Health to get LMICs (7981), but must be tested in South Africa. additional unpublished data. Finally, costing data was Few interventions that integrate attention to MNS converted to a single currency, but was not adjusted to disorders into treatment programs for other chronic account for inflation to preserve the integrity of the diseases (82) or blend conventional treatment of MNS original data. disorders with traditional medicines have been imple- mented and tested in a LMIC. Before interventions can Conclusion be implemented on a national scale, they must be tested This narrative overview examines the epidemiological in South Africa and the effectiveness data used to guide context of MNS disorders in South Africa and reviews scale-up. what is known about their costs and the cost-effectiveness Fourth, in concert with evaluation of the effectiveness of their treatments. Existing data suggests that providing of interventions, there is a need for more data on cost- mental health services in the context of other health effectiveness and the economic impact of a range of interventions and prevention efforts aimed at limiting interventions and intervention packages. At present, alcohol consumption may be most cost-effective. Further cost-effectiveness research primarily examines specific research on the costs related to MNS disorders is greatly treatments, rather than care packages, such as coordi- needed to develop an evidence base to support effective nated treatment for patients with co-morbid conditions, and efficient implementation and advocacy. prevention efforts integrated with primary health care, Building political will is critical for the implementa- or cooperation with traditional healers. Future cost- tion of more integrated models of mental health care. effectiveness studies will need to examine a broader Economic data will be one key factor in making a per- selection of integrated interventions. suasive case and assisting policymakers to make more National or provincial cost-effectiveness data may informed choices about the importance of investment differ substantially from global or regional findings in mental health care and inclusion of mental health in and could be important for bringing about changes in the basket of options for the proposed national health funding priorities (26, 73). For instance, regional cost- insurance. While this review has put forward a set of effectiveness data do not fully account for inefficiencies in South Africa’s fragile health system, such as high potential priorities for researchers to address, further absenteeism and unfilled posts. Furthermore, there is a analysis must be conducted in tandem with conversations need to examine the broader societal benefits, such as with policymakers able to introduce changes based on gains in productivity and employment and reduction the findings. in costs to other parts of the economy, for instance, policing and crime, child protection, or social work Main findings services. Cost-effectiveness data can inform choices on resource allocation, and information on economic gains . South Africa faces a growing burden of mental, will help with advocacy for mental health services. These neurological, and substance use (MNS) disor- types of economic data are particularly important given ders, which are often co-morbid with HIV and the context of South Africa’s planned implementation other chronic diseases. A considerable mental health treatment gap exists, with significant care of a national health insurance. shortages in rural areas. . Indirect costs, primarily from foregone income Limitations due to MNS disorders, are substantial in sub- The analysis and findings in this review must be acknowl- Saharan Africa. edged in light of several limitations. A narrative overview . The most cost-effective treatment interventions was selected rather than a systematic review because there in sub-Saharan Africa incorporate mental health is little economic research related to MNS disorders in care into community-based services. Taxation of sub-Saharan Africa. As a result, there is great need for an alcohol is a ‘‘best buy’’ for prevention. introduction to the topic that challenges current thinking, 8 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap 3. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3: e442. Key messages for action 4. Beyenburg S, Mitchell AJ, Schmidt D, Elger CE, Reuber M. . Four policy-relevant knowledge gaps are identi- Anxiety in patients with epilepsy: systematic review and sug- gestions for clinical management. Epilepsy Behav 2005; 7: 16171. fied in South Africa: 5. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool k Epidemiological and economic burdens of Karim SS, Coovadia HM. Health in South Africa: changes and MNS disorders must be fully understood challenges since 2009. Lancet 2012; 380: 202943. to inform spending decisions 6. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370: 85977. k More data on the use, costs, and effective- 7. Ramokgopa G. A milestone for mental health in South Africa. ness of traditional therapies for MNS Afr J Psychiatry 2012; 15: 379. disorders are necessary to develop inter- 8. Summit PitNMH. The Ekurhuleni declaration on mental ventions that combine traditional and health*2012. Afr J Psychiatry 2012; 15: 3813. biomedical care 9. National health insurance in South Africa. In: DoHSA, ed. k Effective strategies for integrating mental 2011, p. 159. Available from: http://us-cdn.creamermedia.co.za/ assets/articles/attachments/34471_nhi.pdf [cited 18 July 2013]. health services into primary care must be 10. Tomlinson M, Lund C. Why does mental health not get the designed and tested attention it deserves. PLoS Med 2012; 9: e1001178. k Context specific data on the cost-effective- 11. Shiffman J, Smith S. Generation of political priority for global ness of integrated intervention models of health initiatives: a framework and case study of maternal cares is essential for advocacy and spending mortality. Lancet 2007; 370: 13709. 12. Drummond MF, Sculpher MJ, Torrence GW, O’Brien BJ, choices Stoddort GL. Methods for the economic evaluation of . Economic data is critical for advocacy, to health care programmes. Oxford, UK: Oxford University Press; develop integrated models of mental health care and will inform choices between competing 13. Disease control priorities related to mental, neurological, spending priorities. developmental and substance abuse disorders. Geneva: World Health Organization; 2006. Available from: http://whqlibdoc. who.int/publications/2006/924156332x_eng.pdf [cited 18 July 2013]. Authors’ contributions 14. Clark DM. Implementing NICE guidelines for the psychologi- KH, AS, RW, and HJ developed the concept for the cal treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry 2011; 23: 31827. paper. HJ and RW conducted the literature review. HJ 15. Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT. drafted the manuscript with assistance from RW and KH. Grand challenges in global mental health: integration in RT, IP, CN, AS, KH, RW, ST and KK reviewed and research, policy, and practice. PLoS Med 2013; 10: e1001434. provided comments on the manuscript. 16. World Bank (2013). GINI index. Available from: http://data. worldbank.org/ondicators/si.pov.gini [cited 15 October 2013]. 17. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Ethical issues Bradshaw D. The burden of non-communicable diseases in There are no ethical concerns with this paper and ethical South Africa. Lancet 2009; 374: 93447. review board approval was not required as no human 18. World health report 2001: mental health: new understanding, subjects were involved. new hope. Geneva, Switzerland: World Health Organization; 19. World Health Organization. Mental health atlas: 2005. World Acknowledgements Health Organization. Available from: http://www.who.int/mental_ Thanks to Patrizia Favini and Alex K Smith for their assistance in health/evidence/mhatlas05/en/ [cited 16 July 2013]. the preparation of this manuscript. 20. Williams SL, Williams DR, Stein DJ, Seedat S, Jackson PB, Moomal H. Multiple traumatic events and psychological distress: the South Africa stress and health study. J Trauma Conflict of interests and funding Stress 2007; 20: 84555. 21. Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SG, None of the authors declare any conflict of interest with the Kessler RC, et al. Lifetime prevalence of psychiatric disorders in material in this paper. South Africa. Br J Psychiatr 2008; 192: 11217. 22. Kleintjes S, Flisher A, Fick M, Railoun A, Lund C, Molteno C, References et al. The prevalence of mental disorders among children, adolescents and adults in the Western Cape, South Africa. Afr J 1. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Psychiatry 2006; 9: 15760. Michaud C, et al. Disability-adjusted life years (DALYs) for 291 23. Havenaar JM, Geerlings MI, Vivian L, Collinson M, Robertson diseases and injuries in 21 regions, 19902010: a systematic B. Common mental health problems in historically disadvan- analysis for the Global Burden of Disease Study 2010. Lancet taged urban and rural communities in South Africa: prevalence 2013; 380: 2197223. and risk factors. Soc Psychiatr Psychiatr Epidemiol 2008; 43: 2. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources 20915. for mental health: scarcity, inequity, and inefficiency. Lancet 24. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, 2007; 370: 87889. Williams DR. The South African Stress and Health (SASH) Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 9 (page number not for citation purpose) Helen Jack et al. study: 12-month and lifetime prevalence of common mental 44. Nubukpo P, Cle´ment J, Houinato D, Radji A, Grunitzky E, disorders. S Afr Med J 2009; 99: 33944. Avode´ G, et al. Psychosocial issues in people with epilepsy in 25. Kessler R, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Togo and Benin (West Africa) II: quality of life measured using Ormel J, et al. Special articles. The global burden of mental the QOLIE-31 scale. Epilepsy Behav 2004; 5: 72834. disorders: an update from the WHO World Mental Health 45. Mbewe EK, Uys LR, Nkwanyana NM, Birbeck GL. A primary healthcare screening tool to identify depression and anxiety (WMH) surveys. Epidemiol Psychiatr Sci 2009; 18: 23. disorders among people with epilepsy in Zambia. Epilepsy 26. Gureje O, Chisholm D, Kola L, Lasebikan V, Saxena S. Cost- Behav 2013; 27: 296300. effectiveness of an essential mental health intervention package 46. Flisher AJ, Lund C, Funk M, Banda M, Bhana A, Doku V, in Nigeria. World Psychiatr 2007; 6: 428. et al. Mental health policy development and implementation in 27. Kessler RC, Angermeyer M, Anthony JC, de Graaf R, four African countries. J Health Psychol 2007; 12: 50516. Demyttenaere K, Gasquet I, et al. Lifetime prevalence and 47. World Health Organisation (2011). Mental health atlas 2011. age-of-onset distributions of mental disorders in the World Available from: http://www.who.int/mental_health/publications/ Health Organization’s World Mental Health Survey Initiative. mental_health_atlas_2011/en/ [cited 16 July 2013]. World Psychiatr 2007; 6: 168. 48. Lund C, Kleintjes S, Kakuma R, Flisher AJ. Public sector 28. Lynskey MT, Strang J. The global burden of drug use and mental health systems in South Africa: inter-provincial com- mental disorders. Lancet 2013; 382: 15402. parisons and policy implications. Soc Psychiatr Psychiatr 29. Baxter AJ, Patton G, Scott KM, Degenhardt L, Whiteford HA. Epidemiol 2010; 45: 393404. Global epidemiology of mental disorders: what are we missing? 49. Petersen I, Lund C. Mental health service delivery in PLoS One 2013; 8: e65514. South Africa from 2000 to 2010: one step forward, one step 30. Seedat S, Stein DJ, Jackson PB, Heeringa SG, Williams DR, back. S Afr Med J 2011; 101: 7517. Myer L. Life stress and mental disorders in the South African 50. Sorsdahl K, Flisher A, Wilson Z, Stein D. Explanatory models stress and health study. S Afr Med J 2009; 99: 37582. of mental disorders and treatment practices among traditional 31. Norman R, Bradshaw D, Schneider M, Pieterse D, Groenewald healers in Mpumulanga, South Africa. Afr J Psychiatry 2010; P. Revised burden of disease estimates for the comparative risk 13: 28490. factor assessment, South Africa 2000. Cape Town: Medical 51. Sorsdahl K, Stein DJ, Flisher AJ. Traditional healer attitudes Research Council; 2006. and beliefs regarding referral of the mentally ill to Western 32. Flisher AJ, Liang H, Laubscher R, Lombard CF. Suicide doctors in South Africa. Transcult Psychiatr 2010; 47: 591609. trends in South Africa, 196890. Scand J Publ Health 2004; 52. Green BN, Johnson CD, Adams A. Writing narrative literature 32: 41118. reviews for peer-reviewed journals: secrets of the trade. Journal 33. Els C, Boshoff W, Scott C, Strydom W, Joubert G, Van der Ryst of Chiropractic Medicine 2006; 5: 10117. E. Psychiatric co-morbidity in South African HIV/AIDS 53. South African Department of Health (2012). Mental health patients. S Afr Med J  Cape Town Medical Association of policy framework for South Africa and strategic plan 2014 South Africa 1999; 89: 9924. 2020 (final draft) Pretoria. In: DOHS SA, ed. Government 34. Olley BO, Seedat S, Stein DJ. Persistence of psychiatric Printer; 2012, pp. 148. disorders in a cohort of HIV/AIDS patients in South Africa: 54. Hu TW. Perspectives: an international review of the national a 6-month follow-up study. J Psychosom Res 2006; 61: 47984. cost estimates of mental illness, 19902003. J Ment Health Pol 35. Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Econ 2006; 9: 3. Common mental disorders among HIV-infected individuals in 55. McLeod H, Rothberg A, Pels L, Eekhout S, Mubangizi DB, South Africa: prevalence, predictors, and validation of brief psy- Fish T. The costing of the proposed chronic disease list benefits chiatric rating scales. AIDS Patient Care STDs 2008; 22: 14758. in South African Medical Schemes in 2001. Centre for Actuarial 36. Freeman M, Nkomo N, Kafaar Z, Kelly K. Factors associated Research, University of Cape Town; 2002. Available from: http:// with prevalence of mental disorder in people living with HIV/ www.commerce.uct.ac.za/Research_Units/CARE/RESEARCH/ AIDS in South Africa. AIDS Care 2007; 19: 12019. Papers/Chronic Disease List Report.pdf [cited 18 July 2013]. 37. Singh D, Berkman A, Bresnahan M. Seroprevalence and HIV- 56. Truter I. Prescribing of drugs for Alzheimer’s disease: a South associated factors among adults with severe mental illness: a African database analysis. Int Psychogeriatr 2010; 22: 264. vulnerable population. S Afr Med J 2009; 99: 5237. 57. Provinces spend 46% of combined capital budgets. Available 38. Cook JA, Cohen MH, Burke J, Grey D, Anastos K, Kirstein L, from: http://www.sanews.gov.za/south-africa/provinces-spend-46- et al. Effects of depressive symptoms and mental health quality combined-capital-budgets [cited 19 July 2013]. of life on use of highly active antiretroviral therapy among 58. Petersen I, Lund C, Bhana A, Flisher AJ. A task shifting ap- HIV-seropositive women. J Acquir Immune Defic Syndr 2002; proach to primary mental health care for adults in South Africa: 30: 4019. human resource requirements and costs for rural settings. 39. Epilepsy and HIV*a dangerous combination. Lancet Neurol Health Pol Plann 2012; 27: 4251. 2007; 6: 747. 59. Lund C, Boyce G, Flisher AJ, Kafaar Z, Dawes A. Scaling up 40. Lin EH, Korff MV. Mental disorders among persons with child and adolescent mental health services in South Africa: diabetes*results from the World Mental Health Surveys. J human resource requirements and costs. J Child Psychol Psychosom Res 2008; 65: 57180. Psychiatry 2009; 50: 112130. 41. James BO, Omoaregba JO, Eze G, Morakinyo O. Depression 60. Gillis L, Koch A, Joyi M. The value and cost-effectiveness of among patients with diabetes mellitus in a Nigerian teaching a home-visiting programme for psychiatric patients. S Afr Med hospital. S Afr J Psychiatr 2010; 16: 614. J 1990; 77: 309. 42. Issa BA, Yussuf AD, Baiyewu O. The association between 61. Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental psychiatric disorders and quality of life of patient with diabetes illness and lost income among adult South Africans. Soc mellitus. Iranian J Psychiatr 2007; 2: 304. Psychiatr Psychiatr Epidemiol 2013; 48: 84551. 43. Oladiji J, Akinbo S, Aina O, Aiyejusunle C. Risk factors of 62. Esan OB, Kola L, Gureje O. Mental disorders and earnings: post-stroke depression among stroke survivors in Lagos, results from the Nigerian National Survey of Mental Health and Nigeria. Afr J Psychiatr 2009; 12: 4751. Well-being (NSMHW). J Ment Health Pol Econ 2012; 15: 77. 10 Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 (page number not for citation purpose) Closing the mental health treatment gap 63. Kirigia J, Sambo L. Cost of mental and behavioural disorders in 73. Chisholm D, Saxena S. Cost effectiveness of strategies to com- Kenya. Ann Gen Psychiatr 2003; 2: 7. bat neuropsychiatric conditions in sub-Saharan Africa and 64. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, South East Asia: mathematical modelling study. BMJ 2012; Normand S-LT, et al. Short screening scales to monitor popu- 344: e609. lation prevalences and trends in non-specific psychological 74. Siskind D, Baingana F, Kim J. Cost-effectiveness of group distress. Psychol Med 2002; 32: 95976. psychotherapy for depression in Uganda. J Ment Health Policy 65. Canavan ME, Sipsma HL, Adhvaryu A, Ofori-Atta A, Jack H, Econ 2008; 11: 127. Udry C, et al. Psychological distress in Ghana: associations with 75. Choosing interventions that are cost effective. Available from: employment and lost productivity. Int J Ment Health Syst 2013; http://www.who.int/choice/costs/CER_thresholds/en/ [cited 1 7: 9. October 2013]. 66. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva 76. Colton CW, Manderscheid RW. Congruencies in increased M, et al. Treatment and prevention of mental disorders in mortality rates, years of potential life lost, and causes of death low-income and middle-income countries. Lancet 2007; 370: among public mental health clients in eight states. Prev Chronic 9911005. Dis 2006; 3: A42. 67. Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S. 77. Hyman SE. The diagnosis of mental disorders: the problem of Reducing the global burden of depression Population-level reification. Annu Rev Clin Psychol 2010; 6: 15579. analysis of intervention cost-effectiveness in 14 world regions. 78. Nxumalo N, Alaba O, Harris B, Chersich M, Goudge J. The British Journal of Psychiatry 2004; 184: 393403. Utilization of traditional healers in South Africa and costs to 68. Chisholm D. Cost-effectiveness of first-line antiepileptic drug patients: findings from a national household survey. J Publ treatments in the developing world: a population-level analysis. Health Pol 2011; 32(Suppl 1): S12436. Epilepsia 2005; 46: 7519. 79. Blank MB, Hanrahan NP, Fishbein M, Wu ES, Tennille JA, Ten 69. Chisholm D, van Ommeren M, Ayuso-Mateos JL, Saxena S. Have TR, et al. A randomized trial of a nursing intervention for Cost-effectiveness of clinical interventions for reducing the HIV disease management among persons with serious mental global burden of bipolar disorder. The British Journal of illness. Psychiatr Serv 2011; 62: 131824. Psychiatry 2005; 187: 55967. 80. Crepaz N, Passin WF, Herbst JH, Rama SM, Malow RM, 70. Chisholm D, Rehm J, Van Ommeren M, Monteiro M. Reducing Purcell DW, et al. Meta-analysis of cognitive-behavioral inter- the global burden of hazardous alcohol use: a comparative ventions on HIV-positive persons’ mental health and immune costeffectiveness analysis. J Stud Alcohol Drugs 2004; 65: 782. functioning. Health Psychol 2008; 27: 414. 71. Anderson P, Chisholm D, Fuhr DC. Effectiveness and costef- 81. Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, fectiveness of policies and programmes to reduce the harm Wissow L. Grand challenges: improving HIV treatment out- caused by alcohol. Lancet 2009; 373: 223446. comes by integrating interventions for co-morbid mental illness. 72. Chisholm D, Gureje O, Saldivia S, Villalo´n Caldero´n M, PLoS Med 2013; 10: e1001447. Wickremasinghe R, Mendis N, et al. Schizophrenia treatment 82. Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, Rabadan- in the developing world: an interregional and multinational Diehl C, et al. Grand challenges: integrating mental health care cost-effectiveness analysis. Bull World Health Organ 2008; 86: into the non-communicable disease agenda. PLoS Med 2013; 54251. 10: e1001443. Citation: Glob Health Action 2014, 7: 23431 - http://dx.doi.org/10.3402/gha.v7.23431 11 (page number not for citation purpose)

Journal

Global Health ActionTaylor & Francis

Published: Dec 1, 2014

Keywords: mental health; South Africa; economics; health planning; policy; costs and cost analysis

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