by Annette Bauer
Earlier this year the former Prime Minister placed targeted mental health support for new mums at the top of the agenda for mental health service reform. This included an investment of £290 million for specialist care over the next five years for mothers before and after having their babies.
While this is great news and a timely response to the identified costs that perinatal mental health problems carry to society, there remain many questions about the best allocation of resources in this area.
With funding from NHS England, we examined some of the potential costs and economic consequences of best practice interventions in the perinatal mental health area. We wanted to know whether interventions, that ‘work’, were also good value for money. We defined best practice as interventions that had demonstrated good outcomes in randomised controlled trials or other appropriate evaluations.
Our first task was to set a scope and review the literature
We only included interventions that were specifically aiming to prevent or reduce perinatal mental illness (defined as mental illness during pregnancy and up to one year after birth).
Based on the reviewed literature we categorised studies by four types of interventions, those:
- provided universally to all women during the perinatal period,
- targeted at high-risk groups,
- for women with mild or subthreshold symptoms,
- targeted at women with moderate to severe symptoms,
- and those with severe mental illness.
We also identified studies, which evaluated service models that improved access to treatment.
Second, we assigned pound values to resource inputs and to outcomes
We evaluated costs of interventions based on resource input information provided in studies (unless cost values had already been published in the studies we reviewed) and then established economic consequences linked to the remission or prevention of mental illness, including impact on mothers as well as on the child (where studies evaluated child outcomes). Estimates from an earlier study informed the calculations. Such values referred to life-time costs and included a wide range of impacts on the public sector (in particular in form of health and social care, and education) and to individuals and wider society (in particular in form of productivity and health-related quality of life losses),
Interventions had the potential to be good value of money
All interventions along the pathway (‘Tiers’) from universal provision to highly specialist provision for people with severe problems had the potential to be good value for money.
Each of the intervention we identified as successful in preventing or achieving early remission of perinatal mental illness led to economic benefits from a societal perspective (this referred to gains to individuals in form of improvements in quality of life or productivity as well as gains to government in form of reduced use of public sector services). For example, multi-disciplinary support for women with severe mental illness via mother and baby units had potentially very large overall societal benefits.
In addition, some interventions had the potential to offset costs from a government perspective. Those included:
- Universally provided parent education (provided in classes and involving fathers) and an infant sleep intervention (provided by in women’s homes)
- Interventions that targeted women at high social risk and offered peer support or addressed multiple risk factors
- Interventions for women with elevated, subthreshold symptoms initiated during the antenatal period; those included some form of mother-infant relationship support and were provided in less intensive ways i.e. in form of self-help or group based formats.
- Individual CBT (in women’s home), group based CBT and multi-disciplinary care for women with moderate to major symptoms;
- Interventions addressing major depression postnatally such as facilitated exercise programme (in addition to specialist treatment) and group-based interpersonal therapy.
Although it was difficult to quantify potential cost savings, our evidence suggested that – in line with NICE recommendations and in support of guidance for perinatal and maternal mental health pathways – interventions were best provided as part of collaborative care approaches that include screening and early identification.
In English studies, midwives and health visitors had an important role in early identification of perinatal mental illness and providing support to those affected. It is important to note that in the studies we reviewed clinical supervision was provided to non-mental health professionals.
A word of caution
Findings need to be interpreted with caution as there were important gaps in evidence.
Comparing the economic case between interventions was not possible because studies evaluated different sets of outcomes over different time periods. There might be other interventions that were not in the scope of this study (i.e. do not directly aim to support the mother perinatal mental illness) but that have important impacts, including economic ones. In addition, most of the literature was concerned with intervention that reduced perinatal depression and more knowledge is needed to understand the benefits of interventions addressing other types of mental illness during the perinatal period. What’s more, the impact of interventions during the perinatal period on (long-term) child outcomes is far from established and further evidence is required.
Furthermore, it is important to bear in mind that most of the net benefits refer to economic gains realised over the medium- or long-term. As is typical for interventions in the early and prevention areas, only a few interventions were able to offset costs in the very short-term (e.g. typically during the follow-up periods of the trials) by reducing health and social care costs. It is therefore important for the health system to consider the longer-term economic advantages when considering investment to prevent or address the mental health needs of mothers during the perinatal period.
Bauer A, Knapp M, Adelaja B (2016) Best Practice for Perinatal Mental Health Care: the Economic Case, Personal Social Services Research Unit, London.
About the author
Annette Bauer is Research Fellow within the Personal Social Services Research Unit at the LSE.