CATALYST Health Economics Consultants, Northwood, Middlesex
Correspondence: Dr Julian F. Guest, CATALYST Health Economics Consultants, 34b High Street, Northwood, Middlesex HA6 IBN, UK. Tel: +44 (0) 1923 450 045; Fax: +44 (0) 1923 450 046; e-mail: jg.catalyst{at}dial.pipex.com
Declaration of interest This study was funded by a grant from Janssen-Cilag, Saunderton, UK
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ABSTRACT |
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Aims To estimate the annual socio-economic burden imposed by bipolar disorder on UK society.
Method The annual cost of resource use attributable to managing bipolar disorder was calculated. Indirect societal costs were also calculated.
Results The annual National Health Service (NHS) cost of managing bipolar disorder was estimated to be £199 million, of which hospital admissions accounted for 35%. The annual direct non-health-care cost was estimated to be £86 million annually and the indirect societal cost was estimated to be £1770 million annually.
Conclusions The annual cost to UK society attributable to bipolar disorder was estimated to be £2 billion at 1991/2000 prices (estimated 297 000 people with the disorder). Ten per cent of this cost is attributable to NHS resource use, 4% to non-health-care resource use and 86% to indirect costs.
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INTRODUCTION |
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METHOD |
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Primary care resource use
The DIN-link database contains information on 0.9 million live patients
managed by approximately 360 general practitioners (GPs) in 100 nationally
distributed general practices (using AAH Meditel System 5 clinical software,
version 5.7.x for UNIX; now System 5, Torex Health, Bromsgrove,
Worcestershire, UK). The database was interrogated to obtain the annual amount
of primary care resource use (i.e. GP consultations, GP-prescribed drugs and
GP-initiated diagnostic tests) between 1 January 1998 and 31 December 1998
attributable to managing bipolar disorder. Patients were included if they had
a note entry of one of the following Read codes, together with an addition or
amendment to their case notes in the study year, indicating that they were
still registered with their GP: hypomania/mania (E221); other
manicdepressive psychoses (E22Z); affective psychoses (E22). The
resource use estimates derived from the DIN-link database were extrapolated to
the whole of the NHS by multiplying by a factor of 75, which takes into
account the size of the data-set population relative to that of the whole UK
and the relative underrecording of certain data items when the database is
cross-referenced against other sources
(Martin, 1995).
Secondary care in-patient resource use
Hospital in-patient data were based on the IBM Hospital Episode Statistics
database, which contains information compiled from the statutory returns from
the 300 trusts in England. The database was interrogated to obtain the annual
number of hospital episodes attributable to bipolar disorder in accordance
with the diagnostic codes of ICD-10 (World
Health Organization, 1992) (i.e. F31.0-F31.9 for 1995/96 to
1997/98). Patients were included in the data-set if they had a primary
diagnosis of bipolar disorder between 1 April 1995 and 31 March 1998. Results
were extrapolated to the whole UK by multiplying by 1.2 (i.e. the ratio of the
population of the UK to that of England).
Other health care resource use
Published sources were used to provide information on resource utilisation
by psychiatric patients using NHS day hospitals
(Department of Health,
1999a), out-patient services
(Department of Health,
1999b), community mental health teams (CMHTs;
Onyett et al, 1995) and special (high-security) hospitals (Department of Health,
2000a,c).
This was supplemented with information obtained from interviews with ten NHS
consultant psychiatrists who had experience of people with bipolar
disorder.
Personal social service resource use and the criminal justice
system
Data were obtained on resource utilisation by people with bipolar disorder
using residential services (D. Chisholm, personal communication, 1999), the
criminal justice system (Stationery
Office, 2000a) and non-NHS day care facilities
(Department of Health, 1998), the latter being supplemented with information obtained from telephone
interviews with managers at seven non-NHS day care facilities.
Resource costs
Unit resource costs were obtained (D. Chisholm, personal communication,
1999; Netten et al,
1999; Haymarket Publications,
2000; Stationery Office,
2000b) and, where necessary, uprated to 1999/2000 prices
using the Health Service Inflation Index
(Netten et al, 1999).
By assigning these costs to the resource use estimates, the annual direct cost
attributable to bipolar disorder was calculated at 1999/2000 prices.
Indirect resource use and costs
The indirect cost arising from excess unemployment
(Gareth Hill et al,
1996), absenteeism from work
(Lepine et al, 1997)
and suicide (Sharma & Markar,
1994) among individuals with bipolar disorder was estimated using
the human capital approach (Drummond
et al, 1998), by applying the current annual average wage
(Office for National Statistics,
2000) to the estimated number of people with bipolar disorder
absent from work as a result of morbidity and mortality. A 6% annual discount
rate was applied to the indirect costs of unemployment arising from people
with bipolar disorder who commit suicide in the study year and, therefore, who
are absent from the workforce in subsequent years.
Sensitivity analysis
Univariate sensitivity analyses tested the robustness of the study results
to changes in resource use activity affecting health-care, non-health-care and
indirect costs.
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RESULTS |
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GP consultations
Based on all the people with bipolar disorder in the DIN-link database, it
was estimated that there were 315 000 GP consultations attributable to bipolar
disorder during 1998. Hence, the annual cost of GP consultations attributable
to bipolar disorder was estimated to be £5.2 million.
GP-prescribed drugs
Fifty-eight per cent of patients in the DIN-link data-set received
medication for bipolar disorder prescribed by their GP during 1998. This
corresponds to an estimated 79 125 patients receiving approximately 1.2
million GP-prescribed items during the study year
(Table 1). These GP-prescribed
drugs cost £8.5 million.
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The mean annual cost of GP-prescribed medication was £107 per patient receiving medication. This corresponds to a mean annual cost of £249 per GP and £809 per general practice for medication for bipolar disorder.
GP-initiated tests
People with bipolar disorder undergo a mean 111 000 tests per year. These
include blood drug levels, biochemistry tests, thyroid function tests and
haematology tests, costing the NHS £1.2 million annually.
In-patient episodes
Between 1 April 1997 and 31 March 1998 there were 12 400 annual hospital
episodes for bipolar disorder in the UK, costing £69 million. These
episodes accounted for 4% of the 290 019 annual episodes for mental health
(Department of Health,
2000a). From the interviews it was estimated that about
30% of these episodes would result in a patient being transported to a
hospital by ambulance, costing the NHS £670 000 annually.
Table 2 summarises these data,
stratified by different specialities.
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Table 2 shows that 86% and 10% of episodes are admitted to mental illness beds and old age psychiatry beds, respectively. Furthermore, mental illness and old age psychiatry accounted for 85% and 11%, respectively, of the costs of hospital care for bipolar disorder.
Forty-four per cent of the hospitalisation costs attributable to bipolar disorder were due to patients suffering from either mania or hypomania without psychotic symptoms, 27% to patients suffering from depression without psychotic symptoms, 16% to those suffering from mania with psychotic symptoms, 6% to patients suffering from depression with psychotic symptoms, 8% to those with a mixed episode, 3% to those in remission and 2% to other bipolar disorders.
The estimated mean annual number of hospital in-patient episodes per person with bipolar disorder was greater among the 25-to 34-year age group, at seven episodes per year per 100 patients (equivalent to almost two-thirds of all the in-patient episodes), and was seven times greater than the annual number of episodes per patient in the <16- and >84-year age groups. Generally, the annual number of hospital in-patient episodes per patient decreased with age among patients over 34 years of age. Additionally, the percentage of episodes associated with manic and hypomanic symptoms decreased with age. Conversely, proportionally more episodes were associated with depressive symptoms as patients' age increased.
Out-patient and ward attendances
Approximately 2 million annual psychiatric out-patient attendances are
conducted under the auspices of mental illness and psychiatry of old age in
the UK (Department of Health,
1999b), of which 14% was estimated to be because of
bipolar disorder. Hence, it was estimated that a mean 277 000 attendances a
year are attributable to bipolar disorder, costing £28.5 million.
There are a mean 96 000 annual psychiatric ward attendances in the UK (Department of Health, 1999b), of which 5% was estimated to be because of bipolar disorder. This suggests that there are a mean 5000 attendances a year attributable to bipolar disorder, costing £0.5 million.
Community mental health team contacts
The annual cost of CMHTs in the UK was estimated to be £380 million.
Fourteen per cent of total CMHT contact was estimated to be because of bipolar
disorder, corresponding to an annual cost of £53.2 million.
NHS day hospital attendances
There are approximately 4.6 million attendances at psychiatric day
hospitals annually in the UK (Department of
Health, 1999a), of which 10% was estimated to be because
of bipolar disorder. This corresponds to about 459 000 attendances a year,
costing £28.9 million.
Special hospitals
The approximate 1350 beds managed by the three high-security hospital
authorities in the UK cost the NHS £135.2 million in 1999/2000
(Department of Health,
2000a). Based on data from a study of admissions to one
special hospital in 1987/88 (Gunn et
al, 1991), this analysis assumed that 2% of in-patients are
admitted because of bipolar disorder, costing the NHS an estimated £2.7
million in 1999/2000.
Total annual NHS cost
The total annual health-care cost attributable to managing bipolar disorder
was estimated to be £199 million
(Table 3).
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Residential care
People with bipolar disorder were estimated to occupy 4822 places in
residential accommodation, costing £67.8 million.
Table 4 summarises these data,
stratified by home type.
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Non-NHS day care attendances
There are approximately 4.7 million attendances annually at non-NHS day
care facilities in the UK by people with a mental illness
(Department of Health, 1998),
of which 16% was estimated to be because of bipolar disorder. This corresponds
to an estimated 754 000 attendances a year, costing £18.1 million.
Criminal justice system
We were unable to find any published evidence that the incidence of either
imprisonment or people on remand was higher among those with bipolar disorder
than in the general population. Therefore, this analysis assumed that the cost
incurred by the criminal justice system attributable specifically to bipolar
disorder is zero.
Indirect societal costs
Indirect costs due to excess unemployment among people with bipolar
disorder
The prevalence of bipolar disorder in the UK was estimated to be 0.5%
(Bebbington & Ramana,
1995), which is similar to the lifetime risk and annual prevalence
rates and equates to approximately 297 000 people with bipolar disorder in the
UK annually. The unemployment rate among people with bipolar disorder was
estimated to be 46%, of whom 60% are available for work
(Gareth Hill et al,
1996). This compared with an unemployment rate among the general
population in the UK in 1999/2000 of 3%
(Office for National Statistics,
2000). Hence, an excess of 76 500 people annually are unemployed
as a result of having bipolar disorder. Therefore, the annual indirect cost
due to excess unemployment among people with bipolar disorder was estimated to
be £1510 million at 1999/2000 prices.
Indirect costs due to absenteeism from work among people with bipolar
disorder
The rate of excess absenteeism from work among those with major depression
compared with those without depression was estimated to be about 9 days over a
6-month period in the UK (Lepine et
al, 1997). Assuming that all of these subjects were in
full-time employment, this suggests an excess absenteeism rate of 8%. By
assuming comparable absenteeism from work among the UK's estimated 96 300
people with bipolar disorder who are employed
(Kind & Sorensen, 1993),
the associated indirect cost would be £152 million per year at 1999/2000
prices.
Indirect costs due to suicide
The annual incidence of bipolar disorder is 0.009% and 0.0096% for males
and females, respectively (Bebbington &
Ramana, 1995). Hence, there are 4454 new cases of bipolar disorder
diagnosed in the UK annually. The suicide rate among people with bipolar
disorder is 1.5% annually for the first 10 years following diagnosis
(Sharma & Markar, 1994).
This equates to an excess of 640 suicides because of bipolar disorder
annually, with an associated indirect cost of £179 million undiscounted
or £109 million discounted.
Indirect costs due to carers
A review of the published literature did not identify any evidence that
there was a higher unemployment rate among carers than the general population;
therefore, it was estimated that there are no indirect costs specifically
attributable to carers of people with bipolar disorder.
Total annual societal cost of bipolar disorder
The total annual societal cost of bipolar disorder in 297 000 people was
estimated to be £2055 million annually
(Table 5) or approximately
£6919 per person with bipolar disorder.
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Sensitivity analyses
Health care costs
Sensitivity analyses (Table
6) showed that doubling the annual number of in-patient episodes
and CMHT contacts would increase the annual NHS cost of managing bipolar
disorder by 35% and 27%, respectively. Conversely, halving the annual number
of in-patient episodes and CMHT contacts would reduce the annual NHS cost of
managing bipolar disorder by 18% and 13%, respectively. However, the annual
NHS cost is not sensitive to changes in the use of any other health care
resource.
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Non-health-care direct costs
Sensitivity analyses (Table
7) showed that doubling of the annual number of residential places
would increase the annual non-health-care cost of managing bipolar disorder by
79%. Conversely, halving the annual number of residential places would reduce
the annual non-health-care cost of managing bipolar disorder by 39%. The
annual non-health-care cost attributable to bipolar disorder is also sensitive
to the assumptions pertaining to the use of the criminal justice system by
people with bipolar disorder. If people with bipolar disorder made twice as
much use of the criminal justice system as the general population, the annual
non-health-care cost of managing bipolar disorder would increase by 91%.
Conversely, if people with bipolar disorder made half as much use of the
criminal justice system as the general population, the annual non-health-care
cost of managing bipolar disorder would decrease by 45%. However, the annual
non-health-care cost of managing bipolar disorder is not sensitive to changes
in the annual number of non-NHS day care attendances.
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Indirect costs
Sensitivity analyses (Table
8) showed that doubling of the annual number of unemployed people
with bipolar disorder would lead to an 83% increase in the annual indirect
cost attributable to bipolar disorder. Conversely, a 50% reduction in the
annual number of unemployed people would lead to a 43% decrease in the annual
indirect cost attributable to bipolar disorder. However, the annual indirect
cost attributable to bipolar disorder is not sensitive to changes in the
excess rate of absenteeism from work or in the annual number of suicides.
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DISCUSSION |
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Uncertainty
In this analysis there is considerable uncertainty surrounding the
prevalence of bipolar disorder in the UK because of the lack of robust
epidemiological surveys. Community-based psychiatric surveys in other
countries estimate the total prevalence of bipolar disorder to be 1.0-2.5%,
which is substantially higher than the number of people treated for bipolar
disorder (Bebbington & Ramana,
1995). Also, there may be a high level of unmet need, although
some patients may develop coping strategies or endure symptoms below the
thresholds for treatment, given the current riskbenefit ratios of
available drugs. Finally, the variation in diagnostic threshold can contribute
to the uncertainty surrounding the prevalence of bipolar disorder
(Akiskal, 1996).
This analysis used interviews with psychiatrists and managers of day care facilities to estimate the percentage of their workload that was associated with managing people with bipolar disorder. In the hierarchy of evidence, such expert opinion is the least reliable compared with, for example, randomised control trials (Stevens & Raftery, 1994), but in the absence of relevant published data this was the only suitable method with which to model these resource items. However, the estimated percentage of psychiatric out-patient workload and CMHT workload attributable to bipolar disorder was comparable to that reported by others (Onyett et al, 1995; National Health Service in Scotland, 1999).
The prevalence of bipolar disorder among patients in the DIN-link database was about 0.25%. This was comparable with the 0.5% prevalence assumed in our study (Bebbington & Ramana, 1995). However, some patients may be managed almost exclusively in secondary care, whereas others may not receive any health care. Furthermore, some people with bipolar disorder may have been misdiagnosed under a Read code that was not included in the DIN-link data-set. The estimated prevalence of people with bipolar disorder who attend psychiatric out-patient services is between 0.12 and 0.24%, although the proportion of these patients in contact with their GP is unknown.
Sensitivity
The annual health care cost attributable to bipolar disorder is most
sensitive to changes in the number of hospital admissions and CMHT contacts.
However, there is little uncertainty about the annual number of hospital
admissions, which was derived from statutory Department of Health returns,
although some people with bipolar disorder may have been excluded from our
analysis, such as those who have only one manic episode not followed by a
depressive episode. The estimated cost of CMHT contacts made use of the survey
by Onyett et al
(1995), which examined the
organisation and operation of CMHTs in England. The structure of CMHTs may
have changed since this survey was performed, but we were unable to find more
recent published data on the structure of CMHTs to inform our analysis.
Therefore, there remains some uncertainty surrounding the cost of CMHT
contacts pertaining to bipolar disorder. The annual non-health-care cost
attributable to bipolar disorder is most sensitive to changes in the number of
residential places. However, there is little uncertainty about the annual
number of residential places, which was derived from a database used in a
study by Chisholm (D. Chisholm, personal communication, 1999). The annual
non-health-care cost is also sensitive to changes in the assumptions about the
number of contacts made by people with bipolar disorder with the criminal
justice system. A Swiss study suggested that people with bipolar disorder were
between two and three times more likely to engage in criminal activity than
the general population (Modestin et
al, 1997). However, we found no evidence suggesting an
increased risk of imprisonment among people with bipolar disorder in the UK.
This discrepancy is worthy of further investigation.
The annual indirect cost attributable to bipolar disorder was sensitive to changes in the number of unemployed people, which was based on a survey of those in the Manic Depression Fellowship. However, the membership of the Fellowship may not be representative of all people with bipolar disorder. The baseline indirect costs in our study relate to people receiving treatment for bipolar disorder. Including untreated cases could substantially increase the indirect costs. However, because such people have not presented to the medical services, they may not exhibit the same level of morbidity and mortality as those who do present. Nevertheless, they may still endure reduced functioning and accrue costs.
We estimated that 640 people with bipolar disorder commit suicide annually. This is equivalent to about 11% of the 5905 suicides in the UK per year (Ray et al, 1998). Additionally, in one survey of people with bipolar disorder, 47% reported at least one attempted suicide (Gareth Hill, et al, 1996). In comparison, the annual number of deaths because of depression was estimated to be 2600 (Gareth Hill et al, 1996).
Study limitations
Primary care resource use was based on the DIN-link database. However,
limitations in diagnostic categories may mean that some patients included in
the data-set may have been suffering from unipolar psychosis. Nevertheless, it
was assumed that all patients with a diagnostic code of affective
psychosis suffer from bipolar disorder. Furthermore, patients with
other conditions, such as schizophrenia and schizoaffective disorder, may have
been included under the diagnostic categories for mania and
hypomania, reflecting the difficulties in making a differential
diagnosis for this disorder.
The cost of drugs used to treat bipolar disorder constitutes less than 2% of the total cost of GP prescribing for all psychiatric conditions (Department of Health, 2000d) and about 5%, 14% and 14% of general psychiatric in-patient, out-patient and general community team costs, respectively (Department of Health, 2000d). Treatment choices are particularly important in patients with bipolar disorder where compliance with conventional maintenance treatment is low (Keck et al, 1997). Some atypical antipsychotics have been shown to have antimanic properties (Tohen & Grundy, 1999; Keck et al, 2000) and a lower risk of extrapyramidal symptoms than is associated with typical antipsychotics (Miller et al, 2001), potentially leading to improved compliance. The cost of drugs prescribed by psychiatrists in out-patient clinics has not been included in the present analysis. However, because most drugs are prescribed and dispensed in the community, this is unlikely to lead to a substantial difference in the annual drug cost. Moreover, the estimated annual primary care drug cost of £8.5 million for people with bipolar disorder is small compared, for example, with the drug costs for schizophrenia for England in 1992/93. These were estimated to be about £32 million (£39 million at 1999/2000 prices) (Knapp, 1997).
A number of services have not been costed in this study, including a work rehabilitation scheme provided by the NHS, referrals to either a psychotherapist or clinical psychologist and attendances at a drug or alcohol dependency service. The associated costs of these are likely to be proportionally very low and within our sensitivity analyses. All these services are provided within the NHS and form part of the care provided by out-patient clinics, CMHTs or day hospitals, and our baseline estimates are likely to include some of these costs. The analysis also excluded the intangible costs of patients and their families. The psychological burden of living with bipolar disorder and its disruptive effect on daily living affects the usual activity of patients and their families (Onyett et al, 1995). Such activity may not involve paid employment and is difficult to quantify.
Comparison with schizophrenia
Compared with schizophrenia, bipolar disorder is a neglected disease. This
is true if one compares research output in academic journals on the one hand
and NHS planning documents on the other. The present study illustrates that
bipolar disorder costs less than schizophrenia: £2 billion compared with
£3.7 billion at 1999/2000 prices. In-patient care for schizophrenia
accounts for over 90% of the annual direct health care cost (£864
million at 1999/2000 prices) (Knapp,
1997), which was substantially higher than the 35% of the annual
direct health care cost (£69 million) attributable to in-patient care
associated with bipolar disorder in our study. Allowing for the difference in
time between the two studies, this difference suggests that, despite being
possibly related conditions (Goodwin &
Jamison, 1990; Maziade et
al, 1995), treatment patterns differ substantially.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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The authors also thank Janssen-Cilag for their support of this study.
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