Sound Decision Making in Uncertain Times: Can Systems Modelling Be Useful for Informing Policy and Planning for Suicide Prevention?

Mental health impacts of COVID-19: A retrospective analysis of dynamic modelling projections for Australia

Background

In early 2020, we developed a dynamic model to support policy responses aimed at mitigating the adverse mental health effects of the COVID-19 pandemic in Australia. As the pandemic has progressed, it has become clear that our initial model forecasts overestimated the impacts of infection control measures (lockdowns, physical distancing, etc.) on suicide, intentional self-harm hospitalisation, and mental health-related emergency department (ED) presentation rates.

Methods

Potential explanations for the divergence of our model predictions from observed outcomes were assessed by comparing simulation results for a set of progressively more refined models with data on the prevalence of moderate to very high psychological distress and numbers of suicides, intentional self-harm hospitalisations, and mental health-related ED presentations published after our modelling was released in July 2020.

Results

Allowing per capita rates of spontaneous recovery and intentional self-harm to differ between people experiencing moderate to very high psychological distress prior to the pandemic and those developing comparable levels of psychological distress only as a consequence of infection control measures substantially improves the fit of our model to empirical estimates of the prevalence of psychological distress and leads to significantly lower predicted effects of COVID-19 on suicide, intentional self-harm hospitalisation, and mental health-related ED presentation rates.

Conclusion

Accommodating the influence of prior mental health on the psychological effects of population-wide social and economic disruption is likely to be critical for accurately forecasting the mental health impacts of future public health crises as they inevitably arise.

Cost-effectiveness of system-level mental health strategies for young people in the Australian Capital Territory: a dynamic simulation modelling study

BACKGROUND

Regional mental health planning is a key challenge for decision makers because mental health care is a complex, dynamic system. Economic evaluation using a system dynamics modelling approach presents an opportunity for more sophisticated planning and important evidence on the value of alternative investments. We aimed to investigate the cost-effectiveness of eight systems-based interventions targeted at improving the mental health and wellbeing of children, adolescents, and young adults in the Australian Capital Territory (ACT).

METHODS

We assessed eight interventions for children and young people (aged ≤25 years) with low, moderate, and high-to-very-high psychological distress: technology-enabled integrated care, emergency department-based suicide prevention, crisis response service, family education programme, online parenting programme, school-based suicide prevention programme, trauma service for youths, and multicultural-informed care. We developed a system dynamics model for the ACT through a participatory process and calibrated the model with historical data, including population demographics, the prevalence of psychological distress, and mental health services provision. We calculated incremental cost-effectiveness ratios compared with business as usual for cost (AU$) per: quality-adjusted life-year (QALY), suicide death avoided, self-harm related hospital admissions avoided, and mental health-related emergency department presentation, using a 10-year time horizon for health-care and societal perspectives. We investigated uncertainty through probabilistic sensitivity analysis and deterministic sensitivity analysis, including using a 30-year timeframe.

FINDINGS

From a societal perspective, increased investment in technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care were expected to improve health outcomes (incremental QALYs 4517 [95% UI -3135 to 14 507] for technology-enabled integrated care; 339 [91 to 661] for family education; 724 [114 to 1149] for the online parenting programme; and 137 [88 to 194] for multicultural-informed care) and reduce costs ($-91·4 million [-382·7 to 100·7]; $-12·8 million [-21·0 to -6·6]; $-3·6 million  [-6·3 to 0·2]; and $-3·1 million [-4·5 to -1·8], respectively) compared with business as usual using a 10-year time horizon. The incremental net monetary benefit for the societal perspective for these four interventions was $452 million (-351 to 1555), $40 million (14 to 74), $61 million (9 to 98), and $14 million (9 to 20), respectively, compared with business as usual, when QALYs were monetised using a willingness to pay of $79 930 per QALY. Synergistic effects are anticipated if these interventions were to be implemented concurrently. The univariate and probabilistic sensitivity analyses indicated a high level of certainty in the results. Although emergency department-based suicide prevention and school-based suicide prevention were not cost effective in the base case (41 QALYs [0 to 48], incremental cost $4·1 million [1·2 to 8·2] for emergency department-based suicide prevention; -234 QALYs [-764 to 12], incremental cost $90·3 million [72·2 to 111·0] for school-based suicide prevention) compared with business as usual, there were scenarios for which these interventions could be considered cost effective. A dedicated trauma service for young people (9 QALYs gained [4 to 16], incremental cost $8·3 million [6·8 to 10·0]) and a crisis response service (-11 QALYs gained [-12 to -10], incremental cost $7·8 million [5·1 to 11·0]) were unlikely to be cost effective in terms of QALYs.

INTERPRETATION

Synergistic effects were identified, supporting the combined implementation of technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care. Synergistic effects, emergent outcomes in the form of unintended consequences, the capability to account for service capacity constraints, and ease of use by stakeholders are unique attributes of a system dynamics modelling approach to economic evaluation.

FUNDING

BHP Foundation.

The economic costs of alcohol-related harms at the local level in New South Wales

INTRODUCTION

Alcohol is a harmful, toxic and addictive substance that causes many diseases and injuries. Alcohol use also incurs a financial cost to the health care system and wider economy. This project aimed to undertake a cost impact analysis of alcohol-related harms at the local level in New South Wales (NSW). The alcohol-related harms costing model is an interactive tool designed for use by local health districts, stakeholders such as Liquor and Gaming NSW, NSW Independent Liquor and Gaming Authority and community stakeholders.

METHODS

Costs included in the analysis were alcohol-related hospitalisations, deaths, crimes, emergency department attendances, outpatient presentations and their impacts on productivity. Two local government areas (LGA) were used as case studies to demonstrate local impacts.

RESULTS

In 2019-2020, the total cost of alcohol-related harms for NSW was estimated at $9 billion, at a rate of $120.3 million per 100,000 population. The total costs were comprised of alcohol-attributable premature mortality ($8.3 billion), non-fatal health care costs ($275 million) and crime costs ($457 million). A comparative analysis of two case study LGAs estimated that alcohol-related harms cost $195 million for the Northern Beaches LGA and $351 million for the Central Coast LGA.

DISCUSSION AND CONCLUSIONS

This research has developed a 'proof-of-concept' model to estimate the cost of alcohol-related harms at the local level in Australia, empowering health agencies and local community stakeholders to use economic evidence in their submissions in response to new liquor licence applications and other policies that impact their local community. This economic evidence can be used to improve the quality of decisions on alcohol regulation and policies. There are a number of future research opportunities that would enhance the economic evidence available to liquor licensing decision-makers.

Simulation Models for Suicide Prevention: A Survey of the State-of-the-Art

Suicide is a leading cause of death and a global public health problem, representing more than one in every 100 deaths in 2019. Modeling and Simulation (M&S) is widely used to address public health problems, and numerous simulation models have investigated the complex, dependent, and dynamic risk factors contributing to suicide. However, no review has been dedicated to these models, which prevents modelers from effectively learning from each other and raises the risk of redundant efforts. To guide the development of future models, in this paper we perform the first scoping review of simulation models for suicide prevention. Examining ten articles, we focus on three practical questions. First, which interventions are supported by previous models? We found that four groups of models collectively support 53 interventions. We examined these interventions through the lens of global recommendations for suicide prevention, highlighting future areas for model development. Second, what are the obstacles preventing model application? We noted the absence of cost effectiveness in all models reviewed, meaning that certain simulated interventions may be infeasible. Moreover, we found that most models do not account for different effects of suicide prevention interventions across demographic groups. Third, how much confidence can we place in the models? We evaluated models according to four best practices for simulation, leading to nuanced findings that, despite their current limitations, the current simulation models are powerful tools for understanding the complexity of suicide and evaluating suicide prevention interventions.