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The economic impact of post traumatic stress disorder in Northern Ireland

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This report was produced in 2012 as a joint outcome of a partnership between the Northern Ireland Centre for Trauma and Trsnsfornstion (now closed) and Ulster University. The study was undertaken to inform service providers and policy makers in Northern Ireland about the economic impact of the civil conflict (the Troubles). The report was subsequently the subject of a peer reviewed paper published in the Journal for Traumatic Stress.
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THE ECONOMIC
IMPACT OF
POST TRAUMATIC
STRESS DISORDER IN
NORTHERN
IRELAND
A REPORT ON THE DIRECT AND
INDIRECT HEALTH ECONOMIC
COSTS OF POST TRAUMATIC
STRESS DISORDER AND THE
SPECIFIC IMPACT OF CONFLICT IN
NORTHERN IRELAND
The research team gratefully acknowledge the
financial support and guidance provided by Dr.
Peter Warrian and the Lupina Foundation in the
completion of this study.
The study draws upon primary data derived
from the Northern Ireland Study of Health and
Stress (NISHS). The support of the Research &
Development Office of Northern Ireland in funding
the original NISHS is gratefully acknowledged.
The UK’s Big Lottery Fund provided the grant for the
initial study of trauma related disorders published in
2008 (Trauma, Health & Conflict, Ferry et al, 2008).
The Fund’s support for this earlier study is gratefully
acknowledged.
The NISHS was carried out in conjunction with the
World Health Organization World Mental Health
(WMH) Survey Initiative which is supported by
the National Institute of Mental Health (NIMH; R01
MH070884), the John D. and Catherine T. MacArthur
Foundation, the Pfizer Foundation, the US Public
Health Service (R13-MH066849, R01-MH069864, and
R01 DA016558), the Fogarty International Center
(FIRCA R03-TW006481), the Pan American Health
Organization, Eli Lilly and Company, Ortho-McNeil
Pharmaceutical, GlaxoSmithKline, and Bristol-Myers
Squibb.
We thank the staff of the WMH Data Collection and
Data Analysis Coordination Centres for assistance
with instrumentation, fieldwork, and consultation on
data analysis.
Thanks are also extended by the research
partnership to the following individuals and
departments who have contributed data and
information to the report and provided analytical
advice:
Sandy Fitzpatrick and Ricky McLoughlin, HSC
Business Services Organisation.
Department for Social Development, Analytical
Services Unit.
Professor Vani Borooah, University of Ulster.
Professor John Brazier, University of Sheffield.
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
TWO THIRDS OF THE
ADULT POPULATION
HAVE EXPERIENCED ONE
OR MORE TRAUMATIC
EVENT TYPES DURING
THEIR LIFETIME
01
Finola Ferry
David Bolton
Brendan Bunting
Siobhan O’Neill
Samuel Murphy
Barney Devine
AUTHORS
ACKNOWLEDGEMENTS
PREFACE
The Lupina Foundation works with partners across the world
to support innovative and progressive thinking in health care.
In 2003 we established a relationship with the Northern
Ireland Centre for Trauma and Transformation (NICTT) and
have funded a number of international activities and research
programmes undertaken by the Centre.
We have been particularly pleased to be involved
with the subject of this report, an investigation into
the health economic impact of post traumatic stress
disorder (PTSD) in Northern Ireland, undertaken by
a partnership of the NICTT and the University of
Ulster. Given the history of violence since the late
1960’s, it was clear to the Foundation that this was
an area worthy of enquiry with unique opportunities
and obligations to understand better the needs of
individuals who suffer PTSD, and the needs of their
communities.
In this report the NICTT-UU research team have
sought to provide the population or epidemiological
context for PTSD looking at the wider need
associated with the years of conflict. From there
they have investigated the direct service costs
and the indirect costs associated with PTSD, again
looking more closely at the impact of the conflict.
In approaching the issue from this perspective
the economic arguments become available as
an additional strand in considering and making
judgments about policy, strategy and services.
A health economics approach to any health concern
allows us to better understand the impact of illness
and to make informed choices about interventions
and treatment options. It also clarifies the costs
of not taking action, or, as in this case, of relying
on approaches, systems and services that are not
addressing the identified needs as effectively as
alternatives. More specifically, this type of analysis
is highly relevant to the making of informed choices,
where resources are limited (as they usually
are) and allows judgements to be made about
the benefits and costs of current provision and
switching to one or more alternative approaches,
including the costs of pump priming any changes.
The Foundation hopes that this study will be put to
good use. Our aim is to leave behind resources and
analyses that have real utility at both the political
and personal levels, ultimately endeavouring
by both means to improve the lot of those who
suffer and who can be helped through progressive
approaches to health care and improving
interventions.
Peter Warrian PhD
Managing Director
The Lupina Foundation
Munk Centre for International Studies
02
Introduction 03
Summary of Findings 04
Background to the Research 05
What is Post Traumatic Stress Disorder 06
Understanding the Context 07
Other Studies 08
Method 11
Results 12-16
Implications for Policy, Serice & Practice 19-20
Appendices 21-25
References 25-26
CONTENTS
INTRODUCTION
As outlined in a previous report by the research team,
Northern Ireland presents a specific case study for
the examination of the experience and impact of
psychological trauma given its recent history of over
30 years of civil conflict.
A body of community studies and other literature on the Northern
Ireland conflict point to the substantial mental health impact associated
with many years of violence. One of the most striking findings to
emerge from the ‘Trauma, Health and Conflict’ (TH&C) Report (Ferry et
al., 2008) was in relation to the elevated rates of post traumatic stress
disorder (PTSD) among the Northern Ireland population.
The current Report updates and extends the findings of the TH&C
Report, focusing specifically on the societal economic impact of PTSD
in Northern Ireland. As far as can be detected by the research team,
this report represents the first ever economic cost-of-illness study that
focuses exclusively on PTSD. The current Report therefore represents
an important contribution to the international literature. Aside from its
contribution to the literature, this report aims to increase awareness
among policy makers, planners, commissioners, service providers,
service users and the wider public of the extent of the public health
burden of PTSD among the general population and the associated
adverse economic implications.
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
03
SUMMARY OF THE KEY FINDINGS
This study investigated the direct service costs (e.g. visits to family doctors
and other health services, and prescribed medication) and indirect costs
(e.g. costs of lost work productivity) associated with PTSD over a one-year
period (2008), and also estimated the impact of the conflict-related PTSD. In
addition the study considered the economic value of reduced health related
quality of life associated with PTSD. The key findings from the current
report are outlined as follows...
THE PREVALENCE OF PSYCHOLOGICALLY
TRAUMATIC EXPERIENCES AND PTSD
Two thirds of the adult population have
experienced one or more traumatic event types
during their lifetime.
It is estimated that 39% of the adult population
have had one or more traumatic experiences
linked to the conflict.
The study found that the estimated prevalence
of 12-month PTSD in the adult population was
5.1%1 while the estimated lifetime prevalence was
8.8%2.
Northern Ireland has the highest level of 12-month
and lifetime PTSD among all comparable studies
undertaken across the world, including in other
areas of conflict.
Based on case-by-case examination, it is
estimated that 27% of individuals with 12-month
PTSD (approximately 18,000 adults) have PTSD
linked to a conflict-related traumatic event.
THE ECONOMIC COSTS
Direct service costs among individuals with PTSD
arising from all types of traumatic experiences
were estimated to be £33.0 million over 12
months (2008 prices).
Indirect costs among individuals with PTSD
arising from all types of traumatic experiences
were estimated to be £139.8 million over 12
months (2008 prices).
The total estimated costs of resources used and
lost among individuals with PTSD (direct and
indirect costs) were therefore estimated to be
£172.8 million over 12 months (2008 prices).
Assuming that 27% of 12-month PTSD is linked to
conflict-related traumatic events, it is estimated
that the total annual costs (2008 prices) among
individuals with 12-month PTSD associated with
conflict were £46.7 million.
The economic value of the reduced quality of life
or human costs associated with PTSD was also
examined. This part of the study concluded that
over 12,000 quality adjusted life years (QALYs)
were lost among individuals with PTSD in 2008 3.
04
Direct Costs £33.0m (19%)
Indirect Costs £139.8m (81%)
Direct and Indirect Costs of
PTSD (2008)
1. 12-month PTSD describes the percentage of the population who met the criteria for the disorder in the previous 12 months.
2. Lifetime PTSD describes the percentage of the population who met the criteria for PTSD at any point in their life.
3. A Quality Adjusted Life Year is an index ranging from 0-1, which weights a given year by the health–related quality of life of an individual for that year.
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
BACKGROUND TO THE RESEARCH
This research has been undertaken by a partnership of the Northern Ireland
Centre for Trauma & Transformation (NICTT) and the Bamford Centre of
Mental Health and Wellbeing, University of Ulster (UU) with funding from
the Lupina Foundation of Canada. The study is based primarily on secondary
analysis of data from the Northern Ireland Study of Health and Stress
(NISHS) which is the largest representative population study of mental
health in Northern Ireland.
The NISHS is the first epidemiological study
of mental health in Northern Ireland based on
validated diagnostic criteria. The study is part of
the World Mental Health (WMH) Survey Initiative, a
series of standardised population (epidemiological)
surveys of mental health, substance use, and
behavioural disorders in over 30 countries
throughout the world, coordinated and supervised
by the Harvard Medical School (Kessler and Üstün,
2008a).
These studies allow the identification of individuals
who met the criteria for a range of mental disorders
according to the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) (American Psychiatric
Association (APA), 1994). The NISHS, along with
all other WMH studies also sought information on
socio-demographic characteristics, use of health
and related services, and medication and quality of
life. A more detailed description of this study can be
found in Appendix 2.
Based on a analysis of data from the NISHS, the
NICTT-UU research partnership have previously
provided the first representative estimates of
the prevalence of traumatic experiences, PTSD
and other mental health disorders associated
with trauma among the Northern Ireland adult
population (Ferry et al., 2008; Bunting et al., in
press). These estimates reveal that PTSD and
other disorders associated with trauma represent
a significant public health burden in Northern
Ireland. This burden of trauma and related disorders
has major economic implications for individuals,
families, the health service, employers, government
and the wider community.
This particular study extends the previous analysis
by estimating the economic burden of post
traumatic stress disorder in Northern Ireland over a
one-year period (i.e. 2008).
05
WHAT IS POST TRAUMATIC STRESS DISORDER?
While a range of mental health disorders may develop as a consequence of
exposure to traumatic events, PTSD is unique in that it is the only mental
health disorder that must be preceded and directly linked to a traumatic
stressor, i.e. for diagnostic purposes. The disorder describes a range of
psychological and physical problems that can sometimes follow particular
threatening or distressing events and was first classified as a disorder in
1980 ( APA, 1980) under the umbrella of anxiety disorders.
Results in the current report are based on PTSD
estimates according to the updated DSM-IV criteria
(APA, 1994), which is outlined in detail in Appendix
1.
The current diagnostic criteria for PTSD stipulate
that the individual must have experienced
a traumatic event which involved actual or
threatened death or serious injury, or a threat
to the physical integrity of oneself or others. In
addition the individual’s immediate response must
be characterised by intense fear, helplessness or
horror. PTSD is characterised by three clusters of
commonly observed symptoms or reactions that
develop subsequent to this experience, namely:
1. Re-experiencing of the event such as nightmares
or flashbacks;
2. Avoidance of things that remind the person
of the event and numbing of emotions and
responsiveness;
3. Hyper-vigilance symptoms such as jumpiness,
irritability and sleep disturbance.
Following the first classification of PTSD in 1980, a
body of research and related literature emerged in
the area of trauma and trauma-related disorders and
needs. Of particular interest are the population or
epidemiological studies of trauma and PTSD.
Evidence from these studies has demonstrated that
the experience of traumatic events is common,
with two-thirds of the general population having
experienced at least one significant traumatic event
during their lifetime (Galea et al., 2005).
Estimates of the prevalence of 12-month PTSD
among the general population range from 0.5%
(Levinson et al., 2007) to 3.6% (Kessler et al.,
2005) while estimates of the prevalence of lifetime
PTSD range from 1.0% (Helzer et al., 1987) to 6.8%
(Kessler et al., 2005).
06
07
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
UNDERSTANDING THE CONTEXT
This current study is the latest in a series of research projects undertaken
by the UU and NICTT partnership which have focused on the experience
and impact of psychological trauma in Northern Ireland. The health
economic costs presented within the report extends previous analyses
on trauma and PTSD and associated disorders reported in ‘Trauma, Health
and Conflict’ (2008) and other related publications (Bunting et al., in press).
Collective consideration of sources provides an insight into the extent of
the burden of traumatic experiences and PTSD as well as the mental health
needs associated with PTSD and associated disorders.
In summary:
It is estimated that 61% of the Northern Ireland
adult population have experienced a traumatic
event at some point in their lifetime.
An estimated 39% of the Northern Ireland adult
population have had one or more traumatic
experiences linked to the conflict. This represents
a distinctive and very significant stressor on
individuals, families and communities.
It is estimated that 5.1% of the adult population
(approximately 68,000 adults) are estimated to
have had PTSD in the previous 12-months. An
estimated 27% of this 12-month PTSD figure
(approximately 18,000 adults) was linked to
conflict-related traumatic events.
An estimated 8.8% (approximately 118,000) of
adults have had PTSD at some point in their life. It
is estimated that 29% of this lifetime PTSD figure
was associated with conflict-related traumatic
events.
Findings from the ‘Trauma, Health and Conflict’
Report (2008) show that individuals who met the
criteria for PTSD were more likely to have a range
of other mental health disorders and also a range
of chronic physical conditions.
Of those who met the criteria for PTSD only 61%
ever sought help for their PTSD symptoms. Of
this group only 59% received services that they
considered to be ‘helpful or effective’. (In short,
just 36% of people who met the criteria for PTSD
said they got help they considered to be ‘helpful
or effective’).
Additionally, the NISHS revealed that whereas
people with depression and other mood disorders
on average seek help within 12 months of the
onset of their symptoms, people with anxiety
disorders (of which PTSD is an example) wait
an average of 22 years following the onset of
symptoms before seeking help
This series of figures provides a strong rationale for
the examination of the economic consequences of
psychological trauma and PTSD. The elevated rates
of PTSD among the Northern Ireland population and
the association between PTSD and other disorders
represent a substantial public health issue.
Furthermore, given evidence of low levels of help
seeking and lengthy delays, it is clear there are
substantial levels of unmet need, which on the face
of it probably have major economic implications for
individuals, families, employers and wider society
due to lost productivity and reduced quality of life.
The current study seeks to cast more light on the
scale of these costs
08 WHAT OTHER STUDIES HAVE FOUND ABOUT THE
COST OF TRAUMATIC EXPERIENCES AND PTSD?
Besides the number of individuals directly affected, mental health disorders
have substantial economic implications for individuals and for the population
and its institutions and services (McCrone et al., 2008; Greenberg et al.,
2003; Thomas and Morris; 2003).
First, mental health disorders require treatment
and medication and therefore are associated
with specific healthcare costs. Second, given the
debilitating nature of mental health disorders,
individuals are often unable to carry out their
normal daily activities at home or in the work place,
which invariably results in economic consequences
for individuals, families, employers and government
(Almond and Healy 2003; Kessler and Frank, 1997).
Finally, and inextricably linked with the previous
point, mental health disorders are associated with
significant reductions in health related quality of
life, with individuals enduring in some cases long-
term pain and suffering associated with their illness
(Linzer et al., 1996; Spitzer et al., 1995), to which we
might add the impact on families and carers.
In recent years there has been an increasing body of
research into the economic impact of mental health
disorders. The majority of studies in this area have
however focused on depression, broad categories
of anxiety disorders or mental illness in general
(McCrone et al., 2008; London School of Economics
and Political Science, 2006; The Northern Ireland
Association for Mental Health, 2004; Thomas and
Morris, 2003; Rice and Miller, 1995; Stoudemeire et
al., 1986).
In 2003 McCrone and colleagues however noted
that there had been no health economic cost-of-
illness studies specifically focusing on the economic
impact of PTSD on the general population. The
literature review for this study confirms that since
2003 no such studies have been published nor have
there been any studies published on the economic
burden of other trauma related disorders.
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
09
NORTHERN
IRELAND HAS THE
HIGHEST LEVEL OF
12-MONTH AND
LIFETIME PTSD IN
ADULT POPULATION
IN COMPARABLE
STUDIES ACROSS
THE WORLD
10
THE ESTIMATED
PREVALENCE OF
12-MONTH PTSD
IN THE ADULT
POPULATION WAS
5.1% WHILE THE
ESTIMATED LIFETIME
PREVALENCE
WAS 8.8%
IT IS ESTIMATED
THAT 27% OF
INDIVIDUALS
WITH 12-MONTH
PTSD HAVE PTSD
LINKED TO A
CONFLICT-RELATED
TRAUMATIC EVENT
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
METHOD
OVERALL STUDY APPROACH
The current study adopts a similar methodology to a
previous study by Thomas and Morris (2003) in their
estimation of the economic cost of depression in
England, which represents a standardised approach
to cost-of-illness analysis widely used in similar
research.
A ‘prevalence-based’ approach was used to
estimate the total direct and indirect costs among
adults with PTSD in Northern Ireland within a one-
year period. Specifically this cost-of-illness study
estimates the economic burden among all prevalent
cases of PTSD in Northern Ireland in 2008 given the
available data.
The main body of this report considers two broad
cost categories, namely ‘direct’ and ‘indirect’
economic costs. Direct costs incorporate the
cost of visits to service providers and the cost of
medication among the sub-group of individuals who
met the criteria for 12-month PTSD. Indirect costs
capture the cost of reduced productivity associated
with incapacity days among this subgroup and also
the cost of ‘presenteeism ’ or reduced productivity
while at work4.
Aside from these two major cost categories,
the human costs associated with PTSD are also
considered in Appendix 3. Human costs represent
the burden of reduced health related quality of life
among individuals with PTSD. While this additional
category does not refer to resources used or lost or
indeed money in real terms, an attempt has been
made to capture the estimated economic value of
reduced health related quality of life.
Where appropriate, average cost estimates (from
the NISHS) were combined with PTSD prevalence
rates and adult population figures to obtain an
estimate of the overall cost among the Northern
Ireland population.
DATA SOURCES
Information and data from a variety of sources
were utilised and merged to produce economic
cost estimates. A detailed description of these data
sources can be found in Appendix 2. The current
study is based largely on analysis of the NISHS.
The NISHS data was used to obtain estimates of the
prevalence (or epidemiology) of 12-month PTSD
among the general adult population.
This dataset also contained detailed information
on units of service use, units of medication, work
performance, rates of employment and reduced
quality of life (measured in lost Quality Adjusted Life
Years (QALYs)) among individuals with 12-month
PTSD. The number of working days lost as a
result of PTSD and other acute stress disorders
was obtained from the Analytical Services Unit,
Department for Social Development Northern
Ireland (DSDNI, 2008). The relevant unit costs of
service visits were derived from the Personal Social
Services Research Unit (Curtis, 2008).
Medication costs were taken from Prescription
Cost Analysis data provided by the Health & Social
Care Board (HSC) Business Services Organisation
(HSCNI, 2008). Gender and age specific wage
rates were derived from the Annual Survey of
Hours and Earnings (ASHE) conducted by the
Department of Enterprise, Trade and Investment
(DETNI, 2008). Finally, similar to previous studies,
the cost of a QALY was assumed to be the cost-
effectiveness threshold for economic evaluations,
as recommended by the National Institute of Clinical
Excellence (Appleby et al., 2007). Northern Ireland
mid-year adult population estimates were obtained
from the Northern Ireland Statistics and Research
Agency (NISRA, 2010).
A more detailed overview of the data sources and
methods of analysis used to produce this report is
provided in Appendix 2.
HOW WAS PTSD
ASSESSED IN THE STUDY?
Estimates of the 12-month and lifetime prevalence
of PTSD among the adult population of Northern
Ireland were obtained from analysis of data from
the NISHS. The survey instrument used to elicit
information from NISHS participants included a
detailed ‘PTSD’ section. At the beginning of this
section, participants were presented with 29 types
of traumatic events and asked whether they had
experienced them during their lifetime.
If an individual endorsed a specific traumatic
event, they were subsequently asked more
detailed questions about the event including the
age at which they first experienced this event.
Individuals were also asked further questions about
re-experiencing, avoidance and hyper-vigilance
symptoms associated with a ‘random event’
and ‘worst event’ among those event types that
participants endorsed. Responses to questions
within this PTSD section were then processed using
statistical algorithms or codes which identified
those individuals that met the criteria for 12-month
and lifetime DSM-IV PTSD.
4. Presenteeism in this context is the term used to refer to reduced
productivity among individuals with PTSD while at work.
11
ISRAEL
SOUTH AFRICA
MEXICO
ESEMeD
LEBANON
NEW ZEALAND
USA
NORTHERN IRELAND
RESULTS
EXPERIENCE OF TRAUMATIC EVENTS
AMONG ADULTS IN NORTHERN IRELAND
Overall 60.6% of the NISHS sample experienced
at least one type of traumatic event during their
lifetime. Combining this estimate with Northern
Ireland’s adult population for 2008 suggests that
approximately 813,000 adults have experienced
a traumatic event during their lifetime. This
figure largely coincides with the estimate from
international studies that two thirds of the general
population will experience a traumatic event during
their lifetime (Galea et al., 2005). Males were
significantly more likely to have experienced a
traumatic event than females.
Table 1:
Lifetime experience of traumatic events
Lifetime experience of any traumatic event .......... %
Overall Sample* 60.6
Males 64.8
Females 56.9
*X2 test indicates significant gender differences at
the 5% level of significance5.
THE PREVALENCE OF PTSD AMONG ADULTS
IN NORTHERN IRELAND
Analysis of data from the NISHS suggests 5.1%
of the adult population met the criteria for PTSD
in the last 12 months while 8.8% met the criteria
at some point in their life (lifetime PTSD). If we
combine these prevalence rates with Northern
Ireland population figures, we can conclude that
approximately 118,000 adults met the criteria for
PTSD at some point in their lifetime. The 12-month
figure, which represents the best estimate of current
levels of PTSD among the population, suggests that
approximately 68,000 individuals met the criteria for
PTSD in the previous 12 months.
In contrast to findings in relation to the experience
of traumatic events, females were significantly more
likely than males to meet the criteria for lifetime
and 12-month PTSD. Case-by-case analysis of the
sub-group of individuals who met the criteria for
PTSD in terms of the qualifying event (i.e. the event
linked to PTSD) reveals that approximately 29% of
lifetime PTSD was associated with conflict-related
traumatic events, representing an estimated 34,000
individuals. An estimated 27% of 12-month PTSD
was associated with conflict-related traumatic
events, which corresponds to approximately 18,000
individuals.
Table 2:
Prevalence of post traumatic stress disorder
among the Northern Ireland population
Total % Males Females
12-month PTSD* 5.1 4.0 6.1
Lifetime PTSD* 8.8 6.4 11.0
*X2 test indicates significant gender differences at
the 5% level5.
Figure 1 compares the 12-month rates of PTSD in
Northern Ireland with rates from a selection of other
WMH countries that have produced estimates. At
5.1%, the 12-month prevalence of PTSD in Northern
Ireland is higher than estimates from all other WMH
Survey Initiative countries including countries with a
recent history of civil conflict.
The same is also true with respect to lifetime
prevalence figures, with Northern Ireland again
having the highest rates across all countries (Alonso
et al., 2004; Kessler et al, 2005; Oakley-Browne et
al., 2006; Herman et al., 2008; Levinson et al., 2008;
Karam et al., 2008, Medina-Mora et al., 2008).
5. A chi-squared or X2 test is a statistical test which examines if differences (in
exposure to trauma for example) between two groups are likely to occur by chance.
ESEMeD is a collaboration of six western European countries:
Belgium, France, German, Italy, Spain and the Netherlands.
0 1 2 3 4 5 6
Figure 1: The 12-month prevalence of PTSD in selected WMH Survey Initiative countries
12
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
RESULTS
THE ECONOMIC COST OF PTSD IN 2008
As described previously, estimates of mental health
disorders provide a valuable insight into the level
of need within a given population. An evaluation of
the extent of the social and economic burden posed
by these estimates however offers a more in-depth
evidence base to inform the planning, provision,
targeting and allocation of appropriate services.
The subsequent series of results presents findings
from an economic cost-of-illness study, focusing on
individuals who met the criteria for PTSD in the 12
months previous to the interview. Given that NISHS
data collection was completed in 2008, these costs
are estimated based on 2008 prices or unit costs.
DIRECT COSTS
SERVICE VISITS
In cost-of-illness studies, direct costs incorporate
costs under two sub-categories: the cost of service
visits or treatment associated with a particular
illness or disorder and also the cost of medication
taken by individuals with this disorder. In the service
use section of the NISHS interview, participants
were asked about their visits to various treatment
providers in the previous 12 months for problems
with their ‘emotions, nerves or mental health’.
Table 3 summarises the costs of service visits in
2008 among individuals with PTSD. Using PTSD
prevalence information and total adult population
data, an estimate was then made of the total
number of visits to each service provider among
individuals with PTSD.
For example, the most frequently visited service
provider was the GP or family doctor with over
118,000 visits from individuals with PTSD in 2008.
An estimate of the total cost of visits to a range of
providers was then estimated by multiplying the
total number of visits by the relevant unit cost using
PSSRU information. Hospital stays (given their
relatively higher unit cost) represent the highest
cost among individuals with PTSD followed by GP
visits and psychiatrist visits. The total estimated
costs of service visits among this cohort were just
over £27.3 million.
Hospital stay 37,458 219 8,203,409
Psychiatrist 16,735 316 5,288,240
GP/family doctor 118,341 52 6,153,707
Psychologist 10,415 72 749,893
Social worker (mental health) 7,125 89 634,096
Social worker (health service) 2,691 138 371,412
Counsellor (mental health) 37,602 40 1,504,093
Counsellor (health service) 79,027 40 3,161,071
Other mental health professional 10,627 57 605,751
Other health professional 8,999 42 337,451
Healer 7,335 37.5 308,061
27,317,184
Table 3:
Cost of service visits
among individuals with
PTSD in 2008 Total visits among
individuals with PTSD
in NI
Unit cost
in 2008 (£)
Total costs
among
individuals with
PTSD (£)Service provider
Figure 2:
Proportional breakdown of total service
visit costs (£27.3 million) among individuals
with PTSD in 2008 13
Hospital 30%
Psychiatrist 19%
GP / Family Doctor 23%
Psychologist 3%
Social Worker (MH) 2%
Social Worker (HS) 1%
Counsellor (MH) 6%
Counsellor (HS) 12%
Other (MH) 2%
Other Health Prof 1%
Healer 1%
Abbreviations : MH = Mental Health / HS = Health Service
MEDICATION
The second sub-category of direct costs is the cost associated with medication. Table 4 provides estimates of
the costs of medication among individuals who met the criteria for PTSD in the previous 12 months. These
costs are presented according to British National Formulary (BNF) categorisation of medication types6. The
cost estimates provided in Table 4 represent an aggregation of these individual costs according to their
relevant BNF category. The total cost of medication among individuals with PTSD in 2008 was estimated to
be over £5.7 million. Considering both service use and medication costs, it is estimated that the total direct
cost associated with individuals who met the criteria for PTSD was almost £33 million. Service visit costs
accounted for 83% of total direct cost while medication accounted for 17%.
Table 4: Costs of medication among individuals with PTSD in 2008
Medication category7 Total costs among individuals with PTSD in 2008 (£)
Hypnotics and anxiolytics 911,311
Drugs used in psychoses and related disorders 958,521
Anti-depressant drugs 3,214,504
Central nervous system stimulants 74,352
Drugs used in nausea and vertigo 8,199
Anti-epileptics 430,885
Drugs used in Parkinsonism and related disorders 60,634
5,658,406
The second major cost category to be considered
in estimating the economic burden associated with
a disorder is indirect costs, namely the cost of lost
productivity. As outlined in the methods section
(Appendix 2), this was estimated by combining
information on incapacity benefits relating to days
lost due to PTSD and other acute stress rections
with age and gender specific wage rate information.
Data from the Department for Social Development
suggests that 6278 individuals were in receipt of
Incapacity Benefit as a result of PTSD or acute stress
reactions (an early response sometimes experienced
after traumatic events). Table 5 summarises
estimates of the economic costs associated with this
lost productivity.
Among males, the highest number of working
days lost as a result of PTSD and other acute stress
reactions was among the 40-49 age group while the
50-59 age group represented the highest number
of days lost among females. Despite females
being significantly more likely than males to meet
the criteria for 12-month PTSD (as outlined in
previous results), total work loss days and total cost
associated with PTSD were higher among males.
These findings undoubtedly reflect gender
differences in retirement age among other
influencing factors. In total over two million working
days were lost as a result of PTSD and other acute
stress disorders, representing a total economic
burden of £113.6 million, a figure which far exceeds
the direct costs of medication and service use
INDIRECT COSTS
LOST PRODUCTIVITY FROM INCAPACITY DAYS
14
Hypnotics & Anxiolytics (16%)
Drugs used in Psychoses & Related Disorders (17%)
Anti-depressants (57%)
Drugs used in Vertigo & Nausea (0%)
Anti-epileptics (8%)
Central Nervous System Drugs (1%)
Drugs used in Parkinsonism & related disorders (1%)
Figure 3:
Proportional
breakdown of total
medication cost
(£5.7 million) among
individuals with PTSD
in 2008
6. A more detailed outline of medication costs among individuals who
met the criteria for 12-month PTSD will be provided on request by
the research team. This includes estimates of the total number of
prescriptions, unit costs and total costs of individual medication types
rather than the broad categories presented in this report.
7. Categorisation of medication is based on the British National
Formulary categorisation for 2008. This information was obtained from
Prescription Cost Analysis data for Northern Ireland (HSCNI, 2008).
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
RESULTS
NUMBER OF WORKING DAYS LOST DUE
TO PTSD AND OTHER ACUTE STRESS REACTIONS TOTAL COSTS (£)
Age-group Males Females Males Females
Less than 21 52,925 48,860 1,618,780 1,129,827
22-29 139,065 119,700 6,306,312 4,728,970
30-39 226,960 193,480 12,539,385 9,057,514
40-49 312,020 335,365 20,536,900 14,778,111
50-59 296,720 413,545 19,153,479 17,103,768
60-65 144,490 - 6,611,704 -
1,172,180 1,110,950 66,766,560 46,798,191
Total days lost: 2,283,130 Total cost: 113,564,751
Males 1.78 374.22 6,831,316
Females 5.56 829.77 19,384,405
26,215,721
Table 5:
Cost of lost productivity associated with PTSD and other acute stress reactions in 2008
Table 6:
Cost of ‘presenteeism’
among individuals with
PTSD in 2008
PRESENTEEISM
In addition to lost productivity associated with
incapacity days, individuals with mental health
disorders are also less productive while in the
workplace compared to their ‘healthy’ counterparts
(Alonso et al., 2010). This aspect of reduced
productivity is known as ‘presenteeism’. The level
of presenteeism and associated economic cost was
also estimated in the current study. As outlined
in the methods section in Appendix 2, the NISHS
included a question on work performance.
Table 6 summarises the levels of presenteeism
among males and females with 12-month PTSD
based on a comparison of these individuals with
those who did not have 12 month PTSD. Males
who met the criteria for PTSD were almost 2% less
productive (presenteeism rate) compared to those
who did not meet the criteria for PTSD.
The corresponding presenteeism rate for females
who met the criteria for PTSD was just over 5.5%.
Combining these estimates with gender specific
wage rates for 2008 provides the average lost
productivity among these individuals. Finally,
combining these estimates with figures on
employment rates and adult population figures, it
is estimated that the total costs of presenteeism
among individuals who met the criteria for PTSD
and who were employed was approximately £26.2
million in 2008.
Considering both the cost of lost productivity as a
result of incapacity and the cost of presenteeism,
it is estimated the total indirect cost associated
with PTSD were approximately £139.8 million in
2008. Productivity losses from days out of work
accounted for 81% of these total indirect costs,
while presenteeism accounted for 19%.
Presenteeism rate
(%)
Average
productivity loss
among individuals
with PTSD in 2008
(£)
Total
productivity loss
in 2008 (£)
COST OF INCAPACITY BENEFIT (IB) PAYMENTS
In addition to these opportunity costs of lost productivity among individuals with PTSD, the economic
implications of these incapacity days in terms of social security payments are noteworthy. As previously
mentioned, an estimated 6278 individuals were in receipt of incapacity benefit as a result of PTSD or acute
stress disorder. Combining the number of individuals on IB with the duration of their benefit and associated
weekly benefit rate suggests that the total cost of these benefits were £27.5 million. Although inclusion of
these costs does not fit with the human capital model upon which indirect cost estimates are based (see
Appendix 2), these social security payments represent a real economic cost that could potentially be averted
by investment in effective PTSD treatment (benefit estimates were provided by the DSDNI on request).
15
DAYS OUT OF ROLE
Alonso and colleagues (2010) examined the effect of a range of physical and mental disorders on ‘days out
of role’ based on merged data from 24 countries in the WMH Survey Initiative (including data from Northern
Ireland). Specifically, the authors investigated how many days individuals were totally unable to carry out
their work or normal activities. Results reveal that PTSD was the most disabling mental disorder among
all high income countries included in the analysis (including Northern Ireland) with an average of 16.2
days additional days out of role per year. Assuming that this average figure applies to Northern Ireland the
analysis suggests that in the region of 1.1 million days out of role may be lost per year as a result of PTSD.
TOTAL DIRECT AND INDIRECT COSTS
By combining direct and indirect costs this report
provides an estimate of the total economic burden
of resources used (service use and medication)
and resources lost (productivity losses and
presenteeism) among individuals with PTSD.
These combined costs are estimated to have
been £172.8 million in 2008 (19% direct costs and
81% indirect costs). Table 7 and Figure 4 provide
a more detailed breakdown of these total costs
in terms of each of the cost elements considered
previously. Productivity losses accounted for the
largest proportion of overall costs (66%) followed by
service visits (16%), presenteeism (15%) and finally
medication (3%).
THE ECONOMIC BURDEN OF PTSD
ASSOCIATED WITH CONFLICT IN NORTHERN
IRELAND
One of the aims of this report was to consider the
social and economic burden of conflict-related
trauma and PTSD in Northern Ireland. As outlined
in Appendix 2, the NISHS did not include a specific
question about traumatic events associated with
the Northern Ireland “Troubles”. However case-by-
case analysis of individuals who met the criteria
for 12-month PTSD and specifically the qualifying
event directly linked to PTSD, suggests that 27% of
all 12-month PTSD is linked to a ‘conflict-related’
traumatic event. If we assume that the total
economic cost associated with PTSD are uniformly
distributed among all those with 12-month PTSD
regardless of their profile of traumatic experiences,
we can tentatively apportion £46.7 million of these
total costs to conflict-related PTSD (see table 7). The
limitations of this evaluation will be considered in
subsequent sections.
Direct costs Service visits 27,317,184
Medication costs 5,658,406
Indirect costs Productivity losses 113,564,751
Presenteeism 26,215,721
172,756,062
Table 7:
The total direct and
indirect costs among
individuals with 12-month
PTSD in 2008
Figure 4:
Proportional breakdown of
the total direct and indirect
cost (£172.8 million) among
individuals with PTSD in 2008
Cost category
Cost
sub-category
Costs among all
individuals with
12-month PTSD (£)
16
Presenteeism (15%)
Service Visits (16%)
Medication (3%)
Productivity Losses (66%)
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
17
THE TOTAL
ESTIMATED COSTS
OF RESOURCES
USED AND
LOST AMONG
INDIVIDUALS WITH
PTSD (DIRECT AND
INDIRECT COSTS)
WERE ESTIMATED
TO BE £172.8
MILLION IN 2008
18
DIRECT SERVICE
COSTS AMONG
INDIVIDUALS
WITH PTSD WERE
ESTIMATED TO BE
£33.0 MILLION IN
2008
INDIRECT
COSTS AMONG
INDIVIDUALS
WITH PTSD WERE
ESTIMATED TO BE
£139.8 MILLION IN
2008
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
LIMITATIONS TO THIS STUDY
The implications of findings presented in the
current report should be drawn with a number of
limitations in mind. First, given the constraints of
the NISHS dataset, some cost estimates represent
the economic burden among individuals with PTSD
in Northern Ireland rather than the costs specifically
linked to PTSD itself.
To expand on this point, individuals with PTSD often
have other co-morbid mental health disorders and
we would expect that these conditions will have an
additional impact on cost estimates. A larger dataset
would facilitate the isolation of costs specifically
associated with PTSD through more sophisticated
analysis that controls for co-morbid mental health
disorders, social deprivation and other important
factors. In due course an international collaborative
health economics study could be undertaken,
drawing upon a much larger dataset, to answer
questions as to the costs associated purely and
simply with PTSD.
That said, PTSD is seldom found alone particularly
in its chronic state, and proper assessments of
costs should take account of disorders that are to
found in association with PTSD. The key point is
that this study has isolated a distinctive group of
participants, given the relatively high PTSD figures
in Northern Ireland compared to findings from
related studies in other countries. The findings
therefore provide a basis for judgements about
what measures could be taken to address the needs
of PTSD sufferers in the population.
A further limitation relates to the exclusion of a
number of cost categories in relation to PTSD: The
NISHS did not include individuals who were living
in institutions such as hospitals, prisons and care
homes. In addition, the NISHS focused exclusively
on the adult population. The prevalence of mental
health disorders such as PTSD and associated costs
among individuals living in institutions and those
aged under 18 years are therefore not included.
Due to the lack of available information on the
proportion of suicides associated with PTSD, the
cost of premature mortality associated with PTSD
related suicide is not included.
For similar reasons, costs associated with short-
term sickness absence due to PTSD are also
excluded. Furthermore, this report does not
provide an estimate of caregiver burden associated
with PTSD. Those who suffer with mental health
problems generally do not exist in isolation and
rely on practical support from family, friends and
caregivers. The aforementioned exclusions suggest
that economic cost estimates herein represent a
substantial underestimation.
Finally, the estimated proportion of 12-month PTSD
associated with conflict did not include PTSD linked
to ‘sudden death of a loved one’ or ‘trauma to a
loved one’. The international research instrument
(the CIDI) did not have a specific question as to
whether experience of these events was related to
the Northern Ireland conflict and therefore it could
not be inferred with reasonable confidence whether
these traumatic experiences were directly linked to
the conflict.
As a result, assessment of costs associated with
PTSD linked to the civil conflict is also likely to be
conservative.
DEVELOPING CLINICALLY EFFECTIVE
AND COST EFFECTIVE SERVICES
Recovery from chronic PTSD is very unlikely if
sufferers do not have access to effective trauma
focussed treatment (Kessler et al., 1995). This
research-based insight is also borne out by clinical
experience such as that acquired by the clinical
team at NICTT between 2002 and 2011, which
provided specialist trauma focussed cognitive
therapy (Ehlers and Clark, 2000) for chronic trauma
sufferers (Duffy et al., 2007).
The National Institute for Health & Clinical
Excellence (NCCMH, 2005) and GAIN/CREST
(CREST, 2003) recommend access to either trauma
focussed cognitive behavioural therapy (CBT) or
Eye Movement Desensitization and Reprocessing
(EMDR) therapy for the effective treatment of PTSD.
The DHSSPS Mental Health Services Framework,
with reference to NICE, GAIN/CREST and the
Bamford Report (2007), also requires that “People
with post traumatic stress disorder (PTSD) should
be treated by suitably qualified and supervised
practitioners who have the experience and skills to
provide evidence based psychological treatments
for PTSD”. (Overarching Standard 48, Service
Framework for Mental Health and Wellbeing;
DHSSPSNI, 2010).
Despite the limitations noted above, the results
presented in the current report suggest that the
economic burden associated with individuals with
PTSD is substantial. As noted at the beginning of
the current report, individuals who suffer from
anxiety disorders such as PTSD, wait on average
22 years from disorder onset before they seek help
for their symptoms (Bunting et al., under review).
Furthermore, analysis of the NISHS also suggests
that just 36% of people who met the criteria for
PTSD said they got help they considered to be
‘helpful or effective’ (Bunting et al., under review).
19
IMPLICATIONS FOR POLICY, SERVICE AND PRACTICE
This combination of lengthy delays in treatment
seeking and the lack of access to effective
treatments may help explain the substantial costs of
productivity losses found in this report and, coupled
with the elevated prevalence of PTSD among the
adult population of Northern Ireland, point to
substantial levels of unmet need in the community
and the need for strategic service developments.
With a lack of readily accessible and effective
services and treatments capable of curing PTSD and
related disorders as early as possible (rather than
just controlling and managing symptoms), the costs
of PTSD and associated disorders are recurring
year on year on year and are mounting as PTSD
becomes more chronic and as individuals develop
associated co-morbid mental health disorders.
In other words, people with chronic PTSD and
associated multiple disorders are likely to have
increasing needs and therefore increasing patterns
of service usage (direct costs) with increased
indirect costs as they seek to manage mounting
and enduring distressing symptoms, unless they
can access effective services which would cure their
underlying trauma related disorders.
In relation to the civil conflict, the years of violence
have, according to the findings of the NISHS
and related studies, resulted in a distinctive and
additional group of PTSD sufferers (and others
with other trauma related disorders besides PTSD).
As with trauma sufferers generally, their needs
associated with PTSD are likely to increase over
the years as a function of the chronic nature of this
disorder.
This unique cohort of our population generally
experienced their first conflict related traumatic
event when they were relatively young, and those
who developed PTSD from which they have not
recovered will be chronic sufferers with more
complicated and additional needs.
They are also ageing. The costs of providing
ongoing services for this part of our community
therefore, are likely to increase over the years, and
will also aggregate, year upon year by at least the
same amount, with inflationary increases; that
is, unless readily accessible effect services are
developed which are capable of addressing the
underlying trauma disorders.
The choice is between funding an increasing
demand for maintenance and illness-management
services, or investing in curative services
and therapies that will, in spite of short term
investments, reduce the long term costs and
demands on services, whilst improving the quality
of life and social and economic contributions of
sufferers.
The latter can be achieved by, amongst other
things, supporting the development of evidence
based effective services so that they are routinely
and readily accessible across the community,
through strategic cooperation across Government
Departments, and with and between the statutory
and voluntary sectors.
Building capacity at all levels to more effectively
detect and address trauma related needs requires a
graduated and a strategic workforce development
plan.
Improved capability at primary and secondary
care levels needs to be supported by centres of
excellence, if a stepped care approach is to be
enabled and knowledge and skills development are
to be supported.
Adopting a similar approach to Layard and
colleagues in The Depression Report (The London
School of Economics, 2006), it can be argued that
investment in effective treatments for PTSD and
associated disorders will ‘pay for itself’. Taking
trauma focused CBT as an example of NICE
approved effective treatment for PTSD, NICE
recommends a course of 8-12 weeks of treatment
for individuals with chronic PTSD (NCCMH, 2005).
It is estimated from the NICTT that an average
course of CBT for an individual who suffers chronic
PTSD is approximately £1,500, which means that it
would cost approximately £102 million to treat all
individuals with 12-month PTSD in Northern Ireland
(68,000 individuals).
While treatment success rates and the costs of
training also need to be taken into account, the
costs of incapacity days alone exceeds this figure
suggesting that economic gains can be made in
the long run by developing effective services and
treatments for PTSD such as CBT and EMDR.
The argument for an economic approach to trauma
related needs, including those that have arisen
as a consequence of the civil conflict, becomes
another argument in the case for strategic service
development to sit alongside the humanitarian
goal of reducing suffering and improving the
quality of life for individuals, families and the wider
community.
20
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
CRITERION A: STRESSOR
The person has been exposed to a traumatic event
in which both of the following have been present:
1. The person has experienced, witnessed, or been
confronted with an event or events that involve
actual or threatened death or serious injury, or a
threat to the physical integrity of himself/herself
or others.
2. The person’s response involved intense fear,
helplessness, or horror. Note: in children, it may
be expressed instead by disorganized or agitated
behaviour.
CRITERION B: INTRUSIVE RECOLLECTION
The traumatic event is persistently re-experienced in
at least one of the following ways:
1. Recurrent and intrusive distressing recollections
of the event, including images, thoughts, or
perceptions. Note: in young children, repetitive
play may occur in which themes or aspects of the
trauma are expressed.
2. Recurrent distressing dreams of the event. Note:
in children, there may be frightening dreams
without recognizable content
3. Acting or feeling as if the traumatic event
were recurring (includes a sense of reliving
the experience, illusions, hallucinations, and
dissociative flashback episodes, including those
that occur upon awakening or when intoxicated).
Note: in children, trauma-specific re-enactment
may occur.
4. Intense psychological distress at exposure
to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
5. Physiologic reactivity upon exposure to internal
or external cues that symbolize or resemble an
aspect of the traumatic event
CRITERION C: AVOIDANT/NUMBING
Persistent avoidance of stimuli associated with the
trauma and numbing of general responsiveness (not
present before the trauma), as indicated by at least
three of the following:
1. Efforts to avoid thoughts, feelings, or
conversations associated with the trauma.
2. Efforts to avoid activities, places, or people that
arouse recollections of the trauma.
3. Inability to recall an important aspect of the
trauma.
4. Markedly diminished interest or participation in
significant activities.
5. Feeling of detachment or estrangement from
others.
6. Restricted range of affect (e.g., unable to have
loving feelings).
7. Sense of foreshortened future (e.g., does not
expect to have a career, marriage, children, or a
normal life span).
CRITERION D: HYPER-AROUSAL
Persistent symptoms of increasing arousal (not
present before the trauma), indicated by at least two
of the following:
1. Difficulty falling or staying asleep.
2. Irritability or outbursts of anger.
3. Difficulty concentrating.
4. Hyper-vigilance.
5. Exaggerated startle response.
CRITERION E: DURATION
Duration of the disturbance (symptoms in B, C, and
D) is more than one month.
CRITERION F: FUNCTIONAL SIGNIFICANCE
The disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
Specify:
Acute: if duration of symptoms is less than three
months.
Chronic: if duration of symptoms is three months or
more.
Specify:
With delayed onset: if onset of symptoms is at least
six months after the stressor.
21
APPENDIX 1
DSM-IV CRITERIA FOR PTSD (APA, 1994)
Diagnostic criteria for PTSD include a history of exposure to a traumatic
event meeting two criteria and symptoms from each of three symptom
clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-
arousal symptoms. A fifth criterion concerns duration of symptoms and a
sixth assesses functioning.
OVERALL STUDY APPROACH
The current study adopts a similar methodology to
a previous study by Thomas and Morris (2003), in
their estimation of the economic cost of depression
in England, which represents a standardised
approach to cost-of-illness analysis widely used in
similar research.
A ‘prevalence-based’ approach was used to
estimate the total cost of PTSD among adults
in Northern Ireland within a one year period.
Specifically this cost-of-illness study estimates
the economic burden of all prevalent cases of
PTSD disorders in Northern Ireland in 2008 given
the available data. The main body of this report
considers two broad cost categories, namely ‘direct’
and ‘indirect’ economic costs.
Direct costs incorporate the cost of visits to service
providers and the cost of medication among the
sub-group of individuals who met the criteria for
12-month PTSD. Indirect costs capture the cost of
reduced productivity associated with incapacity
days among this subgroup and also the cost of
‘presenteeism’ or reduced productivity while at
work. Aside from these two major cost categories,
the human costs associated with PTSD are also
considered in Appendix 3.
Human costs represent the burden of reduced
health related quality of life among individuals with
PTSD. While this additional category does not refer
to resources used or lost or indeed money in real
terms, an attempt has been made to capture the
estimated economic value of reduced health related
quality of life.
OVERVIEW OF DATA SOURCES
Information and data from a variety of sources
were utilised and merged to produce economic
cost estimates. The current study is based largely
on analysis of the Northern Ireland Study of Health
and Stress (NISHS) which provided estimates of the
prevalence/epidemiology of PTSD. This dataset also
contained detailed information on units of service
use, units of medication, work performance, rates of
employment and reduced quality of life (measured
in lost Quality Adjusted Life Years (QALYs)) among
individuals with 12 month PTSD. A more detailed
description of the NISHS is provided below.
The number of working days lost as a result of PTSD
and other acute stress disorders was obtained from
the Department for Social Development Northern
Ireland (DSDNI, 2008). The relevant unit cost of
service visits were derived from the Personal Social
Services Research Unit (Curtis, 2008).
Medication costs were taken from Prescription
Cost Analysis data provided by the Health &
Social Care Board (HSC). Gender and age specific
wage rates derived from the Annual Survey of
Hours and Earnings (ASHE) conducted by the
Department of Enterprise, Trade and Investment
(DETNI, 2008). Finally, similar to previous studies,
the cost of a QALY was derived from the cost-
effectiveness threshold for economic evaluations,
as recommended by the National Institute of Clinical
Excellence (Appleby et al., 2007).
THE NORTHERN IRELAND STUDY OF HEALTH
AND STRESS (NISHS)
The NISHS is one of over 30 national and
international World Mental Health (WMH) Survey
Initiative studies being undertaken under the
auspices of the World Health Organisation (Kessler
and Üstün, 2008a). All studies used the same survey
instrument, the WMH Composite International
Diagnostic Interview (CIDI) (Kessler and Üstün,
2008b) to investigate the prevalence of a wide
range of mental and behavioural disorders based
on validated diagnostic criteria. All WMH studies
are being coordinated and supervised by Harvard
University and besides providing valuable national
data also open the opportunity for international
comparisons.
The NISHS is a representative household survey of
English speakers, 18 years and older in Northern
Ireland. The participants in the NISHS were selected
from a random sample of households. Face-to-face
interviews were carried out between February 2004
and August 2008 with a response rate of 67%. The
survey was administered in two parts.
Part 1 included a screening section and assessment
of ‘core disorders’ such as depression and general
anxiety (n=4340). Part 2 included questions about
risk factors, and service use along with assessments
of additional disorders such as PTSD. In total 1986
participants completed the total interview (Parts
1 and 2) while 4340 completed Part 1 only. All
analyses presented in the current report are based
on those who completed the full interview (N=1986).
Specifically related to the current report, the PTSD
section of the NISHS included detailed questions
about traumatic life events. This section was
administered to all Part 1 respondents who met
lifetime criteria for any ‘core disorder’ plus a
probability subsample of other respondents. At
the beginning of this section, participants were
presented with 29 types of traumatic events and
asked whether they had experienced them during
their lifetime.
The survey instrument did not contain a specific
question to link specific incidences of these 29
trauma types to the civil conflict in Northern Ireland.
To obtain an estimate of the prevalence of traumatic
events associated with the “Troubles”, the research
team identified events from the list that were likely
to be ‘conflict-related’. If an individual endorsed a
specific traumatic event, they were subsequently
asked more detailed questions about the event
including the age at which they first experienced
this event.
Individuals were also asked further questions about
re-experiencing, avoidance and hyper-vigilance
symptoms associated with a ‘random event’ and
‘worst event’ among those event types endorsed.
22
APPENDIX 2
COST-OF-ILLNESS STUDY METHODS
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
Responses to questions within this PTSD section
were then processed using statistical algorithms/
codes which identified those individuals that met
the criteria for 12-month and lifetime DSM-IV PTSD.
INFORMATION ON UNITS OF RESOURCES
USED OR LOST AMONG INDIVIDUALS WITH
PTSD
1.The NISHS
Information on the number of visits to a range of
service providers for ‘problems with emotions,
nerves or mental health’ was obtained from the
‘service use’ section of the NISHS. Specifically
the NISHS data provides estimates of the number
of hospital stays and visits to psychiatrist,
psychologists, GPs, counsellors, social workers,
healers, other mental health professionals and other
medical professionals. The ‘pharmacoepidemiology’
section of the dataset provides comprehensive
information on the types of medication taken by
each individual for ‘problems with emotions, nerves
or mental health’ in the previous 12 months.
The NISHS also contains detailed information on
current employment and employment history. The
rates of ‘presenteeism’ among males and females
who met the criteria for PTSD was estimated
based on responses to a question on work
performance. Specifically individuals were asked:
‘On a scale from 0-to-10 where 0 is the worst job
performance anyone could have at your job and 10
is the performance of a top worker, what number
describes your overall job performance on the days
you worked during the past 30 days?
Finally, the NISHS included the SF-12, a multi-
dimensional generic survey used to assess
health related quality of life (Ware et al., 1996).
Econometric modelling, developed by Brazier and
Roberts (2004) was then applied to individual SF-
12 responses to determine an individual’s Quality
Adjusted Life Year (QALY). This is an index from
0-1 which basically weights a given year with an
individual’s health related quality of life. A QALY of
1 represents perfect health while 0 represents the
worst imaginable health state.
2. Prescription Cost Analysis data
Estimates of average annual dosages of individual
medications were obtained from the Health & Social
Care Board (HSC), Business Services Organisation
(BSO). This information is based on British National
Formulary drug listings and was compiled using
medication information based on a sample of GP
practices across Northern Ireland.
3. Department of Social Development
Estimates of the total number of incapacity days
due to PTSD were obtained from the Northern
Ireland Department of Social Development (DSDNI),
Analytical Services Unit. DSDNI statistics provided
information on the total number of individuals
on incapacity benefit as a result of PTSD and
other acute stress reactions in 2008 as well as the
number of days of incapacity benefit for these
individuals. These figures were available by gender
and age group which facilitated more accurate cost
estimation.
INFORMATION ON UNIT COSTS OF
RESOURCES (2008 PRICES)
1. Personal Social Services Research Unit
Estimates of the unit costs of the services were
extracted from the Unit Costs of Health and
Social Care 2008 (Curtis, 2008). This is an annual
publication produced by the Personal Social
Services Research Unit (PSSRU) which aims to
provide the most up to date information on the
costs of services in the health and social care sector
in the UK.
2. Prescription Cost Analysis data
Estimates of the unit costs of individual medication
types were obtained from the Health & Social Care
Board (HSC).
3. Department of Enterprise, Trade and
Investment
Information on the average annual salaries in
Northern Ireland in 2008 was obtained from the
Annual Survey of Hours and Earnings (ASHE)
conducted by the Department of Enterprise, Trade
and Investment (DETNI, 2008). These figures were
categorised by age and gender. The overall average
male salary for 2008 was just over £21,000 while the
average female salary was almost £15,000.
4. National Institute of Clinical Excellence
(NICE)
As previously outlined, this study attempts to
estimate the monetary value of reductions in health
related quality of life (QoL). A similar approach
has been adopted by a number of studies led by
the Sainsbury Centre for mental health in which
a monetary value was attached to lost life quality,
which is normally expressed in Quality Adjusted Life
Years (QALYs) (SCMH, 2003; NIAMH, 2004). In this
study, a QALY indicates the value of one year (2008
in this case) weighted by an individual’s valuation of
their health state. Similar to these previous studies,
the cost of a QALY was derived from the cost-
effectiveness threshold (£30,000) as recommended
by the National Institute of Clinical Excellence
(Appleby et al, 2007).
5. Northern Ireland Statistics and Research
Agency (NISRA)
Mid-year adult population estimates for 2008 (age
and gender specific where relevant) were obtained
from NISRA (NISRA, 2010). These figures were
combined with prevalence data from the NISHS
to determine the total number of PTSD cases,
which in turn were used to provide population cost
estimates.
23
APPENDIX 2
COST-OF-ILLNESS STUDY METHODS
ANALYTIC PROCEDURES
This cost-of-illness study estimates the economic
burden of all prevalent cases of PTSD in Northern
Ireland in 2008. The units of resources in each cost
category were combined with the relevant unit cost
to obtain an estimate of the total economic cost
among individuals with PTSD. Where appropriate,
the average costs of each cost element (described
above) were estimated among individuals with
12-month DSM-IV PTSD. Total costs within the
Northern Ireland population were then estimated
by combining costs from the individual level with
estimates of the total number of 12-month cases
of PTSD in Northern Ireland (described earlier).
Methods of analysis used in the estimation of each
cost category are described in more detail below.
All analyses were implemented using Stata
statistical software v10.0 (StatCorp, 2007).
1. Direct Costs
Direct costs of visits to service providers were
estimated by combining the number of visits to
each service provider for individuals with PTSD
with the unit costs of these services. The average
number of visits to each provider was combined
with an estimate of the total number of cases of
PTSD to determine the total number of visits among
the adult population. This total was then multiplied
by the relevant unit cost (Curtis, 2008) to obtain an
estimate of the total cost of service visits.
The NISHS also provided information on the types
of medication taken by individuals with PTSD in the
year previous to the interview. By combining this
information with the total number of cases of PTSD
in Northern Ireland, the research team estimated
the total number of individuals with PTSD taking
each type of medication in the previous year. This
information was combined with Prescription Cost
Analysis data from the HSC BSO, which provides
estimates of the average annual dosage of these
medication types in Northern Ireland as well as
associated costs.
The total cost of each medication type and total
medication cost were therefore obtained by
multiplying the total number of individuals taking
each type of medication with the relevant costs of
the average annual dosage in 2008.
2. Indirect costs
The theoretical approach adopted for the calculation
of indirect costs was the Human Capital Approach.
This approach assumes that an individual’s
productive contribution to the economy is best
estimated using their wage rate. In other words,
wage rate is an indication of an individual’s
marginal productivity (Becker, 1964). This study
therefore considers what individuals would have
contributed to the economy in terms of productivity
had they not had 12-month PTSD.
The cost of lost productivity associated with PTSD
was obtained by combining age and gender specific
incapacity benefit data (DSDNI, 2008) with age and
gender specific wage rates for 2008 (DETNI, 2008).
This study also includes an estimate of
‘presenteeism’ among individuals with PTSD who
were in employment at the time of the interview.
This captures the lost productivity among
individuals with PTSD while at work. Average
rates of presenteeism (reduced work performance)
among individuals who met the criteria for PTSD
were combined gender specific wage rates to
derive an estimate of the average economic cost of
presenteesim. This figure was then multiplied by
gender specific PTSD prevalence rates, employment
rates and adult population figures to estimate the
total economic cost of presenteeism among the
adult population.
3. Costs of reduced quality of life
An estimate of the reduced health related quality
of life was obtained by calculating a 2008 Quality
Adjusted Life Year (QALY, ranging from 0-1) for each
participant in the NISHS. As previously described,
this information was derived from the SF-12 (Brazier
and Roberts, 2004). An average QALY for 2008 was
then calculated for individuals (by gender) who
met the criteria for 12-month PTSD and compared
to the average QALY for those who did not meet
the criteria, to obtain estimates of the average
QALYs associated with PTSD. The total number of
QALYs lost in 2008 was obtained by multiplying this
average figure with PTSD prevalence rates and adult
population figures.
In an attempt to place an economic value on these
reductions in quality of life, the research team used
the NICE cost-effectiveness threshold (£30,000)
as an indication of the monetary value of a QALY
(Appleby et al., 2007). These additional human costs
are outlined in Appendix 3.
24
APPENDIX 2
COST-OF-ILLNESS STUDY METHODS
REPORT
ECONOMIC IMPACT OF
POST TRAUMATIC STRESS
IN NORTHERN IRELAND
Table 7 considers the human costs associated with PTSD by placing a monetary estimate on lost QALYs
among individuals with PTSD. Although these less tangible are rarely included in cost-of-illness estimates as
they do not reflect used or lost resources, this category of costs attempts to capture the reduced life quality
(pain, suffering, impairment and such like) associated with mental health disorders that other cost categories
fail to take into account.
Comparing estimates of the average QALYs among men and women, with and without PTSD, for 2008
provides an indication of the average lost QALYs among individuals with PTSD. Combining these estimates
with gender specific PTSD prevalence and population figures suggests that over 12,000 QALYs were lost in
2008 among individuals with PTSD. Assuming that the monetary value of a QALY is £30,000 as per the upper
cost-effectiveness threshold limit applied by NICE (Appelby et al., 2007) it is estimated that the monetary
value of lost quality of life associated with PTSD was over £361 million in 2008.
25
APPENDIX 3
THE HUMAN COSTS OF PTSD
Males 0.2657 6,880
Females 0.1229 5,173
12,053
Total cost: £361,590,000
Table 7:
Estimated costs associated with reduced health
related quality of life among individuals with PTSD
Average loss in
QALYs among
individuals with
PTSD
Total loss in
QALYs among
individuals with
12-month PTSD
Alonso, J., Petukhova, M., Vilagut, G., Chatterji, S.,
Heeringa, S., Üstün, T. B. Et al. (2010). Days out of role
due to common physical and mental conditions: results
from the WHO World Mental health Surveys. Molecular
Psychiatry, 1-13.
Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R.,
Brugha, T. S., Bryson, H., et al. (2004). Prevalence of mental
disorders in Europe: results from the European Study of the
Epidemiology of Mental Disorders (ESEMeD) project. Acta
Psychiatrica Scandanavia. 420, 21-27.
Almond, S. & Healy, A. (2003). Mental health and absence
from work: new evidence from the UK Quarterly Labour
Force Survey. Work, Employment & Society. 17, 731-742.
American Psychiatry Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.). Washington
DC: American Psychiatric Association.
American Psychiatry Association. (1980). Diagnostic and
statistical manual of mental disorders (3rd ed.). Washington
DC: American Psychiatric Association.
Appelby, J., Devlin, N. & Parkin, D. (2007). NICE’s cost
effectiveness threshold. British Medical Journal, 335 doi:
10.1136/bmj.39308.560069.BE
Bamford Review. (2007). The Reform and Modernisation of
Mental Health and Learning Disability Services. Available
for download from: http://www.rmhldni.gov.uk/
Brazier, J. E. & Roberts, J. R. (2004). The estimation of a
preference-based index from the SF-12. Medical Care,
42(9):851-859
Bunting, B. P., Ferry, F. R., Murphy, S. D., O’Neill, S. M. &
Bolton, D., (under review). Conflict-related trauma and the
epidemiology of posttraumatic stress disorder in Northern
Ireland: evidence from the Northern Ireland Study of Health
and Stress, Journal of Traumatic Stress Studies.
Bunting, B. P., Murphy, S. D., O’Neill, S. M. & Ferry, F. R. (in
press). Lifetime prevalence of mental health disorders and
delay in treatment following initial onset. Evidence from the
Northern Ireland Study of Health and Stress, Psychological
Medicine.
CREST. (2003). The management of post traumatic
stress disorder in adults. A publication of the Clinical
Resource Efficiency Support Team of the Northern Ireland
Department of Health, Social Services and Public Safety,
Belfast.
Curtis, L. (2008). Unit Costs of health and Social Care 2008.
Kent: Personal Social Services Research Unit (PSSRU).
Available for download from: http://www.pssru.ac.uk/uc/
uc2008contents.htm.
Department of Health, Social Services and Public Safety
(DHSSPSNI). (2010). Service Framework for Mental Health
and Wellbeing. Belfast: DHSSPSNI.
Department of Social Development (DSDNI). (2008).
Information on incapacity benefits recipients for PTSD or
acute disorders was obtained from the Analytical Services
Unit within the DSD.
Department of Employment, Trade and Investment
Northern Ireland (DETINI). (2008). Northern Ireland Annual
Survey of Hours and Earnings 2008. NISRA. Available for
download at : http://www.detini.gov.uk/ashe_1.pdf
Duffy, M., Gillespie, K. & Clark, D. M. (2007) Post-traumatic
stress disorder in the context of terrorism and other
civil conflict in Northern Ireland: randomised controlled
REFERENCES
26
trial. British Medical Journal, 334,1147. DOI:10.1136/
bmj.39021.846852.BE
Ehlers, A. & Clark, D. M. (2000) A cognitive model of post-
traumatic stress disorder. Behaviour Research and Therapy,
38, 319-345.
Ferry, F., Bolton, D., Bunting, B., Devine, B., McCann, S. &
Murphy S. (2008). ‘Trauma, Health and Conflict’ in Northern
Ireland. A study of the epidemiology of trauma related
disorders and qualitative investigation of the impact of
trauma on the individual. Londonderry: Northern Ireland
Centre for Trauma and Transformation and University of
Ulster Psychology Research Institute.
Galea, S., Nandi, A. & Vlahov, D. (2005). The epidemiology
of post-traumatic stress disorder after disasters.
Epidemiologic Reviews, 27, 78-91.
Greenberg, P. E., Kessler, R. C, Birnbaum, H. G., Leong, S.
A., Lowe, S. W., Berglund, P. A. & Corey-Lisle, P. K. (2003).
The economic burden of depression in the United States:
how did it change between 1990 and 2000? Journal of
Clinical Psychiatry, 64 (12), 1465-75.
Health and Social Care Northern Ireland (HSCNI) (2008).
Information on average annual medication dosages and
associated cost were obtained from the Business Services
Organisation with the HSC.
Helzer J. E., Robins, L. N. & McEvoy, L. (1987). Post-
traumatic stress disorder in the general population:
Findings from the Epidemiologic Catchment Area Survey.
New England Journal of Medicine. 317 (26): 1630-1634.
Herman, A. A., Williams, D., Stein, D. J., Seedat, S.,
Heeringa, S. G, & Moomal, H. (2008). The South African
health and stress study (SASH): a foundation for improving
mental health care in South Africa. In R.C. Kessler & T.B.
Üstün (Eds.), The WHO world mental health surveys: global
perspectives on the epidemiology of mental disorders
(pp.238-264). New York: Cambridge University Press.
Kessler, R. C., Berglund, P., Demler, O., Jin, R. & Walters, E.
E. (2005). Lifetime prevalence and age-of-onset distributions
of DSM-IV disorders in the National Comorbidity Survey
Replication (NCS-R). Archives of General Psychiatry, 62(6),
593-602.
Kessler, R. C. & Frank, R. G. (1997). The impact of
psychiatric disorders on work loss days. Psychological
Medicine. 27, 861-873. DOI: 10.1017/S0033291797004807
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M. &
Nelson, C.B. (1995). Posttraumatic- Stress-Disorder in
the National Comorbidity Survey, Archives of General
Psychiatry, 52 (12), 1048-1060.
Kessler, R. C., Üstün, T. B. (2008a). The WHO world mental
health Surveys: global perspectives on the epidemiology of
mental disorders. New York: Cambridge University Press.
Kessler, R. C., Üstün, T. B. (2008b). The world health
organization composite international diagnostic interview.
In R.C. Kessler & T.B. Üstün (Eds.), The WHO world mental
health surveys: global perspectives on the epidemiology
of mental disorders (pp.58-90). New York: Cambridge
University Press.
Levinson, D., Lerner, Y., Zilber, N., Levav, I. & Polakiewicz, J.
(2008). The prevalence of mental disorders and service use
in Israel: results from the national health survey, 2003-2004.
In R.C. Kessler & T.B. Üstün (Eds.), The WHO world mental
health surveys: global perspectives on the epidemiology
of mental disorders (pp.346-363). New York: Cambridge
University Press.
Linzer, M., Spitzer, R., Kroenke, K., Williams, J.B., Hahn, S.,
Brody, D., et al. (1996). Gender, quality of life, and mental
disorders in primary care: Results from the PRIME-MD 1000
study. The American Journal of Medicine. 101 (5), 526-533.
McCrone, P., Dhanasiri, S., Patel, A., Knapp, M., & Lawton-
Smith, S. (2008) Paying the Price: the Cost of Mental Health
Care in England to 2026. London: King’s Fund.
McCrone P, Knapp M and Cawkill P, (2003). Posttraumatic
stress disorder (PTSD) in the armed forces: Health
economic considerations. Journal of Traumatic Stress, 16
(5), 519-522.
National Collaborating Centre for Mental Health. (2005).
Post-traumatic stress disorder (PTSD): The management of
PTSD in adults and children in primary and secondary care.
Leicester: British Psychological Society.
Northern Ireland Association for Mental Health/ Sainsbury
Centre for Mental Health. (2004) Counting the Cost: The
Economic and Social Costs of Mental Illness in Northern
Ireland. Northern Ireland Association for Mental Health:
Belfast.
Northern Ireland Statistics and Research Agency
(NISRA). (2010). Historical Mid-Year Population Estimate
Publications. Home Population by sex & single year of
age. Available to download at: http://www.nisra.gov.uk/
demography/default.asp17.htm
Oakley Browne, M. A., Wells, J. E., Scott, K. M. & McGee,
M. A., for the New Zealand Mental Health Survey Research
Team (2006). Lifetime prevalence and projected lifetime risk
of DSM-IV disorders in Te Rau Hinengaro: The New Zealand
Mental Health Survey (NZMHS). Australian and New
Zealand Journal of Psychiatry, 40, 865-874.
Rice, D.P. & Miller, L.S. (1995). The economic burden
of affective disorders. British Journal of Psychiatry
(Supplement). 27, 34-42.
Sainsbury Centre for Mental Health (SCMH). (2003).
The Economic and Social Costs of Mental Illness.
London: SCMH. Avaialble for download at: http://www.
centreformentalhealth.org.uk/publications/publications_list.
aspx?SortID=d
Spitzer, R. L., Kroenke, K., Linzer, M., Hahn, S. R., Williams,
J.B., deGruy III, F. V. Et al. (1995). Health-Related Quality of
Life in Primary Care Patients With Mental Disorders. Results
from the PRIME-MD 1000 Study. JAMA,274,1511-1517.
StataCorp. (2007). Statistical software. Release 10.0. College
Station, TX: Stata.
Stoudemire, A., Frank, R., Hedemark, N., Kamlet, M. &
Blazer, D. (1986). The economic burden of depression.
General Hospital Psychiatry. 8 (6), 387-394
The London School of Economics and Political Science.
(2006). The Depression Report. A new deal for depression
and anxiety disorders. LSE: London.
Thomas, C. M. & Morris, S. (2003). Cost of depression
among adults in England in 2000. British journal of
psychiatry. 183, 514-519.
Ware, J. Jr., Kosinski, M. & Keller, S. D. (1996). A 12-Item
Short-Form Health Survey: construction of scales and
preliminary tests of reliability and validity. Medical Care, 34
(3), 220-33.
REFERENCES
WITH FUNDING FROM
THE LUPINA FOUNDATION, CANADA
THE ECONOMIC IMPACT OF POST
TRAUMATIC STRESS DISORDER IN
NORTHERN IRELAND
A REPORT ON THE DIRECT AND INDIRECT HEALTH ECONOMIC COSTS AMONG
INDIVIDUALS WITH POST TRAUMATIC STRESS DISORDER AND THE SPECIFIC IMPACT
OF CONFLICT IN NORTHERN IRELAND
WITH FUNDING FROM
THE LUPINA FOUNDATION, CANADA
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