MIND-ECON: The longer term, average & distributional effects of mental health interventions & the causal impact of mental illness on economic outcomes

South Africa has a high burden of mental illness, with around a third of adults suffering from a mental disorder at some point in their life. Around three-quarters of people with mental disorders such as depression, anxiety and alcohol use never access mental health treatment. Untreated mental illness is the third largest contributor to the national burden of disease. Mental illness also contributes to the national burden of disease associated with chronic communicable diseases (such as HIV) and non-communicable diseases, such as diabetes. Including mental health care as part of chronic disease care in primary care clinics is seen as a way to improve access to mental health treatment, as well as improve chronic disease outcomes.

A trial, called MIND, is currently being run in the Western Cape looking at different ways of providing brief mental health counselling in primary care services for patients with depression or alcohol use disorders who also suffer from diabetes or HIV. The aim of MIND is to examine the most effective and cost-effective way to provide mental health counselling services through community health workers. The MIND trial will collect information on patients' mental health at three points in time to look at whether there are changes in patients' level of depression and hazardous/harmful alcohol use as a result of the counselling.

We are proposing to build on the MIND trial in the MIND-ECON study. We will analyse existing data from the MIND trial and collect additional information from patients at a further time point (2 years), so that we can examine the long-term effects of the counselling intervention. We will also examine whether the counselling had different effects on patients' depression or alcohol disorder, depending on their socio-economic status. We will measure socio-economic status by creating an index based on household characteristics (e.g. the type of house the patient lives in, type of toilet, their source of drinking water and energy for cooking) and asset ownership (e.g. whether they own a fridge, stove, TV, etc.). We will also look at the impact of changes in mental health on an individual's employment, productivity, and other economic outcomes such as out-of-pocket payments.

In addition to patient economic outcomes, we will further capture information from other members of the household so that we can learn what impact patients' mental illness has on the family and those who care for them and what coping strategies are used to deal with the burden of mental illness.

Very little is known about the long-term impact of psychological counselling on mental health in this context and even less is known about the impact of mental health on economic outcomes or on the caregiving burden. MIND-ECON will provide valuable information on the relationship between mental health and economic outcomes, as well as how mental health outcomes from the counselling may be affected by socio-economic status.

MIND-ECON will be an efficient way to collect further much needed data since it builds on an existing study. Issues that are sometimes risky in trials, such as whether the study can recruit enough patients, are already in place. We will seek the needed additional ethical approvals to collect information from the patients and the members of their household.

We will use state-of-the art methods to analyse these data and will draw on a range of expertise in this UK-SA collaboration, which will also support capacity development. We will use MIND's existing stakeholder advisory group consisting of policymakers, staff from the HIV and diabetes clinics, and mental health patient groups to help us ensure that our findings can feed directly into changing policy and practice and have a large impact. We will ensure our results are widely publicised to various audiences and through different media. We will seek to influence policy in South Africa and globally on improving access to mental health care.

This three-year study builds on an existing cluster randomised control trial (MIND) which examines the cost-effectiveness of integrating a brief, structured counselling intervention into chronic disease care within South Africa's public primary health care system. Evidence suggests the intervention is effective [16,32,33], but MIND focuses on assessing different resourcing models for delivery of the three sessions of counselling. There are about 1200 participants in the trial, recruited from 24 primary care clinics offering HIV and diabetes services in the Western Cape.

Participants are adults taking antiretroviral therapy for HIV or medication for diabetes, who screen positive for harmful alcohol use or depression and do not currently receive treatment for a mental health condition. Data has been collected at baseline, 6 and 12 months' follow-up on socioeconomic and demographic information as well as their physical and mental health.

The MIND-ECON will build on MIND and collect data on patients at an additional follow-up point (24 months). It will also collect data from an adult member of the patient's household. The aims of MIND-ECON are to examine 1) what is the longer term impact of the intervention on mental health outcomes, and 2) what is the socioeconomic distribution of the mental health effects from the intervention. We expect the intervention to have heterogeneous effects according to socioeconomic status of patients, and we will construct an asset index to assess this. Understanding this differential impact will help target interventions more effectively. Further, we will examine the impact of mental illness on 3) economic outcomes such as employment, productivity and out-of-pocket payments, and 4) the household caregiver burden.

We will take account of confounding variables in our models. An important contribution to knowledge will be that we can make causal inference statements. This fills a significant gap in the literature.

South Africa is a middle-income country with the highest levels of income inequality worldwide. Approximately 27 million people live below the national poverty line [28]. In addition to economic inequality, the country faces considerable health inequalities. A South African household survey estimated that up to 30% of adults will experience at least one mental disorder in their lifetime, including alcohol use disorder (AUD) [3]; these disorders display a strong socioeconomic gradient [4], and contribute to lost income among adults [5]. South Africa also has the highest burden of HIV worldwide [25], with this burden falling disproportionately on the poor. Common mental disorders (CMDs) such as depression and anxiety and AUDs have been shown to be risk factors for HIV acquisition and disease progression [26]. Similarly, South Africa faces a growing epidemic of diabetes, which has been shown to be intimately associated with depression [27].

While the South African public health system has made substantial progress in increasing access to HIV-related treatment, and while services for diabetes are available, services for mental disorders are predominantly restricted to the treatment of serious mental illness within residential facilities, albeit with serious concerns about quality of care. Services for common mental disorders at the primary care level are largely unavailable.

These three inequalities - in income, in the burden of ill-health, and in access to health services of adequate quality - contribute to a vicious cycle of poverty and illness. Extremely low levels of economic growth compound this challenge: government budgets are inadequate to respond to the increasing burden of disease. The "Life Healthcare Esidemeni" tragedy - where approximately 143 patients with serious mental illness died from causes including starvation, thirst and neglect when transferred to a number of low cost NGO facilities - is a stark and tragic reminder of the challenges facing South Africa.

Within such a context, it is imperative that resource allocation decisions within the public health system are based on evidence of both effectiveness and equity impact, so that the greatest good can be achieved from limited resources.

MIND-ECON will support the SA Department of Health's National Mental Health Policy Framework and Strategic Plan 2013-2020 to address the substantial treatment gap and the inequity in services, by providing the evidence to help ensure that quality mental health services are accessible, equitable, comprehensive and integrated at all levels of the health system [29]. If policymakers are aware of the full economic benefits of mental health (and mental health interventions), this could alter their return on investment calculations, encouraging the scale up of mental health activities and support the government's ongoing "Investment Case for Mental Health".

MIND-ECON will impact on i) policymakers, planners and decision-makers, ii) health, mental health and social care practitioners in the public and NGO sectors, and iii) patients, their families, carers and civil society organisations that represent service users with mental health problems.

In order to ensure MIND-ECON will maximise its potential economic and societal impact, we will engage in a series of actions. We will seek direct exchange (e.g. via holding joint workshops and dissemination activities) with relevant South African networks and events, including the SAMRC's bi-annual South African Community Epidemiology Network on Drug Abuse meeting, the South African Federation for Mental Health's annual meeting, the Central Drug Authority's Annual Meeting, and the National and Provincial Department of Health Research Days, and the South African National AIDS Council (SANAC). We will raise public awareness through social media channels, policy briefs and our project website, and seek to disseminate and influence through our stakeholder advisory group (SAG).