Read the full case study for 'A coping programme for family carers of people with dementia: economic evidence' here (HTML)
Martin Knapp, Klara Lorenz, Adelina Comas-Herrera, Gill Livingston, Michela Tinelli, Danielle Guy 2019

• what dementia is and how it affects people
• carer stress, how to recognise it and techniques for managing it
• how to manage difficult behaviour
• how to access support that is available for people with dementia and family carers
• maintaining skills learned and planning for the future.

Read the full case study for 'Peer-led self-management for people with severe mental health issues. A small-scale social care intervention: economic evidence' here (PDF)
Martin Knapp, Annette Bauer, Michela Tinelli, Danielle Guy 2019

Read the full case study for 'Person-centred support for people living with dementia in care homes: economic evidence' here (PDF)
Michela Tinelli, Renee Romeo, Martin Knapp, Danielle Guy 2019

KEY POINTS

• Almost all (95%) of the average cost of care home residence (£792 per week) is accounted for by room and board charges. Hospital contacts contribute the largest proportion of the additional healthcare costs. The absence of an association between cost and needs emphasizes the importance of a more needs-based service system which could result in clinical and economic advantages.
• Person-centred, integrated, and in-reach care home services responding to the needs of individual residents may improve health outcomes and quality of life at reasonable costs.
• Interventions providing good value for money, similar to the Wellbeing and Health for People with Dementia or Enhanced Care Home Outcomes interventions are good value for money.

An evaluation of peer-led self-management training for people with severe psychiatric diagnoses
Cyhlarova E, Crepaz-Keay D, Reeves R, et al Journal of Mental Health Training, Education and Practice, 10, 3-13. 2015

This Mental Health Foundation intervention runs for nine-months and involves workshops and peer-group meetings in which participants learn goal-setting and problem-solving techniques and have an opportunity to socialise and share experiences. Well-being, functional living skills, absences from work and use of health, social care and criminal justice services were measured for 262 participants at baseline, six months and three months post-intervention. The cost of the intervention was calculated to be £894 per person. We were unable to identify a suitable comparison group. For the intervention group, well-being and functional living skills improved over time. Costs associated with use of services over the first 6 months were on average £20 per week higher than at baseline. However, at three months post-intervention these were £62 per week lower than at baseline. If the intervention was responsible for 27 per cent of these identified savings, and if individuals using the service would not have experienced changes without it, then peer-led self-management could be considered cost-effective. Detailed findings have been published.

Autism Spectrum Disorder in Adults: Diagnosis and Management [CG142]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers diagnosing and managing suspected or confirmed autism spectrum disorder (autism, Asperger’s syndrome and atypical autism) in people aged 18 and over. It aims to improve access and engagement with interventions and services, and the experience of care, for people with autism.

In August 2016, 2 research recommendations were removed from this guideline.

Recommendations
This guideline includes recommendations on:

identification and assessment
interventions for autism
interventions for challenging behaviour
interventions for coexisting mental disorders
assessment and interventions for families, partners and carers
organising and delivering care
Who is it for?
Health and social care professionals (including those in the independent sector)
Commissioners and providers
Adults with autism and their families, partners and carers

Related NICE guideline:
APPENDIX 18:HEALTH ECONOMIC EVIDENCE – EVIDENCE TABLES OF PUBLISHED STUDIES Authors not listed

Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill-Health
McDaid D, Park A, Knapp M Public Health England, London. 2017

A return on investment resource to support local commissioners in designing and implementing mental health and wellbeing support services.

Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial.
Knapp M, King D, Romeo R, et al British Medical Journal, 347, f6342. 2013

Objective To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone.

Design Cost effectiveness analysis nested within a pragmatic randomised controlled trial.

Setting Three mental health and one neurological outpatient dementia service in London and Essex, UK.

Participants Family carers of people with dementia.

Intervention Eight session, manual based, coping intervention delivered by supervised psychology graduates to family carers of people with dementia added to usual treatment, compared with usual treatment alone.

Primary outcome measures Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score (HADS-T) of affective symptoms and quality adjusted life years (QALYs) in cost effectiveness analyses over eight months from baseline.

Results Of the 260 participants recruited to the study, 173 were randomised to the START intervention, and 87 to usual treatment alone. Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period (mean difference −1.79 (95% CI −3.32 to −0.33)), indicating better outcomes associated with the START intervention. There was a small improvement in health related quality of life as measured by QALYs (0.03 (−0.01 to 0.08)). Costs were no different between the intervention and usual treatment groups (£252 (−28 to 565) higher for START group). The cost effectiveness calculations suggested that START had a greater than 99% chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £30 000 per QALY gained, and a high probability of cost effectiveness on the HADS-T measure.

Conclusions The manual based coping intervention START, when added to treatment as usual, was cost effective compared with treatment as usual alone by reference to both outcome measures (affective symptoms for family carers, and carer based QALYs).

Cost-effectiveness analysis of a supported employment intervention for people with mood and anxiety disorders in Denmark - the IPS-MA intervention
Hellström L, Kruse M, Christensen TN, Trap Wolf R, Eplov LF. Cost-effectiveness analysis of a supported employment intervention for people with mood and anxiety disorders in Denmark - the IPS-MA intervention 2021

Cost-effectiveness of an Integrated Care Home Support Service in Oxfordshire, England.
Tsiachristas A, et al International Journal of Integrated Care, 17, 1-8. 2017

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure.

Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER).

Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves.

Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE’s threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%.

Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy’s law in the economic evaluation of complex interventions.

Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective.

Lessons learned: Evidence-based, integrated, and in-reach care home services improve health outcomes at reasonable costs. These value-for-money interventions can improve efficiency in elderly care and meet the complex needs of an rapidly increasing part of the population.

Limitations: The impact of the CHSS on quality of life is not included in the economic evaluation.

Suggestions for future research: Investigate whether the cost-effectiveness results are sustainable in time and replicable in other settings.

Early intervention for first‐episode psychosis: broadening the scope of economic estimates
Park A, McCrone P, Knapp M Early Intervention in Psychiatry, 10, 144-151. 2016

AIM:

To explore the economic impacts of early intervention in England on outcomes and costs for people with first-episode psychosis.
METHODS:

Three decision analytical models were constructed to compare treatment by early intervention for first-episode psychosis with standard care in relation to employment, education, homicide and suicide. Data on effectiveness and costs were taken from previous studies and expert opinion. Sensitivity analyses tested the robustness of assumptions.
RESULTS:

Our models indicate that early intervention demonstrates savings of £2087 per person over 3 years from improved employment and education outcomes. In addition, the annual costs over 10 years related to homicide after early intervention were £80 lower than for standard care. There were also annual savings of £957 per person for early intervention over 4 years compared to standard care as a result of suicides averted.
CONCLUSIONS:

Not only can investment in early intervention help reduce some of the long-term costs and consequences of mental disorders to the health-care system. In addition, there are broader economic benefits that strengthen the potential cost savings to society.

Economic analyses of supported employment programmes for people with mental health conditions: A systematic review
Park, A., Rinaldi, M., Brinchmann, B., Killackey, E., Aars, N., Mykletun, A., & McDaid, D. Economic analyses of supported employment programmes for people with mental health conditions: A systematic review 2022

Economic evaluation of a liaison psychiatry service
Parsonage M and Fossey M Centre for Mental Health, London. 2011

This report provides an independent economic evaluation of the Rapid Assessment Interface and
Discharge (RAID) psychiatric liaison service operating in City Hospital, Birmingham. It is based
mainly on a critical scrutiny and re-analysis of data collected as part of a wider internal review.
We conclude that the service generates significant cost savings and is excellent value for money.
Psychiatric liaison services provide mental health care to people being treated for physical health
conditions in general hospitals. The co-occurrence of mental and physical health problems is very
common among these patients, often leading to poorer health outcomes and increased health
care costs. An effective liaison psychiatry service offers the prospect of saving money as well as
improving health.
RAID is an award-winning service which offers comprehensive mental health support, available
24/7, to all people aged over 16 within the hospital.
The analysis of cost savings in the internal review of RAID focused on the ability of the service to
promote quicker discharge from hospital and fewer re-admissions, resulting in reduced numbers of
in-patient bed-days.
Based on a comparison of lengths of stay and rates of re-admission in similar groups of patients
before and after RAID was introduced in December 2009, in place of a previous, smaller liaison
service, the internal review estimated that cost savings are in the range of £3.4 – £9.5 million a year.
Most of these savings come from reduced bed use among elderly patients.
To allow for uncertainty in these estimates, we undertook a cost-benefit analysis of RAID based
on very conservative assumptions, seeking to address the question of whether the service is
demonstrably good value for money even if its claimed benefits are put at the bottom end of a
plausible range.
This should provide decision makers with a sound starting point for future planning, including the
review of possible options for service re-design.
Our analysis indicates that the incremental cost of RAID (i.e. the additional cost of the service
compared with its predecessor) is around £0.8 million a year. In comparison, we estimate on
conservative assumptions that RAID generates incremental benefits in terms of reduced bed use
valued at £3.55 million a year, implying a benefit:cost ratio of more than 4:1.
The service also offers some potential savings in addition to reductions in bed use, such as fewer
discharges of elderly patients to institutional care rather than their own homes.
We conclude that the RAID service is good value for money, particularly as the benefits included in
the assessment are over and above any improvements in health and quality of life which are the
fundamental justification for health spending. Unlike most health care interventions, RAID actually
saves money as well as improving the health and well-being of its patients.
We identify possible areas for further work at the end of the report.

Effective Interventions in Schizophrenia: The Economic Case
Andrew A, Knapp M, McCrone P Personal Social Services Research Unit, London. 2012

Making the business case for effective interventions for people with schizophrenia and psychosis

Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: randomised controlled trial
Coulton S, Clift S, Skingley A, et al British Journal of Psychiatry, 207, 250-255. 2015

Abstract
BACKGROUND:
As the population ages, older people account for a greater proportion of the health and social care budget. Whereas some research has been conducted on the use of music therapy for specific clinical populations, little rigorous research has been conducted looking at the value of community singing on the mental health-related quality of life of older people.

AIMS:
To evaluate the effectiveness and cost-effectiveness of community group singing for a population of older people in England.

METHOD:
A pilot pragmatic individual randomised controlled trial comparing group singing with usual activities in those aged 60 years or more.

RESULTS:
A total of 258 participants were recruited across five centres in East Kent. At 6 months post-randomisation, significant differences were observed in terms of mental health-related quality of life measured using the SF12 (mean difference = 2.35; 95% CI = 0.06-4.76) in favour of group singing. In addition, the intervention was found to be marginally more cost-effective than usual activities. At 3 months, significant differences were observed for the mental health components of quality of life (mean difference = 4.77; 2.53-7.01), anxiety (mean difference = -1.78; -2.5 to -1.06) and depression (mean difference = -1.52; -2.13 to -0.92).

CONCLUSIONS:
Community group singing appears to have a significant effect on mental health-related quality of life, anxiety and depression, and it may be a useful intervention to maintain and enhance the mental health of older people.

Evaluation of Integrated Personal Commissioning (IPC)
Thom G SQW Limited, London. 2018

The Department of Health has commissioned a summative evaluation of the Integrated Personal Commissioning (IPC) programme. The evaluation will be carried out by a consortium led by SQW, in partnership with Bryson Purdon Social Research (BPSR), Social Care Institute for Excellence (SCIE), the Social Policy Research Unit (SPRU) and the Centre for Health Economics (CHE) both at the University of York, and Mott MacDonald.

Integrated Personal Commissioning (IPC) was launched in April 2015. It is a partnership between NHS England and the Local Government Association.

IPC is an approach to joining up health and social care, and other services where appropriate. The purpose is to enable people, with help from carers and families, to combine the resources available to them in order to control their care. This is achieved through personalised care planning and personal budgets. IPC also aims to support people to develop the skills and confidence needed to self-manage their care in partnership with carers, the voluntary, community and social enterprise (VCSE) sector, community capacity and peer support.

Evaluation of the Rotherham Mental Health Social Prescribing Service 2015/16/-2016/17
Dayson C and Bennett E Centre for Regional Economic and Social Research, Sheffield. 2017

Updated findings of an independent evaluation of the Rotherham Social Prescribing Mental Health Service, a service to help users of secondary mental health services build their own packages of support by accessing voluntary activity in the community. Voluntary activities covered four broad themes: befriending and peer support, education and training, community activity groups and therapeutic services. The service was delivered in partnership by Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH) and a group of local voluntary sector organisations led by Voluntary Action Rotherham. The evaluation looks at the impact of the service on the well-being of service users, the wider outcomes and social benefits, the impact of the service on discharge from secondary mental health services and explores the potential economic benefits of the service. It reports that over the two years of the evaluation, the service had engaged with more than 240 users of secondary mental health services in Rotherham. The service made a significant and positive impact on the well-being of mental health service users, with more than 90 per cent of service users making progress against at least one wellbeing outcome measure. Service users also experienced a range of wider benefits, including taking part in training, volunteering, taking up physical activity and sustained involvement in voluntary sector activity. Initial evidence about discharge from mental health services was also positive. The evaluation estimates that the well-being benefits experienced by service users equate to social value of up to £724,000: a social return on investment of £1.84 for every £1 invested in the service.

Evidence and Initiatives for Integrating Personal Budgets for People with Mental Health Problems
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2014

Because integrating personal budgets is a relatively new initiative, evidence is still emerging about the impact they might have on people’s health and wellbeing.

However, evidence suggests that people with mental health problems can benefit significantly from having increased choice and control over their care, because their needs tend to cross boundaries between health and social care.

This section discusses some of the evidence from a recent evaluation of personal health budgets. It also describes some recent initiatives by government to promote the integration of services around an individual’s needs.

Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA)
Underwood M, Lamb SE, Eldridge S, et al Health Technology Assessment, 17, 1-281. 2013

Headline

Study finds no evidence to support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in elderly care home residents.
Abstract
Background:

Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population.
Objective:

To evaluate the impact of a ‘whole-home’ intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents.
Design:

A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison).
Setting:

Seventy-eight care homes in Coventry and Warwickshire and north-east London.
Participants:

Care home residents aged ≥ 65 years.
Interventions:

Control intervention: Depression awareness training programme for care home staff. Active intervention: A ‘whole-home’ exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group.
Main outcome measures:

Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death.
Results:

We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI −0.33 to 0.60) and depressed cohort (0.22, 95% CI −0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI −£655 to £1404); the mean difference in quality-adjusted life-year was −0.0014 (95% CI −0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly.
Conclusion:

The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents.
Trial registration:

Current Controlled Trials ISRCTN43769277.
Funding:

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.

Exploring the potential cost-effectiveness of a vocational rehabilitation program for individuals with schizophrenia in a high-income welfare society
Evensen S, Wisløff T, Lystad JU, Bull H, Martinsen EW, Ueland T, Falkum E. Exploring the potential cost-effectiveness of a vocational rehabilitation program for individuals with schizophrenia in a high-income welfare society 2019

Home Care in Dementia: Critical Components for Effectiveness
Challis D, Clarkson P, Sutcliffe C, et al Personal Social Services Research Unit, Manchester. 2019

Most people with dementia live in private households and promoting their wellbeing is a key policy objective. However, little is known about the most appropriate or effective forms of home care, taking into account the views of service users and their carers. Home care has become an area of increasing concern in recent years in terms of availability, quality, cost and effectiveness. This mixed methods study will investigate the effectiveness of home care for people with dementia. First, using data from an evidence synthesis of relevant literature, metrics relating to process and effectiveness will be calculated for specialist home care support for people with dementia, generic forms of home care and service receipt which is a mix of the two. Second, a naturalistic study will follow up people receiving different forms of home care over a 6-month period. Post-hoc analysis will estimate the relative effectiveness and cost by comparing each approach. Third, the views of carers about home care support to people with dementia will be canvassed using themes identified in the literature review. Data will be analysed both qualitatively and quantitatively. An established Public, Patient and Carer Involvement Group will contribute to the study.

Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis
Knapp M, Andrew A, McDaid D, et al Personal Social Services Research Unit and Centre for Mental Health, London. 2014

The health service spent £2.0 billion on services for people with psychosis in
2012/13. Over half (54%) of this total was devoted to inpatient care. This means
that spending is currently skewed towards the more expensive parts of the
system, at £350 average cost per day for inpatient care compared with £13
average cost per day in community settings.

Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis
Knapp M, Andrew A, McDaid D, et al Rethink Mental Illness, London. 2014

This study provides economic evidence to support the case for investing in effective, recovery-focused services for people with schizophrenia and psychosis. Drawing on a wide range of data, it sets out the evidence for the cost-effectiveness for a range of interventions and service. Those discussed are: Early Detection (ED) services; Early Intervention (EI) teams; Individual Placement and Support (IPS); Family therapy; Criminal justice liaison and diversion; Physical health promotion, including health behaviours; Supported housing; Crisis Resolution and Home Treatment (CRHT) teams; Crisis houses; Peer support; Self-management; Cognitive Behavioural Therapy (CBT); Anti-stigma and discrimination campaigns; Personal Budgets (PBs); and Welfare advice. For each intervention the report provides information on the context, the nature of the intervention, the evidence on effectiveness and cost-effectiveness, and the policy and practice implications. The report finds evidence to suggest that all of the interventions contribute to recovery outcomes, reduced costs and/or better value for money. Examples of the savings incurred through particular interventions are also included. The study was undertaken by a team from the Personal Social Services Research Unit (PSSRU), at the London School of Economics and Political Science (LSE), the Centre for Mental Health, and the Centre for the Economics of Mental and Physical Health (CEMPH) at King’s College London.

Is integrated care associated with service costs and admission rates to institutional settings? An observational study of community mental health teams for older people in England
Wilberforce M, Tucker S, Brand C, et al International Journal of Geriatric Psychiatry, 31, 11, 1208-1216. 2016

Objectives:To evaluate the association between the degree of integration in community mental healthteams (CMHTs) and: (i) the costs of service provision; (ii) rates of mental health inpatient and carehome admission.Methods:An observational study of service use and admissions to institutional care was undertaken for aprospectively-sampled cohort of patients from eight CMHTs in England. Teams were chosen to repre-sent‘high’or‘low’levels of integrated working practice and patients were followed-up for seven months.General linear models were used to estimate service costs and the likelihood of institutional admission.Results:Patients supported by high integration teams received services costing an estimated 44% morethan comparable patients in low integration teams. However, after controlling for case mix, no signif-icant differences were found in the likelihood of admission to mental health inpatient wards or carehomes between team types.Conclusions:Integrated mental health and social care teams appeared to facilitate greater access tocommunity care services, but no consequent association was found with community tenure. Furtherresearch is required to identify the necessary and sufficient components of integrated community men-tal health care, and its effect on a wider range of outcomes using patient-reported measures.

Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomized, controlled trial
Livingston G, Barber J, Rapaport P Lancet Psychiatry, 1, 539-548. 2014

Background Two-thirds of people with dementia live at home supported mainly by family carers. These carers
frequently develop clinical depression or anxiety, which predicts care breakdown. We aimed to assess the clinical
eff ectiveness (long-term reduction of depression and anxiety symptoms in family carers) and cost-eff ectiveness of a
psychological intervention called START (STrAtegies for RelaTives).
Methods We did a randomised, parallel-group trial with masked outcome assessments in three UK mental-health
services and one neurological-outpatient dementia service. We included self-identifi ed family carers of people with
dementia who had been referred in the previous year and gave support at least once per week to the person with
dementia. We randomly assigned these carers, via an online computer-generated randomisation system from an
independent clinical trials unit, to either START, an 8-session, manual-based coping intervention delivered by
supervised psychology graduates, or treatment as usual (TAU). The primary long-term outcomes were aff ective
symptoms (Hospital Anxiety and Depression Scale total score [HADS-T]) 2 years after randomisation and costeff ectiveness (health and social care perspectives) over 24 months. Analysis was by intention to treat, excluding
carers with data missing at both 12 and 24 months. This trial is registered ISCTRN70017938.
Findings From November 4, 2009, to June 8, 2011, we recruited 260 carers. 173 carers were randomly assigned to
START and 87 to TAU. Of these 260 participants, 209 (80%) were included in the clinical effi cacy analysis
(140 START, 69 TAU). At 24 months, compared with TAU the START group was signifi cantly better for HADS-T
(mean diff erence –2·58 points, 95% CI –4·26 to –0·90; p=0·003). The intervention is cost eff ective for both carers
and patients (67% probability of cost-eff ectiveness at the £20 000 per QALY willingness-to-pay threshold, and 70%
at the £30 000 threshold).
Interpretation START is clinically eff ective, improving carer mood and anxiety levels for 2 years. Carers in the
control TAU group were seven times more likely to have clinically signifi cant depression than those receiving
START. START is cost eff ective with respect to carer and patient outcomes, and National Institute for Health and
Care Excellence (NICE) thresholds. The number of people with dementia is rapidly growing, and policy
frameworks assume that their families will remain the frontline providers of (unpaid) support. This cost-neutral
intervention, which substantially improves family-carers’ mental health and quality of life, should therefore be
widely available.

Maintenance Cognitive Stimulation Therapy (CST) for dementia: a single-blind, multi-centre, randomized controlled trial of Maintenance CST vs. CST for dementia
Aguirre E, Spector A, Hoe J, et al Trials, 11, 46-46. 2010

Background: Psychological treatments for dementia are widely used in the UK and internationally, but only rarely have they been standardised, adequately evaluated or systematically implemented. There is increasing recognition that psychosocial interventions may have similar levels of effectiveness to medication, and both can be used in combination. Cognitive Stimulation Therapy (CST) is a 7-week cognitive-based approach for dementia that has been shown to be beneficial for cognition and quality of life and is cost-effective, but there is less conclusive evidence for the effects of CST over an extended period.; Methods/design: This multi-centre, pragmatic randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of Maintenance CST groups for dementia compares a intervention group who receive CST for 7 weeks followed by the Maintenance CST programme once a week for 24 weeks with the control group who receive CST for 7 weeks, followed by treatment as usual for 24 weeks.The primary outcome measures are quality of life of people with dementia assessed by the QoL-AD and cognition assessed by the ADAS-Cog. Secondary outcomes include the person with dementia’s mood, behaviour, activities of daily living, ability to communicate and costs; as well as caregiver health-related quality of life. Using a 5% significance level, comparison of 230 participants will yield 80% power to detect a standardised difference of 0.39 on the ADAS-Cog between the groups. The trial includes a cost-effectiveness analysis from a public sector perspective.; Discussion: A pilot study of longer-term Maintenance CST, offering 16 weekly sessions of maintenance following the initial CST programme, previously found a significant improvement in cognitive function (MMSE) for those on the intervention group. The study identified the need for a large-scale, multi-centre RCT to define the potential longer-term benefits of continuing the therapy. This study aims to provide definitive evidence of the potential efficacy of maintenance CST and establish how far the long-term benefits can be compared with antidementia drugs such as cholinesterase inhibitors.

Making the Case for Public Health Interventions: Public Health Spending and Return on Investment
King's Fund, Local Government Association King's Fund and Local Government Association, London. 2014

These infographics from the King’s Fund and the Local Government Association set out key facts about the public health system and the return on investment for some public health interventions. They show the changing demographics with a growing ageing population and the impact of social and behavioural determinants on people’s health. The document also highlights the costs of key health and social services and estimates the potential returns on investment on preventative interventions. For instance, Birmingham’s Be Active programme of free use of leisure centres and other initiatives returned an estimated £23 in quality of life, reduced NHS use and other gains for every £1 spent. Every £1 spent on improving homes saves the NHS £70 over 10 years. Befriending services have been estimated to pay back around £3.75 in reduced mental health service spending and improvements in health for every £1 spent. Every £1 spent on drugs treatment saves society £2.50 in reduced NHS and social care costs and reduced crime.

Making the Long-Term Economic Case for Investing in Mental Health to Contribute to Sustainability
McDaid D European Union, Brussels. 2011

Poor mental health has a significant economic impact on the health system and the wider economy
in Europe, with implications for the potential achievement of the Europe 2020 strategy on economic
growth. This brief primer considers what is known about the potential short, mid and longer term
economic benefits of actions across the life course focused on mental health promotion, mental
disorder prevention and early intervention. Actions that can be undertaken both within and external
to the mental health system are highlighted, drawing on recent economic analyses prepared in a UK
context, supplemented by data from other parts of Europe and elsewhere.
There is considerable variation in the strength of the evidence base and in the time period required
to achieve a return on investment. The most attractive actions include early actions in childhood
which can have substantial benefits that last well into adulthood, as well as interventions to promote
health in workplaces. Improved job retention rates reduce the need to pay social welfare payments
related to employment and disability. Workplace health promotion activities might also reduce the
risk of early retirement due to poor mental health.
Economic restructuring is not just associated with the current economic climate it is a constant
activity; there may also be interest in interventions to strengthen the mental health and resilience of
those who have been made unemployed or are at risk of unemployment or enforced change of role
at work. Loss of job, or downsizing of role have been associated with a reduction in mental health;
again early actions can reduce the risks of these events and their resource consequences for health
care systems.
Other activities examined here include tackling post natal depression, reducing the risk of suicide,
early identification of psychosis, promoting the mental health of older people, the use of debt and
financial advice services, tackling chronic co-morbid physical and mental health problems, and
addressing the issue of medically unexplained systems.

Mental Health of Adults in Contact with the Criminal Justice System [NG66]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2017

This guideline covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system. It aims to improve mental health and wellbeing in this population by establishing principles for assessment and management, and promoting more coordinated care planning and service organisation across the criminal justice system.

Also see NICE’s guideline on physical health of people in prison, which covers mental health assessment for the prison population as part of the first-stage health assessment for people going into prison, and continuity of mental health care for people leaving prison.

Recommendations
This guideline includes recommendations on:

assessing and managing a person’s mental health problems, including assessing risk to themselves and others
planning their care
psychological and pharmacological interventions
how services should be organised
staff training
Who is it for?
Commissioners and providers of health and justice services
All health and social care professionals working with adults in contact with the criminal justice system in community, primary care, secondary care and secure settings
Adults in contact with the criminal justice system who have or may have mental health problems

Related NICE guideline:
Appendix T: Health economic evidence – economic profiles Authors not listed

Mental Health Problems in People with Learning Disabilities: Prevention, Assessment and Management [NG54]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers preventing, assessing and managing mental health problems in people with learning disabilities in all settings (including health, social care, education, and forensic and criminal justice). It aims to improve assessment and support for mental health conditions, and help people with learning disabilities and their families and carers to be involved in their care.

Recommendations
This guideline includes recommendations on:

organising and delivering care
involving people in their care
prevention, including social, physical environment and occupational interventions
annual GP health checks
assessment
psychological interventions, and how to adapt these for people with learning disabilities
prescribing, monitoring and reviewing pharmacological interventions
Who is it for?
Healthcare professionals
Social care practitioners
Care workers
Education staff
Commissioners and service providers
People with learning disabilities and their families and carers

Related NICE guideline:
Appendix S: Health economic evidence –economic profiles Authors not listed

Mental Health Promotion and Mental Illness Prevention: The Economic Case
Knapp M, McDaid D, Parsonage M Personal Social Services Research Unit, London. 2011

Mental ill health is the largest single cause of disability in the UK, contributing almost 23% of the overall burden of disease compared to about 16% each for cancer and cardiovascular disease. The economic and social costs of mental health problems in England are estimated at around £105 billion each year.

Money Matters: Reviews of Cost-effective Initiatives
Institute of Public Care The Institute for Research and Innovation in Social Services, Glasgow. 2011

This set of eight case studies, produced by the Institute of Public Care on behalf of IRISS (the Institute for Research and Innovation in Social Services), provides detailed analysis of the cost-effectiveness of a series of recent social care initiatives, ranging from nationwide and relatively high-profile schemes such as individual budgets to those thus far unique to one country, city or local authority area in the UK.

In each case, the report provides an overview of the initiative – its origins, including previous variants of the scheme, who it is intended to help, and how it works in practice – before justifying claims of cost-effectiveness by reference to detailed comparative costings, using one illustrative implementation of the scheme where the initiative is nationwide. Based on the analysis, the report sets out the initiative’s applicability to other settings as well as potential impediments to broader implementation.

The eight initiatives scrutinised are:

A study of Shared Lives schemes in south east England for providing care in the carer’s own home for individuals placed there by the local authority.
An extra-care housing scheme completed in Bradford.
Health in mind – social inclusion support for people with mental health needs in Bradford based round a series of mental health “well-being cafes”.
LinkAge Plus – analysis of nationwide DWP-funded pilot schemes for an holistic approach to provision of services for older people.
The Rapid Response Adaptations Programme – a Welsh initiative for providing adaptations such as ramps to let people return to their own homes.
A project in north west England to guide older people with low-level needs through a self-assessment process.
Analysis of various pilot sites taking different approaches to individual budgets, based on a broader evaluation conducted in 2008.
A project in two acute trusts in London to reconfigure hospital discharge procedures to emphasise rehabilitation.

No Health without Mental Health: A Cross Government Mental Health Outcomes Strategy for People of all Ages
Department of Health and Social Care Department of Health, London. 2011

This reports sets out 6 objectives to improve mental health, wellbeing and outcomes for people with mental health problems.

Older People: Independence and Mental Wellbeing [NG32]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older and how to identify those most at risk of a decline.

Recommendations
The guideline includes recommendations on:

principles of good practice
group-based activities
one-to-one activities
volunteering
identifying people most at risk of a decline
Who is it for?
Local authorities working in partnership with organisations in the public, private, voluntary and community sectors that come into contact with older people
The NHS and other service providers with a remit for older people
It may also be of interest to older people, their families and carers
Commissioners of services for older people should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Independence and mental wellbeing (including social and emotional wellbeing) for older people Economic analysis Mallender J, Pritchard C, Tierney R, et al

Peer Support for People with Dementia: A Social Return on Investment (SROI) Study
Semple A, Willis E, de Waal H Health Innovation Network, London. 2015

Reports on a study using Social Return on Investment (SROI) analysis to examine the impact and social value of peer support groups as an intervention for people with dementia. Three peer support groups in South London participated in the study. A separate SROI analysis was carried out for each individual group to find out what people valued about the groups and how they helped them. The report presents the outcomes for each group, the indicators for evidencing these outcomes and the quality and duration of outcomes experienced. It then provides detail on the methodology used to calculate the impact and the social return on investment. Overall, the study found that peer support groups provide positive outcomes for people with dementia, their carers and the volunteers who support the groups. The benefits of participating in peer support groups included: reduced isolation and loneliness; increased stimulation, including mental stimulation; and increased wellbeing. Carers experienced a reduction in carer stress, carer burden and reduction in the feeling of loneliness. Volunteers had an increased sense of wellbeing through their engagement with the group, improved knowledge of dementia and gained transferrable skills. Overall the study found that for every pound (£) of investment the social value created by the three groups evaluated ranged from £1.17 to £5.18.

Peer Support in Mental Health Care: Is it Good Value for Money?
Trachtenberg M, Parsonage M, Shepherd G Centre for Mental Health, London. 2013

Peer support workers – people with their own lived experience of mental illness – provide mutually supportive relationships in secondary mental health services. Increasing numbers are being employed, both in this country and elsewhere.

This paper makes a first attempt at assessing whether peer support provides value for money, looking specifically at whether peer support workers can reduce psychiatric inpatient bed use. Because of the very high cost of inpatient care, the savings that result from even small changes in bed use may be sufficient to outweigh the costs of employing peer workers.

People Powered Recovery: Social Action and Complex Needs. Findings from a Call for Evidence
Turning Point All-Party Parliamentary Group on Complex Needs and Dual Diagnosis, London. 2018

The UK All-Party Parliamentary Group (APPG) on complex needs and dual diagnosis was established in 2007 in recognition of the fact that people seeking help often have a number of over-lapping needs including problems around access to housing, social care, unemployment services, mental health provision or substance misuse support. This report sets out the findings from a call for evidence on how social action can improve outcomes and develop more responsive services for people with complex needs or a dual diagnosis. Social action is about people coming together to tackle an issue, support others or improve their local area, by sharing their time and expertise through volunteering, peer-led groups and community projects. The report provides examples of how social action can support recovery, self-worth and confidence, boost employment prospects and skills, reduce stigma, better shape services to meet people’s needs, contribute to better health and wellbeing and save money. It also looks at how to overcome some of the challenges and barriers to developing social action focused around complex needs. These include resources, stigma, procedural issues, leadership, commissioning structures and demonstrating benefits.

Prevention. A Shared Commitment: Making the Case for a Prevention Transformation Fund
Local Government Association Local Government Association, London. 2015

This document identifies and collates key pieces of evidence about the cost effectiveness of prevention in order to make the case for greater investment in prevention interventions. The report recommends that the Government should introduce a Prevention Transformation Fund, worth at least £2 billion annually. This would enable some double running of new investment in preventative services alongside ‘business as usual’ in the current system, until savings can be realised and reinvested into the system – as part of wider local prevention strategies. Based on the analysis of an extensive range of intervention case studies that have provided a net cost benefit, the report suggests that investment in prevention could yield a net return of 90 per cent.

Promoting Health, Preventing Disease: Is There an Economic Case?
Merkur S, Sassi F, McDaid D European Observatory on Health Systems and Policies, Denmark. 2013

A core question for policy-makers will be the extent to which investments
in preventive actions that address some of the social determinants of health
represent an effi cient option to help promote and protect population health.
Can they reduce the level of ill health in the population? How strong is the
evidence base on their effectiveness and, from an economic perspective,
how do they stack up against investment in the treatment of health problems?
Are there potential gains to be made by reducing or delaying the need for the
consumption of future health care resources? Will they limit some of the wider
costs of poor health to society, such as absenteeism from work, poorer levels of
educational attainment, higher rates of violence and crime and early retirement
from the labour force due to sickness and disability?
This policy summary provides an overview of what is known about the economic
case for investing in a number of different areas of health promotion and
non-communicable disease prevention. It focuses predominantly on addressing
some of the risk factors for health: tobacco and alcohol consumption, impacts
of dietary behaviour and patterns of physical activity, exposure to environmental
harm, risks to mental health and well-being, as well as risks of injury on
our roads.
It highlights that there is an evidence base from controlled trials and welldesigned observational studies on the effectiveness of a wide range of health
promotion and disease prevention interventions that address risk factors to
health. Moreover, the cost–effectiveness of a number of health promotion and
disease prevention interventions has been shown in multiple studies. Some of
these interventions will be cost-saving, but

REMCARE: reminiscence groups for people with dementia and their family caregivers? Effectiveness and cost-effectiveness pragmatic multicentre randomised trial
Woods R et al Health Technology Assessment, 16, 1-121. 2012

Abstract
OBJECTIVES:
The aim of the REMiniscence groups for people with dementia and their family CAREgivers (REMCARE) study was to assess the effectiveness and cost-effectiveness of joint reminiscence groups for people with dementia and their family caregivers as compared with usual care.

DESIGN:
A multicentre, pragmatic randomised controlled trial with two parallel arms – an intervention group and a usual-care control group – was carried out. A restricted dynamic method of randomisation was used with an overall allocation ratio of 1 : 1, restricted to ensure intervention groups of a viable size. Assessments, blind to treatment allocation, were carried out at baseline, 3 months and 10 months (primary end point).

SETTING:
Most participants were recruited through NHS Memory Clinics and Community Mental Health Teams for older people. Assessments were usually carried out in the person’s home, and treatment groups were held in a variety of community settings.

PARTICIPANTS:
A total of 488 individuals (mean age 77.5 years) with mild to moderate dementia (meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria), who were initially living in the community, and who had a relative or other caregiver maintaining regular contact, who could act as an informant and was willing and able to participate in the intervention, were recruited to the study. Most carers were spouses (71%). A total of 350 dyads completed the study.

INTERVENTIONS:
The intervention consisted of joint reminiscence groups held weekly for 12 consecutive weeks, followed by monthly maintenance sessions for a further 7 months. The sessions followed a treatment manual, and were led by two trained facilitators in each centre, supported by a number of volunteers. Up to 12 dyads were invited to attend each group.

MAIN OUTCOME MEASURES:
The primary outcome measures were self-reported quality of life for the person with dementia and psychological distress for the carer [General Health Questionnaire-28 item version (GHQ-28)]. Secondary outcome measures included autobiographical memory and activities of daily living for the person with dementia, carer stress for the carer and mood, relationship quality and service use and costs for both parties.

RESULTS:
The intention-to-treat analysis identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes [self-reported quality of life in Alzheimer’s disease: mean difference 0.07, standard error (SE) 0.65; F = 0.48; p = 0.53]. Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a subscale of the GHQ-28 at the 10-month end point (mean difference 1.25, SE 0.5; F = 8.28; p = 0.04). Compliance analyses suggested some benefits for people with dementia who attended more reminiscence sessions; however, carers attending more groups showed increased caregiving stress. Use of health- and social-care services was modest, with no significant difference in service use between conditions. Owing to negligible difference in quality-adjusted life-year gains (derived from European Quality of Life-5 Dimensions) between the conditions the planned full economic analysis was curtailed.

CONCLUSIONS:
This trial does not provide support for the effectiveness or cost-effectiveness of joint reminiscence groups for people with dementia and their carers. Although there may be some beneficial effects for people with dementia who attend sessions as planned, this must be viewed in the context of raised anxiety and stress in their carers. The reasons for these discrepant outcomes need to be explored further, and may necessitate reappraisal of the movement towards joint interventions.

TRIAL REGISTRATION:
Current Controlled Trials ISRCTN42430123.

FUNDING:
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 48. See the HTA programme website for further project information.

Report of the Annual Social Prescribing Network Conference
Social Prescribing Network Social Prescribing Network, University of Westminster, London. 2016

Report of the annual social prescribing network conference, which sets out a definition of social prescribing, outlines principles for effective service provision and the steps needed to evaluate and measure the impact of social prescribing. It also includes an analysis of a pre-conference survey, completed by 78 participants to explore their experience of social prescribing. Key ingredients identified that underpin social prescribing included: funding, healthcare professional buy-in, simple referral process, link workers with appropriate training, patient centred care, provision of services, patient buy-in and benefits of social prescribing. The benefits of social prescribing fell into six broad headings: physical and emotional health and wellbeing; behaviour change; cost effectiveness and sustainability; capacity to build up the voluntary community; local resilience and cohesion; and tackling the social determinants of ill health. Afternoon sessions covered the following topics: obtaining economic data on social prescribing; engaging different stakeholders in social prescribing; standards and regulations that could be applied to social prescribing services; qualities and skills necessary to commission high quality social prescribing services; designing research studies on social prescribing. Short case studies are included. There was consensus from participants that social prescribing provides potential to reduce pressures on health and care services through referral to non-medical, and often community-based, sources of support.

Supported employment: cost-effectiveness across six European sites
Knapp M, Patel A, Curran C, et al World Psychiatry, 12, 1, 60-68. 2013

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support (IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n=312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment.

The economics of housing and health: The role of housing associations
Buck D, Simpson M, Ross S King's Fund, London. 2016

This report, based on work commissioned by the National Housing Federation from The King’s Fund and the New NHS Alliance, looks at the economic case for closer working between the housing and health sectors. The authors demonstrate how housing associations provide a wide range of services that produce health benefits, which can both reduce demand on the NHS and create social value.

The report concludes that there is no one piece of economic analysis that will persuade health providers or commissioners to work with or commission housing associations. However, the case studies in the report illustrate the economic benefits that housing association can provide through:

providing safe, decent homes that enhance wellbeing. This has health impacts that are valued, and can save the NHS money
alleviating the overall cost burden of illness and treatment
helping to offset and reduce costs of delivering health care to individuals
demonstrating cost-effectiveness in helping to meet the objectives of the NHS and of improving health more broadly
demonstrating the cost–benefits of their interventions in terms of the value of improvements to people’s health and savings to the NHS.
The report is one of a set of three commissioned by the National Housing Federation; the second report focuses on how housing associations can develop a business case that will be better understood by the health sector and the third explores how the health and housing sectors differ in their approach, language and terminology, roles, and use of evidence.

The effect of telecare on the quality of life and psychological well-being of elderly recipients of social care over a 12-month period: the Whole Systems Demonstrator cluster randomised trial
Hirani SP, Beynon M, Cartwright M Age and Ageing, 43, 334-341. 2013

Abstract
BACKGROUND:
home-based telecare (TC) is utilised to manage risks of independent living and provide prompt emergency responses. This study examined the effect of TC on health-related quality of life (HRQoL), anxiety and depressive symptoms over 12 months in patients receiving social care.

DESIGN:
a study of participant-reported outcomes [the Whole Systems Demonstrator (WSD) Telecare Questionnaire Study; baseline n = 1,189] was nested in a pragmatic cluster-randomised trial of TC (the WSD Telecare trial), held across three English Local Authorities. General practice (GP) was the unit of randomisation and TC was compared with usual care (UC).

METHODS:
participant-reported outcome measures were collected at baseline, short-term (4 months) and long-term (12 months) follow-up, assessing generic HRQoL, anxiety and depressive symptoms. Primary intention-to-treat analyses tested treatment effectiveness and were conducted using multilevel models to control for GP clustering and covariates for participants who completed questionnaire measures at baseline assessment plus at least one other assessment (n = 873).

RESULTS:
analyses found significant differences between TC and UC on Short Form-12 mental component scores (P < 0.05), with parameter estimates indicating being a member of the TC trial-arm increases mental component scores (UC-adjusted mean = 40.52; TC-adjusted mean = 43.69). Additional significant analyses revealed, time effects on EQ5D (decreasing over time) and depressive symptoms (increasing over time). CONCLUSIONS: TC potentially contributes to the amelioration in the decline in users' mental HRQoL over a 12-month period. TC may not transform the lives of its users, but it may afford small relative benefits on some psychological and HRQOL outcomes relative to users who only receive UC. International Standard Randomised Controlled Trial Number Register: ISRCTN 43002091.

The Social and Economic Costs of Mental Health Problems in Scotland
Scottish Association for Mental Health Scottish Association for Mental Health, Glasgow. 2011

In 2006, the Scottish Association for Mental Health published a report, What’s It Worth?, which presented high-level estimates of the social and economic costs of mental health problems in Scotland for the year 2004/05.

What’s it Worth Now? updates the estimates of social and economic costs given in that publication, with a particular focus on the employment-related costs of mental ill health, both in work and out of work. The report also reviews the main policies, interventions and other actions that the available evidence shows to be effective in reducing the scale of these work-related costs.

Transition Between Inpatient Mental Health Settings and Community or Care Home Settings [NG53]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers the period before, during and after a person is admitted to, and discharged from, a mental health hospital. It aims to help people who use mental health services, and their families and carers, to have a better experience of transition by improving the way it’s planned and carried out.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
This guideline includes recommendations on:

overarching principles for good transition
planning for admission and discharge
out-of-area admissions
support for families and carers
Who is it for?
Providers of care and support in inpatient and community mental health and social care services
Front-line practitioners and managers in inpatient and community mental health and social care services
Commissioners of mental health services
People who use inpatient and community mental health services, their families and carers

Related NICE guideline:
Economics, economic modelling, appendix C3.2 Cost–utility analysis of a 2-year multi-staged psychological intervention for bipolar I patients with their first, second or third hospitalisation vs Generic outpatient treatment of bipolar affective disorders (active treatment as usual) Trachtenberg M and Knapp M