Mental health policy and practice across Europe: an overview

Financing and funding 83
Europe or Australia. This geographical unevenness is relevant because the results
of economic evaluations may not transfer readily from one country to another
because of differences in health systems, financing arrangements, incentive
structures and relative price levels. There might also be differences in the choice
of comparator: a service model might look an attractive option compared to
standard arrangements in one country but not in comparison to the norm elsewhere.
It is infeasible and indeed unnecessary to carry out an evaluation every
time a policy decision needs to be taken, but evidence-based decisions should
generally be better than evidence-free decisions. This could mean using the
results from a study carried out in another country, or updating a previous
study, or carrying out a modest adaptation to adjust for context.
There is also an imbalance in the topic coverage of the economic evidence
base: with more on pharmaceutical treatments than on psychotherapies, little
on service organization and almost nothing on mental health promotion
(Knapp et al. 2004). For example, one recent review of interventions to tackle
depression identified 58 studies, half of which were evaluations of drug therapies,
with only two on promotion or screening (Barrett et al. 2005). Many of these
studies – certainly most of the better studies – had been completed quite
recently. Enhanced primary care management of depression pushes up health
care costs but leads to larger savings in productivity losses by reducing absenteeism
(Rost et al. 2004). Some recent studies have begun to look at combination
treatments, multi-professional interventions and collaborative care models,
many of which look relatively cost-effective (Simon et al. 2001; Neumeyer-
Gromen et al. 2004; Pirraglia et al. 2004). There are also attempts to pool
evidence from across different treatment options by looking more broadly at
cost-effective intervention strategies and their impact on morbidity (Andrews
et al. 2004; Chisholm et al. 2004, 2005).
As we noted earlier, the volume of cost-effectiveness evidence has grown
noticeably in the past couple of decades. We are not going to attempt to review
or summarize that evidence, but some general comments are pertinent. There
have tended to be more cost-effectiveness studies in diagnostic areas where new
classes of medication have been launched. A lot of depression studies followed
the licensing of the early Selective Serotonin Reuptake Inhibitors (SSRIs) and
later antidepressants with other mechanisms of action. Similarly, the arrival of
the atypical antipsychotics and the cholinesterase inhibitors stimulated a lot of
economic research on, respectively, the treatment of schizophrenia (Basu 2004)
and Alzheimer’s disease (Jonsson 2004). In each of these diagnostic areas today’s
evidence base is dominated by drug trials, most of them industry-sponsored.
Not all of the research is of an adequate standard, and arguments abound as to
the validity of industry-sponsored trials. The National Institute for Health and
Clinical Excellence for England and Wales (NICE) somewhat controversially
considered the new drug treatments for Alzheimer’s disease to be effective
but not cost-effective (Loveman et al. 2004). Diagnostic areas with relatively
less recent psychopharmacological developments appear to have attracted fewer
cost-effectiveness analyses. For instance, there have been very few evaluations
of interventions for child and adolescent mental health problems (Romeo et al.
2005), bi-polar disorder (Knapp et al. 2004), most anxiety disorders (Andlin-
Sobocki and Wittchen 2005) or personality disorders.