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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 5 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?”) 7 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] 18