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What Can Be Done at What Cost

Michael Schoenbaum, PhD; Brittany Butler, BA; Sheryl Kataoka, MD, MSHS; Grayson Norquist, MD, MSHS; Benjamin Springgate, MD; Greer Sullivan, MD, MSHS; Naihua Duan, PhD; Ronald C. Kessler, PhD; Kenneth Wells, MD, MPH

Arch Gen Psychiatry. 2009;66(8):906-914.

Context  Concerns about mental health recovery persist after the 2005 Gulf storms. We propose a recovery model and estimate costs and outcomes.

Objective  To estimate the costs and outcomes of enhanced mental health response to large-scale disasters using the 2005 Gulf storms as a case study.

Design  Decision analysis using state-transition Markov models for 6-month periods from 7 to 30 months after disasters. Simulated movements between health states were based on probabilities drawn from the clinical literature and expert input.

Setting  A total of 117 counties/parishes across Louisiana, Mississippi, Alabama, and Texas that the Federal Emergency Management Agency designated as eligible for individual relief following hurricanes Katrina and Rita.

Participants  Hypothetical cohort, based on the size and characteristics of the population affected by the Gulf storms.

Intervention  Enhanced mental health care consisting of evidence-based screening, assessment, treatment, and care coordination.

Main Outcome Measures  Morbidity in 6-month episodes of mild/moderate or severe mental health problems through 30 months after the disasters; units of service (eg, office visits, prescriptions, hospital nights); intervention costs; and use of human resources.

Results  Full implementation would cost $1133 per capita, or more than $12.5 billion for the affected population, and yield 94.8% to 96.1% recovered by 30 months, but exceed available provider capacity. Partial implementation would lower costs and recovery proportionately.

Conclusions  Evidence-based mental health response is feasible, but requires targeted resources, increased provider capacity, and advanced planning.

Author Affiliations: RAND Corporation, Arlington, Virginia (Dr Schoenbaum) and Santa Monica, California (Dr Wells); Semel Institute, Health Services Research Center, University of California, Los Angeles (UCLA) (Ms Butler and Drs Kataoka, Duan, and Wells); Department of Psychiatry, University of Mississippi (Dr Norquist); Robert Wood Johnson Foundation Clinical Scholars Program, UCLA, and Rapid Evaluation and Action for Community Health in New Orleans, Louisiana (REACH-NOLA) (Dr Springgate); Little Rock Veterans Affairs, Little Rock, Arkansas, and Department of Psychiatry, University of Arkansas, Fayetteville (Dr Sullivan); and the Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts (Dr Kessler). Dr Schoenbaum is now with the National Institute of Mental Health, Bethesda, Maryland; Ms Butler and Dr Sullivan, RAND Corporation, New Orleans, Louisiana, and Santa Monica, California, respectively; and Dr Duan, Columbia University, New York, New York.

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