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The shocking economic toll of mental illness (Straits Times Premium)

By Vikram Khanna, Associate Editor & Senior Columnist, The Straits Times

The estimated $16 billion a year for Singapore is staggering but does not cover the full spectrum of invisible costs

One of the statistics that startled me recently was that anxiety and depression in the post-pandemic era could be costing Singapore 2.9 per cent of its gross domestic product – or nearly $16 billion every year – in lost productivity, according to a study by Duke-NUS Medical School. But as shocking as this may seem, it’s likely to be, if anything, a gross underestimate if all the direct and indirect costs of anxiety, depression and other mental illnesses are taken into account.

Having had to deal with the mental illness of a (now late) sibling for more than 40 years, I have witnessed, up close and personal, how debilitating and terrifying its impact can be – most of all, for the person directly affected, but also for others, as well as the costs that it entails.

Aggregated across all the victims of mental illness in the population, the total economic costs, both direct and indirect, would be difficult to quantify.

Incomplete data

First, the data is typically incomplete and based on subjective accounts of only those who are willing to respond to surveys. Second, most studies do not cover all forms of mental illnesses – such as schizophrenia, bipolar illness, “mixed states” and eating disorders. Third, the second- and higher-order effects of mental illness are often not taken into account. For example, many of them lead to other diseases and disorders, such as diabetes, alcoholism, drug abuse, cardiovascular disease and strokes. These comorbidities also have high costs, and some of them cause premature deaths, as in the case of my sibling.

But mental illness is rarely, if ever, listed as the cause of death in death certificates. Thus, to the extent that mortality statistics are used as a guide to allocating health resources, mental health tends to be underfunded.

The Duke-NUS study was based on survey data from 5,725 Singaporean adults, seeking to identify those with symptoms of anxiety or depression. It found that 14 per cent to 15 per cent had symptoms consistent with depression and/or anxiety.

Only 32 per cent sought healthcare to treat their conditions and 24 per cent consulted a mental healthcare provider; 13 per cent made at least one visit to an emergency department and 9 per cent were admitted to hospital. This increased healthcare costs by an average of $1,050 a year for these individuals. In addition, the affected respondents reported missing 17.7 days of work a year on average, and being 40 per cent less productive at work as a result of their conditions, yielding total health costs and productivity losses attributable to anxiety and depression of $15.7 billion.

The study provides a valuable baseline estimate of some of the economic costs of anxiety and depression – two of the most common mental health conditions. But the costs would be much higher if all mental health conditions and the costs of the comorbidities resulting from them were included as well.

Indirect costs are under-measured

The indirect costs should also include “opportunity costs” of mental health problems – that is, the potential that people who suffer from such conditions are not able to achieve because of missed opportunities. For example, a substantial proportion of young people with mental illness are unable to complete their tertiary education, or in some cases, even their secondary education, which represents a direct loss of investment in human capital.

Even if they find jobs afterwards, those jobs would be typically lower paid than if they were well educated. So not only are they less productive in the jobs they end up doing, but those jobs fall short of what they might have been able to secure if not for their mental illness. Apart from my sibling, I have known many such people who are extremely bright but were unable to finish their studies because of their condition, cannot hold down any job, and are reduced to doing only part-time work, if that.

There is also the fact that mental illness does not only affect those who suffer from it, but also their family members, including parents, spouses, children, siblings and even friends, who often have to double up as caregivers. They, too, face productivity losses and negative health effects as a result of having to take time off, as well as increased stress.

The children of mentally ill people, especially the very young, run the risk of abuse and unstable domestic life. Their upbringing and education, too, can be affected. All of those effects also need to be factored into the indirect costs of mental illness.

There are social costs as well – for example, the costs associated with the use of social services, the justice system and the police, who often get involved in cases involving the mentally ill. The Duke-NUS study did not include these indirect costs in its study, but Dr Eric Finkelstein, who led the project, said in an e-mail that they – as well as costs borne by caregivers – should be addressed in future efforts.

Some global estimates of the economic costs of mental health conditions and related consequences are eye-opening. For example, a 2011 study by the World Economic Forum and Harvard School of Public Health projected that globally, the costs would rise from US$2.5 trillion in 2010, to US$6 trillion (S$8.1 trillion) by 2030. That would exceed the costs associated with cancer, diabetes and respiratory ailments combined. If this seems surprising, consider the fact that while these ailments mostly affect people quite late in adulthood, the onset of mental illness is relatively early – typically between the ages of 18 and 21 – which means it impacts almost the entire working lives of those affected.

Treatment gaps

Their problems are compounded by the fact that frequently, mentally ill people are reluctant to seek help, as the Duke-NUS study confirmed in the case of Singapore. There are several reasons for this.

First, there is denial. Many of the mentally ill find it hard to acknowledge that they have such a condition – partly for fear of being stigmatised, which is unfortunately justified in many societies, including ours.

The Duke-NUS study found that those with higher education and who were employed were more likely not to seek treatment.

Even family members are reluctant to admit to outsiders that one of their own has a mental illness. They try to cope in secret, until the situation gets out of hand, as it invariably does.

While remedies are readily available and have become better with the discovery of new and safer anti-depressants and anti-psychotic drugs, the process of treatment is not straightforward. Even though there are protocols for diagnosis, such as the DSM-IV criteria which classify mental disorders, medical opinions vary widely – far more so than for most other illnesses because of the mysterious complexity of the symptoms.

For instance, some psychiatrists diagnosed my sibling as having a bipolar disorder while others diagnosed schizophrenia and still others diagnosed “mixed states”. Some favoured the use of electroconvulsive therapy – which involves administering electrical shocks to the brain under anaesthesia – while others discouraged it.

Drug prescriptions also vary. Moreover, a drug that works for one mentally ill patient may not work for another with a similar condition. So, the process of finding a drug that is effective often involves trial and error. Also, many drugs – especially the older anti-psychotics – can have side effects, even though they might be able to control some symptoms.

Combined with patient denial, side effects compromise compliance with medication, which prolongs the illness – and the longer it goes on without effective treatment, the worse it becomes, and the higher the resulting costs.

Treatment benefits

Despite these problems, the benefits of medical intervention are significant. A study in the medical journal Lancet estimates that for every US$1 invested in scaled-up treatment for depression and anxiety, there is a US$4 return in better health and productivity.

The Duke-NUS study points out that the high treatment gap in Singapore is concerning, and calls for measures to promote help-seeking and uptake of treatment.

The Government has been increasingly proactive. Since the Covid-19 pandemic, when cases spiked, it has created a multi-agency task force to address mental health issues. Plans are afoot to offer a tiered system of care in which individuals with symptoms of mental illness are first offered self-, family-, and workplace-based support, followed by progressively higher levels of care through mental health professionals, clinics and hospitals depending on the severity of symptoms.

A partnership programme is in place between general practitioners (GPs) and the Institute of Mental Health, to enable GPs to tackle mental health issues – an essential step, given that GPs are often the first port of call for people who feel unwell.

The Duke-NUS researchers also suggest that given the fact that those with better education and who have jobs are less likely to seek treatment, there is a need for targeted interventions in educational and workplace settings.

They note that while many employers have scaled up their wellness programmes for their staff and are considering expanding mental health-related benefits, more needs to be done.

Some of the recommendations in the mental health toolkit for employers by the National Council of Social Service include: treating both mental and other illnesses as equally urgent and extending corporate insurance coverage to mental health, training managers and front-line supervisors on mental health issues, introducing policies that improve work-life balance, and partnering with mental health providers to offer counselling for employees.

But perhaps the most important step is to reduce the stigma associated with mental illness, which profoundly affects how its victims feel about themselves. When stigma is widespread, many of those affected and their families might remain reluctant to seek treatment, no matter what resources are in place.

There is evidence that stigma in society is significant. For instance, a 2016 survey on attitudes towards mental illness in Singapore revealed that 50.8 per cent of respondents believed it was a sign of personal weakness and 42.8 per cent were unwilling to work closely with a person with a mental health condition.

Hopefully, these percentages have reduced since, but stigma still persists. There’s a lot that can be done to reduce it. We must encourage open conversations about mental health. Celebrities – many of whom have suffered from mental illness – as well as others who have endured it must share their stories of struggle and recovery.

There must be anti-discriminatory legislation in place, just like there is against racism and sexism. Society must recognise that mental illness is a real health issue, like cancer, arthritis or diabetes, and is neither self-inflicted nor a matter of shame, and above all, that people who suffer from it should not be equated with their illness. It’s something they have; it’s not what they are.

Originally published in The Straits Times (Premium): The shocking economic toll of mental illness