Articles

Scaling-up treatment of depression and anxiety: a global

return on investment analysis
Dan Chisholm, Kim Sweeny, Peter Sheehan, Bruce Rasmussen, Filip Smit, Pim Cuijpers, Shekhar Saxena

Summary
Background Depression and anxiety disorders are highly prevalent and disabling disorders, which result not only in Lancet Psychiatry 2016
an enormous amount of human misery and lost health, but also lost economic output. Here we propose a global Published Online
investment case for a scaled-up response to the public health and economic burden of depression and anxiety April 12, 2016
http://dx.doi.org/10.1016/
disorders.
S2215-0366(16)30024-4
See Online/Comment
Methods In this global return on investment analysis, we used the mental health module of the OneHealth tool to http://dx.doi.org/10.1016/
calculate treatment costs and health outcomes in 36 countries between 2016 and 2030. We assumed a linear increase S2215-0366(16)30031-1
in treatment coverage. We factored in a modest improvement of 5% in both the ability to work and productivity at Department of Mental Health
work as a result of treatment, subsequently mapped to the prevailing rates of labour participation and gross domestic and Substance Abuse, WHO,
product (GDP) per worker in each country. Geneva, Switzerland
(D Chisholm PhD, S Saxena MD);
Victoria Institute of Strategic
Findings The net present value of investment needed over the period 2016–30 to substantially scale up effective Economic Studies, Melbourne,
treatment coverage for depression and anxiety disorders is estimated to be US$147 billion. The expected returns to VIC, Australia (K Sweeny PhD,
Prof P Sheehan PhD,
this investment are also substantial. In terms of health impact, scaled-up treatment leads to 43 million extra years of
Prof B Rasmussen PhD); Trimbos
healthy life over the scale-up period. Placing an economic value on these healthy life-years produces a net present Institute (Netherlands
value of $310 billion. As well as these intrinsic benefits associated with improved health, scaled-up treatment of Institute of Mental Health and
common mental disorders also leads to large economic productivity gains (a net present value of $230 billion for Addiction), Utrecht,
Netherlands (Prof F Smit PhD);
scaled-up depression treatment and $169 billion for anxiety disorders). Across country income groups, resulting
and Department of Clinical,
benefit to cost ratios amount to 2·3–3·0 to 1 when economic benefits only are considered, and 3·3–5·7 to 1 when the Neuro and Developmental
value of health returns is also included. Psychology, Vrije Universiteit
Amsterdam, Netherlands
(Prof F Smit, Prof P Cuijpers PhD)
Interpretation Return on investment analysis of the kind reported here can contribute strongly to a balanced
investment case for enhanced action to address the large and growing burden of common mental disorders worldwide. Correspondence to:
Dr Dan Chisholm, Department of
Mental Health and Substance
Funding Grand Challenges Canada. Abuse, WHO, Geneva 1211,
Switzerland
ChisholmD@WHO.int
Copyright © Chisholm et al. Open Access article distributed under the terms of CC BY.

Introduction estimated US$2·5–8·5 trillion in lost output was

Worldwide, investments in mental health are very attributed to mental, neurological and substance use
meagre. Data from WHO’s Mental Health Atlas 2014 disorders, depending on the method of assessment
survey1 suggest that most low-income and middle-income used.2 This sum is expected to nearly double by 2030 if a
countries spend less than US$2 per year per person on concerted response is not mounted.2 In view of this
the treatment and prevention of mental disorders concern, the promotion of mental health and wellbeing
compared with an average of more than $50 in high- have been explicitly included in the United Nations’
income countries. As a result of this limited investment 2015–30 Sustainable Development Goals.6
in public mental health, a substantial gap exists between Cost-effectiveness studies have largely restricted
the need for treatment and its availability. This large themselves to a consideration of the specific
treatment gap affects not just the health and wellbeing of implementation costs and health outcomes of an
people with mental disorders and their families, but also intervention, and have typically not extended to a full
has inevitable consequences for employers and estimation of the wider socioeconomic value of
governments as a result of diminished productivity at investment in mental health innovation and service
work, reduced rates of labour participation, foregone tax scale-up. As shown in the Lancet Commission on
receipts, and increased health and other welfare Investing in Health, elucidation and enumeration of
expenditures. Findings of several national and these wider economic and social benefits provides a
international studies2–5 have shown the enormous more comprehensive assessment of the returns on
economic challenge these disorders pose to communities investment.7 In particular, increasing attention and
and society at large as a result of foregone production emphasis is being given to extending valuation to also
and consumption opportunities as well as health and include the intrinsic value of improved health (a so-called
social care expenditures. In 2010, worldwide, an full income approach to national accounting).7

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Research in context
Systematic review they did not report sufficient detail. Accordingly, we did an
We did a systematic review of studies published until Jan 1, additional search on May 21, 2105, to widen our search to
2015, of the effect of treatment of depression and anxiety include anxiety disorders with greater emphasis on economic
disorders on economic outcomes (return to work, absenteeism, outcomes in PubMed, EMBASE, PsycINFO and the Cochrane
and presenteeism rates). We searched an existing database on Library (search terms listed in appendix p 5). We found few
psychological treatments of depression, which has been useful data and these could not be synthesised
described in detail by Cuijpers and colleagues, and has been meta-analytically. The same conclusion was made in a similar
For the published used in a series of earlier published meta-analyses. We review of the scientific literature.
meta-analyses see http://www. identified abstracts by combining terms indicative of
evidencebasedpsychotherapies. Interpretation
psychological treatment and depression (both medical subject
org This analysis sets out a model linking the prevalence of
headings terms and text words; search terms listed in appendix
depression and anxiety disorders with expected health and
p 4). For this database, we examined 17 061 abstracts from
economic benefits of scaled-up treatment, including restored
PubMed (4007 abstracts), PsycINFO (3147 abstracts), Embase
labour participation and productivity. Results from the analysis
(5912 abstracts), and the Cochrane Central Register of
suggest that monetised benefits of better health and labour
Controlled Trials (3995 abstracts). We included all randomised
force outcomes outweigh the costs of achieving them by
trials comparing a psychological treatment with a control
2·3–3·0 to 1 when economic benefits only are considered, and
condition (waiting list, care as usual, placebo), another
3·3–5·7 to 1 when the value of health returns is also included.
psychological treatment, pharmacotherapy, or combined
treatment. We excluded studies in adolescents, children, and Treatment of common mental disorders leads to improvements
inpatients, and maintenance trials. We scrutinised all in economic production and health outcomes. Clinicians should
440 studies identified in this database for economic outcome increase the detection and management of people with
data. Although four studies had data for functioning at work, depression and anxiety disorders.

Here we did a global return on investment analysis for then established the health effects of scaled-up coverage
mental health in people aged 15 years and older focusing of effective intervention, and finally calculated the
on depression and anxiety disorders, which are the most economic effect of improved mental health outcomes in
prevalent mental disorders. These disorders lead to large terms of enhanced labour participation and productivity.
losses in work participation and productivity, and yet Panel 1 provides more detail on the health and economic
lend themselves to effective and accessible treatment as benefits captured in, and omitted from, the analysis. The
part of an integrated programme of chronic disease key outputs of the model are year-on-year estimates of
management.8–10 the total costs of treatment scale-up and system
strengthening (ie, the investment), increased healthy
Methods life-years gained as a result of treatment (ie, health
Analytical framework return), the value associated with better health (ie, the
Because depression and anxiety disorders represent a value of health returns), and enhanced levels of
public health challenge worldwide, we did a global productivity (ie, economic return). The stream of costs
investment appraisal in low-income, middle-income, and incurred and benefits obtained between 2016 and 2030
high-income countries. The 36 countries for which we were discounted at a rate of 3%, to give a net present
modelled costs and benefits of scaled-up treatment, value. All costs and monetised benefits were expressed in
which span all six of WHO’s major regions, account for constant US$ for the year 2013.
80% of the world’s population and 80% of the global
See Online for appendix burden of depression and anxiety disorders (appendix p 1). Population and disease modelling
Results for these countries were aggregated and reported We used the mental health module of the inter-UN
For the OneHealth tool see by income level (low, lower-middle, upper-middle, high). agency OneHealth tool to estimate the number of people
http://www.who.int/choice/ We set the scale-up period at 2016–30, in line with the with depression and anxiety disorders living in the
onehealthtool
timeline of the post-2015 Sustainable Development 36 large countries until 2030. Estimates are based on UN
Goals. population projections and Global Burden of Disease
The economic and social benefits of good mental prevalence estimates for 2010.11,12 The global point
health include both its intrinsic value (improved mental prevalence rate for anxiety disorders is 7·3%;13 for
health and wellbeing) and also its instrumental value, in depression it is 3·2% for men, and 5·5% for women.14
terms of being able to form and maintain relationships, The OneHealth tool also links the epidemiology of
to work or pursue leisure interests, and to make decisions depression and anxiety disorders (prevalence, incidence,
in everyday life. To assess the value of these benefits, first remission, excess mortality, and disability weight)12–14 to
we estimated the population in need in each country, country-specific life tables, so that cases averted and

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healthy life-years gained over time at the population level

can be estimated. Healthy life-years reflect time spent by Panel 1: Health, economic, and social benefits of scaled-up treatment for depression
the population in a particular state of health with a and anxiety disorders
known degree of disability. Estimation of healthy life- Health effects
years for depression took into account its association To establish the effect of treatment, we used rates of improved recovery or remission and
with excess mortality (due to suicide and other causes of levels of functioning. Improved functioning translates into fewer life-years spent by the
death).14 population in a state of diminished health, whereas an increased rate of remission leads
to a decrease in the prevalence of these disorders over time. Depression is also associated
Intervention effects, costs, and coverage with an excess risk of premature mortality because of suicide and other causes of death.
Intervention effects We projected a reduction in excess mortality, amounting to an increase in healthy life
We restricted the analysis of interventions within the expectancy, as a result of averting cases of depression in the population. Although
OneHealth tool to treatment because the evidence on depression and anxiety disorders are often comorbid with each other, and with a range of
prevention of depression and anxiety is quite weak and of other health disorders (eg, substance use disorder, other non-communicable diseases and,
uncertain generalisability to low-income and middle- in certain populations, in people with HIV/AIDS) we were not able to account for these
income country settings.15 In line with WHO’s Mental comorbidities in the analysis. Additionally, we were unable to capture the positive effect
Health Gap Action Programme (mhGAP) intervention of treatment on the mental and physical health of close family members, including
guide, modelled interventions included basic psycho­ infants of mothers with perinatal depression, despite robust evidence that depression can
social treatment for mild cases, and either basic or more adversely affect infant attachment and subsequent child growth and cognitive
intensive psychosocial treatment plus anti­ depressant development.
drug for moderate to severe cases.16 Moderate to severe
cases of depression were split into first-episode and Economic effects
recurrent episode cases. We calculated the health effect A direct potential benefit of successfully treating common mental disorders is a decrease in
of treatment in terms of a proportionate improvement in overall health-care costs. Although interventions have their own costs, these can be more
the rate of remission, equivalent to a shortening of the than offset by a reduction in other services, notably hospital-based inpatient episodes or
duration of an episode of illness, and also, up to the point outpatient visits. Reduced use of informal and indigenous health-care providers, such as
of recovery, an improvement in the average level of faith healers or traditional healers, is a further expected source of cost savings in many
functioning as reflected in the disability weight for the countries. Estimation of the predicted extent of these cost offsets is very challenging at the
disorder.8,10 The appendix shows the effect size estimates international level because it requires detailed information about both the varying level of
and their derivation (appendix p 2); these take into comorbidity across diverse populations and the typical use of non-intervention related
account partial response, the lag time between onset of services. Accordingly, we did not explicitly consider such effects in our analysis. Similarly, we
the disorder and treatment, and expected levels of non- did not have sufficient information across countries to model the reduced need for other
adherence in treated populations. welfare-related services potentially available to people with depression and anxiety
disorders, including unemployment benefit or income support and social or disability
Intervention costs assistance. In the mainly high-income countries where such welfare support is widely
We worked out total costs in a given year for a country available, depression and other common mental disorders account for a significant
by multiplying resource use needs by their respective proportion of overall payments.5 Instead, the analysis focused on the financial benefits
unit costs to give a cost per case, which was then flowing from increased rates of workforce participation and productivity. The analysis only
multiplied by the total number of cases expected to considers the contribution to the economy as a whole through increased economic output;
receive a particular intervention. Country-specific unit it does not estimate the various income shares of this output.
costs of inpatient and outpatient care were taken from a Social effects
WHO database, adjusted to 2013 price levels.17 Treatment Conceptually distinct from improvements in clinical functioning (health effect) and the
costs relied on previous cost-effectiveness studies and restored ability to do paid work (economic effect), the successful treatment of depression
resource need profiles garnered from existing treatment and anxiety disorders leads to improved opportunities for individuals and households to
guidelines and costing studies.10,16,18,19 Key categories of pursue their leisure interests, participate more in social and community activities, and
resource use were: medication: 6 months continual carry out household production roles. The economic worth of these non-market
antidepressant drug (generically produced fluoxetine) production and welfare gains is incorporated into our estimate of the intrinsic value of
was included for moderate to severe cases; outpatient mental health.
and primary care: regular visits were needed for all
cases, ranging from four per case per year for basic
psychosocial treatment, up to 14–18 visits for moderate providers trained in the identification, assessment, and
to severe cases receiving antidepressant drug and management of depression and anxiety disorders; and
intensive psychosocial treatment (half of whom are inpatient care: few cases are expected to be admitted to
assumed to receive this on an individual basis, the other hospital (2–3% of moderate to severe cases only, for an
half in groups); in line with the mhGAP intervention average length of stay of 14 days).
guide, it is envisaged that this care and follow-up would Additionally, we included an estimate of the expected
largely be undertaken in non-specialist health care level of programme costs and shared health system
settings by doctors, nurses and psychosocial care resources needed to deliver interventions as part of an

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integrated model of chronic disease management. These base case, we conservatively modelled a 5% restored
include programme management and administration, ability to work as a result of treatment, with half and
training and supervision, drug safety monitoring, health double that rate used under pessimistic and optimistic
promotion and awareness campaigns, and strengthened scenario analyses. Impaired productivity was assessed
logistics and information systems. We expressed both with respect to whole days off work (absenteeism)
estimates as an on-cost to the estimated direct health- and also partial days of impaired activity while an
care costs. The baseline value for this on-cost was 10% individual is at work (presenteeism). Compared with
(and therefore grows in absolute terms during scale-up). adults without common mental disorders in a range of
low-income, middle-income, and high-income countries
Intervention coverage participating in the World Mental Health Survey,
The appendix provides coverage rates used for each 4–15 more days out of role per year were recorded
individual intervention at different levels of national because of depression and 8–24 days because of
income (appendix p 3). Summing across all interventions generalised anxiety disorders; additional time lost per
and their respective populations in need, it is estimated year due to presenteeism was 11–25 partial disability days
that—depending on the income level of the country— for depression and 12–26 for generalised anxiety
between 7% and 28% of all people with depression disorders.25,26 Again, there are few empirical studies upon
currently receive treatment, equivalent to a treatment gap which to base estimates of the effect of effective treatment
of 72–93% (table 1). A gradual, linear increase in treatment of depression and anxiety on productivity, and these
coverage to a third of all cases in low-income countries point towards small differences between intervention
and to more than half of cases in high-income countries and control groups (panel 2).27–33 Expressed as a proportion
would close the current gap by 29–39%; the use of of total working days per year (220 days), and allowing
separate target coverage rates for low-income, middle- for both the onset of effect as well as the time lag between
income, and high-income countries reflects differences improved health and return to work, we modelled a 5%
in which they stand now with respect to treatment increase in working days as a result of reduced
coverage, and are intended to reflect what has been absenteeism, and a 5% increase through reduced
achieved through programme scale-up efforts in countries presenteeism. Again, these baseline values were varied
such as Chile and the UK.20 Because of even lower starting up and down by a factor of 2 and 0·5, respectively, in an
coverage levels, the modelled gap reduction for anxiety uncertainty analysis. These losses in and returns to
disorders is lower than for depression (16–25%). productivity were linked to the prevailing rates of labour
participation in the working age population (age
Effect of labour force on treatment 15–65 years) and gross domestic product (GDP) per
We modelled the economic effect of decreased morbidity worker in each of the 36 assessed countries34,35 to calculate
in terms of increased participation in and increased productivity losses at current levels of treatment coverage
productivity of the workforce. With regards to labour and productivity gains after scaled-up treatment. The
force participation, very few studies have assessed the model does not account for potential changes in
extent to which effective depression treatments get retirement age or working patterns over time, although
people back into work, and when measured, estimates an increase in retirement age and more flexible working
have been subject to local factors such as prevailing levels patterns might enhance the overall productivity gains by
of unemployment in the economy (panel 2).21–24 For our people with depression and anxiety with treatment.

Economic value of health benefits

Current Target Current gap Reduced gap % gap
coverage coverage reduction Improvements in labour force outcomes represent the
instrumental value of improved mental health after
Depression
effective treatment of common mental disorders.
Low-income countries 7% 34% 93% 66% 29%
Independent of this instrumental value, being alive and
Lower middle-income countries 14% 42% 86% 58% 32%
healthy is also valuable in itself. For this analysis, we
Upper middle-income countries 21% 49% 79% 51% 35%
followed the approach adopted by Stenberg and
High-income countries 28% 56% 72% 44% 39%
colleagues,36 who divided the overall value of a life-year
Anxiety disorders
into its economic (instrumental) and health (intrinsic)
Low-income countries 5% 20% 95% 80% 16%
elements. For the Lancet Commission on Investing in
Lower middle-income countries 10% 30% 90% 70% 22%
health, the value of a 1 year increase in life expectancy in
Upper middle-income countries 15% 35% 85% 65% 24%
low-income and middle-income countries was estimated
High-income countries 20% 40% 80% 60% 25% to be 2·3 times per person national income, and
*Treatment coverage was modelled to increase from current to target rates linearly. 1·6 times per person national income worldwide (using a
discount rate of 3%).7 Stenberg and colleagues36 attributed
Table 1: Current and target levels of scaled-up treatment coverage for depression and anxiety disorders
two-thirds of that derived value to the instrumental
(all interventions combined), by country income level*
components, which are measured here directly via the

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Panel 2: Labour force effects of treatment

Labour force participation Labour force productivity
There are very few studies showing the extent to which effective A comprehensive review of 440 published trials in an existing
depression treatments get people back into work. Two studies database of psychological and pharmaceutical interventions in
undertaken in the USA reported a 6% increase in employment depression24 was specifically undertaken for this project (by
retention in patients with depression whose care was monitored researchers at the Vrije Universiteit Amsterdam, Amsterdam,
and managed closely.20,21 Findings of another US study22 of patients Netherlands, and the Trimbos Institute, Utrecht, Netherlands)
in primary care showed that, at 6 months, employment rates were to identify the effect of effective treatment on productivity;
52·5% for patients with no care versus 72·2% for patients with care. unfortunately, very few trials reported these effects. However,
For low-income and middle-income countries, programme some treatment trials done in the USA, Korea, and India have
evaluation data for livelihoods from four countries—China, India, estimated the effect of intervention on productivity loss. The
Ghana, and Pakistan—were made available by BasicNeeds, which decrease in absenteeism reported in these studies was close to For more on BasicNeeds see
showed that the proportion of people with depression undertaking 1 day per month.20,29–32 Only two studies reported the findings http://www.basicneeds.org
income-generating activities increased by more than 50%, and in for presenteeism separately from days lost because of
those with anxiety by more than 30% (Chris Underhill, BasicNeeds, absenteeism: in the Korean study, treated patients had 24 more
personal communication). These estimates are in line with the productive hours per month,29 whereas in the Indian study,
assessment of the BasicNeeds programme in Kenya, which for a patients receiving the collaborative care had 4 fewer partial
more mixed caseload showed an 43% improvement in the days lost than controls.30 By conservatively assuming that
proportion of enrollees in income generation or productive work.23 1 partial day is equivalent to a third of a whole day, we estimate
Because these data are based on observation rather than under that almost 1 complete day of unimpaired work is restored per
controlled trial conditions, we can infer only a clear association month through reduced presenteeism. Expressed as a
between exposure to treatment and subsequent earnings rather proportion of total working days per year (220 days), and
than a definitive effect of intervention. For our base case, we allowing for both the onset of effect and the time lag between
therefore conservatively modelled a 5% restored ability to work as improved health and return to work, a 5% increase in working
a result of treatment, with half and double that rate used under days is gained through reduced absenteeism, and a 5% increase
pessimistic and optimistic scenario analyses. through reduced presenteeism.

labour force outcomes, leaving the remaining third for access to all the data in the study and had final
the intrinsic benefits of health, which is equivalent to responsibility for the decision to submit for publication.
0·5 times per person income.
Results
Uncertainty analysis Across the 36 largest countries in the world, in the absence
We assessed the sensitivity of results to plausible of scaled-up treatment, it is projected that more than
variations around these and other key input parameters 12 billion days of lost productivity (equivalent to more than
by constructing optimistic and pessimistic scale-up 50 million years of work) are attributable to depression and
scenarios. For the upper estimate: total investment costs anxiety disorders every year, at an estimated cost of
were assumed to be 20% lower than baseline, as a result US$925 billion. Assuming the same distribution of costs
of lower than expected use of expensive hospital across lower-income and higher-income countries holds
outpatient and inpatient care or the development of more for all other countries (representing 20% of the world’s
efficient interventions, including internet-based treat­ population), the global cost per year is $1·15 trillion.
ments; and productivity effects were set at double their Compared with people without these disorders, 4·7 billion
baseline rate (10% rather than 5%); the intrinsic value of extra days are lost, at a cost of $592 billion (36% of the total
a year of health life was set at 0·7 times GDP per person cost); this figure can be termed the excess productivity loss
(rather than 0·5). For the lower estimate: total investment of these disorders (figure 1).
costs were assumed to be 20% higher than baseline, as a Table 2 shows the estimated cost of scaling up treatment
result of higher than expected drug prices, service use for depression and anxiety, expressed as the net present
and programme management; productivity effects were value of the total expenditure required over the scaling-up
set at half their baseline rate (2·5% rather than 5%); and period between 2016 and 2030 (ie, the cumulative cost
the intrinsic value of a year of health life was set at over 15 years of steady scale-up, but discounted at a rate of
0·3 times GDP per person (rather than 0·5). 3%). These costs relate to incremental treatment coverage
in the population over and above current levels of
Role of the funding source coverage. For all 36 countries, the total cost amounts to
The funders of the study had no role in study design, US$91 billion for depression and $56 billion for anxiety
data collection, data analysis, data interpretation, or disorders. Treatment of mild cases accounts for less than
writing of the report. The corresponding author had full 10% of total costs for depression and 20% for anxiety

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disorders. After standardising for population size, the Table 2 shows results for two key health outcomes: cases
cost is actually quite low; for depression treatment, the averted (reduced prevalence) and healthy life-years gained
average annual cost during 15 years of scaled-up (equivalent to disability-adjusted life-years averted). Across
investment is $0·08 per person in low-income countries, the 36 countries represented in the analysis, we recorded a
$0·34 in lower middle-income countries, $1·12 in upper small decrease in the estimated prevalence of depression
middle-income countries and $3·89 in high-income and anxiety disorders as a result of treated cases recovering
countries (table 2). Per person costs for anxiety disorders from illness more quickly; in the next 15 years, this gradual
are nearly half that of depression. decrease in prevalence translates into millions of averted
cases (73 million fewer cases of depression, and 45 million
fewer cases of anxiety disorder). Weighting these averted
$500 Excess loss Comparative loss
prevalent cases by the average level of improved
$450
functioning or reduced disability provides a measure of
Productivity loss (US$ billion, 2013)

$400
healthy life-years gained. For depression and anxiety
$350
disorders combined, the cumulative number of healthy
$300
life-years gained over 15 years is 43 million.
$250 Table 2 also shows the difference in aggregate GDP
$200 between a continued current coverage scenario and one
$150 reflecting scaled-up treatment and enhanced productivity;
$100 again, this and the total economic return for the entire
$50 period of scale-up has been discounted at 3% to give a net
0
Low-income and middle- High-income
present value. For all 36 countries combined, the net
income countries (n=26) countries (n=10) present value is $399 billion ($230 billion for depression
Excess loss $185 $148 and $169 billion for anxiety disorders). The intrinsic
Comparative loss $276 $316 value of health returns show a net present value of more
Figure 1: Lost productivity attributable to depression and anxiety disorders than $250 billion for scaled-up depression treatment and
at current treatment coverage, by country income level (US$ billion, 2013) more than $50 billion for anxiety disorders (table 2).

Low-income Lower Upper High-income All countries

countries (N=6) middle-income middle-income countries (N=10) (N=36)
countries (N=10) countries (N=10)
Total population of countries analysed (millions, 2013) 443 2215 2101 992 5751
Depression
Total investment (net present value, US$ million) 517 7164 20 338 63 503 91 522
Average annual investment (net present value, US$ 0·08 0·34 1·12 3·89 1·50
per person)
Health returns (averted prevalent cases) 6 150 311 25 989 404 25 607 740 15 750 268 73 497 723
Health returns (healthy life-years gained) 2 234 781 15 692 290 11 414 429 7 567 211 36 908 711
Economic returns (US$ millions) 1190 18 799 52 732 157 022 229 744
Value of health returns (US$ millions)* 991 21 679 56 435 178 588 257 694
Benefit to cost ratio (economic returns) 2·3 2·6 2·6 2·5 2·5
Benefit cost ratio (economic and value of health 4·2 5·7 5·4 5·3 5·3
returns)
Anxiety disorders
Total investment (net present value, US$ millions) 304 3797 8966 42 668 55 735
Average annual investment (net present value, US$ 0·05 0·16 0·52 2·44 0·88
per person)
Health returns (averted prevalent case) 3 395 363 16 59 719 12 980 180 12 077 053 45 052 316
Health returns (healthy life-years gained) 416 232 2 220 716 1 711 767 1 604 069 5 952 783
Economic returns (US$ millions) 824 11 578 26 691 129 705 168 797
Value of health returns (US$ millions)* 181 2966 8453 40 409 52 009
Benefit cost ratio (economic returns) 2·7 3·0 3·0 3·0 3·0
Benefit cost ratio (economic and value of health 3·3 3·8 3·9 4·0 4·0
returns)

*Healthy life-years gained multiplied by GDP per person multiplied by 0·5.

Table 2: Costs and benefits of scaled up treatment of depression and anxiety disorders, 2016–30

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By summing the discounted costs and benefits for all

Economic benefits: depression
countries in an income group, we derived a summary 12
measure of the relationship between the benefits of
scaled-up treatment and the associated costs of 10
investment (table 2, figure 2). Restricting assessment to

Benefit:cost ratio
8
the economic returns to investment, benefit to cost
6·0 6·2
ratios for scaled-up depression treatment across 6
5·5
5·9
country income groupings were in the range of 4
2·3 to 2·6. For anxiety disorders the ratios were slightly 2·6
2·3 2·6 2·5
higher (range 2·7–3·0). Extension of the benefit–cost 2
1·0 1·1 1·0 1·0
analysis to include the estimated value of health returns
0
increased the ratio of benefit to cost, especially for
depression because of the higher health returns for this Economic benefits: anxiety
disorder compared with anxiety disorders. Benefit to 12
cost ratios for depression now exceed those for anxiety
disorders (range 4·2–5·7), and were more than double 10

the ratio when only economic benefits of depression

Benefit:cost ratio

8
treatment scale-up were considered. Benefit to cost 7·0 7·2 7·2
6·4
ratios for anxiety disorders increased by a third 6

(range 3·3–4·0). 4
We did uncertainty analysis to ascertain the sensitivity 2·7
3·0 3·0 3·0
of results to plausible changes in key study parameters. 2
1·0 1·1 1·0 1·0
Benefit to cost ratios fell to or almost reached parity 0
under the more pessimistic scenario when only economic
benefits were considered, and did not exceed 3 even Economic and value of health benefits: depression
when the value of health benefits was included (figure 2). 12
11·3 11·1 10·9
By contrast, the more optimistic scenario produces
10
benefit to cost ratios of 5·5–7·2 (economic benefits only) 8·8
and 7·5–11·3 when the value of health benefits was
Benefit:cost ratio

8
added in. As expected, results were quite sensitive to the
6
estimated rate of enhanced labour participation and 5·7 5·4 5·3
productivity. We also assessed the effect of changing the 4 4·2
rate used to discount future costs and benefits to the 3·0
2·2 2·6
2 1·9
present time. At a discount rate of 6%, the net present
value of total investments and returns would be 25% 0
less; with no discounting, they would be 35% higher in
absolute terms. Because such a change in discount rate Economic and value of health benefits: anxiety

was applied to both costs and benefits, the ratio of benefit 12

to cost, our summary return on investment metric, is not 10

affected. 8·9 8·9
8·3
Benefit:cost ratio

8
7·5
Discussion 6
This analysis sets out, for the first time, a global
4·0
investment case for a scaled-up response to the massive 4
3·3
3·8 3·9
public health and economic burden of depression and 2 1·7 1·6 1·8
anxiety disorders. Previous international economic 1·5
studies of mental health have assessed the economic 0
Low-income Lower middle- Upper middle- High-income
effect of these disorders,2,3 the cost-effectiveness of countries (n=6) income countries income countries countries (n=10)
different intervention strategies,8,10 and the cost of scaling (n=10) (n=10)
up care,18,19 but not the value of both economic and health
Figure 2: Baseline, upper, and lower benefit to cost ratios for scaled-up treatment of depression and anxiety
benefits of intervention scale up. disorders, by country income group
Notwithstanding the general limitations of any
projection modelling study, the analysis suggests that the and 2030 is $147 billion, equivalent to less than $10 billion
investment needed to substantially scale up effective per year on average. Extending the scope to the 20% of
treatment coverage for depression and anxiety disorders the world’s population not living in the 36 countries
in the 36 countries included in this analysis is substantial; represented in the study would increase the cost by about
the net present value of all investments between 2016 25% to $184 billion. However, the returns to this

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investment are also substantial, with benefit to cost ratios of disease, demographic change, and intervention effects
of 2·3–3·0 when economic benefits only are considered, in the future, which limits their precision.
and 3·3–5·7 when the value of health returns are also Several effects were not included in the analysis. One
included.
To put these findings into context, any benefit was the negative effect of maternal depression on early
to cost ratio exceeding 1 provides a rationale for child development, for which there is clear evidence;38
investment. Compared with some other potential the health, social, and economic benefits of effective
investments in health, ratios of the order reported here treatment of maternal depression on the cognitive and
can be deemed relatively modest. For example, a return physical development of newly born babies was not
on investment analysis for malaria, also for 2016–30, but assessed, but there is some evidence that this could be
using the full value of a statistical life-year, estimated substantial over the longer term.39 Likewise, the monetary
benefit to cost ratios in the range of 28:1 to 40:1.37 An and non-monetary impact of effective treatment on
investment case done for maternal, reproductive, family and other caregivers has not been factored in.
neonatal, and child health obtained a benefit to cost ratio Additionally, no account has been taken of the substantial
of less than 10:1 for 2013–35,36 which is closer to the effect of depression and its treatment on physical health
results obtained in this study. Inclusion of other benefits outcomes; depression is a risk factor for disorders such
arising from scaled-up treatment of common mental as hypertension, stroke, coronary heart disease, and
disorders that could not be captured though the present substance use disorders (just as these conditions are risk
modelling exercise, notably reduced welfare support factors for depression), and adversely affects outcomes
payments, and improved outcomes for other affected through reduced help-seeking and adherence.40 Inclusion
people (eg, partners and children of women with of these additional effects of treatment would bolster
perinatal depression) would generate higher ratios of identified economic returns. Taking appropriate account
benefit to cost. Set against that, treatment programmes of the regular co-occurrence of depression and anxiety in
might cost more or achieve less than anticipated, as individuals would be expected to lead to strong synergies
highlighted by the uncertainty analysis. on the treatment side, leading to potentially reduced
One limitation of our study is that although the investment costs, but health and economic outcomes for
projected level of overall prevalence of depression and these comorbid cases might be slower or harder to
anxiety disorders is quite well-established,12-14 the same achieve.
cannot be said for treated prevalence. The analysis done Although the analysis accounted for age and sex (eg, in
here allows for a gradual linear increase in effective terms of disease prevalence, labour force participation
service coverage for depression and anxiety disorders in and treatment eligibility), it was not possible to consider
all parts of the world in the next 15 years. However, for the effect of socioeconomic status as a mediator and
this to happen, not only will a new level of political predictor of good health and economic outcomes.
commitment and resource mobilisation be required, but Poverty has an adverse effect on the risk of depression
also a significant reorientation of public health systems and anxiety disorders through higher levels of stress,
towards chronic disease identification and management.9 social exclusion, violence and trauma, but the evidence
Partial or weak implementation of envisaged treatment base for the mental health effect of interventions
programmes, including appropriate management of targeted at the poor remains insubstantial.41 In many
recurrent cases of depression or insufficient promotion countries, poor people face significant barriers to
and awareness programmes, will inevitably reduce the accessing services, including the financial cost of
number of cases effectively reached and therefore the seeking and paying towards health care. Finally, it should
health and other benefits obtained. It is also possible that be acknowledged that the workplace itself can be a
as treatment coverage in the population increases source of stress for many people, and that there is a
substantially, the average cost per case might go up, for consequent need to integrate mental health and
example as a result of reaching out to more remote or wellbeing into new or existing employee support
less well-served parts of a country. Target coverage rates programmes.
were accordingly set at a modest level in this analysis (an A crucial issue related to but outside the scope of this
upper value of 56% of depression cases in high-income return on investment analysis is the source of financing
countries). Aside from projected treatment coverage and for investments required to scale-up services for
effectiveness, a further crucial parameter for this analysis depression and anxiety disorders. As previously noted,
concerns the effect of treatment on labour force the absolute amount needed for investment (eg, on a per
participation and productivity, for which there remains a person basis) is modest, but because existing service
paucity of evidence. As concluded by a systematic review, coverage level is so low in most countries, the gap
such data are not hard to collect alongside clinical trials between current and required spending can be large.18,19
and other studies, and need to be uniformly measured Accordingly, both rich and poor countries need to
more often.27 More generally, population health models carefully consider the merits of different health financing
(eg, the OneHealth tool) rely on many input parameters, mechanisms. For many countries, the first question to
data sources, and assumptions regarding expected rates address concerns the extent to which domestic financing

8 www.thelancet.com/psychiatry Published online April 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30024-4

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represents a feasible and sufficient method for financing 2 Bloom DE, Cafiero E, Jané-Llopis E, et al. The global economic
mental health services, perhaps as part of a package of burden of noncommunicable diseases. Geneva: World Economic
Forum, 2011.
measures to be paid for from enhanced revenue 3 Hu TW. Perspectives: an international review of the national cost
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Contributors major depressive disorder: a meta-analytic review of psychological
DC and SS conceived, planned, and oversaw the study. DC led the interventions. Int J Epidemiol 2014; 43: 318–29.
analysis of treatment costs and health outcomes, and drafted the paper. 16 WHO. mhGAP (Mental Health Gap Action Programme)
KS led the development of the methodology and model for estimating Intervention Guide. Geneva: World Health Organization, 2010.
productivity effects. PS and BR contributed to the conceptual 17 WHO-CHOICE. Country-specific unit costs. http://www.who.int/
development of the return on investment model and its constituent parts. choice/country/country_specific (accessed Nov 2, 2015).
PC and FS led the systematic review of productivity effects of treatment. 18 Chisholm D, Lund C, Saxena S. Cost of scaling up mental
All authors reviewed, commented on, and approved the report. healthcare in low- and middle-income countries. Br J Psychiatry
2007; 191: 528–35.
Declaration of interests 19 Chisholm D, Burman-Roy S, Fekadu A, et al. Estimating the cost of
We declare no competing interests. implementing district mental healthcare plans in five low- and
middle-income countries: the PRIME study. Br J Psychiatry 2016;
Acknowledgments
208 (suppl 56): s71–78.
We thank the contribution of Chris Underhill, Jess McQuail, and
20 De Silva MJ, Lee L, Fuhr DC, et al. Estimating the coverage of
Uma Sunder of BasicNeeds, who provided country-level data for
mental health programmes: a systematic review. Int J Epidemiol
productivity outcomes for people enrolled into their mental health and 2014; 43: 341–53.
development programme; colleagues in the Department of Health
21 Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach,
System Governance and Financing (Jeremy A Lauer and and care management for depressed workers and impact on clinical
Melanie Bertram) regarding conceptualisation and review of return on and work productivity outcomes: a randomized controlled trial.
investment frameworks in health, and Eirini Karyotaki at VU JAMA 2007; 298: 1401–11.
Amsterdam University for her contribution to a systematic review; 22 Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of
Shelly Chopra for her contribution to a background literature search and disseminating quality improvement programs for depression in
to the development of the conceptual framework used in this study . managed primary care: a randomized controlled trial. JAMA 2000;
Development of the mental health module of the OneHealth tool, which 283: 212–20.
was used in this analysis for estimating health impacts, was made 23 Schoenbaum M, Unützer J, McCaffrey D, Duan N, Sherbourne C,
possible through the EMERALD project on mental health system Wells KB. The effects of primary care depression treatment on
strengthening in low-income and middle-income countries, which is patients’ clinical status and employment. Health Serv Res 2002;
funded by the European Union under the 7th Framework programme 37: 1145–58.
(Grant agreement 305968). DC and SS are staff members of WHO. All 24 Lund C, Waruguru M, Kingori J, et al. Outcomes of the mental
opinions expressed in this report rest with the authors; they do not health and development model in rural Kenya: a 2-year prospective
necessarily represent the decisions, policy, or views of WHO. cohort intervention study. In Health 2013; 5: 43–50.
25 Alonso J, Petukhova M, Vilagut G, et al. Days out of role due to
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