B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 2 ) , 1 8 0 , 1 9 ^ 2 3
The Maudsley long-term follow-up of child oneself, emotional disturbance and associ-
ated somatic symptoms, depressive sympto-
matology and attributional style. Criminal
and adolescent depression Records Office (CRO) files were examined
for criminal history data. Interviews were
3. Impact of comorbid conduct disorder on service use conducted with 149 participants, and the
and costs in adulthood representativeness of the sample for whom
cost data were obtained (n140) was
examined by comparison with those for
MARTIN KNAPP, PAUL McCRONE, ERIC F OMBONNE, JENNIFER BEECHAM
whom service use data were unavailable.
and GAIL WOSTEAR
Background Depression in childhood The Maudsley long-term follow-up of Service use measurement
or adolescence often has morbidity childhood and adolescent depression has Recognising that there are potentially many
found strong threads of continuity in psy- health and other consequences of childhood
implications continuing into adulthood,
chiatric morbidity running through to mental illness, we adopted a wide-ranging
generating needs for specialist services al, 2001a
adulthood (Fombonne et al, 2001a,b). The approach to measuring service use. For this
and support. aims of this study were to examine patterns purpose we employed a customised adap-
of service use and costs for adults who as tation of the Client Service Receipt Inventory
Aims To estimate the patterns of service children were treated for depression; to (CSRI) (Beecham & Knapp, 1992, 2001).
use and costs in adulthood of former compare those who had major depressive In the interviews we asked about the
patients. disorder (MDD) with those who had use of psychiatric in-patient stays, psychi-
depression and comorbid conduct disorder atric out-patient attendances, general
Method Service use and other cost- (CD±MDD); and to explore whether per- hospital in-patient stays, general hospital
related data were collected from former sonal, family and situational characteristics out-patient
out-patient attendances, contacts with the
in childhood are related to service use police, prison terms served, court atten-
patients.Comparisons were made
patterns and cost levels in adulthood. In this dances and contacts with probation officers
between those people with and without paper we focus on the first and second of from the age of 17 years until the inter-
comorbid conduct disorder in childhood these aims. While it is increasingly being view date. Other services, expected to be
and with data for the general population. recognised that economic studies are needed used more frequently, were measured for
in the mental health field, there are precious a 6-month period: these were general
Results Data on 91people with few in relation to the problems of child- practitioners, psychiatrists, psychologists,
depression (only) and 49 with comorbid hood and adolescence, and fewer still that community psychiatric nurses, other nurses,
conduct disorder revealed high adulthood follow up patients into adulthood (Knapp, social workers, counsellors and day care.
1997; Knapp & Henderson, 1999). Subjects were asked to provide details of
service utilisation rates and costs.In-
the number of contacts with each service
patient care and criminal justice services and their duration. The uptake of some
were used more frequently by the METHOD services was relatively low. Consequently,
comorbid group and total costs were the psyhiatrist and psychologist categories
Sample were combined, as were the various crim-
significantly higher.There were also
The sample was drawn from those adults inal justice services and general health care
indications of higher service use by the who as children attended the Child and services (general practitioners and nurses).
comorbid group than the general adult Adolescent Psychiatric Department of the
population. Maudsley Hospital (south London) be-
tween 1970 and 1983. The Maudsley Item Cost calculation
Conclusions The high and enduring Sheet database was searched, as described Service use data were combined with
long-term costs associated with childhood (2001a
in full by Fombonne et al (2001a), to identify appropriate unit costs to generate service
depression and conduct disorder give 245 children who met DSM±IV criteria for costs per subject. Unit costs for 1996±
major depressive disorder with or without 1997 were obtained from a recognised
further reason for early and effective
conduct disorder (American Psychiatric national source (Netten & Dennett, 1997)
intervention. Association, 1994). The interviews covered and supplemented from a previous study
lifetime rates of affective disorders and al,
(McCrone et al, 1998) with adjustments
Declaration of interest This study other psychiatric disorders; social dysfunc- to 1996±1997 values.
was funded by a special grant from the tion in key domains of adult life; family Costs were presented (and analysed) as
Medical Research Council and a grant psychiatric history; childhood experiences annual figures. Therefore, costs of services
from the Department of Health. of care and abuse; adverse life events; social used since age 17 years were divided by
support networks; and patterns of service the number of years elapsed between then
use. Interviewees completed self-report and the interview date, and costs for
assessments of self-esteem, self-efficacy, services measured over a 6-month period
personality, beliefs and assumptions about were multiplied by two.
KNAP P E T AL
Using unpublished unit cost figures population. Comparisons could not be greater proportion of the MDD group lived
from the Home Office we calculated total made for all services because national data with two parents and this group also had a
and annual crime costs for each participant are not as comprehensive as data collected significantly higher average IQ score
from their CRO records. These Home for this sample, nor were they straight- (although this was measured only for 84
Office costs primarily include expenditure forward because the period over which (2001a
subjects). Fombonne et al (2001a,b) have
by the criminal justice system. We reported service use was measured differed. described the sample along these and various
these costs separately to ensure that we did Analyses were carried out using SPSS other dimensions, and we do not repeat the
not double-count, as criminal justice ser- version 7 (SPSS, 1997) and STATA release details here. There were few statistically
vice contacts were also recorded from the 6 (Stata Corporation, 1999). significant differences (at the 5% level of
interviews. significance) between the costed sample
(n140) and those for whom cost data
were not obtained (n9). As children,
Statistical analyses Sample size and characteristics members of the costed sample group were
The representativeness of the costed sample For the period 1970 to 1983, a total of significantly more likely to have received
was tested by comparing it to the subjects 5380 children were recorded in the data- 0.019)
individual therapy (66% v. 25%, P0.019)
for whom cost data were not available. base maintained by the Child and Adoles- and their parents were more likely to have
Chi-squared tests were conducted for cate- cent Psychiatry Department, 935 of whom received counselling (49% v. 0%,
gorical variables. The proportions of sub- had depressive syndromes. Ratings were 0.007).
P0.007). Of the costed sample 49 (35%)
jects in the two groups (depression made from case notes for 645 of them. Of had had CD±MDD as children, and in the
without or with conduct disorder) using the 245 people who met criteria for non-costed sample the figure was 4 (44%)
each service (or group of services) were DSM±IV major depressive disorder, 8 had 0.721).
compared using logistic regression, control- died (6 CD±MDD, 2 MDD), 48 could not
ling for gender and age. Controlling for age be traced, and 40 either refused to be inter-
was particularly important because sample viewed or repeatedly failed to keep
members had different exposure times for appointments with interviewers. Of the Service use patterns
services since age 17 years. The dependent remaining 149 who were successfully inter- Utilisation rates were quite high, both for
variable used in the logistic models took viewed in adulthood, 53 had had CD± services used since age 17 years and for those
the value 1 if the service was used and 0 if MDD in childhood. Service use data were used in the 6 months immediately prior to
it was not. Independent variables were missing for 9 of these 149 people, leaving interview (Table 1). For example, 12
group (1 indicating depression with con- 91 with MDD (when a child) and 49 with (13%) people with MDD in childhood and
duct disorder, and 0 without), gender (1 CD±MDD. 13 (27%) people with CD±MDD had at
for men, 0 for women) and age in years. A majority (61%) of the 140 partici- least one psychiatric in-patient admission
Regression analyses were used to com- pants were female and the average age since age 17. For psychiatric out-patient
pare service costs between the groups with when first attending the Maudsley was services the respective proportions were
and without conduct disorder. The depen- 13.8 years (depression group) and 14.1 22% (20) and 31% (15) and for criminal
dent variable was the annual cost of each years (comorbid group). A significantly justice services 36% (33) and 65% (32); the
service in turn; independent variables were
Table 1 Number and percentage of adults using services during follow-up period
again group, gender and age. Cost data
are often highly skewed, because a substan-
tial number of subjects may have no contact Service (n 91) (n 49)
MDD (n91) CD^MDD (n49) OR1 (95% CI) P
with a specific service whereas a small num- No. (%) No. (%)
ber may have a very high level of utilis-
ation. Non-normality of cost variables is Since age 17 years
only a problem in regression analysis if General hospital in-patient 55 (60) 35 (71) 2.25 (0.98^5.19) 0.056
the regression residuals are themselves not General hospital out-patient 64 (70) 39 (80) 1.57 (0.68^3.64) 0.288
normally distributed, in which case a method Psychiatric hospital in-patient 12 (13) 13 (27) 2.81 (1.12^7.01) 0.027
such as bootstrapping can be employed Psychiatric hospital out-patient 20 (22) 15 (31) 1.71 (0.76^3.87) 0.194
(Thompson & Barber, 2000). Bootstrap re- Criminal justice services2 33 (36) 32 (65) 3.52 (1.62^7.65) 50.001
gression was used here. We generated 1000
random samples with replacement from the During preceding 6 months
original data-set, each the same size as the General health3 69 (76) 37 (76) 1.03 (0.46^2.34) 0.934
original. Regression coefficients were calcu- Psychiatrist/psychologist 6 (7) 3 (6) 1.01 (0.24^4.31) 0.989
lated on each of the 1000 re-samples, the Social worker 5 (5) 5 (10) 2.06 (0.55^7.65) 0.282
distribution of the coefficients for the group Community psychiatric nurse 5 (5) 2 (4) 0.84 (0.15^4.63) 0.843
variable was observed, and the probability Counsellor 8 (9) 4 (8) 0.92 (0.26^3.27) 0.894
calculated that in the population this coeffi-
Day care 4 (4) 1 (2) 0.46 (0.05^4.27) 0.492
cient would equal zero (Mooney & Duval,
1993). CD, conduct disorder; CD ^MDD, major depressive disorder with comorbid conduct disorder.
1. Odds ratio (odds of comorbid group using service compared with depression group).
Finally, the figures for service use were 2. Police, probation, court attendances, prison.
compared with data from the general 3. General practitioners, general nurses.
HI DHOO I ON
C H I L D HOO D D E P R E S S ION A N D S E R V I C E C O S T S IN A D U LT HOO D
proportions for use of prison were 2% (2) associated with general health care, social significantly higher for the comorbid group
and 14% (7). worker contacts (particularly for the CD± (mean of £179) than for the MDD group
The proportions of children treated for MDD group) and day care. (£32) (bootstrapped t-test, P50.001).
CD±MDD who had used psychiatric in- The annualised costs of some individual Again, there was a wide variation in the
patient and criminal justice services since services were significantly higher for the crime costs (85% of the MDD group and
age 17 years were significantly (P50.05) CD±MDD than the MDD group, notably 61% of the CD±MDD group had no crime
higher than for those treated for MDD as general hospital out-patient visits and crim- costs). The maximum annualised crime
children (Table 1). There was also a trend inal justice services, after adjusting for gender costs were £522 and £2208 for the MDD
for this group to make more use of psy- and age. Even when differences were not and CD±MDD groups respectively.
chiatric out-patient and general hospital statistically significant, the trend was for
in-patient and out-patient services. Looking costs to be higher for CD±MDD than for Cost contributions
at the 6-month period before the follow-up MDD, with the exception of day care.
In-patient care accounted for 57% of the
interview, 76% (both groups) had seen Overall, the annualised total cost for the
service costs for the MDD group and 51%
their general practitioner at least once (the CD±MDD group (£1372) was more than
of the costs for the CD±MDD group (Table
average number of contacts was 2.15 for twice that of the MDD group (£631,
3). Legal services accounted proportionately
the MDD group and 2.55 for the CD± 0.015).
for eight times as much cost in the CD±
MDD group), and 4±10% had consulted a The distribution of service costs was
MDD group compared with the MDD
psychiatrist, social worker, community substantially skewed. The median annual
psychiatric nurse or counsellor. cost for the MDD group was £147 with a
range of £0 to £7327. For the CD±MDD
Service costs group the median was £326 and the range Comparison with population data
was £5 to £7532. The difference in costs Use of prison
Annualised costs indicate intensity of use,
was again found to be statistically signifi- In the general population it has been esti-
weighted by their resource implications.
cant (P0.031) when the Kruskal±Wallis mated that approximately 4% of people
The largest cost elements, not surprisingly,
non-parametric test was used. who were born in 1953 had received a cus-
were associated with psychiatric and general
in-patient service use (Table 2). Criminal todial sentence by the time they were aged
justice service use since age 17 years was 1999a
40 (Home Office, 1999a). In this study
high for the CD±MDD group but not for Crime costs (where all subjects were aged 25±43 years)
the MDD group. In the 6 months before The annualised costs of crimes committed we found that 2% (95% CI 0±8%) of sub-
the follow-up interview, highest costs were since age 17 (based on CRO data) were jects who had had MDD as children and
14% (95% CI 6±27%) of those who had
Table 2 Annualised service costs per patient (1996/7 »s)
had CD±MDD had spent some time in cus-
tody since the age of 17. Comparing the
Service (n 91)
MDD (n91) (n 49)
CD^MDD (n49) P population figure to the 95% confidence
Mean s.d. Mean s.d. intervals reveals that the CD±MDD group
are significantly more likely to be impri-
Since age 17 years soned. Some of these people would have
General hospital in-patient 161 585 270 653 0.235 been remanded to custody rather than given
General hospital out-patient 32 57 81 130 0.003 a custodial sentence, although we do not
Psychiatric hospital in-patient 193 893 422 1148 0.101 know the proportions. Official figures reveal
Psychiatric hospital out-patient 64 432 79 242 0.723 that approximately 29% of those in custody
Criminal justice services1 11 65 232 805 0.011 are on remand (Home Office, 1995,
1999b). Even allowing for the likelihood
Total lifetime costs per year 462 1133 1085 1790 0.015
that some of the CD±MDD group with cus-
During preceding 6 months todial stays were only ever remanded and
not sentenced, it is still probable ± particu-
General health2 51 65 65 120 0.375
larly given that the average age of this sample
Psychiatrist/psychologist 13 58 15 66 0.995
was less than 40 years ± that subjects who
Social worker 22 92 150 619 0.067
had had CD±MDD were much more likely
Community psychiatric nurse 5 32 9 45 0.627
to be imprisoned than the general popu-
Counsellor 19 80 12 65 0.549 lation average, whereas the MDD group
Day care 58 425 36 254 0.631 were similar to the general population.
Total 6-month costs per year 169 513 287 798 0.293
Use of out-patient care
Total service costs 631 1324 1372 2209 0.015
Based on the rate of out-patient appoint-
Costs of crime since age 17 years 32 91 179 425 50.001 ments per year (psychiatric and general
health), which we assumed to be constant,
CD, conduct disorder; CD ^MDD, major depressive disorder with comorbid conduct disorder.
1. Police, probation, court attendances, prison.
we estimated (using a cumulative Poisson
2. General practitioners, general nurses. distribution) that 15% (95% CI 9±24%)
KNAP P E T AL
Table Contribution of services to annualised general population and also an increased the comparisons do indicate that members
total cost likelihood for the MDD group, although of the MDD group have a similar level of
the latter is not significant at the 95% level use of criminal justice and out-patient ser-
Service MDD CD^MDD
of confidence. vices and a trend towards greater use of
in-patient care than the general population,
while the CD±MDD group use all these ser-
% % Use of GP care
vices substantially more than the general
We found that the mean number of general population. However, no clear differences
Since age 17 years
practitioner (GP) contacts during the pre- can be detected between these groups and
vious 6 months was 2.2 for the MDD group the general population with regard to gen-
In-patient 26 20 and 2.6 for the CD±MDD group. If we eral practitioner care. The finding that the
Out-patient 5 6 assume a constant rate of GP contacts over MDD group did not appear to be high ser-
Psychiatric hospital the year then we have annual averages of vice users compared with the general popu-
In-patient 31 31 4.4 (95% CI 3.4±5.4) and 5.2 (95% CI lation is of prime importance. However,
Out-patient 10 6 3.1±7.3) respectively. In the general popu- caution is necessary as the range of services
Criminal justice services 2 17 lation, the mean number of GP contacts in for which we could make such comparisons
1993 for those aged 16±64 years was 5 was limited. It is unlikely that the average
Subtotal 73 79
(Foster et al, 1995). annual care cost of £631 would be matched
During preceding 6 months in the general population. Although we were
General health 8 5
DISCUSSION able to compare proportions of people using
Psychiatrist/psychologist 2 1 in-patient care and being imprisoned, we
Importance of findings
Social worker 3 11 were not able to compare lengths of stay,
Children with conduct disorder and/or which are clearly important `drivers' of cost.
Community psychiatric 1 1 depression can generate quite high costs in
childhood (Knapp et al, 1999), but there
Counsellor 3 1 are few published studies of the economic Previous findings
Day care 9 3 consequences of mental health problems Although no previously published study has
in childhood or adolescence, or of their made comparisons of costs for children
Subtotal 27 21
treatment. Among the exceptions are Siegert with MDD and CD±MDD, the large body
Total 100 100 & Yates (1980), Bickman et al (1996), of international evidence (as reviewed by
Greenwood et al (1996), Byford et al Maughan & Rutter, 1998) of impaired per-
CD, conduct disorder; CD ^MDD, major depressive (1999), Knapp et al (1999) and Leibson et
disorder with comorbid conduct disorder. sonal development and social functioning
al (2001). There have been few published for adults who had CD±MDD as children
of the MDD group and 39% (95% CI 25± UK studies to date that have followed chil- would suggest that service use and costs
54%) of the CD±MDD group would have dren with disorders through into adulthood are high. In an American study comparing
had an appointment during the previous 3 and examined the economic consequences, adult mental health service users who had
months. In 1993 it was estimated that although other work is emerging (Scott et also received child psychiatric services with
16% of the general population aged 16±44 al,
al, 2001). The study reported here is there- those who had not received child services,
years would have had out-patient or accident fore unusual in its focus. Woodward (1995) found that the former
and emergency clinic contacts during such a group had higher levels of service use and
period (Foster et al, 1995). Therefore, the
al, Limitations also were more likely to have been involved
CD±MDD group were 2.4 times more Although the service and crime costs for the in criminal activity as adults. The adult-
likely than the general population to have CD±MDD group are high, they are likely to hood follow-up of a conduct disorder sample
used this type of service and this was statis- be an underestimate of the true costs. For by Scott et al (2001) found substantial costs
tically significant, whereas the MDD group instance, the costs of lost employment as a through to age 28 years, particularly linked
were fairly similar to the population norm. result of ill health have not been included, to criminality. In another American study,
nor have the costs associated with the Weissman et al (1999) found that 55% of
high levels of suicide and suicide attempts adults who had had MDD were admitted
Use of in-patient care al, 2001b
(Fombonne et al, 2001b). to hospital for psychiatric reasons during
In a similar manner we estimated that 12% The comparisons between the service a follow-up period of some 10 years, and
(95% CI 6±21%) of the MDD group and use data reported here and population fig- 45% were admitted for medical reasons.
22% (95% CI 12±37%) of the CD±MDD ures also need to be treated with caution The respective figures for a `healthy' com-
group would have been in-patients during because the periods over which measures parison group were 5% and 19%. The fig-
the previous year (psychiatric and general were taken were not the same. In partic- ures for the MDD subjects in that study
hospital stays combined). This compares ular, the General Household Survey (Foster were, therefore, much higher than those re-
with 9% of the general population between al,
et al, 1995) measures service use for the ported here. Some of the difference in ad-
the ages of 16 and 44 years (Foster et al, previous year or the previous 3 months. In missions between American and UK MDD
1995). Therefore, we see a higher rate of order to make comparisons we have subjects may be due to idiosyncrasies in
use of services for the CD±MDD group assumed a constant rate of service use which the respective health care systems, but other
(by a factor of 2.6) compared with the may not necessarily hold true. Nevertheless, factors may also be influential.
HI DHOO I ON
C H I L D HOO D D E P R E S S ION A N D S E R V I C E C O S T S IN A D U LT HOO D
The House of Commons Health Committee CLINICAL IMPLICATIONS
looked at child and adolescent mental
health services a few years ago. They com- & Children with comorbid depression and conduct disorders have higher adulthood
mented that: service use and costs than those without conduct disorder, and also than those of the
The cost of conduct disorder, both in terms ofthe general population.
quality of life ofthose who have conduct disorder
and the people around them, and in terms of the & The cost of criminal justice services associated with comorbid depression and
resources necessary to counteract them, is high. conduct disorder is substantially greater than with depression alone.
It is therefore important that treatment for con-
duct disorder is both effective and cost-effective & Treatment strategies need to take into account the long-term resource
(House of Commons Health Committee, 1997: implications of childhood mental health problems.
If the sentiment in this quotation is extended LIMITATIONS
to include childhood depression, it is clear
& Many subjects were lost to follow-up. It is possible that these had different service
from the findings of the present study that
the interpretation of `cost-effective' needs use and cost profiles to those who were followed up.
to be broadened to range beyond the child- & The estimated costs were underestimates of the true costs.
hood years. There are high, and certainly
enduring, costs associated with childhood & Service use and costs were not directly measured for a general population sample,
depression and especially with comorbid although secondary comparisons could be made.
conduct disorder. Early, effective interven-
tions could do much to reduce these cost
consequences while also improving the
quality of life of the individuals concerned.
MARTIN KNAPP, PhD, PAUL McCRONE, PhD, Centre for the Economics of Mental Health, Institute of
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