Relapse prevention is not only possible, but desirable on many levels. It is fundamental to providing effective continuing care for people with mental illness. Relapse prevention is essential to developing individual care pathways for people with mental illness that incorporate the multiple areas needed to effectively support treatment and recovery. It is part of a longer-term investment in the wellbeing of Australians—aiming to reduce the prevalence and duration of mental illness and thereby its impact on individuals, families, communities, and health and community services.
Relapse prevention is desirable for several pragmatic reasons. Firstly, it reduces the negative impact of mental illness on individuals and their families and carers, as well as their communities. Prolonged and repeated periods experiencing the symptoms of mental illness severely disrupt a person's life and erode their confidence and wellbeing (Ralph 2000). The more relapses, the more disabled a person is likely to become; there is evidence that each relapse increases both residual symptoms (Shepherd et al 1989) and social disabilities (Hogarty et al 1991).
As a result, people who experience repeated episodes of mental illness are more dependent on their families and carers. This greatly increases the burden on families and carers, contributing to their distress and reducing their quality of life. It has been estimated that individual carers contribute, on average, 104 hours per week caring for a person with mental illness (MHCA & CAA 2000). Repeated relapses impact in multiple ways on families and carers, including severely limiting the employment and social opportunities for those with a major role in caring for someone with mental illness (CAA 1998, CAA 1997).
Preventing relapse vastly improves the quality of life of people with mental illness and enables them to more fully participate in work, leisure and relationships. Effective relapse prevention enables people to gain mastery over their symptoms, which increases their sense of control over their lives (Mueser et al 2002). A greater sense of control and efficacy can reduce the feeling of being 'entrapped' by the illness, a feeling that is commonly reported by people with mental illness and that may lead to depression (Birchwood et al 1993).
Being able to participate in meaningful activities is also important to the productivity of communities. The lack of participation of community members with mental illness is a considerable cultural and economic loss to communities. Mental disorders were the leading cause of years of 'healthy' life lost due to disability in 1996, accounting for nearly 30% of the total years of healthy life lost (AIHW 2002 p109).
Secondly, preventing relapse reduces the cost of mental illness to the Australian community. People who experience recurrent episodes are more dependent on health and community services, and every relapse that requires medical intervention imposes a cost on the health care system. In a recent randomised controlled trial in the UK, costs for the patients who relapsed were over four times higher than those for the non-relapse group (Almond et al 2004).
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Expenditure for mental disorders has increased from $2,247 million to $3,741 million in the period 1993–94 to 2000–01 (AIHW 2005). This represents a change from 7.4% of total allocated health expenditure in 1993–94 to 7.5% in 2000–01. In the same period, expenditure on community mental health has increased from $340 million to $842 million. The increase in expenditure on community mental health shows the change of focus in mental health from hospital care to community care.
For Australia, in 2000-01, $3.7 billion was spent for people with mental disorders. This accounted for 7.5% of health system costs (AIHW 2005). This expenditure includes expenditure for depression, anxiety, psychotic disorders and substance use disorders, but does not include expenditure for dementia, which is categorised as part of nervous system disorders in the AIHW disease expenditure classification.
Expenditure on mental disorders compares with $5.5 billion for cardiovascular diseases, $4.9 billion for nervous system disorders, and $4.6 billion for musculoskeletal diseases (AIHW 2005). Mental disorders were identified as the third leading cause of overall health burden (14%) after cardiovascular diseases (20%) and cancers (19%) in 1996 (AIHW 2002 p109).
Health care expenditure for mental disorders for 2000-2001 can be broken down as follows (AIHW 2005):
- Hospital and aged care homes $1,561M;
- Medical and other health professionals $633M;
- Pharmaceuticals $616M;
- Research $109M; and
- Community and public health $821M.
Direct evidence to support the cost-benefit of relapse prevention is not currently available. This is because few programs are clearly defined as relapse prevention, as separate from interventions that provide treatment, rehabilitation or recovery services; so, it is not possible to isolate the effects of programs specifically aimed at relapse prevention. Furthermore, effective relapse prevention spans many different sectors of service delivery, and it is difficult to clearly specify, quantify and cost such multifaceted and multisectoral interventions. For example, despite their extensive data collections for health and welfare, the AIHW is not able to extract the costs for people with mental illness from most of the databases related to the multiple health and welfare sectors from which people with mental illness might receive services.
One of the few interventions clearly identified as relapse prevention is teaching people to recognise the early warning signs of their mental illness. Novacek and Raskin (1998) report evidence from a large uncontrolled study of 370 people with severe mental illness, showing that teaching recognition of early warning signs was associated with better outcomes, which included fewer relapses and hospitalisations and reduced treatment costs.
Indirect evidence of the effectiveness of relapse prevention is available, however, from several sources. Randomised controlled clinical trials show that effective treatments that can prevent or reduce the severity of relapse have positive effects by reducing hospitalisations, decreasing length of stay if a hospitalisation is required, increasing the number of days in the community, reducing the level of symptomatology, and increasing the likelihood of obtaining employment (Mueser, Bond & Drake 2001). The European EPSILON study revealed that higher needs, greater symptom severity and longer psychiatric history are associated with higher health care costs (Knapp et al 2002). Furthermore, a study examining the cost of mental health care in the United States from 1993 to 1995 by analysing insurance records for mental health claims, reported that greater use of outpatient care (which is more likely to be focused on relapse prevention) decreased the costs of care by reducing the level of more expensive inpatient care (Outcomes and Accountability Alert 1999).