The economic cost of OCD in England: who pays?

As an Elf Economist, research on obsessive-compulsive disorder (OCD) often escapes my attention. As the authors of a recent article Comprehensive Psychiatry Note that there is relatively little economic evidence on OCD. Indeed, a quick search of PubMed reveals that 5 papers in total Published in 2023, tagged with MeSH terms for OCD and Economyalthough estimates for OCD prevalence may be as high as 3%.

OCD is characterized by repetitive, unwanted thoughts (obsessions) and repetitive behaviors that a person feels compelled to perform (compulsions). These behaviors and thoughts can significantly interfere with daily activities and cause distress.

In the UK, OCD treatment follows a 'stepped care' model, starting with cognitive behavioral therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs; learn more). Read Alan Underwood's 2016 Mental Elf blog). However, inpatient treatment may also be needed, which is more expensive for health care.

A greater understanding of the cost of illness for OCD may help allocate resources for research and care. Thus, Kocher and colleagues (2023) conducted a cost-of-illness (CoI) study that attempted to estimate the economic burden of OCD in the UK over a one-year period.

OCD ranks in the top 10 for the global burden of neuropsychiatric disability, but little is known about the economic cost of OCD to individuals or society.

Methods

To estimate the overall cost of the disease for the UK, the researchers modeled children, adults and older people with OCD separately, applying different rates of prevalence and severity and identifying different treatment pathways for these groups. Prevalence and severity estimates were obtained from publicly available national surveys and published studies of the distribution of violence in each group. The study is described as using a 'bottom-up' approach, meaning that individual cost components are added together rather than considered separately from the total cost estimate.

Costs were calculated separately for different subpopulations. In addition to the unit costs of NHS treatments, out-of-pocket costs and individual treatment costs were also taken into account, as was the cost of lost productivity due to reduced ability to work. Some inputs were based on expert opinion, and the researchers sensitively attributed these to the scenario analysis.

Results

The annual cost of illness for OCD in the UK is estimated to be £378 million from a carer's perspective. That's £525 per person with OCD.

When including social costs such as lost productivity, out-of-pocket costs, and personal care, CoI rose dramatically to £5 billion and averaged £7,077 per person with OCD.. These social costs accounted for 92% of the total GDP, highlighting the significant economic impact beyond health care costs. Lost productivity alone – measured for adults only – was estimated at £4,797 per person, or £3.5 billion for the population. On average, patients were estimated to spend around £1,400 a year on individual treatment.

An analysis of costs by age showed that adults bear the greatest health care costs overallBecause of the higher prevalence of OCD Average cost of care for children was highest (£651) due to more regular provision of expensive treatments Like CBT. The severity of OCD also affected care costs, with severe cases costing more on average: £902 for people with severe OCD and £174 for people with mild OCD symptoms.

In terms of treatment, SSRIs are cheaper at around £48 per patient, compared to £1,417 in care costs per person receiving CBT. At the other end of the scale, inpatients pay an average of £8,658 a year.

Scenario analyzes and sensitivity analyzes showed that accounting for comorbid depression would more than double the estimated cost of health care, and similar effect sizes were found when presentation and caregiver productivity losses were considered.

The annual cost of illness (including out-of-pocket costs) for OCD in the UK has been estimated to be over £5 billion, which is approximately £7,077 per individual diagnosed with OCD. On average, patients spend around £1,400 a year on individual treatments.

Results

Despite relatively little research into the economic impact, it is estimated that health and care services spend around £378 million caring for people with OCD in the UK.
When the wider societal costs are taken into account, the cost of the disease is £5 billion, or £7,077 per person with OCD.
Research shows that patients and wider society are costing more than the NHS.

OCD can reduce productivity through absenteeism, absenteeism (working less efficiently), and reduced work hours for caregivers; this cost has been estimated to be more than the cost of health services such as the NHS.

Strengths and limitations

The authors are relatively conservative, which I consider a strength. They focus their analysis of the underlying situation on inputs they can trust to some extent, namely prevalence and health care cost estimates. This means we can take their headline estimate of £378m to represent a Relatively robust lower threshold for OCD-related costs in the UK.

Another strength of the study is that divides estimates by age and severitythis not only makes the findings more informative, but also makes it easier for readers to feel the results.

One of the main limitations of the study is its reliance on expert opinion for analyzes outside of the baseline condition and the authors do not do a good job of describing how they obtained these peer reviews. We do not know whether they used a recognized and validated framework, and conclusions drawn from these inputs (for example, regarding comorbid depression and private therapy) should not be considered reliable.

Although the authors are relatively conservative in their estimation of economic costs (increased robustness), they are uncertain about their reliance on expert opinion in their analyzes (decreased robustness). Clear reporting of methods is critical in determining reliability and validity.

Implications for practice

Cost-of-illness studies tend to produce large numbers that are difficult to interpret in isolation. We've written about similar studies over the years bipolar disorder, perinatal mental health problems, multimorbidity, and probably others. But what should we read in these numbers?

Well, the authors make some comparisons with other mental health conditions, noting that the cost is lower than the costs shown for depression, but higher than those for anorexia. personally, I would be very wary of such comparisons, as the most important determinant of the differences may be methodological choices.for example, time horizon, inclusion and exclusion of different cost categories, and approaches to population stratification.

Where studies like this are most useful are the within-study comparisons they facilitate. For example, the size of the cost burden associated with private treatment and out-of-pocket costs is quite high at over £1,700 per person per year, especially compared to the NHS cost of £525 per person. The evidence here is weak, based on expert opinion, so should not be taken at face value, but highlights an important area for future research. Further research could examine the frequency with which different groups of people with OCD seek individual therapy, how much it costs them, and the impact it has on their lives.

Overall, this study makes a good case For the significance of the economic burden of OCD in the UKand findings should inform future strategies for investment in relevant research and care for people with OCD.