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The economic cost of brain disorders in Europe
Article first published online: 19 DEC 2011
© 2011 The Author(s). European Journal of Neurology © 2011 EFNS
European Journal of Neurology
Volume 19, Issue 1, pages 155–162, January 2012
How to Cite
Olesen, J., Gustavsson, A., Svensson, M., Wittchen, H.-U., Jönsson, B., on behalf of the CDBE2010 study group and the European Brain Council (2012), The economic cost of brain disorders in Europe. European Journal of Neurology, 19: 155–162. doi: 10.1111/j.1468-1331.2011.03590.x
See editorial by Winter et al., on page 4.
- Issue published online: 19 DEC 2011
- Article first published online: 19 DEC 2011
- Received 19 September 2011 Accepted 11 October 2011
- brain disorder;
Background and purpose: In 2005, we presented for the first time overall estimates of annual costs for brain disorders (mental and neurologic disorders) in Europe. This new report presents updated, more accurate, and comprehensive 2010 estimates for 30 European countries.
Methods: One-year prevalence and annual cost per person of 19 major groups of disorders are based on ‘best estimates’ derived from systematic literature reviews by panels of experts in epidemiology and health economics. Our cost estimation model was populated with national statistics from Eurostat to adjust to 2010 values, converting all local currencies to Euros (€), imputing cost for countries where no data were available, and aggregating country estimates to purchasing power parity–adjusted estimates of the total cost of brain disorders in Europe in 2010.
Results: Total European 2010 cost of brain disorders was €798 billion, of which direct health care cost 37%, direct non-medical cost 23%, and indirect cost 40%. Average cost per inhabitant was €5.550. The European average cost per person with a disorder of the brain ranged between €285 for headache and €30 000 for neuromuscular disorders. Total annual cost per disorder (in billion € 2010) was as follows: addiction 65.7; anxiety disorders 74.4; brain tumor 5.2; child/adolescent disorders 21.3; dementia 105.2; eating disorders 0.8; epilepsy 13.8; headache 43.5; mental retardation 43.3; mood disorders 113.4; multiple sclerosis 14.6; neuromuscular disorders 7.7; Parkinson’s disease 13.9; personality disorders 27.3; psychotic disorders 93.9; sleep disorders 35.4; somatoform disorder 21.2; stroke 64.1; and traumatic brain injury 33.0.
Conclusion: Our cost model revealed that brain disorders overall are much more costly than previously estimated constituting a major health economic challenge for Europe. Our estimate should be regarded as conservative because many disorders or cost items could not be included because of lack of data.
The economic cost of diseases is becoming an increasingly important parameter for health and research policies, but solid estimates are often missing. At the European level, this is the rule rather than the exception. For policy analysis (the main aim of cost estimates), it is useful to keep mental and neurologic disorders together under the term brain disorders, just like cardiovascular diseases are viewed together despite differing etiology . Also, research discovers mechanisms that are of equal importance to mental and neurologic disorders . World Health Organization (WHO) data indicate that, together, these disorders account for one-third of the burden of all diseases in the wealthy part of the world . Estimates of the cost of brain disorders complement burden of disease estimates, providing information about the economic consequences of morbidity. The European Brain Council (EBC) is a federation of European wide organizations with an interest in the brain and its disorders (http://www.europeanbraincouncil.org). It initiated a study of the economic cost of brain disorders in Europe in 2004, revealing that the total cost for Europe was 386 billion € for the year 2004 . In many ways, that study was covering new ground by focusing on Europe as an entity, by presenting cost for all European countries and by studying mental and neurologic disorders together. However, the necessary epidemiologic and/or economic data were not available for many items or for many disorders. In the mean time, more such data have become available allowing a major new study that includes 30 European countries. Essentials of that study are presented here, whilst a very extensive report will be published separately .
A description of the methodology of this study is presented elsewhere in greater detail [5,6].
Study organization and search criteria
The study was planned and organized by the present authors who formed a steering group. Nineteen subcommittees, one for each group of disorders, consisting of epidemiologic and health economic experts from all over Europe  performed systematic literature reviews with explicit search criteria regarding the prevalence and cost of brain disorders in Europe, using relevant search terms in all major search engines as well as reference lists from recovered articles. To be included, studies needed to report (i) state-of-art data on the prevalence or cost or resource use, (ii) diagnostic information according to the World Health Organization’s ICD-10 (http://apps.who.int/classifications/apps/icd/icd10online/or) Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR ), and (iii) data from any of 30 European countries (EU27, Iceland, Norway, and Switzerland) or combinations of countries. Additionally, reanalysis of available epidemiologic studies was conducted to estimate effects of comorbidity, age, and gender. Studies should have a sound and robust methodology for patient selection, data collection, instrumentation, statistical analysis, and reporting of results. We selected the most common brain disorders for which a preliminary search indicated that a necessary minimum of data were available. This applied to 12 group of disorders already addressed in our 2004 report, namely addictive disorders (i.e., alcohol dependence, opiate dependence), affective disorders (i.e., bipolar disorder and major depression), psychotic disorders (i.e., schizophrenia), anxiety disorders (panic and generalized anxiety disorder, obsessive-compulsive and post-traumatic stress disorders, agoraphobia, social, and specific phobia) and somatoform disorders, brain tumor, dementia, epilepsy, migraine, multiple sclerosis, Parkinson’s disease, stroke, and traumatic brain injury. Further seven disorders were newly considered, namely specific eating disorders (anorexia and bulimia nervosa), child and adolescent disorders (i.e., attention deficit and hyperkinetic disorders, conduct disorders), mental retardation, personality disorders, sleep disorders as well as neuromuscular disorders.
A large number of the full spectrum of over 500 mental and neurologic disorders could not be included owing to lack of appropriate epidemiologic and economic data.
Geographic scope and cost approach
We included all member states of the European Union (EU) plus Iceland, Norway, and Switzerland with a total 2010 population of 514 million. Age-specific 12-month prevalence for each disorder was derived from the epidemiologic reviews and was estimated on the basis of age-specific prevalence in terms of number of persons affected by this disorder. As a result of a substantial proportion of patients with more than one diagnosis (for example, depression and anxiety disorders), the aggregate number of patients was reduced based on the available evidence of comorbidity in each disorder to reduce the risk of double counting (for details see Ref. ). We included the direct health care, direct non-medical, and indirect cost of all resources used or lost owing to illness, irrespective of payer. Direct health care cost, direct non-medical cost, and indirect cost were estimated separately and added to give the total disease cost. For most disorders and countries, cost data collected with a bottom–up approach were available, which provided a direct source for estimating the cost per patient. In a few instances (e.g., addiction in France and Spain), only aggregated cost data collected with a top–down approach was available from which we could estimate a per patient cost by dividing by the estimated number of patients. Our approach was prevalence based (in terms of 12-month diagnoses) as most brain disorders are long lasting or chronic and usually incur cost over many years. To the extent possible, cost data were derived from populations comparable to those used for estimating prevalence and adjusted where needed, e.g., by only considering direct health care costs for the proportion of patients on active treatment.
European cost-of-illness model and validation
Epidemiologic data were available for many, but not for all countries. We therefore conducted separate surveys with country-specific experts in all European countries to assess whether available rates from other countries were also considered appropriate for each respective country. In case of evidence for differences, adjustments were made (for example, for addiction).The resulting ‘best-prevalence estimate’ (EU: 12-month median) was used in countries where no prevalence data were available.
Cost data were available for fewer countries, and we imputed values for countries with no data. Furthermore, cost data were from different years. To arrive at values for all of Europe in 2010, imputations were made to adjust for such differences . Cost data were multiplied with the inflation rate in the relevant country using the consumer price index. National currencies were converted into € using nominal exchange rates from the European Central Bank adjusted for comparative price levels (i.e., purchasing power parity–adjusted exchange rates). The national health care expenditure was used to adjust direct health care cost, the gross domestic product for direct non-medical cost, and the wage level for indirect cost.
To arrive at a value for Europe, the cost per patient was multiplied by the number of persons affected as derived from the 12-month estimates for each country. Finally, cost values for each country were added to arrive at the cost in Europe.
The results of this study were validated by comparing to the former cost study, to external data from administrative data bases, to other European reviews and data from the United States.
Role of funding sources
The sponsor of the study, the EBC, is a professional, not for profit organization, representing a number of European wide professional and patient organizations. Funding was given to the EBC with the only restriction being that the funds must be used for the study of the cost of brain disorders. The present authors were appointed by the EBC, but the organization had no influence on the planning, execution, or writing up of the study. The funding came from two professional organizations and one pharmaceutical company. Neither of them had anything to do with planning, execution, or writing up of the study. Thus, the present report is entirely the responsibility of the authors and the study group behind them.
Prevalence and cost per person of different disorders
The cost per subject with a disorder of the brain was highly variable by disorder. A person with a neuromuscular disorder, for example, was estimated to cost € 30 000 per year and a subject with a headache disorder € 285. The prevalence and cost of each of the 19 groups of disorders and of their subdiagnoses for all of Europe are presented in Table 1. Headache disorders and anxiety disorders were the most prevalent but at the same time had the lowest cost per patient. Neuromuscular disorders and brain tumors were comparatively rare but very costly per case. Mood disorders (bipolar disorder and major depression), dementia, and stroke were common as well as costly per case. The high cost of mental retardation, sleep disorders, and headache disorders is perhaps surprising, considering the low level of attention devoted to these disorders. In Fig. 1, we present the total cost for each of the 19 groups of brain disorders.
|Disorders||Estimated number of subjects affected (millions)||Cost per patient (€PPP 2010)||Indirect costs||Total||Total costs (million €PPP 2010)||Indirect costs||Total|
|Direct health care costs||Direct non-medical costs||Direct health care costs||Direct non-medical costs|
|Addiction||15.5||1782||873||1572||4227||27 685||13 569||24 430||65 684|
|Alcohol dependence||14.6||1689||922||1671||4281||24 596||13 430||24 336||62 361|
|Anxiety disorders||69.1||670||2||405||1077||46 267||144||27 969||74 380|
|Panic disorder||7.9||844||0||661||1505||6670||0||5224||11 894|
|Social phobia||10.1||721||0||476||1196||7277||0||4806||12 083|
|Specific phobia||22.7||472||0||378||850||10 717||0||8595||19 312|
|Brain tumor||0.2||13 387||0||8203||21 590||3208||0||1966||5174|
|Child/Adolescent disorders||5.9||439||3156||0||3595||2601||18 724||0||21 326|
|Autism||0.6||1255||26 006||0||27 261||695||14 413||0||15 109|
|Dementia||6.3||2673||13 911||0||16 584||16 949||88 214||0||10 5163|
|Headache||152.8||59||0||226||285||9039||0||34 475||43 514|
|Medicine overuse headache||8.3||305||0||1986||2291||2533||0||16 503||19 037|
|Migraine||49.9||84||0||286||370||4181||0||14 282||18 463|
|Tension type headache||84.4||24||0||41||64||1991||0||3441||5433|
|Mental retardation||4.2||6970||3364||0||10 334||29 204||14 097||0||43 301|
|Mood disorders||33.3||781||464||2161||3406||26 016||15 437||71 952||11 3405|
|Bipolar disorder||3.0||622||560||6002||7183||1860||1675||17 956||21 491|
|Major depression||30.3||797||454||1782||3034||24 156||13 762||53 996||91 914|
|Multiple sclerosis||0.5||9811||8438||8725||26 974||5295||4554||4709||14 559|
|Neuromuscular disorders||0.3||7133||5641||17 278||30 052||1834||1450||4442||7726|
|ALS||0.1||11 240||11 559||4665||27 463||596||613||247||1457|
|CIDP||0.0||15 507||2746||3759||22 012||223||40||54||317|
|GBS||0.0||51 682||0||2319||54 001||342||0||15||358|
|MMN||0.0||15 507||2747||3759||22 012||40||7||10||57|
|Muscular dystrophies||0.1||1320||5547||30 186||37 053||177||744||4050||4972|
|Myasthenia gravis||0.0||9124||779||1111||11 014||375||32||46||453|
|PDN||0.0||15 507||2746||3759||22 012||80||14||19||113|
|Parkinson’s disease||1.2||5626||4417||1109||11 153||7029||5519||1386||13 933|
|Personality disorders||4.3||773||625||4929||6328||3342||2701||21 301||27 345|
|Borderline PD||2.3||956||1161||6809||8925||2224||2701||15 843||20 769|
|Psychotic disorders||5.0||5805||0||12 991||18 796||29 007||0||64 920||93 927|
|Sleep disorders||44.9||441||0||348||790||19 796||0||15 630||35 425|
|Sleep apnea||12.5||1008||0||1109||2117||12 599||0||13 853||26 452|
|Somatoform disorder||20.4||468||0||570||1037||9547||0||11 622||21 169|
|Stroke||8.2||5141||2035||599||7775||42 352||16 769||4932||64 053|
|Stroke (incident)||1.3||13 850||5534||1616||21 000||17 570||7021||2050||26 641|
|Stroke (prevalent)||7.0||3556||1399||413||5368||24 782||9748||2882||37 412|
|Traumatic brain injury||3.7||2697||893||5219||8809||10 106||3348||19 560||33 013|
|Trauma (incident)||1.2||4158||52||4156||8366||5023||62||5021||10 106|
|Trauma (prevalent mod/sev)||2.5||2002||1294||5725||9020||5083||3285||14 539||22 907|
|Total||Number of diagnoses 380.1||296 374||18 6250||315 101||797 725|
Distribution on different types of costs
There was a large variation in the distribution of cost categories across disorders. The relative distribution is shown in Fig. 2. Persons with eating disorders had the highest proportion of direct health care cost (72%), whereas these only constituted 12% in child/adolescent or personality disorders. The direct non-medical cost constituted the highest proportion in child/adolescent disorders (88%) and dementia (84%). Indirect cost made up the bulk of the cost in personality disorders (78%) and headache (79%).
The aggregated cost was € 798 billion for all 19 groups of disorders in the whole of Europe in 2010. The majority of the estimated cost of brain disorders was direct cost, 60%, divided into direct health care cost 296 billion and direct non-medical cost 186 billion. Indirect cost at 315 billion constituted the remaining 40% (Fig. 3).
Per capita costs for all European countries are given in Table 2. The mean cost per capita in Europe was estimated at € 1550. The total cost for all brain disorders in individual countries ranged between 437 million in Malta and 153 billion in Germany (Table 2). The country-specific estimates should be interpreted with some caution as they are a result of model estimations from the European cost model.
|Country||Population size||Per capita cost||Total costs|
|Austria||8 375 290||1910||15 996|
|Belgium||10 827 000||1699||18 396|
|Bulgaria||7 563 710||421||3181|
|Czech Republic||10 506 813||970||10 190|
|Denmark||5 534 738||1773||9813|
|Estonia||1 340 127||747||1001|
|Finland||5 351 427||1610||8617|
|France||64 714 074||1658||107 301|
|Germany||81 802 257||1867||152 719|
|Greece||11 305 118||1414||15 990|
|Hungary||10 014 324||867||8682|
|Ireland||4 467 854||1703||7611|
|Italy||60 340 328||1433||86 459|
|Latvia||2 248 374||691||1554|
|Lithuania||3 329 039||631||2101|
|The Netherlands||16 574 989||1802||29 861|
|Norway||4 858 199||2104||10 222|
|Poland||38 167 329||775||29 588|
|Portugal||10 637 713||1234||13 130|
|Romania||21 462 186||525||11 263|
|Slovakia||5 424 925||735||3988|
|Slovenia||2 046 976||1185||2425|
|Spain||45 989 016||1692||77 791|
|Sweden||9 340 682||1882||17 580|
|Switzerland||7 785 806||1872||14 573|
|United Kingdom||62 008 048||2169||134 476|
Our estimate of the cost in 2010 of the 12 disorders included in our previous study  was almost exactly the same as in 2004 when corrected for inflation and increase in population. The total direct health care cost in Europe in 2010 was € 1.260 billion (OECD statistics, 2011, available at http://stats.oecd.org). Our estimate for brain disorders of 296 billion corresponded to 24% of this figure. Cost of dementia in Europe was estimated by Wimo et al.  to € 160 billion or 60% higher than our estimate, mostly owing to the rather uncertain estimates of the cost of informal care. Other studies in epilepsy, stroke, and multiple sclerosis obtained results similar to ours [9–11]. US data were compared with our values for Germany because of the similar economic level of the two countries. For anxiety disorders and sleep disorders, similar results were obtained, but for the majority of disorders, cost in the United States was higher in agreement with the much higher cost of direct health care in the United States [12–17].
The present study showed that the total cost of brain disorders (mental and neurologic disorders) in Europe in 2010 was € 798 billion. Direct health care cost was 295 billion, non-medical cost (nursing homes etc.) 186 billion, and the indirect cost (absenteeism from work, pensions etc.) 315 billion. This high cost of brain disorders may be surprising, but WHO data suggest that brain disorders cause one-third of the burden of all diseases and are thus in agreement with the present study . Inputs to the present study were the 1-year prevalence and the annual cost per case of 19 groups of brain disorders (mental and neurologic disorders combined) in the European Union plus Iceland, Norway, and Switzerland with a total population of 514 million. Almost one hundred experts participated in this extensive project to achieve the best possible estimates. The number of diagnoses of brain disorders in 1 year was 380 million in Europe. This is not the number of affected persons, however, because many have two or more diagnoses. According to our recent estimate, approximately one-third of the population in Europe were affected by at least one brain disorder within a given year .
A number of methodological uncertainties must be mentioned. Whilst the epidemiologic data are mostly solid, data were not available from all European countries and had to be imputed for the rest. Economic data were more scarce and in some instances, only available from one or a few countries. Further, indirect costs are dependent on assumptions on the value of lost production, which adds to the uncertainty in our estimates. Despite these uncertainties, data for each individual country are probably reasonably precise because of the use of our robust health economic model . In any case, they are the best European data available. Another issue is whether the aggregated figure of the total cost of brain disorders in all of Europe is correct or over- or underestimated. It is difficult to attribute the resource use and indirect cost to a specific disorder if a person suffers from more than one disorder. This may lead to the same cost being included in more than one disorder, so-called double counting. To the extent possible, we have corrected for double counting in the cost estimates by considering the excess cost for each disorder (i.e., the additional cost that a person with the disorder causes, irrespective of whether they have any other disorders) . Thereby, we have not attempted to correct for double counting in the number of persons with the disorder, but instead in what additional cost they incur. Still, the available evidence is limited, and we have not considered all overlap between the 19 disorders and the individual diagnoses within each of these disorders. The best way of avoiding double counting would have been a field study in all 30 European countries of representative populations who recorded disease-specific cost prospectively. We have previously estimated for a grant application that such a study, even after compromises and simplifications, would cost in excess of 100 million Euros and, hence, be impossible to finance. In the present study, we did everything possible to correct for double counting, but some degree of overestimation cannot be ruled out.
Although we covered the highly prevalent disorders, there are hundreds of less common disorders, some very costly per patient, that were not included because of the lack of data. We also did not include indirect cost of insomnia, mild head trauma, mental retardation, and developmental disorders, all expected to be of considerable magnitude. The cost of crime because of addiction or personality disorder was not included. Appetite regulation is a brain phenomenon, but obesity was not included under eating disorders. On balance, we consider the risk of underestimation far greater than the risk of overestimation.
A comparison to the cost of other major disease categories is important but uncertain because of scarcity of data for other diseases and differing methodologies. The European Heart Network reported a cost of cardiovascular disorders of € 192 billion (http://www.ehnheart.org). The cost of cancer was estimated differently in different studies to be between 150 and 250 billion  (http://www.comparatorreports.se). The direct health care cost of diabetes was between 20 and 83 billion, to which unknown indirect cost should be added . The cost of rheumatoid arthritis was 25 billion (http://www.comparatorreports.se) and of chronic obstructive lung disease 39 billion . Thus, several brain disorders were considerably more expensive than conditions otherwise considered to be very costly. WHO previously projected that major depression in future would top the list of the 20 most burdensome disorders in the Western world. This has already happened in Europe .
The total annual cost figure of brain disorders, 798 billion Euros, makes it apparent that these disorders are the biggest health challenge of the century, posing a serious threat to our social and health care systems as well as to the future of European economy. Furthermore, the prevalence and cost of brain disorders are going to increase because of increasing life expectancy. In particular, the number of patients with neurodegenerative disorders, stroke, depression, and anxiety will increase. Increased focus on research strategies, prevention, and care is necessary to reduce the future cost of brain disorders. A recent ‘disorder of the brain summit’ resulted in a series of proposals for future actions . Working toward reducing stigma and ignorance that still clouds the view on many brain disorders should be an immediate action. Current knowledge allows better and earlier diagnosis and better treatment paradigms, but they are not easily implemented in Europe, as there seems to have been no improvement over the last 6 years . Although such actions might be associated with higher initial direct health care cost, it is easily offset by a reduction of direct non-medical cost and indirect costs. Finally, research budgets and teaching plans in medical schools and other health-related educational institutions may need to be revisited in the light of the present data.
Research in context panel
Nineteen subcommittees, one for each group of disorders, consisting of epidemiologic and health economic experts from all over Europe  performed systematic literature reviews with explicit search criteria regarding the prevalence and cost of brain disorders in Europe. They used relevant search terms in all major search engines as well as reference lists from recovered articles. To be included, data needed to report (i) state-of-art data on the prevalence or cost or resource use, (ii) diagnostic information according to the World Health Organization’s ICD-10 http://apps.who.int/classifications/apps/icd/icd10online/or DSM-IVTR , and (iii) data from any of 30 European countries (EU27, Iceland, Norway, and Switzerland) or combinations of countries. Additionally, reanalysis of available epidemiologic studies were conducted to estimate effects of comorbidity, age, and gender. Studies should have a sound and robust methodology for patient selection, data collection, instrumentation, statistical analysis, and reporting of results.
The only previous European wide data are from our previous study published in 2005. In comparison, we now add a number of cost items and seven further brain disorders plus update to 2010 values. We now find that the previous study grossly underestimated the cost of brain disorders. With 798 billion Euros per year in Europe, the cost is comparable to the cost of cardiovascular diseases, cancer, and diabetes put together.
The study was funded by grants from the European Federation of Neurological Societies, the European College of Neuropsychopharmacology and H. Lundbeck A/S.
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Albena Jordanova, Amir Musayev, Anders Gustavsson, Andrea Gabilondo, Andreas Maercker, Beatrice Melin, Bengt Jönsson, Bernhard Walder, Brenda Gannon, Brigitte Schlehofer, Carlo Faravelli, Christer Allgulander, Christina Ljungcrantz, Corinna Jacobi, Dafin F. Muresanu, David Hilton Jones, Eda Ehler, Ettore Beghi, Fiona Norwood, Francisco Aguilera, Frank Jacobi, Frank Jacobi, Gisela Kobelt, Gunther Meinlschmidt, Hans-Christoph Steinhausen, Hans-Ulrich Wittchen, Jan Verschuuren, Jean-Michel Vallat, Jennifer Glaus, Jens-Peter Reese, Jes Olesen, Jim van Os, Joan Bentzen, Jordi Alonso, Jose Garcia-Ibanez, Judith Dams, Jürgen Rehm, Klaus Lauer, Klaus von Wild, Korinna Karampampa, Lars Jacob Stovner, Laszlo Vécsei, Laura Fratiglioni, Leonard H van den Berg, Linus Jönsson, Luis Salvador-Carulla, Marc Perrin, Maria Milenkova, Martin Knapp, Martin Preisig, Massimo Moscarelli, Mattias Ekman, Mattias Linde, Maura Pugliatti, Mikael Svensson, Mohamed Mhadi Rogers, Olli Tenovuo, Peter Van den Bergh, Philippe Azouvi, Pieter Vos, Poul Jennum, Rafael Martinez-Leal, Richard Dodel, Roland Simon, Roselind Lieb, Stefanie Drabsch, Susana Otero, Tobias Kurth, Weili Xu, Yaroslav Winter.