It is increasingly recognised across the world that intervening early in mental illness not only spares millions from untold misery but can save millions in finances. Martin Knapp provides an overview of a field of study that could transform this century and in which LSE leads the way.
A colleague recently needed to take time off as they were suffering from depression. There was no round-robin “get well” card, no public acknowledgement of the reason for their absence. Nor would the colleague have wanted that. The incident jarred as a reminder that, even in the most enlightened of places, mental health can still be problematic, seen by some people as an embarrassment or – worse – as a source of shame. Such stigma – and the discrimination that can accompany it – is extraordinary given the latest figures on the prevalence of mental health issues: one in four people suffer.
Sperm to worm
This hugely complex issue affects every area of life. It is suggested that a good welfare state provides support from “cradle to grave”, but in thinking about mental health we should perhaps replace the phrase with “sperm to worm”. Studies show the far-reaching impact of a mother’s mental health on her unborn child, and we know that there can be mental health consequences of bereavement that last many years. One of our recent LSE studies looked at the impact of perinatal depression – poor maternal mental health around the time of birth – on the offspring as they develop through childhood and adolescence. There have been many studies showing how maternal depression damages a child’s emotional, behavioural and intellectual development, but what we added was an indication of the economic consequences of this damage. We do not do this kind of work because we believe that economic impacts are more important than quality of life impacts, but because it can be enormously useful to bring economic information to the attention of key decision-makers who are often struggling to manage tight, or perhaps shrinking, budgets.
People with mental health issues are more likely to smoke, to overeat, to be unemployed, to be in poverty, to have disrupted education and to end up in the criminal justice system. Major mental disorders shorten the lifespan by 10 to 17 years – a bigger impact than many cancers or smoking. There is no field of social policy that mental health does not touch. Our research here at LSE has taken us into each of these fields to address each of these topics. We have, for example, looked at the economic case for targeting smoking cessation and weight-management efforts on young people with psychosis, because these young people smoke much more than average and a side-effect of their medications is often significant weight gain.
In other studies, we have described the workplace experiences of employees with mental health issues and how line managers’ attitudes can have a very strong impact, and have shown that there are often substantial economic benefits for employers, both from preventing mental health issues emerging and then from responding to them appropriately if they do. In schools, efforts to tackle bullying and to invest in social and emotional learning can similarly have substantial economic as well as wellbeing pay-offs.
Contention and alarm
The assumed or known links between crime and mental illness generate a lot of concern, but also some unhelpfully alarmist reactions from some parts of the media. Of course, the links are there. There is a higher probability of someone with psychosis committing a homicide than someone without the illness, but what is not widely appreciated is that having psychosis is associated with a higher risk of being a victim of homicide. Thankfully, homicides are rare, but antisocial crimes are not. There is plenty of evidence connecting childhood behavioural problems such as conduct disorder (a mental illness that affects 5 per cent of five- to ten-year-olds), teenage delinquency and adulthood crime. In one study we showed that the costs of crime up to age 28 for ten-year-olds with conduct disorder were ten times higher than for ten-year-olds without any behavioural issues. That’s the bad news; the good news is that something can be done to treat this and similar disorders in childhood. As another study showed, parenting programmes reduce the chance that conduct disorder persists into adulthood and are cost-saving to the public sector over a 20-year period.
An area that also interests us, and particularly exercises policymakers, is the vicious circle that connects common mental disorders like depression and anxiety with social and economic disadvantage. People with depression are more likely to be unemployed, to get into debt and to fall into poverty. But – in the opposite direction – unemployment, unmanageable debt and poverty are risk factors for developing or exacerbating depressive symptoms. The challenges for social and economic policy are certainly at least as profound as the challenges for health-care systems. Work led by Richard Layard at LSE a few years ago argued that by improving access to some talking therapies it was possible to improve both health and engagement in employment. This provided an evidence platform from which the English government launched its Improving Access to Psychological Therapies programme. This is now transforming access to evidence-based psychotherapy across the country.
Is it worth it?
Funding bodies across the world – whether governments, health insurance companies, local commissioners or, of course, individual patients themselves – want to be sure that the treatments they pay for are going to be effective: they want treatments to improve health. Likewise, a public sector body launching a new preventive strategy wants to be confident that it will stop mental health issues emerging in the first place. But those funders and other decision-makers also want to be sure that those treatments and strategies represent good value for money. This does not mean that, say, an antipsychotic drug has to be cost-saving, but rather that the amount it costs is in some sense justified by the improvements in health and wellbeing that it generates.
Much of our current LSE work is concerned with this “Is it worth it?” question: is a particular mental health intervention worth the resources needed to deliver it? As researchers it is not our role to decide whether something is “worth it” – that is for wider societal consideration – but we can carry out cost-effectiveness analyses to feed important evidence into those considerations. In a 2011 report for England’s Department of Health, we brought together cost-effectiveness evidence on 15 different mental health promotion and mental illness prevention interventions, primarily with the aim of helping local commissioners (funders) to make better use of their budgets. Our findings have proved very useful for both national and local decision-making.
Dementia: a crisis in slow motion?
Many of our current studies are looking at ways to improve treatment and care of dementia – a most devastating and distressing illness, and one that is becoming much more common. There are 44 million people with dementia worldwide, but this will more than treble by 2050.
Last December, health ministers from the G8 countries met in London for an unprecedented event: a Dementia Summit. At the end of the day, they issued both a Declaration and a Communiqué, spelling out the challenges so often experienced by individuals living with dementia and their families, and recommending a set of actions for the international community. They also agreed to set up the World Dementia Council, of which I am a member, which gives me the chance to feed into the global debate some lessons from research, including from our own work at LSE.
A recent study has shown how quality of life for family carers of people with dementia can be improved – and affordably. Carers were helped to learn better coping strategies, delivered in eight face-to-face sessions with junior psychologists. This included information on where to get emotional support, as well as techniques to improve their understanding of dementia, and how to manage behavioural problems often associated with the illness, plan for the future, relax and engage in meaningful enjoyable activities. Working with researchers from University College London we found that the coping strategy worked: it was more effective than standard support in improving carers’ mental health and quality of life. It was also cost-effective: it was worth spending money on.
As the number of people with dementia grows over coming decades – as it will inexorably across the globe – we urgently need evidence from studies such as this. There are lots of dementia studies now underway at the School, including evaluations of promising-looking interventions and projections of future needs and how best to meet them.
The prevalence of most mental health problems – taking into account age and gender – does not vary much across the world, although differences in exposure to traumatic experiences, or school or workplace stress, and differences in resilience will generate some disparities. What do vary enormously, however, are rates of recognition of mental illness and rates of treatment. For more than a decade now, the World Health Organization has campaigned for wider recognition of the “Mental Health Gap”, particularly in poorer parts of the world.
Low-income countries are likely to give priority in their health systems to diseases in childhood and mass “killers” such as malaria. But as national incomes grow they devote more resources to mental health. However, what works in a high-income country such as Britain is unlikely to transfer readily to, say, sub-Saharan Africa, and what might be acceptable in one ethnic or cultural group may be taboo in another. A number of LSE staff and PhD students – including Cath Campbell, David McDaid and Victoria de Menil – have looked at how mental health issues are identified (or not) and responded to in low-income countries, and how best to work with local skills and resources. LSE is committed to investing more effort in global health, and we intend to make sure that mental health is a part of this welcome new emphasis.
The School’s international interest in mental health is also clearly evident through the many studies conducted collaboratively with teams elsewhere in Europe and across the Atlantic. Recently we reported how economic hardship – such as the economic crisis currently gripping much of the world – intensifies the social exclusion of people with mental health issues, for example through unemployment, in the EU-27 countries. Males and individuals with lower education are especially vulnerable.
Good costs and bad costs
LSE helps policymakers understand the difference between what could be called “good costs” – the effective treatment of mental illness – and “bad costs” – the huge economic and wellbeing effects felt by individuals, communities, employers and the economy as a result of neglect, marginalisation and persecution. This is one area where LSE really has the capacity to make the world a happier place.
Martin Knapp is Professor of Social Policy and Director of the Personal Social Services Research Unit at LSE.
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See also: NHS will pay a high price for short-term mental health cuts, report warns
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