From the Editor

When we think about mental illness, we often think about loss – loss of friendships, loss of opportunities, and, in some cases, loss of life.

From a societal perspective, mental illness is often accompanied by another loss: economic.

Here are two papers that consider the long economic shadow cast by mental illness.

In the first, the authors consider mental illness and high-use consumers of health care. Specifically, the paper asks a simple if important question: looking at people who heavily use the health-care system, what percentage have mental health and addiction problems? The second paper, which draws on US data, calculates the cost of treating mental health disorders compared to other disorders.


Mental Illness and High Health Care Use

“Rates of Mental Illness and Addiction among High-Cost Users of Medical Services in Ontario”

Jennifer M. Hensel et al., The Canadian Journal of Psychiatry

June 2016

In most developed countries, health care spending is on the rise. In 2011, Canada spent 11% of its gross domestic product (GDP) on health care, up from 9% in 2000. Similarly, over the same decade, the United States and the United Kingdom experienced a 4% and 2% rise, respectively, in the fraction of GDP being spent on health care. It is being increasingly recognized that a very small proportion of individuals account for a disproportionate amount of health care spending. In Ontario (Canada’s most populous province), the top 5% of users account for 60% of expenditures on hospital, home, and emergency health care, the services that drive spending. This pattern is not dissimilar to what has been reported in the United States and Australia. Ontario allocates over 40% of its program spending to publicly funded health care with evidence that this will continue to expand. Consequently, and following on recommendations made in other jurisdictions, policy and intervention initiatives in Ontario are shifting to target the highest users of health care resources in an attempt to contain and reduce growing costs.

Although mental health care is a costly resource, it accounts for a fraction of overall expenditures, which are driven by acute medical and surgical care. Mental illness and physical health problems, however, often co-occur with negative implications for health care utilization and outcomes. Previous studies have shown that individuals with mental illness comorbidity use hospital and emergency medical services at a high rate and often have higher medical costs compared to those without mental illness. To our knowledge, however, the actual rate of mental illness and addiction among high-costing users (HCUs) of medical services has not been quantified on a population level. If HCUs have significant mental illness comorbidity, then this should be accounted for in the design, organization, and implementation of supports and services that aim to improve health outcomes and reduce costs in this user group.

Dr. Jennifer Hensel

So opens a new paper by Dr. Hensel et al., just published in The Canadian Journal of Psychiatry.

In this paper, they consider high-costing users and mental illness.

Here’s what they did:

· Drawing on the data generated by the Ontario Health Insurance Plan, the authors used several databases to consider adult health spending. Inpatient data, for example, was drawn from the Health Information-Abstract Database. Mental illness and addiction data came from hospitalization databases, and also outpatient physician billing data.

· Non-mental health medical service use was calculated for the individual from inpatient hospitalizations and obstetrical deliveries, same day surgeries, ED visits, dialysis and cancer care, complex continuing care hospitalizations, and home care visits. Note that, in keeping with high-costing user literature, outpatient physician services weren’t included. (!)

· Costs were clustered into percentiles. “Percentiles were further clustered into the top 1% of users, the top 2% to 5% of users, the top 6% to 50% of users, and the bottom 50% of users.”

· The authors also looked for individuals if a mental health or addiction diagnosis had been made within two years. The focus was on severe, persistent mental illness: “1) psychotic disorders, 2) major mood disorders, and 3) substance use disorders, excluding nicotine dependence.

· Statistical analysis was performed.

Here’s what they found:

· With OHIP, there were 10,909,351 eligible individuals in Ontario as of April 1, 2011.

· Most (71%) didn’t use any medical services included in the study during the observation period. (!)

· “The top 5% of medical service users (representing 1.4% of the total population of Ontarians) accounted for 56.1% of the health care costs ($8.8 billion) during the observation period, with nearly half of that attributed to the top 1% only ($3.8 billion)…” (!!)

· Mental illness: just 5.7% of the zero-cost group, and the percentage rose with use of the system. With the top 1%, it was 17.0%. (!!)

· “Unadjusted and adjusted odds ratios for all groups compared to the zero cost referent group were statistically significant, with the odds of mental illness comorbidity for the top 1% group being almost 4 times that of the zero-cost referent group…”

· When anxiety and other disorders were included, the rate of diagnosed mental illness rose to 39.3% in the top 1% (and 21.3 in the zero-cost group). (!!)

The authors conclude:

Nearly 1 in 5 of HCUs in Ontario has a diagnosed major mood, psychotic, or substance use disorder. When anxiety and other disorders are included, this burden rises to more than 1 in 3. Effective interventions will likely require a comprehensive multidisciplinary approach that attends to the social, medical, and psychiatric needs of these complex patients. Considering and addressing mental illness and addiction in HCUs may result in cost savings and improved health outcomes.

A few thoughts:

1. Wow.

2. This paper is good and makes important observations.

3. I like the conclusion.

4. I’ll say it again: I like the conclusion.

5. I’ve made this point before, and it’s worth repeating: the historic separation of physical and mental health is false and unhelpful. In this paper, the authors consider HCUs – finding many people with complicated physical health problems have mental health problems. Trying to address one without trying to address the other seems ill advised.


Mental Disorders and Costs

“Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion”

Charles Roehrig, Health Affairs

Online, 18 May 2016


Estimates of annual health spending for a comprehensive set of medical conditions are presented for the entire US population and with totals benchmarked to the National Health Expenditure Accounts. In 2013 mental disorders topped the list of most costly conditions, with spending at $201 billion.

The National Health Expenditure Accounts (NHEA), maintained by the Centers for Medicare and Medicaid Services, provide official estimates of annual health spending in the United States. The NHEA covers spending by the entire US population broken out by type of service and source of payment, but not by medical condition. For many years the Agency for Healthcare Research and Quality (AHRQ) has produced estimates of spending by medical condition from its Medical Expenditure Panel Survey (MEPS), but they are limited to the civilian noninstitutionalized population and include double counting of spending that involves multiple conditions. The Commerce Department’s Bureau of Economic Analysis recently released the Health Care Satellite Account, which promises to be an ongoing source of spending by medical condition, without double counting, for the civilian noninstitutionalized population. Estimates of health spending by medical condition for the entire US population, without double counting and benchmarked to the NHEA, were first developed in a 2009 study published in Health Affairs that covered the period 1996–2005. This article updates those estimates through 2013, using similar data and methods. The inclusion of institutionalized populations has a significant impact on total spending and brings mental disorders to the top of the list of medical conditions with the highest estimated spending: $201 billion in 2013.

Charles Roehrig

So opens a new paper published in Health Affairs (Online).

This paper is relatively straight-forward, and requires less of a summary.

Here’s what the author did:

· Using US data, as described above, Roehrig compared medical conditions for the year 2013.

Here’s what Roehrig found:

He concludes:

In 1996 the most costly medical condition, by far, was heart conditions, at $105 billion, with mental disorders a distant second at $79 billion. They had equal spending in 2004 ($131 billion each; data not shown), and by 2013 spending on mental disorders had moved far ahead—reaching $201 billion versus $147 billion spent on heart conditions.

He continues:

One key finding of this study is the degree to which spending on mental disorders in 2013 exceeded that on all other medical conditions, including heart conditions, trauma, and cancer. Spending on mental disorders tends to be underestimated in other sources because institutionalized populations are excluded.

My final thought: a surprising result. Of course, this is US data, but it shows the incredible cost associated with mental illness – and, by extension, the great need to better organize services south of the 49th parallel… and, for that matter, north of the 49th parallel.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.