Just as the brain is a highly complex organ, analyzing the impact of brain disorders – medically, socially and economically – is by no means a simple task. A new report from the European Brain Council cuts through the complexity to clarify the societal costs of brain disorders (1).
The societal burden of brain disorders is immense, and should be considered one of the 21st century’s top global health challenges. This is one of the main conclusions of a new report on
the extent and costs of mental and neurological diseases. The report is based on a study that was coordinated by the European Brain Council (EBC) and the European College of Neuropsychopharmacology (ECNP) and is an update of an earlier report from 2005.
The 2011 report is the latest to provide consolidated data on the current scope and costs of brain disorders across Europe (2), and the numbers are staggering. It is estimated that the direct and indirect 2010 costs of brain disorders in Europe totalled EUR 798 billion, and that more than a third of the population, corresponding to 164.8 million people, were affected. Out of the total 2010 direct health care expenditures in Europe, EUR 1,260 billion, the direct costs of brain disorders represented a full 24 per cent.
But brain disorders are not only a European challenge. US data point to a situation just as serious as Europe’s, and the World Economic Forum concluded in a separate 2011 report that the developing world will be increasingly burdened by disorders of the brain as their economies continue to grow and their populations continue to age. A case in point is China, where mental disorders have recently overtaken heart disease and cancer as the single largest strain on the Chinese health care budget.
Bengt Jönsson, professor of Health Economics at the Stockholm School of Economics, co-authored the report and also sat on the EBC steering committee responsible for the analysis. He admits to being surprised by the scope of the problem and how much work still lies ahead before a comprehensive understanding of the real costs of brain disorders to society has been gained. Nonetheless, he stresses that the estimates in the report are very conservative and that the actual costs are probably even higher.
“Despite the facts that we have improved data and that we have included new diseases compared to the last report in 2005, my main reflection is that we still have a lot of work ahead of us before we have the full picture of the scope, costs and burden of brain disorders,” he says.
Numbers make it tangible
Bengt Jönsson explains that one of the key objectives of the EBC report is to express the burden of brain disorders in economic terms so that politicians, authorities and the man on the street can grasp the extent of the costs in tangible terms. The numbers cut through the complexity and make the intangible tangible.
“A prerequisite for a constructive discussion about a disease and the burden it places on society is a common understanding of the scope and size of the problem. This has been missing – and is to some extent still missing – in the area of brain disorders. The epidemiological data available simply have not been of a standard that has allowed us to see the whole picture. This means that the concept of brain disorders and talking about them as an entity is still a new one.”
“By considering the costs of all resources used or lost due to the diseases,” Bengt Jönsson explains, “irrespective of who the payer is, we are hoping to see the problem as a whole and get a sense of its magnitude. Otherwise we cannot start coming up with solutions and answers,” says Bengt Jönsson.
And it is clear that solutions and answers are urgently required. In addition to their massive economic consequences, brain disorders also place heavy personal burdens on patients. The distress associated with coming to terms with a diagnosis, not being able to carry out one’s usual activities, and struggling with for instance darkness and sadness, all contribute significantly to the burden of brain disorders.
Huge indirect costs
Of all costs associated with brain disorders, 40 per cent are indirect costs and are attributed to lost production due to work absence or early retirement. Simply put, these indirect costs are a measurement of wasted human potential and resources. In comparison, only 30 per cent of total costs are direct health care costs; among other things, these comprise physicians’ visits, hospitalizations and pharmaceuticals. The remaining 30 per cent are direct nonmedical costs, including social services, special accommodations and informal care.
According to Bengt Jönsson, the analysis places the actual costs of brain disorders in a wider context. “A very small part of the burden of brain disorders is actually on the health care system,” he says. “That forces us to apply a broader perspective; we need to look not only at what we are spending, but also at the resources we are losing.” He points to the importance of spending money wisely. “Well-conceived programmes that increase spending on prevention and improved treatment can reduce total costs. Conversely, poorly designed cost containment policies can increase total costs.”
The inability to lead productive lives, which many patients face as a result of their diagnoses, is not the only loss of resources caused by brain disorders. The time and resources that family members have to spend in order to compensate for and help with the consequences of brain disorders must also be considered.
“The fact is that family and relatives carry a major burden in managing these diseases,” Bengt Jönsson asserts. “Alzheimer’s disease and other types of dementia are obvious examples. Patients with these diseases have limited contact with the health care system, but are to a large extent taken care of by families, friends or even members of the local community. We need to acknowledge this unequal distribution of the burden. We must recognize that if family and relatives did not carry this huge part of the load, and instead left it for the rest of society to handle, there would be an enormous increase in public expenditures on these diseases. An increase we simply would not be able to afford.”
Be smarter and work smarter
According to Bengt Jönsson, the EBC report will ideally serve as both a wakeup call, making clear the current burden of brain disorders in Europe, and also as a reminder of the challenges ahead. “Given Europe’s current financial and demographic conditions, we cannot expect an increase in the resources available to deal with brain disorders. So we have to be smarter and work smarter with the resources available to us today,” says Bengt Jönsson.
“As an economist,” he continues, “I have been working with a number of diseases and their economic impact throughout my career. And what really strikes me about brain disorders is how little we still know about the brain and the appalling lack of effective treatments. So, we are of course in great need of new and better treatments. This is the real prerequisite for progress and impact in the area of brain disorders.”
An optimistic pessimist
Bengt Jönsson is both optimistic and pessimistic about the possibilities of progress. “I think we have every opportunity to make changes for the better, and that we are to some extent on the right track. I believe it is realistic to expect improvements in anumber of disease areas in the coming years.” He points to depression in particular as an area in which improvements can be made: “We can be better at diagnosing and treating patients with depression, and hence reduce the costs associated with the disease. Depression is a very common disease, and many patients are treated in primary care by local General Practitioners. But knowledge of the disease and its treatments varies enormously across Europe. If we can establish best prac-tices in most places, this would be a fantastic achievement that would improve the lives of millions of patients suffering from depression. And this is not a cost issue; it is a matter of building competencies and being well organized.”
“Europe is not the only place where there is room for improvement,” he points out. “Depression is also an area where it is possible to develop cost-effective treatment alternatives in countries with middle and low incomes.”
While Bengt Jönsson remains optimistic concerning progress in specific disease areas, pessimism still rules his views of the overall development of brain disorder costs in the coming years. He believes an increase in the costs of brain disorders is the most realistic scenario when the next EBC report is published in 2016.
“First, because we will witness increased incidence and prevalence. With ageing populations, we will simply have more people being affected by disorders of the brain. Second, the progress made in the treatment of brain disorders is rather limited. We might be moving in the right direction, but we are moving slowly.” As a third reason, Bengt Jönsson points to the growth of “new“ brain disorders related to social behaviour such as bulimia, anorexia, ADHD and hyperactivity in young children. “We still do not understand these diseases or what explains the increase in the number of persons diagnosed. But realistically, these diseases will add to the burden.”
Progress is possible
Armed with more than 30 years of experience in the field of health economics, the Swedish professor is nonetheless convinced that progress is always possible.
“When I started my career in the 1970s in Sweden, one of the major reasons for people failing to show up for work was ulcers. But with the development of new medicines, we were able to treat and cure this disease, and ulcers no longer keep people from living a normal life. Later on in the 1980s and 1990s it was back pain and back trouble that kept people at home. We did not find a cure for back pain, but we did become much more knowledgeable about this area and discovered measures that could improve the quality of life for these patients – including how to get them back to work. The prevention and treatment of cardiovascular diseases is another area in which medical progress has reduced productivity costs in recent decades. What we see now is that the
major reason why people have to give up working is mental diagnoses – anxiety, depression, etc.,” says Bengt Jönsson.
“We have begun taking the initial steps of understanding how do deal with this challenge. And I believe we will be successful. Our knowledge and understanding of the brain are expanding all the time, and in both human and economic terms we simply cannot afford not to improve. I believe we will. We are on the right track.”
- Lundbeck has given an unrestricted grant to the preparation of the report, but has had no further role in the study design, collection of data, analysis, interpretation or the preparation of the manuscript.
- The study was conducted for all countries in the European Union (EU27) and Iceland, Norway and Switzerland.
- Gustavsson et al. – Cost of disorders of the brain in Europe 2010.
European Neuropsychopharmacology, 2011.
- World Economic Forum and the Harvard School of Public Health –
The Global Economic Burden of Non-communicable Diseases, 2011.
Bengt Göran Jönsson
Professor, PH.D., M.A., B.A.
- Professor, Stockholm School of Economics,
- Founding Director, Center for Medical
Technology Assessment, Linköping University ,
- Professor, Department of Health and Society,
Linköping University, Sweden
- Director, IHE, Swedish Institute for Health
Economics, Lund, Sweden
- Lecturer, Department of Economics, Lund