The social costs of anxiety disorders

The social costs of anxiety disorders
“Experience and Evidence in Psychiatry: Symposium on Somatics and
Anxiety Disorders”
Disorders”, Madrid, 19th April 2006
Frank Jacobi & HansHans-Ulrich Wittchen
Technische Universitä
Universität Dresden
Institute of Clinical Psychology and Psychotherapy
Overview
1. The spectrum of anxiety disorders
2. What is special in anxiety disorders?
¾ high prevalence
¾ early onset
¾ persistence
¾ comorbidity
¾ low treatment rates
3. Indicators of social cost
4. The social costs of anxiety disorders in the context of all disorders of
the brain
1
The spectrum of anxiety disorders (DSM-IV)
¾ panic disorder (with and without agoraphobia)
¾ agoraphobia (without panic disorder)
¾ social phobia
¾ specific phobias
¾ generalized anxiety disorder (GAD)
¾ obsessive-compulsive disorder (OCD)
¾ posttraumatic stress disorder (PTSD)
¾ anxiety disorder NOS
t Special features: partly different risk factors and correlates and
consequences, various degree of within anxiety disorders overlap
To understand the burden we need epidemiological studies:
Research and reference populations
Total general population
Epidemiology is able to provide a more complete
picture of patterns of morbidity and supplement
findings from clinical research
Subjects with a diagnosis in lifetime (lifetime prevalence/risk)
High risk subjects (current subsyndromal, partial remission)
Subjects with current disorders but not in
treatment (undiagnosed, untreated)
Patients in treatment
services (treated prevalence)
research
2
What is special in anxiety disorders?
prevalence – onset – persistence
Increasingly higher prevalence estimates for
anxiety disorders in 3 decades
(due to broader and more specific coverage – no evidence for “real
increase”
increase”)
12month
prevalence (%)
S1 Marks review
S2 Wittchen review
S9
S6
S10
15
8-10%
10
Studies:
13-18%
20
5-7%
S3
S7 S8
S4 S5
S6 NCS
S7 NEMESIS
S8 OHS
S9 EDSP
S10 GHS-MHS
S2
5
S3 ECA
S4 MFS
S5 Edmonton
S1
0
pre 1980
studies in the 80ies
studies in the 90ies
Wittchen & Jacobi,
ECNP 2003
3
First onset of anxiety disorders is predominantly
before age of 20
1.00
cumulative %
0.75
0.50
"specific phobias"
social phobia
OCD
panic disorder
GAD
0.25
Within anxiety disorders: PD, GAD
later than phobias and OCD
0.00
0
5
10
15
20
25
30
Age of onset (years)
EDSP, 2005
Persistence: 1212-month
12-month / lifetime prevalence
Any anxiety disorder
PTSD
Unlike to depression – if you have
a lifetime anxiety disorder you are
very likely to also have an anxiety
disorder currently!
OCD
Specific phobia
Social phobia
GAD
12-month
lifetime
Agoraphobia
Panic disorder
NCS-R, 2005
0
5
10
15
20
25
30
35
%
4
Where is the position of anxiety disorder within all disorders of the brain?
“Size and Burden of Mental Disorders in Europe”:
Material and methods
• Standardized search for EU-publications (N=212 studies all languages)
• Iterative data collection process (114 country-specific experts)
• Inclusion of unpublished material (additional 19 studies)
• Agreement on definition and conventions (DSM-III-R/IV-diagnoses & criteria, 12-month, etc.)
• Original data for standardized reanalyses (7 EU-countries, N = 28.000+, mean, 95% CI)
• Data compilation by country, age, gender and diagnoses for experts review
• Preparation of peer review “state of the art” papers by diagnostic domains
• Circulation to all country- and topic-specific experts (over 100 experts)
• Linkage with Health-Economic panel (collaboration with European Brain Council, EBC)
•
Reanalyses and statistical modelling of data
The collaborative EBC-ECNP network: Contributing core experts
EBC
EBC-ECNP
Panel members and
review authors
(mental disorders):
Carlo Altamura, IT
Jules Angst, CH
Eni Becker, NL
Claudine Berr, FR
Terry Brugha, UK
Ron de Graaf, NL
Carlo Faravelli, IT
Lydia Fehm, DE
Tom Fryers, UK
Tomas Furmark, SE
Renee Goodwin, US
Frank Jacobi, DE
Ludwig Kraus, DE
Roselind Lieb, DE
Eugene Paykel, UK
Antoine Pelissolo, FR
Lukas Pezawas, US
Stefano Pini, IT
Jürgen Rehm, CH, CA
Anita Riecher-Rössler, CH
Karen Ritchie, FR
Wulf Rössler, CH
Robin Room, SE
Hans Joachim Salize, DE
Wim van den Brink, NL
Jim van Os, NL
Johannes Wancata, AT
Hans-Ulrich Wittchen, DE
Panel members and
review authors
(COI-reviews):
Patrik Andlin-Sobocki, SE
Jenny Berg, SE
Mattias Ekman, SE
Lars Forsgren, SE
Bengt Jönsson, SE
Linus Jönsson, SE
Gisela Kobelt, FR
Peter Lindgren, SE
Mickael Löthgren, UK
Jes Olesen, DK
Country specific
epidemiol. experts
(mental disorders):
Christer Allgulander, SE
Jordi Alonso, ES
Jules Angst, CH
Terry Brugha, UK
Ron de Graaf, NL
Eva Dragomirecka, CZ
Carlo Faravelli, IT
Erkki Isometsä, FI
Heinz Katschnig, AT
Jean-Pierre Lèpine, FR
Jouko Lönnqvist, FI
Julien Mendlewicz, BE
Povl Munk-Jörgensen, DK
Bozena Pietrzykowska, PL
Zoltan Rihmer, HU
Inger Sandanger, NO
Jon G. Stefánsson, IS
Miguel Xavier, PT
Panel members
(neurological):
Ettore Beghi, IT
Karin Berger, DE
Gudrun Boysen, DK
Sonja v. Campenhausen, DE
Richard Dodel, DE
Lars Forsgren, SE
W.H. Oertel, DE
Jes Olesen, DK
Maura Pugliatti, IT
Franco Servadei, IT
Uwe Siebert, DE
Lars Stovner, NO
Thomas Truelsen, SE
Manfred Westphal, DE
Coordinator of
data collection:
Frank Jacobi DE
Steering committee members are underlined
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Coverage and Definitions
Mental disorders (DSM-IIR-DSM-IV)
Geographical Scope
Affective disorders: Bipolar disorders, major
depression, dysthymia
Anxiety disorders: panic disorder, agoraphobia,
GAD, social phobia, specific phobia, OCD, PTSD
Dementia
Psychotic disorders (focus on schizophrenia)
Somatoform disorders: hypochondriasis, pain disorders,
Somatisation disorder
Substance use disorders: Alcohol abuse and dependence,
Illegal drug abuse and dependence, nicotine dependence
Eating disorders: anorexia nervosa, bulimia
Other disorders of the brain:
Parkinson’s disease, Migraine and other headaches
Stroke, Epilepsy, Brain trauma, Brain tumour,
Multiple Sclerosis
EU member countries
(EU-25) and Iceland,
Norway and Switzerland
Latest findings: Anxiety accounts for a large proportion of all mental disorders!
12-month prevalence (%, 95% CI) and estimated number of subjects
12
12-month
affected in the EU
eating disorders
1,1 Mio (0,9 - 1,7)
2,0 Mio (1,4 - 2,1)
ill. subst. dep.
2,6 Mio (2,4 - 3,0)
OCD
3,6 Mio (2,8 - 5,3
psychotic disorders
2,4 Mio (1,7 - 2,4)
bipolar disorder
3,9 Mio (3,3 - 4,7)
agoraphobia
GAD
5,8 Mio (5,2 - 6,1)
5,2 Mio (4,3 - 5,3)
panic disorder
6,6 Mio (5,4 - 9,2)
social phobia
7,1 Mio (5,8 - 8,6)
alcohol dependence
somatof. disorders
18.9 Mio. (12.6-21.1)
specific phobias
18.4 Mio. (17.2-19.0)
major depression
18.5 Mio. (14.3-18.6)
0
1
2
3
4
Note:
Numbers add up to more than 27% and 82 million subjects
because subjects can have more than one disorder
(comorbidity)
5
6
7
8
9
Wittchen & Jacobi (2005), Neuropsychopharmacology
6
Are these 12-month prevalence EU estimates
12
12-month
““suprisingly”
suprisingly”
suprisingly” high?
Yes – if you consider that some of the previous epidemiological studies
revealed somewhat lower estimates, because of
+ A restricted range of disorders covered
+ Narrower time window (e.g. restricted the prevalence period to 2 weeks)
+ Additional so-called “clinical significance” criteria
Are those 12-month prevalence EU estimates
12
12-month
““surprisingly”
surprisingly”
surprisingly” high?
Yes – if you consider that some of the previous epidemiological studies
revealed somewhat lower estimates, because of
+ A restricted range of disorders covered
+ Narrower time window (e.g. restricted the prevalence period to 2 weeks)
+ Additional so-called “clinical significance” criteria
Not – however if you account in previous studies for the above mentioned
methodological differences
Not – in comparison to somatic disorders: In this age range, over 70% of the
general population has at least one somatic disorder (“Why should the brain
less frequently affected?”)
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What is special in anxiety disorders? (cont.)
comorbidity
Comorbidity is a fundamental characteristic of mental disorders
and increases by age
(and the way they are defined in current classification systems)
OR Anxiety with:
Suds:
2.6
Depression: 6.9
Somatoform: 3.4
OR Depression:
Anxiety:
7.0
Suds:
2.7
Somatoform: 3.5
80
54.3% of all
anxiety disorders
are comorbid
60,2% of
the mood
disorders
70
proportion comorbid
60
50
40
30
41,2% of substance use
disorders
20
10
OR Substance with:
Anxiety:
2.5
Depression: 2.7
Somatoform: 1.9
49,2% of the
somatoform
disorders
0
OR Somatoform:
Anxiety:
3.5
Suds:
2.1
Depression: 3.5
18-29
30-39
40-49
50-59
60-65
Age group
8
.. And might have important etiological implications, for example
example
Symptom progression models: Sequential comorbidity in anxiety
disorders
Onset of
cascade
Precursors: Behavioral inhibition/separation anxiety, (trauma)
Specific and social phobia
panic attacks, agoraphobia, panic disorder
Increased neurobiological,
cognitive, behavioral
sensitization
GAD
Secondary depression
Suicidality
Increased
impairment/disability
Substance use disorders
5
10
15
20
age
25
30
35+
Cumulative risk of cases with primary anxiety disorder by age of onset of
secondary depressive disorder
Cumulative % of
Cum.
risk (%)
depression
60
50
40
no anxiety dx
30
20
10
0
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
By age of onset
EDSP, 2001
9
Cumulative risk of cases with primary anxiety disorder by age of onset of
secondary depressive disorder
Cumulative % of
depression
60
50
PD
GAD
AG
SPP
SoP
no anxiety dx
40
30
20
10
0
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
By age of onset
EDSP, 2001
Anxiety disorders are also associated with increased somatic
morbidity: Comorbidity with selected physical conditions
Physical
Conditions
No Anxiety
Disorder
n (%)
Anxiety
Disorder
n (%)
AOR (95% CI)
significant
reduction of
health related
QoL (SF-36)
Cardiac diseases
88 (2.3)
18 (3.7)
1.79 (0.85-3.79)
Respiratory
diseases
191 (5.4)
43 (10.5)
1.71 (1.13-2.57)**
X
Gastrointestinal
diseases
113 (2.9)
29 (7.4)
2.10 (1.24-3.54)**
X
Arthritic
conditions
956 (24.6)
138 (32.0)
1.66 (1.24-2.21)**
X
Metabolic
syndromes
279 (7.6)
38 (9.9)
1.56 (1.02-2.37)*
X
Allergic
conditions
461 (12.3)
75 (18.1)
1.39 (1.00-1.95)*
X
Migraine
headaches
271 (6.2)
72 (17.0)
2.12 (1.51-2.98)**
X
Thyroid diseases
340 (8.4)
68 (15.9)
1.59 (1.13-2.24)**
Any past month
physical condition
2295 (59.6)
315 (74.2)
1.70 (1.27-2.27)**
X
Sareen et al. (subm.)
AOR: Odds Ratio adjusted for sociodemographic variables and comorbid depression and SUD
10
What is special in anxiety disorders? (cont.)
treatment rates
Treatment rates are extremely low in almost all mental disorders –
increase by degree of comorbidity
By type of disorder
By comorbidity
anxiety
100%
100%
90%
90%
80%
80%
70%
no treatment
both
only psychological
only drug
no consultation
60%
50%
70%
60%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
any mood any anxiety any alcohol psychotic
disorder
disorder
disorder
disorder
just one disorder
more than one
disorder
ECNP-Task Force Report 2005 : Size and burden of Mental Disorders in the EU
11
… and if treatment occurs – it occurs predominantly very late!
Cumulative lifetime probability of treatment contact in anxiety disorders
Wang et al. (2005), Archives of General Psychiatry
Summary (1): Special features of anxiety disorders
• High prevalence
• Early onset and persistence
• High comorbidity rates (with secondary mental disorders and with somatic disorders)
• Low rates of treatment
Wittchen & Jacobi (2005), Neuropsychopharmacology
Goodwin et al. (2005), Neuropsychopharmacology
Fehm et al. (2005), Neuropsychopharmacology
Lieb et al. (2005), Neuropsychopharmacology
ESEMeD/MHEDEA 2000 Investigators (2004), Acta
Psychiatrica Scandinavica
12
Burden indicators and cost estimates
social impairment – high utilizers – total and hidden costs
Almost invariably marked social impairment and disability in
anxiety disorders
•
By diagnostic definition and criteria anxiety disorders always imply social
role impairment and clinically significant suffering
• Unlike to episodic disorders like depression, persistent (anticipatory anxiety)
and special (panic attacks) features are associated with a pronounced longlong-term
burden in terms of subjective suffering and disruption in social roles
• However,
However, research has been slow to incestigate this in greater detail!
• A crude indicator applied across the majority of studies is number of
disability (sick leave)
leave) days
• Also reduced work productivity (when at work)
work) important factor for high
indirect costs (Greenberg et al., 2001; Simon et al., 2000)
13
Example:
Proportion of subjects with days lost, days impaired (or both) due
to mental health problems in pure and comorbid 12-month GAD
80
Days lost
% subjects having any
lost/impaired days
70
Days impaired
60
50,5
Total lost/impaired
67,8
55,4
52,5
50
40
30,7
31,5
30
20
14,9
13
6,5
10
6,8
5,4
0,7
0
No GAD/No MDD
GAD/No MDE
MDD/No GAD
GAD + MDD
Diagnostic comparison groups
Wittchen et al. (2002), International Clinical Psychopharmacology
Total number of disability days in the past month in the
population: Population attributable fraction of 12-month mental
and anxiety disorders
mental disorder
other than
anxiety 16%
any somatic
disorder
56%
any anxiety
disorder
25%
other
3%
PAF controlled for the presence of
other types of disorder
14
High – and overutilization
Number of doctor visits in the past 12-months by diagnostic status:
anxiety patients are high utilizers of health care resources
no mental disorder
6,9
any anxiety disorder
12,4
any mental disorder
10,0
OCD
18,8
specific phobia
12,1
social phobia
15,4
GAD
14,6
agoraphobia
16,1
panic disorder
19,1
0
4
8
12
16
20
But only a small proportion of excess utilization rates can be explained
by mental health care visits!
The total estimated cost of brain disorders in Europe by disease area
(€ PPP billion) Andlin-Sobocki et al 2005, modified)
All brain disorders:
Health care costs:
Direct non-medical
Indirect costs:
386.176 billion €
135.446 “
72.201 “
178.529 “
Mental disorders
Health care costs:
Direct non-medical
Indirect costs:
110.061
51.673
132.985
Addiction
Health care costs:
Direct non-medical
Indirect costs:
57.274
16.655
3.962
36.657
Affective disorders
Health care costs:
Direct non-medical
Indirect costs:
105.666
28.639
- NE77.027
Anxiety disorders
Health care costs:
Direct non-medical
Indirect costs:
41.373
22.072
-NE19.301
Psychotic disorders
Health care costs:
Direct non-medical
Indirect costs:
35.229
29.885
5.374
- NE-
mental disorders
294.719 billion
Neurological disorders
neurological
83.934
Health care costs:
Direct non-medical
Indirect costs:
21.286
20.259
42.389
Neurosurgical disorders
neurosurgical
7.523 billion
Health care costs:
Direct non-medical
Indirect costs:
4.099
269
3.155
Note: under-estimation (especially indirect costs)
15
Despite past limitations and vast variation with regard to the relative
contribution of cost components – good concordance across studies
Annual cost estimates for anxiety
Annual cost estimates for depression
Rice & Miller (1996): 46 billion $
Rice & Miller (1996): 31 billion $
DuPont et al. (1996): 47 billion $
DuPont et al (1996): 44 billion $
Greenberg et al. (1999): 42 billion $
Greenberg et al (1999): 53 billion $
(in 1998 costs: 63.1 billion $)
Andlin-Sobocki et al. (2005): 41 billion €
Andlin-Sobocki et al. (2005): 105 billion €
(including bipolar disorders)
The total health care and societal costs of anxiety disorders are
roughly the same as for depression
Additional effects of illnessillness-related life course changes with
adverse financial implications that have so far never been taken
into account in cost studies!
¾ under-estimation of (especially indirect) costs / Further “hidden costs” of untreated
anxiety disorders (e.g., Candilis & Pollack, 1997)
¾ Other indices not or only partially covered in these cost estimations:
• Subsequent unemployment (Etner et al., 1997; Leon et al., 1995; Yayakody et al., 1998)
• Work in under-payed jobs (Etner et al., 1997; Kessler & Greenberg, in press)
• Educational under-achievement (Kessler et al. 1995)
• Teen childbearing, marital timing and instability (Kessler et al. 1997, 1998)
16
Summary (2): The underestimated cost and burden
of anxiety disorders
burden as a function of…
prevalence
x
“active” time within an affected individual
X
cost per case
Summary (2): The underestimated cost and burden
of anxiety disorders
¾ prevalence: 1/4 of the population will suffer an anxiety disorder at least
once in their lifetime, ~15% are affected in any given year
¾ “active”
active” time within an affected individual: early onset, persistence
¾ cost:
cost: risk factor status, high degree of current and lifetime comorbidity
¾ cost (cont.):
cont.): extremely high indirect costs and relatively low direct costs
¾ despite burden:
burden: large degree of unmet needs of patients with anxiety
disorders (low treatment rates unless complex comorbid complications occur,
considerably delayed treatment, particularly low treatment rates in adolescents and
young adults)
Limitations: incomplete data base with regard to prevalence/incidence in the elderly and in children, incomplete costs
estimates, incomplete data for many countries, lack of data on sequential comorbidity, lack of data concerning burden
17
Summary (2): The underestimated cost and burden
of anxiety disorders
burden as a function of…
prevalence
x
“active” time within an affected individual
x
cost per case
Avoidable burden?
[email protected]
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