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This paper addresses the use of health economics in relation to posttraumatic stress disorder (PTSD) in the Armed Forces, with a view to assessing the feasibility of carrying out future evaluative studies. Although psychological and pharmacological interventions can be used to treat PTSD, no economic evaluations are known to exist. There is an economic burden associated with PTSD, and treatments require the use of scarce resources. Health economics provides tools (including cost-effectiveness, cost-benefit, and cost-utility analyses) to ascertain the relative efficiency of different treatment options. The paper concludes that the quality of life and resource consequences of PTSD require a better understanding of the economics of the disorder and the alternative ways to treat it.

Background: Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings. Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment. This study estimates this impact., Method: Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study. Service use over a 3 month period was measured and lost employment recorded. These data were used to estimate economic costs. Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled., Results: The mean total cost of services and lost employment across the sample was Pound Sterling1906 for the 3-month period with formal services accounting for 9.3% of this figure. Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone. Total 3-month costs were on average higher for chronic fatigue syndrome (Pound Sterling3515 v. Pound Sterling1176) but when sample differences were taken account of the mean difference was reduced to Pound Sterling1406 (P = 0.086). Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment. Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment., Conclusion: Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment. Treatments need to be developed which recognize these impacts.

Treatment of neurological disorders with intravenous immunoglobulin (IVIg) is an increasing feature of our practice for an expanding range of indications. For some there is evidence of benefit from randomised controlled trials, whereas for others evidence is anecdotal. The relative rarity of some of the disorders means that good randomised control trials will be difficult to deliver. Meanwhile, the treatment is costly and pressure to "do something" in often distressing disorders considerable. This review follows a 1 day meeting of the authors in November 2000 and examines current evidence for the use of IVIg in neurological conditions and comments on mechanisms of action, delivery, safety and tolerability, and health economic issues. Evidence of efficacy has been classified into levels for healthcare interventions (tables 1 and 2).

Background: Depression in childhood or adolescence often has morbidity implications continuing into adulthood, generating needs for specialist services and support., Aims: To estimate the patterns of service use and costs in adulthood of former patients., Method: Service use and other cost-related data were collected from former patients. Comparisons were made between those people with and without comorbid conduct disorder in childhood and with data for the general population., Results: Data on 91 people with depression (only) and 49 with comorbid conduct disorder revealed high adulthood service utilisation rates and costs. Inpatient care and criminal justice services were used more frequently by the comorbid group and total costs were significantly higher. There were also indications of higher service use by the comorbid group than the general adult population., Conclusions: The high and enduring long-term costs associated with childhood depression and conduct disorder give further reason for early and effective intervention.

Objective: To review the economic cost of Alzheimer's disease, to determine the level of research expenditure directed at this illness and to make comparisons with cancer, stroke and heart disease., Method: A literature search of cost-of-illness studies was conducted and major funders of research were contacted. Cost-of-illness estimates were updated and adjusted to enable comparability across the four disease areas., Results: The direct costs of Alzheimer's disease were estimated to be between 7.06 billion pounds sterling and 14.93 billion pounds sterling , which was substantially greater than stroke (3.2 billion pounds sterling), heart disease (4.05 billion pounds sterling ) and cancer (1.6 billion pounds sterling excluding informal care costs). Research expenditure on Alzheimer's disease was 57% of that on stroke, 10% of that on heart disease and 3% of that on cancer., Discussion: Alzheimer's disease imposes a high economic burden. However, spending on research is disproportionately low compared with spending on other major illnesses. In the light of these two findings we recommend further discussion of the distribution of public funding for research into this disease., (Copyright 2001 John Wiley & Sons, Ltd.)

Background: The high acquisition cost of the atypical antipsychotics has prompted their closer clinical and economic evaluation. This study aims to examine the financial implications of using atypical antipsychotics in a defined catchment area sample of patients with schizophrenia., Method: Service costs over a 10-month period were compared between groups of patients fulfilling DSM-IV criteria for schizophrenia who were taking different atypical antipsychotic agents., Results: All patients studied were taking clozapine (N = 31). risperidone (N = 19), or olanzapine (N = 41). Clozapine was used in more chronic patients, while risperidone and olanzapine were prescribed in both chronic and recently diagnosed cases. After background group differences were controlled for, patients on risperidone treatment incurred the lowest costs. The monthly costs for the clozapine and olanzapine groups were higher than for risperidone by US $246 and US $566, respectively., Conclusion: Clozapine was reserved for more severe forms of schizophrenia, but its cost impact was relatively low. Risperidone, as prescribed in ordinary practice, may be more cost-effective than olanzapine.

Objective: To compare the occurrence of needs of patients with schizophrenia in Amsterdam, Copenhagen, London, Santander and Verona., Method: Patients with schizophrenia were interviewed with the Camberwell Assessment of Need. The mean numbers of total, met and unmet needs were compared across the sites. Ratings for individual domains were also examined. Means were adjusted, using multiple regression analysis, to control for patient differences between sites., Results: The highest levels of unmet need were in Amsterdam and London. The number of met needs were similar. Adjusting for patient differences reduced the estimated number of unmet needs and total needs in Copenhagen, but made little difference elsewhere. There were many site differences for individual domains., Conclusion: Needs vary between different countries. Unmet needs are greater in large urban areas like London and Amsterdam. Differences in the pattern of individual needs may be partly explained in terms of service provision.

The objective of this study is to identify factors that predict the costs of community mental health services. A random sample of individuals, selected from all identified cases of psychosis in two geographically defined catchment areas, were interviewed before the establishment of community mental health teams and then after these teams had been operating for approximately 2.5 years. One of the sectors developed an intensive community service, with a more standard service in the other sector. Significant predictors of higher costs were older age and higher levels of disability. Predictors of lower costs were longer duration of illness and more years of education. A reduced model revealed that being male and having more symptoms were also predictors of higher costs. After controlling for background characteristics, it was revealed that services provided to clients from the intensive sector were $1,894 more expensive over 6 months than those provided to standard sector clients.

Psychiatric reform and the current system of mental health care in England are outlined, the system context of the National Health Service (NHS) is described. Recent institutional change in the NHS has introduced internal market elements. More than 90 mental hospitals have been closed. The TAPS study, a longitudinal study evaluating mental hospital closure is described. Results show a range of advantages of the post-discharge care arrangements. Studies evaluating services with a home treatment and community focus (DLP, PRiSM) suggest that community mental health care is feasible. Shortages and problems of the current system of care (acute beds, intensive residential and rehabilitation services) are outlined.

Objective: To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse., Method: Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status., Results: A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant., Conclusion: Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.

Background: The five-country European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study aimed to develop standardised and reliable outcome instruments for people with schizophrenia. This paper reports reliability findings for the Camberwell Assessment of Need--European Version (CAN-EU)., Method: The CAN-EU was administered in each country, at two points in time to assess test-retest reliability, and was rated by two interviewers at the first administration. Cronbach's alpha, test-retest reliability and interrater reliability were compared between the five sites. Reliability coefficients and standard errors of measurement for summary scores were estimated., Results: Sites varied in levels and spread of needs. Alphas were 0.48, 0.58 and 0.64 for total, met and unmet needs respectively. Test-retest reliability estimates, pooled over sites, were 0.85 for the total needs, 0.69 for met needs and 0.78 for unmet needs. Pooled estimates for interrater reliability were higher, at 0.94, 0.85 and 0.79 for total, met and unmet needs respectively. There were statistically significant differences in interrater reliability between sites., Conclusion: The results confirm the feasibility of using CAN-EU across sites in Europe and its psychometric adequacy.

Background: In international research on the consequences of psychiatric illnesses for relatives of patients, the need for an internationally standardised measure has been identified., Aims: To test the internal consistency and the test-retest reliability of the Involvement Evaluation Questionnaire (IEQ) in five European countries., Method: The IEQ was administered twice to a sample of relatives or friends of patients with an ICD-10 diagnosis of schizophrenia. Reliability was tested using Cronbach's alpha, intraclass correlation coefficients and standard error of measurement. Reliability estimates were tested between sites., Results: Test sample sizes ranged from 30 to 90 across sites, and retest sample sizes ranged from 21 to 77. Cronbach's alpha values of IEQ sub-scales and sumscore were substantial at most sites; but at two, alpha values were moderate. Intraclass correlation coefficients were substantial to high at all sites. The standard errors of measurement differed across sites, indicating differences in performance., Conclusion: The reliability of the IEQ in five languages varies across sites, but is sufficiently high in at least four out of five.

Background: The greater frequency of mental illness in deprived and inner-city populations is well recognised; allocation of funds in the UK health service makes some allowance for this. However, it is not clear whether the differences are similar for all levels of mental health care need., Aims: To study the range in prevalence of mental health problems and care at primary care, general secondary care and forensic care levels., Method: We used mainly descriptive statistics to study evidence available from existing sources--some based on indicators of likely need, some on observed prevalence of treatment., Results: Among English health authority areas, the most morbid have about twice the prevalence of primary care level mental illness of the least morbid. For secondary care the ratio is between 2.5 and 4 to 1, while for services for mentally disordered offenders it is in excess of 20:1., Conclusions: Where needs indices are used for resource allocation, responsible authorities should ensure that they produce ranges reflecting the full compass of services funded. For forensic services the range of morbidity levels may be so great that funding needs to rest at a larger population level than that of health authorities.

Background: The objective of this study was to compare casemix groups in Italy and the UK. Three hypotheses were tested. First, that length of stay would be shorter in Italy. Second, that diagnosis would not be an effective predictor of length of stay. Third, that diagnosis-based groups would be better predictors of length of stay in Italy due to shorter in-patient episodes., Methods: In-patient episodes in Pavia (Italy) and Camberwell (UK) for patients with psychosis were allocated to four Healthcare Resource Groups. Average lengths of stay, and coefficients of variation in the two areas were compared. A regression model was constructed to determine the impact of diagnosis groups, gender, age and area on length of stay., Results: Length of stay was significantly shorter in Pavia than in Camberwell for three of the four groups. The coefficient of variation was generally above 1, indicating a lack of within-group similarity. With outliers trimmed, the figures were below 1, except for one group in Camberwell. Pavia revealed greater group homogeneity than Camberwell, with one exception. The regression model explained 9% of variation when the two areas were both included, and around 5% when compared separately. Age had a non-linear impact on length of stay in Camberwell., Conclusions: We have again shown that diagnosis does not adequately predict length of stay. However, in Italy, where admissions are for shorter periods, diagnosis groups are more homogeneous. This may be because the initial part of a hospital stay is due to clinical factors, whereas prolonged stay is influenced by supply-side issues.

There has recently been an expansion of paraprofessional staff involved in the provision of care for the severely mentally ill. In this paper we shall evaluate the effects of a community support worker (CSW) service in South London. A sample of patients with severe mental illness receiving the service was assessed over a 6-month period in order to examine the effects of continuing use of CSWs on outcomes, service use and costs. During the study period there were improvements in outcome reflecting service satisfaction, needs, quality of life and social behaviour. Whilst provision of the CSW service did not lead to extra total service costs, service use and cost data suggest that CSWs are associated with the substitution of in-patient use by community-based services.

Social networks have been shown to be smaller in individuals with severe mental illness than in the general population. Patients' social networks and social support may impact on their utilisation of psychiatric services. This literature review focuses on social networks, social support and mental health service use in patients with mental illness. Most studies suggest that smaller social networks or less social support are associated with more frequent hospitalisation. Qualitative aspects of the social network are also related to the risk of hospitalisation. The relationship between social networks and other types of service use is not established.

Background: This paper sets out the rationale for the PRiSM Psychosis Study, and the research design used. Nine accompanying papers present the main results. The questions addressed by the PRiSM Psychosis Study are: can the gains of experimental studies which have demonstrated benefits arising from treatment by community mental health teams be translated to routine settings? If so, are the benefits diluted in ordinary clinical practice? What are the costs?, Method: A prospective nonrandomised controlled trial of two types of community mental health service, in two phases: case identification followed by patient interviews. For the case identification the research team conducted the complete ascertainment of all prevalent cases of psychosis in the two study catchment areas in the index year (1991-1992). From all 514 patients with psychotic disorders thus identified, 302 were randomly allocated for interview, along with a key informant clinician and a carer. Interviews were under taken at two time points, two years apart., Results: This paper presents the socio-demographic, clinical and ethnic characteristics of the patients., Conclusions: The people with psychosis interviewed for the PRiSM Psychosis Study are representative of the whole epidemiologically based patient population identified.

Background: Social networks are important for people with severe mental illness, and services need to assess whether they succeed in improving social contacts., Methods: In a prospective controlled study, social network data were obtained in an epidemiologically representative sample of people with psychotic disorders both before (Time 1) and two years after (Time 2) the introduction of two sectorised community mental health services in south London (one intensive service with two specialist teams, one standard service with a generic team)., Results: There were significant baseline differences between sectors with social networks being smaller in the sector later served by the intensive service. Social network size increased within the intensive service sector, but not in the standard service sector. There was a significant sector effect for the network component of relatives (intensive > standard) and in the other ('non friends') component (standard > intensive) after adjusting for baseline differences., Conclusions: The findings suggest that the intensive sector community mental health service enhanced people's social networks with their relatives, relative to the standard service. The reverse is the case for other contacts.

Background: The costs and the effectiveness of mental health services need to be evaluated if provision is to be efficient. Service use and costs are described for two geographical areas in south London., Method: Service use was measured comprehensively for clients in both sectors for two six-month time periods using the Client Service Receipt Interview. This information was combined with unit costs to calculate service costs. The 'hidden' costs of informal care and unsupported accommodation were also calculated., Results: At baseline significantly more intensive sector clients had in-patient stays but by the follow-up this difference had disappeared. There was significantly more use of supported accommodation in the intensive sector during both time periods. Baseline and follow-up total service costs were significantly higher for the intensive sector. Costs were spread disproportionately and a small number of services accounted for a large proportion of cost., Conclusions: While the cost at Time 2 was significantly greater in the intensive sector, this was largely due to the high use of supported accommodation. There was some convergence in cost between the sectors over time.

Background: Service evaluation requires a detailed understanding of the services studied., Method: Community mental health services evaluated in the PRiSM Psychosis Study in south London are described. The intensive sector and standard sector services are contrasted., Results: The intensive sector had two teams with extended opening hours: a psychiatric acute care and emergency (PACE) team, and a psychiatric assertive continuing care (PACT) team focusing on care for people with chronic illness. In the standard sector there was a generic community team providing office-hour assessments, case management of the severely mentally ill and close liaison with in-patient services. The team made use of the local psychiatric emergency clinic and of other local resources. The intensive sector was characterised by: more admissions to fewer beds, more nonhospital residential places, extended hours, on-call rota, wider range of interventions, more medical and nursing staff, a lower nursing grade mix and higher staff turnover. The standard sector had a less highly resourced generic community psychiatric service., Conclusions: Change in services has been more marked in the intensive sector.

Background: Increasingly, evaluations of mental health services include an economic component, although often only summary statistics such as the mean or median are reported. Measures of variation are often limited to the standard error or standard deviation, though costs are rarely normally distributed and vary substantially between patients. The aim of this study is to identify factors that can explain variations in the cost of mental health services for epidemiologically representative cases of psychosis., Methods: Cases with ICD-10 diagnoses of functional psychosis were drawn from a sample that included all identified cases of psychosis in two geographically defined sectors in Camberwell, south London. Mental health service use was measured and costed. A predictive model was developed using multiple regression analyses, in which patient characteristics and previous service use indicators were used as predictor variables. Services were measured using the Client Service Receipt Interview., Results: Among the 147 cases included, the amount of cost variation explained by the model was 31.5%. The most significant predictive factor was social functioning, which was highly negatively associated with cost., Conclusions: Current mental health service use can be predicted to a reasonable extent by previous service use and patient characteristics, especially the degree of social disability. Identification of such factors can aid the effective allocation of scarce resources. In particular, subgroups of patients who use most resources can be identified and targeted by mental health services.

Background: Large social networks in patients with severe mental illness have been reported to be associated with a low rate of hospitalisation. We aim to determine whether social network size is related to the likelihood of hospitalisation and the amount of service use., Method: As part of a prospective controlled study, baseline interview data for a random sample of one-year prevalent cases with non-organic psychosis were analysed with respect to social network characteristics and service use during a six-month period., Results: The likelihood of hospitalisation decreased with an increase in network size, while the number of services used by patients grew as the social network size increased., Conclusions: While larger social networks may be associated with a lower likelihood of hospitalization, they may also be related to wider use of non-hospital services.

For an evaluation of a mental health care programme to be comprehensive, it should include an economic component. However, very few cost instruments appear to exist, and only one has been fully described in the literature. This paper seeks to review the studies where costs have been calculated. For this exercise to be facilitated the different elements which make up overall cost are described. A number of areas have experienced economic evaluations, and the more important studies are described. The paper concludes that all too often evaluations either fail to measure costs or do so in an incomplete and inappropriate way.

Background: People with severe mental illness often have a complex mixture of clinical and social needs. The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs. There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool. The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services., Method: A draft version of the instrument was designed by the authors. Modifications were made following comments from mental health experts and a patient survey. Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument., Results: The mean number of needs identified per patient ranged from 7.55 to 8.64. Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 0.99 and 0.78 respectively. The percentage of complete agreement on individual items ranged from 100-81.6% (inter-rater) and 100-58.1% (test-retest)., Conclusions: The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness. It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes.

This paper examines the link between diagnosis and length of psychiatric in-patient stay. Up to now the main method of predicting the use of in-patient services has been to use diagnosis-related groups (DRGs), primarily in the USA. Previous findings have revealed that DRGs generally predict less than 10% of variation in hospital stay. Psychiatric DRGs are considered to lack homogeneity and are too broad. Nevertheless, diagnosis, as an indicator of resource utilization, is now on the agenda in the UK and a study which examines the link between service use and diagnosis per se is called for. Altogether 5482 patients were allocated to 43 diagnostic categories (DCs). These DCs covered mental disorders, drug and alcohol-related problems, diseases of the nervous system and sense organs, and other related illnesses. Age was used in an attempt to refine the model further. Coefficients of variation were calculated for the DCs, and multivariate regression analysis was performed to gauge predictiveness. The results reveal that DCs contain extremely limited homogeneity and only predict 3% of variation in length of stay. When age group is included the results are only marginally improved, although the numbers contained in some DCs are low. Diagnosis, even when clearly defined, is a poor indicator of resource utilization.

Background: Part of the community psychiatric nurse (CPN) service was reorganised into a community support team (CST), with staff acting as case managers. An economic evaluation ran parallel to the comparison with generic CPN care., Method: Eighty-two clients were randomly allocated to experimental and control groups. Costs were comprehensively measured over a pre-referral period (three months), and then at 6, 12, and 18 months., Results: The economic evaluation found a cost difference between the groups. Generic group costs averaged 89 pounds per patient per week more than CST group costs. The difference was only significant for the first six months. Changes in the burden of cost across agencies were observed., Conclusions: Although CPN inputs and costs were higher for the CST group, there was a significant short-term reduction in total cost. Beyond the short term, the CST did not confer cost or cost-effectiveness advantages.