Economic Evaluation of Mobile Mental Health Units in Greece: The Case of Cyclades Islands

Background: In Greece, the provision of mental health services is limited to people residing in rural and remote areas. The operation of Mobile Mental Health Units (MMHUs) has been introduced in the Cyclades islands. It is an innovative policy intervention that has been shown to be effective and efficient internationally. Objective: The aim was to evaluate the operation of MMHUs in the Cyclades islands based on real-world evidence (RWE), from a societal perspective. Methods: A cost-effectiveness analysis was performed where outcomes and costs were elaborated and classified based on two comparators, 1) with MMHUs’ operation and 2) without MMHUs’ operation. Clinical primary outcomes were based on RWE data and were elaborated for the Disability-Adjusted Life Years (DALYs) values calculation, for a 12 months’ time horizon. Data descriptive statistics were performed with SPSS Statistics 22.0. Direct medical, non-medical and indirect costs were incorporated. Unit costs and monetary values were extracted from published data. Sensitivity analysis was undertaken to test the robustness of the results. Results: The operation of MMHUs in the Cyclades islands led to an incremental cost of €12,250.78 per DALY averted. A substantial higher increase is observed in the direct non-medical costs of the non-MMHUs’ operation where patients had to pay approximately €2,602 per capita annually for their in Greece. MMHUs appear to overcome the existing NHS structural inefficiencies by minimizing public expenditures and patients’ income losses by preventing and improving their mental health status.


Introduction
The burden of illnesses from mental health disorders is by far the highest of all health problems worldwide, ranging from 10% to 13% of the total burden of illness from all diseases and accounting for 32.4% of years lost due to mental illness or disability (YLDs) and 13% of Disability-Adjusted Life Years (DALYs) [1] [2] [3].
In Greece, the provision of mental health is limited to people residing in rural and remote areas although the universal and free access to health care constitutes fundamental principles of the National Health System (ESY) since its establishment in 1983. This has been discussed and characterized as a major public health problem with marked consequences for society [4] [5] [6]. Numerous studies in the country report increases in mental health disorders, such as major depression, diseases of nervous system, even suicides et al. [6] [7] [8] [9].
Greece is a country with a plethora of islands. Hence the authorities diachronically are confronted with the severe structural dysfunction of inadequate provision of medical care in the islands [10]. The operation of Mobile Mental Health Units (MMHUs) has been introduced in the Cyclades islands. It is an innovative policy intervention that has been shown to be effective and efficient internationally [11] [12] [13] [14] [15]. The MMHUs have a community orientation and are based on the interconnection with the local medical bodies of the islands in order to enable the development of actions for the promotion of public mental health [16]. The operation of MMHUs is mainly aimed at the provision of primary mental health services, but also workshops, educational seminars to health professionals, teachers and other professional groups e.g. police officers, have been organized so as to be able to identify, manage and refer people in need for mental health care [17].
The Association for Regional Development and Mental Health (EPAPSY) has taken over the responsibility of the MMHUs operation in the northeastern and western Cyclades, an initiative funded by the Greek Ministry of Health and local authorities. The mission of the MMHUs is to provide free access to mental health services in the 12 islands of Cyclades, in accordance to the principles of community psychiatry [16]. Prior to the MMHUs operation, mental care provision for the residents of Cyclades was very restricted [17]. The majority of patients with mental disorders were either not treated or mistreated due to the lack

Methodology
An economic evaluation analysis has been performed and more precisely, a cost-effectiveness analysis (CEA). Outcomes and costs were elaborated and classified based on two comparators, 1) with MMHUs' operation and 2) without MMHUs' operation. Clinical primary outputs were based on RWE data obtained by EPAPSY. The survey was granted an EPAPSY's approval.

Sample
In  [20]. The calculation was formulated as follows:

Cost Data
The human capital approach, and most particularly direct medical and non-medical costs as well as indirect costs, were incorporated in the analysis and The indirect cost estimation included: 1) patients' productivity losses due to early retirement, 2) income losses due to mortality and disability, 3) disability benefits as well as 4) informal care provided by caregivers for the seriously ill pa-

Economic Evaluation Analysis
Costs and outcomes estimates for both comparators were used for the conduction of CEA and more specifically, for the incremental cost effectiveness ratio The societal perspective was used in the analysis for a 12-month time horizon, given that overall direct and indirect costs are incorporated, illustrating both governments' expenses, a part of which is the NHS, and patients' private expenses.

Sensitivity Analysis
We have patient-level cost data which are right-skewed (small proportion of patients will have large costs which distort the mean value of the sample). For this reason, in order to compare the means of the two interventions, we used

Results
Descriptive statistics, as presented in    Table 4.  Table 5 shows the results of the mean difference between the two treatment arms for the base case analysis and two sensitivity analyses (±10% in unit costs)

Discussion
The increasing prevalence of mental disorders has severe implications in terms of costs and burden of disease since they are related to severe distress and functional impairment that can have dramatic consequences not only for those affected but also for their families and their social and work-related environment.
Τhe burden from mental disorders worldwide is ranging from 10% to 13% of the global burden of disease and is identified as the leading cause for patients with disabilities among all disease groups [1] [2] [3].
In the European Union (EU), due to the continuing demographic changes and the longer life expectancy, the long-term burden of mental disorders is even expected to double by 2030, in both direct and indirect costs [28] [29]. It should be also noted that in many high-income as well as EU countries, access to mental health care is generally restricted due to lack of qualified personnel, infrastructure and preventive programs as well as effective evidence-based treatments [30] [31]. This is a positive and rather expected finding given that the relevant increase in the MMHUs' operation arm facilitates patients' access to medication and consequently covers the existing unmet needs that deteriorate their mental health status. Adversely, all other direct healthcare cost components, such as medical visits and hospitalization in the MMHUs' non-operation arm, had to be pro-Health vided by specialists located in Athens or even in Syros, impacting negatively patients' income. This is the reason for which the societal perspective was chosen in this economic evaluation and broader outcomes of the direct and indirect costs were taken into account since the effects of any mental intervention strongly rely on social outcomes. Nonetheless, the operation of Mobile Health Units (MHUs) has already been shown as a cost-effective and cost saving option by other researchers and its use in the field of mental health is suggested [36] [37] [38] [39]. In addition, the findings of this study are in accordance with the results of a study conducted in New Hampshire which estimated the operational cost of the MMHUs to be €495,858 in 2015 [40].
A potential limitation of the study is that it focuses only on a specific area and the results cannot be generated in the country. However, the use of RWE in a remote geographical area confirms our results, mapping the existing unmet needs and the necessity of the MMHUs' operation. Another limitation of the study is the use of one year analytical clinical and economic data in the economic evaluation analysis, given the lack of comparable data. Obviously, the existence of time-series data would provide more reliable and robust results.

Conclusion
The operation of MMHUs in geographical areas where access to mental care is limited, appears to be a cost-effective option for patients suffering from mental disorders. In Greece, a country with a large number of inaccessible and sparsely populated remote areas, MMHUs appear to overcome the existing NHS structural inefficiencies by minimizing public expenditures as well as patients' income and productivity losses and improving their mental health status. Economic evaluation studies' results based on the use of RWE should support rational resources' allocation and health policy decision making.