Direct and indirect costs in persons with chronic back pain and comorbid mental disorders—A systematic review

doi:10.1016/j.jpsychores.2012.05.008

Journal of Psychosomatic Research

Volume 73, Issue 2, August 2012, Pages 79-85

https://doi.org/10.1016/j.jpsychores.2012.05.008 Get rights and content

Abstract

Objective

Direct inpatient and outpatient healthcare costs as well as indirect costs (e.g. productivity losses) are hypothesized to be increased in chronic back pain (CBP) patients with mental disorders. The aim of this systematic review is to examine this hypothesis by comparing costs in CBP patients with and without mental disorders.

Methods

A comprehensive literature search (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS) was conducted. All studies were included which allowed for a comparison of direct and indirect costs between CBP patients with and without mental disorders.

Results

Of 2283 potentially relevant articles, 10 studies fulfilled the inclusion criteria. Total healthcare costs (SMD = 0.16 [SE = 0.06]; n = 1), CBP-related healthcare costs (SMD = 0.21 [0.06]; n = 1), CBP-related primary care visits (OR = 1.6 [95%-CI:1.2–2.3]; n = 1), CBP-related specialty care visits (OR = 1.4 [1.0–2.0];n = 1), CBP-related radiologic procedures (OR = 1.6 [1.0–2.5]; n = 1) and mental health visits (OR = 8.1 [7.3–9.1]; n = 2) were increased in CBP patients with depression. The incidence of new surgeries was increased in CBP patients with PTSD (OR = 4.2 [1.6–10.8]; n = 1). Pain-related healthcare use (n = 1) in CBP patients with both depression and anxiety and CBP-related hospital admissions (n = 1) in CBP patients with depression were not increased. Regarding indirect costs results were inconsistent for both return to work rates (n = 3) and work absence (n = 2).

Conclusion

The results indicate increased direct but not indirect costs in CBP patients with mental disorders. However, the evidence is limited due to the low number of studies per outcome. This is all the more problematic, since the adequate allocation of healthcare resources will become a major topic of health care policy due to limited resources.

Introduction

Prevalence rates of chronic back pain (CBP) in the general population are estimated to be 5.9% to 11.1% [1]. CBP poses a large economic burden for the healthcare system [2]. For example, direct healthcare costs of low back pain were estimated to be £1632 million in the UK in 1998. Costs of informal care and productivity losses related to low back pain totalled approximately £10668 million [3]. Annual direct costs of CBP were reported to be higher than €7000 per person in Germany [1]. Indirect costs such as work absenteeism represents a majority of overall costs associated with CBP [1], [2].

Systematic reviews on costs in patients with other medical diseases than CBP reported substantially increased direct and indirect costs in medically ill patients with comorbid mental disorders [4], [5], [6]. Persons with CBP are at increased risk for comorbid mental disorders [7], [8]. While mental disorders in CBP have consistently been linked with impaired quality of life [9], [10], greater disability [11], [12], [13], increased risk of chronicity [14] and decreased pain self-management such as reduced exercise duration [15], the existing evidence regarding costs in CBP and comorbid mental disorders is ambiguous. Hence, the present systematic review aims to aggregate data on the association between mental disorders and direct and indirect costs in CBP patients. The following research questions will be addressed:

1)
To what extent are comorbid mental disorders in CBP patients associated with increased costs in comparison to CBP patients without mental comorbidity?
2)
Are there differences in this association with regard to specific comorbid mental disorders?

Section snippets

Method

The data collection for this study was part of the project “Meta-analysis of quality of life and healthcare costs in somatically ill patients with comorbid mental disorders”, funded by the Landesstiftung Baden-Württemberg [4], [5], [6], [10].

Results

The database search yielded 2283 potentially relevant articles, which were evaluated in a preliminary sensitive selection process by one reviewer (see Fig. 1). Then, two reviewers independently selected relevant studies from a set of 873 abstracts or full papers. Finally, 10 primary studies fulfilled inclusion criteria [11], [20], [21], [22], [23], [24], [25], [26], [27], [28]. For one potentially relevant dissertation abstract, no full text could be located [19].

Discussion

Some evidence was found for increased direct healthcare costs but not indirect costs in CBP patients with mental disorders compared to CBP patients without mental disorders. Self-evidently, increased direct costs were particularly pronounced with regard to mental healthcare costs, but not limited to these mental health specific costs. Of eight studies, six reported slightly to moderately increased total and back pain-related overall, inpatient and outpatient costs underlining a significant

Conclusion

Similar to other diseases [4], [5], [6] the results of the available studies point in the direction of increased direct healthcare costs in CBP patients with comorbid mental disorders. However, as yet, the (only modest) evidence indicates that mental disorders in CBP are not as highly associated with incremental healthcare costs as in other medical diseases. Since the adequate allocation of healthcare resources will become a major topic in the future due to evermore limited resources, these

Competing interest statement

The authors have no competing interests to report.

Acknowledgments

We would like to thank the Landesstiftung Baden-Württemberg for funding the research project.

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ReviewDirect and indirect costs in persons with chronic back pain and comorbid mental disorders—A systematic review

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Method

Results

Discussion

Conclusion

Competing interest statement

Acknowledgments

Spine J

Pain

Gen Hosp Psychiatry

Pain

J Clin Epidemiol

Pain

Pain

Pain

Arch Phys Med Rehabil

Med Clin North Am

Psychosomatics

J Affect Disord

Gen Hosp Psychiatry

Gen Hosp Psychiatry

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review

Expert Opin Pharmacother

Healthcare costs in patient with diabetes mellitus and comorbid mental disorders—a systematic review

Diabetologia

Increased 12-month prevalence rates of mental disorders in patients with chronic somatic diseases

Psychother Psychosom

Quality of life in medically ill persons with comorbid mental disorders: a systematic review and meta-analysis

Psychother Psychosom

Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys

Psychol Med

Review
Direct and indirect costs in persons with chronic back pain and comorbid mental disorders—A systematic review